Nephrology
RCT: Renal Denervation Reduces Blood Pressure in Chinese Patients With Uncontrolled Hypertension
7 Sep, 2024 | 14:57h | UTCStudy Design and Population: This was a prospective, multicenter, randomized, sham-controlled trial investigating the efficacy and safety of catheter-based radiofrequency renal denervation (RDN) in Chinese patients with uncontrolled hypertension despite standardized triple antihypertensive therapy. A total of 217 patients (mean age 45.3 years, 21% female) were randomized 1:1 to receive RDN or a sham procedure.
Main Findings: At 6 months, patients who underwent RDN showed a significantly greater reduction in 24-hour ambulatory systolic blood pressure (−13.0 mm Hg) compared to the sham group (−3.0 mm Hg), with a baseline-adjusted difference of −9.4 mm Hg (P<0.001). Significant reductions were also observed in 24-hour diastolic BP and office systolic and diastolic BP. One access site complication occurred in the RDN group but resolved without further issues.
Implications for Practice: This trial demonstrates that RDN is an effective and safe option for reducing blood pressure in patients with uncontrolled hypertension, offering a potential adjunct to antihypertensive therapy in this population. Further research may solidify its role in managing resistant hypertension.
Reference: Jiang X et al. (2024). Efficacy and Safety of Catheter-Based Radiofrequency Renal Denervation in Chinese Patients With Uncontrolled Hypertension: The Randomized, Sham-Controlled, Multi-Center Iberis-HTN Trial. Circulation. https://doi.org/10.1161/CIRCULATIONAHA.124.069215
Link: https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.124.069215
RCT: No Difference in Postoperative Complications Between Continuation and Discontinuation of Renin-Angiotensin System Inhibitors Before Major Surgery – JAMA
31 Aug, 2024 | 19:12h | UTCStudy Design and Population: This multicenter randomized clinical trial included 2,222 patients who had been treated with renin-angiotensin system inhibitors (RASIs) for at least 3 months and were scheduled for major noncardiac surgery at 40 hospitals in France between January 2018 and April 2023. The participants were randomly assigned to either continue RASIs until the day of surgery or to discontinue them 48 hours before surgery.
Main Findings: The trial found no significant difference in the primary outcome—a composite of all-cause mortality and major postoperative complications within 28 days—between the continuation and discontinuation groups (22% in both groups, RR 1.02, 95% CI 0.87-1.19). However, the continuation group experienced a higher incidence of intraoperative hypotension (54% vs. 41%, RR 1.31, 95% CI 1.19-1.44).
Implications for Practice: Continuation of RASIs before major noncardiac surgery does not increase the risk of postoperative mortality or major complications, but it does elevate the risk of intraoperative hypotension. Clinicians should weigh these risks when deciding whether to continue or discontinue RASIs before surgery.
Meta-Analysis: Renal Denervation Modestly Reduces Blood Pressure in Uncontrolled Hypertension – J Am Heart Assoc
17 Aug, 2024 | 16:14h | UTCStudy Design and Population: This updated meta-analysis evaluated 15 randomized clinical trials, encompassing 2,581 patients, to assess the efficacy and safety of catheter-based renal denervation (RDN) in patients with uncontrolled hypertension. The trials included both patients on antihypertensive medications (ON-Med) and those off medications (OFF-Med), with comparisons made between RDN and sham or standard therapy.
Main Findings: RDN led to a modest but statistically significant reduction in blood pressure across both ON-Med and OFF-Med groups. In the OFF-Med group, 24-hour ambulatory systolic BP was reduced by 3.7 mm Hg (95% CI, -5.41 to -2.00). In the ON-Med group, the reduction was 2.23 mm Hg (95% CI, -3.56 to -0.90). Sham-controlled trials reinforced these findings, showing consistent BP reductions, thus validating the effect of RDN. However, the degree of BP reduction is modest and may be clinically limited.
Implications for Practice: While RDN appears to have a favorable safety profile and provides consistent BP reductions, the modest nature of these reductions suggests that its clinical utility may be more limited. Further research is needed to identify which patient populations might benefit the most from RDN and to optimize procedural techniques for greater efficacy.
