BACKGROUND:Communication is central to living donor kidney transplantation (LDKT). Patients must understand treatment options, donor risks, family implications, and the possibility of pre-emptive transplantation. However, how LDKT communication is perceived and managed by nephrology and transplant professionals across care settings remains insufficiently explored. METHODS:A qualitative descriptive interview study was conducted with nephrologists and nurses involved in communication with patients who may be LDKT candidates. Participants were purposively sampled from Italian low- (1-50 procedures) and high-volume (>50 procedures) transplant centers and dialysis centers across Northern, Central, and Southern Italy. Semi-structured interviews were conducted between May-October 2025 and analyzed using reflexive thematic analysis. RESULTS:Eighteen professionals were interviewed: 10 nephrologists and 8 nurses. Seven themes were identified: introducing LDKT in the care pathway; communicating benefits and donor risks; navigating recipient, donor, and family dynamics; barriers to equitable communication; professional attitudes and trust; communication competence and team coordination; and peer support and patient associations. Communication emerged as a longitudinal, relational, and organizationally mediated process. Participants emphasized early, repeated, and tailored information, with attention to donor voluntariness, recipient reluctance, family expectations, and socioeconomic constraints. High-volume transplant centers described more structured pathways; lower-volume and dialysis centers reported greater reliance on individual initiative, relational continuity, and local routines. CONCLUSIONS:LDKT communication should be recognized as a clinical and ethical competence. Improving practice requires structured training, interprofessional coordination, time, accessible materials, and stronger integration between dialysis units, transplant centers, and patient associations. Standardized yet personalized communication may support informed, voluntary, and more equitable decision-making.
BACKGROUND:Renal ultrastructural diagnosis still relies on glutaraldehyde fixation, but this fixative is toxic and has limited tissue penetration. We evaluated whether acid-free glyoxal can provide adequate preservation for renal transmission electron microscopy and whether diagnostically useful information can be recovered from paraffin-embedded tissue. METHODS:Normal human renal cortical tissue from nephrectomy specimens was fixed in acid-free glyoxal for 24, 48, or 72 hours and processed for transmission electron microscopy; tissue fixed in 2.5% buffered glutaraldehyde served as a control. Additional acid-free glyoxal-fixed paraffin-embedded samples were recovered and reprocessed. Preservation of podocyte foot processes, slit diaphragms, endothelial fenestrations, and the glomerular basement membrane were assessed. Conventional histology, automated immunohistochemistry, and exploratory immunofluorescence were also evaluated. RESULTS:Fixation for 24 hours preserved the main ultrastructural components of the glomerular filtration barrier, although the basement membrane appeared less compact than after glutaraldehyde fixation. Preservation improved markedly after 48 and 72 hours, with clear slit diaphragms, endothelial fenestrations, and balanced image contrast. Tissue recovered from paraffin blocks also yielded adequate ultrastructural detail for common diagnostic questions. Conventional histology was preserved, whereas automated immunohistochemical reactivity was reduced for the markers tested. CONCLUSIONS:With appropriate fixation times, acid-free glyoxal provides good to excellent preservation of renal glomerular ultrastructure and allows recovery of diagnostically useful transmission electron microscopy findings from paraffin-embedded tissue, supporting its use as a safer and more versatile alternative to glutaraldehyde in renal diagnostic pathology.
