Robert Nee

Kidney diseases are an important public health problem, rising in global significance. In place for nearly 2 decades, the Centers for Disease Control and Prevention's Kidney Disease Surveillance System is the first comprehensive surveillance system developed in the United States, focused exclusively on tracking kidney disease before ESKD. The Kidney Disease Surveillance System incorporates key data and trends from multiple, large national-level survey data sources (National Health and Nutrition Examination Survey), electronic medical record data (Military and Veterans Affairs Health Systems), health care claims (Medicare, Optum), and social determinants of health (American Community Survey). The prevalence of CKD among civilian US adults remains steady between 13% and 14%. The prevalence is higher among older, female, non-Hispanic Black adults and those with diabetes or hypertension. Among US veterans, the incidence of CKD and rates of diagnosis of AKI increased from 2008 to 2022 (incidence: 62.8 to 71.5/1000 person-years, AKI: 84.9 to 241.7 cases/1000 person-years). Awareness of the disease nationwide among persons with CKD has historically been low (<10%), but starting in 2013, has increased to approximately 25%. Persons with CKD self-report more problems with sleep, and those aged 65 years and older self-report a higher prevalence of functional limitations. Improvements in quality-of-care measures, including medication prescription and increase in both serum creatinine and albuminuria testing were observed. Increased self-reported physical activity was observed among persons with CKD. Food insecurity increased among persons with CKD, with the highest prevalence in young, female, non-Hispanic Black, and Hispanic adults. Although population-level prevalence of CKD remains stable, higher AKI and CKD rates are being observed in health systems settings. This project's website can be found at https://wwwn.cdc.gov/KDSS/. Robust surveillance is key to raising awareness of kidney disease, its risk factors, care quality, and outcomes. Surveillance findings may inform policy and evidence-based practices that reduce premature morbidity and mortality, improve quality of life, and reduce cost.

Key Points: Because of low patient numbers and uneven geographical distribution, nephrology fellows may not have experience caring for home hemodialysis (HHD) patients. We developed and preliminarily validated a formative HHD objective structured clinical examination. The objective structured clinical examination may be used to assess HHD curriculum and basic HHD clinical skills in individual fellows. Background: The Accreditation Council for Graduate Medical Education requires graduating nephrology fellows demonstrate competence in home hemodialysis (HHD). Because low patient numbers may lead to training gaps, clinical experience may be enhanced using simulation. We designed and preliminarily validated a formative objective structured clinical examination (OSCE) assessing clinical care of an uncomplicated patient initiating HHD, using a unified model of construct validity. Methods: The OSCE was developed by a nephrology fellow and five faculty (three practicing HHD). The nine-member test committee (five in HHD practice; one HHD care partner) assessed test item difficulty/relevance and determined passing scores. The final test consisted of 27 items (31 possible points); seven were evidence-based/standard-of-care questions (9.5 possible points). Passing score was 20 of 31 points (65%). Median relevance for all items was “important” or “essential.” Content validity index was 0.84. On preliminary validation by 11 board-certified volunteers (four practicing HHD), overall mean±SD score was 27.5±2 (100% passing), kappa=0.83 (95% confidence interval, 0.67 to 0.99). Validator evidence-based question score was 9.0±0.6. Results: Thirty-eight fellows (9 programs, 21 first-year; 17 second-year) were tested. Seventy-one percent passed (Cronbach α=0.70). Fellows' mean±SD scores were lower than validators: 21.5±4.0 versus 27.5±2, P < 0.001, as were their scores on evidence-based questions: 7.4±1.4 versus 9.0±0.6, P < 0.001. Eighty-eight percent of evidence-based/standard-of-care questions were answered correctly by validators versus 62% by fellows (P < 0.001). Forty-two percent of fellows were able to name four potential benefits and two risks associated with HHD; 79% recognized that the primary risk of buttonhole cannulation was infection. Seventy-four percent correctly identified minimum single pool Kt/V for thrice-weekly hemodialysis, and 29% knew the minimum standard weekly Kt/V target. Eighty-eight percent of fellows surveyed (22 of 25) agreed/strongly agreed that the OSCE was useful in self-assessing proficiency. Conclusions: The OSCE may be used as a formative assessment of fellow proficiency in prescribing HHD.

