Faculty Bibliography

Atrial fibrillation (AF) is the most common sustained arrhythmia, with a prevalence and incidence significantly higher in adults with chronic kidney disease (CKD) compared to the general population. This risk increases with reduced kidney function, affecting up to 25% of all CKD patients and 30% of those on receiving chronic dialysis. AF is associated with increased morbidity and mortality, including higher risks of stroke, heart failure, myocardial dysfunction and progression to kidney failure. The bidirectional relationship between AF and CKD is driven by a convergence of traditional risk factors-such as hypertension and diabetes-and CKD-specific abnormalities. Key pathophysiologic mechanisms include systemic inflammation, oxidative stress, autonomic dysfunction, and disordered mineral metabolism. These factors promote structural remodeling, atrial fibrosis, and electrical instability, creating a highly arrhythmogenic substrate. Treatment options for AF include anticoagulation, rate and rhythm control medications, other cardiovascular therapies (e.g. sodium glucose cotransporter 2 inhibitors[SGLT2i]) and procedures aimed at normalizing rhythm and reducing stroke risk. Patients with CKD are often undertreated with AF medications and procedures, in part due to lack of robust randomized clinical trial data on efficacy and safety, particularly with advanced CKD. This narrative review summarizes key literature on the epidemiology, risk factors, mechanisms and treatment of AF in adults with CKD, and highlights critical areas for future research.

BACKGROUND:Legalization of cannabis across several US states may increase its use by individuals on hemodialysis, particularly among those with chronic pain. Contemporary data on frequency or factors associated with cannabis use by this population are limited. METHODS:We conducted a secondary analysis of the HOPE Consortium Trial to Reduce Pain and Opioid Use in Hemodialysis, a randomized trial that tested whether a cognitive behavioral therapy intervention lowered pain interference in people with chronic pain receiving hemodialysis at 103 US dialysis facilities. We analyzed baseline demographic characteristics, social and medical history, pain intensity, pain interference, and cannabis use. Multivariable logistic regression was used to examine associations of baseline data with cannabis use. Linear regression was used to examine whether cannabis use modified the response to the intervention. RESULTS:Among 643 participants, 102 (16%) reported current cannabis use, 133 (21%) reported former use, and 408 (63%) had never used. Current users were younger than never or past users combined (median age 54 vs. 63 years) and more likely to be disabled (79% vs. 66%), to have received dialysis for >5 years (40% vs. 30%), and to self-report depression (41% vs. 31%), anxiety (28% vs. 20%), or any psychological disorder (51% vs. 38%), and less likely to be married (16% vs. 34%). Current cigarette smoking (odds ratio [OR]=3.22, 95% confidence interval (CI) 1.61-6.46) and alcohol use (OR=2.82, 95% CI 1.37-5.80) were independently associated with cannabis use, as were age, relationship status, neighborhood segregation index, and cocaine/heroin use. Cannabis use did not modify response to the intervention. CONCLUSIONS:Current cannabis use was reported by 16% of HOPE participants and was more common among younger, unmarried individuals who use other substances, but did not alter response to our intervention. More research is needed on the consequences of cannabis use among people receiving hemodialysis.

INTRODUCTION/UNASSIGNED:Tc-DTPA) tracer clearance is the gold standard for bilateral kidney function, involving extended clearance times and radioactivity. Imaging-derived total kidney volumes are functional proxies but do not probe tissue quality. METHODS/UNASSIGNED:tests. RESULTS/UNASSIGNED:= 0.880 and 0.700, respectively). In addition, MR metrics differentiated proteinuria status. DISCUSSION/UNASSIGNED:Advanced DW MRI metrics may provide surrogates of mGFR and proteinuria. Parameters from bipolar encoding in diastole (emphasizing tubular flow) and flow compensation in systole (emphasizing vascular flow) were often informative.