BACKGROUND:IgA nephropathy (IgAN) is associated with a high risk of kidney failure. Whenever this occurs, the best treatment option is kidney transplantation. IgAN recurrence in the kidney allograft may increase the risk of allograft loss. The association of glomerular crescents in native IgAN is a negative prognostic factor for the progression to kidney failure. The aim of our study was to clarify whether the presence of crescents in native kidney biopsies represents a risk factor for IgAN recurrence in renal allografts. METHODS:The association between glomerular crescents in native kidney biopsies and IgAN recurrence was investigated in IgAN patients who underwent kidney transplantation at Lausanne University Hospital from 2003 to 2019. A systematic literature review was performed in MEDLINE, Embase, Cochrane CENTRAL, Web of Science and PMC from inception to November 2025, excluding reviews. Aggregate data were analyzed in a meta-analysis. The overall Risk Ratio (RR) with their corresponding 95% confidence interval (95% CI) was obtained via the Hartung-Knapp-Sidik-Jonkman adjustment method, after verifying heterogeneity (I2). Reporting bias was visualized in a funnel plot using STATA. RESULTS:The Lausanne cohort included 63 patients with IgAN who underwent kidney transplantation. We found no association between glomerular crescents in native kidney biopsies and IgA recurrence in the renal allograft. Five additional cohorts were included in our meta-analysis, ultimately merging data from 311 patients, of whom 23% with recurrent IgAN. Crescent prevalence ranged from 12 to 62%, confirming the absence of association with an increased risk of IgAN recurrence [RR 1.53 (95% CI: 0.40-5.90), P = .41]. CONCLUSIONS:Glomerular crescents, especially when present in more than 25% of viable glomeruli, remain an unfavorable prognostic factor for the progression of IgAN to kidney failure; however, they may not represent a risk factor for disease recurrence in renal allografts.
BACKGROUND:Olfactory dysfunction is increasingly recognized in patients with chronic kidney disease, particularly among those receiving maintenance hemodialysis (HD). Despite its potential clinical relevance for nutrition and quality of life, longitudinal data on olfactory function in HD patients remain limited. METHODS:This prospective observational study included 100 patients undergoing maintenance HD and 52 healthy controls. Olfactory function was assessed using the identification component of the Sniffin' Sticks Test and expressed as the percentage of correctly identified odors. Sixty HD patients underwent repeat olfactory testing after approximately one year. Multivariable regression models were used to evaluate clinical and biochemical factors associated with baseline olfactory function and its longitudinal change. RESULTS:Baseline olfactory identification scores were significantly lower in HD patients compared with controls (60.6% vs 76.1%, P < .001). Overall, 91% of HD patients exhibited olfactory dysfunction, including 74% with hyposmia and 17% with anosmia. Higher global cognitive function scores (β = .42, P = .001) and higher serum albumin levels (β = .29, P = .015) were independently associated with better baseline olfactory performance. Baseline olfactory performance independently predicted longitudinal change (β = .012, P = .006), whereas dialysis adequacy (Kt/V) was not associated with olfactory outcomes. CONCLUSIONS:Olfactory dysfunction is highly prevalent in patients undergoing maintenance hemodialysis and is closely linked to cognitive and serum albumin levels. Longitudinal olfactory trajectories vary across individuals and did not appear to be strongly associated with dialysis adequacy in this cohort, suggesting that olfactory impairment may reflect overall disease burden rather than dialysis dose.
Hypertension in haemodialysis is common, prognostically important, and difficult to manage because blood pressure measurement is often imprecise, extracellular volume is dynamic, and low blood pressure may reflect heart failure, frailty, impaired forward flow, autonomic dysfunction, or excessive ultrafiltration rather than therapeutic success. Contemporary evidence supports ambulatory blood pressure monitoring as the reference standard and home blood pressure monitoring as the most practical longitudinal method, while accepted targets remain unsettled. Treatment should begin with standardised assessment of interdialytic blood pressure burden and sodium-volume control through dietary sodium restriction, dialysate sodium consideration, dry-weight reassessment, ultrafiltration management, and adequate treatment time. This sequence helps distinguish true treatment resistance from pseudoresistance caused by dialysis-unit measurement artefacts, volume excess, short treatment time, sodium burden, medication nonadherence, poorly timed dosing, or dialytic drug removal. Once persistent hypertension is confirmed despite sodium-volume and dry-weight-oriented care, pharmacotherapy becomes necessary. Beta-blockers have the strongest outcome-linked support in haemodialysis, whereas calcium channel blockers (CCBs) are practical complementary agents, and conventional renin-angiotensin system (RAS) blockade is best reserved for selected indications. Mineralocorticoid receptor antagonists (MRAs) should be considered cautiously because recent large dialysis trials and updated meta-analytic evidence have not confirmed clear cardiovascular benefit. Sacubitril/valsartan is biologically plausible when hypertension coexists with heart failure with reduced ejection fraction, left ventricular dysfunction, recurrent congestion, or high natriuretic peptide burden. However, it should be framed as a promising but not yet established selective option rather than routine escalation therapy.
