Our research broadens the knowledge of kidney disease.

Cirrhosis and Severe Acute Respiratory Syndrome Coronavirus 2 Infection in US Veterans: Risk of Infection, Hospitalization, Ventilation, and Mortality

George N. Ioannou, Peter S. Liang, Emily Locke, Pamela Green, Kristin Berry, Ann M. O’Hare, Javeed A. Shah, Kristina Crothers, McKenna C. Eastment, Vincent S. Fan, Jason A. Dominitz

Background and Aims: Whether patients with cirrhosis have an increased risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the extent to which infection and cirrhosis increase the risk of adverse patient outcomes remain unclear. Approach and Results: We identified 88,747 patients tested for SARS-CoV-2 between March 1, 2020, and May 14, 2020, in the Veterans Affairs (VA) national health care system, including 75,315 with no cirrhosis–SARS-CoV-2-negative (C0-S0), 9,826 with no cirrhosis–SARS-CoV-2-positive (C0-S1), 3,301 with cirrhosis–SARS-CoV-2-negative (C1-S0), and 305 with cirrhosis–SARS-CoV-2-positive (C1-S1). Patients were followed through June 22, 2020. Hospitalization, mechanical ventilation, and death were modeled in time-to-event analyses using Cox proportional hazards regression.

Randomized, Placebo-Controlled Trial of Rifaximin Therapy for Lowering Gut-Derived Cardiovascular Toxins and Inflammation in CKD

Cassandra Kimber, Shiqin Zhang, Cassandra Johnson, Raymond E. West, III, Alexander J. Prokopienko, Jonathan D. Mahnken, Alan S. Yu, Andrew N. Hoofnagle, Diana Ir, Charles E. Robertson, Makoto Miyazaki, Michel Chonchol, Anna Jovanovich, Bryan Kestenbaum, Daniel N. Frank, Thomas D. Nolin, Jason R. Stubbs

Recent evidence suggests the systemic accumulation of by-products of gut microbes contributes to cardiovascular morbidity in patients with CKD. Limiting the generation of toxic bacterial by-products by manipulating the intestinal microbiota may be a novel strategy for reducing cardiovascular disease in CKD. Rifaximin is a minimally absorbed, oral antibiotic that targets intestinal pathogens and is commonly used as chronic therapy for the prevention of encephalopathy in patients with cirrhosis.

Achieved blood pressure post-acute kidney injury and risk of adverse outcomes after AKI: A prospective parallel cohort study

Ian McCoy, Sandeep Brar, Kathleen D. Liu, Alan S. Go, Raymond K. Hsu, Vernon M. Chinchilli, Steven G. Coca, Amit X. Garg, Jonathan Himmelfarb, T. Alp Ikizler, James Kaufman, Paul L. Kimmel, Julie B. Lewis, Chirag R. Parikh, Edward D. Siew, Lorraine B. Ware, Hui Zeng & Chi-yuan Hsu for the Assessment, Serial Evaluation, and Subsequent Sequelae in Acute Kidney Injury (ASSESS-AKI) study investigators

There has recently been considerable interest in better understanding how blood pressure should be managed after an episode of hospitalized AKI, but there are scant data regarding the associations between blood pressure measured after AKI and subsequent adverse outcomes. We hypothesized that among AKI survivors, higher blood pressure measured three months after hospital discharge would be associated with worse outcomes. We also hypothesized these associations between blood pressure and outcomes would be similar among those who survived non-AKI hospitalizations.

Prevention of Urinary Stones With Hydration (PUSH): Design and Rationale of a Clinical Trial

Charles D Scales Jr, Alana C Desai, Jonathan D Harper, H Henry Lai, Naim M Maalouf, Peter P Reese, Gregory E Tasian, Hussein R Al-Khalidi, Ziya Kirkali, Hunter Wessells, Urinary Stone Disease Research Network, including Sandra Amaral, Janet Audrain-McGovern, Brittney Henderson, Kristen Koepsell, Adam Mussell, Jodi A Antonelli, Linda A Baker, Joyce Obiaro, Cynthia Rangel, Martinez Hill, Madeline Worsham, Fionnuala Cormack, Mathew Sorensen, Karyn Yonekawa, Holly Covert, Tristan Baxter, Elsa Ayala, Vincent Mellnick, Douglas Coplen, Juanita Taylor, Aleksandra Klim, Deborah Ksiazek, Sri Sivalingam, Katherine Dell, Juan Calle, Paige Gotwald, Marina Markovic, John Lieske, Andrew Rule, Stephen Erickson, Aaron Potrezke, Andrea Ferrero, David Sas, Angela Waits, Courtney Lenort, Kevin Weinfurt, Hayden Bosworth, Honqiu Yang, Laura Johnson, Angela Venetta, Omar Thompson

Rationale & objective: Although maintaining high fluid intake is an effective low-risk intervention for the secondary prevention of urinary stone disease, many patients with stones do not increase their fluid intake. Study design: We describe the rationale and design of the Prevention of Urinary Stones With Hydration (PUSH) Study, a randomized trial of a multicomponent behavioral intervention program to increase and maintain high fluid intake. Participants are randomly assigned (1:1 ratio) to the intervention or control arm. The target sample size is 1,642 participants. Setting & participants: Adults and adolescents 12 years and older with a symptomatic stone history and low urine volume are eligible. Exclusion criteria include infectious or monogenic causes of urinary stone disease and comorbid conditions precluding increased fluid intake.

