Clinical Journal of the American Society of Nephrology最新文献

{"title":"Trends in Vascular Access Placement among Patients Initiating Hemodialysis with a Catheter.","authors":"Michael Allon,Yi Zhang,Mae Thamer,Timmy Lee","doi":"10.2215/cjn.0000001076","DOIUrl":"https://doi.org/10.2215/cjn.0000001076","url":null,"abstract":"BACKGROUNDVascular access practice guidelines recommend placement of a permanent vascular access _ arteriovenous fistula (AVF) or graft (AVG) _ to avoid complications associated with central venous catheters (CVC). Despite these guidelines, there has been a recent decrease in pre-dialysis AVF placement and an increase in patients starting hemodialysis with a CVC only. We evaluated whether there has been an increase in the placement of an AVF or AVG in the first six months after dialysis initation to offset the increase in patients starting dialysis with a CVC.METHODSThis was a retrospective cohort study using the United States Renal Data System. We identified 522,598 patients initiating hemodialysis with a CVC between 2016 and 2022. The exposure was the calendar year of hemodialysis initiation, and the main outcome was the proportion of patients with placement of an AVF or AVG within 6 months of hemodialysis initiation.RESULTSThe proportion of patients initiating hemodialysis with a CVC only increased from 62% in 2016 to 74% in 2022 (P<0.001), while the proportion receiving an AVF or AVG within six months of dialysis initiation declined from 34% to 26% (P<0.001). In adjusted Fine-Gray competing risk analysis, compared with 2016 as the reference year, hazard ratios for AVF/AVG placement declined markedly beginning in 2019 (sHR 0.89, 95% CI 0.87-0.90 in 2019; 0.77, 0.76-0.78 in 2020; 0.75, 0.74-0.76 in 2021; and 0.69, 0.68-0.70 in 2022). The standardized 6-month cumulative incidence of AVF/AVG placement decreased from 15% in 2016 to 11% in 2022 (P<0.001).CONCLUSIONSContrary to national vascular access guidelines, there has been a nearly one-third secular decrease in placement of an AVF or AVG among patients initiating hemodialysis with a CVC, compounding the lower rates of access placement prior to dialysis initiation.","PeriodicalId":50681,"journal":{"name":"Clinical Journal of the American Society of Nephrology","volume":"1 1","pages":""},"PeriodicalIF":9.8,"publicationDate":"2026-04-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147753245","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Authors' Reply: SGLT2 Inhibitors vs GLP-1 Receptor Agonists Type 2 Diabetes, the Kidney Conundrum.","authors":"Matthew F Blum,Morgan E Grams","doi":"10.2215/cjn.0000001074","DOIUrl":"https://doi.org/10.2215/cjn.0000001074","url":null,"abstract":"","PeriodicalId":50681,"journal":{"name":"Clinical Journal of the American Society of Nephrology","volume":"9 1","pages":""},"PeriodicalIF":9.8,"publicationDate":"2026-04-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147739063","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Towards a Peritoneal Dialysis-First Policy in the UK and Europe: A Phenotype-Based Analysis of Survival and System-Level Implications.","authors":"Hatem Ali,Tibor Fülöp,Anna Maria Casula,Andre Paola Ortega Alban,Samar Abd ElHafeez,Rizwan Hamer","doi":"10.2215/cjn.0000001060","DOIUrl":"https://doi.org/10.2215/cjn.0000001060","url":null,"abstract":"BACKGROUNDWhether peritoneal dialysis (PD) is associated with lower mortality than hemodialysis (HD) in contemporary practice remains debated, particularly across heterogeneous patient populations and in the presence of competing transplantation. We examined modality-associated mortality differences across data-driven phenotypes of incident dialysis patients in the United Kingdom (UK) using a competing-risks framework.METHODSWe analysed 96,809 adults initiating dialysis in the UK Renal Registry between 2007 and 2021. Unsupervised k-prototypes clustering was used to derive phenotypes based on age, sex, ethnicity, primary kidney disease, hemoglobin, serum albumin, and transplant-listing status. Mortality during the dialysis phase prior to transplantation was analysed using competing-risks methods, treating kidney transplantation as a competing event. Cumulative