Faculty Bibliography

RATIONALE & OBJECTIVE/OBJECTIVE:Adults receiving maintenance hemodialysis (HD) frequently report pain, yet detailed descriptions of pain in this population are lacking. This study examines pain locations, characteristics, and associations with other symptoms in adults receiving HD. STUDY DESIGN/METHODS:Cross-sectional analysis. SETTING & PARTICIPANTS/METHODS:Adults with moderate to severe chronic pain receiving maintenance HD enrolled in the multicenter HOPE Consortium Trial from 2021 to 2023. EXPOSURES/METHODS:Sociodemographic, pain treatment, dialysis, medical comorbidity, and psychological and behavioral characteristics. Other patient-reported symptoms. OUTCOME/RESULTS:Pain interference and severity as assessed by the Brief Pain Inventory (BPI) Interference and Severity subscales (range 0-10). ANALYTICAL APPROACH/METHODS:Multivariable regression with LASSO to examine associations between participant characteristics and pain interference/severity, and Spearman's correlation to examine relationships between other symptoms and pain interference/severity at baseline. RESULTS:Among 643 participants, the median (IQR) BPI interference was 6.6 (5.1-7.9) and severity was 6.0 (4.5-7.5). 84% of participants reported pain >1 year and 75% had daily pain. 89% and 66% of participants endorsed musculoskeletal and neuropathic pain, respectively. Of 32 body regions, the median (IQR) number of painful regions was 8 (4-14). C ommon regions in females were lower back (72%), knees (64%), legs (60%), and upper back (59%). A similar pattern existed for males. In LASSO analyses, cardiovascular disease and depression were associated with significantly higher pain interference whereas White race (ref: Black race) and non-Hispanic ethnicity were associated with significantly lower pain interference. Similar findings were noted for pain severity. Pain catastrophizing and symptoms of fatigue, depression, and anxiety were moderately correlated with pain interference (r>0.4). LIMITATIONS/CONCLUSIONS:Neither relationship directionality nor causality can be inferred. CONCLUSIONS:Among adults treated with HD who have chronic pain, pain locations were numerous and diverse, with substantial musculoskeletal and neuropathic characteristics. Factors associated with pain interference were predominantly sociodemographic and psychological rather than those related to comorbid diseases and dialysis.

INTRODUCTION/BACKGROUND:The coronavirus disease 2019 (COVID-19) pandemic caused unprecedented disruptions to healthcare systems worldwide, significantly affecting patients with chronic kidney disease (CKD). In this study, we evaluated the impact of the pandemic on healthcare-seeking behavior and CKD progression among patients in New York City. METHODS:Using electronic health records from PCORnet's INSIGHT Clinical Research Network, we conducted a retrospective cohort study focused on 84,062 patients with CKD aged 50 years or older with multiple chronic conditions seen between 2017 and 2022. Patients were identified using pre-pandemic CKD diagnostic codes, and confirmed by estimated glomerular filtration rate (eGFR) measurements. Care disruption was defined as receiving fewer visits than recommended by Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. We used linear mixed-effects models to estimate annual eGFR changes and analyze trends in care visits stratified by CKD stage and care disruption. RESULTS:. Care visits declined sharply in 2020 across patients at all but the end stage, with incomplete recovery by 2022. Patients with adequate pre-pandemic care maintained their visits above KDIGO levels, while those with inadequate care increased visits during the pandemic. Pronounced eGFR decline occurred in 2020 (10.6%), with slower declines observed thereafter. CONCLUSION/CONCLUSIONS:The COVID-19 pandemic disrupted CKD care, potentially leading to reduced healthcare-seeking behavior and accelerated kidney function decline in 2020. Slower decline post-2020 may reflect improved healthcare utilization, better medication adherence, and new therapies, and other factors.

