bluuebunny/crossref_metadata_2025_split huggingface dataset:
#989 Fund and incentivize multidisciplinary CKD care: what can we learn from the French CKD bundled payment program?
Authors: Raffray Maxime , Vigneau Cécile , Couchoud Cécile , Augé Estelle , Bricard Damien , Raynaud Denis , Campéon Arnaud , Frimat Luc , Bayat Sahar 
Published: May 2024

Abstract

Background and Aims
Multidisciplinary care (MDC) is crucial to slow down the progression of Chronic Kidney Disease (CKD) and prevent or post-pone kidney replacement therapy. To incentivize the development of that care, France launched a nationwide bundled payment program (CKD-BP) targeted to patients with CKD G4 and G5. In this study, we review the implementation of the program, 3 years into its launch.

Method
First, using the CKD-BP program data collected by participating facilities, we described the characteristics and trajectories of patients enrolled from 2020 through 2022. Second, from exploratory interviews with medical and management staff, we performed a thematic analysis to identify the obstacles encountered during implementation and the changes introduced by the program.

Results
Since 2020, 157,863 patients were reported by 408 facilities (median age 75 y-o, 40% women, 77% G4). Missing data frequencies were high for comorbidities. Each year, around 4200 dialysis start (5% of patients) and 2600 deaths (3% of patients) were reported. On average, 47% and 40% of patients visited nurses and dietitians at least once a year respectively. From 22 interviews across 7 facilities, we identified challenges of implementation: adapting information systems, gathering the support of facility management and organizing the care in a context of workforce shortage, specifically nurses. Despite those challenges, facilities welcomed positively the new model, notably with increased time between nurses and patients and affirmation of dietitian's role.

Conclusion
We estimate the exhaustiveness of the CKD-BP program at 40% of all French patients with G5 CKD (around 4,600 dialysis start reported in 2021, compared to 11,000 from the national exhaustive REIN registry data). The results of this study suggest that interventions to accompany facilities in adapting their information systems are a priority to ensure efficient allocation of medical time and quality of the data. The results also suggest the need for increased flexibility regarding what professional is considered in the CKD-BP program, beyond nurses and dietitians. These challenges remain to be addressed in order to complete a successful shift from fee-for-service to assessable value-based care for CKD in France.
#832 Sickle cell trait and APOL1 high risk genotype increase the risk of ESKD similar to diabetes in British Africans
Authors: Gilchrist Mark , Sharp Luke , Murray-Leech Jacques , Patel Kashyap 
Published: May 2024

Abstract

Background and Aims
Little is known of the risk of end-stage kidney disease (ESKD) in British Africans with Sickle Cell Trait or APOL1 High-risk genotypes. We aim to determine the prevalence of the APOL1 high-risk genotype and genetically defined Sickle Cell Trait in British Africans and their association with ESKD.

Method
We analysed 7380 British Africans from a UK population cohort, UK Biobank. It contains deep phenotypes, biomarkers, and DNA sequence data. We used whole exome sequencing data to identify carriers of known APOL1 high risk genotypes (G1G1, G1G2, G2G2) and SCT (heterozygous carriers of p.Glu7Lys in HBB). We identified individuals with ESKD (in receipt of renal replacement therapy including kidney transplant) using self-report, hospital admissions records, and general practice records. We used a cox proportional hazard model to determine the risk of ESKD with these genotypes adjusted for age, sex, hypertension, smoking and diabetes.

Results
1131/7380 (17.9%) British Africans carry the APOL1 High risk genotype whereas 860/7380 (14.3%) had genetically defined SCT. Both risk states were found in 216/7380 individuals. Together, 32.2% carry one or both of these variants and 36/2207 (1.6%) developed ESKD. Of those with neither SCT nor APOL1 HR genotype 32/5173 (0.67%) developed ESKD.
The multivariable cox-proportional hazard model showed that APOL1 high risk genotype increased the risk of ESKD by two-fold (HR 2.12-95% CI 1.19-3.79), p = 0.011. Surprisingly, the risk of ESKD was also two-fold higher in SCT carriers (HR 2.59 95% CI 1.44-4.68), p = 0.002 independent of APOL1 genotype. This risk was of ESKD for people with either SCT or the APOL1 high risk genotype was similar to that associated with diabetes (HR 2.75 95% 1.58-4.80), p &lt; 0.001.
The polygenic score for eGFR did not change the risk of ESKD in these carriers.

