Introduction:Good sleep hygiene is recommended for individuals with chronic kidney disease (CKD). However, limited research has explored sleep hygiene in this population. This study aimed to examine sleep hygiene in individuals with CKD and explore its relationship with sleep outcomes and fatigue. Methods:A cross-sectional survey in 4 nephrology units across 3 Australian states to assess sleep hygiene (sleep hygiene index[SHI]), sleep outcomes (Pittsburgh sleep quality index[PSQI]), and fatigue (functional assessment of chronic illness therapy - fatigue[FACIT-F]). Linear regression models were constructed to identify the relationships between sleep hygiene, fatigue, and sleep outcomes. Results:Of the 231 survey participants, the mean age was 63 ± 16 years, 67% were male, and 62% received hemodialysis. Overall, sleep hygiene was good (mean SHI: 13.7 ± 7.7); however, sleep outcomes were poor (mean PSQI: 9.1 ± 4.5), and fatigue was high (mean FACIT-F: 27.1 ± 10.0). Only 17% were aware of sleep hygiene. Frequent poor sleep hygiene included daytime napping, irregular bed and wake times, and worry when in bed. Poor sleep hygiene scores were independently associated with greater fatigue (coefficient [β]: -0.54, 95% confidence interval [CI]: -0.70 to -0.38) and with poorer sleep outcomes (coefficient[β]: 0.16, 95% CI: 0.08-0.25). Conclusion:Sleep hygiene was associated with fatigue and sleep outcomes; however, despite generally good sleep hygiene practices, poor sleep and high fatigue remained common in individuals with CKD. This suggests that sleep hygiene alone is insufficient and should form only 1 component of a broader, multifaceted approach to improving sleep and fatigue in this population.

BACKGROUND:Sleep disturbances are common in chronic kidney disease (CKD), yet patient priorities, reporting behaviors, and experiences of sleep management remain poorly understood. This study explored perceived causes of sleep disturbance, patient-prioritized sleep outcomes, and experiences of reporting and managing sleep problems. METHODS:A multicenter, convergent mixed-methods study of adults with CKD stage 4-5, including those receiving kidney replacement therapy. Participants were recruited from four nephrology units across three Australian states. Survey data were analyzed using descriptive statistics and subgroup comparison, and interview data using thematic analysis, with findings integrated through triangulation. RESULTS:A total of 234 participants completed the survey and 14 participated in interviews. Participants were predominantly male (67%), aged over 60 years, and receiving hemodialysis (62%). Overall, 73% were classified as poor sleepers. Fragmented sleep (56%), nocturia (44%), and restless legs syndrome (27%) were the most common contributors. Feeling refreshed on waking and satisfaction with sleep were the highest-priority outcomes, ranked above social participation, ability to work, and hospital admissions. Forty-one percent reported that their treating team had never asked about sleep, and among those who raised concerns, almost one-quarter received no management. Pharmacological therapy was the most commonly reported clinical management (33%), despite a preference for nonpharmacological strategies. Nine percent used a wearable sleep tracker; with a further 41% willing to try one. CONCLUSION:In this cohort, sleep disturbances were common, under-recognised, and inconsistently managed. Management approach does not fully align with patient preferences. Greater access to nonpharmacological approaches and wearable technologies may support monitoring and engagement.