Purpose To evaluate the impact of surgical intervention on long-term renal outcomes for adult patients with congenital ureteropelvic junction obstruction (UPJO). Methods We queried service members diagnosed with UPJO from the United States Military Health System electronic health records from 2005 to 2020. We assessed demographic, laboratory, radiology, surgical intervention, and outcome data. We evaluated the impact of surgical intervention on renal function based on the estimated glomerular filtration rate (eGFR), hypertension (HTN, defined as any prescription for blood pressure [BP] medication and/or average of two BP readings ≥ 130/80 mmHg more than 2 weeks apart), and changes in renal excretory function on radionuclide scans. Results We identified 108 individuals diagnosed with congenital UPJO; mean follow-up of 7 years. Mean age at diagnosis was 25 years; 95% male; 69% White, 15% Black. At diagnosis, median BP was 130/78 mmHg and mean eGFR 93 ml/min/1.73m². Subsequently, 85% had pyeloplasty and 23% had stent placement. There were no significant differences in mean eGFR pre- and post-intervention (94 vs. 93 ml/min/1.73m², respectively; p = 0.15) and prevalence of defined HTN (59% vs. 61%, respectively; p = 0.20). Surgical intervention for right-sided UPJO significantly reduced the proportion of patients with delayed cortical excretion (54% pre vs. 35% post, p = 0.01) and T½ emptying time (35 min vs. 19 min, p = 0.009). Similar trends occurred with left-sided UPJO but were not significant. Conclusion Surgical intervention was not associated with significant differences in the long-term outcomes of kidney function and HTN prevalence in our young adult cohort. However, renal excretory function improved on radionuclide scans.

Significance Statement: Black adults in the United States have 2–4 times higher incidence of kidney failure than White adults. Yet, the reasons underlying this disparity remain poorly understood. Among 547,188 US veterans with new-onset CKD, according to a new race-free GFR equation, Black veterans had a 2.5-fold higher cumulative incidence of kidney failure, compared with White veterans, in any follow-up period from CKD onset. This disparity resulted from a combination of higher hazards of progression to kidney failure and lower hazards of competing-risk death in Black veterans. Both, in turn, were largely explained by the younger age at CKD onset in Black veterans, underscoring an urgent need to prevent early onset and slow progression of CKD in younger Black adults. Background: The Black adult population is well known to have higher incidence of kidney failure than their White counterpart in the United States, but the reasons underlying this disparity are unclear. We assessed the racial differences in kidney failure and death from onset of CKD on the basis of the race-free 2021 CKD Epidemiology Collaboration equation and examined the extent to which these differences could be explained by factors at the time of CKD onset. Methods: We analyzed a national cohort consisting of 547,188 US veterans (103,821 non-Hispanic Black and 443,367 non-Hispanic White), aged 18–85 years, with new-onset CKD between 2005 and 2016 who were followed through 10 years or May 2018 for incident kidney failure with replacement therapy (KFRT) and pre-KFRT death. Results: At CKD onset, Black veterans were, on average, 7.8 years younger than White veterans. In any time period from CKD onset, the cumulative incidence of KFRT was 2.5-fold higher for Black versus White veterans. Meanwhile, Black veterans had persistently >2-fold higher hazards of KFRT throughout follow-up (overall hazard ratio [95% confidence interval], 2.38 [2.31 to 2.45]) and conversely had 17%–48% decreased hazards of pre-KFRT death. These differences were reduced after accounting for the racial difference in age at CKD onset. Conclusions: The 2.5-fold higher cumulative incidence of kidney failure in Black adults resulted from a combination of higher hazards of progression to kidney failure and lower hazards of the competing risk of death, both of which can be largely explained by the younger age at CKD onset in Black compared with White adults.

