Importance Apolipoprotein L1 locus ( APOL1 ) high-risk alleles are associated with incidence of chronic kidney disease (CKD) among people with African ancestry. Few studies have examined the effect of genetic return of results on blood pressure (BP) management and control. Objective To determine whether providing APOL1 high-risk genotype results to people with hypertension and their clinicians would reduce systolic BP (SBP) and improve CKD screening and diagnosis. Design, Setting, and Participants From July 1, 2020, to September 30, 2023, adults aged 18 to 70 years with hypertension and self-reported African ancestry were enrolled at 14 institutions and 54 clinical sites across the US. Eligible patients either (1) lacked diagnoses of diabetes and CKD or (2) had a diagnosis of CKD with or without diabetes. Interventions Participants were randomized to receive APOL1 genotype results immediately (intervention) or 6 months after enrollment (control). Clinical decision support encouraged appropriate CKD screening, diagnosis, and antihypertensive therapy. Main Outcomes and Measures The primary outcome was change in SBP in individuals with APOL1 high-risk allelles at 3 months, assessed in a modified intention-to-treat analysis. Prespecified per-protocol subgroup analyses included those with uncontrolled BP (baseline SBP ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg), uncontrolled BP while receiving antihypertensive therapy, and CKD at enrollment. Secondary outcomes included urine microalbumin screening and new CKD diagnoses. Results Of 6754 individuals recruited (mean [SD] age, 55.3 [10.3] years; 4310 women [63.8%]), 954 (14.1%; mean [SD] age, 54.9 [10.0] years; 600 women [62.9%]) had 2 APOL1 risk alleles. At 3 months, there was no difference in SBP between the intervention and control groups (between-group difference, −0.3 mm Hg [95% CI, −2.7 to 2.1 mm Hg]). Among 377 individuals with uncontrolled BP, the mean SBP change was −4.1 mm Hg (95% CI, −7.7 to −0.5 mm Hg) more in the intervention group than the control group ( P = .004). SBP improvement was also observed for the intervention in the subgroup of patients with uncontrolled BP receiving antihypertensive therapy (SPB difference, −4.3 mm Hg [95% CI −8.0 to −0.5 mm Hg]; P = .004), but not the CKD subgroup (SPB difference, 0.8 mm Hg [95% CI, −3.0 to 4.5 mm Hg]). Provision of APOL1 genotype led to increased urine microalbumin screening (between-group difference, 17.3% [95% CI, 9.6%-24.9%]; P < .001) and CKD diagnoses (between-group difference, 5.7% [95% CI, 2.2%-9.3%]; P = .002) at 6 months. Conclusions and Relevance Provision of APOL1 genotype high-risk results to participants and clinicians was not associated with SBP reduction overall. Among the subset of patients with uncontrolled BP, the intervention group had a significant SBP reduction. APOL1 disclosure also increased the rate of CKD screening and diagnosis. Effects of reporting APOL1 genotype merit further investigation among those with uncontrolled BP. Trial Registration ClinicalTrials.gov Identifier: NCT04191824

