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Safely Correct Hyponatremia With Continuous Renal Replacement Therapy: A Flexible, All-Purpose Method Based On The Mixing Paradigm, Sheldon Chen, Jerry Yee, Robert Chiaramonte

Nephrology Articles

Treating chronic hyponatremia by continuous renal replacement therapy (CRRT) is challenging because the gradient between a replacement fluid's [sodium] and a patient's serum sodium can be steep, risking too rapid of a correction rate with possible consequences. Besides CRRT, other gains and losses of sodium- and potassium-containing solutions, like intravenous fluid and urine output, affect the correction of serum sodium over time, known as osmotherapy. The way these fluids interact and contribute to the sodium/potassium/water balance can be parsed as a mixing problem. As Na/K/H(2) O are added, mixed in the body, and drained via CRRT, the net balance of …

Effect Of Intensive Versus Standard Bp Control On Aki And Subsequent Cardiovascular Outcomes And Mortality: Findings From The Sprint Ehr Study, Paul E. Drawz, Nayanjot Kaur Rai, Kristin Macfarlane Lenoir, Maritza Suarez, James R. Powell, Dominic S. Raj, Srinivasan Beddhu, Anil K. Agarwal, Sandeep Soman, Paul K. Whelton, James Lash, Frederic F. Rahbari-Oskoui, Mirela Dobre, Mark A. Parkulo, Michael V. Rocco, Andrew Mcwilliams, Jamie P. Dwyer, George Thomas, Mahboob Rahman, Suzanne Oparil, Edward Horwitz, Nicholas M. Pajewski, Areef Ishani

Nephrology Articles

Background: Adjudication of inpatient AKI in the Systolic Blood Pressure Intervention Trial (SPRINT) was based on billing codes and admission and discharge notes. The purpose of this study was to evaluate the effect of intensive versus standard BP control on creatinine-based inpatient and outpatient AKI, and whether AKI was associated with cardiovascular disease (CVD) and mortality.

Methods: We linked electronic health record (EHR) data from 47 clinic sites with trial data to enable creatinine-based adjudication of AKI. Cox regression was used to evaluate the effect of intensive BP control on the incidence of AKI, and the relationship between incident AKI …

Clinically Adjudicated Deceased Donor Acute Kidney Injury And Graft Outcomes, Sherry G. Mansour, Nadeen J. Khoury, Ravi Kodali, Sarthak Virmani, Peter P. Reese, Isaac E. Hall, Yaqi Jia, Yu Yamamoto, Heather R. Thiessen-Philbrook, Wassim Obeid, Mona D. Doshi, Enver Akalin, Jonathan S. Bromberg, Meera N. Harhay, Sumit Mohan, Thangamani Muthukumar, Pooja Singh, Francis L. Weng, Dennis G. Moledina, Jason H. Greenberg, Francis P. Wilson, Chirag R. Parikh

Nephrology Articles

BACKGROUND: Acute kidney injury (AKI) in deceased donors is not associated with graft failure (GF). We hypothesize that hemodynamic AKI (hAKI) comprises the majority of donor AKI and may explain this lack of association.

METHODS: In this ancillary analysis of the Deceased Donor Study, 428 donors with available charts were selected to identify those with and without AKI. AKI cases were classified as hAKI, intrinsic (iAKI), or mixed (mAKI) based on majority adjudication by three nephrologists. We evaluated the associations between AKI phenotypes and delayed graft function (DGF), 1-year eGFR and GF. We also evaluated differences in urine biomarkers among …

Sentinel Vascular Access Monitoring After Endovascular Intervention Predicts Access Outcome, Lalathaksha Kumbar, Edward L. Peterson, Matthew Zaborowicz, Anatole Besarab, Jerry Yee, Gerard Zasuwa

Nephrology Articles

BACKGROUND AND OBJECTIVES: The vascular access pressure ratio test identifies dialysis vascular access dysfunction when three consecutive vascular access pressure ratios are >0.55. We tested whether the magnitude of the decline in vascular access pressure ratio 1-week post-intervention could alert of subsequent access failure.

DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: The retrospective study included all vascular access procedures at one institution from March 2014 to June 2016. Data included demographics, comorbidities, vascular access features, %ΔVAPR = ((Pre-Post)/Pre] × 100% assessed within the first 2 weeks post-percutaneous transluminal balloon angioplasty, time-to-next procedure, and patency. The log-rank test compared the area under the …

Coronal Mode Ultrasound Guided Hemodialysis Cannulation: A Pilot Randomized Comparison With Standard Cannulation Technique, Lalathaksha Kumbar, Vivek Soi, Elizabeth Adams, Cheryl Brown-Deacon, Mohamed Zidan, Jerry Yee

Nephrology Articles

BACKGROUND: Infiltrations from cannulation result in significant morbidity including loss of hemodialysis (HD) vascular access (VA). Cannulation is dependent on personnel skill and VA characteristics. Surface marking of VA lacks real-time information and traditional ultrasound (US) devices are large, expensive, requiring skilled operators. Sonic Window© (Analogic Ultrasound, Peabody, MA, USA) is a coronal mode ultrasound device (CMUD) approved for VA cannulation.

METHODS: Single center randomized, prospective pilot study comparing handheld US-guided cannulation of new arteriovenous fistula (AVF) to standard cannulation practices. Patients with end stage renal disease (ESRD) on in-center HD who had a new AVF cleared for cannulation and …

Effects Of Intensive Bp Control In Ckd, Alfred K. Cheung, Mahboob Rahman, David M. Reboussin, Timothy E. Craven, Tom Greene, Paul L. Kimmel, William C. Cushman, Amret T. Hawfield, Karen C. Johnson, Cora E. Lewis, Suzanne Oparil, Michael V. Rocco, Kaycee M. Sink, Paul K. Whelton, Jackson T. Wright, Jan Basile, Srinivasan Beddhu, Udayan Bhatt, Tara I. Chang, Glenn M. Chertow, Michel Chonchol, Barry I. Freedman, William Haley, Joachim H. Ix, Lois A. Katz, Anthony A. Killeen, Vasilios Papademetriou, Ana C. Ricardo, Karen Servilla, Barry Wall, Dawn Wolfgram, Jerry Yee

Nephrology Articles

The appropriate target for BP in patients with CKD and hypertension remains uncertain. We report prespecified subgroup analyses of outcomes in participants with baseline CKD in the Systolic Blood Pressure Intervention Trial. We randomly assigned participants to a systolic BP target of(intensive group;

Potential Deaths Averted And Serious Adverse Events Incurred From Adoption Of The Sprint (Systolic Blood Pressure Intervention Trial) Intensive Blood Pressure Regimen In The United States: Projections From Nhanes (National Health And Nutrition Examination Survey), Adam P. Bress, Holly Kramer, Rasha Khatib, Srinivasan Beddhu, Alfred K. Cheung, Rachel Hess, Vinod K. Bansal, Guichan Cao, Jerry Yee, Andrew E. Moran, Ramon Durazo-Arvizu, Paul Muntner, Richard S. Cooper

Nephrology Articles

BACKGROUND: SPRINT (Systolic Blood Pressure Intervention Trial) demonstrated a 27% reduction in all-cause mortality with a systolic blood pressure (SBP) goal ofmellitus, stroke, or heart failure. To quantify the potential benefits and risks of SPRINT intensive goal implementation, we estimated the deaths prevented and excess serious adverse events incurred if the SPRINT intensive SBP treatment goal were implemented in all eligible US adults.

