Effect of Dietary Phosphate Restriction in Pre-Dialysis Chronic Kidney Disease Patients with Hyperphosphataemia in Southern Nigeria.

BACKGROUND: Hyperphosphataemia is a common cardiovascular risk factor in chronic kidney disease (CKD). Dietary counseling and control are key aspects in the management of CKD. Although some studies have shown the beneficial effects of dietary phosphate restriction on cardiovascular and bone health in haemodialysis patients, little is known about its effect in pre-dialysis CKD patients. AIM: To determine the effect of dietary phosphate restriction in predialysis CKD patients with hyperphosphataemia. METHODS: A hospital-based interventional study involving 72 predialysis CKD patients with hyperphosphataemia randomly allocated into 2 groups. Group 1 had nutritional counseling on dietary phosphate restriction while group 2 had no form of dietary phosphate restriction. All participants were placed on a phosphate binder throughout the study period of 3 months. At the end of the third month, a repeat of baseline tests (serum phosphate, calcium, albumin, creatinine and serum lipids) and anthropometric measurements were done and compared between the 2 groups. RESULTS: The mean age in the treatment and control groups were 54.6±14.7 years and 54.9±14.5 years, respectively. The mean serum phosphate (5.7±0.5 vs. 5.5± 0.4mg/dl), calcium (7.9±0.9 vs. 7.8± 0.7mg/dl), albumin (3.8±0.4 vs. 3.9±0.7g/dl), creatinine (3.9±1.3 vs. 3.7±1.2mg/dl) and body mass index (BMI) (25.0±3.9 vs.25.4±3.1kg/m2) were similar in both groups. Serum phosphate, potassium, fasting blood glucose (FBG), total cholesterol, triglycerides and BMI were significantly reduced while there was no significant change in serum calcium-phosphate product and haematocrit following dietary phosphate restriction in addition to use of phosphate binders. However, on comparison of the changes between the treatment and control groups preand post- intervention, there was no significant change in serum phosphate but there was significant decrease in serum potassium, triglyceride and FBG. CONCLUSION: The use of phosphate binders in pre-dialysis CKD significantly reduced serum phosphate while additional dietary phosphate restriction had no significant effect on serum phosphate lowering and there was no significant change in nutritional status in predialysis CKD patients with hyperphosphataemia.

CONTEXTE: L'hyperphosphatémie est un facteur de risque cardiovasculaire courant dans la maladie rénale chronique (MRC). Le conseil et le contrôle diététiques sont des aspects clés dans la gestion de la MRC. Bien que certaines études aient montré les effets bénéfiques de la restriction alimentaire en phosphate sur la santé cardiovasculaire et osseuse chez les patients en hémodialyse, peu est connu sur son effet chez les patients atteints de MRC pré-dialyse. OBJECTIF: Déterminer l'effet de la restriction alimentaire en phosphate chez les patients atteints de MRC pré-dialyse avec hyperphosphatémie. MÉTHODES: Étude interventionnelle hospitalière impliquant 72 patients atteints de MRC pré-dialyse avec hyperphosphatémie, répartis aléatoirement en 2 groupes. Le groupe 1 a reçu des conseils nutritionnels sur la restriction alimentaire en phosphate tandis que le groupe 2 n'a reçu aucune forme de restriction alimentaire en phosphate. Tous les participants ont été mis sous un chélateur de phosphate pendant toute la période d'étude de 3 mois. À la fin du troisième mois, les tests de base (phosphate sérique, calcium, albumine, créatinine et lipides sériques) et les mesures anthropométriques ont été répétés et comparés entre les 2 groupes. RÉSULTATS: L'âge moyen dans les groupes traitement et contrôle était respectivement de 54,6±14,7 ans et 54,9±14,5 ans. Les moyennes du phosphate sérique (5,7±0,5 contre 5,5±0,4 mg/dl), du calcium (7,9±0,9 contre 7,8±0,7 mg/dl), de l'albumine (3,8±0,4 contre 3,9±0,7 g/dl), de la créatinine (3,9±1,3 contre 3,7±1,2 mg/dl) et de l'indice de masse corporelle (IMC) (25,0±3,9 contre 25,4±3,1 kg/m2) étaient similaires dans les deux groupes. Le phosphate sérique, le potassium, la glycémie à jeun (GAJ), le cholestérol total, les triglycérides et l'IMC ont été significativement réduits, tandis qu'il n'y avait aucun changement significatif dans le produit calcium-phosphate sérique et l'hématocrite suite à la restriction alimentaire en phosphate en plus de l'utilisation de chélateurs de phosphate. Cependant, en comparant les changements entre les groupes traitement et contrôle avant et après l'intervention, il n'y avait pas de changement significatif du phosphate sérique, mais il y avait une diminution significative du potassium sérique, des triglycérides et de la GAJ. CONCLUSION: L'utilisation de chélateurs de phosphate chez les patients atteints de MRC pré-dialyse a significativement réduit le phosphate sérique, tandis que la restriction alimentaire en phosphate supplémentaire n'a eu aucun effet significatif sur la réduction du phosphate sérique et il n'y avait aucun changement significatif de l'état nutritionnel chez les patients atteints de MRC pré-dialyse avec hyperphosphatémie. MOTS-CLÉS: Maladie rénale chronique, Pré-dialyse, Hyperphosphatémie, Restriction alimentaire.