RATIONALE & OBJECTIVE/UNASSIGNED:Randomized controlled trials (RCTs) show that integrated palliative care can improve symptoms compared with usual care in many serious illnesses, yet there are no comparable RCTs in chronic kidney disease (CKD). STUDY DESIGN/UNASSIGNED:We conducted a pilot feasibility RCT comparing kidney palliative care (KPC) integrated with CKD care with usual CKD care. SETTING & PARTICIPANTS/UNASSIGNED:English and Spanish speakers aged ≥18 years with CKD stage IV and V, or receiving dialysis, seen at an urban safety-net hospital. EXPOSURES/UNASSIGNED:Participants were randomized to usual CKD care or to usual CKD care plus 6-monthly ambulatory KPC visits. OUTCOMES/UNASSIGNED:Primary outcomes were feasibility of recruitment, retention, intervention delivery, and data collection. Secondary outcomes included change in symptom burden at 6 months, measured by the Integrated Palliative Outcome Scale (IPOS)-Renal (lower scores represent lower burden), quality of life measured by the Kidney Disease Quality of Life 36-item survey, and engagement in advance care planning. ANALYTICAL APPROACH/UNASSIGNED:Feasibility outcomes are reported as proportions and clinical outcomes as descriptive summaries of change in scores. RESULTS/UNASSIGNED:Of the 146 people approached, 84 (56%) consented, 75 (89%) were randomized, and 57 (76%) completed the trial. 56% of participants were Hispanic and 32% were Black, with 49% on Medicaid and 13% uninsured. The mean age of participants was 61 years, and 31% were receiving dialysis. A mean of 4-6 intervention visits was attended. At 6 months, the intervention group had a 4.1-point decrease in IPOS score (standard deviation 13.4), whereas the mean IPOS score of the control group increased by 0.6 points (standard deviation 7.8) from baseline. LIMITATIONS/UNASSIGNED:Small sample size and limited number of providers to assess generalizability. CONCLUSIONS/UNASSIGNED:We demonstrate the feasibility of an RCT comparing integrated KPC with usual CKD care in a safety-net hospital. Although this study was not powered to detect significance in change of clinical outcomes, our findings suggest that there is value in testing KPC in efficacy trials and that these are feasible.

BACKGROUND:Tools for predicting heart failure (HF) in CKD patients remain limited. We aimed to study whether standard ECG features or heart rate variability parameters predict de novo HF hospitalization in individuals with CKD. METHODS:Utilizing a large NYU ECG database linked with electronic health records (2012-2021), we analyzed a cohort of patients with pre-existing CKD. Besides standard ECG features, we extracted heart rate variability (measures the time between consecutive heart beats in milliseconds) features from the ECGs as predictors. The index ECG was the first ECG performed after the index eGFR date (baseline) and was required to be done prior to initiation of dialysis, end-stage kidney disease (ESKD), or transplant. The primary outcome was time to index HF hospitalization (≥30 days after the index ECG) based on discharge ICD-10 codes. LASSO-penalized Cox regression was used to identify predictors. Sensitivity analyses used Fine-Gray competing risk models for death and ESKD. RESULTS:Among 11,409 individuals (median age: 72; ∼50% male) with a median of 976 days, 880 individuals (8%) experienced an index HF hospitalization. Models incorporating ECG and clinical parameters had excellent discrimination (C-statistic 0.76 in the training set and 0.73 in the validation set). Among ECG features, the PR interval, corrected QT, and T axis were independently associated with higher risks of index HF hospitalization ≥30 days after the index ECG in both primary models (p<0.001 for all) and in models accounting for competing risks (p<0.01 for all). History of arrhythmia (hazard ratio (HR, 1.60, 95% CI: 1.36-1.88), valvular disease (HR1.51, 95% CI: 1.27-1.81), and diabetes (HR 1.41, 95% CI: 1.22-1.65) were the strongest clinical predictors. HRV parameters were not independently associated with HF. CONCLUSIONS:Although ECG-derived HRV indices were not independently associated with risk of HF, several standard ECG features are associated with HF hospitalization in CKD.

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>.

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.