Background & Aims Among end stage kidney disease (ESKD) patients, guidelines recommend dietary potassium (K) restriction given concerns about hyperkalemia. Yet there are sparse data informing dietary K intake recommendations in this population. We examined associations between dietary K intake and fiber consumption with mortality and health-related quality of life (HRQOL) in a multi-center prospective hemodialysis cohort. Methods Among 687 hemodialysis patients from the prospective NIH “Malnutrition and Racial Disparities in Chronic Kidney Disease” cohort recruited across 16 dialysis clinics, dietary K intake was assessed using protocolized Food Frequency Questionnaires (FFQs) over 10/2011-9/2022. Given the high fiber content of plant-based K-rich foods, we examined associations of dietary K and fiber pairings across four exposure groups (low K/low fiber, low K/high fiber, high K/low fiber, high K/high fiber) with mortality using Cox regression and Short-Form 36 survey HRQOL scores using linear mixed effects models. To account for energy intake differences, we used a “Standard Model” and “Residual Model” which directly and indirectly adjusted for energy using a residual, respectively. Results High K/high fiber intake was associated with lower mortality in expanded case-mix analyses in Standard Models (ref: low K/low fiber): aHR (95%CI) 0.69 (0.50, 0.96). High K/high fiber intake was associated with higher (better) HRQOL physical functioning and physical component scores over time using Standard Models (ref: low K/low fiber): estimates (β) (95% CIs) +7.54 (1.99, 13.09) and +1.96 (0.07, 3.84), respectively. High K/high fiber intake was also associated with higher (better) role limitations due to physical health, energy/fatigue, and physical component scores over time in Residual Models. Conclusions In a prospective hemodialysis cohort, higher K intake from foods with higher fiber content was associated with better survival and HRQOL. Further studies are needed to determine the precise amount and sources of dietary K intake that confer optimal health outcomes in ESKD.

PURPOSE OF REVIEW:While adequate glycemic control is a cornerstone of mitigating the cardio-kidney-metabolic risk of end-stage kidney disease (ESKD) patients with diabetes, including those receiving dialysis or kidney transplantation, there are limitations in the accuracy and/or convenience of traditional glycemic metrics in these populations. This has led to growing interest in continuous glucose monitoring (CGM) as an automated, minimally-invasive digital technology in diabetic ESKD patients. RECENT FINDINGS:In the dialysis population, growing research shows that CGM is clinically reliable for use based on error grid analysis, although a wide range of mean absolute relative difference (MARD) values have been observed across cohorts and CGM devices. There are fewer studies of CGM in kidney transplant recipients (KTR's), which suggest reasonable analytical accuracy. While CGM has the potential to empower ESKD patients to participate actively in their disease management, broader adoption is limited by barriers at the healthcare system, financial, patient, and provider levels. SUMMARY:While emerging data support the clinical utility of CGM in ESKD, further research is needed to determine its efficacy and to inform the development and validation of decision support tools, educational interventions, and implementation strategies for broader uptake and integration into routine care in dialysis patients and KTR's.

Abstract Background Currently there is insufficient evidence to inform the co-design of an exercise intervention as part of a multimodal intervention for renal cachexia. Co-design is an effective approach in collaborating with service users, carers and healthcare professionals to identify acceptable methods of improving delivery of care. The aim of this study was to use a co-design process to adapt an exercise intervention for patients with or at risk of renal cachexia as part of a cRCT for a multimodal intervention (NCT07107087) Methods The objectives were as follows: (1) To co-design a strategy to promote optimal recruitment and adherence to an exercise intervention for those with or at risk of renal cachexia receiving HD, (2) To produce a conceptual model in relation to the implementation of an exercise intervention for this group. Using Bird and colleagues generative co-design framework for healthcare innovation, we adopted three stages of pre-design, co-design, and post-design. Accordingly, three workshops were conducted to correspond to each stage and the operational decisions recorded in seven steps to report the iterative design of the exercise intervention. The co-design workshops took place in November 2023 (n = 10), June 2024 (n = 11) and February 2025 (n = 6). Public co-design partners from Northern Ireland and England representing Kidney Care UK, Northern Ireland Kidney Patients Association and Northern Ireland Kidney Research Fund, participated in the workshops. Results Contexts, intervention factors, mechanisms and outcomes which influence the uptake of, and adherence to, an exercise intervention within this patient population were identified. These included: the exercise intervention with an individualised and flexible approach; ensuring the exercise programme is manageable for patients receiving HD (session duration, timing and fistula awareness); ensuring the content of the exercise booklets is relatable and achievable (using household items rather than traditional exercise equipment and accrediting everyday activities as part of exercise log); providing support during the intervention (weekly telephone calls and progress tracking); and invitation to patients receiving HD considered most promising to encourage recruitment, sustain involvement and maximise impact from trusted healthcare professionals. Conclusion Using the generative co-design framework for healthcare innovation, a conceptual model has been produced to promote optimal recruitment and adherence to an exercise intervention as part of a multimodal intervention for renal cachexia management in practice. This has informed component design, the wider implementation plan and evaluation design of a multimodal intervention for renal cachexia.