Care of Adults with Advanced Chronic Kidney Disease.

Chronic kidney disease (CKD) impacts over 10% of the global population. Adults with CKD face significant morbidity and mortality. As kidney disease progresses, the risk of adverse outcomes increases. Here, we present an overview of strategies to care for adults with advanced CKD (stage 4-5 CKD, not receiving kidney replacement therapy). We aim to guide clinicians through several aspects of CKD care, ranging from recommended laboratory assessments to interdisciplinary support for patients as they plan for kidney replacement therapy (dialysis, transplantation, or conservative management). We incorporate considerations of health equity and person-centered care, empowering clinicians to deliver high-quality care to people with CKD.

Shared decision-making in selecting modality of renal replacement therapy confers better patient prognosis after the initiation of dialysis.

INTRODUCTION: The effect of shared decision-making (SDM) regarding the choice of renal replacement therapy (RRT) for chronic kidney disease (CKD) patients on their mortality after the induction of dialysis therapy has not been adequately investigated. METHODS: Patients who initiated dialysis at our hospital were divided into two groups according to whether they participated in SDM in the outpatient clinic, and survival analysis was performed. We also examined the effect of SDM in the outpatient clinic on mortality. RESULTS: Of the 554 patients, 123 (22.2%) were in the SDM group. The survival rate was significantly higher in the SDM group (p = 0.001, log-rank test). Multivariate analysis excluding ADL, which competed with SDM, showed that SDM was significantly associated with mortality (HR 0.593, 95% CI: 0.353-0.997, p = 0.049). CONCLUSION: SDM regarding RRT selection in the outpatient clinic may be associated with a better patient prognosis after dialysis induction.

The Impact of Frailty and Severe Cognitive Impairment on Survival Time and Time to Initiate Dialysis in Older Adults With Advanced Chronic Kidney Disease: A Prospective Observational Cohort Study.

Background and objectives Frailty and cognitive impairment significantly impact survival time and time to initiate dialysis in older adults with advanced chronic kidney disease (CKD). This study aims to evaluate the effects of frailty and cognitive impairment on these outcomes and determine the most effective assessment tool for predicting early dialysis initiation and short survival time. Materials and methods This prospective observational cohort study involved 240 patients aged ≥65 years with stage 4 or 5 CKD, recruited from a nephrology outpatient department (ambulatory care) between March 2020 and March 2021. Frailty was assessed using the Physical Frailty Phenotype (PFP), PRISMA-7, Clinical Frailty Scale (CFS), and FRAIL scale. Cognitive function was evaluated using the Montreal Cognitive Assessment (MoCA). The primary outcomes were time to initiate dialysis and survival time, with secondary outcomes including hospitalization rates, length of stay, and mortality after dialysis initiation. Results Frail patients only showed significantly shorter time to dialysis initiation when identified by the PFP and FRAIL scale (28.3 months for frail vs. 31.2 months for non-frail, p = 0.028; 26.9 months for frail vs. 30.9 months for non-frail, p = 0.038). The PFP, FRAIL, and CFS tools indicated significantly shorter survival times for frail patients compared to non-frail patients (26.8 months for frail vs. 30.6 months for non-frail, p = 0.003). Frailty is strongly correlated with severe cognitive impairment, as 45.5% of frail patients (according to the FRAIL scale) have dementia compared to 15.1% of non-frail patients (p<0.001). However, cognitive impairment did not significantly affect the time to dialysis initiation or survival time. Hospitalization rates and length of stay in the hospital were significantly higher only for frail patients identified by PRISMA-7, with a median hospital length of stay of 9.15 days for frail patients vs 6.37 days for non-frail patients (p = 0.044). Overall, 37.5% of the patients did not survive during the study follow-up, with frail patients having a higher mortality rate. Conclusion Frailty, mainly when assessed by PFP and FRAIL, is a significant predictor of early dialysis initiation and reduced survival time in older adults with advanced CKD. Cognitive impairment, while prevalent, did not independently predict these outcomes. Regular frailty screening should be incorporated into CKD management to tailor interventions and improve patient outcomes.

