BMC Nephrology

BackgroundMuscle impairment in chronic kidney disease (CKD) contributes to decreased physical performance, frailty, and higher mortality risk. Regular exercise improves muscle function in CKD. This pilot randomized controlled study evaluated the efficacy of a home-based, video-supervised exercise program on muscle function and physical endurance in CKD. MethodsSedentary adults (n=32) with moderate-to-severe nondialysis CKD (eGFR <60 mL/min/1.73m2) were randomized to 12 weeks of moderately intense home-based, video-supervised exercise or usual care. Co-primary outcomes included in-vivo muscle mitochondrial bioenergetics (rate of phosphocreatine [PCr] recovery, kPCr) using phosphorus-31 (31P) magnetic resonance spectroscopy and work efficiency using graded cycle exercise testing. Secondary outcomes included 6-minute walk distance test (6MWD), total work, and peak oxygen consumption (VO2peak). Other outcomes were body composition measures and plasma cytokines. Linear mixed models estimated between-group differences. ResultsParticipants included 23 exercisers (EX) and nine in usual care (UC), with mean (SD) ages of 62.6 (10.8) and 67.2 (8.2) years, and eGFRs of 35.0 (12.6) and 32.3 (12) mL/min/1.73m2, respectively. No serious adverse events occurred; 90.5% of EX completed [&ge;]75% of sessions. Compared to UC, EX resulted significantly increased in-vivo muscle mitochondrial bioenergetics (0.20min-1, 95%CI [0.05,0.35], P=0.01), total work (5.03kJ, 95%CI [1.25,8.80], P=0.007), and 6MWD (39.1m, 95%CI [7.1,71.1], P=0.014). EX preserved fat-free mass (2.23kg, 95%CI [0.46, 4.0], P=0.011) and marginally decreased fat mass (-2.05kg, 95%CI [-4.5, 0.37], P=0.087) compared to UC. IL-8 concentration differed most between EX vs. UC (effect size -1.23, 95%CI [-0.67, -0.02], P=0.016). Differences in IL-6, TNF-, IL-1{beta}, IL-10, VO2peak and work efficiency were non-significant between groups. ConclusionsAmong adults with stage 3-5 CKD, 12-weeks of moderately intense home-based video-supervised, personalized exercise is feasible and improves muscle oxidative capacity and physical endurance. By addressing common barriers to exercise, such exercise protocols could help mitigate the functional decline and frailty associated with CKD. Key PointsO_LIA home-based video-supervised exercise program was feasible with a high level of adherence in nondialysis chronic kidney disease (CKD). C_LIO_LIA 12-week moderately intense home-based exercise program improved muscle mitochondria oxidative capacity and physical endurance in nondialysis CKD. C_LIO_LIAddressing common barriers to exercise could help mitigate the functional decline and frailty associated with CKD. C_LI

Physical inactivity is common in chronic kidney disease (CKD) and is associated with poor neuromuscular and functional outcomes. Whether habitual physical activity (PA) influences adaptations to structured exercise in CKD remains unclear. This study examined if adaptations to combined flywheel resistance and aerobic exercise (FRE+AE) differed based on self-reported PA in Veterans with CKD stages 3 and 4. Twenty older male Veterans with CKD stages 3-4 (mean eGFR 37.9 +/- 10.2 mL/min/1.73 m2) were randomized to six weeks of FRE+AE (n=11) or health education (EDU; n=9). Participants were classified as meeting (Meets PA) or below (Low PA) weekly moderate intensity PA recommendations using the 7-day Physical Activity Recall. Outcomes included vastus lateralis muscle thickness (VL MT), knee extensor power output (60/s and 180/s), gait speed (GS), and five-repetition sit-to-stand (STS). FRE+AE increased VL MT (p=0.030), power output at 180/s (p=0.021), GS (p=0.001), and reduced STS time (p=0.012), with significant between-group differences versus EDU for VL MT (p=0.009) and GS (p=0.028). Low PA experienced greater increases in power output at 60/s (Hedges g; Low PA=0.44, Meets PA=0.25) and 180/s (Hedges g; Low PA=1.38, Meets PA=0.38) compared to Meets PA after FRE+AE. Conversely, Meets PA had greater improvements in GS (Hedges g; Low PA=0.93, Meets PA=1.29) and STS (Hedges g; Low PA=-0.72, Meets PA=-2.20) compared to Low PA. Six weeks of FRE+AE produced clinically meaningful neuromuscular and functional improvements in Veterans with CKD stages 3 and 4 irrespective of PA level, supporting FRE+AE as a feasible intervention in this population.