BACKGROUND:Dyslipidemia, distinctly characterized by hypertriglyceridemia and impaired high-density lipoprotein cholesterol (HDL-C) metabolism in patients with chronic kidney disease (CKD), is associated with kidney disease progression. However, evidence on the renal outcomes of Triglyceride (TG)-targeting lipid-lowering therapies (LLTs), such as fibrates and niacin, often prescribed to patients with non-dialysis-dependent (NDD) CKD, is insufficient and equivocal. METHODS:We designed this retrospective cohort study using a target trial emulation framework and leveraged data from a nationwide cohort of 3,562,882 US Veterans to identify incident CKD patients initiating de novo LLTs. We compared eGFR decline from baseline and the odds of rapid eGFR decline in fibrate and niacin initiators versus statin initiators using the mixed-effects model-predicted 1-year, 3-year, and 10-year eGFR slopes, adjusted for baseline covariates. We also compared the risk of major adverse kidney events [MAKE] (composite of a sustained ≥57% decrease in eGFR from baseline, sustained eGFR<15 mL/min/1.73 m2, incident end-stage renal disease, and all-cause death) using Cox proportional hazards models adjusted for baseline covariates during follow-up of up to 10 years. RESULTS:Among 68,073 patients with incident CKD, 62,866 initiated de novo statin, 3,202 fibrate, or 2,005 niacin therapy. Compared to statin use, de novo fibrate initiators had slower eGFR decline (difference in 10-year slope: 0.26 mL/min/1.73 m2/year [95% CI, 0.11, 0.40], P<0.001), whereas the eGFR decline was not statistically significant in the niacin vs. statin comparison. The risk of MAKE was not significantly different in fibrate (hazard ratio, 0.94 [95% CI, 0.88, 1.01], P=0.09) or niacin (0.96 [0.89, 1.04], P=0.31) users after a median follow-up of 3.69 years. CONCLUSIONS:Among patients with NDD-CKD, unlike niacin, long-term fibrate use (compared to statin use) was associated with slower eGFR decline, suggesting renoprotective effects of fibrates. Further studies are warranted to investigate whether fibrate use is beneficial for preventing other outcomes, such as adverse cardiovascular events.

BACKGROUND:The plant-dominant low-protein diet (PLADO), providing 0.6-0.8 g/kg/d of protein with ≥50% derived from plant sources, may improve acid-base balance and metabolic outcomes in chronic kidney disease (CKD). However, concerns remain regarding safety and feasibility, and experimental evidence is limited. OBJECTIVE:This protocol describes a randomized controlled trial (RCT), designed to evaluate the efficacy, nutritional and biochemical safety, implementation feasibility, and cost-effectiveness of PLADO compared with the standard renal diet in adults with CKD stages 3-5. METHODS:This unblinded, parallel-group RCT will enroll 48 adults with CKD stages 3-5 in a medical center in Lebanon and randomize participants 1:1 to PLADO or standard-of-care renal diet for 6 months, followed by a 3-month free-living phase. Both groups will receive monthly individualized dietary counselling. OUTCOMES:The primary outcome is change in metabolic acidosis between groups, assessed by plasma total CO₂ from baseline to 6 months. Improvements in acid-base status are hypothesized to result from reduced dietary acid load, increased fiber intake, and favourable gut microbiota-related metabolic changes. Secondary outcomes include biochemical markers (uremia and anemia markers, electrolytes), nutritional status (GLIM criteria), gastrointestinal symptoms, quality-of-life (EQ-5D-5 L), gut microbiota composition, and cost-effectiveness. A mixed methods process evaluation will assess intervention fidelity, adherence, and reach. EXPECTED CONTRIBUTION:This trial will provide experimental evidence on the efficacy, safety, and feasibility of PLADO in the conservative management of CKD stages 3-5, informing dietary practice in resource-limited settings, where healthcare delivery is challenged by limited insurance coverage and economic instability. TRIAL REGISTRATION:NCT06932042.

