Publications by authors named "Michael J. Choi"

62 Publications

Improving Primary Care Delivery for Patients Receiving Maintenance Hemodialysis.

Am J Kidney Dis 2021 May 13. Epub 2021 May 13.

The Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD; Division of General Internal Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD.

The beneficial impact of primary care, focused on all aspects of a patients' health (rather than a disease-specific focus) is well established. Recognized benefits include greater receipt of preventive care and counseling, lower utilization of emergency care and hospitalization for ambulatory care sensitive conditions, and decreased early mortality. While the importance of primary care and care coordination at the primary care-specialty interface is well recognized, the role of primary care within traditional and emerging care models for patients receiving maintenance in-center hemodialysis remains ill-defined. In this perspective article, we will describe: 1) the role of primary care for patients receiving maintenance hemodialysis and the current evidence regarding the receipt of primary care among those patients; 2) the key challenges to delivery of primary care for these complex patients, including suboptimal care coordination between nephrology and primary care providers (PCPs), the intensity of dialysis care, and the limited capacity of nephrologists and PCPs to meet the broad health needs of hemodialysis patients; 3) the potential strategies for improving the delivery of primary care for patients receiving hemodialysis; and 4) future research needs to improve primary care delivery for this high-risk population.
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http://dx.doi.org/10.1053/j.ajkd.2021.02.340DOI Listing
May 2021

Hemodialysis Emergencies: Core Curriculum 2021.

Am J Kidney Dis 2021 05 23;77(5):796-809. Epub 2021 Mar 23.

MedStar Georgetown University Hospital, Washington, DC. Electronic address:

Since maintenance hemodialysis (HD) first became available in the United States in 1962, there has been tremendous growth in the population of patients with kidney failure. HD has become a routine treatment carried out in outpatient clinics, hospitals, nursing facilities, and in patients' homes. Although it is a complex procedure, HD is quite safe. Serious complications are uncommon due to the use of modern HD machines and water treatment systems as well as the development of strict protocols to monitor various aspects of the HD treatment. The practicing nephrologist must be knowledgeable about life-threatening complications that can occur during HD and be able to recognize, manage, and prevent them. This installment in the AJKD Core Curriculum in Nephrology reviews the pathogenesis, management, and prevention of 9 HD emergencies. The HD emergencies covered include dialyzer reactions, dialysis disequilibrium syndrome, uremic/dialysis-associated pericarditis, air embolism, venous needle dislodgement, vascular access hemorrhage, hemolysis, dialysis water contamination, and arrhythmia episodes.
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http://dx.doi.org/10.1053/j.ajkd.2020.11.024DOI Listing
May 2021

Higher Prevalence of Concurrent Thrombocytopenia in Patients Receiving Continuous Renal Replacement Therapy in the Cardiac Intensive Care Unit.

Blood Purif 2021 Feb 25:1-8. Epub 2021 Feb 25.

Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA,

Introduction: Thrombocytopenia (TCP) is a common finding in patients receiving continuous renal replacement therapy (CRRT).

Objective: The purpose of this study was to assess the nature of TCP in patients receiving CRRT.

Methods: This is a single-center case-control observational study of 795 patients involving over 166,950 h of delivered CRRT at Johns Hopkins Hospital. Concurrent TCP in patients receiving CRRT was defined as a decrease in platelet count of ≥50% any time within 72 h of initiation of CRRT with strict exclusion criteria.

Results: There was a higher incidence of TCP in the cardiac intensive care unit (CICU) (22.5%) compared to medical ICU (MICU) (13.1%). Using logistic regression, the odds of developing concurrent TCP in patients receiving CRRT was 2.46 (95% CI 1.32-3.57, p < 0.05) times higher in the CICU compared with the MICU. There was no difference in the incidence of severe or profound TCP or timing of acute TCP between the CICU and MICU.

Conclusion: Safe delivery of dialysis care in the ICU is paramount and creating awareness of potential risks such as concurrent TCP in patients receiving CRRT should be part of this care.
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http://dx.doi.org/10.1159/000513366DOI Listing
February 2021

Trials and tribulations of diagnosing and preventing contrast-induced acute kidney injury.

J Thorac Cardiovasc Surg 2020 Jul 31. Epub 2020 Jul 31.

Division of Nephrology, Georgetown University, Washington, DC. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2020.06.147DOI Listing
July 2020

Burnout and Emotional Well-Being among Nephrology Fellows: A National Online Survey.

J Am Soc Nephrol 2020 04 2;31(4):675-685. Epub 2020 Mar 2.

Department of Medicine, Division of Nephrology, Johns Hopkins University, Baltimore, Maryland.

Background: Physician burnout and emotional distress are associated with work dissatisfaction and provision of suboptimal patient care. Little is known about burnout among nephrology fellows.

Methods: Validated items on burnout, depressive symptoms, and well being were included in the American Society of Nephrology annual survey emailed to US nephrology fellows in May to June 2018. Burnout was defined as an affirmative response to two single-item questions of experiencing emotional exhaustion or depersonalization.