KEY POINTS:The phase 2 ENVISION trial evaluated efficacy and safety of intravenous sibeprenlimab, a selective A PRoliferation-Inducing Ligand inhibitor. Because the trial was conducted during the coronavirus disease 2019 pandemic, we assessed if sibeprenlimab affected humoral responses to coronavirus disease 2019 infection or vaccine. Sibeprenlimab treatment resulted in reduced pathogenic IgA and preserved protective humoral response to coronavirus disease 2019 vaccine and infection. BACKGROUND:In phase 2 ENVISION trial, sibeprenlimab, a selective A PRoliferation-Inducing Ligand inhibitor, significantly decreased proteinuria and stabilized eGFR in adults with IgA nephropathy. This exploratory substudy evaluated coronavirus disease 2019 (COVID-19) severity, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-specific antibody responses to vaccine and infection, and circulating B-cell populations in patients with IgA nephropathy treated with sibeprenlimab or placebo. METHODS:Participants enrolled in ENVISION ( NCT04287985 ) received 12 monthly intravenous infusions of sibeprenlimab (2, 4, or 8 mg/kg) or placebo. COVID-19 infection and vaccination data were recorded for all participants. In a substudy, serum IgG responses to SARS-CoV-2 spike protein, its receptor binding domain (RBD), and nucleocapsid antigen were assessed, with further analysis of serum IgM and IgA and salivary IgA against RBD in a subset of participants. Circulating T cells and B-cell subsets were analyzed by flow cytometry. RESULTS:Overall, symptomatic COVID-19 incidence was comparable between groups (33.3% sibeprenlimab versus 44.7% placebo), indicating no observable excess risk of COVID-19 infection with sibeprenlimab. Of 155 participants, 72 (sibeprenlimab n =52; placebo n =20) consented to the substudy. Within the substudy, COVID-19 seroconversion rates were 100% for IgG against SARS-CoV-2 RBD (IgG-RBD) after vaccination or infection. Peak IgG-RBD titers after mRNA vaccination exceeded protective thresholds in all COVID-19-naive sibeprenlimab recipients, and IgG-RBD durability was comparable between sibeprenlimab and placebo. COVID-19-specific IgG, IgA, and IgM antibody responses to infection were preserved, and IgA-RBD responses detected in saliva suggested preservation of mucosal immunity with sibeprenlimab. No meaningful perturbations in B or T cells were observed. CONCLUSIONS:A PRoliferation-Inducing Ligand inhibition with sibeprenlimab reduced pathogenic IgA while preserving mucosal immunity and systemic antibody responses to COVID-19 vaccination and infection. The absence of B-cell perturbations and the apparent absence of an increased risk of impaired vaccine response suggest that sibeprenlimab may not confer clinically significant immunosuppressive risks; the substudy's size and exploratory design preclude definitive conclusions, warranting further evaluation. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER:ClinicalTrials.gov, NCT04287985 .

[This corrects the article DOI: 10.1016/j.ekir.2025.103743.].

Introduction Good sleep hygiene is recommended for individuals with chronic kidney disease (CKD). However, limited research has explored sleep hygiene in this population. This study aimed to examine sleep hygiene in individuals with CKD and explore its relationship with sleep outcomes and fatigue. Method A cross-sectional survey in four nephrology units across three Australian states to assess sleep hygiene (Sleep Hygiene Index, SHI), sleep outcomes (Pittsburgh Sleep Quality Index, PSQI), and fatigue (Functional Assessment of Chronic Illness Therapy – Fatigue, FACIT-F). Linear regression models were constructed to identify the relationships between sleep hygiene, fatigue, and sleep outcomes. Results Of the 231 survey participants, the mean age was 63±16 years, 67% were male, and 62% received haemodialysis. Overall, sleep hygiene was good (mean SHI: 13.7 ±7.7); however, sleep outcomes were poor (mean PSQI: 9.1± 4.5) and fatigue was high (mean FACIT-F: 27.1± 10.0). Only 17% were aware of sleep hygiene. Frequent poor sleep hygiene included daytime napping, irregular bed and wake times, and worry when in bed. Poor sleep hygiene scores were independently associated with greater fatigue (coefficient: -0.54; 95% confidence interval: -0.70, -0.38) and with poorer sleep outcomes (coefficient: 0.16; 95% confidence interval: 0.08, 0.25). Conclusion Sleep hygiene was associated with fatigue and sleep outcomes; however, despite generally good sleep hygiene practices, poor sleep and high fatigue remained common in individuals with CKD. This suggests that sleep hygiene alone is insufficient and should form only one component of a broader, multifaceted approach to improving sleep and fatigue in this population.