Key Points Administration of testosterone was associated with decline in the slope of eGFR in transgender veterans. Administration of testosterone was associated with increase in creatinine in first 12 months of hormone initiation in transgender veterans. Administration of estrogen was associated with stability of eGFR slope in transgender veterans. Background The impact of hormone therapy (HT) on kidney function in transgender and gender-diverse (TGD) individuals remains poorly understood, and this lack of data poses challenges in caring for TGD individuals with kidney disease. The aim of this study was to compare serum creatinine levels and eGFR slope, a critical marker of kidney function, in transgender women (TW) and transgender men (TM) relative to cisgender (non-TGD) controls. Methods We conducted a longitudinal cohort study of veterans using Veterans Health Administration care from January 2006 to December 2019. Serum creatinine and eGFR were assessed using algorithms based on affirmed gender and sex assigned at birth. Within-group changes over time were assessed using generalized linear mixed-effect models with random intercept and time modeled as a categorical variable. Two-way fixed-effects models were used to assess changes in eGFR slopes relative to HT initiation compared with cisgender controls. Results The analytic dataset included 6616 veterans of whom 262 were receiving HT (214 [3%] TW and 48 [0.72%] TM) and 6354 were cisgender not receiving HT (1988 [30%] cisgender women and 4366 [66%] cisgender men). Serum creatinine was higher as early as 3 months after HT initiation in TM veterans with stabilization by 12 months, whereas TW veterans did not demonstrate any significant change in their serum creatinine. eGFR was significantly lower in TM veterans after HT initiation, whereas it remained stable in TW veterans. Conclusions Our findings suggest that HT is associated with divergent effects on kidney function. These findings suggest the need for individualized kidney monitoring and potentially refined eGFR calculations for TGD populations.

BACKGROUND:In patients with chronic kidney disease (CKD), lower and subfunctional high-density lipoprotein cholesterol (HDL-C) is associated with poor cardiovascular outcomes. Notwithstanding such poor outcomes, the primary therapeutic target in patients with CKD is low-density lipoprotein cholesterol (LDL-C), and the comparative effectiveness of commonly used lipid-lowering therapies (LLTs) in changing HDL-C levels in patients with non-dialysis-dependent CKD (NDD-CKD) remains unclear. METHODS:In this retrospective cohort study, using a target trial emulation framework, we examined a nationwide cohort of 3,562,882 US Veterans with normal kidney function enrolled between October 2004 and September 2006 and identified 247,270 incident CKD patients eligible for de novo LLT exposure, occurring during longitudinal follow-up until October 2019. We defined de novo LLT initiation using pharmacy dispensation data and followed patients for up to 1 year. We compared the intraindividual slopes of HDL-C levels in de novo fibrates and niacin users with those in statin users, using mixed-effects models adjusted for baseline and time-varying covariates. We also compared the odds of having a clinically meaningful (>10% from baseline) increase in HDL-C following LLT initiation. RESULTS:A total of 38,223 patients with incident CKD initiated de novo LLT (statin [n = 35,284], fibrate [n = 1,805], and niacin [n = 1,134]). The mean (standard deviation) age was 67.3 (10.5) years; 95.0% were men, and 20.6% were Black. Compared to statin users, the multivariable-adjusted annualized intraindividual increase of HDL-C was significantly higher following fibrate {1.15 mg/dL/year (95% confidence interval [CI]: 0.43, 1.87); p = 0.002} and niacin monotherapy (2.51 mg/dL/year [95% CI: 1.62, 3.41]; p < 0.001). Furthermore, niacin (OR: 1.37 [95% CI: 1.07, 1.75]; p = 0.012) was more likely than statins to provide a clinically meaningful elevation in HDL-C. Our findings were consistent in several sensitivity analyses. CONCLUSION:Among patients with NDD-CKD, de novo prescriptions of fibrates or niacin are associated with a greater increase in HDL-C levels compared to statins. Further studies are warranted to investigate whether such differences have meaningful effects on clinical outcomes.