RCT: Dietary Acid Reduction with Fruits and Vegetables Slows CKD Progression and Lowers CVD Risk in Hypertensive Patients – Am J Med
17 Aug, 2024 | 15:49h | UTCStudy Design and Population: This five-year randomized control trial included 153 hypertensive patients with macroalbuminuria and normal kidney function. Participants were randomly assigned to one of three groups: a diet rich in base-producing fruits and vegetables, oral sodium bicarbonate (NaHCO3), or Usual Care. The primary objective was to assess the effects of dietary acid reduction on chronic kidney disease (CKD) progression and cardiovascular disease (CVD) risk.
Main Findings: The study found that both fruits and vegetables and NaHCO3 slowed CKD progression compared to Usual Care, with significantly higher estimated glomerular filtration rates in the intervention groups. However, only the fruits and vegetables group showed significant reductions in systolic blood pressure, LDL cholesterol, and body mass index, leading to greater improvements in CVD risk indices.
Implications for Practice: The results support using fruits and vegetables as a foundational treatment for hypertension to reduce CKD progression and lower CVD risk, potentially with reduced reliance on pharmacological interventions.
RCT: Intravenous Amino Acids Reduce AKI Incidence in Cardiac Surgery Patients – N Engl J Med
3 Aug, 2024 | 19:12h | UTCStudy Design and Population: In this multinational, double-blind, randomized clinical trial, 3511 adult patients scheduled for cardiac surgery with cardiopulmonary bypass were recruited from 22 centers across three countries. Patients were randomly assigned to receive an intravenous infusion of either a balanced mixture of amino acids (2 g/kg/day) or a placebo (Ringer’s solution) for up to three days.
Main Findings: The primary outcome, occurrence of acute kidney injury (AKI), was significantly lower in the amino acid group (26.9%) compared to the placebo group (31.7%) with a relative risk of 0.85 (95% CI, 0.77 to 0.94; P=0.002). The incidence of severe AKI (stage 3) was also reduced in the amino acid group (1.6% vs. 3.0%; relative risk, 0.56; 95% CI, 0.35 to 0.87). There were no substantial differences between the groups regarding secondary outcomes such as the use and duration of kidney-replacement therapy or all-cause 30-day mortality.
Implications for Practice: The infusion of amino acids in adult patients undergoing cardiac surgery appears to reduce the incidence of AKI, indicating a potential protective renal effect. However, this intervention did not significantly impact other secondary outcomes, including mortality and the use of kidney-replacement therapy. These findings suggest that amino acids could be considered as a strategy to mitigate AKI risk in this patient population, although further research is needed to explore long-term benefits and other clinical outcomes.
RCT: Thrombectomy improves outcomes in acute stroke with large infarcts – N Engl J Med
25 May, 2024 | 19:35h | UTCStudy Design and Population: This randomized clinical trial investigated the efficacy of thrombectomy in combination with standard medical care versus medical care alone in patients with acute stroke and large infarcts. Participants included 333 patients with proximal cerebral vessel occlusion in the anterior circulation, presenting within 6.5 hours of symptom onset. They were randomized in a 1:1 ratio to either undergo thrombectomy or receive only medical care. An Alberta Stroke Program Early Computed Tomographic Score of ≤5 was used to define large infarcts.
Main Findings: The primary outcome, assessed by the modified Rankin scale score at 90 days, showed a median score of 4 in the thrombectomy group compared to 6 in the control group, indicating better functional outcomes with thrombectomy (generalized odds ratio, 1.63; 95% CI, 1.29 to 2.06; P<0.001). Mortality at 90 days was significantly lower in the thrombectomy group (36.1%) compared to the control group (55.5%) with an adjusted relative risk of 0.65. However, thrombectomy was associated with a higher rate of symptomatic intracerebral hemorrhage (9.6% vs. 5.7% in the control group).
Implications for Practice: The findings suggest that thrombectomy, when added to standard medical care, can significantly improve functional outcomes and reduce mortality in patients with large infarct strokes. However, the increased risk of symptomatic intracerebral hemorrhage must be considered when deciding on this intervention. These results support the broader use of thrombectomy in clinical settings with similar patient profiles but underscore the need for careful risk-benefit analysis due to the potential for serious hemorrhagic complications.