Conclusion
We show for the first time that 1 in 3 British Africans carry either two APOL1 high-risk variants or sickle cell trait, both of which double the risk of ESKD. These genetic risk factors increase the risk of developing ESKD to a level similar to that resulting from diabetes. A sensible starting point would be a trial of screening and aggressive management of conventional risk factors for ESKD.
#2888 Measured glomerular filtration rate and risk of adverse outcomes in 6059 patients from the Stockholm CREAtinine Measurements (SCREAM) project
Authors: Fu Edouard L , Coresh Josef , Grams Morgan , Inker Lesley , Levey Andrew , Carrero Juan-Jesus 
Published: May 2024

Abstract

Background and Aims
Evidence on the risks of adverse outcomes associated with glomerular filtration rate (GFR) has been limited to estimated GFR (eGFR), due to limited availability of large-scale data with measured GFR (mGFR). These studies either used creatinine (eGFRcr), cystatin C (eGFRcys), or both (eGFRcr-cys), which can be influenced by the non-GFR determinants of creatinine and cystatin C. Here, we aimed to (1) quantify associations between mGFR and the risk of all-cause mortality and kidney failure with replacement therapy (KFRT) and (2) investigate which filtration marker most closely resembled these associations.

Method
We included 6059 adults referred for single-point plasma iohexol clearance between 2011-2021 in Stockholm, Sweden (SCREAM project), and who had simultaneous measures of creatinine and cystatin C. eGFR was calculated with the CKD-EPI 2012 (eGFRcys) and 2021 (eGFRcr and eGFRcr-cys) equations. Hazard ratios were estimated using Cox regression, adjusting for age, sex, medical history, medications and urinary albumin-to-creatinine ratio (UACR).

Results
Mean age was 59 years, 40% were women, median mGFR was 66 ml/min/1.73 m2 and median UACR was 1.1 mg/mmol. During median 3.8 years of follow-up, 1961 individuals died and 425 progressed to KFRT. Associations between mGFR and mortality increased linearly for values &lt;90 ml/min/1.73 m2 and were not statistically significant between 90-120 ml/min/1.73 m2 (Figure). Compared with mGFR of 90 ml/min/1.73 m2, hazard ratios for mortality were 1.5 (95% CI 1.3-1.6), 1.7 (1.5-1.8), 2.0 (1.8-2.1) and 2.4 (2.0-2.7) for 60, 45, 30 and 15 ml/min/1.732, respectively (Table). eGFRcr-cys most closely resembled the mortality risk relationships of mGFR. Conversely, eGFRcr had a strong U-shaped pattern with underestimation of risks &lt;90 ml/min/1.73 m2 and overestimation of risks between 90-120 ml/min/1.73 m2; for eGFRcys this pattern was reversed. Associations between mGFR and KFRT were also linear (Figure). Compared with mGFR of 60 ml/min/1.73 m2, hazard ratios for KFRT were 2.1 (1.4-3.0), 6.2 (4.5-8.5), and 32.1 (23.4-44.0) for 45, 30 and 15 ml/min/1.732, respectively (Table). Both mGFR and estimating equations displayed similar monotonic risk associations.

Conclusion
In the largest study on mGFR and outcomes to date, lower mGFR was linearly associated with an increase in the risks of mortality and KFRT. eGFRcr-cys closely resembled the relationship between mGFR and mortality, whereas eGFRcr under-estimated mortality risk and had a U-shaped association. All estimating equations had similar associations with KFRT risk.
#2033 Patient characteristics and outcomes of an inter- and multidisciplinary nephrology and cardiology clinic
Authors: Rho Elena , Martinetti Christian , George Britta , Ruschitzka Frank , Frank Michelle , Schachtner Thomas 
Published: May 2024

Abstract

Background and Aims
The prevalence of cardiorenal syndrome is increasing due to the growing number of patients with chronic kidney disease (CKD) and heart failure (HF). To further improve outcomes in this high risk population, an interdisciplinary, evidence-based and patient-centered approach is advocated. Hence, it was the aim of this study to identify and describe the patient population which might profit from an inter- and multidisciplinary nephrology and cardiology clinic at a tertiary university hospital.