METHODS: SPRINT eligibility criteria were applied to the 1999 to 2006 National Health and Nutrition Examination Survey and linked with the National Death Index through December 2011. SPRINT eligibility included age ≥50 years, SBP of 130 to …

Phase 2 Randomized, Double-Blind, Placebo-Controlled Trial Of Rg7667, A Combination Monoclonal Antibody, For Prevention Of Cytomegalovirus Infection In High-Risk Kidney Transplant Recipients, Julie H. Ishida, Anita Patel, Aneesh K. Mehta, Philippe Gatault, Jacqueline M. Mcbride, Tracy Burgess, Michael A. Derby, David R. Snydman, Brinda Emu, Becket Feierbach, Ashley E. Fouts, Mauricio Maia, Rong Deng, Carrie M. Rosenberger, Lynn A. Gennaro, Natalee S. Striano, X C. Liao, Jorge A. Tavel

Nephrology Articles

Cytomegalovirus (CMV) infection is a significant complication after kidney transplantation. We examined the ability of RG7667, a combination of two monoclonal antibodies, to prevent CMV infection in high-risk kidney transplant recipients in a randomized, double-blind, placebo-controlled trial. CMV-seronegative recipients of a kidney transplant from a CMV-seropositive donor (D+R-) were randomized to receive RG7667 (n = 60) or placebo (n = 60) at the time of transplant and 1, 4, and 8 weeks posttransplant. Patients were monitored for CMV viremia every 1 to 2 weeks posttransplant for 24 weeks. Patients who had seroconverted (D+R+) or withdrawn before dosing were excluded from …

Bone-Specific Alkaline Phosphatase And Bone Turnover In African American Hemodialysis Patients, Lenar Yessayan, Carol L. Moore, Mei Lu, Jerry Yee

Nephrology Articles

INTRODUCTION: Noninvasive measures of bone activity include intact parathyroid hormone (iPTH) and bone-specific alkaline phosphatase (BSAP). Whether BSAP measurement alone or in combination with other biochemical data provides more reliable information about bone turnover than iPTH alone in African Americans on hemodialysis is unknown.

METHODS: This cross-sectional study aimed to determine the optimal predictor and cutoff points for BSAP, iPTH, calcium and phosphorus in classifying bone biopsy findings. Forty-three African American hemodialysis patients were available for analysis. Biochemical data on the day of biopsy across a spectrum of qualitative histologic bone features were compared. Classification and regression tree analysis was …

Introduction Of Biosimilar Therapeutics Into Nephrology Practice In The United States: Report Of A Scientific Workshop Sponsored By The National Kidney Foundation, Jay B. Wish, Chaim Charytan, Glenn M. Chertow, Kamyar Kalantar-Zadeh, Alan S. Kliger, Robert J. Rubin, Jerry Yee, Steven Fishbane

Nephrology Articles

Biosimilars are biologic medicines highly similar to the reference product with no meaningful clinical differences in terms of safety, purity, and potency. All biologic medicines are produced by living cells, resulting in an inherent heterogeneity in their higher order structures and post-translational modifications. In 2010, the US Congress enacted legislation to streamline the approval process for biosimilars of products losing patent protection, with the goal of decreasing costs and improving patient access to therapeutically important but expensive biologic agents. In 2015, the US Food and Drug Administration approved the first biosimilar agent through this pathway. Approval of additional biosimilar agents …

Ultrafiltration Rate Thresholds In Maintenance Hemodialysis: An Nkf-Kdoqi Controversies Report, Holly Kramer, Jerry Yee, Daniel E. Weiner, Vinod Bansal, Michael J. Choi, Laura Brereton, Jeffrey S. Berns, Milagros Samaniego-Picota, Paul Scheel, Michael Rocco

Nephrology Articles

High hemodialysis ultrafiltration rate (UFR) is increasingly recognized as an important and modifiable risk factor for mortality among patients receiving maintenance hemodialysis. Recently, the Kidney Care Quality Alliance (KCQA) developed a UFR measure to assess dialysis unit care quality. The UFR measure was defined as UFR≥13mL/kg/h for patients with dialysis session length less than 240 minutes and was endorsed by the National Quality Forum as a quality measure in December 2015. Despite this, implementation of a UFR threshold remains controversial. In this NKF-KDOQI (National Kidney Foundation-Kidney Disease Outcomes Quality Initiative) Controversies Report, we discuss the concept of the UFR, which …

Cumulative Fluid Balance And Mortality In Septic Patients With Or Without Acute Kidney Injury And Chronic Kidney Disease, Javier A. Neyra, Xilong Li, Fabrizio Canepa-Escaro, Beverley Adams-Huet, Robert D. Toto, Jerry Yee, S S. Hedayati

Nephrology Articles

OBJECTIVE: Incident acute kidney injury and prevalent chronic kidney disease are commonly encountered in septic patients. We examined the differential effect of acute kidney injury and chronic kidney disease on the association between cumulative fluid balance and hospital mortality in critically ill septic patients.