The discovery of Cystic Fibrosis Transmembrane conductance Regulator (CFTR) modulators has revolutionized the management and clinical outcomes of cystic fibrosis. However, the pleiotropic effects of these new treatments outside the lungs are still largely unknown. Here we report two unusual cases of acute kidney injury in patient with cystic fibrosis (pwCF) following a first exposure to aminoglycoside while under triple correction therapy. We hypothesize that CFTR modulator therapy restored the reabsorption of aminoglycoside in the proximal tubule of the kidneys, a process that is primarily deficient in patients with cystic fibrosis, thus exacerbating the toxicity of these molecules.
BACKGROUND:Clinical evidence comparing the renal impact of proton pump inhibitors (PPIs) and Histamine-2 receptor antagonists (H2RAs) in patients with chronic kidney disease (CKD) receiving traditional non-steroidal anti-inflammatory drugs (tNSAIDs) is lacking. We evaluated CKD progression risk associated with PPIs versus H2RAs within a tNSAID-treated cohort to inform clinical prescribing. METHODS:This retrospective cohort study used South Korean nationwide claims data (2018-2023). Stabilized inverse probability of treatment weighting (SIPTW) balanced the cohorts. Restricted cubic spline Cox regression addressed non-linear associations between CKD progression and cumulative exposure to tNSAIDs and acid suppressants (PPIs or H2RAs). Sensitivity analyses addressing unspecified CKD stages confirmed the robustness of the primary findings. RESULTS:Among 141 093 tNSAID initiators with CKD prescribed PPIs (n = 5315) or H2RAs (n = 7112), PPIs were associated with higher CKD progression risk than H2RAs (adjusted hazard ratio [aHR] 1.38, 95% CI 1.10-1.74). Baseline comorbidities-hypertension (aHR 2.03, 95% CI 1.37-2.99]), diabetes (1.69 [1.29-2.21]), and a history of kidney disease (1.43 [1.13-1.81])-and prior diuretic use (2.00 [1.56-2.58]) were associated with increased risk of CKD progression. In contrast, dapagliflozin or empagliflozin use was protective (0.49 [0.27-0.89]). The risk of CKD progression for PPIs relative to H2RAs was most pronounced in females, those with CKD stage 3, patients aged ≥71 years, and those with 1-15 days of treatment (all P < .05). CONCLUSION:Our findings suggest that H2RAs may be associated with a lower risk of CKD progression than PPIs in tNSAID users with CKD, potentially offering a safer alternative when PPI therapy is not indispensable.
BACKGROUND:This study aimed to investigate the associations between the physical activity of hemodialysis (HD) patients and their informal caregivers and measures of their well-being and quality of life (QoL). METHODS:This multi-center cross-sectional study included one hundred and four HD patient- informal caregiver pairs [HD patients: 76 males (73.1%) vs. Caregivers: 32 males (30.8%)], who completed a form collecting demographic and clinical information, followed by five self-reported questionnaires: 1) The International Physical Activity Questionnaire (IPAQ) short form, 2) the Center for Epidemiological Studies Depression Scale (CES-D), 3) the Generalized Anxiety Disorder Scale (GAD-7), 4) the Fatigue Assessment Scale (FAS) and 5) the 36-Item Short Form Survey Instrument-2nd version (SF-36v2). Additionally, caregivers were also asked to complete the Zarit Burden Interview (ZBI). RESULTS:HD patients had a mean IPAQ score of 856.4 MET-min/week (moderate activity). Their mean questionnaire scores were: CES-D 14.5 ± 9.0, GAD-7 5.1 ± 5.4, FAS 24.0 ± 8.0, physical component summary 41.0 ± 10.7, and mental component summary 47.7 ± 9.7. Notably, 38.5% of patients exhibited depressive symptomatology and 55.8% reported fatigue. Informal caregivers had a mean IPAQ score of 1564 MET-min/week (moderate activity) and the following mean scores: CES-D 13.7 ± 8.2, GAD-7 4.7 ± 4.7, FAS 20.4 ± 6.8, ZBI 22.2 ± 15.6, physical component summary 52.3 ± 9.7, and mental component summary 48.7 ± 8.3. Among informal caregivers, 36.5% showed depressive symptoms and 38.0% reported fatigue. CONCLUSIONS:The study demonstrated the significance of integrating physical activity and exercise into the daily routines of HD patients and their informal caregivers. More active individuals reported experiencing less fatigue, greater vitality, and improved overall physical health.