Method
We screened 552 patients who from 01.01.2015 and 30.06.2022 had been in the nephrology and in the cardiology outpatient clinics of the University Hospital of Zurich. Patients with kidney or heart transplantation or on dialysis were excluded. Out of the remaining patients, we identified 223 patients having CKD 2-5 and HF. Characteristics with respect to entity and cause of kidney and heart disease, cardiovascular risk factors, therapy, incidence of acute kidney injury (AKI), hospitalisations and patient survival were recorded.

Results
The most common cause of CKD was a cardiorenal syndrome type 2 (42%, 95/223). 59/223 (26%) had at least moderate albuminuria. At the beginning of follow-up, 61/223 (26%) were in CKD2, 95/223 (42%) in CKD3a, 47/223 (21%) in CKD3b, 6/223 (7%) in CKD4 1, 2/223 (1%) in CKD5. Ischemic cardiomyopathy was the most common cause of heart failure, (36%, 80/223 patients). 119/223 patients (53%) had HFrEF, 41/223 (19%) HFmrEF and 63/223 (28%) HFpE. 64/223 (28%) of the patients were treated with SGLT2i,159/223 (71%) with RASi of which 37 (17%) were on an ARNI. Patients under combined RASi and SGLT2i were younger (66 vs 73 years, p = 0.005), were more likely to have diabetes (44% vs 30%), HFrEF rather than HFpEF (70% vs 7% p = 0.002) and had a better kidney function at the beginning of follow-up (eGFR 65 vs 55 ml/min/1.73 m2, p &lt; 0.001).
Hospitalization-rate due to HF and incidence of AKI were high with 0.6/patient/year and 4.8/patient/year respectively. 72/223 (32%) patients died during the mean follow-up of 3.1 years.

Conclusion
We identified a high-risk patient population with cardiorenal disease that might particularly benefit from evidence-based and patient-centered interdisciplinary care. A cardiorenal outpatient clinic may have the potential to improve a personalized approach in more vulnerable patients.
#2079 The impact of body composition measures on survival and cardiovascular events in patients with chronic kidney disease
Authors: Randhay Ashveer , Horner Daniela Viramontes , Fluck Richard , Taal Maarten W , Eldehni Tarek 
Published: May 2024

Abstract

Background and Aims
Multimorbidity, frailty and sarcopenia are increasingly prevalent in people with chronic kidney disease (CKD). Creatinine Muscle Index (CMI) has been proposed as a novel surrogate marker of muscle mass, and lower CMI was associated with frailty and increased mortality in the Atherosclerosis Risk in Community Study [1]. Waist to hip ratio (WHR) has also been proposed as a surrogate marker of visceral adiposity. In order to investigate the impact of body composition on outcomes, we analysed data collected from a large CKD cohort using CMI and WHR as markers of muscle mass and adiposity respectively to examine their effects on 5-year survival and cardiovascular events.

Method
1741 people with CKD stage 3 were recruited from 32 primary care practices. Cystatin C was measured using the Abbott c16000 Analyser (Abbott Diagnostics). eGFR cystatin (eGFRcys) was calculated using the CKD-EPI Cystatin C Equation (2012). CMI was calculated as the product of serum creatinine and eGFRcys (CMI [mg/day per 1.73 m2]= eGFRcys [ml/min per 1.73 m2] × serum creatinine [mg/dl] × 1 dl/100 ml × 1440 min/day). Cox proportional hazard model was used to examine if CMI and WHR predicted death or cardiovascular events.

Results
Mean age of the participants was 72.9 ± 9 years. Mean eGFRCr was 53.5 ± 11.8 ml/min/1.73 m2. Mean eGFRcys was 45.1 ± 16.0 ml/min/1.73 m2. Mean CMI was 766.45 ± 239.2 mg/day/1.73 m2. 300 (17.2%) participants died during 5 years of observation.
In a Cox proportional hazards model which included CMI, WHR and age, lower CMI per standard deviation change (B = −0.202, HR 0.817, p = 0.007), higher WHR per standard deviation change (B = 0.313, HR 1.37, p &lt; 0.001) and age at baseline (B = 0.088, HR 1.09, p &lt; 0.001) were independent predictors of mortality at year 5 of follow-up. CMI per standard deviation change also predicted cardiovascular events at 5 years using a univariable cox proportional hazards model, (B = −0.095, HR 0.91, p = 0.03).