The Kidney Failure Risk Equation (KFRE) has emerged as a key tool in stratifying risk among patients with chronic kidney disease (CKD) stages 3–5. Since its introduction in 2011, it has been extensively validated and is now recommended by the 2024 KDIGO guidelines for use in clinical practice. This review summarizes the development, validation, and clinical application of the KFRE, including its utility in nephrology referral, kidney replacement therapy (KRT) planning, and post-transplant populations. We also discuss limitations in its use, such as overestimation of risk in older adults, biological variability, its performance in specific subgroups and clinical relevance in the era of effective renoprotective therapies. Despite extensive validation, real-world outcome data on the KFRE’s impact remain limited, underscoring the need for prospective implementation studies.

Background In phase 2 ENVISION trial, sibeprenlimab, a selective A PRoliferation-Inducing Ligand inhibitor, significantly decreased proteinuria and stabilized eGFR in adults with IgA nephropathy. This exploratory substudy evaluated coronavirus disease 2019 (COVID-19) severity, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-specific antibody responses to vaccine and infection, and circulating B-cell populations in patients with IgA nephropathy treated with sibeprenlimab or placebo.Methods Participants enrolled in ENVISION () received 12 monthly intravenous infusions of sibeprenlimab (2, 4, or 8 mg/kg) or placebo. COVID-19 infection and vaccination data were recorded for all participants. In a substudy, serum IgG responses to SARS-CoV-2 spike protein, its receptor binding domain (RBD), and nucleocapsid antigen were assessed, with further analysis of serum IgM and IgA and salivary IgA against RBD in a subset of participants. Circulating T cells and B-cell subsets were analyzed by flow cytometry.Results Overall, symptomatic COVID-19 incidence was comparable between groups (33.3% sibeprenlimab versus 44.7% placebo), indicating no observable excess risk of COVID-19 infection with sibeprenlimab. Of 155 participants, 72 (sibeprenlimab n=52; placebo n=20) consented to the substudy. Within the substudy, COVID-19 seroconversion rates were 100% for IgG against SARS-CoV-2 RBD (IgG-RBD) after vaccination or infection. Peak IgG-RBD titers after mRNA vaccination exceeded protective thresholds in all COVID-19-naive sibeprenlimab recipients, and IgG-RBD durability was comparable between sibeprenlimab and placebo. COVID-19-specific IgG, IgA, and IgM antibody responses to infection were preserved, and IgA-RBD responses detected in saliva suggested preservation of mucosal immunity with sibeprenlimab. No meaningful perturbations in B or T cells were observed.Conclusions A PRoliferation-Inducing Ligand inhibition with sibeprenlimab reduced pathogenic IgA while preserving mucosal immunity and systemic antibody responses to COVID-19 vaccination and infection. The absence of B-cell perturbations and the apparent absence of an increased risk of impaired vaccine response suggest that sibeprenlimab may not confer clinically significant immunosuppressive risks; the substudy's size and exploratory design preclude definitive conclusions, warranting further evaluation.Clinical Trial registry name and registration number: ClinicalTrials.gov, .