BACKGROUND:To investigate the association of a nurse-led dynamic urine monitoring protocol with acute kidney injury (AKI) risk and clinical outcomes in patients with severe hymenoptera stings. METHODS:A historically controlled retrospective design was adopted, with nurse-led dynamic urine monitoring protocol implementation date (January 1, 2022) as the cutoff. Patients were divided into historical control (2019-2021) and dynamic monitoring (2022-2024) groups. The protocol included objective urine color grading, high-frequency dynamic recording, and a standardized situation-background-assessment-recommendation escalation protocol. After propensity score matching was used to balance baseline covariates, AKI incidence and intervention timeliness were compared. Multivariate logistic regression was used to assess the independent association of nurse-led dynamic urine monitoring protocol with AKI risk. RESULTS:Post-propensity score matching, 260 patients were included. Compared with the historical control group, the dynamic monitoring group had lower overall AKI incidence (33.8% vs. 52.3%, P = .003) and fewer patients progressing to severe AKI (Kidney Disease Improving Global Outcomes [KDIGO] stages 2-3; 27.7% vs. 42.3%, P = .013). Regarding response timeliness, the dynamic monitoring group showed shorter times to initiate urine alkalinization and achieve target fluid resuscitation volume, as well as a shorter length of stay in the emergency intensive care unit ([ICU]; all P < .001). Nurse-led dynamic urine monitoring protocol was independently associated with a lower AKI risk (odds ratio [OR] = 0.409, 95% confidence interval [CI]: 0.232-0.720, P = .002). CONCLUSION:Nurse-led dynamic urine monitoring protocol implementation is independently associated with reduced AKI incidence and shorter emergency ICU length of stay in patients with severe hymenoptera stings. By enabling early recognition and standardized response, nurse-led dynamic urine monitoring protocol is a potentially effective strategy for refined nursing care in this high-risk population.
BACKGROUND:Anti-complement factor H antibody- (anti-CFH Ab) associated atypical hemolytic uremic syndrome (aHUS) is a known cause of pediatric complement-mediated thrombotic microangiopathy. In our center, plasma exchange (PEX) until remission paired with immunosuppression continues to be the mainstay of therapy, due to limited access to eculizumab. We wanted to study the long-term outcome of this cohort. METHODS:We conducted a retrospective cohort study of children (<12 years) with Anti-CFH Ab-associated aHUS admitted between January 2017 and December 2024 at our center. Clinical, laboratory, treatment, and outcome data were retrieved from medical records. The primary outcome was renal recovery, defined as eGFR >90 mL/min/1.73 m2 with normal blood pressure, no significant proteinuria, and absence of hematuria at last follow-up or at 5 years. RESULTS:Of 66 records screened, 40 children were eligible. Median age at presentation was 7 years (interquartile range [IQR] 5,8). Median anti-CFH Ab titer was 306 AU/mL (IQR 214-426). Low C3 was noted in 55% of subjects. All patients received PEX (median 11 cycles; IQR 7.25, 20) and immunosuppression. Median follow-up was 24 months (IQR 7-53). At last follow-up, 21 (52.5%) achieved complete renal recovery, while 19 (47.5%) had CKD stage 2-4. Relapse incidence was 7.1 per 100 person-years, usually within 6 months of onset. No baseline clinical, laboratory, or treatment variable except duration of dialysis independently predicted renal recovery. Persistent proteinuria was observed up to 6 months but subsequently improved. CONCLUSIONS:PEX paired with immunosuppression remains effective for anti-CFH Ab-associated aHUS, but further studies are needed to refine protocols and evaluate complement inhibitors for improved long-term outcomes.