Ethnic and seasonal variations in FGF-23 and markers of chronic kidney disease-mineral and bone disorder.

Background: Fibroblast growth factor 23 (FGF-23) and other markers of chronic kidney disease-mineral and bone disorder (CKD-MBD) provide valuable insights into disease processes, treatment options and patient prognosis. However, limited research has explored potential associations with ethnicity or season, particularly in multi-ethnic populations residing in high-latitude regions. Methods: We evaluated CKD-BMD markers in a diverse cohort of CKD patients, who were participants of The CANADIAN AIM to PREVENT (the CAN AIM to PREVENT) study. FGF-23, calcium, phosphate, 25-hydroxyvitamin D (25-OHD) and intact parathyroid hormone (iPTH) in 1234 participants with pre-dialysis CKD (mean estimated glomerular filtration rate: 41.8 ± 14.3 mL/min) were analyzed. Mixed-effects general linear regression models adjusted for demographic and biological factors were used to compare repeated measurements across patient groups categorized by ethnicity (East Asian, White, South Asian, Black, Southeast Asian) and seasons. Results: Compared with other groups, White participants exhibited 8.0%-18.5% higher FGF-23 levels, Black participants had 0.17-0.32 mg/dL higher calcium levels, White participants had 10.0%-20.1% higher 25-OHD levels, South Asian participants had 7.3%-20.1% lower 25-OHD levels and Black participants had 22.1-73.8% higher iPTH levels, while East Asian participants had 10.7%-73.8% lower iPTH levels. Seasonal variations were also observed. FGF-23 levels were 11.9%-15.5% higher in summer compared with other seasons, while calcium levels were 0.03-0.06 mg/dL lower in summer. 25-OHD levels were 5.6%-10.6% higher in summer and autumn compared with other seasons. Conclusions: This study shows that FGF-23 and CKD-MBD markers in a Canadian pre-dialysis CKD cohort vary independently by ethnicity and season. Further research is needed to understand the reasons and clinical significance of these findings.

Risk factors and clinical prediction models for osteoporosis in pre-dialysis chronic kidney disease patients.

BACKGROUND: Osteoporosis in pre-dialysis chronic kidney disease (CKD) patients has been overlooked, and the risk factors of osteoporosis in these patients have not been adequately studied. OBJECTIVE: To identify risk factors for osteoporosis in pre-dialysis CKD patients and develop predictive models to estimate the likelihood of osteoporosis. METHODS: Dual-energy X-ray absorptiometry was used to measure bone mineral density, and clinical examination results were collected from 326 pre-dialysis CKD patients. Binary logistic regression was employed to explore the risk factors associated with osteoporosis and develop predictive models. RESULTS: In this cohort, 53.4% (n = 174) were male, 46.6% (n = 152) were female, and 21.8% (n = 71) were diagnosed with osteoporosis. Among those diagnosed with osteoporosis, 67.6% (n = 48) were female and 32.4% (n = 23) were male. Older age and low 25-(OH)-Vitamin D levels were identified as risk factors for osteoporosis in males. For females, older age, being underweight, higher bone alkaline phosphatase (NBAP), and advanced CKD (G5) were significant risk factors, while higher iPTH was protective. Older age, being underweight, and higher NBAP were risk factors for osteoporosis in the G1-4 subgroup. In the G5 subgroup, older age and higher NBAP increased the risk, while high 25-(OH)-Vitamin D or iPTH had protective effects. Nomogram models were developed to assess osteoporosis risk in pre-dialysis patients based on gender and renal function stage. CONCLUSION: Risk factors for osteoporosis vary by gender and renal function stages. The nomogram clinical prediction models we constructed may aid in the rapid screening of patients at high risk of osteoporosis.

Real-Time Use of SGLT2i Verified in Pre-dialysis: The RSVP Cross-sectional Study.

