Background and objectives Patients with CKD are more likely than others to have abnormalities in serum potassium (K + ). Aside from severe hyperkalemia, the clinical significance of K + abnormalities is not known. We sought to examine the association of serum K + with mortality and hospitalization rates within narrow eGFR strata to understand how the burden of hyperkalemia varies by CKD severity. Associations were examined between serum K + and discontinuation of medications that block the renin-angiotensin-aldosterone system (RAAS), which are known to increase serum K + .Design, setting, participants, & measurements A cohort of patients with CKD (eGFR,60 ml/min per 1.73 m 2 ) with serum K + data were studied (n=55,266) between January 1, 2009, and June 30, 2013 (study end). Serum K + , eGFR, and covariates were considered on a time-updated basis. Mortality, major adverse cardiovascular events (MACE), hospitalization, and discontinuation of RAAS blockers were considered per time at risk.Results During the study, serum K + levels of 5.5-5.9 and $6.0 mEq/L were most prevalent at lower eGFR: they were present, respectively, in 1.7% and 0.2% of patient-time for eGFR of 50-59 ml/min per 1.73 m 2 versus 7.6% and 1.8% of patient-time for eGFR,30 ml/min per 1.73 m 2 . Serum K + level ,3.5 mEq/L was present in 1.2%-1.4% of patient-time across eGFR strata. The median follow-up time was 2.76 years. There was a U-shaped association between serum K + and mortality; pooled adjusted incidence rate ratios were 3.05 (95% confidence interval, 2.53 to 3.68) and 3.31 (95% confidence interval, 2.52 to 4.34) for K + levels ,3.5 mEq/L and $6.0 mEq/L, respectively. Within eGFR strata, there were U-shaped associations of serum K + with rates of MACE, hospitalization, and discontinuation of RAAS blockers.Conclusions Both hyperkalemia and hypokalemia were independently associated with higher rates of death, MACE, hospitalization, and discontinuation of RAAS blockers in patients with CKD who were not undergoing dialysis. Future studies are needed to determine whether interventions targeted at maintaining normal serum K + improve outcomes in this population.

Metformin-associated GI symptoms in patients with T2DM lead to lower physical and mental HRQoL, which may result in patient nonadherence or physician reluctance to optimally titrate the metformin dose.

When using a contemporary definition at one point in time, ESA hyporesponsiveness was potently and persistently associated with greater mortality, greater iron and ESA use, and lower hemoglobin levels compared to non-ESA hyporesponsiveness.

Background Patients on hemodialysis have an elevated risk for COVID-19 infection but were not included in efficacy trials of SARS-CoV-2 vaccines. Methods We conducted a retrospective, observational study to estimate the real-world effectiveness and immunogenicity of two mRNA SARS-CoV-2 vaccines in a large, representative population of adult hemodialysis patients in the United States. In separate, parallel analyses, patients who began a vaccination series with BNT162b2 or mRNA-1273 in January and February 2021 were matched with unvaccinated patients and followed after they completed the first of two doses. In a subset of patients, blood samples were collected approximately 28 days after the second dose and anti-SARS-CoV-2 immunoglobulin G was measured. Results A total of 12,169 patients received the BNT162b2 vaccine (matched with 44,377 unvaccinated controls); 23,037 patients received the mRNA-1273 vaccine (matched with 63,243 unvaccinated controls). Compared with controls, vaccinated patients' risk of being diagnosed with COVID-19 post-vaccination became progressively lower after the first dose (day 1) to days ≥43. Following a COVID-19 diagnosis, vaccinated patients were significantly less likely than unvaccinated patients to be hospitalized (for BNT162b2, 28.0% versus 43.4%; for mRNA-1273, 37.2% versus 45.6%) and significantly less likely to die (for BNT162b2, 4.0% versus 12.1%; for mRNA-1273, 5.6% versus 14.5%). Antibodies were detected in 98.1% (309/315) and 96.0% (308/321) of BNT162b2 and mRNA-1273 patients, respectively. Conclusions In patients on hemodialysis, vaccination with BNT162b2 or mRNA-12 was associated with a lower risk of COVID-19 diagnosis and significantly lower risk of hospitalization or death among those diagnosed with COVID-19. SARS-CoV-2 antibodies were detected in nearly all patients after vaccination. These findings support the use of these vaccines in this population.

