Adiposity measures, lean body mass, physical activity and mortality: NHANES 1999–2004

BACKGROUND: Obesity and physical inactivity are major public health problems. We studied the associations between measures of adiposity, lean body mass, leisure time physical activity (LTPA), and death in those with and without chronic kidney disease (CKD). METHODS: Associations between body mass index (BMI), waist circumference (WC), percent body fat, lean body mass (assessed with Dual-Energy X-ray Absorptiometry[DEXA]), leisure time physical activity (LTPA) and death were examined using the National Health and Nutrition Examination Surveys (NHANES 1999–2004). All-cause mortality was ascertained by linkage of NHANES files with the National Death Index. RESULTS: 9,433 non-CKD participants and 2,153 CKD participants who had fat mass measured using DEXA, BMI, WC, LTPA and mortality data were included. After adjusting for demographics, comorbid conditions, kidney function measures, C-Reactive Protein (CRP), and sodium intake there was no significant risk for death noted with higher WC, fat mass and BMI in those with and without CKD. When examining normal, overweight, and obese groups based on BMI criteria, being overweight (BMI 25–29.9 kg/m(2)) was associated with lower risk of death in those without CKD (Hazard ratio 0.62, 95% CI 0.40, 0.95). Higher lean body mass was associated with lower risk for death in those without kidney disease but not in the CKD population. There was a significantly higher risk for death among those who did not meet the minimum LTPA goals compared to those who met or exceeded the recommended activity levels (>450 MET/min/week) in those with and without CKD (CKD Hazard ratio: 1.36, 95% CI 1.003, 1.85; non-CKD HR 1.65, 95% CI 1.21, 2.26). CONCLUSIONS: In a representative sample of the US population, higher LTPA levels and lean body mass were associated with lower mortality in those without kidney disease. In CKD, higher LTPA was associated with lower risk of death. There was no association between adiposity measures and death in those with and without CKD except for lower mortality associated with overweight among those without CKD. The data suggests the need to develop programs to facilitate an increase in physical activity in people with and without kidney disease

Evaluating the impact of donor eGFR and HLA-DR mismatch on graft survival in living donor kidney transplants

BackgroundThis study assesses the impact of human leukocyte antigen (HLA)-DR mismatch and donor-estimated glomerular filtration rate (eGFR) on outcomes of living donor kidney transplantation (LDKT), which are especially relevant to the availability of multiple donors and paired kidney exchanges.MethodsUsing data from the Scientific Registry of Transplant Recipients (SRTR), we retrospectively analyzed graft survival in adult LDKT recipients transplanted between January 2013 and September 2022. Recipients with 0 HLA-DR mismatches were compared to those with 1-2 HLA-DR mismatches. Cox models assessed the association between donor eGFR and graft and patient survival, stratifying by a) HLA-DR mismatches, and b) HLA-DR mismatches and recipient age.ResultsAmong 44,080 recipients, 7,195 had 0 HLA-DR mismatches and 36,885 had 1-2 HLA-DR mismatches. The recipients’ mean age was 49.1 for the 0 HLA-DR mismatch group and 50.4 for the 1-2 HLA-DR mismatch group. The donors’ mean age was 43.1 and 43.8, with an eGFR of 101.0 and 99.9 ml/min, respectively. A higher donor eGFR was associated with better graft survival. Stratified analyses showed higher donor eGFR levels reduced the risk of graft loss in cases with DR mismatch (p < 0.001) but not in cases without HLA-DR mismatch (p = 0.81). This effect was significant for recipients aged 18-39 and over 60. Similar results were observed for patient survival.ConclusionsHigher donor eGFR was associated with lower risks of graft loss and patient death in the HLA-DR mismatch group but not the 0 HLA-DR mismatch group. These results emphasize the importance of considering both HLA-DR matching and donor kidney function, particularly for younger recipients to avoid sensitization for future transplants

Association of low center performance evaluations and pediatric heart transplant center behavior in the United States

BACKGROUND: To date, no study has evaluated the effects of low center performance evaluations (CPE) on pediatric heart transplant center behavior. We sought to assess the impact of low CPE flags on pediatric heart transplant center listing and transplant volumes and center recipient and donor characteristics. METHODS: We included centers performing at least 10 pediatric (age \u3c18 years) transplants during the Scientific Registry of Transplant Recipients reporting period January 2009-June 2011 and evaluated consecutive biannual program specific reports until the last reporting period January 2016-June 2018. We evaluated changes in center behavior at following time points: a year before flagging, a year and two years after the flag; and at last reporting period. RESULTS: During our study period, 24 pediatric centers were non-flagged and 6 were flagged. Compared to non-flagged centers, there was a decline in candidate listings in flagged centers at the last reporting period (mean increase of 5.5 ± 12.4 listings vs ?\u3e mean decrease of 14.0 ± 14.9 listings; p = .003). Similarly, the number of transplants declined in flagged centers (mean increase of 2.6 ± 9.6 transplants vs ?\u3e mean decrease of 10.0 ± 12.8 transplants; p = .012). Flagged centers had declines in listings for patients with restrictive cardiomyopathy, re-transplant, renal dysfunction, those on mechanical ventilation and extracorporeal membrane oxygenation. There was no significant change in donor characteristics between flagged and non-flagged centers. CONCLUSIONS: Low CPE may have unintended negative consequences on center behavior leading to declines in listing and transplant volumes and potentially leading to decreased listing for higher risk recipients

Outcomes following in-hospital cardiopulmonary resuscitation in people receiving maintenance dialysis