BACKGROUND: The use of sodium-glucose cotransporter 2 inhibitors (SGLT2i) in nephrology practice is increasingly becoming standard of care in patients with diabetes or those with proteinuria. OBJECTIVES: The primary outcome was to identify the proportion of pre-dialysis patients with chronic kidney disease (CKD) G3a, G3b, or G4 prescribed an SGLT2i and describe their characteristics. METHODS: This was a retrospective, multicentric, cross-sectional study of patients with CKD followed at 4 pre-dialysis clinics in the province of Quebec, Canada. We collected data of multiple covariates associated with prescribing SGLT2i in patients over 18 years of age with CKD G3a, G3b, or G4. We then performed a multivariate logistic regression to assess their associations. RESULTS: Of the 874 patients included, 22.7% were prescribed an SGLT2i. Factors most strongly associated included male sex (odds ratio [OR] = 4.88, 95% CI = 2.38-10.03), being prescribed metformin (OR = 4.30, 95% CI = 2.23-8.31), having type 2 diabetes (OR = 4.00, 95% CI = 1.86-8.62), or having an albumin-to-creatinine ratio greater than 300 mg/g (OR = 1.84, 95% CI = 1.08-3.14). The majority of patients (60.4%) had their SGLT2i initiated by the pre-dialysis clinic and the most frequent adverse event was an initial increase in serum creatinine 1 week after starting treatment (33.9%). CONCLUSION AND RELEVANCE: An increasing number of patients with CKD are being prescribed SGLT2i. Nonetheless, significant disparities in sex, severity of disease, and comorbidities remain. We suggest that specific strategies be put in place to promote prescribing of SGLT2i in women and other at-risk populations, in particular among nephrology teams, to improve patient care.

Primary and specialist care interaction and referral patterns for individuals with chronic kidney disease: a narrative review.

BACKGROUND: Timely referral of individuals with chronic kidney disease from primary care to secondary care is evidenced to improve patient outcomes, especially for those whose disease progresses to kidney failure requiring kidney replacement therapy. A shortage of specialist nephrology services plus no consistent criteria for referral and reporting leads to referral pattern variability in the management of individuals with chronic kidney disease. OBJECTIVE: The objective of this review was to explore the referral patterns of individuals with chronic kidney disease from primary care to specialist nephrology services. It focused on the primary-specialist care interface, optimal timing of referral to nephrology services, adequacy of preparation for kidney replacement therapy, and the role of clinical criteria vs. risk-based prediction tools in guiding the referral process. METHODS: A narrative review was utilised to summarise the literature, with the intent of providing a broad-based understanding of the referral patterns for patients with chronic kidney disease in order to guide clinical practice decisions. The review identified original English language qualitative, quantitative, or mixed methods publications as well as systematic reviews and meta-analyses available in PubMed and Google Scholar from their inception to 24 March 2023. RESULTS: Thirteen papers met the criteria for detailed review. We grouped the findings into three main themes: (1) Outcomes of the timing of referral to nephrology services, (2) Adequacy of preparation for kidney replacement therapy, and (3) Comparison of clinical criteria vs. risk-based prediction tools. The review demonstrated that regardless of the time frame used to define early vs. late referral in relation to the start of kidney replacement therapy, better outcomes are evidenced in patients referred early. CONCLUSIONS: This review informs the patterns and timing of referral for pre-dialysis specialist care to mitigate adverse outcomes for individuals with chronic kidney disease requiring dialysis. Enhancing current risk prediction equations will enable primary care clinicians to accurately predict the risk of clinically important outcomes and provide much-needed guidance on the timing of referral between primary care and specialist nephrology services.

Haematological Indices and Iron Status in Pre-Dialysis Chronic Kidney Disease Patients.

BACKGROUND: Chronic kidney disease (CKD) is associated with haematological changes, the commonest being anaemia. The number and function of white blood cells (WBC) and platelets are equally affected. Iron deficiency is a common cause of anaemia in the CKD population and anaemia has been associated with reduced cardiac function, increased rates of hospitalization, morbidity and mortality. This study aimed to determine the haematological indices and iron status among pre-dialysis CKD patients. METHOD: A hospital-based cross-sectional study involving 95 predialysis CKD patients and 95 age- and sex-matched apparently healthy controls. Full blood count, peripheral blood film, serum ferritin, transferrin saturation, C-reactive protein (CRP), electrolytes, urea and creatinine, serum folate and vitamin B12 were done in all study participants. Comparisons were made between results obtained from participants in both groups. RESULT: The mean ages were 58.1 ± 14.9 years and 58.3 ± 15.0 years in the CKD group and controls, respectively. The male:female ratio was 1:0.9 in both groups. The prevalence of anaemia was 51.6% and 3% in patients with CKD and controls, respectively. There was no significant difference in the total WBC count, neutrophil and lymphocyte differentials, platelet count, serum vitamin B12 and folate in patients with CKD and controls. The prevalence of iron deficiency among patients with CKD was 32.6%, of which 62.5% were absolutely iron-deficient while 37.5% were functionally iron-deficient. The median ferritin and CRP were also higher in CKD. (p =0.001). CONCLUSION: Anaemia and iron deficiency are common in predialysis CKD patients. Early diagnosis and treatment are important to avoid the problems associated with them. MOTS-CLÉS: Maladie rénale chronique, Anémie, Carence en fer, Pré-dialyse.