BackgroundPatient activation, defined as the knowledge, skills, and confidence to manage ones health, is associated with better outcomes in chronic disease. However, evidence on interventions that improve activation in people with end-stage kidney disease on hemodialysis remains limited. Methods and analysisThis single-centre, prospective, participant-blinded, randomised controlled trial conducted with adults undergoing chronic hemodialysis in an acute dialysis unit tests the hypothesis that adding tailored activation interventions to usual care improves patient activation and reduces complications in hemodialysis patients compared to usual care alone. A target sample size of 140 patients was recruited and randomised to iPAD interventions or usual care in a 1:1 ratio with an expected intervention period of at least 6 months. The primary outcome of iPAD was change in patient activation from baseline to 18 months. Ethics and disseminationThis study has been approved by all institutional ethics review boards involved in the study. Participants could only be enrolled following informed written consent. Results will be published in peer-reviewed journals and presented at scientific and clinical conferences. ConclusionRecruitment and enrolment targets were successfully achieved, with the cohort broadly representative of the dialysis population, including strong participation from culturally and linguistically diverse and socioeconomically disadvantaged groups. The careful planning and successful execution of the study in resource-constrained environments highlight its feasibility and flexibility, establishing it as a scalable and cost-efficient model for broad implementation in dialysis care globally.

AimTo evaluate the association between monocyte-to-lymphocyte ratio (MLR) and cardiovascular outcomes in chronic kidney disease (CKD). MethodsWe systematically searched Medline, EMBASE, Web of Science, and Scopus from inception to May 28, 2025. We included peer-reviewed observational studies assessing MLR and cardiovascular outcomes or all-cause death in CKD. Two reviewers independently screened studies, extracted data, and assessed risk of bias using the Newcastle-Ottawa Scale. Findings were narratively synthesized and p-values pooled using Fishers method. Statistical significance was set at p < 0.05. ResultsEleven studies (n = 18,631) met our inclusion criteria. The study population ranged from non-dialysis CKD to end-stage kidney disease on dialysis, with follow-up from 1 to 24 months. Five studies (n = 16,974) examined cardiovascular death and generally reported significant associations with elevated MLR; Fishers method indicated strong overall evidence (p < 0.001). Six studies (n = 4,587) assessed cardiovascular events, yielding inconsistent findings, although some reported significant associations and identified predictive thresholds (e.g., 0.43). Five studies (n = 15,682) showed increased risk of all-cause death with increasing MLR and a predictive threshold of 0.63. Fishers method again supported strong overall evidence (p < 0.001). All except one of the eleven studies were rated as good quality. ConclusionElevated MLR could predict cardiovascular and all-cause death in CKD. Evidence for cardiovascular events remains inconsistent, and thresholds proposed in individual studies may not be generalizable. Large-scale, multi-ethnic, and prospective studies with standardized protocols are needed to validate MLRs role in cardiovascular risk stratification.

ObjectiveThe objective of this scoping review is to describe how exercise has been prescribed for hemodialysis patients. IntroductionExercise interventions have received more attention from the nephrology community in the last few years. Despite some limitations in the findings, there is currently robust evidence suggesting that exercise is clinically important and provides benefits to hemodialysis patients. Even so, there is little evidence precisely detailing and describing how exercise can be prescribed and delivered for this population. Inclusion criteriaBased on the PCC framework, we will review and include evidence from hemodialysis patients (Participants); describing exercise interventions (Concept); in all settings and designs (Context). The evidence that included any other kidney replacement therapy other than hemodialysis will be excluded. MethodsThis review will follow the JBI methodology for scoping reviews and the PRISMA-ScR. We will perform a comprehensive literature search using MEDLINE, EMBASE, SPORTDiscuss, CINAHL, and LILACS databases without date or language restrictions from inception until December 2021. Websites, books, and guidelines from prominent societies and associations will also be searched. Experimental, quasi-experimental, observational, and protocol evidence from adults with chronic kidney disease ([&ge;]18 years) undergoing hemodialysis that prescribed exercise as an intervention will be considered. Two independent reviewers will screen title and abstract and perform the full-text review. Data extraction will be done by the main reviewer and checked by a second reviewer. Data characterizing the exercise interventions (e.g., type, setting, frequency, duration, intensity, volume, progression, periodization, professionals involved, etc.) will be extracted from selected evidence. The qualitative and quantitative results will be synthesized and presented in tables and figures along with a narrative summary.