DESIGN: Retrospective cohort study.

SETTING: Urban academic medical center ICU.

PATIENTS: ICU adult patients with severe sepsis or septic shock and serum creatinine measured within 3 months prior to and 72 hours of ICU admission. Patients with estimated glomerular filtration rate less than 15 mL/min/1.73 m or receiving chronic dialysis were excluded.

INTERVENTIONS: None.

MEASUREMENTS AND …

Increasing Access To Kidney Transplantation: Easy As A-B-O, Jerry Yee

Nephrology Articles

No abstract provided.

Iron Therapy Challenges For The Treatment Of Nondialysis Ckd Patients, Francesco Locatelli, Sandro Mazzaferro, Jerry Yee

Nephrology Articles

The clinical consequences of untreated, severe anemia in patients with nondialysis CKD can be significant, but disparities exist in the anemia treatment guidelines and position papers issued from working groups and associations across the world. These differ in hemoglobin target and iron levels and their emphasis on various iron markers and other clinical outcomes. Not surprisingly, disparities are observed in anemia treatment strategies among patients with nondialysis CKD across different areas of the world. Over the past decade, the prescription and dosage of both iron therapies and erythropoiesis-stimulating agents have shifted, with notable regional differences observed. Moreover, there is ongoing …

Improving Transitions In Ckd: Failure Mode, Jerry Yee

Nephrology Articles

No abstract provided.

Dipstick Albuminuria And Acute Kidney Injury Recovery In Critically Ill Septic Patients, Javier A. Neyra, Xilong Li, Lenar Yessayan, Beverley Adams-Huet, Jerry Yee, Robert D. Toto

Nephrology Articles

AIM: Acute kidney injury (AKI) is a frequent complication of sepsis, a pro-inflammatory state that alters tubular handling of filtered albumin. We hypothesized that dipstick albuminuria (DA) is associated with a lower rate of AKI recovery in septic patients.

METHODS: This was a single-centre, retrospective cohort study of adults with sepsis-associated AKI in an urban academic intensive care unit (ICU). Patients with unknown baseline serum creatinine (SCr), absent urinalysis, and those with estimated glomerular filtration rate (eGFR)/min per 1.73m(2) or receiving chronic renal replacement therapy (RRT) were excluded. The independent variable was DA (negative or trace, 30 mg/dL, and ≥100 …

Pgx: Pharmacogenomics During Generation X, Jerry Yee

Nephrology Articles

No abstract provided.

The Authors Reply, Javier A. Neyra, Fabrizio Canepa-Escaro, Jerry Yee, Lenar Yessayan

Nephrology Articles

No abstract provided.

Chronic Kidney Disease Classification In Systolic Blood Pressure Intervention Trial: Comparison Using Modification Of Diet In Renal Disease And Ckd-Epidemiology Collaboration Definitions, Michael V. Rocco, Arlene Chapman, Glenn M. Chertow, Debbie Cohen, Jing Chen, Jeffrey A. Cutler, Matthew J. Diamond, Barry I. Freedman, Amret Hawfield, Eric Judd, Anthony A. Killeen, Kent Kirchner, Cora E. Lewis, Nicholas M. Pajewski, Barry M. Wall, Jerry Yee

Nephrology Articles

BACKGROUND: Interventional trials have used either the Modification of Diet in Renal Disease (MDRD) or chronic kidney disease (CKD)-Epidemiology Collaboration (CKD-EPI) equation for determination of estimated glomerular filtration rate (eGFR) to define whether participants have stages 3-5 CKD. The equation used to calculate eGFR may influence the number and characteristics of participants designated as having CKD.