The failing kidney allograft: A review and recommendations for the care and management of a complex group of patients

Michelle Lubetzky, Ekamol Tantisattamo, Miklos Z. Molnar, Krista L. Lentine, Arpita Basu, Ronald F. Parsons, Kenneth J. Woodside, Martha Pavlakis, Christopher D. Blosser, Neeraj Singh, Beatrice P. Concepcion, Deborah Adey, Gaurav Gupta, Arman Faravardeh, Edward Kraus, Song Ong, Leonardo V. Riella, John Friedewald, Alex Wiseman, Amtul Aala, Darshana M. Dadhania, Tarek Alhamad

The return to dialysis after allograft failure is associated with increased morbidity and mortality. This transition is made more complex by the rising numbers of patients who seek repeat transplantation and therefore may have indications for remaining on low levels of immunosuppression, despite the potential increased morbidity. Management strategies vary across providers, driven by limited data on how to transition off immunosuppression as the allograft fails and a paucity of randomized controlled trials to support one approach over another. In this review, we summarize the current data available for management and care of the failing allograft. Additionally, we discuss a suggested plan for immunosuppression weaning based upon the availability of re-transplantation and residual allograft function. We propose a shared-care model in which there is improved coordination between transplant providers and general nephrologists so that immunosuppression management and preparation for renal replacement therapy and/or repeat transplantation can be conducted with the goal of improved outcomes and decreased morbidity in this vulnerable patient group.

Upper Reference Limits for High-Sensitivity Cardiac Troponin T and N-Terminal Fragment of the Prohormone Brain Natriuretic Peptide in Patients With CKD

Nisha Bansal, Leila Zelnick,Christie Ballantyne, Paulo Chaves, Robert Christenson, Joseph Coresh, Chrisde Filippi, James de Lemos, Lori Daniels, Alan S. Go, Jiang He, Susan Heydati, Kuni Matsushita, Vijay Nambi, Michae Shlipak, Jonathan Taliercio, Stephen Seliger, on behalf of the CRIC Study Investigators

The utility of conventional upper reference limits (URL) for N-terminal pro brain natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T (hsTnT) in chronic kidney disease (CKD) remains debated. We analyzed the distribution of hsTnT and NT-proBNP in people with CKD in ambulatory settings to examine the diagnostic value of conventional URL in this population.

Chronic Kidney Disease Rescuing kidney patients from early demise: Role of anti-cytokine therapies

T. Alp Ikizler, Jonathan Himmelfarb

Biomarkers of the inflammatory state are elevated in individuals with chronic kidney disease (CKD) and are also robust predictors of cardiovascular disease (CVD) and mortality in this population. In addition to its predictive ability, inflammation has been implicated in the pathogenesis of atherosclerotic CVD, primarily through NLRP3 inflammasome and interleukin-1 (IL-1) and interleukin-6 (IL-6) signaling pathways. Based on these data, it has been suggested that ameliorating the inflammatory response through anti-cytokine therapies could improve CVD risk factors and potentially survival in CKD. A recent clinical trial published in the Lancet evaluated the effect of targeting IL-6 in patients with CKD. What did the study show?

Supporting Real-Time Ethical Deliberation in Contingency Capacity During the COVID-19 Pandemic

Catherine R. Butler, Mark R Tonelli

 

The reality of resource limitation during the Coronavirus Disease 2019 (COVID-19) pandemic has deeply challenged established approaches to healthcare system emergency response. Early preparation during the pandemic focused on defining algorithms to ration life-saving resources in crisis capacity settings when person-centered decision-making must give way to population-level priorities (Committee on Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations, and Institute of Medicine 2012; Emanuel et al. 2020). Thus far, few regions of the US have formally declared crisis capacity. Rather, healthcare resource availability has been characterized by a drawn-out and dynamic intermediate state between “usual” and “crisis” capacity.

Supporting the Employment Goals of People With Kidney Disease

In this issue of AJKD, van der Mei et al share insights gained from their qualitative study of barriers and facilitators of employment among 27 working-age people with kidney disease receiving care in nephrology, dialysis, and transplant clinics in the Netherlands who were interviewed between 2015 and 2019. What emerges from their analysis of interview transcripts and recordings is an appreciation for the complex, dynamic, and multifaceted relationship between kidney disease and employment. Their study shows that the ability of patients with kidney disease to work depends not only on their motivation to do so and the type of treatment they are receiving (eg, transplant, peritoneal dialysis, or hemodialysis) but also on a wide range of other factors.

Risk factors for adverse outcomes among 35 879 veterans with and without diabetes after diagnosis with COVID-19

Pandora L Wander, Elliott Lowy, Lauren A Beste, Luis Tulloch-Palomino, Anna Korpak, Alexander C Peterson, Bessie A Young, Edward J Boyko

Introduction: Risk factors and mediators of associations of diabetes with COVID-19 outcomes are unclear. Research design and methods: We identified all veterans receiving Department of Veterans Affairs healthcare with ≥1 positive nasal swab for SARS-CoV-2 (28 February–31 July 2020; n=35 879). We assessed associations of diabetes (with and without insulin use) with hospitalization, intensive care unit (ICU) admission, or death at 30 days, and with hazard of death until the censoring date. Among participants with diabetes (n=13 863), we examined associations of hemoglobin A1c and antihyperglycemic medication use with COVID-19 outcomes. We estimated mediation between diabetes and outcomes by comorbidities (cardiovascular disease, heart failure, and chronic kidney disease), statin or ACE inhibitor/angiotensin receptor blocker (ARB) use, and cardiac biomarkers (brain natriuretic peptide and troponin).