BackgroundLife-sustaining hemodialysis (HD) is onerous for patients, especially those with multiple co-morbidities and advanced age. A standard HD prescription is 720 minutes per week. Alternative HD regiments have been proposed in attempt to maintain quality of life (QOL). Studies are needed to investigate the efficacy and safety of less frequent HD prescriptions in this population. This is an institution-wide observational study in New Brunswick, Canada to compare HD prescriptions and the impact on QOL and mortality. ObjectiveThe purpose of this study is to assess the current HD prescribing practices at a provincial healthcare institution in relation to patient QOL. DesignProspective Observational Study. SettingSingle centre hospital and satellite hemodialysis units. PatientsVoluntarily consented patients undergoing in-centre hemodialysis treatment. MeasurementsObservational clinical data was collected for each study participant from their hospital and dialysis electronic medical records. The KDQOL-36TM questionnaire was used to assess patient-reported quality of life at the time of consent. MethodsAdults undergoing in-centre or satellite site HD for at least 3 months were eligible to participate. Consenting patient participants were grouped by HD prescription whether they were prescribed 720 minutes or more per week or less than 720 minutes per week. All participants completed the KDQOL-36 TM questionnaire to estimate QOL and groups were compared using the Mann-Whitney U statistical test. Emergency department visits, hospitalizations, and mortality were analyzed using a negative binomial regression or a logistic regression. ResultsWe enrolled 140 patient participants; 41 were undergoing less than 720 minutes per week of HD and 99 were undergoing 720 minutes or more of HD per week. Patients who were undergoing less than 720 minutes per week of HD were older [Median (IQR): 76 (72- 81) yrs. vs. 64 (55 - 75) yrs.; p < 0.001], had higher median (IQR) QOL scores on the Symptoms/ Problems List scale on the KDQOL-36 TM questionnaire [79.2 (70.8 - 88.5 vs. 70.8 (62.5 - 81.3); p = 0.0022], and were less likely to present to the emergency department (incident rate ratio 0.52, 95% confidence interval [CI] 0.33-0.81). Mortality was similar between groups, even when adjusted for age and comorbidity score (odds ratio 1.62, 95% CI 0.59-4.49). LimitationsPatient participant enrollment was limited by the single centre nature of this study. As this was an observational study, we did not account for how long the patients had been prescribed less than 720 minutes of hemodialysis. We did not include a frailty assessment of the study participants. A higher number of study participants may have identified significant trends in mortality. ConclusionsThe results of this study show that patients undergoing less than 720 minutes of weekly HD had a higher QOL score for the KDQOL-36 TM Symptoms/ Problems List scale, were less frequently in the emergency department and were not more likely to die than patients undergoing 720 minutes or more of weekly HD. Further studies are required to assess the feasibility and safety of a conservative model of HD prescribing to improve QOL of patients with palliative care treatment goals.

BackgroundChronic kidney disease (CKD) is associated with an increased risk for cardiovascular events, hospitalizations or mortality. In populations aged [&ge;]40 years, CKD is as prevalent as diabetes or coronary heart disease. Awareness for CKD though is generally low in public, patients and physicians, which hinders early diagnosis and treatment to decelerate disease progress. MethodWe analyzed baseline data collected in 2010 from 3,334 participants with CKD stages 1-5 from German CKD cohorts and registries. CKD unawareness and 95%-confidence intervals (CI) was estimated according to patients answer to the question whether they had ever been told to suffer from a CKD. Prevalence ratios (PR) with 95%-CI were estimated in categories of age, sex, CKD stages, BMI, hypertension, diabetes and other relevant comorbidities. ResultsCKD unawareness was high, reaching 82% (95% CI: 80%-84%) for CKD stages 1 or 2, 71% (68%-73%) in CKD 3a, 49% (45%-54%) in CKD 3b and still 30% (24%-36%) in CKD4, in each stage increasing with age. CKD unawareness was similarly high in patients with hypertension, diabetes or cardiovascular comorbidities. Women were more often unaware than men (PR=1.07 (1.02;1.12)), this sex difference increased with increasing CKD stage. Macroalbuminuria (PR=0.90 (0.82; 1.00)), anemia (PR=0.78 (0.73; 0.83)) and BMI [&ge;]40 (PR=0.88 (0.77; 1.00)) were associated with higher CKD awareness. ConclusionEven in older patients or in patients with comorbidities, CKD unawareness was high. Sex differences were largest in later stages. Guideline oriented treatment of patients with hypertension or diabetes could increase awareness. Patient-physician communication about CKD might be amendable.