Results: Responses from 347 of 808 eligible first- and second-year adult nephrology fellows were examined (response rate=42.9%). Most fellows were aged 30-34 years (56.8%), male (62.0%), married or partnered (72.6%), international medical graduates (62.5%), and pursuing a clinical nephrology fellowship (87.0%). Emotional exhaustion and depersonalization were reported by 28.0% and 14.4% of the fellows, respectively, with an overall burnout prevalence of 30.0%. Most fellows indicated having strong program leadership (75.2%), positive work-life balance (69.2%), presence of social support (89.3%), and career satisfaction (73.2%); 44.7% reported a disruptive work environment and 35.4% reported depressive symptoms. Multivariable logistic regression revealed a statistically significant association between female gender (odds ratio [OR], 1.90; 95% confidence interval [95% CI], 1.09 to 3.32), poor work-life balance (OR, 3.97; 95% CI, 2.22 to 7.07), or a disruptive work environment (OR, 2.63; 95% CI, 1.48 to 4.66) and burnout.

Conclusions: About one third of US nephrology fellows surveyed reported experiencing burnout and depressive symptoms. Further exploration of burnout-especially that reported by female physicians, as well as burnout associated with poor work-life balance or a disruptive work environment-is warranted to develop targeted efforts that may enhance the educational experience and emotional well being of nephrology fellows.
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http://dx.doi.org/10.1681/ASN.2019070715DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7191917PMC
April 2020

Prophylactic Anticoagulation in Adult Patients with Nephrotic Syndrome.

Clin J Am Soc Nephrol 2020 01 1;15(1):123-125. Epub 2019 Oct 1.

Department of Medicine, Division of Nephrology and Hypertension, MedStar Georgetown University Hospital, Washington, DC

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http://dx.doi.org/10.2215/CJN.05250419DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6946067PMC
January 2020

Erythropoiesis-Stimulating Agents and Cancer: Myth or Truth.

Adv Chronic Kidney Dis 2019 07;26(4):221-224

Henry Ford Hospital, Detroit, MI; Professor of Clinical Medicine, Wayne State University, Detroit, MI.

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http://dx.doi.org/10.1053/j.ackd.2019.04.001DOI Listing
July 2019

Primary care physicians' perceptions of barriers and facilitators to management of chronic kidney disease: A mixed methods study.

PLoS One 2019 22;14(8):e0221325. Epub 2019 Aug 22.

The Welch Center for Prevention, Epidemiology, and Clinical Research, Baltimore, Maryland, United States of America.

Background: Given the high prevalence of chronic kidney disease (CKD), primary care physicians (PCPs) frequently manage early stage CKD. Nonetheless, there are challenges in providing optimal CKD care in the primary care setting. This study sought to understand PCPs' perceptions of barriers and facilitators to the optimal management of CKD.

Study Design: Mixed methods study.

Settings And Participants: Community-based PCPs in four US cities: Baltimore, MD; St. Louis, MO; Raleigh, NC and San Francisco, CA.

Methodology: We used a self-administered questionnaire and conducted 4 focus groups of PCPs (n = 8 PCPs/focus group) in each city to identify key barriers and facilitators to management of patients with CKD in primary care.

Analytic Approach: We conducted descriptive analyses of the survey data. Major themes were identified from audio-recorded interviews that were transcribed and coded by the research team.

Results: Of 32 participating PCPs, 31 (97%) had been in practice for >10 years, and 29 (91%) practiced in a non-academic setting. PCPs identified multiple barriers to managing CKD in primary care including at the level of the patient (e.g., low awareness of CKD, poor adherence to treatment recommendations), the provider (e.g., staying current with CKD guidelines), and the health care system (e.g., inflexible electronic medical record, limited time and resources). PCPs desired electronic prompts and lab decision support, concise guidelines, and healthcare financing reform to improve CKD care.

Conclusions: PCPs face substantial but modifiable barriers in providing care to patients with CKD. Interventions that address these barriers and promote facilitative tools may improve PCPs' effectiveness and capacity to care for patients with CKD.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0221325PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6705804PMC
March 2020

The Use of Erythropoiesis-Stimulating Agents in Patients With CKD and Cancer: A Clinical Approach.

Am J Kidney Dis 2019 11 5;74(5):667-674. Epub 2019 Aug 5.

MedStar Georgetown University Hospital, Washington, DC. Electronic address:

Erythropoiesis-stimulating agents (ESAs) have been used to manage anemia in chronic kidney disease (CKD) to reduce transfusion requirements and anemia symptoms. Lack of objective benefit of normalizing hemoglobin (Hb) levels and increased evidence of ESA-induced complications in persons with anemia has resulted in clinicians generally attempting to maintain Hb levels in the 10- to 11-g/dL range. In 2000, concerns in patients with cancer arose attributable to associations of ESA use with increased mortality, thrombotic complications, and cerebrovascular accidents led to a change in US Food and Drug Administration oncology guidelines regarding limitation of ESA use for chemotherapy-induced anemia. No guidance was rendered for individuals with CKD and cancer. Persons with CKD with remote or active malignancy should receive the lowest ESA doses possible that achieve a maximum Hb level of 10g/dL. Based on current data, although ESAs may promote progression or worsen outcomes in some cancers, we lack data that ESAs increase the likelihood of developing new cancers in patients on dialysis or earlier stages of CKD.
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http://dx.doi.org/10.1053/j.ajkd.2019.04.022DOI Listing
November 2019

Primary Care Physicians' Perceived Barriers to Nephrology Referral and Co-management of Patients with CKD: a Qualitative Study.