Rationale & Objective The long-term outcomes associated with IV vs. oral iron replacement therapy in patients with chronic kidney disease (CKD) are unclear. We investigated the association of IV vs oral iron replacement therapy with incident end-stage kidney disease (ESKD) and with all-cause mortality in a national cohort of US Veterans with eGFR <60ml/min/1.73m2. Study Design National VA historical cohort study. Setting & Participants 17,428 incident new users of oral iron replacement therapy and a comparable group of 879 incident new users of IV iron replacement therapy during October 1, 2004, through September 30, 2006, with longitudinal follow-up until September 30, 2019. Predictor Incident new use of oral vs. IV IRT. Outcomes ESKD and mortality. Analytical Approach We examined the association of oral vs IV IRT with outcomes using competing risk regression and Cox models. We used propensity score matching to account for differences in baseline characteristics. Results Event rates were overall higher in patients receiving IV iron replacement, but the risk was mitigated after PS matching, with no significant association observed between the type of iron therapy and ESKD (subhazard ratio: 1.07, 95%CI: 0.82-1.39, p=0.6), or all-cause mortality (hazard ratio: 1.07, 95%CI: 0.96-1.20, p=0.2). Limitations Potential selection bias and residual confounding. Conclusions In this large national cohort of patients with chronic kidney disease, IV iron was not significantly associated with higher risk of incident ESKD and all-cause mortality when compared to oral iron therapy. The comparative effectiveness of the different iron replacement modalities will need to be studied further in clinical trials.

Background: Ready-to-eat, shelf-stable tortillas contain several phosphorus- and aluminum-containing additives that may increase the risk of adverse events in patients with chronic kidney disease (CKD). Objective: The present study aimed to measure the dietary aluminum and phosphorus burden in store-bought corn and wheat flour tortillas. Design: This cross-sectional study analyzed the elemental content of commercially available corn and wheat flour tortillas collected from 2019 to 2020. Setting: Twenty-one elements were quantified by ICP-MS and ICP-OES from 14 corn and 13 wheat flour tortilla brands purchased from local supermarkets in Southern California in 2019-2020. Statistical analyses performed: Multiple group comparisons were analyzed by one-way ANOVA with Tukey's post hoc test. Outliers were identified using the ROUT test on GraphPad/PRISM and statistical significance was determined using nonparametric Mann-Whitney and Kruskal-Wallis tests. All conditions (soft corn, hard corn, and wheat) were compared using Dunn's multiple comparison test. Results: Ready-to-eat wheat flour tortillas generally contained more phosphorus than corn tortillas. Tortillas with aluminum listed as a food additive contained higher aluminum concentrations than those without such listing, exceeding the tolerable weekly intake. Conclusions: Our study suggests that food additives contribute to the dietary burden of aluminum and phosphorus in ready-to-eat wheat flour tortillas. While additional investigations are warranted to confirm our findings, food reformulation strategies and clear food labeling will aid in reducing excess phosphorus and aluminum intake from processed foods.