Association between periodontal inflamed surface area and systemic inflammatory biomarkers among pre-dialysis chronic kidney disease patients.

Background: Several studies have shown an association between chronic kidney disease (CKD) and periodontitis. However, only few studies have quantified the burden of periodontal inflammation in pre-dialysis CKD patients. The aim of this study was to determine the association between periodontal inflamed surface area (PISA) and systemic inflammatory biomarkers among pre-dialysis CKD patients. Materials and Methods: 120 pre-dialysis CKD participants were recruited into this study. 60 participants constituted Group A (those with periodontitis) while 60 participants constituted Group B (those without periodontitis). Full periodontal examination was carried out in the participants for the estimation of PISA. Blood samples also collected to determine levels of high sensitivity C-reactive protein (hsCRP) and interleukin-6 (IL-6) in all participants. Independent t-test was used to compare means of PISA, hsCRP and IL-6 levels in the two groups. Pearson correlation analysis was used to determine association between PISA and (hsCRP and IL-6). Results: The mean value of hsCRP was significantly higher in Group A compared to Group B (3.41 mg/L vs. 2.18 mg/L). PISA moderately correlated with hsCRP (r = 0.4, P < 0.01) in both groups. hsCRP also moderately correlated with IL-6 (r = 0.6, P < 0.001) in both groups. Conclusion: This study demonstrates that there was an association between PISA and hsCRP. Increased hsCRP level in Group A revealed the inflammatory burden imposed by periodontitis.

Predictive Effect of System Inflammation Response Index for Progression of Chronic Kidney Disease in Non-Dialyzing Patient.

Purpose: Scant research has been conducted on the interplay between the systemic inflammation response index (SIRI) and chronic kidney disease (CKD). The present study endeavors to meticulously scrutinize the association between SIRI and renal function. Additionally, we aim to assess its efficacy in predicting the progression of CKD in non-dialysis patients. Patients and Methods: Adult patients with CKD who were not undergoing dialysis were enrolled, and follow-up data were obtained. Data from distinct groups were extracted and meticulously compared. A comprehensive analytical approach was adopted, including logistic regression analysis, Kaplan-Meier analysis, Cox proportional hazards regression analysis, and subgroup analysis. Results: Our study included 1420 patients, with a mean age of 61 ± 17 years, and 63% were male. 244 (17.2%) patients experienced the progression of CKD. As the level of ln(SIRI) increased, patients tended to be older, with a higher proportion of males, and increased prevalence rates of hypertension, stroke, heart failure, and progression of CKD. Additionally, the levels of baseline creatinine and C-reactive protein were elevated, while the levels of estimated glomerular filtration rate and hemoglobin decreased. Upon adjusting for demographic and biochemical variables, logistic regression analysis indicated that ln(SIRI) was independently associated with advanced CKD in pre-dialysis patients (OR=1.59, 95% CI: 1.29-1.95, P<0.001). Moreover, Cox proportional-hazard analysis revealed that ln(SIRI) independently predicted CKD progression (HR: 1.3, 95% CI: 1.07-1.59, P=0.009). Conducting a subgroup analysis, we observed significant interactions between ln(SIRI) levels and gender (p<0.001), age (p=0.046), and hypertension (p=0.028) in relation to the progression of CKD. Conclusion: Our study's findings demonstrate a significant association between SIRI and fundamental renal function, and independently establish a correlation between SIRI and the progression of CKD in pre-dialysis patients. These observations suggest that SIRI holds promise as a potential predictor for CKD progression.

Real-world trends in pre-dialysis blood pressure levels of patients undergoing dialysis in Japan using a web-based national database.

The prevalence of hypertension is high among patients undergoing dialysis. We extracted data of patients undergoing dialysis between 2012 and 2020 with recorded pre-dialysis systolic blood pressure (SBP) using a web-based national database in Japan. Following the 2019 Japanese Society of Hypertension guidelines, we classified SBP and assessed its trends over time based on sex, age, diabetes status, and the anti-hypertensive medication use. Using the 2020 database, we examined 336,759 Japanese patients undergoing dialysis (114,249 female; 222,510 male). The mean age was 69.4 ± 12.5 years, and the mean SBP was 152.3 ± 24.7 mm Hg. The prevalence rate of pre-dialysis hypertension was 70.2%, with 32.5%, 24.5%, and 13.2% of patients having grade I, grade II, and grade III hypertension, respectively. From 2014 to 2020, prevalence rate of pre-dialysis hypertension and absolute values of pre-dialysis SBP were higher in dialysis patients with diabetes than in those without diabetes across all age groups and sexes. Younger patients with diabetes or those on anti-hypertensive medication exhibited an SBP of approximately 160 mm Hg. Cerebrovascular death in patients with diabetes was associated with a higher rate of pre-dialysis hypertension than that in those without diabetes, and there was a significant difference in the prevalence of grade III hypertension between the two groups. In conclusion, the mean pre-dialysis SBP among patients undergoing dialysis remained high, and younger patients with diabetes or those receiving anti-hypertensive medications had poor blood pressure control. Optimal blood pressure management may be necessary to reduce the risk of cardiovascular mortality.