J Gen Intern Med 2019 07 16;34(7):1228-1235. Epub 2019 Apr 16.

Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA.

Background: Effective co-management of patients with chronic kidney disease (CKD) between primary care physicians (PCPs) and nephrologists is increasingly recognized as a key strategy to ensure the delivery of efficient and high-quality CKD care. However, the co-management of patients with CKD remains suboptimal.

Objective: We aimed to identify PCPs' perceptions of key barriers and facilitators to effective co-management of patients with CKD at the PCP-nephrology interface.

Study Design: Qualitative study SETTING AND PARTICIPANTS: Community-based PCPs in four US cities: Baltimore, MD; St. Louis, MO; Raleigh, NC; and San Francisco, CA APPROACH: We conducted four focus groups of PCPs. Two members of the research team coded transcribed audio-recorded interviews and identified major themes.

Key Results: Most of the 32 PCPs (59% internists and 41% family physicians) had been in practice for > 10 years (97%), spent ≥ 80% of their time in clinical care (94%), and practiced in private (69%) or multispecialty group practice (16%) settings. PCPs most commonly identified barriers to effective co-management of patients with CKD focused on difficulty developing working partnerships with nephrologists, including (1) lack of timely adequate information exchange (e.g., consult note not received or CKD care plan unclear); (2) unclear roles and responsibilities between PCPs and nephrologists; and (3) limited access to nephrologists (e.g., unable to obtain timely consultations or easily contact nephrologists with concerns). PCPs expressed a desire for "better communication tools" (e.g., shared electronic medical record) and clear CKD care plans to facilitate improved PCP-nephrology collaboration.

Conclusions: Interventions facilitating timely adequate information exchange, clear delineation of roles and responsibilities between PCPs and nephrologists, and greater access to specialist advice may improve the co-management of patients with CKD.
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http://dx.doi.org/10.1007/s11606-019-04975-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6614220PMC
July 2019

KDOQI US Commentary on the 2017 ACC/AHA Hypertension Guideline.

Am J Kidney Dis 2019 04;73(4):437-458

Department of Medicine, University of Utah, Salt Lake City, UT.

Hypertension is a modifiable risk factor for cardiovascular morbidity and mortality and reduction of elevated blood pressure (BP) remains an important intervention for slowing kidney disease progression. Over the past decade, the most appropriate BP target for initiation and titration of BP-lowering medications has been an area of intense research and debate within the clinical community. In 2017, the American College of Cardiology and the American Heart Association (ACC/AHA) in conjunction with several other professional societies released new hypertension guidelines based on data from a systematic review of clinical trials and observational data. While many of the recommendations in the ACC/AHA hypertension guideline are relevant to nephrology practice, BP targets and management strategies for patients receiving dialysis are not discussed. This Kidney Disease Outcomes Quality Initiative (KDOQI) commentary focuses largely on recommendations from the ACC/AHA hypertension guidelines that are pertinent to individuals at risk of chronic kidney disease or with non-dialysis-dependent chronic kidney disease. This KDOQI commentary also includes a brief discussion of the consensus statement regarding hypertension diagnosis and management for adults receiving maintenance dialysis published by the European Renal and Cardiovascular Medicine Working Group of the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) and the Hypertension and the Kidney working group of the European Society of Hypertension. Overall, we support the vast majority of the ACC/AHA recommendations and highlight select areas in which best diagnosis and treatment options remain controversial.
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http://dx.doi.org/10.1053/j.ajkd.2019.01.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6740329PMC
April 2019

Use of Renin-Angiotensin System Blockade in Advanced CKD: An NKF-KDOQI Controversies Report.

Am J Kidney Dis 2018 12 7;72(6):873-884. Epub 2018 Sep 7.

Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, CA.

Multiple clinical trials have demonstrated that renin-angiotensin system (RAS) blockade with either angiotensin-converting enzyme inhibitors or angiotensin receptor blockers effectively reduces chronic kidney disease (CKD) progression. However, most clinical trials excluded participants with advanced CKD (ie, estimated glomerular filtration rate [eGFR]<30mL/min/1.73m). It is acknowledged that initiation of RAS blockade is often associated with an acute reduction in eGFR, which is thought to be functional, but may result in long-term preservation of kidney function through the reductions in glomerular intracapillary pressure conferred by these agents. In this National Kidney Foundation-Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) report, we discuss the controversies regarding use of RAS blockade in patients with advanced kidney disease. We review available published data on this topic and provide perspective on the impact of RAS blockade on changes in eGFRs and potassium levels. We conclude that more research is needed to evaluate the therapeutic index of RAS blockade in patients with advanced CKD.
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http://dx.doi.org/10.1053/j.ajkd.2018.06.010DOI Listing
December 2018

An Introduction to dialysis education: Issues, innovations and impact.

