Vijay Kher

Excessive sodium intake is a major contributor to hypertension, cardiovascular disease, and other non-communicable diseases (NCDs), posing a persistent public health challenge. Physicians, as trusted health advisors, are central to promoting salt reduction strategies in routine clinical practice. This study describes a physician capacity-building initiative conducted by Sapiens Health Foundation in three metropolitan cities of India: Chennai, Mumbai, and Delhi, between June 2024-February 2025. The workshops aimed to strengthen physician knowledge and counselling skills regarding dietary salt reduction and the use of low-sodium salt substitutes (LSS). Each workshop featured expert presentations, interactive discussions, and evidence-based educational resources. Evaluation methods differed by location: Chennai and Mumbai used structured feedback forms, while Delhi implemented pre- and post-training assessments to measure knowledge gains. Findings showed that while many physicians were aware of the WHO’s recommended salt intake, gaps remained in areas such as hidden salt sources, sodium-to-salt conversions, low sodium salt (LSS) substitutes and appropriate use of LSS in clinical practice. Post-training results indicated improved knowledge across all cities, with statistically measurable gains in Delhi. This initiative demonstrated that structured workshops can enhance physician capacity in salt reduction and dietary counselling and encourage them to act as advocates within clinical and community settings. Integrating such training into medical education and aligning it with national public health strategies can help reduce salt consumption at the population level. Wider adoption of this model, supported by digital learning tools, could improve health outcomes and reduce the burden of NCDs in India.

Key Points: Among patients receiving maintenance dialysis, an inadequate hemoglobin response to erythropoiesis-stimulating agents (ESAs) is associated with a higher risk of adverse outcomes. Among patients in ASCEND-D, all three different prespecified definitions of ESA hyporesponsiveness were similarly associated with major adverse cardiovascular event outcomes. ESA hyporesponsiveness should be considered an important clinical parameter for risk-stratifying patients with kidney failure requiring dialysis. Background: Hyporesponsiveness to erythropoiesis-stimulating agents (ESAs) is a common clinical problem and is associated with major adverse cardiovascular events (MACEs). Although several definitions have been proposed, data examining associations with MACE in clinical trials are limited. Methods: Anemia Studies in Chronic Kidney Disease: Erythropoiesis via a Novel Prolyl Hydroxylase Inhibitor Daprodustat-Dialysis (ASCEND-D, NCT02879305), a large event-driven cardiovascular outcomes trial, randomized 2964 patients receiving maintenance dialysis to either daprodustat or conventional ESAs. All patients received an ESA for at least 6 weeks before randomization and were managed with dosing algorithms for iron and randomized treatment. Three definitions of ESA hyporesponsiveness were prespecified: (1) ESA hyporesponsiveness definition 1 (HypoR1): an erythropoietin resistance index ≥2 U/kg per week per gram per liter or prior ESA dose/estimated dry weight ≥450 U/kg per week, (2) ESA hyporesponsiveness definition 2 (HypoR2): erythropoietin resistance index ≥1.5 U/kg per week per gram per liter, and (3) ESA hyporesponsiveness definition 3 (HypoR3): baseline ESA dose (U/wk) in top 20th percentile. Adjusted Cox regression models were fit to examine the association of each definition with the adjudicated MACE composite (death, nonfatal myocardial infarction, and nonfatal stroke). Results: Baseline ESA hyporesponsiveness was present in 12%, 20%, and 20% of patients according to definitions HypoR1, HypoR2, and HypoR3, respectively. Compared with those without hyporesponsiveness, all definitions were associated with a higher risk of the composite MACE outcome: adjusted hazard ratio (HR) 1.32 (95% confidence interval [CI], 1.04 to 1.68) for HypoR1, HR 1.33 (95% CI, 1.08 to 1.63) for HypoR2, and HR 1.36 (95% CI, 1.12 to 1.66) for HypoR3. There was no evidence for effect modification by randomized treatment (P interaction > 0.40 for all). Conclusions: Baseline ESA hyporesponsiveness is a potent predictor of MACE among patients receiving maintenance dialysis in ASCEND-D. All prespecified definitions were similarly associated with a higher risk of MACE. Clinical Trial registry name and registration number: NCT02879305.