IntroductionLifestyle interventions have been shown to produce favorable changes in some health outcomes in patients with chronic kidney disease (CKD). However, few such studies, employing "real world" methods have been completed in patients with CKD. ObjectiveThis study tested the effectiveness of a comprehensive, multicomponent, lifestyle intervention, delivered through individualized counseling on a variety of health outcomes in pre-dialysis CKD patients. MethodsEligible patients were assigned randomly to the intervention (TR) or usual care group (UC). A six-month home-based program involving personalized counseling to increase physical activity to recommended levels among stage G3a to G4 CKD patients while exchanging plant proteins for animal proteins was implemented. Physical function, cardiovascular function, dietary intake, medication use, and health-related quality of life (HRQOL) were assessed at baseline and after 1-month, 3-months (M3) and 6-months (M6). ResultsForty-two, patients (age 60.2 {+/-} 9.2, BMI 34.5 {+/-} 7.8) participated in this study (TR=27 UC=15). The intervention reduced (p<0.05) brachial (bSBP) and central systolic blood pressures (cSBP) at month 3 (M3) but both were attenuated at month 6 (M6). Scores on the effect of kidney disease subscale of the HRQOL measure improved in the intervention group at M3 and M6. There was no change in the other measures of HRQOL or in any physical function scores. ConclusionsThis personalized multi-component lifestyle intervention enabled CKD patients to self-report fewer concerns with how CKD affected their daily lives independent of changes in physical function.

ImportanceFrailty is common among dialysis patients and significantly affects the quality of life for both patients and their caregivers. However, limited evidence exists on the long- term changes in physical function in this population. ObjectiveTo examine 8-year trajectories of physical function and assess associations with baseline dialysis duration and physical function status among Japanese dialysis patients. DesignNationwide, cohort study. SettingJapan; data obtained from a registry. Participants223,501 Japanese adults receiving hemodialysis enrolled in the 2010 Japanese Society for Dialysis Therapy Renal Data Registry. ExposuresBaseline dialysis duration (<5, 5-<10, 10-<20, 20-<30, [&ge;]30 years) and physical function were assessed using the Eastern Cooperative Oncology Group Performance Status, categorized as non-frail, frail, or bedridden. Main Outcomes and MeasuresPhysical function at 8 years was similarly classified as non- frail, frail, bedridden, or deceased. Multinomial logistic regression was used to estimate adjusted odds ratios, average marginal effects, and predicted probabilities based on baseline exposures. ResultsAmong patients with complete baseline and 8-year follow-up data, 59.9% died, 8.8% became frail, 2.4% were bedridden, and 28.9% remained non-frail. Longer dialysis duration and baseline frailty or bedridden status were associated with increased odds of subsequent frailty, bedridden status, and mortality. Compared with patients with <5 years of dialysis, those with [&ge;]30 years had a 1.6% (95% confidence interval, 0.6%-2.6%) higher probability of frailty and a 13.0% (95% confidence interval, 11.8%-14.3%) higher probability of death. Compared with non-frail status at baseline, frailty was associated with a 0.0% (95% confidence interval, -0.4% to 0.4%) change in frailty and a 15.8% (95% confidence interval, 14.5%-17.0%) increase in death; bedridden status was associated with a 1.7% (95% confidence interval, 1.1%-2.3%) increase in being bedridden and a 27.6% (95% confidence interval, 26.5%-28.8%) increase in death. Conclusions and RelevanceIn this nationwide 8-year study, majority of the hemodialysis patients experienced either death or functional decline. Longer dialysis duration and baseline frailty were associated with adverse outcomes, although absolute increases in frailty were modest. These findings highlight the need for early, values-based shared decision-making in the management of dialysis patients.

Rationale & ObjectivePerson-centered care (PCC), which incorporates patients preferences and values not only for medical care but also for their life, in decision making has been proposed for promoting advance care planning (ACP) among patients with kidney failure. However, how variations in PCC affect ACP participation remain unclear. Therefore, we examined variations in PCC across facilities and examined the association between PCC and ACP participation. Study DesignMulticenter cross-sectional study. Setting & ParticipantsJapanese adults receiving outpatient hemodialysis at six dialysis centers. ExposuresPCC was measured using the 13-item Japanese version of the Primary Care Assessment Tool-short form. OutcomeACP participation as defined by discussion with the attending physician or written documentation or notes regarding treatment preferences. Analytical ApproachA general linear model was used to examine the correlates of the quality of PCC. Modified Poisson regression models were used to examine the associations of ACP participation. ResultsA total of 453 individuals were analyzed; 26.3% participated in ACP. Compared to respondents with no usual source of care (USC), higher PCC was associated with greater ACP participation in a dose-response manner (vs. no USC, adjusted prevalence ratios for the first to fourth quartiles: 1.36, 2.31, 2.64, and 3.10, respectively). Among the PCC sub-domains, first contact, longitudinality, comprehensiveness (services provided), and community orientation were particularly associated with ACP participation. There was a maximum of 12.0 points of facility variation in the quality of PCC. LimitationsPossible reverse causation and unmeasured confounders. ConclusionsHigh PCC quality was associated with ACP participation. The substantial disparity in PCC between facilities provides an opportunity to revisit the quality improvement in PCC.