BackgroundA combination of safety concerns and labeling changes impacted use of erythropoiesis-stimulating agents (ESAs) in renal anemia. Data regarding contemporary utilization in pre-dialysis chronic kidney disease (CKD) are lacking.MethodsElectronic healthcare records and medical claims data of pre-dialysis CKD patients were aggregated from a large US managed care provider (2011–13). ESA use patterns, characteristics, and outcomes of ESA-treated/untreated patients were quantified.ResultsAt baseline, 109/32,308 patients (0.3%) were ESA users. Treated patients were older, had more advanced CKD (58.8% vs 5.4% with stage 4/5 vs 3) and greater prevalence of comorbid diabetes, hypertension, heart failure, and peripheral vascular disease. An additional 266 patients initiated ESA: hemoglobin at initiation was 8–10 g/dL in 193 of these and >10 g/dL in the remainder; 61.7% had stage 4/5 CKD; prevalence of cardiovascular disease was high (50.8% heart failure; 25.2% prior myocardial infarction; 24.1% prior stroke). During follow-up, rates of death and cardiovascular events were higher in baseline ESA users and ESA naives versus non-users.ConclusionsESA use in pre-dialysis CKD patients was exceedingly rare and directed disproportionately to older, sicker patients; these patients had high rates of death and cardiovascular events. These data provide context for contemporary use of ESA in pre-dialysis CKD.Electronic supplementary materialThe online version of this article (10.1186/s12882-018-0925-2) contains supplementary material, which is available to authorized users.

Key Points Question Is enrollment in a chronic condition special needs plan (C-SNP) associated with improved outcomes in patients with end-stage kidney disease (ESKD)? Findings In this cohort study of 2545 C-SNP enrollees matched at the facility level to patients not enrolled in C-SNP and 1986 C-SNP enrollees matched at the county level to patients not enrolled in C-SNP, C-SNP enrollees had significantly lower hospitalization rates and mortality risk than matched patients who were not enrolled in a C-SNP. Meaning The findings of this study suggest that enrollment in a C-SNP may improve outcomes compared with standard care for patients with ESKD.

It is widely thought that patients with end-stage renal disease who remain vocationally active and/or commercially insured following dialysis initiation have better clinical outcomes and higher quality of life than those who do not. However, scientifically robust data are lacking. Here, we examined whether vocational status (active, N = 1848; inactive, N = 10,001) and, separately, insurance status (commercial, N = 4858; Medicare/self-pay, N = 13,329; Medicaid, N = 3528) were associated with clinical outcomes and Kidney Disease Quality of Life (KDQOL) scores among a cohort of patients who initiated dialysis at a large US dialysis organization during 2015-2016. Outcomes were considered from the day after index (31 days after dialysis initiation for vocational status and 1 day after initiation for insurance status) until the earliest of death, discontinuation of dialysis, transplant, loss to follow-up, or end of study (30 September 2016). Comparisons were made using intention-to-treat principles and generalized linear models adjusted for imbalanced patient characteristics, including sociodemographic variables. Vocational inactivity (vs. vocational activity) was independently associated with higher rates of mortality and hospitalization, lower rates of transplant, and lower KDQoL scores in 4 of 5 domains. Similar trends were observed when comparing Medicare/self-pay or Medicaid insurance to commercial insurance. Vocational activity, and separately, commercial insurance, were independently associated with better clinical and quality of life outcomes compared to other insurance and vocational categories. These findings may inform patient and physician education, and guide advocacy efforts.

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