POCN's Chronic Kidney Disease Center of Excellence

Author: Stephen Thomas,

  • Tackling Anemia in Chronic Kidney Disease

    Tackling Anemia in Chronic Kidney Disease

    Anemia affects 15.4% of patients with chronic kidney disease (CKD) in the United States, with prevalence rising with disease progression, age, and among Black, Hispanic, and female populations. Linked to reduced erythropoietin (EPO) production and impaired iron metabolism, anemia in CKD worsens quality of life, increases hospitalizations, and raises cardiovascular and mortality risks. Standard treatments like iron supplementation, erythropoietin-stimulating agents (ESAs), and blood transfusions have limitations, including gastrointestinal side effects, risk of iron overload, and cardiovascular concerns. Novel therapies like hypoxia-inducible factor prolyl hydroxylase (HIF-PH) inhibitors show promise by enhancing endogenous EPO production and improving iron metabolism with fewer side effects.

    Managing anemia in CKD remains challenging, particularly in ESA-resistant patients or those with cardiovascular disease or secondary hyperparathyroidism. Inflammation and elevated hepcidin levels contribute to functional iron deficiency and ESA hyporesponsiveness. Emerging treatments, including HIF-PH inhibitors and hepcidin antagonists, target these underlying issues, potentially improving hemoglobin levels and reducing reliance on traditional therapies.

    Reference: Pramod S, Goldfarb DS. Challenging patient phenotypes in the management of anaemia of chronic kidney disease. Int J Clin Pract. 2021;75(11):e14681. doi: 10.1111/ijcp.14681.

  • Managing Hyperkalemia in Chronic Kidney Disease

    Managing Hyperkalemia in Chronic Kidney Disease

    Patients with chronic kidney disease (CKD) are at increased risk for hyperkalemia, a serious condition involving elevated plasma potassium levels. Low-potassium diets have been a key management strategy since the 1960s, as declining kidney function limits potassium excretion. Although compensatory mechanisms like colonic secretion help, many patients with CKD still experience postprandial hyperkalemia—potassium spikes after meals—due to impaired renal and cellular responses. Dietary adjustments, such as adding fiber and balancing meals, can help but do not fully address this challenge.

    Potassium exchange resins, such as patiromer and sodium zirconium cyclosilicate, effectively manage chronic hyperkalemia by boosting fecal potassium excretion but show limited efficacy in preventing postprandial potassium spikes. Their mechanisms, which bypass kidney-like regulation, may not align with meal-related potassium absorption. While these medications are valuable for chronic management, they do not replace the need for dietary considerations or replicate healthy kidney function. Further research is needed to refine strategies for managing postprandial hyperkalemia in CKD.

    Reference: St-Jules DE, Clegg DJ, Palmer BF, Carrero JJ. Can Novel Potassium Binders Liberate People with Chronic Kidney Disease from the Low-Potassium Diet? A Cautionary Tale. Clin J Am Soc Nephrol. 2022;17(3):467-472. doi: 10.2215/CJN.09660721.

  • Fatigue and Sleep Quality as Mediators Between Depression and Renal Function in Patients With CKD-ND

    Fatigue and Sleep Quality as Mediators Between Depression and Renal Function in Patients With CKD-ND

    Researchers aimed to investigate whether fatigue and poor sleep quality mediate the relationship between depression and renal function in patients with nondialysis chronic kidney disease (CKD-ND). The cross-sectional study involved 242 participants from a medical center in Central Taiwan, with an average age of 70.5 years. Data were collected using various scales for emotional support, fatigue, depression, and sleep quality, along with medical records for estimated glomerular filtration rate (eGFR). Structural equation modeling and bootstrapping methods were employed to analyze the relationships and mediation effects.

    The results showed that 39% of participants exhibited depressive symptoms, 91% experienced sleep disturbances, and the average eGFR was 25.45 mL/min/1.73 m². Significant correlations were found between depression, fatigue, sleep quality, and renal function. Mediation analysis revealed that fatigue and sleep quality significantly mediated the association between depression and renal function, with indirect effect sizes indicating that these factors play a role in the relationship. The findings suggest that addressing fatigue and sleep quality could potentially mitigate the impact of depression on renal function in patients with CKD-ND.

    Reference: Ho YF, Hsu PT, Yang KL. The mediating effect of sleep quality and fatigue between depression and renal function in nondialysis chronic kidney disease: a cross-sectional study. BMC Nephrol. 2022;23(1):126. doi: 10.1186/s12882-022-02757-z.

  • Insulin Resistance in Non-Diabetic Patients With CKD

    Insulin Resistance in Non-Diabetic Patients With CKD

    Researchers of this study aimed to identify factors associated with insulin resistance and explore its relationship to chronic kidney disease (CKD) progression, cardiovascular events, and mortality in non-diabetic patients with CKD. Data from 1883 participants of the Chronic Renal Insufficiency Cohort Study without diabetes were analyzed using linear regression for insulin resistance, defined by the Homeostasis Model Assessment of Insulin Resistance (HOMA-IR). Cox proportional hazards models examined the association of HOMA-IR, fasting glucose, hemoglobin A1c (HbA1c), and C-peptide with CKD progression, cardiovascular events, and all-cause mortality.

