Category: Patient Management

Restless legs syndrome (RLS) is more prevalent among patients with chronic kidney disease (CKD) undergoing dialysis compared with the general population, but it is often diagnosed late, and its predictors are not well understood. An observational, cross-sectional study aimed to diagnose RLS in a cohort of patients with CKD on dialysis, determine its frequency and severity, compare its prevalence and severity between different dialytic modalities, and identify potential predictive factors.

The study involved 326 patients (241 on hemodialysis [HD] and 85 on automatic peritoneal dialysis [APD]). RLS was diagnosed using the criteria set by the International Study Group on RLS, and its severity was assessed with the RLS Rating Scale. The study found that 19.3% of patients had RLS, with 52.4% of those cases being severe or very severe. There were no significant differences in clinical and demographic characteristics or dialytic modality between patients with and without RLS. However, patients on APD exhibited higher RLS severity compared with those on HD. The findings highlight that RLS is common in patients on dialysis, particularly in its severe forms, and while the type of dialysis does not influence its occurrence, it may affect its severity.

Reference: de Menezes AF, Motta DRMS, de Carvalho FO, et al. Restless Legs Syndrome in Dialysis Patients: Does the Dialysis Modality Influence Its Occurrence and Severity? Int J Nephrol. 2018;2018:1414568. doi: 10.1155/2018/1414568.

Hemodialysis is the predominant treatment for 86.9% of patients with kidney failure, with 80% starting with a catheter. Vascular access complications significantly increase morbidity and mortality. This review highlights newer devices for minimally invasive arteriovenous fistulas (AVF) and other innovations to improve vascular access patency, including endovascular AVF techniques and bioengineered grafts.

Traditional hemodialysis vascular access methods—AVF, arteriovenous graft, and central venous catheter (CVC)—have challenges, with CVCs posing the highest risk of complications. Innovations like the Ellipsys and WavelinQ systems for endovascular AVF creation show promise in reducing surgical reliance, while bioengineered grafts like Humacyl offer new options for patients unsuitable for traditional AVF. Additionally, technologies such as early cannulation grafts and the Inside-Out Surfacer device address immediate and long-term vascular access issues. These advancements emphasize the need for continuous improvement and patient-centered approaches in dialysis care.

Reference: Vachharajani TJ, Taliercio JJ, Anvari E. New Devices and Technologies for Hemodialysis Vascular Access: A Review. Am J Kidney Dis. 2021;78(1):116-124. doi: 10.1053/j.ajkd.2020.11.027.

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.

Chronic kidney disease (CKD) impacts over 37 million adults in the United States, with risk factors including diabetes, hypertension, atherosclerosis, and age, and shows notable racial disparities. CKD is linked to higher morbidity and mortality, often due to accelerated atherosclerotic vascular disease and acute coronary syndromes.

Obesity is now recognized as an independent risk factor for CKD, leading to obesity-related chronic kidney disease (ORCKD). ORCKD features altered renal hemodynamics, chronic inflammation, oxidative stress, and activation of the renin-angiotensin-aldosterone system (RAAS). Primary ORCKD, where obesity is the main cause, is marked by glomerulomegaly and focal segmental glomerulosclerosis. Contributing factors include lipotoxicity, adipocytokine dysregulation, and glomerular hypertension. Early detection of renal injury markers like proteinuria is crucial. Effective management includes weight loss, RAAS inhibitors, and emerging treatments such as CD-36 inhibitors and SGLT-2 inhibitors. Early intervention and comprehensive treatment can improve outcomes and reduce the burden of ORCKD.

Reference: Ali MM, Parveen S, Williams V, Dons R, Uwaifo GI. Cardiometabolic comorbidities and complications of obesity and chronic kidney disease (CKD). J Clin Transl Endocrinol. 2024;36:100341. doi: 10.1016/j.jcte.2024.100341.

A cross-sectional analysis involving 3,193 patients with chronic kidney disease (CKD) aimed to estimate adherence to CKD-specific dietary guidelines, identify factors associated with poor adherence, and examine the relationship between adherence and biomarkers. Dietary intake was assessed using a food frequency questionnaire, and a CKD diet score was developed based on intake of sodium, potassium, fiber, protein, sugar, and cholesterol.

Results showed that lower adherence to dietary recommendations was linked to younger age, higher body mass index, male gender, lower education, and certain lifestyle factors such as smoking, infrequent alcohol consumption, and low physical activity. Lower adherence was also associated with dyslipidemia, higher uric acid, and elevated C-reactive protein levels. These associations were mainly driven by low intake of fiber and potassium, and high intake of sugar and cholesterol. The study underscores the need for promoting CKD-specific dietary recommendations to improve health outcomes and reduce adverse prognoses in patients with CKD.