incidence of death at one and five years was modelled using jack-knife pseudo-value regression with complementary log-log links, adjusting for demographic and clinical covariates. Dialysis modality (HD vs PD) was the primary exposure, with stratified analyses performed within each phenotype. A complementary competing-risks analysis examined time to transplantation.RESULTSAmong incident patients, 24% initiated PD and 76% HD. Three reproducible phenotypes were identified, differing primarily by age, hemoglobin and albumin levels, and transplant-listing status. Across the overall cohort, HD was associated with a higher cumulative incidence of death prior to transplantation at both 1 year (subdistribution hazard ratio [sHR] 1.85, 95% confidence interval [CI] 1.75-1.96) and 5 years (sHR 1.47, 95% CI 1.43-1.51). In stratified analyses, HD was associated with higher mortality across all phenotypes. At one year, adjusted sHRs ranged from 1.55 (95% CI 1.44-1.68) to 2.29 (95% CI 1.87-2.80) across clusters. At five years, the association persisted but attenuated with increasing age, with adjusted sHRs of 2.42 (95% CI 2.23-2.63) in the youngest phenotype, 1.55 (95% CI 1.48-1.61) in the intermediate phenotype, and 1.14 (95% CI 1.11-1.19) in the oldest phenotype. In complementary analyses, time to transplantation did not differ significantly across phenotypes after adjustment.CONCLUSIONSIn contemporary UK practice, hemodialysis was associated with higher mortality during the dialysis phase compared with peritoneal dialysis across distinct patient phenotypes, with time-dependent variation in effect magnitude. These registry-based associations support consideration of phenotype-informed modality selection while acknowledging the potential for residual confounding and the influence of health-system context.","PeriodicalId":50681,"journal":{"name":"Clinical Journal of the American Society of Nephrology","volume":"13 1","pages":""},"PeriodicalIF":9.8,"publicationDate":"2026-04-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147733784","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A Pilot Randomized Controlled Trial of Ultrasound Evaluation of Fluid Tolerance for Acute Kidney Injury (USE-the-FORCE-for-AKI trial).","authors":"Michel Gouin,Karel Huard,Alicia Shen,Jean-Maxime Côté,André Denault,William Beaubien-Souligny","doi":"10.2215/cjn.0000001059","DOIUrl":"https://doi.org/10.2215/cjn.0000001059","url":null,"abstract":"BACKGROUNDIndiscriminate fluid administration in acute kidney injury (AKI) can be harmful and point-of-care ultrasound (POCUS) could be used to assess for fluid tolerance. The objective of pilot study is to determine the feasibility of a randomized trial comparing a fluid management strategy including POCUS to usual care.METHODSThis is a single centre open-label pilot randomized controlled trial that recruited non-critically ill patients with AKI for whom fluid administration had begun or was considered. The intervention consisted in the transmission to the nephrology team of a POCUS report on fluid tolerance (assessment of pulmonary B-lines and systemic venous congestion with the Venous Excess Ultrasound (VExUS) score). The control was usual care without POCUS. The primary outcome was feasibility, defined as protocol adherence.RESULTSEighty patients underwent randomization, 40 were randomized in the POCUS group and 40 in the usual care group, but one withdrew consent before initiating trial procedures. Protocol adherence was achieved in all patients. In the intervention arm, 50% of initial ultrasound reports led to a change in clinical conduct and the provided information was perceived as useful by clinicians (median 4.5/5 (interquartile range: 4.0-5.0)). The intervention led to a higher use of diuretics during the first day after randomization (40% vs 15%, p=0.01) but did not result in difference in cumulative fluid balance or diuretic use at five days, progression to higher stages of AKI, or composite outcome of death and escalation of care.CONCLUSIONSThis pilot trial demonstrate the feasibility of a randomized trial investigating the clinical impact of providing a POCUS fluid tolerance evaluation in AKI. Its impact on clinical