Background Chronic kidney disease is common yet frequently under-recognised in primary care, in part because early disease is asymptomatic and often uncoded in electronic medical records. Missing diagnostic codes can delay appropriate monitoring and management. We aimed to develop a nationwide implementation programme designed to improve chronic kidney disease detection and diagnostic coding in Australian general practice. Methods In this prospective observational cohort study, we report an interim non-prespecified analysis of the CKD Discovery Drive programme. The programme was delivered as a continuing professional development-accredited quality-improvement initiative combining clinician education with structured post-education activities. General practitioners (GPs) across Australia were recruited through email invitations from a national private database (United Clinical). Participating practices extracted practice-level de-identified patient audit data from electronic medical records between May 6 and Dec 31, 2025, using structured query language tools or manual searches. Patients eligible for inclusion in audit and the analysis were younger than 60 years, had an estimated glomerular filtration rate (eGFR) less than 60 mL/min per 1·73 m2, and had attended the practice at least three times in the preceding 2 years. Chronic kidney disease was defined according to Kidney Disease: Improving Global Outcomes criteria as reduced eGFR or abnormal albuminuria persisting for more than 3 months. GPs completed pre-programme and post-programme surveys. The main objective was to assess the proportion of patients meeting diagnostic criteria without a coded chronic kidney disease diagnosis in their electronic medical record. Other objectives included assessing changes (pre-programme vs post-programme) in self-reported GP confidence in chronic kidney disease identification and management and in self-reported frequency of ordering eGFR and urine albumin–creatinine ratio (uACR). Full evaluation of the programme is planned after 2 years of follow up. Findings 80 practices submitted complete datasets, contributing records for 303 736 patients. Of these, 24 702 (8·1%) met chronic kidney disease diagnostic criteria, and 14 887 (60·2%) of 24 702 had chronic kidney disease formally coded. Among patients with coded chronic kidney disease, repeat eGFR testing within 12 months occurred in 11 398 (76·6%), whereas uACR testing was less frequent (6433 [43·2%]). Survey data showed limited clinician confidence: 69 (13·4%) of 515 GPs who responded reported being “very confident” managing chronic kidney disease only, with confidence further reduced in the presence of comorbidities. After programme participation, intended practice improved substantially, with the proportion of GPs who responded that they would “almost always” order uACR alongside eGFR increasing across high-risk groups for chronic kidney disease. Interpretation Early findings suggest that combining audit and feedback, electronic medical record-compatible tools, and peer-supported learning can strengthen chronic kidney disease detection, diagnostic coding, and clinician confidence in primary care. As this is an interim analysis, further follow-up is needed to ascertain the durability and full impact of these implementation strategies. Funding None.

Australia is one of the world's most culturally and linguistically diverse (CALD) nations, yet there is limited research on the characteristics and outcomes of CALD individuals undergoing kidney replacement therapy (KRT). This study aims to examine demographic and clinical characteristics, access to transplantation, and health outcomes of CALD patients receiving KRT in Australia over the past two decades. Data were obtained from the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) between 1 January 2002 and 31 December 2023. Non-Indigenous adults who initiated KRT in Australia during the study period were included. Patients were categorised into three groups: 1) individuals born in Australia/New Zealand (Aus/NZ), 2) CALD English (born in predominantly English-speaking countries), and 3) CALD non-English (born elsewhere). Statistical analysis included chi-squared tests, multivariate regression, and Kaplan-Meier survival curves to evaluate characteristics and outcomes, including mortality and access to transplantation. The cohort consisted of 52,045 patients, 64% of whom were male, with a median age of 62 years, and predominance of Aus/NZ-born individuals. CALD non-English patients had a higher prevalence of diabetic kidney disease, were more likely to commence KRT on peritoneal dialysis and had lower rates of pre-emptive kidney transplant. They were also more likely to live in postcodes with higher socioeconomic disadvantage and in major cities. In contrast, CALD English patients were older at KRT initiation, had higher number of comorbidities and were more likely to be former smokers. Late referrals were relatively consistent across the groups. While native fistulas were the most common vascular access across all groups, they were slightly less frequent in CALD groups. Baseline characteristics are summarised in Table 1. Mortality was highest in CALD-English patients and lowest in CALD-Non-English patients, consistent across all initial KRT modalities (Fig. 1). Cardiovascular disease and withdrawal from dialysis were the leading causes of death, with withdrawal being more frequent in CALD English and Aus/NZ groups, while infections were more common in CALD non-English patients (Fig. 2). Medical comorbidities, age, smoking status, body mass index, living in postcodes with higher socioeconomic disadvantage, and remoteness were all significant predictors of waitlisting and death. After adjustment for the above factors, CALD non-English had higher likelihood of waitlisting (subdistribution hazard ratios (SHR) 1.33, 95% CI: 1.28–1.4) and lower likelihood of death (SHR 0.76, 95% CI 0.74–0.78) (P < 0.001). This study highlights significant differences in the characteristics and outcomes of CALD patients receiving KRT in Australia. CALD non-English patients demonstrated a healthier profile, with higher likelihood of waitlisting for kidney transplantation and lower mortality rates compared to Aus/NZ and CALD English groups. These findings suggest a “healthy immigrant effect” for CALD non-English patients and aligns with the data from the 2021 Australian census, which reported that individuals born in Australia had the highest prevalence of at least one long-term health condition, followed by those born in England, the USA, Scotland, and New Zealand. Further research is warranted to explore barriers to pre-emptive transplant and vascular access use among CALD groups and to evaluate the impact of these disparities on long-term outcomes. A deeper understanding of cultural and systemic factors influencing KRT care may inform policies to ensure equitable access and improve outcomes for all patients. This study may pave the way for similar research in other countries to assess outcomes and patterns of CALD patients on KRT, helping to identify universal and region-specific factors that influence access to care and patient outcomes across diverse populations.