OBJECTIVE Patients receiving dialysis who have diabetes have a high burden of dysglycemia. Whereas traditional glycemic markers have limited accuracy and convenience in dialysis, continuous glucose monitoring (CGM) provides automated, less invasive, and more comprehensive glycemic data than do conventional measures. However, it remains unclear whether CGM is associated with improved clinical outcomes in patients undergoing dialysis. RESEARCH DESIGN AND METHODS We examined the association between CGM use versus non-CGM use and survival among U.S. veterans receiving dialysis who also have diabetes, using linked national Veterans Affairs, U.S. Renal Data System, and Medicare data. We examined data from veterans undergoing dialysis and with diabetes with incident CGM use (newly prescribed CGM) versus non-CGM use over the period January 2012 to December 2023 matched by propensity score (PS) to address confounding by indication and who were followed for all-cause mortality events through February 2025. Associations of CGM use versus non-CGM use with death were evaluated using complete case analysis and multiple imputation. RESULTS Among 2,008 patients in the complete case analysis cohort, CGM use was associated with a lower mortality risk in PS-matched unadjusted and doubly adjusted Cox models (reference: non-CGM use; hazard ratio [HR] 0.86 [95% CI 0.76, 0.98]; and 0.83 [95% CI 0.75, 0.92], respectively). Among 3,088 patients in the multiple imputation cohort, CGM use was also associated with greater survival in PS-matched unadjusted and doubly adjusted Cox models (HR 0.88 [95% CI 0.77, 0.99]; and 0.84 [95% CI 0.73, 0.96], respectively). CONCLUSIONS In veterans receiving dialysis who also had diabetes, incident CGM use was associated with better survival versus non-CGM use. Further studies are needed to determine underlying mechanisms and the impact of CGM on other dialysis outcomes.

INTRODUCTION:Evidence on the anti-inflammatory effects and safety of omega-3 fatty acid supplementation in haemodialysis (HD) patients remains limited, particularly regarding the influence of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) dose, composition, and source. METHODS:We searched PubMed (n = 345), CENTRAL (n = 148) and EMBASE (n = 706) to July 2025. Studies were screened using Covidence, risk of bias was assessed using the Cochrane ROB 1 tool, and analyses were conducted in Review Manager 9.5.1. Only trials reporting C-reactive protein (CRP) were included. Pre-planned subgroup analyses examined formulation type, total daily dose, active ingredient dose, and DHA:EPA composition. Random-effects models were used to generate pooled standardised mean differences (SMDs), with heterogeneity assessed using I2. A sensitivity analysis excluded studies at high risk of bias. The protocol is registered on the Open Science Framework (https://doi.org/10.17605/OSF.IO/JCBHN). RESULTS:Thirteen studies (n = 678) were included (12 in meta-analyses). Two studies were judged high risk of bias, one unclear, and the remainder low risk. Adverse events were poorly reported: eight trials did not report any events, while five described only mild, transient effects (e.g., diarrhoea). Omega-3 fatty acids reduced CRP more than comparators across triglyceride formulations (SMD -0.62, 95 % CI -1.22 to -0.03; P = 0.04, I2 = 74 %); in the <2000 mg/day total dose subgroup (SMD -0.32, 95 % CI -0.61 to -0.04; P = 0.02, I2 = 29 %); and in the <2000 mg/day active ingredient subgroup (SMD -0.36, 95 % CI -0.59 to -0.13; P = 0.003, I2 = 31 %). No statistically significant differences were observed between subgroups. Sensitivity analyses did not materially change the results. CONCLUSION:A daily dose <2000 mg of omega-3 fatty acids in natural triglyceride form appears more effective than synthetic ethyl ester formulations for lowering CRP in HD patients. Larger, high-quality trials are required to confirm therapeutic benefit, determine optimal dosing, and clarify the ideal EPA:DHA composition for this population.

Key Points High-volume hemodiafiltration was associated with a 20% lower all-cause mortality risk compared with hemodialysis in incident patients. High-volume hemodiafiltration was associated with a 29% lower cardiovascular mortality risk compared with hemodialysis in incident patients. Associations between high-volume hemodiafiltration and lower mortality were consistent across demographic and clinical subgroups. Background Evidence for a survival benefit of hemodiafiltration (HDF) over high-flux hemodialysis largely comes from studies based on prevalent ESKD patients with longer dialysis exposure. By contrast, the effect of HDF on mortality of incident patients—those newly starting dialysis—remains less well understood. Methods We analyzed data from 18,515 incident patients (dialysis vintage <3 months) treated between 2019 and 2022 at Fresenius Medical Care NephroCare Clinics. Patients were classified as HDF or hemodialysis on the basis of their predominant dialysis modality during the first year of follow-up (≥75% of sessions). To assess the effect of HDF in the early phase after treatment initiation, follow-up was limited to 2 years. Cox proportional hazards models with inverse probability of treatment weighting were applied to estimate all-cause and cardiovascular disease mortality risk. Results Baseline characteristics between HDF and hemodialysis groups were comparable after inverse probability of treatment weighting. Over a median follow-up of 15.7 months (interquartile range, 6.4–24.0 months), HDF was associated with a lower risk of all-cause mortality compared with hemodialysis (11.7 versus 15.6 per 100 person-years; hazard ratio, 0.80; 95% confidence interval, 0.75 to 0.86). Furthermore, HDF was associated with a lower risk of cardiovascular disease mortality compared with hemodialysis (4.1 versus 6.7 per 100 person-years; hazard ratio, 0.71; 95% confidence interval, 0.63 to 0.80). Conclusions In the large real-world cohort of incident patients with ESKD who are in the early phase of dialysis treatment, online HDF was associated with a significant survival advantage compared with conventional hemodialysis. These findings reinforce the potential clinical benefits of HDF and support early adoption of HDF upon dialysis initiation. Podcast This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/CJASN/2026_07_22_CJASNJuly.21.7.7222.mp3