management and perceived usefulness support the rationale for future, larger-scale studies.","PeriodicalId":50681,"journal":{"name":"Clinical Journal of the American Society of Nephrology","volume":"77 1","pages":""},"PeriodicalIF":9.8,"publicationDate":"2026-04-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147731240","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Cosmic Kidney Disease: Countermeasures to Attenuate Kidney Damage in Space.","authors":"Viola D'Ambrosio,Eric P Cohen,Giovanna Valenti,Keith Siew","doi":"10.2215/cjn.0000001095","DOIUrl":"https://doi.org/10.2215/cjn.0000001095","url":null,"abstract":"","PeriodicalId":50681,"journal":{"name":"Clinical Journal of the American Society of Nephrology","volume":"22 1","pages":""},"PeriodicalIF":9.8,"publicationDate":"2026-04-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147731239","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"APOL1 Genetic Testing and Counseling Does Not Reduce Living Kidney Donors' Willingness to Donate: A Hybrid Type 2 Non-Randomized Controlled Trial.","authors":"Elisa J Gordon,Jessica Gacki-Smith,Justin D Smith,Catherine Wicklund,Debra Duquette,Lutfiyya N Muhammad,Siyuan Dong,Bright Yevugah,Griffin Anderson,John Friedewald,Alexander Gilbert,Darius Tandon,Jacqueline Burgess-Bishop,Monica Fox,Marion Shuck,Phalese A Binion,Veatrice Crawford,Calmetta Coleman,Joann Howard,Akansha Agrawal","doi":"10.2215/cjn.0000001064","DOIUrl":"https://doi.org/10.2215/cjn.0000001064","url":null,"abstract":"BACKGROUNDLiving donors of African ancestry have the highest risk of post-donation kidney disease. Apolipoprotein L1 (APOL1) risk variants may contribute to this risk. This study evaluated the effectiveness and implementation of our culturally appropriate APOL1 Testing and Counseling Program to reduce potential donors' decisional conflict for donation.METHODSThis prospective, non-randomized, pre-post two-site hybrid type 2 effectiveness-implementation study evaluated the impact of the intervention on decisional conflict about donation, preparedness for decision making about donation and for donation, willingness to donate, and satisfaction with informed consent among potential donors of African ancestry undergoing evaluation. The intervention involved donors: using a chatbot providing APOL1 information, receiving culturally competent counseling, and APOL1 genetic testing. Control arm received routine care. We used the RE-AIM framework to longitudinally evaluate implementation outcomes assessed via validated surveys with donors and electronic health record review using linear mixed effects models. Cross-sectional outcomes were assessed using multiple regression models.RESULTSWe enrolled 280 potential donors (75 control arm, 205 intervention arm) (71.07% participation rate). More were female (59%) and had a mean age of 40.2 years (standard deviation [SD] 12.8). No significant differences emerged in most primary and secondary outcomes between the intervention and control groups (decisional conflict Beta (95% CI): -1.05 (-4.13, 2.03), P=0.50), preparation for decision making (Beta (95% CI): -7.02 (-18.83, 4.78); P=0.24), preparedness to donate (Beta (95% CI): 0.04 (-0.48, 0.56); P=0.89), willingness to donate (Beta (95% CI): 0.18 (-0.29, 0.66), P=0.45). The right amount of information to make a decision domain for satisfaction with informed consent was significantly lower in the intervention arm (Beta (95% CI): -0.34 (-0.65, -0.02), P=0.04).CONCLUSIONSOur APOL1 Testing and Counseling Program had no effect on potential donors' willingness to donate regardless of undergoing APOL1 testing, demonstrating the feasibility of its integration into routine donor clinical evaluation.","PeriodicalId":50681,"journal":{"name":"Clinical Journal of the American Society of Nephrology","volume":"16 1","pages":""},"PeriodicalIF":9.8,"publicationDate":"2026-04-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147726235","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Hospitalization Risk in the Integrated Home Dialysis Model: Analysis of the Canadian Organ Replacement Register.","authors":"Louis-Charles Desbiens,Karthik K Tennankore,Rémi Goupil,Jeffrey Perl,Emilie Trinh,Christopher