Semin Dial 2018 03;31(2):99-101

Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

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http://dx.doi.org/10.1111/sdi.12680DOI Listing
March 2018

Risk Variants, Incident Proteinuria, and Subsequent eGFR Decline in Blacks with Hypertension-Attributed CKD.

Clin J Am Soc Nephrol 2017 Nov 19;12(11):1771-1777. Epub 2017 Oct 19.

Due to the number of contributing authors, the affiliations are provided in the Supplemental Material.

Background And Objectives: The natural history of kidney disease among blacks who carry the high-risk variants varies, with only a subgroup progressing to ESRD. We aimed to determine whether the risk variants are associated with incident proteinuria in the context of hypertension-attributed CKD, and whether subsequent kidney function decline after the onset of proteinuria differs by risk status.

Design, Setting, Participants, & Measurements: Using Cox models, we studied the association between risk status and incident proteinuria (defined as a doubling of urine protein-to-creatinine ratio to a level ≥0.22 g/g creatinine) among African-American Study of Kidney Disease and Hypertension (AASK) trial participants with genotyping and without proteinuria at baseline.

Results: Of the 480 participants in our study, 82 (17%) had the high-risk genotypes (2 alleles), and 254 (53%) developed proteinuria over a median follow-up of 6.8 years. At baseline, mean eGFR was lower in the high-risk group compared with the low-risk group (0 or 1 allele; 49.6 versus 53.2 ml/min per 1.73 m, respectively; =0.02), but median proteinuria was similar (0.04 g/g creatinine for both groups; =0.43). Individuals with the high-risk genotypes were 1.72-fold more likely to develop incident proteinuria compared with those with the low-risk genotypes (95% confidence interval, 1.27 to 2.32), independent of age, sex, ancestry, baseline eGFR, baseline systolic BP, and randomized treatment groups. Although eGFR declined faster after the onset of proteinuria, this rate did not differ significantly by risk status.

Conclusions: Among blacks with established moderate CKD, the high-risk variants are associated with greater risk of incident proteinuria. After proteinuria onset, kidney function declines more rapidly but does not differ by risk status. This suggests that factors that lead to proteinuria, beyond , may additionally drive CKD progression.
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http://dx.doi.org/10.2215/CJN.01180117DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5672963PMC
November 2017

Oral Anticoagulants to Prevent Stroke in Nonvalvular Atrial Fibrillation in Patients With CKD Stage 5D: An NKF-KDOQI Controversies Report.

Am J Kidney Dis 2017 Dec 21;70(6):859-868. Epub 2017 Sep 21.

Division of Nephrology and Hypertension, Department of Medicine, Loyola University Chicago, Maywood, IL; Department of Public Health Sciences, Loyola University Chicago, Maywood, IL.

Stroke risk may be more than 3-fold higher among patients with chronic kidney disease stage 5D (CKD-5D) compared to the general population, with the highest stroke rates noted among those 85 years and older. Atrial fibrillation (AF), a strong risk factor for stroke, is the most common arrhythmia and affects >7% of the population with CKD-5D. Warfarin use is widely acknowledged as an important intervention for stroke prevention with nonvalvular AF in the general population. However, use of oral anticoagulants for stroke prevention in patients with CKD-5D and nonvalvular AF continues to be debated by the nephrology community. In this National Kidney Foundation-Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) controversies report, we discuss the existing observational studies that examine warfarin use and associated stroke and bleeding risks in adults with CKD-5D and AF. Non-vitamin K-dependent oral anticoagulants and their potential use for stroke prevention in patients with CKD-5D and nonvalvular AF are also discussed. Data from randomized clinical trials are urgently needed to determine the benefits and risks of oral anticoagulant use for stroke prevention in the setting of AF among patients with CKD-5D.
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http://dx.doi.org/10.1053/j.ajkd.2017.08.003DOI Listing
December 2017

Tenofovir alafenamide nephrotoxicity in an HIV-positive patient: A case report.

Medicine (Baltimore) 2017 Sep;96(36):e8046

Department of Medicine Department of Pathology, Johns Hopkins University, Baltimore, MD.

Rationale: Tenofovir alafenamide (TAF) is novel prodrug of Tenofovir, a nucleotide reverse transcriptase inhibitor. TAF is less nephrotoxic than its predecessor prodrug, tenofovir disoproxil fumarate (TDF). Tenofovir causes mitochondrial dysfunction and tubular injury when there is elevated accumulation in proximal tubule cells. TAF's unique pharmacokinetic profile enables provision of lower required doses for antiviral efficacy. Lower concentrations reach renal tubules minimizing intracellular accumulation and mitochondrial damage. TAF has not been associated with the histologic markers of tenofovir-associated nephrotoxicity that are seen with TDF, such as dysmorphic mitochondria in proximal tubule cells. Here, we report a patient with dysmorphic mitochondria on kidney biopsy after initiating therapy with TAF.