METHODS: We examined the classification of CKD at baseline using both equations in the Systolic Blood Pressure Intervention Trial (SPRINT). eGFR was calculated at baseline using fasting serum creatinine values from a central laboratory.

RESULTS: Among 9,308 participants with baseline CKD classification using the …

Potential Impact Of Prescribing Metformin According To Egfr Rather Than Serum Creatinine, Delphine S. Tuot, Feng Lin, Michael G. Shlipak, Vanessa Grubbs, Chi-Yuan Hsu, Jerry Yee, Vahakn Shahinian, Rajiv Saran, Sharon Saydah, Desmond E. Williams, Neil R. Powe

Nephrology Articles

OBJECTIVE: Many societies recommend using estimated glomerular filtration rate (eGFR) rather than serum creatinine (sCr) to determine metformin eligibility. We examined the potential impact of these recommendations on metformin eligibility among U.S. adults.

RESEARCH DESIGN AND METHODS: Metformin eligibility was assessed among 3,902 adults with diabetes who participated in the 1999-2010 National Health and Nutrition Examination Surveys and reported routine access to health care, using conventional sCr thresholds (eligible if

RESULTS: Among adults with sCr above conventional cutoffs, MDRD eGFR ≥45 mL/min/1.73 m(2) was most common among men (adjusted odds ratio [aOR] 33.3 [95% CI 7.4-151.5] vs. women) and non-Hispanic …

Interdisciplinary Care Clinics In Chronic Kidney Disease, Tanya S. Johns, Jerry Yee, Terrian Smith-Jules, Ruth C. Campbell, Carolyn Bauer

Nephrology Articles

The burden of chronic kidney disease (CKD) is substantial, and is associated with high hospitalization rates, premature deaths, and considerable health care costs. These factors provide strong rationale for quality improvement initiatives in CKD care. The interdisciplinary care clinic (IDC) has emerged as one solution to improving CKD care. The IDC team may include other physicians, advanced practice providers, nurses, dietitians, pharmacists, and social workers--all working together to provide effective care to patients with chronic kidney disease. Studies suggest that IDCs may improve patient education and preparedness prior to kidney failure, both of which have been associated with improved health …

Association Of Hyperchloremia With Hospital Mortality In Critically Ill Septic Patients, Javier A. Neyra, Fabrizio Canepa-Escaro, Xilong Li, John Manllo, Beverley Adams-Huet, Jerry Yee, Lenar Yessayan

Nephrology Articles

OBJECTIVES: Hyperchloremia is frequently observed in critically ill patients in the ICU. Our study aimed to examine the association of serum chloride (Cl) levels with hospital mortality in septic ICU patients.

DESIGN: Retrospective cohort study.

SETTING: Urban academic medical center ICU.

PATIENTS: ICU adult patients with severe sepsis or septic shock who had Cl measured on ICU admission were included. Those with baseline estimated glomerular filtration rate less than 15 mL/min/1.73 m or chronic dialysis were excluded.

INTERVENTIONS: None.

MEASUREMENTS AND MAIN RESULTS: Of 1,940 patients included in the study, 615 patients (31.7%) had hyperchloremia (Cl ≥ 110 mEq/L) on …

Hypertension In Ckd: Sodium Still At The Nexus, Jerry Yee

Nephrology Articles

No abstract provided.

The Evolving Approach To Ethical Issues In Living Donor Kidney Transplantation: A Review Based On Illustrative Case Vignettes, K. K. Venkat, Anne Eshelman

Nephrology Articles

Living donor kidney transplantation which involves performing a major surgical procedure on a healthy person solely to benefit another person has always involved dealing with difficult ethical issues. Beneficence, non-maleficence, donor autonomy, altruistic donor motivation, coercion-free donation, fully informed consent and avoidance of medical paternalism have been the dominant ethical principles governing this field ever since the first successful living donor kidney transplant in 1954. The increasing reliance on living donors due to the rapidly growing disparity between the number of patients awaiting transplantation and the availability of deceased donor kidneys has brought with it a variety of new ethical …