OBJECTIVE:To compare the effects of nondialytic care vs dialysis on hospitalization outcomes in advanced chronic kidney disease (CKD), given that dialysis, as the predominant treatment paradigm for patients with advanced CKD transitioning to end-stage kidney disease, may be associated with high early mortality, health care utilization, and withdrawal. PATIENTS AND METHODS:We examined a national cohort of veterans with advanced CKD (≥2 estimated glomerular filtration rates <25 mL/min per 1.73 m2 separated by ≥90 days from October 1, 2010, to September 30, 2019) categorized according to receipt of dialysis vs nondialytic care, defined as those who did vs did not receive dialysis within 2 years of their index estimated glomerular filtration rate. Propensity score matching was used to account for differences in baseline characteristics across exposure groups. We examined associations of nondialytic care vs dialysis with hospitalization rates and rates of days hospitalized (separately) using Poisson regression. Among hospitalized patients, we examined associations with length of stay (LOS) using linear mixed-effects models. RESULTS:In the 1:1 propensity score-matched cohort of 13,020 nondialytic and 13,020 dialysis patients, dialysis transition was associated with higher rates of hospitalization and days hospitalized (reference: nondialytic care): incident rate ratios (95% CIs), 1.64 (1.61 to 1.66) and 1.71 (1.70 to 1.72), respectively. Dialysis was also associated with longer average LOS vs nondialytic care: 8.6 vs 8.1 days, respectively. In secondary analyses of timing of dialysis transition, incrementally earlier dialysis transitions were associated with increasingly higher hospitalization rates vs nondialytic care, with similar patterns observed for rates of days hospitalized and LOS. CONCLUSION:Compared with nondialytic care, dialysis was associated with higher rates of hospitalization and days hospitalized and longer LOS.

Rationale & Objective:The long-term outcomes associated with intravenous (IV) versus oral iron replacement therapy in patients with chronic kidney disease are unclear. We investigated the association of IV versus oral iron replacement therapy with incident end-stage kidney disease (ESKD) and with all-cause mortality in a national cohort of US veterans with an estimated glomerular filtration rate of < 60mL/min/1.73m2. Study Design:A national Veterans Affairs (VA) historical cohort study. Setting & Participants:Total of 17,428 incident new users of oral iron replacement therapy and a comparable group of 879 incident new users of IV iron replacement therapy during October 1, 2004, through September 30, 2006, with longitudinal follow-up until September 30, 2019. Predictor:Incident new use of oral versus IV IRT. Outcomes:ESKD and mortality. Analytical Approach:We examined the association of oral versus IV IRT with outcomes using competing risk regression and Cox models. We used propensity score matching to account for differences in baseline characteristics. Results:Event rates were overall higher in patients receiving IV iron replacement, but the risk was mitigated after propensity scores matching, with no significant association observed between the type of iron therapy and ESKD (subhazard ratio: 1.07; 95% CI, 0.82-1.39; P = 0.6), or all-cause mortality (hazard ratio: 1.07; 95% CI, 0.96-1.20; P = 0.2). Limitations:Potential selection bias and residual confounding. Conclusions:In this large national cohort of patients with chronic kidney disease, IV iron was not significantly associated with a higher risk of incident ESKD and all-cause mortality when compared to oral iron therapy. The comparative effectiveness of the different iron replacement modalities will need to be studied further in clinical trials.