BackgroundThe effect of dialysis modality on the survival of end-stage renal disease patients is a major public health interest. MethodsIn this retrospective cohort study, all adult end-stage renal disease patients receiving dialysis treatment in Sabah between January 1, 2007 and December 31, 2017 as identified from the Malaysian Dialysis and Transplant Registry were evaluated and followed up through December 31, 2018. The endpoint was all-cause mortality. The observation time was defined as the time from the date of dialysis initiation after the onset of end-stage renal disease to whichever of the following that came first: date of death, date of transplantation, date of last follow-up, date of recovered kidney function, or December 31, 2018. Weighted Cox regression was used to estimate the effect of dialysis modality. Analyses were restricted to patients with complete data on all variables. Results1,837 patients began hemodialysis and 156 patients started with peritoneal dialysis, yielding 7,548.10 (potential median 5.48 years/person) and 747.98 (potential median 5.68 years/person) person-years of observation. 3.1% of patients were lost to follow-up. The median survival time was 5.8 years (95% confidence interval: 5.4, 6.3) among patients who started on hemodialysis and 7.0 years (95% confidence interval: 5.9, indeterminate) among those who started on peritoneal dialysis. The effect of dialysis modality was not significant after controlling for confounders. The average hazard ratio was 0.80 (95% confidence interval: 0.61, 1.05) with hemodialysis as a reference. ConclusionThere was no evidence of a difference in mortality between hemodialysis and peritoneal dialysis.

IntroductionThe global prevalence of chronic kidney disease (CKD) is rising and initial studies suggest that diets predominantly based on greater inclusion of plant foods may be associated with lower CKD risk. As population-based studies are lacking, we investigated the association between habitual plant-based diets and CKD in the UK Biobank cohort. MethodsThe UK Biobank is a large prospective cohort study of participants aged 40-69 years. Habitual diet was assessed using a baseline food frequency questionnaire, and participants were classified into five dietary groups: high meat eaters, low meat eaters, poultry eaters, pescatarians, and vegetarians. To assess the risk of CKD across these groups, we conducted multivariable Cox proportional hazard regression analyses. ResultsDuring follow up of 12.9 years 23,084 out of 416,584 developed CKD. Compared to high meat eaters, only vegetarians had a statistically significant lower risk of CKD [HR = 0.81, 95% CI: 0.71- 0.93]. ConclusionThis is the first population-based study on plant-based diet types and CKD risk. Our findings suggest that vegetarian diets are associated with a lower risk of CKD. Future research is needed to assess the feasibility and acceptability of plant-based diets for the prevention of CKD and other chronic diseases.

BackgroundLow Physical Activity (LPA) is a recognized risk factor for Chronic Kidney Disease (CKD). However, there is currently a lack of research reports addressing the global burden of CKD attributable to LPA. MethodsWe systematically described the burden of CKD attributable to LPA globally, regionally, and nationally using data from the Global Burden of Disease Study 2021. We examined the distribution by age, sex, and time trends. Furthermore, we conducted analyses on cross-national inequalities and frontier analysis. Additionally, we analyzed the distribution of CKD attributable to LPA burden among CKD subtypes. ResultsBetween 1990 and 2021, the burden of CKD attributable to LPA significantly increased, reaching 40,918.47 deaths in 2021, with an age-standardized mortality rate (ASMR) of 0.50 per 100,000 population, 913,068.96 DALYs, and an age-standardized DALYs (ASDR) of 10.81 per 100,000 population. Over the next decade, the global burden of CKD attributable to LPA is projected to continue to rise, with an estimated ASMR of 0.90 per 100,000 population and an ASDR of 11.56 per 100,000 population by 2031. The 85-89 age group had the highest number of deaths, while the 70-74 age group had the highest DALYs, with both ASMR and ASDR increasing with age. Inequalities in CKD burden attributable to LPA exist across different Socio-Demographic Index (SDI) regions, with the Middle SDI region bearing the heaviest burden, but opportunities to alleviate CKD burden exist at all SDI levels. Globally, the highest proportion of CKD attributable to LPA was in hypertensive and diabetic nephropathy. ConclusionsThe burden of CKD attributable to LPA is increasing worldwide and is expected to continue rising over the next decade. Inequalities in CKD burden attributable to LPA exist. Globally, the burden of CKD attributable to LPA is primarily distributed among type 2 diabetes and hypertensive nephropathy. These findings underscore the importance of promoting physical activity in controlling CKD burden, especially targeting high-risk populations and regions.