UNLABELLED:<p>Introduction: Patients with end-stage kidney disease develop cognitive impairment due to comorbidities and dialysis dependence. Among community-dwelling older adults, cognitive (CT) and exercise training (ET) are promising interventions to preserve cognition; these interventions may be tailored for adults undergoing in-center hemodialysis. METHODS:Adult (≥18 years) English-speaking patients undergoing hemodialysis (within 3 months to 3 years of initiation) were enrolled in a 2 × 2 factorial randomized controlled trial: Interventions Made to Preserve Cognitive Function Trial (IMPCT). Participants (n = 121) were block-randomized (September, 2018-February, 2023) into 4 arms: control (SC) (n = 26), intradialytic web-based CT (n = 31), ET using foot peddler (n = 29), and combined CT+ET (n = 35). Participants underwent assessments at baseline and 3 months for executive function, global cognitive function, clinical outcomes, and patient-centered outcomes. We estimated 3-month executive function change (primary outcome) and secondary outcomes using linear regression. RESULTS:There were no differences in 3-month executive function change by arm. Participants exhibited improvement in 3-month global cognitive function in CT+ET arm (Montreal Cognitive Assessment score difference = 2.1, 95% CI: 0.4-3.9), and self-reported 3-month improvement in perceived health change (score difference = 0.8, 95% CI: 0.2-1.4) in ET arm. CONCLUSION/CONCLUSIONS:Clinicians may encourage CT+ET for hemodialysis patients to improve short-term global cognitive function and perceived health. The long-term benefits of these interventions warrant further study. </p>.

BACKGROUND:Cardiovascular disease is the most common cause of morbidity and mortality in kidney transplant recipients. Screening for coronary disease is frequently required prior to kidney transplantation, but coronary intervention has not been shown to be beneficial except in complex coronary artery disease. The likelihood of finding significant coronary artery disease and the benefits of routine pre-transplant screening are uncertain. METHODS:We performed a systematic review and meta-analysis. Medline & Embase were searched to identify manuscripts published between 1998 and 2024 reporting the results of pre-transplant screening. The primary endpoints were the frequency of detecting significant coronary lesions for which there are AHA class 1 indications for revascularization: a) >50% left main stenosis; or b) multi-vessel disease with ejection fraction < 35% during pre-kidney transplant screening. Secondary endpoints included frequency of detecting multivessel disease, proximal left anterior descending artery (LAD) disease, and number of patients who underwent invasive coronary angiography. Meta-regression was used to explore outcome heterogeneity according to the presence of hypertension, diabetes, and age. RESULTS:We identified 1273 studies out of which 44 met eligibility criteria. The mean prevalence of class 1 indications was 2%, although the heterogeneity was high with estimates ranging from 0% to 17%. Estimated prevalence of proximal LAD disease was 2% and left main stenosis was 1%, whereas 10% of patients had multi-vessel coronary artery disease, and 35% were referred for invasive angiography. There was no evidence of significant heterogeneity according to sex of the population or prevalence of diabetes or hypertension. CONCLUSIONS:Identification of class I indications for revascularization during pre-transplant coronary screening was rare.

BACKGROUND:Moderate kidney dysfunction is independently associated with increased cardiovascular death. Sudden cardiac arrest (SCA) accounts for at least 25% of chronic kidney disease (CKD) death. This study aimed to evaluate the impact of moderate CKD on SCA risk. METHODS:(2021 Chronic Kidney Disease Epidemiology Collaboration formula). A population-based SCA study in southern California was used for validation. RESULTS:estimated glomerular filtration rate drop to <90 increased SCA risk (odds ratio, 1.24 [95% CI, 1.18-1.31]). Similar findings were observed in the validation cohort (817 SCA and 3249 controls), where moderate CKD was associated with SCA (odds ratio, 1.54 [95% CI, 1.18-2.00]). CONCLUSIONS:Moderate CKD is associated with an increased risk of SCA in the general population. Further research into the potential integration of moderate renal dysfunction into SCA risk stratification are warranted.