Reference (link to abstract – $ for full-text):
Guidelines on the use of intravenous albumin in various clinical settings – CHEST
25 May, 2024 | 18:49h | UTCThe International Collaboration for Transfusion Medicine Guidelines provides comprehensive guidelines on the use of intravenous albumin across various clinical settings, including critical care, cardiovascular surgery, kidney replacement therapy, and complications of cirrhosis. The guideline emphasizes that there are few evidence-based indications supporting the routine use of albumin to improve patient outcomes. Key findings include:
1 – Critical Care: Limited recommendations for using albumin in adult, pediatric, and neonatal critical care, primarily advising against its routine use for volume replacement or managing hypoalbuminemia due to low or very low certainty of evidence.
2 – Cardiovascular Surgery: No recommendations for using albumin to prime cardiovascular bypass circuits or for volume replacement due to moderate to very low certainty of evidence.
3 – Kidney Replacement Therapy: Albumin is not suggested for preventing or managing intradialytic hypotension or improving ultrafiltration due to very low certainty of evidence.
4 – Cirrhosis Complications: Some conditional recommendations for using albumin in specific scenarios like large-volume paracentesis and spontaneous bacterial peritonitis due to low certainty of evidence; however, it is generally not suggested for other complications of cirrhosis.
Overall, the guidelines advise a cautious approach to albumin use, highlighting the need for more robust evidence to support its broader application in clinical practice.
Reference (link to free full-text):
Cohort Study: Impact of decreasing eGFR on serious adverse drug reactions in CKD patients – Am J Kidney Dis
25 May, 2024 | 18:48h | UTCThis prospective cohort study, part of the French Chronic Kidney Disease-Renal Epidemiology and Information Network (CKD-REIN), involved 3,033 outpatients with moderate to advanced chronic kidney disease (CKD). The study aimed to explore the correlation between estimated glomerular filtration rate (eGFR) and the incidence of serious adverse drug reactions (ADRs). Over a median follow-up of 4.7 years, 360 patients experienced 488 serious ADRs, predominantly kidney and urinary disorders, and hemorrhages, constituting 70% of cases. The study identified antithrombotics and renin-angiotensin system inhibitors as the most common medication classes leading to these ADRs. A significant finding was that a decrease in eGFR is associated with a higher risk of serious ADRs, specifically acute kidney injury and bleeding, which were largely preventable or potentially preventable. The outcomes highlight the critical need for careful drug prescription and monitoring in CKD patients to mitigate serious ADRs.
Reference (link to free full-text):
M-A: Effects of long-term salt substitution on cardiovascular mortality and events – Ann Intern Med
5 May, 2024 | 15:10h | UTCThis systematic review and meta-analysis assessed the impact of long-term salt substitution on cardiovascular outcomes by analyzing data from 16 randomized controlled trials (RCTs). The primary investigation focused on mortality, major cardiovascular events (MACE), and adverse events with a study period of six months or longer. Key findings include a potential reduction in all-cause mortality (rate ratio [RR] of 0.88) and cardiovascular mortality (RR of 0.83), based on low-certainty evidence from studies predominantly conducted in China or Taiwan among older adults or those at higher cardiovascular risk. Results also indicated a slight reduction in MACE (RR of 0.85) with very low certainty. Evidence suggests no significant increase in serious adverse events. Limitations include the dominance of a single large RCT and limited generalizability of results to Western populations. The study concludes that while salt substitution could reduce mortality, the effects on cardiovascular events remain uncertain, with more robust evidence needed for broader demographic applicability.
Reference (link to abstract – $ for full-text):
Systematic Review: Effects of ACE inhibitors and ARBs on kidney and cardiovascular outcomes in diabetic patients – Cochrane Library
4 May, 2024 | 13:32h | UTCStudy Design and Population:
This systematic review and meta-analysis evaluated the effectiveness of angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs) in managing cardiovascular and kidney outcomes in adults with diabetes and kidney disease. It included data from 109 randomized controlled trials totaling 28,341 participants, comparing the impact of ACEi and ARBs, either alone or in combination, against each other, placebo, or no treatment.