BACKGROUND:Access to, and experience of, chronic kidney disease (CKD) care is inequitable-with barriers to accessing quality care for marginalised groups. We conducted an exploratory study employing qualitative approaches to understand the factors that influence access to, and experience of, healthcare services for marginalised people with CKD and at risk of CKD. METHODS:An exploratory study employing qualitative approaches was conducted as a cross-sector collaboration between kidney care services and an activist, antiracist community-based research and social justice organisation (Mabadiliko Community Interest Company (CIC)). Two groups were recruited: 1) those with risk factors for CKD or early-stage CKD, and 2) people who presented late to kidney care services. Semi-structured interviews were co-designed with people with lived experience and conducted by Mabadiliko CIC. Thematic analysis was undertaken, with themes refined by participants. RESULTS:Twenty interviews were undertaken with a diverse cohort of participants. Knowledge and awareness of CKD was limited, and compounded by a lack of delivery of accessible, culturally congruent information. Significant barriers to accessing kidney care exist for marginalised people, including people who are from global majority ethnic backgrounds, Disabled people, and/or people experiencing material hardship. These barriers are compounded by interpersonal discrimination and paternalistic power dynamics within healthcare interactions. CONCLUSION:This study captures the experiences of marginalised people at different stages of their journey with CKD, in accessing and engaging with kidney care services. Participants faced a complex array of challenges, highlighting opportunities for multi-level intervention. We outline recommendations to address these issues, co-developed with participants.
BACKGROUND:Evidence on the effects of 12-week telehealth-supported home-based exercise in advanced non-dialysis chronic kidney disease (CKD) remains limited. This study evaluated its effects on functional capacity, sarcopenia risk, and patient-reported outcomes in patients with stage 4-5 CKD. METHODS:In this prospective, parallel-group randomized controlled trial (October 2024-July 2025), 54 non-dialysis patients aged ≥45 years with stage 4-5 CKD were randomized 1:1 to a 12-week telehealth-supported home-based exercise program plus usual nephrology care or usual care alone. Complete-case analyses included 51 participants (exercise group: n = 25 [stage 4, n = 21; stage 5, n = 4]; control group: n = 26 [stage 4, n = 20; stage 5, n = 6]). The primary outcome was change in 6-minute walk test distance. Secondary outcomes included physical performance, sarcopenia risk, fatigue, mood symptoms, sleep quality, and health-related quality of life. RESULTS:Fifty-one participants completed the study (exercise group, n = 25; control group, n = 26). Compared with controls, the exercise group showed a greater improvement in 6-minute walk test distance (+29.41 ± 35.63 m vs -19.27 ± 33.62 m; P < .001), which remained significant after covariate adjustment. Significant improvements were also observed in sarcopenia risk, fatigue, mood symptoms, sleep quality, physical performance, and quality of life. Among intervention participants, 40% used the web-based platform and 60% received video-based support. CONCLUSIONS:A 12-week telehealth-supported home-based exercise program significantly improved functional capacity and multiple patient-reported outcomes in patients with non-dialysis stage 4-5 CKD.
BACKGROUND:Management of hyperkalemia (HK) is challenging and suboptimal. This study analyzed the prevalence of HK and undetected HK, as well as management, clinical outcomes, healthcare resource utilization (HCRU), and costs. METHODS:Observational study comprising cross-sectional and retrospective analyses using secondary data from electronic health records (608,514 adults) from BIG-PAC database. The population comprised adults (n=7006) with a diagnostic code for HK, potassium >5.0 mmol/L and/or treatment for HK from January 2013 to December 2020, and follow-up ≥2 years. Index date was defined as the first HK event and undetected HK when diagnosis and/or treatment were not observed despite potassium >5.0 mmol/L at index date. RESULTS:The prevalence of HK was 1.15%, of which 0.77% was undetected. Patients with undetected HK (vs diagnosed HK) were younger and less frequently had atherosclerotic cardiovascular disease (20.0% vs 24.1%; p<0.001) and chronic kidney disease (10.8% vs 42.4%; p<0.001). In undetected HK, 58.7% had mild, 35.8% moderate, and 5.4% severe HK. Regarding outcomes, 10.9% and 18.8% (p<0.001) died, and annual hospitalization rates were 15.6% and 33.1% (p<0.001), respectively. Outcomes were more common in diagnosed HK vs undetected HK. Annual costs per patient were higher in diagnosed HK vs undetected HK (€7615 [6381] vs €5005 [4619], USD9241.6 [7743.9] vs USD6074.1 [5605.6]; p<0.001). CONCLUSIONS:Around 1% of patients in Spain had HK; of these, two-thirds were undetected, including patients with moderate-to-severe HK. Despite lower comorbidity burden, these patients experienced substantial clinical events and suboptimal use of cardio-renal protective therapies.