Lessons: This case suggests that at risk individuals may experience tubular mitochondrial injury from lower concentrations of tenofovir with TAF.
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http://dx.doi.org/10.1097/MD.0000000000008046DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6393094PMC
September 2017

Quiz Page July 2017: An Unusual Cause of Hypokalemia.

Am J Kidney Dis 2017 Jul;70(1):A11-A14

Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, MD.

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http://dx.doi.org/10.1053/j.ajkd.2017.04.009DOI Listing
July 2017

Risk Variants and Cardiovascular Disease: Results From the AASK (African American Study of Kidney Disease and Hypertension).

Arterioscler Thromb Vasc Biol 2017 09 1;37(9):1765-1769. Epub 2017 Jun 1.

From the Divisions of Nephrology (T.K.C., M.E.G., M.J.C.) and General Internal Medicine (L.J.A.), Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD (L.J.A., M.E.G., A.T.); Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (A.T.); Division of Nephrology and Hypertension, Department of Medicine, Georgetown University School of Medicine, Washington, DC (M.S.L.); Basic Research Laboratory, Center for Cancer Research, National Cancer Institute, National Institutes of Health and Leidos Biomedical, Frederick National Laboratory, MD (C.A.W.); and Kidney Health Research Collaborative, Department of Medicine, San Francisco VA Medical Center and University of California (M.M.E.).

Objective: Among African Americans, the apolipoprotein L1 () risk variants have been associated with various types of kidney disease and chronic kidney disease progression. We aimed to determine whether these same risk variants also confer an increased risk for cardiovascular disease.

Approach And Results: In a cohort of African Americans with hypertension-attributed chronic kidney disease followed for up to 12 years, we used Cox proportional hazards models to estimate the relative hazard of a composite cardiovascular disease outcome (cardiovascular death or hospitalization for myocardial infarction, cardiac revascularization procedure, heart failure, or stroke) for the high- (2 risk variants) versus low-risk (0-1 risk variant) genotypes. We adjusted for age, sex, ancestry, smoking, heart disease history, body mass index, cholesterol, randomized treatment groups, and baseline and longitudinal estimated glomerular filtration rate, systolic blood pressure, and proteinuria. Among 693 participants with genotyping available (23% high risk), the high-risk group had lower mean estimated glomerular filtration rate (44.7 versus 50.1 mL/min per 1.73 m) and greater proteinuria (median 0.19 versus 0.06) compared with the low-risk group at baseline. There was no significant association between genotypes and the composite cardiovascular disease outcome in both unadjusted (hazard ratio=1.23; 95% confidence interval: 0.83-1.81) and fully adjusted (hazard ratio=1.16; 95% confidence interval: 0.77-1.76) models; however, in using an additive model, high-risk variants were associated with increased cardiovascular mortality.

Conclusions: Among African Americans with hypertension-attributed chronic kidney disease, risk variants were not associated with an overall risk for cardiovascular disease although some signals for cardiovascular mortality were noted.
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http://dx.doi.org/10.1161/ATVBAHA.117.309384DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5570668PMC
September 2017

Ultrafiltration Rate Thresholds in Maintenance Hemodialysis: An NKF-KDOQI Controversies Report.

Am J Kidney Dis 2016 10 19;68(4):522-532. Epub 2016 Jul 19.

Division of Nephrology, Department of Medicine, Wake Forest University, Winston-Salem, NC.

High hemodialysis ultrafiltration rate (UFR) is increasingly recognized as an important and modifiable risk factor for mortality among patients receiving maintenance hemodialysis. Recently, the Kidney Care Quality Alliance (KCQA) developed a UFR measure to assess dialysis unit care quality. The UFR measure was defined as UFR≥13mL/kg/h for patients with dialysis session length less than 240 minutes and was endorsed by the National Quality Forum as a quality measure in December 2015. Despite this, implementation of a UFR threshold remains controversial. In this NKF-KDOQI (National Kidney Foundation-Kidney Disease Outcomes Quality Initiative) Controversies Report, we discuss the concept of the UFR, which is governed by patients' interdialytic weight gain, body weight, and dialysis treatment time. We also examine the potential benefits and pitfalls of adopting a UFR threshold as a clinical performance measure and outline several aspects of UFR thresholds that require further research.
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http://dx.doi.org/10.1053/j.ajkd.2016.06.010DOI Listing
October 2016

American Society of Nephrology Quiz and Questionnaire 2015: ESRD/RRT.

Clin J Am Soc Nephrol 2016 07 19;11(7):1313-20. Epub 2016 Apr 19.

Division of Nephrology, Johns Hopkins University, Baltimore, Maryland.

