Background Patients with chronic kidney disease commonly experience gait abnormalities, which predispose to falls and fall-related injuries. An unmet need is the development of improved methods for detecting patients at high risk of these complications, using tools that are feasible to implement in nephrology practice. Our prior work suggested step length could be such a marker. Here we explored the use of step length as a marker of gait impairment and fall risk in adults with chronic kidney disease. Methods We performed gait assessments in 2 prospective studies of 82 patients with stage 4 and 5 chronic kidney disease (n = 33) or end-stage renal disease (ESRD) (n = 49). Gait speed and step length were evaluated during the 4-m walk component of the Short Physical Performance Battery (SPPB). Falls within 6 months prior to or following enrollment were identified by questionnaire. Associations of low step length (≤47.2 cm) and slow gait speed (≤0.8 m/s) with falls were examined using logistic regression models adjusted for demographics and diabetes and peripheral vascular disease status. Results Assessments of step length were highly reproducible (r = 0.88, p < 0.001 for duplicate measurements at the same visit; r = 0.78, p < 0.001 between baseline and 3-month evaluations). Patients with low step length had poorer physical function, including lower SPPB scores, slower gait speed, and lower handgrip strength. Although step length and gait speed were highly correlated (r = 0.73, p < 0.001), one-third (n = 14/43) of patients with low step length did not have slow gait speed. Low step length and slow gait speed were each independently associated with the likelihood of falls (odds ratio (OR) 3.90 (95% confidence interval (CI) 1.05–14.60) and OR 4.25 (95% CI 1.24–14.58), respectively). Compared with patients who exhibited neither deficit, those with both had a 6.55 (95% CI 1.40–30.71) times higher likelihood of falls, and the number of deficits was associated with a graded association with falls (p trend = 0.02). Effect estimates were similar after further adjustment for ESRD status. Conclusions Step length and gait speed may contribute additively to the assessment of fall risk in a general adult nephrology population.

Refractory hypothyroidism has been increasingly identified worldwide. Primary hypothyroidism is considered refractory when there is a persistent elevation of thyroid-stimulating hormone (TSH) above the upper limit of normal despite escalating doses of levothyroxine with or without the persistence of hypothyroid symptoms. Further escalation of levothyroxine to supratherapeutic doses could be associated with potential complications such as iatrogenic hyperthyroidism, cardiac failure, and other conditions. Therefore, physicians should rule out non-compliance and pursue a further evaluation to identify etiologies for increased requirements or decreased absorption of levothyroxine in patients not achieving therapeutic doses. Here, we present a 40-year-old Indian male with worsening refractory hypothyroidism that resolved following eradication of his Helicobacter pylori ( H. pylori ) infection. Herein, we highlight a unique and reversible cause of refractory hypothyroidism. With this case report, we hope to encourage physicians to include H. pylori testing in the evaluation of primary hypothyroidism refractory to treatment.

Background: Physical inactivity is common in patients receiving hemodialysis, but activity patterns throughout the day and in relation to dialysis are largely unknown. This knowledge gap can be addressed by long-term, continuous activity monitoring, but this has not been attempted and may not be acceptable to dialysis patients. Methods: Ambulatory patients with end-stage kidney disease receiving thrice-weekly hemodialysis wore commercially available wrist-worn activity monitors for 6 months. Step counts were collected every 15 minutes and were linked to dialysis treatments. Physical function was assessed using the Short Physical Performance Battery (SPPB). Fast time to recovery from dialysis was defined as ≤2 hours. Mixed effects models were created to estimate step counts over time. Results: Of 52 patients enrolled, 48 were included in the final cohort. The mean age was 60 years, and 75% were Black or Hispanic. Comorbidity burden was high, 38% were transported to and from dialysis by paratransit, and 79% had SPPB <10. Median accelerometer use (199 days) and adherence (95%) were high. 42 patients (of 43 responders) reported wearing the accelerometer every day, and few barriers to adherence were noted. Step counts were lower on dialysis days (3991 (95% CI 3187-4796) vs. 4561 (95% CI 3757-5365)), but step count intensity was significantly higher during the hour immediately following dialysis than during the corresponding time on non-dialysis days (188 steps/hour increase (95% CI 171-205)); these levels were the highest noted at any time. Post-dialysis increases were more pronounced among patients with fast recovery time (225 (95% CI 203-248) vs. 134 (95% CI 107-161) steps/hour) or those with SPPB≥7. Estimates were unchanged after adjustment for demographics, diabetes status, and ultrafiltration rate. Conclusions: Long-term, continuous monitoring of physical activity is feasible in hemodialysis patients. Highly granular data collection and analysis yielded new insights into patterns of activity following dialysis treatments.

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