    The study found that novel positive associations with HOMA-IR included serum albumin, uric acid, and hemoglobin A1c. However, after adjustment, HOMA-IR was not associated with CKD progression, cardiovascular events, or all-cause mortality. Notably, a one standard deviation increase in HbA1c was positively associated with cardiovascular events. These findings suggest that while potential determinants of insulin resistance were identified, HOMA-IR did not correlate with adverse renal or cardiovascular outcomes or mortality in non-diabetic patients with CKD.

    Reference: Schrauben SJ, Jepson C, Hsu JY, et al. Insulin resistance and chronic kidney disease progression, cardiovascular events, and death: findings from the chronic renal insufficiency cohort study. BMC Nephrol. 2019;20(1):60. doi: 10.1186/s12882-019-1220-6.

  • Understanding Learned Helplessness in Renal Dialysis Patients: Key Attributes, Antecedents, and Consequences

    Understanding Learned Helplessness in Renal Dialysis Patients: Key Attributes, Antecedents, and Consequences

    Learned helplessness is an early psychological concept with unclear implications for renal nursing, particularly among dialysis patients. The authors aimed to analyze learned helplessness in these patients to improve understanding within renal nursing. Using Rodgers’ evolutionary concept analysis method, a systematic literature search across five databases was conducted. The analysis process involved narrowing relevant articles, extracting data, and identifying attributes, antecedents, consequences, surrogate terms, and related terms.

    The study included 22 articles, identifying four attributes of learned helplessness in renal dialysis patients: low self-concept, perceived loss, negative cognitive set, and abandonment of action. Antecedents were sociodemographic characteristics, disease and treatment factors, and psychological factors. Consequences were categorized into psychological problems, physiological issues, quality of life, and health-related behaviors. Surrogate terms were hopelessness and powerlessness, with depression as a related term. The study highlights gaps in awareness and practice challenges related to learned helplessness in dialysis patients and suggests the findings can guide the design of tools and interventions to better incorporate learned helplessness theory into nursing practice.

    Reference: Xie C, Li L, Li Y. Learned Helplessness in Renal Dialysis Patients: Concept Analysis with an Evolutionary Approach. Patient Prefer Adherence. 2022;16:2301-2312. doi: 10.2147/PPA.S373134.

  • Review Finds Uncertain Benefits of Sleep Interventions for Patients With Chronic Kidney Disease

    Review Finds Uncertain Benefits of Sleep Interventions for Patients With Chronic Kidney Disease

    Sleep disorders are common in individuals with chronic kidney disease (CKD). A review aimed to assess the effectiveness and adverse events of various interventions for adults and children with CKD, including those with end-stage kidney disease undergoing dialysis or kidney transplantation. The review included 67 studies with 3427 participants, but many studies had incomplete methodological details, leading to uncertain risk of bias. Meta-analyses involved 36 studies with 2239 participants, with follow-up ranging from 0.3 to 52.8 weeks.

    The authors found that relaxation techniques and exercise had uncertain effects on sleep quality, with very low certainty evidence. Exercise might reduce depression and fatigue moderately, while acupressure could slightly improve sleep latency and time, though its effects on sleep disturbance were unclear. The evidence for acupressure’s impact on sleep quality compared with sham acupressure was very low. Adverse effects of these therapies were uncertain, and no studies reported treatment effects for children. The overall evidence for improving sleep quality in patients with CKD is sparse, indicating a need for more rigorous future research on sleep interventions in this population.

    Reference: Natale P, Ruospo M, Saglimbene VM, Palmer SC, Strippoli GF. Interventions for improving sleep quality in people with chronic kidney disease. Cochrane Database Syst Rev. 2019;5(5):CD012625. doi: 10.1002/14651858.CD012625.pub2.

  • Managing Type 2 Diabetes With Chronic Kidney Disease

    Managing Type 2 Diabetes With Chronic Kidney Disease

    In the United States, about one in ten people have diabetes, and 40% of these develop chronic kidney disease (CKD), increasing their cardiovascular disease risk. Despite American Diabetes Association (ADA) recommendations for managing type 2 diabetes (T2D) with CKD, adherence is under 50%. Screening with spot urine albumin-to-creatinine ratio and estimated glomerular filtration rate at diagnosis and annually helps in early CKD detection and timely interventions. ADA advises good glycemic and blood pressure control and the use of renin–angiotensin system inhibitors, SGLT-2 inhibitors, GLP-1 receptor agonists, and non-steroidal mineralocorticoid receptor antagonists.

    Early CKD detection and intervention are crucial as the disease is asymptomatic, initially. Intensive glycemic control can reduce CKD development in patients with T2D but is less effective for advanced CKD. Dietary and blood pressure control also play critical roles. Effective medications like angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, sodium–glucose cotransporter-2 inhibitors, and glucagon-like peptide-1 receptor agonists help slow CKD progression and reduce cardiovascular risks. However, usage rates are low, underscoring the need for better guideline implementation and collaboration between primary care providers and nephrologists.