BACKGROUND:Falls are thought to be common in patients undergoing maintenance hemodialysis, but little is known about their frequency or outcomes. In this prospective study, we sought to increase our knowledge regarding the incidence, timing, circumstances, and outcomes of falls in this population. METHODS:Between January 2021 and April 2023, adults undergoing maintenance hemodialysis from 103 U.S. dialysis facilities were enrolled in the HOPE Consortium trial, which randomized participants with moderate or severe chronic pain to a pain coping skills cognitive behavioral therapy intervention or usual care. Occurrence of falls was a pre-specified trial outcome. The research team inquired about falls at each four-week follow-up visit during the 36-week study. Multivariable regression was used to explore associations of demographic and clinical characteristics, including patient-reported symptoms, with fall risk. RESULTS:Of 643 trial participants, 178 (28%) experienced 293 falls over a cumulative follow-up period of 429 participant-years for an overall rate of 0.68 falls per participant-year (95% CI: 0.61, 0.76). Accidents were the most frequent cause of falls (38%). It was rare for falls to be related to the hemodialysis treatment or to occur in the hemodialysis unit. Of the 293 falls, 36 (12%) were evaluated in the emergency department without subsequent hospitalization, 41 (14%) resulted in a hospital admission, and 19 (7%) led to a fracture. In multivariable analyses, neither demographic characteristics severity of pain symptoms or medication use such as opioids at enrollment was associated with the fall risk. CONCLUSIONS:Falls were common in this cohort of maintenance hemodialysis patients with chronic pain, occurring in 28% of individuals during a planned follow-up of 36 weeks. Falls rarely occurred in the dialysis unit, with the vast majority occurring at participants' homes and due to accidental causes. There was no significant association between patient-reported symptoms or medication use and the risk of subsequent falls. TRIAL REGISTRATION/BACKGROUND:NCT04571619.

IMPORTANCE/UNASSIGNED:Hyperkalemia is a common complication of taking a renin-angiotensin-aldosterone system inhibitor (RAASi). Post hoc analyses of large randomized clinical trials suggested that the addition of sodium-glucose cotransporter 2 inhibitors (SGLT2i) may attenuate this risk. It is unknown if this observation extends to daily clinical practice. OBJECTIVE/UNASSIGNED:To evaluate the association between SGLT2i initiation and hyperkalemia in individuals receiving RAASi with a background of diabetes, heart failure, or chronic kidney disease. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This population-based retrospective cohort study was conducted in Ontario, Canada, from July 1, 2015, to June 30, 2021. The cohort comprised adults 66 years and older who were prescribed a RAASi and had a history of diabetes or heart failure, an estimated glomerular filtration rate of less than 45 mL/min/1.73 m2, and/or a urine albumin to creatinine ratio of greater than 30 mg/mmol. The data were analyzed between March 28, 2023, and March 22, 2024. EXPOSURE/UNASSIGNED:The study exposure was a new prescription of an SGLT2i compared to noninitiation of an SGLT2i. Inverse probability of treatment weighting by a propensity score for the receipt of SGLT2i was used to achieve balance of baseline covariates in both exposure groups. MAIN OUTCOMES AND MEASURES/UNASSIGNED:The primary study outcome was hyperkalemia, defined as a serum potassium of greater than 5.5 mEq/L or an administrative code for an inpatient or outpatient encounter with hyperkalemia within 1 year of the index date. RESULTS/UNASSIGNED:A total of 20 063 individuals who initiated an SGLT2i (mean [SD] age, 76.9 [6.6] years; 12 020 [59.9%] male) were compared to a pseudopopulation of 19 781 nonusers (mean [SD] age, 76.8 [7.0] years; 11 731 [59.3%] male). In the overall cohort, 95% had diabetes, 17% had heart failure, and 32% had stage 3 to 5 chronic kidney disease. SGLT2i initiation was associated with a lower risk of hyperkalemia (hazard ratio, 0.89 [95% CI, 0.82-0.96]). SGLT2i users had a significantly lower rate of RAASi discontinuation compared to nonusers (36% vs 45%; P < .001). CONCLUSIONS AND RELEVANCE/UNASSIGNED:This cohort study demonstrated that, among individuals with diabetes, heart failure, or chronic kidney disease who were receiving a RAASi, SGLT2i initiation was associated with a lower risk of hyperkalemia and RAASi discontinuation.