The Nephrology Quiz and Questionnaire remains an extremely popular session for attendees of the Annual Kidney Week Meeting of the American Society of Nephrology. During the 2015 meeting, the conference hall was once again overflowing with eager quiz participants. Topics covered by the experts included electrolyte and acid-base disorders, glomerular disease, ESRD and dialysis, and kidney transplantation. Complex cases representing each of these categories together with single best answer questions were prepared and submitted by the panel of experts. Before the meeting, training program directors of nephrology fellowship programs and nephrology fellows in the United States answered the questions through an internet-based questionnaire. During the live session, members of the audience tested their knowledge and judgment on the same series of case-oriented questions in a quiz. The audience compared their answers in real time using a cellphone application containing the answers of the nephrology fellows and training program directors. The results of the online questionnaire were displayed, and then, the quiz answers were discussed. As always, the audience, lecturers, and moderators enjoyed this highly educational session. This article recapitulates the session and reproduces selected content of educational value for the readers of the Clinical Journal of the American Society of Nephrology Enjoy the clinical cases and expert discussions.
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http://dx.doi.org/10.2215/CJN.01280216DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4934831PMC
July 2016

CKD for Primary Care Practitioners: Can We Cut to the Chase Without Too Many Shortcuts?

Am J Kidney Dis 2016 06 15;67(6):826-9. Epub 2016 Apr 15.

Johns Hopkins University School of Medicine, Baltimore, Maryland. Electronic address:

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http://dx.doi.org/10.1053/j.ajkd.2016.02.043DOI Listing
June 2016

American Society of Nephrology Quiz and Questionnaire 2015: Transplantation.

Clin J Am Soc Nephrol 2016 06 25;11(6):1114-22. Epub 2016 Feb 25.

Division of Nephrology, Johns Hopkins University, Baltimore, Maryland.

The Nephrology Quiz and Questionnaire remains an extremely popular session for attendees of the Annual Kidney Week Meeting of the American Society of Nephrology. Once again, the conference hall was overflowing with audience members and eager quiz participants. Topics covered by the expert discussants included electrolyte and acid-base disorders, glomerular disease, ESRD/dialysis, and kidney transplantation. Complex cases representing each of these categories along with single best answer questions were prepared and submitted by the panel of experts. Before the meeting, training program directors of US nephrology fellowship programs and nephrology fellows answered the questions through an internet-based questionnaire. During the live session, members of the audience tested their knowledge and judgment on a series of case-oriented questions prepared and discussed by the experts. They compared their answers in real time using their cell phones with a special application with the answers of the nephrology fellows and training program directors. The correct and incorrect answers were then discussed after the results of the questionnaire were displayed. As always, the audience, lecturers, and moderators enjoyed this highly educational session. This article recapitulates the session and reproduces its educational value for the Clinical Journal of the American Society of Nephrology readers. Enjoy the clinical cases and expert discussions.
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http://dx.doi.org/10.2215/CJN.13451215DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4891764PMC
June 2016

American Society of Nephrology Quiz and Questionnaire 2015: Glomerular Diseases.

Clin J Am Soc Nephrol 2016 05 4;11(5):884-90. Epub 2016 Feb 4.

Division of Nephrology, Johns Hopkins University, Baltimore, Maryland.

The Nephrology Quiz and Questionnaire remains an extremely popular session for attendees of the annual Kidney Week meeting of the American Society of Nephrology. Once again, the conference hall was overflowing with audience members and eager quiz participants. Topics covered by the expert discussants included electrolyte and acid-base disorders, glomerular disease, ESRD/dialysis, and kidney transplantation. Complex cases representing each of these categories, along with single-best-answer questions, were prepared and submitted by the panel of experts. Before the meeting, training program directors of United States nephrology fellowship programs and nephrology fellows answered the questions through an Internet-based questionnaire. During the live session, members of the audience tested their knowledge and judgment on a series of case-oriented questions prepared and discussed by the experts. They compared their answers in real time using their cell phones with a special app with the answers of the nephrology fellows and training program directors. The correct and incorrect answers were then discussed after the results of the questionnaire were displayed. As always, the audience, lecturers, and moderators enjoyed this educational session. This article recapitulates the session and reproduces its educational value for Clinical Journal of the American Society of Nephrology readers. Enjoy the clinical cases and expert discussions.
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http://dx.doi.org/10.2215/CJN.12871215DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4858496PMC
May 2016

Effectiveness of Prevention Strategies for Contrast-Induced Nephropathy: A Systematic Review and Meta-analysis.

Ann Intern Med 2016 Mar 2;164(6):406-16. Epub 2016 Feb 2.

Background: N-acetylcysteine, sodium bicarbonate, statins, and ascorbic acid have been studied for reducing contrast-induced nephropathy (CIN).

Purpose: To evaluate the comparative effectiveness of interventions to reduce CIN in adults receiving contrast media.

Data Sources: MEDLINE, EMBASE, Cochrane Library, ClinicalTrials.gov, and Scopus databases through June 2015. Risk of bias and overall strength of evidence (SOE) of studies were assessed.

Study Selection: Randomized, controlled trials of N-acetylcysteine, sodium bicarbonate, statins, or ascorbic acid that used intravenous (IV) or intra-arterial contrast media and defined CIN with enough data for meta-analysis.