    Reference: Skolnik NS, Style AJ. Importance of Early Screening and Diagnosis of Chronic Kidney Disease in Patients with Type 2 Diabetes. Diabetes Ther. 2021;12(6):1613-1630. doi: 10.1007/s13300-021-01050-w.

  • Study Identifies Optimal eGFR for Dialysis Initiation in Advanced Chronic Kidney Disease

    Study Identifies Optimal eGFR for Dialysis Initiation in Advanced Chronic Kidney Disease

    Researchers of this study aimed to determine the optimal estimated glomerular filtration rate (eGFR) for initiating dialysis in patients with advanced chronic kidney disease (CKD). Using data from the National Swedish Renal Registry, researchers mimicked clinical trial conditions to eliminate biases and estimate adjusted hazard ratios and absolute risks for five-year all-cause mortality and major adverse cardiovascular events (MACE) across various eGFR levels.

    The study included 10,290 patients with a median eGFR of 16.8 mL/min/1.73 m². Of these, 3,822 began dialysis, 4,160 died, and 2,446 experienced a major adverse cardiovascular event (MACE). Results showed a parabolic relationship for mortality, with the lowest risk at eGFR 15-16 mL/min/1.73 m². Initiating dialysis at this eGFR level reduced the five-year mortality risk by 5.1% and the MACE risk by 2.9%, compared with starting at eGFR 6-7. However, this meant starting dialysis four years earlier, yielding a modest mean postponement of death by 1.6 months over five years. The findings aligned with the IDEAL trial, indicating very early dialysis initiation offers a slight mortality and cardiovascular benefit, but the extended dialysis period may not be justifiable for most patients.

    Reference: Fu EL, Evans M, Carrero JJ, et al. Timing of dialysis initiation to reduce mortality and cardiovascular events in advanced chronic kidney disease: nationwide cohort study. BMJ. 2021;375:e066306. doi: 10.1136/bmj-2021-066306.

  • Mental Illness Prevalence in Patients With Chronic Kidney Disease

    Mental Illness Prevalence in Patients With Chronic Kidney Disease

    This study provides the first nationally representative estimates of the prevalence of mental illness and mental health (MH) treatment among US adults with chronic kidney disease (CKD). Using data from the 2015 to 2019 National Survey on Drug Use and Health, the study analyzed 152,069 adults aged 22 and older, including those with CKD (n=2544), no chronic conditions (n=117,235), and those with hypertension or diabetes but not CKD (n=32,290). The prevalence of any mental illness, serious mental illness (SMI), MH treatment, and unmet MH care needs were compared across these groups using logistic regression models.

    Results showed that 26.6% of US adults with CKD had mental illness, including 7.1% with SMI. After adjusting for individual characteristics, adults with CKD were significantly more likely to have any mental illness or SMI than those with no chronic conditions or hypertension/diabetes. Additionally, adults with CKD were more likely to receive MH treatment (21% vs 12% and 18%) and to have unmet MH care needs (6% vs 3% and 5%). These findings highlight the high prevalence of mental illness among US adults with CKD and suggest that better management of MH needs could improve treatment outcomes and quality of life.

    Reference: Wilk AS, Hu JC, Chehal P, Yarbrough CR, Ji X, Cummings JR. National Estimates of Mental Health Needs Among Adults With Self-Reported CKD in the United States. Kidney Int Rep. 2022;7(7):1630-1642. doi: 10.1016/j.ekir.2022.04.088.

  • Study Finds Kidney Transplantation Significantly Improves Quality of Life for Patients With Chronic Kidney Disease

    Study Finds Kidney Transplantation Significantly Improves Quality of Life for Patients With Chronic Kidney Disease

    Patients with chronic kidney disease (CKD) experience a decline in quality of life (QOL) as their renal function deteriorates. Health-related QOL (HRQOL) assessments help estimate health status, disease burden, treatment effectiveness, and survival in patients with CKD. Studies show HRQOL is positively associated with estimated glomerular filtration rate and declines with CKD progression. Kidney transplantation (KT) aims to improve survival and QOL, with research indicating better HRQOL and survival rates in KT patients compared with those on dialysis.

    This study, using data from the KoreaN Cohort Study for Outcomes in Patients With Kidney Transplantation and the KoreaN Cohort Study for Outcomes in Patients With Chronic Kidney Disease, investigated longitudinal changes in HRQOL. Findings indicated that patients who underwent KT had higher SF-36 QOL scores than patients with CKD, suggesting KT provides significant QOL benefits beyond renal function alone. However, CKD-targeted scores did not differ significantly between KT and CKD patients, emphasizing the need for continuous HRQOL assessments and tailored interventions to improve patient outcomes.

    Reference: Ryu JH, Koo TY, Ro H, et al. Better health-related quality of life in kidney transplant patients compared to chronic kidney disease patients with similar renal function. PLoS One. 2021;16(10):e0257981. doi: 10.1371/journal.pone.0257981.