Aim: This retrospective cohort study aims to evaluate the prognostic factors for progression of immunoglobulin A nephropathy (IgAN) to kidney failure (defined as the initiation of kidney replacement therapy or death) and all-cause mortality in an Australian population. Methods: We conducted a retrospective analysis of 363 individual patients with biopsy-proven IgAN over a 21-year period (2000-2020) in the Hunter Region of New South Wales. Demographic data, comorbidities, biopsy features and biochemical markers were collected for a minimum of 12 months following biopsy diagnosis. A multivariable analysis using Cox regression was performed to examine their association with renal progression. Results: A total of 104 patients met the inclusion criteria and were followed for a median of 72 months. The cohort had a mean age at presentation of 45 years, with a predominantly male population. Most patients presented with haematuria and non-nephrotic range proteinuria. We stratified patients into three risk categories: low risk, intermediate risk, and high risk. Twenty-eight patients (26.92%) developed kidney failure and 15 patients (14.4%) experienced a > 20 mL/min eGFR decline within the first 12 months. The multivariable analysis revealed the following key factors associated with kidney failure: additional renal pathology on biopsy (HR 3.90, 95% CI 1.63-9.29), proteinuria (HR 1.15, 95% CI 1.02-1.29) and moderate-severe interstitial fibrosis/tubular atrophy (T2) (HR 7.00, 95% CI 2.32-21.05). There were 17 deaths (16.3%) in the cohort, with a mean survival time of 167.8 months (95% CI 152.6-183.1). Conclusion: In contrast to earlier reports from Australia, our findings emphasise that the progression to kidney failure is not uncommon in IgAN. We identified several predictors of the renal progression that are consistent with the previous studies. This highlights the need for a change in clinical management, as IgAN should no longer be considered a benign condition.

BACKGROUND:The cytokine A proliferation-inducing ligand (APRIL) is considered a key driver of the pathogenesis of IgA nephropathy. Sibeprenlimab, a humanized IgG2 monoclonal antibody, selectively binds to and inhibits APRIL. METHODS:In this phase 3, multicenter, double-blind, randomized, placebo-controlled trial, we assigned adults with biopsy-confirmed IgA nephropathy in a 1:1 ratio to receive either subcutaneous sibeprenlimab at a dose of 400 mg or placebo administered every 4 weeks for 100 weeks. The primary end point for this interim analysis was the 24-hour urinary protein-to-creatinine ratio at 9 months as compared with baseline. The key secondary end point, to be reported at trial completion, is the annualized slope of estimated glomerular filtration rate over 24 months. Other secondary end points included the change in the level of serum immunoglobulin and safety. Exploratory end points included the change in galactose-deficient IgA1 and APRIL concentrations, the spot 24-hour urinary protein-to-creatinine ratio, hematuria, and remission of proteinuria. RESULTS:A total of 510 patients underwent randomization - 259 to the sibeprenlimab group and 251 to the placebo group. The prespecified interim analysis included the first 320 patients (152 who received sibeprenlimab and 168 who received placebo) who had the opportunity to complete the 9-month evaluation of the 24-hour urinary protein-to-creatinine ratio. At 9 months, a significant reduction in 24-hour urinary protein-to-creatinine ratio was observed with sibeprenlimab (-50.2%) as compared with an increase with placebo (2.1%), corresponding to an adjusted geometric least-squares mean 24-hour urinary protein-to-creatinine ratio that was 51.2% (96.5% confidence interval [CI], 42.9 to 58.2) lower with sibeprenlimab than with placebo (P<0.001). The levels of APRIL and pathogenic galactose-deficient IgA1 at week 48 were reduced from baseline by 95.8% and 67.1%, respectively, with sibeprenlimab. The safety profile appeared to be similar with sibeprenlimab and placebo. No deaths were reported, and the incidence of serious adverse events that occurred during the treatment period was 3.5% with sibeprenlimab and 4.4% with placebo. CONCLUSIONS:Sibeprenlimab resulted in a significant reduction in proteinuria as compared with placebo in patients with IgA nephropathy. (Funded by Otsuka Pharmaceutical Development and Commercialization. VISIONARY ClinicalTrials.gov number, NCT05248646.).