BackgroundChronic kidney disease (CKD) represents a growing public health challenge worldwide, particularly in low- and middle-income countries. In Brazil, where most patients with end-stage renal disease (ESRD) depend on the public healthcare system for dialysis and transplantation, ensuring adequate vascular access - among the options arteriovenous fistula (AVF) - is critical to sustaining treatment. Despite its clinical relevance, comprehensive national data on vascular access patterns across both public and private sectors have been historically limited. ObjectiveThis study aimed to examine trends in AVF confection for hemodialysis across Brazil from 2015 to 2023, assessing differences in frequency, geographic distribution and sectorial disparities between the public and the private healthcare sector. MethodsA retrospective population-based analysis was conducted using anonymized data from national administrative databases: DATASUS (public sector) and D-TISS (private sector). The majority of AVF confection procedures were included. Statistical analyses considered regional adjustments and were performed using SPSS v.20, with significance set at p < 0.001. ResultsOver the nine-year period, 376.383 AVF procedures were recorded, with 90,57% occurring in the public sector. While the absolute number of AVF confectioners increased, the ratio of AVFs per 1,000 dialysis patients showed a declining trend. Regional disparities were evident, with the Southeast and South regions presenting higher procedure rates compared to other areas. The private sector consistently reported lower confection rates. ConclusionAlthough, separately, dialysis and AVFs rates have risen steadily in Brazil, the relative rate between than has decreasing trend over the years. The predominance of AVF procedures in the public system maintains higher when compared with the private sector.

IntroductionCatastrophic bleeding can be fatal in patients on hemodialysis using Arteriovenous (AV) fistulas or grafts. Campaigns, such as the UK "Put a Lid On It" and the Australia "Stop the Bleed" have recommended use of bleeding cessation devices, but evidence for their use remains limited. Recent creation of the bleeding cessation device "Kidney-CAP" mandated further study. The objective of this study was to determine how the Kidney-CAP modified decisions related to vascular access, dialysis modality, and kidney transplantation. MethodsCross-sectional surveys were administered at a Canadian academic nephrology program, to health care providers (HCP) managing patients with chronic kidney disease (CKD), to patients on hemodialysis (CKD-HD), and to patients with CKD but not on dialysis (CKD-Clinic). Two tailed, one sample sign test was used to determine if the median response to Likert scale questions differed from "no effect" response, to a p-value of < 0.05. ResultsSurvey respondents included 18 HCP, 23 CKD-HD and 30 CKD-Clinic patients. Having a Kidney-CAP increased CKD-Clinic patients desire to undergo AVF or AVG creation (p=0.020). Having a Kidney-CAP had no impact on CKD-HD patients deside to undergo AVF creation, or to pursue hemodialysis at home, but increased desire to undergo kidney transplantation (p=0.031). Availability of the Kidney-CAP had no impact on HCP recommendations related to AVF creation or kidney transplantation, but increased HCP recommendations for home hemodialysis in ESKD patients (p=0.039 for each). ConclusionThis is the first study to assess the perceived benefit of a bleeding cessation device, with a focus on clinical decision making related to vascular access, kidney transplantation, and dialysis modality. The Kidney-CAP is associated with increased patient uptake of kidney transplantation and creation of AVF. Further study is required to delineate patient decisions within demographic subgroups such as previous kidney transplant, or anticoagulation status.

IntroductionJamaica has a high attributable burden of chronic kidney disease (CKD) but no population-based prevalence estimates. We aimed to estimate the prevalence of CKD and explore associated factors. MethodsA secondary analysis of data from Jamaican residents aged [&ge;]15 years from the nationally representative Jamaica Health and Lifestyle Survey-III was performed. CKD was defined as an estimated glomerular filtration rate (eGFR) <60mL/min/1.73 m2, using the CKD Epidemiology Collaboration (CKD-EPI) 2021 or Schwartz-Lyon equations, and/or albuminuria [&ge;]30 mg/g. Associated factors included age, sex, socio-economic status, education level, body mass index, hypertension, diabetes mellitus, and sickle cell trait. Weighted prevalence estimates were determined accounting for survey design. Multivariable logistic regression was used to evaluate CKD associations. ResultsAnalyses included 583 participants, 217 males, mean {+/-}SD age was 49.0 {+/-} 18.2 years. CKD prevalence was 14.8% [95%CI: 11.5%-18.9%]. Seven percent (7.2% [95%CI: 5.1%-10.1%]) had CKD Stage 3 or higher and 8.8% [95%CI:6.3%-12.0%] had albuminuria. CKD participants were older (mean age 57 versus 46.3 years, p<0.001), had higher mean systolic blood pressure (140.3 mmHg versus 128.3 mmHg, p<0.001), and fasting glucose (6.7 micromoles/L versus 5.8 micromoles/L, p<0.001). In a multivariable regression model, hypertension (OR 2.14, 95%CI: 1.22-3.75), diabetes mellitus (OR 2.39, 95%CI: 1.36-4.19) were associated with CKD. Higher education level was inversely associated with CKD, (OR 0.47, 95%CI:0.25-0.89) and (OR 0.41, 95CI: 0.18-0.96) for secondary and tertiary education respectively. ConclusionAn estimated 1 in 7 Jamaicans have CKD. This may translate to increased health care burden on the Jamaican health system.

