Nephrology considerations in the management of durable and temporary mechanical circulatory support

Durable and temporary mechanical circulatory support (MCS) use is growing for a range of cardiovascular indications. Kidney dysfunction is common in persons evaluated for or receiving durable or temporary MCS, and portends worse outcomes. This kidney dysfunction can be due to pre-existing kidney chronic kidney disease (CKD), acute kidney injury (AKI) related to acute cardiovascular disease necessitating MCS, AKI due to cardiac procedures, and due to acute and chronic MCS effects and complications. Durable MCS, with implantable continuous flow pumps, is used for long-term support in advanced HF refractory to guideline directed medical and device therapy, either permanently or as a bridge to heart transplantation. Temporary MCS-encompassing in this review intra-aortic balloon pumps (IABPs), axial flow pumps, centrifugal flow pumps, and venoarterial ECMO-is used for diverse situations: high risk percutaneous coronary interventions (PCI), acute decompensated heart failure (HF), cardiogenic shock, and resuscitation following cardiac arrest. The wide adoption of MCS makes it imperative to improve understanding of the effects of MCS on kidney health/function, and of kidney health/function on MCS outcomes. The complex structure and functions of the kidney, and the complex health states of individuals receiving MCS, makes investigations in this area challenging, and current knowledge is limited. Fortunately, the increasing nephrology toolbox of non-invasive kidney health/function assessments may enable development and testing of individualized management strategies and therapeutics in the future. We review technology, epidemiology, pathophysiology, clinical considerations, and future directions in MCS and nephrology.

Initial home dialysis is increased for rural patients by accessing urban facilities

Background: The 240,000 rural patients with end stage kidney disease in the United States have less access to nephrology care and higher mortality than those in urban settings. The Advancing American Kidney Health initiative aims to increase the use of home renal replacement therapy. Little is known about how rural patients access home dialysis and the availability and quality of rural dialysis facilities. Methods: Incident dialysis patients in 2017 and their facilities were identified in the United States Renal Data System. Facility quality and service availability was analyzed with descriptive statistics. We assessed the availability of home dialysis methods depending on rural versus urban counties, and then we used multivariate logistic regression to identify the likelihood of rural patients with home dialysis as their initial modality and the likelihood of rural patients changing to home dialysis within 90 days. Finally, we assessed mortality after dialysis initiation based on patient home location. Results: Of the 97,930 dialysis initiates, 15,310 (15.6%) were rural. Rural dialysis facilities were less likely to offer home dialysis (51.4% vs 54.1%, P<0.001). While a greater proportion of rural patients (9.2 vs 8.2%, P<0.001) were on home dialysis, this was achieved by traveling to urban facilities to obtain home dialysis (OR 2.74, P<0.001). After adjusting for patient and facility factors, rural patients had a higher risk of mortality (HR 1.06, P=0.004). Conclusions: Despite having fewer facilities that offer home dialysis, rural patients were more often on home dialysis methods because they traveled to urban facilities, representing an access gap. Even if rural patients accessed home dialysis at urban facilities, rural patients still suffered worse mortality. Future dialysis policy should address this access gap to improve care and overall mortality for rural patients.

Program Report: Nîsohkamâtowak—Helping Patients and Families Living With Kidney Disease in Northern Saskatchewan

Purpose of the Program: Nîsohkamâtowak, the Cree word for Helping Each Other, is an initiative to close gaps in kidney health care for First Nations and Métis patients, their families, and communities in northern Saskatchewan. Nîsohkamâtowak emerged from a collaboration between the Kidney Health Community Program and First Nations and Métis Health Services to find ways to deliver better care and education to First Nations and Métis people living with kidney disease while acknowledging Truth and Reconciliation and the Calls to Action. Sources of Information: This article describes how traditional Indigenous protocols and storytelling were woven into the Nîsohkamâtowak events, gathering of patient and family voices in writing and video format, and how this work led to a collaborative co-designed process that incorporates the Truth and Reconciliation: Calls to Action into kidney care and the benefits we have seen so far. The teachings of the 4 Rs—respect, reciprocity, responsibility, and relevance, were critical to ensuring that Nîsohkamâtowak reports and learning were shared with participants and the communities represented in this initiative. Methods: Group discussions and sharing circles were facilitated in several locations throughout northern and central Saskatchewan. Main topics of discussion were traditional medicines, residential schools impact, community and peer supports for kidney disease patients, and cultural safety education for health care providers. Key Findings: The general themes selected for improvement were education, support within the local community, traditional practices and cultural competency, and delivery of services. To address these gaps in kidney care, the following objectives were co-created with First Nations and Métis patients, families, and communities for Kidney Health to provide culturally appropriate education and resources, to ensure appropriate follow-up support to include strengthening connections to communities and other health authorities, to incorporate traditional practices into program design, and to ensure appropriate service delivery across the spectrum of care with a focus on screening and referral, which is strongly linked to coordination of care with local health centers. Implications: As a result of this work, the Kidney Health Community Program restructured the delivery of services and continues to work with Nîsohkamâtowak advisors on safety initiatives and chronic kidney disease awareness, prevention, and management in their respective communities. The Truth and Reconciliation and Calls to Action are honored to close the gaps in kidney care. Limitations: Nîsohkamâtowak is a local Kidney Health initiative that has the good fortune of having dedicated funding and staff to carry out this work. The findings may be unique to the First Nations and Métis communities and people who shared their stories. Truth and Reconciliation is an ongoing commitment that must be nurtured. Although not part of this publication, the effects of COVID-19 have made it difficult to further advance the Calls to Action, with more limited staff resources and the inability to meet in person as in the past.