Main Findings:
The analysis revealed that ACEi may reduce the risk of kidney failure (RR 0.61, 95% CI 0.39 to 0.94) but generally has little effect on all-cause mortality and cardiovascular death compared to placebo, with low certainty of evidence. Similarly, ARBs showed potential in preventing kidney failure (RR 0.82, 95% CI 0.72 to 0.94) and the progression from microalbuminuria to macroalbuminuria. The effects on cardiovascular outcomes remained uncertain and showed minimal difference compared to placebo or no treatment.
Implications for Practice:
While ACEi and ARBs may aid in preventing kidney failure in patients with diabetic kidney disease, their broader impacts on mortality and cardiovascular health remain uncertain. This underscores the necessity for further rigorous research to verify these findings and better determine the optimal therapeutic strategies. Clinicians should weigh these results against individual patient profiles considering the overall low certainty of the evidence.
Reference (link to abstract – $ for full-text):
Cluster-Randomized Trial: No reduction in hospitalization rates with EHR-based algorithm in chronic kidney disease patients
30 Apr, 2024 | 13:16h | UTCThis study evaluates the effectiveness of a personalized EHR-based algorithm combined with practice facilitators to reduce hospitalization rates among patients with chronic kidney disease, type 2 diabetes, and hypertension. Conducted as an open-label, cluster-randomized trial across 141 primary care clinics, 11,182 patients were divided into two groups: the intervention group (5,690 patients) and the usual-care group (5,492 patients). After one year, the hospitalization rate was slightly lower in the intervention group (20.7%) compared to the usual-care group (21.1%), but this difference was not statistically significant (p=0.58). Secondary outcomes, including emergency department visits, readmissions, cardiovascular events, dialysis, and death rates were similar between the groups, except for a slightly higher rate of acute kidney injury in the intervention group. The study concludes that the EHR-based intervention did not significantly decrease hospitalizations at one year.
Commentary on X:
Original Article: Pragmatic Trial of Hospitalization Rate in Chronic Kidney Disease (ICD-Pieces trial) https://t.co/aJ0Ao0uf90 #Nephrology pic.twitter.com/l4xc54Buxy
— NEJM (@NEJM) April 8, 2024
Reference (link to abstract – $ for full-text):
Cohort Study: Increased fracture risk linked with initiation of antihypertensive medication in older veterans
26 Apr, 2024 | 12:29h | UTCStudy Design and Population:
This retrospective cohort study evaluated the association between antihypertensive medication initiation and fracture risk among older long-term care nursing home residents within the Veterans Health Administration. Conducted from 2006 to 2019 with data analysis spanning 2021 to 2023, the study utilized target trial emulation techniques and included 29,648 residents. A 1:4 propensity score-matched method was employed to compare medication initiators with non-initiators.
Main Findings:
Out of the matched cohort of 64,710 residents, those who initiated antihypertensive medication showed a higher incidence of fractures (5.4 per 100 person-years) compared to controls (2.2 per 100 person-years). The adjusted hazard ratio for fractures was 2.42. Notably, higher risks were observed in subgroups with dementia or elevated blood pressure thresholds (systolic ≥140 mm Hg or diastolic ≥80 mm Hg). Risks for severe falls and syncope were also elevated in the medication-initiating group.
Implications for Practice:
The study indicates a significant association between the initiation of antihypertensive medications and increased fracture risks among older, frail nursing home residents. Given these findings, clinicians should exercise caution and consider enhanced monitoring and preventive strategies when prescribing these medications to this vulnerable population.
Reference (link to abstract – $ for full-text):
Dave, C. V. et al. (2024). Antihypertensive Medication and Fracture Risk in Older Veterans Health Administration Nursing Home Residents. JAMA Intern Med, Published online April 22, 2024. DOI:10.1001/jamainternmed.2024.0507.