Key Points: Sudden cardiac death is a major concern for hemodialysis patients. Mortality is higher on dialysis days and is associated with higher dialysate bicarbonate (D_BIC). Contrary to our hypothesis, there was no consistent association of higher D_BIC with a higher risk of arrhythmia. Further research is needed to assess the optimal D_BIC and mechanisms by which it may improve outcomes for maintenance hemodialysis patients. Background: Sudden death accounts for approximately 25% of deaths among maintenance hemodialysis patients, occurring more frequently on hemodialysis days. Higher dialysate bicarbonate (D_BIC) may predispose to alkalemia and arrhythmogenesis. Methods: We conducted a 12-month analysis of session-level data from 66 patients with implantable loop recorders. We fit logistic regression and negative binomial mixed-effects regression models to assess the association of D_BIC with clinically significant arrhythmia (ventricular tachycardia ≥115 beats per minute [BPM] for at least 30 seconds, bradycardia ≤40 BPM for at least 6 seconds, or asystole for at least 3 seconds) and reviewer confirmed arrhythmia (RCA—implantable loop recorder-identified or patient-marked event for which a manual review of the stored electrocardiogram tracing confirmed the presence of atrial fibrillation, supraventricular tachycardia, sinus tachycardia with rate >130 BPM, ventricular tachycardia, asystole, or bradycardia). Models adjusted for age, sex, race, hemodialysis vintage, vascular access, and prehemodialysis serum bicarbonate and additionally for serum and dialysate potassium levels. Results: The mean age was 56±12 years, 70% were male, 53% were Black, and 35% were Asian. Fewer RCA episodes were associated with D_BIC >35 than 35 mEq/L (incidence rate ratio 0.45 [0.27 to 0.75] and adjusted incident rate ratio 0.54 [0.30 to 0.97]), but the association was not significant when adjusting for serum and dialysate potassium levels (adjusted incident rate ratio, 0.60 [0.32 to 1.11]). Otherwise, no associations between D_BIC and arrhythmia were identified. Conclusions: We observed a lower frequency of RCA with higher D_BIC, compared with D_BIC of 35 mEql/L, contrary to our original hypothesis, but this association was attenuated in fully adjusted models. Validation of these findings in larger studies is required, with a further need for interventional studies to explore the optimal D_BIC concentration.

The scarcity of living organ donors makes it imperative to develop newer innovations to optimize and maximize the utilization of the available pool. ABO and HLA sensitization are important immunological barriers in renal transplant and can potentially lead to rejection of almost one‐third of the willing living donors. Paired kidney exchange (PKE) is a rapidly growing method used to overcome these barriers and has grown in popularity over the last three decades since its introduction in 1986. Evolution of the matching strategies and use of complex algorithms has led to increase in the number of possible matches thereby benefiting multiple recipients. The use of altruistic donors and compatible pairs has also helped in increasing the possible exchanges. This review provides an in‐depth analysis of the evolution, the present global scenario and the future of PKE. It also discusses the recent trends of advanced donation, trans‐organ paired exchange and global kidney exchange and the associated ethical concerns.

Induction therapy is used routinely in kidney transplantation and has been recommended by the 2009 Kidney Disease Improving Global Outcomes (KDIGO) clinical practice guideline as a level 1A recommendation ⁽¹⁾. However, which agent should be used for induction and in which patient remains a matter of debate. Induction agents currently in use include depleting (usually, polyclonal anti‐thymocyte globulin derived from rabbit –rATG) or non depleting (Interleukin 2 receptor antagonists ‐ IL2RA) agents.

Hemodialysis patients have high rates of sudden death, but relationships between serum electrolytes, the dialysis prescription, and intra-dialytic shifts in fluid and electrolyte with arrhythmia are uncertain. We analyzed sixty-six hemodialysis patients who underwent loop recorder implantation with continuous electrocardiographic monitoring, weekly to bi-weekly testing of pre- and post-dialysis electrolytes, and detailed capture of dialysis prescription and flow sheet data for 6 months. The incidence rate ratio (IRR) of reviewer confirmed arrhythmias (RCA) during dialysis through 8 h after dialysis and associations with serum chemistries and dialytic parameters were assessed using adjusted, negative-binomial regression. Among 66 individuals with a mean age of 56 years, 12,480 events were detected in 64 (97%) patients. RCA nadired 12–24 h after dialysis and increased during the final 12 h of the inter-dialytic interval through the first 8 h after dialysis. Higher pre-dialysis serum magnesium concentration was associated with lower incidence rate ratio for arrythmia (IRR per 1 mg/dL increase 0.49, 95% CI; 0.25, 0.94), as was dialysate calcium concentration > 2.5 mEq/L vs. 2.5 mEq/L (IRR 0.52, 95% CI: 0.39, 0.70). Neither intradialytic serum potassium nor weight change were significantly associated with RCA rate. However, there was effect modification such that arrhythmia rate was maximal with concurrently high intradialytic volume and potassium removal (Pinteraction = 0.01). Intra and post-dialytic arrhythmias are common in hemodialysis. Additional studies designed to further elucidate whether modification of the serum magnesium concentration, dialysate calcium concentration, and the extent of intradialytic potassium and fluid removal reduces the risk of per-dialytic arrhythmia are warranted. Clinicaltrials.gov NCT01779856. Prospectively registered on January 22, 2013.

This commentary presents the view of an Expert Group of Indian nephrologists on adaptation and implementation of the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines for evaluation and management of mineral and bone disorder in chronic kidney disease (CKD-MBD) for practice in India. Zonal meetings of nephrologists drawn from the cross-section were convened to discuss the KDIGO guidelines. Recommendations were presented in a central meeting of zonal representatives. The finalized recommendations were reviewed by all the participants. There was a broad agreement on most of the recommendations made by the KDIGO workgroup. Significant departures in the current guidelines from the previous Kidney Disease Outcome Quality Initiative (KDOQI) guidelines were also noted. The participants agreed that the available evidence did not allow more precise recommendations, and the recommended best practice suggestions were often based on relatively weak evidence. There is a remarkable lack of data from Indian patients. We comment on specific areas and amplify certain concepts where we feel that further guidance that goes beyond what is stated in the document might help Indian nephrologists in appropriate implementation of the KDIGO guidelines. This commentary is intended to help define practically implementable best practices based on current disease concepts and available research evidence, thereby positively affecting the quality of management of CKD-MBD in India, and eventually improving patient outcomes.