Influence of blood pressure variations during hemodialysis on the prognosis of dialysis patients.

The prognosis of dialysis patients is poorer than that of the general population. The relationship between dialysis patients' blood pressure (BP) and mortality is controversial. We investigated the relationships between mortality and (i) pre-dialysis BP and (ii) BP variation during hemodialysis in maintenance dialysis patients.We retroactively analyzed the cases of the 284 patients on hemodialysis (mean age 68 ± 13 years old) who had been regularly followed at Kokura Daiichi Hospital, Japan in 2018. We assessed the relationship between the patients' BP components and risk of mortality over a 40-month follow-up.The patients' average systolic/diastolic BP values before dialysis in 2018 were 145 ± 18/77 ± 11, and those after dialysis were 129 ± 17/71 ± 10 mmHg. The prevalence of intradialytic hypotension was 46.8%. During an average follow-up of 35 months, 72 patients died, including from infectious diseases (n = 41), cardiovascular diseases (n = 9), malignancies (n = 5), and others (n = 17). The mortality rate was 32.7% in the pre-dialysis SBP < 140 mmHg group, 20.6% in the 140-159 mmHg group, and 22.2% in ≥ 160 mmHg group. In a multivariable-adjusted analysis, the hazard ratio for mortality in the pre-dialysis SBP < 140 mmHg group with intradialytic hypotension was significantly higher than that in the 140-159 mmHg group.In dialysis patients, pre-dialysis SBP < 140 mmHg and intradialytic hypotension posed a significantly higher risk for mortality. Our findings suggest that not only lower pre-dialysis BP, but also intradialytic hypotension is associated with poor prognosis in dialysis patients.

Analysis of the rate of force development reveals high neuromuscular fatigability in elderly patients with chronic kidney disease.

BACKGROUND: Chronic kidney disease (CKD) induces muscle wasting and a reduction in the maximum voluntary force (MVF). Little is known about the neuromuscular fatigability in CKD patients, defined as the reduction of muscle force capacities during exercise. Neuromuscular fatigability is a crucial physical parameter of the daily living. The quantification of explosive force has been shown to be a sensitive means to assess neuromuscular fatigability. Thus, our study used explosive force estimates to assess neuromuscular fatigability in elderly CKD patients. METHODS: Inclusion criteria for CKD patients were age ≥ 60 years old and glomerular filtration rate (GFR) < 45 mL/min/1.73 m2 not on dialysis, and those for controls were GFR > 60 mL/min/1.73 m2 , age and diabetes matched. The fatigability protocol focused on a handgrip task coupled with surface electromyography (sEMG). Scalars were extracted from the rate of force development (RFD): absolute and normalized time periods (50, 75, 100, 150 and 200 ms, RFD50 , RFD75 , RFD100 , RFD150 and RFD200 , respectively), peak RFD (RFDpeak in absolute; NRFDpeak normalized), time-to-peak RFD (t-RFDpeak ) and the relative force at RFDpeak (MVF-RFDpeak ). A statistical parametric mapping approach was performed on the force, impulse and RFD-time curves. The integrated sEMG with time at 0-30, 0-50, 0-100 and 0-200 ms time intervals relative to onset of sEMG activity was extracted and groups were compared separately for each sex. RESULTS: The cohort of 159 individuals had a median age of 69 (9IQR ) years and body mass index was 27.6 (6.2IQR ) kg/m2 . Propensity-score-matched groups balanced CKD patients and controls by gender with 66 males and 34 females. In scalar analysis, CKD patients manifested a higher decrement than controls in the early phase of contraction, regarding the NRFDpeak (P = 0.009; η2 p  = 0.034) and RFD75 and RFD100 (for both P < 0.001; η2 p  = 0.068 and 0.064). The one-dimensional analysis confirmed that CKD males manifest higher and delayed neuromuscular fatigability, especially before 100 ms from onset of contraction. sEMG was lower in CKD patients than controls in the 0-100 ms (at rest: P = 0.049, Cohen's d = 0.458) and 0-200 ms (at rest: P = 0.016, Cohen's d = 0.496; during exercise: P = 0.006, Cohen's d = 0.421) time windows. Controls showed greater decrease of sEMG than CKD patients in the 0-30 ms (P = 0.020, Cohen's d = 0.533) and 0-50 ms (P = 0.010, Cohen's d = 0.640) time windows. As opposite to females, males showed almost the same differences between groups. CONCLUSIONS: Our study is the first to show that CKD patients have higher fatigability than controls, which may be associated with an impaired motor-unit recruitment, highlighting a neural drive disturbance with CKD. Further studies are needed to confirm these findings.