For the first time in many years, guideline-directed drug therapies have emerged that offer substantial cardiorenal benefits, improved quality of life and longevity in patients with chronic kidney disease (CKD) and type 2 diabetes. These treatment options include sodium-glucose cotransporter-2 inhibitors, nonsteroidal mineralocorticoid receptor antagonists and glucagon-like peptide-1 receptor agonists. However, despite compelling evidence from multiple clinical trials, their uptake has been slow in routine clinical practice, reminiscent of the historical evolution of angiotensin-converting enzyme inhibitor and angiotensin II receptor blocker use. The delay in implementation of these evidence-based therapies highlights the many challenges to optimal CKD care, including: (i) clinical inertia; (ii) low CKD awareness; (iii) suboptimal kidney disease education among patients and providers; (iv) lack of patient and community engagement; (v) multimorbidity and polypharmacy; (vi) challenges in the primary care setting; (vii) fragmented CKD care; (viii) disparities in underserved populations; (ix) lack of public policy focused on health equity; and (x) high drug prices. These barriers to optimal cardiorenal outcomes can be ameliorated by a multifaceted approach, using the Chronic Care Model framework, to include patient and provider education, patient self-management programs, shared decision making, electronic clinical decision support tools, quality improvement initiatives, clear practice guidelines, multidisciplinary and collaborative care, provider accountability, and robust health information technology. It is incumbent on the global kidney community to take on a multidimensional perspective of CKD care by addressing patient-, community-, provider-, healthcare system- and policy-level barriers.

Introduction: Mortality is an important long-term indicator of the public health impact of chronic kidney disease (CKD). We investigated the role of individual comorbidities and multimorbidity on age-specific mortality risk among US veterans with new-onset CKD. Methods: The cohort included 892,005 veterans aged ≥18 years with incident CKD stage 3 between January 2004 and April 2018 in the US Veterans Health Administration (VHA) system and followed until death, December 2018, or up to 10 years. Incident CKD was defined as the first-time estimated glomerular filtration rate (eGFR) was 3 months. Comorbidities were ascertained using inpatient and outpatient clinical records in the VHA system and Medicare claims. We estimated death rates for any cardiovascular disease (CVD, a composite of 6 CVD conditions) and 15 non-CVD comorbidities, and adjusted risks of death (hazard ratio [HR], 95% confidence interval [CI]) overall and by age group at CKD incidence. Results: At CKD incidence, the mean age was 72 years, and 97% were male; the mean eGFR was 52 mL/min/1.73 m2, and 95% had ≥2 comorbidities (median, 4) in addition to CKD. During a median follow-up of 4.5 years, among the 16 comorbidities, CVD was associated with the highest relative risk of death in younger veterans (HR 1.96 [95% CI: 1.61–2.37] in ages 18–44 years and HR 1.66 [1.63–1.70] in ages 45–64 years). Dementia was associated with the highest relative risk of death among older veterans (HR 1.71 [1.68–1.74] in ages 65–84 years and HR 1.69 [1.65–1.73] in ages 85–100 years). The additive effect of multimorbidity on risk of death was stronger in younger than older veterans. Compared to having 1 or no comorbidity at CKD onset, the risk of death with ≥5 comorbidities was >7-fold higher among veterans aged 18–44 years and >2-fold higher among veterans aged 85–100 years. Conclusion: The large burden of comorbidities in US veterans with newly identified CKD places them at the risk of premature death. Compared with older veterans, younger veterans with multiple comorbidities, particularly with CVD, at CKD onset are at an even higher relative risk of death.

Objective: Scleroderma renal crisis (SRC) is a rare and severe manifestation of systemic sclerosis (SSc). Although it is well documented that Black patients with SSc have worse morbidity and mortality than non‐Black patients, racial predilection for SRC is underreported. We examine the association of race and future development of SRC in an SSc cohort.Methods: Using the electronic health record of the US Military Health System, we conducted a comprehensive chart review of each patient with SSc from 2005 to 2016. The final study cohort was comprised of 31 SRC cases and 322 SSc without SRC controls. We conducted logistic regression of SRC as the outcome variable and race (Black versus non‐Black) as the primary predictor variable, adjusted for age, estimated glomerular filtration rate, hypertension, and proteinuria at SSc diagnosis.Results: Of 353 patients, 294 had identifiable race (79 Black, 215 non‐Black). Thirteen of 79 Black patients (16.5%) versus 16 of 215 (7.4%) non‐Black patients developed SRC (P = 0.02). On adjusted analysis, Black patients had a significantly higher risk of developing SRC than non‐Black patients (odds ratio 6.4 [95% confidence interval 1.3–31.2], P = 0.02). Anti‐Ro antibody was present in a higher proportion of Black SRC patients versus Black patients without SRC (45% versus 14%, P = 0.01). Conversely, older age, thrombocytopenia, and anti‐RNA polymerase III antibody at SSc diagnosis were significantly associated with future SRC in the non‐Black cohort.Conclusion: Black race was independently associated with a higher risk of future SRC. Further studies are needed to elucidate the mechanisms that underlie this important association.