Background and hypothesisIn patients with moderate or severe renal disease, hospitalization is often required because of poorly controlled co-morbidities. We aimed to provide evidence that an outpatient health program involving a close collaboration between nephrologists and General Practitioners can be successful in reducing hospitalizations in non-dialysis chronic kidney disease patients. MethodsObservational cohort study on 17,036 stage 1-5 chronic kidney disease patients enrolled in the Emilia-Romagna (Italy) PIRP project between 1st April 2004 and 31st December 2015, and their 70,560 hospitalizations registered in the four years preceding and following their enrolment in the project. Interrupted Time Series analysis was used to estimate hospitalizations trend summarized on 4-monthly basis. ResultsAmong patients who survived 4 years in non-dialysis chronic kidney disease condition, a 2.9% reduction in hospitalizations was observed in the four years following the enrolment in PIRP compared to the four years previously. The change in hospitalizations trend was estimated at -8.09 admission per 1,000 patients and 4-month period. This decrease was mainly accountable to hospitalizations whose main diagnoses at discharge were diseases of the circulatory system and the genitourinary system (-2.68 and -4.76 admissions per 1,000 patients respectively). Patients with heart failure and those with coronary artery disease displayed large reductions in hospitalization trend (-17.08 and -9.48 admissions per 1,000 patients respectively). A reduction of hospitalizations with similar magnitude was also observed for the advanced stages of CKD. ConclusionThe implementation of an integrated public health project that provides for the early management and continuity of care of CKD patients may be a way to reduce hospitalizations, particularly those related to cardiovascular and genitourinary diagnoses. Key learning pointsO_ST_ABSWhat was knownC_ST_ABSWith an integrated and structured program based on the collaboration between nephrologists and General Practitioners, it is possible to better control progression and comorbidity in CKD. This study addsBy continuously following CKD patients with a close collaboration between nephrologists and General Practitioners, hospitalizations can be reduced. Potential impactThe implementation of an integrated model of outpatient management of CKD patients like the PIRP might be beneficial also on hospitals organization and costs, and ultimately on patients quality of life. Graphical abstract O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=123 SRC="FIGDIR/small/25322544v1_ufig1.gif" ALT="Figure 1"> View larger version (50K): org.highwire.dtl.DTLVardef@8d63cforg.highwire.dtl.DTLVardef@93c911org.highwire.dtl.DTLVardef@7587b2org.highwire.dtl.DTLVardef@1fbe88_HPS_FORMAT_FIGEXP M_FIG C_FIG