Risk of Tuberculosis Disease in People With Chronic Kidney Disease Without Kidney Failure: A Systematic Review and Meta-analysis.

BACKGROUND: Kidney failure is an established risk factor for tuberculosis (TB), but little is known about TB risk in people with chronic kidney disease (CKD) who have not initiated kidney replacement therapy (CKD without kidney failure). Our primary objective was to estimate the pooled relative risk of TB disease in people with CKD stages 3-5 without kidney failure compared with people without CKD. Our secondary objectives were to estimate the pooled relative risk of TB disease for all stages of CKD without kidney failure (stages 1-5) and by each CKD stage. METHODS: This review was prospectively registered (PROSPERO CRD42022342499). We systematically searched MEDLINE, Embase, and Cochrane databases for studies published between 1970 and 2022. We included original observational research estimating TB risk among people with CKD without kidney failure. Random-effects meta-analysis was performed to obtain the pooled relative risk. RESULTS: Of the 6915 unique articles identified, data from 5 studies were included. The estimated pooled risk of TB was 57% higher in people with CKD stages 3-5 than in people without CKD (adjusted hazard ratio: 1.57; 95% CI: 1.22-2.03; I2 = 88%). When stratified by CKD stage, the pooled rate of TB was highest in stages 4-5 (incidence rate ratio: 3.63; 95% CI: 2.25-5.86; I2 = 89%). CONCLUSIONS: People with CKD without kidney failure have an increased relative risk of TB. Further research and modeling are required to understand the risks, benefits, and CKD cutoffs for screening people for TB with CKD prior to kidney replacement therapy.

Enacting person-centred care: a multi-perspective study of practices in clinical encounters for people living with chronic kidney disease.

BACKGROUND: There is growing emphasis on the need for ensuring person-centred care for patients living with chronic kidney disease as this will benefit patients, providers, and healthcare systems alike. Nevertheless, less emphasis is given to how this complex concept is practiced in clinical encounters and how it is experienced by patients. This qualitative multi-perspective study investigates how person-centred care for people living with chronic kidney disease is practiced and experienced by patients in clinical encounters at a nephrological ward at a hospital in the capital region of Denmark. METHODS: The study builds upon qualitative methodologies, including field notes from observations of clinical encounters between clinicians and patients in an out-patient clinic (n = ~ 80) and in-person interviews with patients in peritoneal dialysis (n = 4). Key themes from field notes and interview transcripts were identified through thematic analysis. Analyses were informed by practice theory. RESULTS: Findings illustrate that person-centred care is practiced in a relational and situational encounter between patients and clinicians as dialogues about choice of treatment modality, which is shaped by the individual's life circumstances, preferences, and values. The practice of person-centred care appeared to be complex and interlinked with a range of factors, individual to each patient. We identified three themes of relevance for practices and experiences related to person-centred care: (1) Patients' perceptions of living with chronic kidney disease. Perceptions differed according to medical history, life situation and prior experiences with treatment in the healthcare system. These patient-related factors were perceived to be important for person-centred care to unfold; (2) Relations between patients and healthcare professionals were important for patients' experiences of trust and appeared fundamental for the practice and experiences of person-centred care; and (3) Decision-making on treatment modality that is the best fit for each patient's everyday life, appear to be shaped by the patient's need for knowledge about treatment modalities and level of self-determination in the decision-making. CONCLUSIONS: The context of clinical encounters influences the practices and experiences of person-centred care, where health policies and lack of embodiment are identified as barriers for providing and experiencing person-centred care.

Risk Assessment of Pre-dialysis Chronic Kidney Disease (CKD) Patients for Cardiovascular Disease (CVD) in a Tertiary Hospital in Nigeria: A Case-Controlled Cross-Sectional Study.