T Chan,Annie-Claire Nadeau-Fredette","doi":"10.2215/cjn.0000001058","DOIUrl":"https://doi.org/10.2215/cjn.0000001058","url":null,"abstract":"BACKGROUNDInitiating dialysis with peritoneal dialysis (PD) followed by a transition to home hemodialysis (HHD) is known as integrated home dialysis. Hospitalization outcomes in this model are poorly known. We aimed to compare the hospitalization risk before, during, and after a PD-to-HHD transition with individuals receiving HHD as first home dialysis modality.METHODSWe analyzed the Canadian Organ Replacement Register and included individuals initiating home dialysis between 2005 and 2018. Patients transitioning from PD to HHD with less than 365 days of interim facility hemodialysis (\"PD-HHD\" group) were matched 1:1 to individuals receiving HHD as their first home dialysis modality (\"HHD\" group) using a propensity score. Patients were followed until December 2019, death, or a transfer to facility hemodialysis. In the PD-HHD group, the transition window was defined as the last 30 days of PD, the facility hemodialysis period and the first 30 days of HHD. Our primary outcome of all-cause hospitalizations (assessed before, during, and after transition) was analyzed using adjusted negative binomial regression.RESULTSThree hundred and one patients underwent the PD-to-HHD transition and 711 initiated home dialysis in HHD. Hospitalization rates up to 2.17/patient-year (95% confidence interval [CI] 1.91-2.43) were observed during the PD-to-HHD transition, with infectious-related hospitalizations being most frequent (30%). Compared with HHD, the PD-HHD group had higher rates of hospitalization during (Incidence rate ratio [IRR] 2.89 [95% CI 2.01-4.16]) and before the transition (IRR 1.38 [95% CI 1.03-1.85]; predominantly in the year before) but not afterward (IRR 1.04 [95% CI 0.80-1.36]). Higher risk was not observed for cardiovascular-related hospitalizations and less pronounced in patients with short (< 90 days in facility hemodialysis) transitions.CONCLUSIONSMost patients transitioning from PD to HHD experience a higher hospitalization risk before and during the transfer (relative to incident HHD). Yet, their hospitalization risk stabilizes after the transition. This higher risk of hospitalization is less apparent for patients with shorter interim facility hemodialysis.","PeriodicalId":50681,"journal":{"name":"Clinical Journal of the American Society of Nephrology","volume":"24 1","pages":""},"PeriodicalIF":9.8,"publicationDate":"2026-04-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147726031","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Glomerular Filtration Markers: Current and Emerging Insights.","authors":"Andrew S Levey,Sharanya Ramesh,Lesley A Inker","doi":"10.2215/cjn.0000001090","DOIUrl":"https://doi.org/10.2215/cjn.0000001090","url":null,"abstract":"Glomerular filtration markers are exogenous or endogenous solutes that are eliminated from the circulation primarily by glomerular filtration. Their rate of elimination is directly related to the glomerular filtration rate (GFR), and their plasma concentration is inversely related to the GFR. GFR cannot be measured directly in humans, but it can be assessed by using filtration markers - either as measured GFR (mGFR) from clearance measurements using exogenous filtration markers (such as iothalamate and iohexol), or as estimated GFR (eGFR) from estimating equations using plasma concentrations of endogenous filtration markers (metabolites, such as creatinine, and low molecular weight proteins, such as cystatin C). Thus, both mGFR and eGFR may differ from true GFR, and understanding the physiologic processes affecting filtration markers is required for clinical evaluation of GFR. Processes other than GFR that affect the plasma concentration of filtration markers are collectively defined as non-GFR determinants. By design, exogenous filtration markers are minimally affected by non-GFR determinants, but both urinary and plasma clearance measurements are associated with error in mGFR. In contrast, by definition, all endogenous filtration markers are affected by non-GFR determinants, but not by error in clearance measurements. The major