Data Extraction: Two reviewers independently extracted data and assessed study quality.

Data Synthesis: Low-dose N-acetylcysteine plus IV saline compared with IV saline (risk ratio [RR], 0.75 [95% CI, 0.63 to 0.89]; low SOE), N-acetylcysteine plus IV saline compared with IV saline in patients receiving low-osmolar contrast media (RR, 0.69 [CI, 0.58 to 0.84]; moderate SOE), and statins plus N-acetylcysteine plus IV saline versus N-acetylcysteine plus IV saline (RR, 0.52 [CI, 0.29 to 0.93]; low SOE) had clinically important and statistically significant benefits. The following 3 comparisons suggested a clinically important difference that was not statistically significant: sodium bicarbonate versus IV saline in patients receiving low-osmolar contrast media (RR, 0.65 [CI, 0.33 to 1.25]; low SOE), statins plus IV saline versus IV saline (RR, 0.68 [CI, 0.39 to 1.20]; low SOE), and ascorbic acid versus IV saline (RR, 0.72 [CI, 0.48 to 1.01]; low SOE). Strength of evidence was generally insufficient for comparisons of the need for renal replacement, cardiac events, and mortality.

Limitation: Too few studies were done in patients receiving IV contrast media.

Conclusion: The greatest reduction in CIN was seen with N-acetylcysteine plus IV saline in patients receiving LOCM and with statins plus N-acetylcysteine plus IV saline.

Primary Funding Source: Agency for Healthcare Research and Quality.
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http://dx.doi.org/10.7326/M15-1456DOI Listing
March 2016

Comparative Effect of Contrast Media Type on the Incidence of Contrast-Induced Nephropathy: A Systematic Review and Meta-analysis.

Ann Intern Med 2016 Mar 2;164(6):417-24. Epub 2016 Feb 2.

Background: Iodine contrast media are essential components of many imaging procedures. An important potential side effect is contrast-induced nephropathy (CIN).

Purpose: To compare CIN risk for contrast media within and between osmolality classes in patients receiving diagnostic or therapeutic imaging procedures.

Data Sources: PubMed, EMBASE, Cochrane Library, Clinical Trials.gov, and Scopus through June 2015.

Study Selection: Randomized, controlled trials that reported CIN-related outcomes in patients receiving low-osmolar contrast media (LOCM) or iso-osmolar contrast media for imaging.

Data Extraction: Independent study selection and quality assessment by 2 reviewers and dual extraction of study characteristics and results.

Data Synthesis: None of the 5 studies that compared types of LOCM reported a statistically significant or clinically important difference among study groups, but the strength of evidence was low. Twenty-five randomized, controlled trials found a slight reduction in CIN risk with the iso-osmolar contrast media agent iodixanol compared with a diverse group of LOCM that just reached statistical significance in a meta-analysis (pooled relative risk, 0.80 [95% CI, 0.65 to 0.99]; P = 0.045). This comparison's strength of evidence was moderate. In a meta regression of randomized, controlled trials of iodixanol, no relationship was found between route of administration and comparative CIN risk.

Limitations: Few studies compared LOCM. Procedural details about contrast administration were not uniformly reported. Few studies specified clinical indications or severity of baseline renal impairment.

Conclusion: No differences were found in CIN risk among types of LOCM. Iodixanol had a slightly lower risk for CIN than LOCM, but the lower risk did not exceed a criterion for clinical importance.

Primary Funding Source: Agency for Healthcare Research and Quality.
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http://dx.doi.org/10.7326/M15-1402DOI Listing
March 2016

American Society of Nephrology Quiz and Questionnaire 2015: Electrolytes and Acid-Base Disorders.

Clin J Am Soc Nephrol 2016 Apr 29;11(4):735-44. Epub 2016 Jan 29.

Division of Nephrology, Johns Hopkins University, Baltimore, Maryland.

The Nephrology Quiz and Questionnaire remains an extremely popular session for attendees of the annual Kidney Week meeting of the American Society of Nephrology. During the 2015 meeting the conference hall was once again overflowing with eager quiz participants. Topics covered by the experts included electrolyte and acid-base disorders, glomerular disease, end-stage renal disease and dialysis, and kidney transplantation. Complex cases representing each of these categories together with single-best-answer questions were prepared and submitted by the panel of experts. Before the meeting, training program directors of nephrology fellowship programs and nephrology fellows in the United States answered the questions through an internet-based questionnaire. During the live session members of the audience tested their knowledge and judgment on the same series of case-oriented questions in a quiz. The audience compared their answers in real time using a cell-phone app containing the answers of the nephrology fellows and training program directors. The results of the online questionnaire were displayed, and then the quiz answers were discussed. As always, the audience, lecturers, and moderators enjoyed this highly educational session. This article recapitulates the session and reproduces selected content of educational value for theClinical Journal of the American Society of Nephrologyreaders. Enjoy the clinical cases and expert discussions.
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http://dx.doi.org/10.2215/CJN.12801215DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4822677PMC
April 2016

Complete Remission in the Nephrotic Syndrome Study Network.