Conclusion
Lower CMI (a surrogate measure of muscle mass) and higher WHR (a surrogate for visceral adiposity) independently predicted 5 year mortality and cardiovascular events in this predominantly elderly population with CKD stage 3. We conclude that body composition has an important impact on mortality and cardiovascular events in patients with CKD and the mechanisms of this merits further investigation. This could inform future interventions that reduce visceral adiposity and improve muscle mass in people with CKD.
#3096 Exploratory population-based screening of kidney function and heavy metal water source levels in a highly incident CKDu area in Guatemala
Authors: Lou-Meda Randall , Mcsc Annie , González Aguilar , Catalina Álvarez Ana 
Published: May 2024

Abstract

Background and Aims
Chronic kidney disease of unknown etiology (CKDu) has exponentially increased in the rural areas of the Pacific Coast in Central America. A multifactorial etiology has been postulated including exposure to environmental nephrotoxins such as heavy metals. The Pacific Coast of Guatemala has a volcanic topography with a high content of heavy metals, and the rural communities use ground water as their regular drinking consumption. Since the highest age group affected by CKDu are young adults, we postulated an exposure during childhood impacting later in life. We aim to identify changes in kidney function in children and adolescent healthy population from a highly incident CKDu area, and the heavy metal levels from water sources as a hypothesis generation exploratory study.

Method
We performed a population-based cross-sectional study of children and adolescents (below 17 y/o) from La Democracia municipality that were randomly chosen using Epidat software 3.1 from 10 different local schools from March 2019 to March 2020. The study was approved by external ethics board committee external-independent research ethics board committee. Subjects were excluded if they had known diagnosis of CKD, kidney replacement therapy or hypertension. The screening was performed in three different steps including a background assessment questionnaire, clinical assessment, and biochemical testing including creatinine from blood drop using StatSensor XpressTM to calculate estimated glomerular filtration rate (eGFR), urine dipstick, urinary creatinine, and protein. We measured arsenic (33As), cadmium (48Cd), mercury (80Hg), and lead (82Pb) in 21 water wells around the 10 screened schools, while only arsenic (33As), cadmium (48Cd) and mercury (80Hg) were measured in the urine of a small subset of the samples (data not shown in the results).

Results
A total of 508 randomly selected subjects’ and parents’ consent for screening but only 506 completed assessment. The median age was 14 y/o (IQR 11-17) 50% being female, with a close to 30% of the sample having obesity. The blood pressure was abnormal in 28% of the sample and at least 30% of them had an abnormal urine dipstick. The overall eGFR was 98, being the 25th%tile close to 83 ml/min/1.73 m2 BSA (Tables 1 and 2). Water sources showed higher than recommended levels of all heavy metals tested. Interestingly, the schools “Campiña” showed high levels of Arsenic and Cadmium in water sources, being the subjects tested coincidentally among the lowest eGFR of sample.

Conclusion
CKDu is an entity devastating low-resourced communities with young adults being the most affected. A likelihood for a link of early exposure needs to be further explored. Addressing the postulated hypothesis are key to implement preventive strategies, including screening earlier in life such as pediatric population.
#255 PaCE CKD: the impact of caregiving on health states and work productivity in chronic kidney disease: results from an international survey
Authors: Sanchez Juan Jose Garcia , Wu Mai-Szu , Chadban Steven , Correa-Rotter Ricardo , Reichel Helmut , Elsayed Hesham , Rangaswami Janani , Esposito Ciro , Hull Richard , Pentakota Surendra , West Bronwyn , Kularatne Thames , Fifer Simon 
Published: May 2024

Abstract

Background and Aims
Patients with chronic kidney disease (CKD) often rely on informal caregivers for support with their condition, but the effect of these responsibilities on caregivers’ lives is poorly understood. The aim of this study was to quantify the effect of CKD on caregivers’ health states and work productivity across five countries compared with the general population.