limitations of mGFR procedures are complexity and inconvenience of clearance measurements, which constrain their utility in clinical practice. The major limitation of eGFR is error due to variation in the non-GFR determinants of the filtration markers, which can be minimized by use of a panel of markers (panel eGFR). There is ongoing interest in the discovery of new exogenous filtration markers that would enable widespread implementation of mGFR procedures and novel metabolite and low molecular weight endogenous filtration markers that would enable a panel eGFR. In this Review, we discuss current and emerging insights into existing and novel filtration markers.","PeriodicalId":50681,"journal":{"name":"Clinical Journal of the American Society of Nephrology","volume":"242 1","pages":""},"PeriodicalIF":9.8,"publicationDate":"2026-04-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147702188","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Adverse Muscle Composition is Associated with All-Cause Mortality in CKD: A UK Biobank Imaging Study.","authors":"Ainhoa Indurain,Markus Karlsson,Anders Fernström,Fredrik Uhlin,Mårten Segelmark,Olof Dahlqvist Leinhard","doi":"10.2215/cjn.0000001049","DOIUrl":"https://doi.org/10.2215/cjn.0000001049","url":null,"abstract":"BACKGROUNDAdverse muscle composition (AMC), defined by low muscle volume and increased muscle fat infiltration, has been associated with comorbidity and poor function in chronic kidney disease (CKD), and increased mortality in metabolic disorders and the general population. We investigated whether MRI-derived muscle composition is associated with all-cause mortality in a UK Biobank (UKB) imaging study among participants with CKD.METHODSUKB participants with CKD (eGFRCystatinC<60 ml/min/1.73m2) were identified. Thigh fat-free muscle volume and muscle fat infiltration (MFI) were quantified using MRI and AMRA® Researcher. Muscle volume was expressed as a sex- and BMI (body mass index)-invariant z-score. AMC was defined as the coexistence of low muscle volume (z-score <25th percentile, <-0.68 SD) and high MFI (>75th percentile; >7.69% in men and >8.82% in women), based on published UKB imaging thresholds. The mortality data were obtained through the UKB's linkage to national death registries. All-cause mortality was investigated using Kaplan-Meier curves and Cox-regression. Models were adjusted for sex, age, BMI, proteinuria, low hand grip strength, physical activity, smoking, alcohol, previous diagnosis of cancer, prevalent cardiovascular heart diseases, and type 2 diabetes.RESULTSA total of 894 participants with CKD and available mortality data were included (52.5% male, mean±SD age 72.2±5.8 years, BMI 29±5.3 kg/m2, eGFR 53.5±6.4 ml/min/1,73m2). Prevalence of AMC was 32.3%. During a mean follow-up of 3.6 years, 50 participants died. AMC was significantly associated with higher all-cause mortality compared with normal muscle composition in unadjusted analyses [hazard ratio (HR) 6.17, 95% CI 2.36-16.15, p<0.001] and remained significant after adjustment for demographic, lifestyle factors, proteinuria, and clinical factors (HR 4.21, 95% CI 1.49-11.84; p=0.007).CONCLUSIONAMC is associated with greater risk of all-cause mortality in participants with CKD, identifying a high-risk population. Preservation of muscle composition may represent an important therapeutic consideration and potential target for future interventions in CKD management.","PeriodicalId":50681,"journal":{"name":"Clinical Journal of the American Society of Nephrology","volume":"18 1","pages":""},"PeriodicalIF":9.8,"publicationDate":"2026-04-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147680370","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Cell Therapy: The Next Frontier in CKD Management?","authors":"Peter Rossing","doi":"10.2215/cjn.0000001071","DOIUrl":"https://doi.org/10.2215/cjn.0000001071","url":null,"abstract":"","PeriodicalId":50681,"journal":{"name":"Clinical Journal of the American Society of Nephrology","volume":"139 1","pages":""},"PeriodicalIF":9.8,"publicationDate":"2026-04-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147680363","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}