Cohort Study: The impact of rare kidney diseases on kidney failure and survival rates in the UK’s RaDaR cohort
22 Mar, 2024 | 11:29h | UTCStudy Design and Population: This cohort study utilized data from the UK National Registry of Rare Kidney Diseases (RaDaR), encompassing 27,285 participants aged 0-96 years with 28 types of rare kidney diseases, recruited from 108 renal care facilities across the UK. The primary outcomes assessed were the cumulative incidence of mortality and kidney failure, compared with those of a general population with chronic kidney disease (CKD).
Main Findings: Over a median follow-up of 9.6 years, participants with rare kidney diseases exhibited a significantly higher 5-year cumulative incidence of kidney failure (28%) compared to the broader UK CKD population (1%, p<0.0001). However, they also showed better survival rates, with a standardized mortality ratio of 0.42. There was considerable variability in median ages at kidney failure and death, time from dialysis start to death, and time from diagnosis to reaching specific eGFR thresholds among different rare diseases.
Implications for Practice: This study highlights the distinct trajectory of rare kidney diseases compared to more common forms of CKD, with higher rates of kidney failure but improved survival outcomes. These findings emphasize the over-representation of patients with rare kidney diseases in kidney replacement therapy cohorts and underscore the urgent need for targeted therapeutic interventions. Addressing this unmet need could significantly reduce the demand for long-term kidney replacement therapy, benefiting patients and easing healthcare system burdens.
Reference
Wong K, Pitcher D, Braddon F, Downward L, Steenkamp R, Annear N, et al. (2024). Effects of rare kidney diseases on kidney failure: a longitudinal analysis of the UK National Registry of Rare Kidney Diseases (RaDaR) cohort. The Lancet, 395(10223), P1234-P1245. DOI: https://doi.org/10.1016/S0140-6736(23)02843-X. Access the study here: Link
RCT: Quadruple quarter-dose hypertension medication versus monotherapy for ambulatory blood pressure control
20 Mar, 2024 | 18:00h | UTCStudy Design and Population: This randomized clinical trial investigated the efficacy of a combination of four ultra-low-dose blood pressure medications (quadpill) compared to standard monotherapy in adults with hypertension. A total of 591 participants, either untreated or currently on monotherapy for hypertension, were enrolled and randomly assigned to receive either the quadpill (irbesartan 37.5 mg, amlodipine 1.25 mg, indapamide 0.625 mg, and bisoprolol 2.5 mg) or a monotherapy control (irbesartan 150 mg).
Main Findings: At 12 weeks, the quadpill group demonstrated significantly lower mean 24-hour ambulatory systolic and diastolic blood pressure (SBP and DBP) by 7.7 mmHg and 5.3 mmHg, respectively, compared to the monotherapy group, with similar reductions observed during daytime and night-time. Additionally, the rate of blood pressure control (24-hour average BP < 130/80 mmHg) was significantly higher in the quadpill group (77% vs. 50%). The study highlighted the quadpill’s effectiveness in reducing blood pressure variability and enhancing control rates across a 24-hour period.
Implications for Practice: The findings from this study support the superior efficacy of an ultra-low-dose quadruple medication strategy over monotherapy in managing ambulatory blood pressure among hypertensive patients. These results suggest that a quadpill approach could offer a more effective means for clinicians to achieve and maintain blood pressure control in hypertensive patients, potentially improving cardiovascular outcomes.
Reference: Janis M Nolde et al. (2024). Ambulatory blood pressure after 12 weeks of quadruple combination of quarter doses of blood pressure medication vs. standard medication. J Hypertens, 2024 Feb 29. DOI: 10.1097/HJH.0000000000003683. Access the study here: [Link]
Review | Cardiorenal syndrome in the hospital
7 Aug, 2023 | 14:36h | UTCCardiorenal Syndrome in the Hospital – Clinical Journal of the American Society of Nephrology
Commentary on Twitter
The cardiorenal syndrome refers to a group of complex, bidirectional pathophysiological pathways involving dysfunction in both the heart and kidney. This Review focuses on the cardiorenal syndrome encountered in the hospital setting https://t.co/f05vpOPzCx pic.twitter.com/4Is5A2F1km
— CJASN (@CJASN) July 31, 2023
Review | Primary aldosteronism: a pragmatic approach to diagnosis and management
4 Aug, 2023 | 12:06h | UTCPrimary Aldosteronism: A Pragmatic Approach to Diagnosis and Management – Mayo Clinic Proceedings
KDIGO Conference | Managing the symptom burden associated with maintenance dialysis
4 Aug, 2023 | 12:02h | UTCNews Release: KDIGO Announces Publication of “Managing the Symptom Burden Associated with Maintenance Dialysis”
Commentary on Twitter
KDIGO is pleased to announce the publication of “Managing the Symptom Burden Associated with Maintenance Dialysis” in @Kidney_Int. The Conference Report is based on the KDIGO Symptom-Based Complications in Dialysis Controversies Conference in May 2022.
