Nephrology | Links Medicus Content Curation & Alerts in Medicine

RCT: Thrombectomy improves outcomes in acute stroke with large infarcts – N Engl J Med

25 May, 2024 | 19:35h | UTC

Study 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):

Costalat, V. et al. (2024). Trial of Thrombectomy for Stroke with a Large Infarct of Unrestricted Size. N Engl J Med, 390(18), 1677-1689. DOI: 10.1056/NEJMoa2314063

Guidelines on the use of intravenous albumin in various clinical settings – CHEST

25 May, 2024 | 18:49h | UTC

The 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):

Callum J et al. (2024). Use of Intravenous Albumin: A Guideline From the International Collaboration for Transfusion Medicine Guidelines. CHEST, 2024. DOI: https://doi.org/10.1016/j.chest.2024.02.049.

Cohort Study: Impact of decreasing eGFR on serious adverse drug reactions in CKD patients – Am J Kidney Dis

25 May, 2024 | 18:48h | UTC

This 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):

Solène M. Laville et al. (2024). Kidney Function Decline and Serious Adverse Drug Reactions in Patients With CKD. American Journal of Kidney Diseases, 83(5), 601-614.e1. DOI: 10.1053/j.ajkd.2023.09.012.

M-A: Effects of long-term salt substitution on cardiovascular mortality and events – Ann Intern Med

5 May, 2024 | 15:10h | UTC

This 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):

Hannah Greenwood et al. (2024). Long-Term Effect of Salt Substitution for Cardiovascular Outcomes: A Systematic Review and Meta-Analysis. Annals of Internal Medicine, Volume 178, Pages 23-31. DOI: 10.7326/M23-2626.

Systematic Review: Effects of ACE inhibitors and ARBs on kidney and cardiovascular outcomes in diabetic patients – Cochrane Library

4 May, 2024 | 13:32h | UTC

Study 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):

Natale, P. et al. (2024). Comparative Efficacy of ACE Inhibitors and ARB on Kidney and Cardiovascular Outcomes in Diabetic Kidney Disease. Cochrane Database of Systematic Reviews. DOI: 10.1002/14651858.CD006257.pub2.

Cluster-Randomized Trial: No reduction in hospitalization rates with EHR-based algorithm in chronic kidney disease patients

30 Apr, 2024 | 13:16h | UTC

This 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):

Miguel A. Vazquez et al. (2024). Pragmatic Trial of Hospitalization Rate in Chronic Kidney Disease. N Engl J Med, 390(13), 1196-1206. DOI: 10.1056/NEJMoa2311708

Cohort Study: Increased fracture risk linked with initiation of antihypertensive medication in older veterans

26 Apr, 2024 | 12:29h | UTC

Study 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 | UTC

Study 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 | UTC

Study 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 | UTC

Cardiorenal 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 | UTC

Primary 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 | UTC

Managing the symptom burden associated with maintenance dialysis: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference – Kidney International

News 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

Blood Purification for Adult Patients With Severe Infection or Sepsis/Septic Shock: A Network Meta-Analysis of Randomized Controlled Trials – Critical Care Medicine

International Study | Postoperative acute kidney injury affects one in five patients after major surgery

1 Aug, 2023 | 14:23h | UTC

Epidemiology of surgery associated acute kidney injury (EPIS-AKI): a prospective international observational multi-center clinical study – Intensive Care Medicine

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 | UTC

Novel Therapeutics for Management of Lupus Nephritis: What Is Next? – Kidney Medicine

Review | Revisiting resistant hypertension

1 Aug, 2023 | 14:16h | UTC

Revisiting resistant hypertension: a comprehensive review – Internal Medicine Journal

Podcast: #390 Resistant Hypertension – The Curbsiders

Review | Updates on infectious and other complications in peritoneal dialysis

26 Jul, 2023 | 13:23h | UTC

Updates on Infectious and Other Complications in Peritoneal Dialysis: Core Curriculum 2023 – American Journal of Kidney Diseases (free for a limited period)

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

Proton Pump Inhibitor Use, Fatigue, and Health-Related Quality of Life in Kidney Transplant Recipients: Results From the TransplantLines Biobank and Cohort Study – American Journal of Kidney Diseases

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