INTRODUCTION: Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in the chronic kidney disease (CKD) population. CKD patients are more likely to die from CVD before ever reaching end-stage renal disease (ESRD). The study, therefore, seeks to identify the prevalence of risk factors of CVD in CKD patients such as systemic hypertension, anemia, dyslipidemia, hypoalbuminemia, albuminuria, and abnormal calcium/phosphate products. METHODS: The study was a case-control cross-sectional study where one hundred fifty hypertensive CKD patients and age- and sex-matched hypertensive non-CKD subjects were consecutively enrolled at the renal unit of Delta State University Teaching Hospital (DELSUTH), Oghara. RESULTS: The findings of the study revealed the mean ages of cases and controls to be 48.91±11.93 years and 51.0±15.45 years respectively (p-value 0.182). There was an equal number of males and females among the study group and controls (92 males and 58 females) making a male-to-female ratio of 3:2. The prevalence of CVD risk factors such as diabetes mellitus, hypercholesterolemia, hypertriglyceridemia, elevated low-density lipoprotein, anemia, hypocalcemia, hyperphosphatemia, albuminuria, and hypoalbuminemia was significantly higher among the CKD group compared to controls. Similarly, the prevalence of reduced high-density lipoprotein (HDL) was higher among cases than controls, the difference was however not statistically significant. CONCLUSION: The study has shown that systemic hypertension, diabetes, anemia, dyslipidemia, hypoalbuminemia, albuminuria, and abnormal calcium/phosphate products increases the risk for CVD in the general population but is more expressed and significant in CKD patients.

Association between serum iron markers, iron supplementation and cardiovascular morbidity in pre-dialysis chronic kidney disease.

BACKGROUND: The optimal range of serum iron markers and usefulness of iron supplementation are uncertain in patients with pre-dialysis chronic kidney disease (CKD). We investigated the association between serum iron indices and risk of cardiovascular disease (CVD) events and the effectiveness of iron supplementation using Chronic Kidney Disease Japan Cohort data. METHODS: We included 1416 patients ages 20-75 years with pre-dialysis CKD. The tested exposures were serum transferrin saturation and serum ferritin levels and the outcome measures were any cardiovascular event. Fine-Gray subdistribution hazard models were used to examine the association between serum iron indices and time to events. The multivariable fractional polynomial interaction approach was used to evaluate whether serum iron indices were effect modifiers of the association between iron supplementation and cardiovascular events. RESULTS: The overall incidence rate of CVD events for a median of 4.12 years was 26.7 events/1000 person-years. Patients with serum transferrin saturation <20% demonstrated an increased risk of CVD [subdistribution hazard ratio (HR) 2.13] and congestive heart failure (subdistribution HR 2.42). The magnitude of reduction in CVD risk with iron supplementation was greater in patients with lower transferrin saturations (P = .042). CONCLUSIONS: Maintaining transferrin saturation >20% and adequate iron supplementation may effectively reduce the risk of CVD events in patients with pre-dialysis CKD.

Revealing the Connection Between Hemodialysis and Sexual Physiology in Women With End-Stage Renal Disease.

INTRODUCTION: In the recent past, the procedure of hemodialysis has frequently been opted for patients with end-stage renal disease (ESRD) around the globe. In such patients, the concern of sexual dysfunction is highly prevalent, which causes psychological as well as social deterioration in these patients. Wretchedly, this issue has been ignored in developing countries like Pakistan because of social and cultural constraints.  Objectives: The aim was to measure and compare Female Sexual Functions of Dialysis (FSFI) scores among three comparative groups: healthy controls, pre-dialysis patients, and hemodialysis patients. METHODS: A comparative cross-sectional study was carried out with 60 females aged 22-50 years in which 20 were healthy (controls) and 40 were patients with ESRD; of these 40, 20 were taking only oral medicines (pre-dialysis) and 20 were also receiving hemodialysis (hemodialysis). Married women who could read Urdu and were living with live spouses were included, and those with any psychological or psychiatric illness were excluded. Data was collected through a Likert-scaled questionnaire, Urdu translation of the FSFI questionnaire, and scores of each domain were analyzed. Single-tail one-way ANOVA was used to observe the significant difference among the three comparative groups. RESULTS: A strong statistical difference was observed among the hemodialysis, pre-dialysis, and healthy control groups when these three study groups were compared for the mean scores of all related domains of FSFI questtionarie. In each female sexual domain, i.e. Desire, Arousal, Lubrication, Orgasm, Satisfaction, and Pain, the diseased groups (pre-dialysis and hemodialysis) showed lower sexual scores than the healthy group. The lowest scores were observed in the pre-dialysis group (16.4 ± 6.8) and the highest were noticed in the healthy group (29.9 ± 1.8); the hemodialysis group (23.3 ± 5.0) expressed a moderate pattern of scores in each sexual domain. CONCLUSION: ESRD female patients who were receiving hemodialysis along with routine oral medications showed improved sexual physiology (with better FSFI scores) compared to those who were without hemodialysis.