We report the case of a 38-year-old Caucasian man with well-controlled HIV on antiretroviral therapy who developed nephrotic syndrome. The patient presented with a maculopapular rash, lymphadenopathy, oral lesions, nasal congestion and bilateral pitting oedema. Laboratory tests revealed hypoalbuminemia, nephrotic range proteinuria and abnormal liver function. Further investigations confirmed secondary syphilis with positive Treponema pallidum serology. Kidney biopsy showed membranous nephropathy. Treatment with Benzathine benzylpenicillin resulted in a rapid resolution of nephrotic syndrome, improved liver function and normalisation of serum albumin levels. This case highlights the rare but recognised link between syphilis and nephrotic syndrome, emphasising the importance of prompt diagnosis and antibiotic treatment to prevent the need for more aggressive treatments. Syphilis can cause a variety of systemic manifestations, and co-infection with HIV is common due to their shared transmission route. Healthcare providers must remain vigilant in considering syphilis as a potential cause of nephrotic syndrome in HIV-positive patients, particularly when other clinical and laboratory features suggest its presence.

Immunoglobulin A Nephropathy (IgAN) is the most common glomerular disease worldwide [1]. Clinical presentation and prognosis for IgAN is heterogenous, therefore effective management requires an individualized approach. The goal of this activity was for learners to better understand the impact of IgAN on patients' lives, the immunopathogenesis of IgAN, the rationale for novel therapies, the mechanism of action (MOA) and key clinical data for recently approved therapies, and how best to manage patients with IgAN to optimize outcomes. A 26-question, online, CPD-accredited survey was developed, including knowledge, case-based (competence), and confidence questions. Evidence-based feedback and peer responses highlighted correct responses. The activity launched on 17 May, 2024 and data were collected through 6 September, 2024. We report data for ex US nephrologists who completed all the activity questions. 395 nephrologists completed all questions within the data collection timeframe This activity uncovered significant gaps in knowledge, competence and confidence related to the impact of IgAN on patients' lives, the immunopathogenesis of IgAN, the rationale for novel therapies and MOA, and key clinical data for recently approved therapies. As the treatment landscape for IgAN continues to evolve, these results support the need for further education on evolving best practice for the diagnosis, assessment and management of IgAN. This would be beneficial in supporting nephrologists to translate knowledge into clinical practice in order to optimize outcomes for patients.

Kidney cysts are frequently encountered as incidental findings on imaging studies and are typically benign in nature. However, certain cysts exhibit characteristics that may predispose them to malignant transformation. The Bosniak classification, based on contrast-enhanced computed tomography or magnetic resonance imaging, offers a systematic approach to stratifying kidney cysts by their radiological features and estimating the associated risk of malignancy. This classification further informs clinical decision-making regarding surveillance, intervention or referral. This review provides a comprehensive examination of the pathophysiology, epidemiology, diagnostic evaluation and referral pathways for kidney cysts, with an emphasis on the practical application of the Bosniak classification in clinical practice.