Importance:Apolipoprotein L1 locus (APOL1) high-risk alleles are associated with incidence of chronic kidney disease (CKD) among people with African ancestry. Few studies have examined the effect of genetic return of results on blood pressure (BP) management and control. Objective:To determine whether providing APOL1 high-risk genotype results to people with hypertension and their clinicians would reduce systolic BP (SBP) and improve CKD screening and diagnosis. Design, Setting, and Participants:From July 1, 2020, to September 30, 2023, adults aged 18 to 70 years with hypertension and self-reported African ancestry were enrolled at 14 institutions and 54 clinical sites across the US. Eligible patients either (1) lacked diagnoses of diabetes and CKD or (2) had a diagnosis of CKD with or without diabetes. Interventions:Participants were randomized to receive APOL1 genotype results immediately (intervention) or 6 months after enrollment (control). Clinical decision support encouraged appropriate CKD screening, diagnosis, and antihypertensive therapy. Main Outcomes and Measures:The primary outcome was change in SBP in individuals with APOL1 high-risk allelles at 3 months, assessed in a modified intention-to-treat analysis. Prespecified per-protocol subgroup analyses included those with uncontrolled BP (baseline SBP ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg), uncontrolled BP while receiving antihypertensive therapy, and CKD at enrollment. Secondary outcomes included urine microalbumin screening and new CKD diagnoses. Results:Of 6754 individuals recruited (mean [SD] age, 55.3 [10.3] years; 4310 women [63.8%]), 954 (14.1%; mean [SD] age, 54.9 [10.0] years; 600 women [62.9%]) had 2 APOL1 risk alleles. At 3 months, there was no difference in SBP between the intervention and control groups (between-group difference, -0.3 mm Hg [95% CI, -2.7 to 2.1 mm Hg]). Among 377 individuals with uncontrolled BP, the mean SBP change was -4.1 mm Hg (95% CI, -7.7 to -0.5 mm Hg) more in the intervention group than the control group (P = .004). SBP improvement was also observed for the intervention in the subgroup of patients with uncontrolled BP receiving antihypertensive therapy (SPB difference, -4.3 mm Hg [95% CI -8.0 to -0.5 mm Hg]; P = .004), but not the CKD subgroup (SPB difference, 0.8 mm Hg [95% CI, -3.0 to 4.5 mm Hg]). Provision of APOL1 genotype led to increased urine microalbumin screening (between-group difference, 17.3% [95% CI, 9.6%-24.9%]; P < .001) and CKD diagnoses (between-group difference, 5.7% [95% CI, 2.2%-9.3%]; P = .002) at 6 months. Conclusions and Relevance:Provision of APOL1 genotype high-risk results to participants and clinicians was not associated with SBP reduction overall. Among the subset of patients with uncontrolled BP, the intervention group had a significant SBP reduction. APOL1 disclosure also increased the rate of CKD screening and diagnosis. Effects of reporting APOL1 genotype merit further investigation among those with uncontrolled BP. Trial Registration:ClinicalTrials.gov Identifier: NCT04191824.

OBJECTIVE:Social performance-the ability to successfully engage in social interactions-impacts outcomes in end-stage kidney disease (ESKD), including depressive symptoms and low self-efficacy, that are disproportionately experienced by Black Americans. However, the associations between social performance and health behaviors in ESKD are unknown. Social-emotional expertise (SEE) is a construct of individual differences in social performance that may be relevant to ESKD outcomes. Study goals are to establish the relation between SEE and health behaviors in Black American patients with ESKD by (a) examining the association of SEE with depressive symptoms, self-efficacy, and trust-in-physician and (b) the prediction of medication nonadherence and serum phosphorus by SEE. METHOD:Ninety-nine Black Americans receiving in-center hemodialysis completed surveys at baseline and two follow-up visits over 12 months. Bayesian regression captured relations among self-efficacy, depressive symptoms, medication nonadherence, serum phosphorus, and SEE scale scores. RESULTS:SEE was positively associated with self-efficacy and negatively associated with depressive symptoms at baseline. Additionally, baseline SEE significantly predicted 12-month medication nonadherence (R² = .16, 95% credible interval = [.06, .26]) when accounting for self-efficacy and depressive symptoms. SEE at baseline did not predict 12-month serum phosphorus; however, a model with baseline SEE in combination with baseline depressive symptoms did predict 12-month serum phosphorus (R² = .10, 95% credible interval = [.02, .21]). CONCLUSIONS:Higher perceived social performance-as measured by the SEE scale-predicted self-efficacy, depressive symptoms, and medication nonadherence, but not serum phosphorus control, in a cohort of Black Americans with ESKD. Socially focused interventions may have a positive impact on health behaviors among Black patients with ESKD. (PsycInfo Database Record (c) 2026 APA, all rights reserved).

Introduction:Moderate-to-strenuous exercise reduces risk for disability and cardiovascular disease, yet many older adults with chronic kidney disease (CKD) remain sedentary. Most exercise interventions in patients with CKD are not grounded in models of behavior change and are thus limited by dropout. We aimed to test whether patient activation-the knowledge, confidence, and skill to engage in a behavior-associates with exercise frequency. We further aimed to explore characteristics of adults reporting high versus low activation. Our overarching goal was to provide initial evidence of whether activation could be a target for an exercise intervention for older adults with CKD. Methods:We conducted a convergent parallel mixed-methods study informed by the Capability, Opportunity, Motivation, and Behavior (COM-B) model. We collected psychological (including Patient Activation Measure-13 [PAM-13]) and physiological factors corresponding to each component of COM-B. We cross-sectionally tested whether patient activation was associated with exercise (via the Exercise Vital Sign). We interviewed participants and their caregivers. Results:Of 232 adults with CKD stage 3B to 5 (median age: 69 years, 45% women, 26% Black), 26 adults and 9 caregivers contributed to the qualitative component. A 20-point increase in PAM-13 associated with a 0.63 (95% confidence interval: 0.24-1.03; P < 0.05) increase in weekly exercise days, independent of demographics, comorbidities, cognition, and frailty. Activated participants reported more caregiver support, a sense of identity tied to vocation, and altruism. Conclusion:Patient activation associates with exercise frequency in older adults with CKD. Based on qualitative findings, improving activation may involve caregiver support, volunteerism, and vocational rehabilitation.