Read the News Release:… pic.twitter.com/AZKW9TPgxj
— KDIGO (@goKDIGO) August 1, 2023
M-A | Uncertain benefits of blood purification techniques in severe infection or sepsis
4 Aug, 2023 | 11:41h | UTC
International Study | Postoperative acute kidney injury affects one in five patients after major surgery
1 Aug, 2023 | 14:23h | UTC
Commentary on Twitter
? EPIS #AKI, epidemiology of major surgery associated acute kidney injury
➡️ > 10K pts, 1/5 develop PO-AKI: significant burden for health care worldwide!
⬆️ increasing severity of PO-AKI associated with progressive increase in adverse outcomes#FOAMcc
?️ https://t.co/Ps7N7zoMKP pic.twitter.com/gcxkve9OKV— Intensive Care Medicine (@yourICM) July 30, 2023
Novel therapeutics for management of lupus nephritis: what is next?
1 Aug, 2023 | 14:22h | UTCNovel Therapeutics for Management of Lupus Nephritis: What Is Next? – Kidney Medicine
Review | Revisiting resistant hypertension
1 Aug, 2023 | 14:16h | UTCRevisiting resistant hypertension: a comprehensive review – Internal Medicine Journal
Related: Resistant hypertension: A stepwise approach – Cleveland Clinic Journal of Medicine
Podcast: #390 Resistant Hypertension – The Curbsiders
Review | Updates on infectious and other complications in peritoneal dialysis
26 Jul, 2023 | 13:23h | UTCUpdates on Infectious and Other Complications in Peritoneal Dialysis: Core Curriculum 2023 – American Journal of Kidney Diseases (free for a limited period)
Related: ISPD Catheter-related Infection Recommendations: 2023 Update – Peritoneal Dialysis International
Commentary on Twitter
Updates on Infectious and Other Complications in Peritoneal Dialysis: Core Curriculum 2023 by Sana F. Khan, MD. https://t.co/DtYjfG79Yw (FREE) pic.twitter.com/lDeZcN3DJO
— AJKD (@AJKDonline) July 24, 2023
Cohort Study | Proton pump inhibitor use linked to increased fatigue in kidney transplant recipients
26 Jul, 2023 | 13:21h | UTC
Commentary on Twitter
Proton Pump Inhibitor Use, Fatigue, and Health-Related Quality of Life in Kidney Transplant Recipients: Results From the TransplantLines Biobank and Cohort Study https://t.co/DkDTvs9zjo #OpenAccess#VisualAbstract @umcg pic.twitter.com/XooY16qFVT
— AJKD (@AJKDonline) July 25, 2023
M-A | P2Y12 monotherapy after 1-3 months DAPT safely reduces bleeding in PCI patients with CAD and CKD
26 Jul, 2023 | 13:18h | UTCRelated:
De-escalation or abbreviation of dual antiplatelet therapy in acute coronary syndromes and percutaneous coronary intervention: a Consensus Statement from an international expert panel on coronary thrombosis – Nature Reviews Cardiology (if the link is paywalled, try this one)
Long-term Effects of P2Y12 Inhibitor Monotherapy After Percutaneous Coronary Intervention: 3-Year Follow-up of the SMART-CHOICE Randomized Clinical Trial – JAMA Cardiology (link to abstract – $ for full-text)
M-A | Early initiation of renal replacement therapy fails to improve survival rates in AKI patients
25 Jul, 2023 | 13:46h | UTC