Background and hypothesisFinancial toxicity (FT) refers not only to the difficulty in affording medical care but also to the psychological distress and perceived financial burden it imposes. Although dialysis in Japan is extensively covered by public insurance, little is known about the prevalence of FT and its effects on medication adherence. This study aimed to assess the prevalence of FT and examine its association with medication adherence among patients undergoing haemodialysis in Japan. MethodsThis multicentre, cross-sectional study included Japanese adults undergoing in-centre haemodialysis at six facilities. FT was assessed using the Comprehensive Score for Financial Toxicity (COST), and medication adherence was assessed using the 12-item Adherence Starts with Knowledge (ASK-12) scale. The COST scores were compared with published data from Japanese patients with cancer and patients undergoing dialysis from other countries using unpaired t-tests. Associations between the COST and ASK-12 scores were analysed using multivariate general linear models. ResultsIn total, 455 participants were included in the analysis. The mean COST score was 22.0, and 68% of the participants experienced at least mild FT. FT severity was comparable to that of Japanese patients with cancer and significantly lower than that reported among patients undergoing dialysis in Brazil and China. Lower FT (i.e., higher COST scores) was associated with fewer medication adherence difficulties (per 1-point higher: {beta} = -0.19). This association was particularly evident in the inconvenience/forgetfulness and behaviour subdomains (per 1-point higher: {beta} = -0.06 and {beta} = -0.08, respectively). ConclusionsDespite generous public coverage, FT is common among Japanese patients undergoing haemodialysis and is associated with difficulties in medication adherence. The awareness of hidden financial distress and its integration into shared decision-making regarding prescriptions may help improve treatment adherence and patient outcomes. Key learning pointsO_ST_ABSWhat was knownC_ST_ABSO_LIAmong patients undergoing dialysis, medication adherence rates are generally < 70%. C_LIO_LI Financial toxicity is associated with poor medication adherence in oncology. C_LIO_LIHowever, among patients undergoing dialysis receiving publicly funded care, the prevalence of financial toxicity and its effects on medication adherence remain unclear. C_LI This study addsO_LIDespite Japans comprehensive public insurance system, approximately 70% of patients undergoing dialysis experience at least mild financial toxicity levels, comparable to those observed in Japanese patients with cancer. C_LIO_LILower financial toxicity was associated with better medication adherence, particularly in the inconvenience/forgetfulness and behaviour subdomains. C_LI Potential impactO_LIFinancial hardship can cause stress. Healthcare providers should build trust with their patients and foster open discussions on financial and social challenges. C_LIO_LIPractising shared decision-making is essential for prescribing medications that consider patients financial burden. C_LIO_LIProviding work-friendly dialysis schedules may support patients long-term financial independence. C_LI

BackgroundApixaban is increasingly being used in hemodialysis patients. However, uncertainty remains regarding appropriate dosing and risk of accumulation. MethodsWe analyzed apixaban drug levels from a tertiary care dialysis unit collected between August 2017 and January 2023. We compared 2.5 mg once versus twice daily dosing. We applied mixed-effects models analyses including dialysis modality, adjusted standard Kt/V, ultrafiltration and dialyzer characteristics. ResultsWe analyzed 143 apixaban drug levels from 24 patients. Mean (SD) age was 64.2 (15.3) years (45.2% female), median (IQR) follow up 12.5 (5.5 - 21) months. For the 2.5 mg once and twice daily groups, median (IQR) drug levels were 54.4 (< 40 - 72.1) and 71.3 (48.8 - 104.1) ng/mL (P < 0.001). Drug levels were below the detection limit in 30 % and 14 %. Only dosing group (twice versus once daily) was independently associated with higher drug levels (P = 0.002). Follow-up did not suggest accumulation. 95th percentile did not exceed those of non-CKD populations taking 5 mg twice daily. Drug levels before a bleeding (8 episodes) were significantly higher than those without a subsequent bleeding: 115 (SD 51.6) versus 65.9 (SD 31.6) ng/mL (P < 0.001). Patients with versus without a bleeding took concomitant antiplatelet therapy in 86% versus 6% (P < 0.001). In 21% of patients, drug level monitoring resulted in change of dosing. ConclusionApixaban drug monitoring might be a contributory tool to increase safety in patients on hemodialysis. Further prospective outcome studies are warranted to investigate possible target levels.

IntroductionChronic kidney disease (CKD) is a highly prevalent disease with disparities in diagnosis and treatment. Until recently, primary diagnosis for CKD was based on equations that incorporated race and have demonstrated racial bias. This study had two aims comparing outcomes for Black patients and their counterparts: 1) whether using the new 2021 CKD-EPI equation led to decreased disparity with time to diagnosis; and 2) whether there was discordance in the staging between the two equations at potential diagnosis point. MethodsWe evaluated patients aged 18 and over with non-hospitalization related serum creatinine laboratory results between January 1, 2016 and September 30, 2023. We estimated the GFR for each patient using the 2009 and 2021 CKD-EPI creatinine equations. We assessed stage discordance for stages 3a, 3b, 4, and 5 using chi-square tests and the Cochran-Mantel-Haenszel. We used multivariate logistic regression to assess a change in staging based on the equation used. Results15.5% of the 8,080,889 patients included in this study were Black. The median age was 57 years and 15.3% of patients met the criteria for stage 3a CKD or higher using either equation. Discordance in staging by equation and by race existed, especially for Black patients at stages 3a and 3b. 40% of Black patients identified as stage 4 using the 2021 equation were 3b or lower using the 2009 equation. DiscussionWell established medical algorithms with race components are being re-examined. We found more disparity with the initial staging of the disease. The disconnect in the timing of staging by equation for Black patients means a number of these patients may not have received the appropriate treatment. Future work should elucidate the impact of the change in CKD staging with the 2021 CKD-EPI creatinine equation on treatment. ConclusionSignificant disparity exists in the timing and staging of CKD by CKD-EPI equation and by race.