Key PointsAddressing geriatric syndromes in CKD likely requires implementation of an interdisciplinary model of care.Experts shared multilevel barriers to implementation of this model and strategies to mitigate each barrier.Experts felt that patient satisfaction and clinician burnout could improve with implementing interdisciplinary care in CKD.BackgroundDespite their prevalence, prognostic significance, and prioritization by patients, key geriatric syndromes, such as cognitive impairment, frailty, and depression, are not routinely addressed in CKD care in the United States (US). In an interdisciplinary care model, health professionals with diverse expertise collaborate to address all symptoms and functional impairments occurring alongside a patient's chronic disease. Thus, routinely addressing geriatric syndromes in CKD may require implementing this evidence-based model of care and adapting it to the needs of patients with CKD. In a formative step to understanding how health systems could implement an interdisciplinary model of care to address geriatric syndromes in CKD, we interviewed health professionals around the world with relevant expertise.MethodsWe conducted a qualitative study informed by the Consolidated Framework for Implementation Research. We interviewed nephrologists, administrators, geriatricians, palliative medicine specialists, subspecialists, and allied health professionals working in other interdisciplinary clinics from the United States, United Kingdom, India, and Canada. We analyzed results using an inductive-deductive approach.ResultsThematic saturation occurred at 42 experts. Three major domains emerged: barriers to implementation, strategies to mitigate barriers, and benefits of implementation. Barriers were categorized into overarching themes related to (1) aging-friendly policy and workforce availability, (2) organizational culture and structure, and (3) nephrologist and patient perceptions. Strategies to mitigate barriers were categorized into themes related to (1) demonstrating viability, (2) facilitating effective health communication, (3) soliciting support from administrators and clinicians, and (4) expanding the base for patient information and treatment evidence. Proposed benefits of implementation included improved shared decision making and reduced nephrologist burnout.ConclusionsImplementing an interdisciplinary model of care that addresses geriatric syndromes in CKD is possible but will require overcoming policy-related, financial, cultural, and structural barriers. Such a model of care may ultimately benefit patients and nephrologists.

Background: Despite their prevalence, prognostic significance, and prioritization by patients, key geriatric syndromes, such as cognitive impairment, frailty, and depression are not routinely addressed in chronic kidney disease (CKD) care in the United States (US). In an interdisciplinary care model, health professionals with diverse expertise collaborate to address all symptoms and functional impairments occurring alongside a patient’s chronic disease. Thus, routinely addressing geriatric syndromes in CKD may require implementing this evidence-based model of care and adapting it to the needs of patients with CKD. In a formative step to understanding how health systems could implement an interdisciplinary model of care to address geriatric syndromes in CKD, we interviewed health professionals around the world with relevant expertise. Methods: We conducted a qualitative study informed by the Consolidated Framework for Implementation Research. We interviewed nephrologists, administrators, geriatricians, palliative medicine specialists, subspecialists, and allied health professionals working in other interdisciplinary clinics from the US, United Kingdom, India, and Canada. We analyzed results using an inductive-deductive approach. Results: Thematic saturation occurred at 42 experts. Three major domains emerged: barriers to implementation, strategies to mitigate barriers, and benefits of implementation. Barriers were categorized into overarching themes related to 1) aging-friendly policy and workforce availability; 2) organizational culture and structure, and 3) nephrologist and patient perceptions. Strategies to mitigate barriers were categorized into themes related to 1) demonstrating viability; 2) facilitating effective health communication; 3) soliciting support from administrators and clinicians; and 4) expanding the base for patient information and treatment evidence. Proposed benefits of implementation included improved shared decision-making and reduced nephrologist burnout. Conclusions: Implementing an interdisciplinary model of care that addresses geriatric syndromes in CKD is possible but will require overcoming policy-related, financial, cultural, and structural barriers. Such a model of care may ultimately benefit patients and nephrologists.

ABSTRACT:This article offers a guide for NPs for managing hypertension (HTN) in adults in the setting of chronic kidney disease (CKD). It outlines evidence-based strategies, including lifestyle modifications, pharmacologic interventions, and patient education measures, that can be used in patients with CKD to optimize BP control. Special considerations, such as comorbid mental health conditions and individualized treatment plans, are also addressed. NPs play a pivotal role in improving outcomes by fostering patient engagement and adherence. By embracing this holistic approach, NPs are poised to enhance the quality of care and well-being of patients with CKD and HTN.