Clin J Am Soc Nephrol 2016 Jan 10;11(1):81-9. Epub 2015 Dec 10.

Due to the number of contributing authors, the affiliations are provided in the Supplemental Material.

Background And Objectives: This analysis from the Nephrotic Syndrome Study Network (NEPTUNE) assessed the phenotypic and pathology characteristics of proteinuric patients undergoing kidney biopsy and defined the frequency and factors associated with complete proteinuria remission (CRever).

Design, Setting, Participants, & Measurements: We enrolled adults and children with proteinuria ≥0.5 g/d at the time of first clinically indicated renal biopsy at 21 sites in North America from April 2010 to June 2014 into a prospective cohort study. NEPTUNE central pathologists assigned participants to minimal-change disease (MCD), FSGS, membranous nephropathy, or other glomerulopathy cohorts. Outcome measures for this analysis were (1) CRever with urine protein-to-creatinine ratio (UPC) <0.3 g/g with preserved native kidney function and (2) ESRD. Continuous variables are reported as median and interquartile range (IQR; 25th, 75th percentile). Cox proportional hazards modeling was used to assess factors associated with CRever.

Results: We enrolled 441 patients: 116 (27%) had MCD, 142 (32%) had FSGS, 66 (15%) had membranous nephropathy, and 117 (27%) had other glomerulopathy. The baseline UPC was 4.1 g/g (IQR, 1.9, 7.7) and the eGFR was 81 ml/min per 1.73 m(2) (IQR, 50, 105). Median duration of observation was 19 months (IQR, 11, 30). CRever occurred in 46% of patients, and 4.6% progressed to ESRD. Multivariate analysis demonstrated that higher prebiopsy proteinuria (hazard ratio, 0.3; 95% confidence interval, 0.2 to 0.5) and pathology diagnosis (FSGS versus MCD; hazard ratio, 0.2; 95% confidence interval, 0.1 to 0.5) were inversely associated with CRever. The effect of immunosuppressive therapy on remission varied by pathology diagnosis.

Conclusions: In NEPTUNE, the high frequency of other pathology in proteinuric patients affirms the value of the diagnostic kidney biopsy. Clinical factors, including level of proteinuria before biopsy, pathology diagnosis, and immunosuppression, are associated with complete remission.
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http://dx.doi.org/10.2215/CJN.02560315DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4702222PMC
January 2016

Examination of Potential Modifiers of the Association of APOL1 Alleles with CKD Progression.

Clin J Am Soc Nephrol 2015 Dec 1;10(12):2128-35. Epub 2015 Oct 1.

Due to the number of contributing authors, the affiliations are provided in the Supplemental Material.

Background And Objectives: Common apolipoprotein L1 (APOL1) variants are associated with increased risk of progressive CKD; however, not all individuals with high-risk APOL1 variants experience CKD progression. Identification of factors contributing to heterogeneity has important scientific and clinical implications.

Design, Setting, Participants, & Measurements: Using multivariable Cox models, we analyzed data from 693 participants in the African American Study of Kidney Disease and Hypertension to identify factors that modify the association between APOL1 genotypes and CKD progression (doubling of serum creatinine or incident ESRD).

Results: Participant mean age was 54 years old, median GFR was 49 ml/min per 1.73 m(2), and 23% had the APOL1 high-risk genotype (two copies of the high-risk allele). Over a mean follow-up of 7.8 years, 288 (42%) participants experienced CKD progression. As previously reported, the high-risk genotype was associated with higher risk of CKD progression compared with the low-risk genotype (hazard ratio [HR], 1.88; 95% confidence interval [95% CI], 1.46 to 2.41). Although we found some suggestion that obesity (HR, 1.48; 95% CI, 1.05 to 2.08 and HR, 2.44; 95% CI, 1.66 to 3.57 for body mass index ≥ 30 versus <30 kg/m(2); P interaction =0.04) and increased urinary excretion of urea nitrogen (HR, 1.43; 95% CI, 0.98 to 2.09 versus HR, 2.33; 95% CI, 1.65 to 3.30 for urine urea nitrogen ≥ 8 versus <8 g/d; P interaction =0.04) were associated with lower APOL1-associated risk for CKD progression, these findings were not robust in sensitivity analyses with alternative cut points. No other sociodemographic (e.g., education and income), clinical (e.g., systolic BP and smoking), or laboratory (e.g., net endogenous acid production, urinary sodium and potassium excretions, 25-hydroxy vitamin D, intact parathyroid hormone, or fibroblast growth factor 23) variables modified the association between APOL1 and CKD progression (P interaction >0.05 for each).

Conclusions: Sociodemographic factors and common risk factors for CKD progression do not seem to alter APOL1-related CKD progression. Additional investigation is needed to identify nontraditional factors that may affect the association between APOL1 and progressive CKD.
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http://dx.doi.org/10.2215/CJN.05220515DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4670769PMC
December 2015