BACKGROUND:Online hemodiafiltration (HDF) enhances the removal of middle molecules, including large-middle molecules, through the combined action of diffusion and convection. Randomized controlled trials (RCTs) and individual participant data (IPD) meta-analyses demonstrate improved cardiovascular outcomes and, importantly, a reduction in all-cause mortality when HDF is delivered with sufficiently high convective volumes in post-dilution mode. These findings underscore that an adequate convective dose is a critical determinant of clinical benefits compared to high-flux hemodialysis (HD). However, translation into consistent clinical practice remains heterogeneous. Therefore, the Italian Society of Nephrology convened an international, multidisciplinary panel to synthesize randomized evidence comparing online post-dilution HDF with high-flux HD in adults receiving maintenance hemodialysis. METHODS:The critical outcomes included all-cause and cardiovascular mortality, whereas the important outcomes included selected patient-reported health domains, including physical function, patient-perceived cognitive function, pain interference, social participation, and health-related quality of life. The certainty of the evidence was appraised using the GRADE methodology. Structured guidance recommendations and best practice statements were developed through a consensus. Sensitivity analyses were performed to assess the robustness of the observed mortality effect. RESULTS:High-volume post-dilution HDF reduces all-cause mortality (hazard ratio 0.84; 95% CI 0 74-0.95; moderate-certainty evidence) and cardiovascular mortality (hazard ratio 0.78, 95% CI 0.64-0.96; moderate-certainty evidence; data from an individual participant data analysis of trials of high volume HDF versus high-flux HD). Emerging evidence suggests slower deterioration in selected patient-reported domains, including physical function, patient-perceived cognitive function, pain interference, and social participation (low-certainty evidence). Safety with on-line post-dilution HDF has been demonstrated to be similar to that of high-flux HD. CONCLUSIONS:Online post-dilution HDF should be regarded as a dose-dependent therapy. We recommend its use to reduce cardiovascular mortality and suggest high-volume HDF to reduce all-cause mortality and slow deterioration in selected patient-reported health domains. Effective implementation in clinical practice requires a targeted and individualized approach with careful optimization and monitoring of convective volume, along with appropriate treatment time, blood-flow rate, supporting infrastructure, and consideration of patient preferences. This guidance provides evidence-based recommendations and best practice statements for its use.
BACKGROUND:Hemodialysis (HD) patients face a markedly higher risk of falls compared to the general population, leading to fractures, functional decline, and increased mortality. Malnutrition, particularly protein-energy wasting (PEW), is thought to contribute to this vulnerability; however, few studies have prospectively examined the predictive value of nutrition-focused and functional phenotypes in fall risk assessment. METHODS:In this prospective, single-center study, 68 adult HD patients were followed over two years for fall events. Nutritional status was assessed biannually using the Nutrition-Focused Physical Exam (NFPE), serum albumin, and other biochemical markers. Clinical, biochemical, and functional parameters were compared between patients who experienced one or more falls and those who did not, and multivariable logistic regression identified independent predictors of falls. RESULTS:Falls occurred in 38.2% of participants, with 45% of these resulting in major injuries. NFPE-related malnutrition (OR= 6.684, p = 0.020), lower albumin levels (OR=0.160, p=0.015), assisted or dependent ambulation (OR=19.167, p=0.001), and orthostatic hypotension (OR=4.979, p=0.035) were identified as significant fall risk factors. Lower potassium levels were significantly associated with falls in bivariate analysis (p = 0.001) and showed a borderline association in multivariable analysis (p=0.053). CONCLUSIONS:NFPE-defined malnutrition and functional impairment were independently associated with higher odds of falls in this pilot cohort. Routine incorporation of NFPE, targeted nutritional optimization, and functional support strategies may help inform future fall-risk assessment strategies. Larger multicenter studies are needed to validate these findings and to further clarify the potential role of potassium balance in fall risk among hemodialysis patients.