Reference: Kaesler N, Baid-Agrawal S, Grams S, et al. Low adherence to CKD-specific dietary recommendations associates with impaired kidney function, dyslipidemia, and inflammation. Eur J Clin Nutr. 2021;75(9):1389-1397. doi: 10.1038/s41430-020-00849-3.

Heart failure (HF), traditionally classified by left ventricular ejection fraction (LVEF) cutpoints, overlooks its continuum and nuanced treatment responses. The Heart Failure Collaboratory advocates a pragmatic shift to broadly categorize HF into reduced and non-reduced LVEF, reflecting recent guidelines’ evolution. While terms like HFmrEF lack robust evidence and may complicate treatment decisions, HFimpEF should align with HFrEF due to shared characteristics.

Current HF treatments show varying efficacy across LVEF, challenging traditional classifications. Neurohormonal antagonists and sodium glucose co-transporter 2 inhibitors exhibit diverse treatment effects relative to LVEF, with diminishing benefits towards normal ranges. HF device interventions echo these disparities, underscoring the need for nuanced management strategies. While LVEF remains crucial in clinical practice, ongoing research should prioritize novel biomarkers and therapies for tailored interventions, enhancing outcomes across HF’s diverse landscape.

Reference: Dimond MG, Ibrahim NE, Fiuzat M, et al. Left Ventricular Ejection Fraction and the Future of Heart Failure Phenotyping. JACC Heart Fail. 2024 Mar;12(3):451-460. doi: 10.1016/j.jchf.2023.11.005. Epub 2023 Dec 13. PMID: 38099892.

The FIDELITY trial examined finerenone’s impact on heart failure (HF) outcomes in 13,026 patients with type 2 diabetes (T2D) and chronic kidney disease (CKD). Finerenone significantly decreased the risk of HF-related hospitalizations, cardiovascular death, and recurrent HF compared to placebo. Notably, patients with higher baseline estimated glomerular filtration rate (eGFR) and lower urine albumin-to-creatinine ratio (UACR) experienced the lowest incidence of adverse outcomes, yet finerenone consistently improved HF outcomes across all eGFR and/or UACR categories.

These findings highlight finerenone’s potential to ameliorate HF-related outcomes in high-risk T2D patients with CKD, irrespective of their baseline kidney function and albuminuria levels. Further investigation is warranted to elucidate the underlying mechanisms of these benefits and assess the long-term impact of finerenone therapy on cardiovascular outcomes in this patient population.

Reference: Filippatos G, Anker SD, Pitt B, et al. Finerenone and Heart Failure Outcomes by Kidney Function/Albuminuria in Chronic Kidney Disease and Diabetes. JACC Heart Fail. 2022 Nov;10(11):860-870. doi: 10.1016/j.jchf.2022.07.013. Epub 2022 Oct 12. Erratum in: JACC Heart Fail. 2023 Aug;11(8 Pt 1):1034-1035. PMID: 36328655.…

The 2022 ADA Standards of Medical Care in Diabetes and the KDIGO 2022 Clinical Practice Guideline provide evidence-based recommendations for managing diabetes and chronic kidney disease (CKD). These jointly reviewed guidelines emphasize comprehensive care, integrating proven pharmacotherapy with healthy lifestyle practices. Specific consensus statements offer guidance on drug usage, including renin-angiotensin system inhibitors, metformin, sodium–glucose cotransporter 2 inhibitors, glucagon-like peptide 1 receptor agonists, and a nonsteroidal mineralocorticoid receptor antagonist, with the goal of enhancing clinical outcomes for individuals with diabetes and CKD.

Despite alignment between the 2022 ADA Standards of Care and KDIGO 2022 guideline, challenges like high costs and limited healthcare resources may hinder broad implementation of these recommendations, necessitating efforts to improve accessibility and address disparities. Ongoing research in diabetes, CKD, and cardiovascular disease is anticipated to provide further insights, driving continual evolution of clinical practice guidelines.

Reference: de Boer IH, Khunti K, Sadusky T, et al. Diabetes Management in Chronic Kidney Disease: A Consensus Report by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO). Diabetes Care. 2022 Dec 1;45(12):3075-3090. doi: 10.2337/dci22-0027. PMID: 36189689; PMCID: PMC9870667.