Method
Unpaid informal caregivers of patients with CKD, hereafter referred to as caregivers, in Germany, Mexico, Taiwan, the US, and the UK were enrolled to a non-interventional survey. Caregivers of patients with early (stages 1-3) to advanced (stages 4-5) CKD, including those receiving dialysis were enrolled in the study. A general population cohort was included, matched in sample size and demographic characteristics. The surveys assessed health states and work productivity with the following instruments:

Results
Across five countries, an average of 112 (range: 94–138) caregivers were enrolled to the study. Most respondents cared for a patient receiving dialysis—in Germany (65%), Mexico (65%), UK (67%), US (81%), though less than half (48%) of respondents in Taiwan cared for a dialysis dependent patient. Frequently reported caregiving duties were help with household duties and driving to medical appointments.
Caregivers in Germany, Mexico, the US, and UK experienced significantly impaired health states compared with the general population, as demonstrated by lower EQ-5D-5L utility scores. The greatest difference was observed from respondents in Mexico, with 16% lower mean [SD] index scores compared with the general population (0.79 [0.18] versus 0.94 [0.07]). Caregivers of dialysis dependent patients had similar CarerQol utility scores as those caregiving for non-dialysis dependent patients. Caregivers for dialysis dependent patients reported more problems across all CarerQol domains than caregivers for non-dialysis dependent patients. Caregivers in the UK reported significantly more financial problems (33%) as a result of caregiving; caregivers in the US reported significantly more problems (30%) in combining daily activities with care tasks. Caregiving also had a negative effect on work productivity. Rates of absenteeism, presenteeism, work impairment and non-work activity impairment were worse in caregivers compared with the general population. The largest effects were observed in Mexico where a 40% increase in non-work activity impairment was reported.

Conclusion
This study highlights the global burden for caregivers of patients with CKD. The broader impact of disease on caregivers should be accounted for when considering interventions relating to CKD.
#1321 Long term outcomes in people with fluctuating criteria for the diagnosis of chronic kidney disease
Authors: Taal Maarten W , Lucas Bethany , Mcintyre Natasha , Mcintyre Christopher , Fluck Richard 
Published: May 2024

Abstract

Background and Aims
The diagnostic criteria for chronic kidney disease (CKD) recognise that measures of kidney function may fluctuate in the short term by requiring that abnormalities must persist for at least 90 days to support the diagnosis. Nevertheless, studies have reported that even people who meet the diagnostic criteria may have transient or prolonged improvement in kidney function in the absence of specific treatment. In this study we used the opportunity afforded by long term follow-up of a cohort recruited from primary care to assess the impact on outcomes of fluctuations in CKD diagnostic criteria.

Method
Participants with confirmed CKD stage 3 were recruited from primary care practices in 2008-2010. Clinical assessment and protocol laboratory tests were performed at baseline, 1 and 5 year study visits. In 2019-20, information on deaths and latest available outpatient estimated GFR (eGFR) and urine albumin to creatinine ratio (UACR) values was obtained from electronic records. Participants with eGFR ≥60 ml/min/1.73 m2 and UACR &lt;3 mg/mmol were regarded as being in “remission” at each time point. CKD progression was defined as a decline in eGFR of ≥25% and progression to a more advanced stage (KDIGO definition).

Results
The cohort included 1741 participants with median (IQR) age 74 (67-79) years, eGFR 53.8 (45.3-61.7) ml/min/1.73 m2 and UACR 0.3 (0.001-1.5) mg/mmol at baseline. During a median observation period of 9.8 (9.2-10.0) years, 680 participants (39.1%) died and CKD progression was observed in 430 of 1402 (30.6%) but only 24 (1.4%) progressed to CKD stage 5. The prevalence of remission was 495/1737 (28.5%) at baseline, 424/1618 (26.2%) at year 1, 335/1236 (27.1%) at year 5 and 176/1190 (14.8%) at year 10. Remission was present at all three visits in 15.4%, two visits in 13.0% and one visit in 15.8%. Participants with diabetes and those treated with a renin-angiotensin system inhibitor evidenced a lower prevalence of remission at all time points. Blood pressure control to &lt;130/80 mmHg was not associated with remission. Evidence of remission at 1, 2 or 3 study visits was associated with progressively lower incidence of persistent CKD, CKD progression and death at 10 years (Table, p &lt; 0.001 for all trends). No participants with an episode of remission had progressed to CKD stage 5 at 10 years.

Conclusion
A substantial minority of people diagnosed with CKD in primary care exhibit fluctuating diagnostic criteria. People with one or more episodes of remission appear to have a better prognosis than those with persistent CKD but remain at risk of CKD progression. They can therefore be reassured that an episode of remission is associated with an improved prognosis but long-term monitoring of kidney function is still warranted.