BACKGROUND:Patients with chronic kidney disease (CKD) undergoing dialysis have a high mortality risk. Cardiovascular and infectious events are the leading causes of death in this population; in Brazil, data on cause-specific mortality remain limited. Therefore, we analyzed the causes of death among patients treated within a national dialysis facility network. METHODS:This retrospective study evaluated adjudicated causes of death between 2022 and 2024 across 32 Fresenius Medical Care facilities. During monthly meetings, deaths occurring in the previous month were reviewed at each facility, in the presence of the local medical director, head nurse, and two physicians from the national headquarters. RESULTS:During the study period, 9763 patients underwent dialysis (96% hemodialysis/hemodiafiltration; 4% peritoneal dialysis). A total of 1994 deaths were recorded, of which 1742 were adjudicated and included in the analysis. At death, the median age was 72 years, 59% had diabetes, and the dialysis vintage was 37 months. Infection was the leading cause of death (41%), followed by cardiovascular disease (30%). Most deaths occurred in hospitals (84%), and only 2% in dialysis clinics; 52% were classified as unexpected. Compared with cardiovascular deaths, infection-related deaths occurred in older patients, more often in the hospital, and with longer hospital stays. Pneumonia (35%) and sudden death (37%) were the most common infection-related and cardiovascular causes, respectively. CONCLUSION:In this large Brazilian dialysis cohort with adjudicated outcomes, infection was the leading cause of death, followed by cardiovascular disease. Structured, temporally framed mortality review meetings enabled systematic evaluation of deaths, contributing care processes, and patient safety.
BACKGROUND:Hyperkalemia is a common complication in chronic kidney disease (CKD), requiring management to maintain cardiovascular benefits of renin-angiotensin-aldosterone system and mineralocorticoid receptors (RAASi/MRA) therapy. This study evaluated hyperkalemia management and recurrence in CKD patients. METHODS:A prospective, multicenter observational study was conducted across 15 hospitals, enrolling 429 patients with serum potassium > 5.5 mmol/L. Patients were managed per usual practice, and data on recurrence, RAASi/MRA changes, cardiovascular events, and renal function were collected over 2 years. RESULTS:Cohort (mean age 71.5 years, 71.3% male, 88.6% hypertension, 55.9% diabetes) presented with mild, moderate (19.1%), and severe (3.7%) hyperkalemia. Post-event, dietary modifications increased by 39.9%, bicarbonate use by 7.9%, resin use by 2.6%, patiromer use by 10.9%, and sodium zirconium cyclosilicate (SZC) use by 24.6%. Modifications on RAA Si/MRA therapy were as follows: angiotensin-converting enzyme inhibitors reduced in 12% and suspended in 6.8%; angiotensin II receptor blockers reduced in 5.49% and suspended in 7.32%; and MRA reduced in 12.73% and suspended in 21.82%. Recurrence occurred in 43.8%, with higher rates in patients with baseline estimated glomerular filtration rate <30 ml/min (49.1% vs 38.8%, P = 0.03). Recurrent hyperkalemia was associated with faster eGFR decline (-2.4 ml/min/year, P < 0.001). Kaplan-Meier analysis showed no differences in overall survival between patients with and without recurrence. The study found no significant difference between patiromer/SZC and resins in efficacy (recurrence rates). CONCLUSION:Integrating potassium binders into CKD therapeutic strategies may improve hyperkalemia management and allow sustained RAASi/MRA use. Recurrence remains significant, impacting renal function, although causality is unclear. The mortality difference requires further study.