Background: The global epidemiology of end-stage kidney disease (ESKD) reflects each nation’s unique genetic, environmental, lifestyle, and sociodemographic characteristics. The response to ESKD, particularly regarding kidney replacement therapy (KRT), depends on local disease burden, culture, and socioeconomics. Here, we explore geographic variation and global trends in ESKD incidence and prevalence and examine variations in KRT modality, practice patterns, and mortality. We conclude with a discussion on disparities in access to KRT and strategies to reduce ESKD global burden and to improve access to treatment in low- and middle-income countries (LMICs). Summary: From 2003 to 2016, incidence rates of treated ESKD were relatively stable in many higher income countries but rose substantially predominantly in East and Southeast Asia. The prevalence of treated ESKD has increased worldwide, likely due to improving ESKD survival, population demographic shifts, higher prevalence of ESKD risk factors, and increasing KRT access in countries with growing economies. Unadjusted 5-year survival of ESKD patients on KRT was 41% in the USA, 48% in Europe, and 60% in Japan. Dialysis is the predominant KRT in most countries, with hemodialysis being the most common modality. Variations in dialysis practice patterns account for some of the differences in survival outcomes globally. Worldwide, there is a greater prevalence of KRT at higher income levels, and the number of people who die prematurely because of lack of KRT access is estimated at up to 3 times higher than the number who receive treatment. Key Messages: Many people worldwide in need of KRT as a life-sustaining treatment do not receive it, mostly in LMICs where health care resources are severely limited. This large treatment gap demands a focus on population-based prevention strategies and development of affordable and cost-effective KRT. Achieving global equity in KRT access will require concerted efforts in advocating effective public policy, health care delivery, workforce capacity, education, research, and support from the government, private sector, nongovernmental, and professional organizations.

Introduction: Among kidney transplant recipients (KTRs) with end-stage kidney disease (ESKD) due to atypical hemolytic uremic syndrome (aHUS), recurrence is associated with poor allograft outcomes. We compared graft and patient survival of aHUS KTRs with and without prophylactic/early use of eculizumab, a monoclonal antibody that binds complement protein C5, at the time of transplantation. Methods: We conducted a retrospective cohort study using the United States Renal Data System. Out of 123 624 ESKD patients transplanted between January 1, 2008, and June 1, 2016, we identified 348 (0.28%) patients who had “hemolytic uremic syndrome” as the primary cause of ESKD. We then linked these patients to datasets containing the Healthcare Common Procedure Coding System (HCPCS) code for eculizumab infusion. Patients who received eculizumab prior to or within 30 days of transplant represented the exposure group. We calculated crude incidence rates and conducted exact logistic regression, adjusted for recipient age and sex, for the study outcomes of graft loss, death-censored graft loss, and mortality. We also estimated the average treatment effect (ATE) by propensity-score matching, to reduce the bias in the estimated treatment effect on graft loss. Results: Our final study cohort included 335 aHUS KTRs (23 received eculizumab, 312 did not), with a mean duration of follow-up of 5.8 ± 2.7 years. There were no significant differences in baseline demographic and clinical characteristics between the eculizumab versus non-eculizumab group. Patients who received prophylactic/early eculizumab were less likely to experience graft loss compared with those who did not receive eculizumab (0% vs 20%, P = .02), with an adjusted odds ratio of 0.13 ( P = .02). In the propensity-score-matched sample, the ATE (eculizumab vs non-eculizumab) was −0.20 (95% confidence interval [CI] = −0.25 to −0.15, P < .001); thus, treatment was associated with an average of 20% reduction in graft loss. There was no significant difference in the risk of death between the 2 groups. Conclusions: Although there was no significant difference in the risk of death, prophylactic/early use of eculizumab was significantly associated with improved graft survival among aHUS KTRs. Given the high cost of eculizumab, randomized controlled trials are much needed to guide prophylactic strategies to prevent graft loss.