Background:Many patients who start peritoneal dialysis (PD) transition to hemodialysis (HD) after a PD-related complication. Patient psychological factors may influence clinical outcomes. One possible factor is health mindset, or patient belief that their health knowledge and ability can change. The goal of this study is to evaluate the longitudinal associations of baseline health mindset with patient outcomes after one year. Methods:The Health Mindset Scale (HMS, score 3-18) was administered on paper during clinic to a convenience sample of 100 adult PD patients, to quantify patient mindset along a continuum from fixed mindset (lower scores) to growth mindset (higher scores). Participants were 31% African American, 4% Hispanic, and 64% White American. Demographic and comorbid information were abstracted from medical records. Outcomes assessed at 1 year were death, transition to HD, renal transplant, and maintaining PD. Results:HMS scores were highest in patients who subsequently received a renal transplant (mean 15, SD 2.1), indicating a growth mindset. HMS scores in patients who died were lower (mean 10, SD 5.2) suggesting a more fixed mindset. Among those who maintained PD, HMS scores were between fixed and growth mindset (mean 12.8, SD 4.2) and similar to those who transitioned to HD (mean 13, SD 4.2). One-way ANOVA for difference in HMS scores by clinical outcome was p = 0.042. Conclusions:This initial longitudinal study suggests associations between mindset and clinical outcomes. The HMS is a novel and easily administered instrument that quantifies one patient psychological component that could contribute to patient outcomes, and that could also be modified. The HMS may identify individuals who could benefit from specific interventions to favor a growth mindset, with the goal of supporting optimal clinical outcomes.

Key PointsAfrican American patients have unique insights on hemodialysis adherence and use of motivational interviewing to promote adherence.Key themes were mental health issues; historical mistrust; social determinants of health; and importance of provider cultural competence.Themes led to a novel conceptual model, which will inform the design of a motivational interviewing-based protocol to improve adherence.BackgroundCompared with White patients, African American (AA) patients have a four-fold higher prevalence of kidney failure and higher hemodialysis nonadherence. Adherence behaviors are influenced by psychosocial factors, including personal meaning of a behavior and self-confidence to enact it. We assessed perspectives of AA hemodialysis patients on unique factors affecting dialysis adherence, and use of motivational interviewing (MI), an evidence-based intervention, to improve these factors, dialysis adherence, and outcomes in AAs.MethodsSelf-identified AA hemodialysis patients (N=22) watched a brief video describing MI and then completed a semistructured interview or focus group session. Interview questions explored unique barriers and facilitators of hemodialysis adherence in AAs and perceived utility of MI to address these obstacles. Verbatim transcripts and an iterative inductive/deductive approach were used to develop a hierarchical coding system. Three experienced coders independently coded the same two transcripts. Coding was compared, and discrepancies were reconciled by a fourth coder or consensus. Transcripts, quotations, and codes were managed using Microsoft Excel 2016 and SPSS version 28.0.ResultsThemes and subthemes emerged and culminated in a novel conceptual model informed by three theoretical models of behavior change: Theory of Self-Care Management for Vulnerable Populations; Social Cognitive Theory; and Self Determination Theory. This conceptual model will inform the design of a culturally tailored, MI-based intervention to improve dialysis adherence in AAs.ConclusionsIntegrating AA hemodialysis patient perspectives is critical for enhancing dialysis care delivery and the design of effective interventions such as MI to improve dialysis adherence in AA and promote kidney health equity. AA hemodialysis patients view MI as a tool to clarify patient priorities, build trust, and promote patient-provider therapeutic alliance. Cultural tailoring of MI to address unique barriers of AAs with kidney failure will improve adherence and health outcomes in these vulnerable patients.

Adults over the age of 60 comprise the fastest growing population with chronic kidney disease (CKD) in the United States. Older adults with advanced CKD face high mortality rates due to cardiovascular hospitalizations and high morbidity due to falls and physical frailty.1 Exercise, or structured physical activity, can benefit both cardiovascular mortality and physical frailty, but many exercise interventions for adults with CKD are hindered by nonadherence and drop-out.2 Engagement in interventions may be improved by applying principles of behavior change.

Arroyo, Juan Pablo MD, PhD; McPherson, John MD; Umeukeje, Ebele MD, MPH Author Information