Effect of Mineral-Balanced Deep-Sea Water on Kidney Function and Renal Oxidative Stress Markers in Rats Fed a High-Salt Diet

This study investigated the effect of mineral-balanced deep-sea water (DSW) on kidney health using an animal model of kidney injury due to a high-sodium diet. High magnesium/low sodium (HMLS) and high magnesium/high calcium (HMHC) DSW samples with different mineral contents were prepared. Sprague–Dawley rats were fed an 8% sodium chloride (NaCl) diet for four weeks to induce kidney injury, and each group was supplied with purified water or mineral water. Kidney injury was observed in the NaCl group according to increased kidney injury markers and malondialdehydes, providing evidence of oxidative stress. However, the kidney injury was repaired by the intake of mineral-balanced DSW. It was confirmed that the HMLS and HMHC groups showed improved Na+ excretion through the urine. Kidney injury markers in urine decreased and upregulation of low-density lipoprotein receptor-related protein2 mRNA expression was observed in the HMLS and HMHC groups. In addition, superoxide dismutase activity was increased in the HMHC groups. The gene expression patterns of the RNA sequencing were similar between the CON and HMLS groups. These results suggest that DSW has beneficial effects on kidney health due to the balanced magnesium and calcium levels in models of kidney injury caused by excessive sodium intake.

Risk of kidney health among returnee Nepali migrant workers: A survey of nephrologists

Background: Anecdotal reports suggest an increasing prevalence of kidney problems in returnee Nepali migrant workers from the Gulf countries and Malaysia. Aims and Objectives: This study aims to (a) explore the magnitude of the kidney health-related problems in returnee Nepali migrant workers; and, (b) assess the need for further scientific investigations. Materials and Methods: This was a self-administered survey of practicing nephrologists in Nepal. All 51 nephrologists working in Nepal (at the time of this study) were approached by email for anonymous participation using an online survey platform. Data were collected between December 2019 and February 2020. Descriptive statistics were generated for data analysis. Results: A total of 38 nephrologists completed the survey. Almost all their migrant patients were: younger than 40 years, males, from rural areas of Nepal, and had worked in Gulf countries or Malaysia. Most (92.1%) of the respondents reported that the causes behind kidney-related problems of returnee migrant workers were of unknown etiology and less likely to be linked to traditional risk factors. Chronic kidney disease and glomerulonephritis were the most common kidney health-related problems. The vast majority of respondents (76.3%) thought that the returnee migrant workers are at a higher risk of kidney-related problems than the general Nepali population. Conclusion: Nepali labor migrants in the countries of the Gulf and Malaysia could be at a higher risk of kidney health-related problems than the general Nepali population. Further rigorous scientific investigation is warranted to examine the kidney-health-related risk of Nepali migrant workers.

Metabolites Associated with Coffee Consumption and Incident Chronic Kidney Disease

Background and objectivesModerate coffee consumption has been associated with lower risk of CKD; however, the exact biologic mechanisms underlying this association are unknown. Metabolomic profiling may identify metabolic pathways that explain the association between coffee and CKD. The goal of this study was to identify serum metabolites associated with coffee consumption and examine the association between these coffee-associated metabolites and incident CKD.Design, setting, participants, & measurementsUsing multivariable linear regression, we identified coffee-associated metabolites among 372 serum metabolites available in two subsamples of the Atherosclerosis Risk in Communities study (ARIC; n=3811). Fixed effects meta-analysis was used to pool the results from the two ARIC study subsamples. Associations between coffee and metabolites were replicated in the Bogalusa Heart Study (n=1043). Metabolites with significant associations with coffee in both cohorts were then evaluated for their prospective associations with incident CKD in the ARIC study using Cox proportional hazards regression.ResultsIn the ARIC study, mean (SD) age was 54 (6) years, 56% were daily coffee drinkers, and 32% drank >2 cups per day. In the Bogalusa Heart Study, mean (SD) age was 48 (5) years, 57% were daily coffee drinkers, and 38% drank >2 cups per day. In a meta-analysis of two subsamples of the ARIC study, 41 metabolites were associated with coffee consumption, of which 20 metabolites replicated in the Bogalusa Heart Study. Three of these 20 coffee-associated metabolites were associated with incident CKD in the ARIC study.ConclusionsWe detected 20 unique serum metabolites associated with coffee consumption in both the ARIC study and the Bogalusa Heart Study, and three of these 20 candidate biomarkers of coffee consumption were associated with incident CKD. One metabolite (glycochenodeoxycholate), a lipid involved in primary bile acid metabolism, may contribute to the favorable kidney health outcomes associated with coffee consumption. Two metabolites (O-methylcatechol sulfate and 3-methyl catechol sulfate), both of which are xenobiotics involved in benzoate metabolism, may represent potential harmful aspects of coffee on kidney health.