RATIONALE & OBJECTIVE: Previous studies showing poor cardiopulmonary resuscitation (CPR) outcomes in the dialysis population have largely been derived from claims data and are somewhat limited by a lack of detailed characterization of CPR events. We aimed to analyze CPR-related outcomes in individuals receiving maintenance dialysis. STUDY DESIGN: Retrospective chart review. SETTING & PARTICIPANTS: Using electronic medical records from a single academic health care system, we identified all hospitalized adult patients receiving maintenance dialysis who had undergone in-hospital CPR between 2006 and 2014. EXPOSURE: Initial in-hospital CPR. OUTCOMES: Overall survival, predictors of unsuccessful CPR, predictors of death during the same hospitalization among initial survivors, predictors of discharge-to-home status. ANALYTICAL APPROACH: We provide descriptive statistics for the study variables and used RESULTS: A total of 184 patients received in-hospital CPR: 51 (28%) did not survive the initial CPR event, and 77 CPR survivors died (additional 42%) later during the same hospitalization (overall mortality 70%). Only 18 (10%) were discharged home, with the remaining 32 (17%) discharged to a rehabilitation facility or a nursing home. In the multivariable model, the only predictor of unsuccessful CPR was CPR duration (OR, 1.41; 95% CI, 1.24-1.61; LIMITATIONS: Retrospective study design, single-center study, no information on functional status. CONCLUSIONS: Patients receiving maintenance dialysis experience high mortality following in-hospital CPR and only 10% are discharged home. These data may help clinicians provide useful prognostic information while engaging in goals of care conversations

Adiposity, Physical Function, and Their Associations With Insulin Resistance, Inflammation, and Adipokines in CKD

Rationale & Objectives: Adiposity and physical fitness levels are major drivers of cardiometabolic risk, but these relationships have not been well-characterized in chronic kidney disease (CKD). We examined the associations of visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT), intrahepatic fat, and physical function with inflammation, insulin resistance, and adipokine levels in patients with CKD. Study Design: Prospective cohort study. Setting & Participants: Participants with stages 3-5 CKD not receiving maintenance dialysis, followed up at one of 8 clinical sites in the Chronic Renal Insufficiency Cohort (CRIC) Study, and who underwent magnetic resonance imaging of the abdomen at an annual CRIC Study visit (n = 419). Predictors: VAT volume, SAT volume, intrahepatic fat, body mass index, waist circumference, and time taken to complete the 400-m walk test (physical function). Outcomes: Markers of inflammation (interleukin 1β [IL-1β], IL-6, tumor necrosis factor receptor 1 [TNFR1], and TNFR2), insulin resistance (homeostasis model assessment of insulin resistance), and adipokine levels (adiponectin, total and high molecular weight, resistin, and leptin). Analytical Approach: Multivariable linear regression of VAT and SAT volume, intrahepatic fat, and physical function with individual markers (log-transformed values), adjusting for relevant covariates. Results: Mean age of the study population was 64.3 years; 41% were women, and mean estimated glomerular filtration rate was 53.2 ± 14.6 (SD) mL/min/1.73 m2. More than 85% were overweight or obese, and 40% had diabetes. Higher VAT volume, SAT volume, and liver proton density fat fraction were associated with lower levels of total and high-molecular-weight adiponectin, higher levels of leptin and insulin resistance, and lower high-density lipoprotein cholesterol and higher serum triglyceride levels. A slower 400-m walk time was associated only with higher levels of leptin, total adiponectin, plasma IL-6, and TNFR1 and did not modify the associations between fat measures and cardiometabolic risk factors. Limitations: Lack of longitudinal data and dietary details. Conclusions: Various measures of adiposity are associated with cardiometabolic risk factors. Physical function was also associated with the cardiometabolic risk factors studied and does not modify associations between fat measures and cardiometabolic risk factors. Longitudinal studies of the relationship between body fat and aerobic fitness with cardiovascular and kidney disease progression are warranted

Recurrence of iga nephropathy after kidney transplantation in adults

Background and objectives: In patients with kidney failure due to IgA nephropathy, IgA deposits can recur in a subsequent kidney transplant. The incidence, effect, and risk factors of IgA nephropathy recurrence is unclear, because most studies have been single center and sample sizes are relatively small. Design, setting, participants, & measurements: We performed a multicenter, international, retrospective study to determine the incidence, risk factors, and treatment response of recurrent IgA nephropathy after kidney transplantation. Data were collected from all consecutive patients with biopsy-proven IgA nephropathy transplanted between 2005 and 2015, across 16 “The Post-Transplant Glomerular Disease” study centers in Europe, North America, and South America. Results: Out of 504 transplant recipients with IgA nephropathy, recurrent IgA deposits were identified by kidney biopsy in 82 patients; cumulative incidence of recurrence was 23% at 15 years (95% confidence interval, 14 to 34). Multivariable Cox regression revealed a higher risk for recurrence of IgA deposits in patients with a pre-emptive kidney transplant (hazard ratio, 3.45; 95% confidence interval, 1.31 to 9.17) and in patients with preformed donorspecific antibodies (hazardratio, 2.59; 95%confidence interval, 1.09 to 6.19).Afterkidneytransplantation,development of de novo donor-specific antibodies was associated with subsequent higher risk of recurrence of IgA nephropathy (hazard ratio, 6.65; 95% confidence interval, 3.33 to 13.27). Immunosuppressive regimen was not associated with recurrent IgA nephropathy in multivariable analysis, including steroid use. Graft loss was higher in patients with recurrence of IgA nephropathy compared with patients without (hazard ratio, 3.69; 95% confidence interval, 2.04 to 6.66), resulting in 32% (95% confidence interval, 50 to 82) graft loss at 8 years after diagnosis of recurrence. Conclusions: In our international cohort, cumulative risk of IgA nephropathy recurrence increased after transplant and was associated with a 3.7-fold greater risk of graft loss