Blosser CD, Barbir EB, Shaikhouni S
… +1 more, Murakami N
Am J Kidney Dis
· 2026 Jun · PMID 42167833
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Kidney transplant recipients are at least twice as likely to develop cancer compared with immunocompetent people. Cancer is now the second leading cause of death in kidney transplant recipients. Candidates and recipients...Kidney transplant recipients are at least twice as likely to develop cancer compared with immunocompetent people. Cancer is now the second leading cause of death in kidney transplant recipients. Candidates and recipients are living longer with chronic conditions and immunosuppression, which increases the risk of cancers, especially skin and kidney cancers, lymphoma, and plasma cell dyscrasias. Given the complexities associated with the care of transplant patients with cancer, along with the advent of novel cancer therapies that include targeted and immunotherapies (ie, immune checkpoint inhibitors and CAR-T cells), there is a growing need for nephrologists to understand and manage the associated risks and optimize diagnosis and treatment. The screening and management of cancer in the setting of kidney transplantation is best accomplished by a multidisciplinary team, involving knowledgeable nephrologists, oncologists, and patients. In this Core Curriculum, we review common pretransplant and posttransplant cancers and management strategies through a series of clinical cases.
Zeng M, Zhang C, Gao X
… +4 more, Zhang J, Jiang S, Cao Y, Liu ZH
Am J Kidney Dis
· 2026 May · PMID 42142611
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RATIONALE & OBJECTIVE: The α3α4α5 chain of type IV collagen, encoded by the COL4A3, COL4A4, and COL4A5 genes, is critical for the structural integrity and function of the glomerular basement membrane as well as ocular an...RATIONALE & OBJECTIVE: The α3α4α5 chain of type IV collagen, encoded by the COL4A3, COL4A4, and COL4A5 genes, is critical for the structural integrity and function of the glomerular basement membrane as well as ocular and auditory structures. This study estimated the prevalence of pathogenic variants of these 3 genes in the general Chinese population. STUDY DESIGN: Cross-sectional study. SETTING & PARTICIPANTS: We analyzed genomic data from 10,588 participants in ChinaMAP (Metabolic Analytics Project) who were recruited through unbiased sampling across 27 Chinese provinces. EXPOSURE: Pathogenic variants in COL4A3, COL4A4, and COL4A5 genes. OUTCOMES: Prevalence and allele frequency of pathogenic COL4A3-COL4A5 variants. ANALYTICAL APPROACH: Predicted pathogenic variants were identified through a filtering workflow that adhered to American College of Medical Genetics and Genomics and Association for Molecular Pathology guidelines, using ANNOVAR and Variant Effect Predictor for annotation. Prevalence was calculated as the proportion of individuals carrying at least one pathogenic variant. Wilson's score method was used to calculate 95% confidence intervals (CIs). RESULTS: 93 pathogenic variants in COL4A3, COL4A4, or COL4A5 were identified in the ChinaMAP cohort. Prevalences were 0.99% for COL4A3, 0.41% for COL4A4, and 0.15% for COL4A5, yielding an overall prevalence of 1.55% (95% CI, 1.33%-1.80%). No significant difference in the allelic frequency of COL4A5 variants was observed between male and female participants (P = 0.548). Two COL4A3 missense variants, p.Leu1598Arg and p.Gly1286Arg, were identified as having notably high prevalences of 0.20% and 0.13%, respectively. LIMITATIONS: The lack of detailed clinical information precluded the definitive classification of many variants of uncertain significance, there was a lack of data on the presence of kidney disease, and there is uncertain generalizability to the Chinese population. CONCLUSIONS: This study revealed a high prevalence of pathogenic COL4A3, COL4A4, and COL4A5 variants in the Chinese population-approximately 1.6-fold higher than that in the Genome Aggregation Database cohort-indicating a substantial genetic burden of collagen IV-related disorders in China. These findings may inform clinical management related to diagnosis and genetic testing. PLAIN-LANGUAGE SUMMARY: Type IV collagen genes (COL4A3, COL4A4, and COL4A5) are essential for kidney function. When these genes carry harmful variants, they can cause Alport syndrome and other kidney disorders. Using genomic data from 10,588 Chinese adults, we found that 1 in 64 people (1.55%) carry these variants, approximately 1.6 times the rate reported in other populations. Two genetic variants were found to be particularly common in Chinese individuals. These findings may inform clinical practice related to diagnosis and genetic testing to enable more personalized kidney care.
Bansal N, Tabada GH, Kang Y
… +10 more, Stirling K, Zelnick LR, Garcia EA, Bota S, An J, Harrison TN, Singer DE, Sood M, Garg AX, Go AS
Am J Kidney Dis
· 2026 May · PMID 42142610
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RATIONALE & OBJECTIVE: The performance of clinical risk prediction scores for ischemic stroke and bleeding are not well established in those with CKD and atrial fibrillation (AF). We aimed to evaluate the performance of...RATIONALE & OBJECTIVE: The performance of clinical risk prediction scores for ischemic stroke and bleeding are not well established in those with CKD and atrial fibrillation (AF). We aimed to evaluate the performance of three risk scores for ischemic stroke and intracranial bleeding in patients across a broad range of kidney function. STUDY DESIGN: Retrospective study. SETTING & PARTICIPANTS: The study included two community-based cohorts of adults with incident AF (Kaiser Permanente and Ontario, Canada). EXPOSURE: Baseline estimated glomerular filtration rate (eGFR) was calculated using outpatient serum creatinine measures, excluding those with a kidney transplant or on dialysis. OUTCOMES: Three risk scores for ischemic stroke (ATRIA, CHADS-VASc and RCHADS) and one for major bleeding (HAS-BLED) were calculated across eGFR categories (≥60, 45-59, 30-44, and <30 mL/min/1.73 m). Outcomes included ischemic stroke and intracranial hemorrhage. ANALYTICAL APPROACH: C-statistics were calculated and calibration plots generated within eGFR strata. RESULTS: There were 101,360 adults with incident AF in the Kaiser Permanente cohort and 33,200 adults with incident AF in the Ontario cohort. Mean risk scores for stroke and bleeding were higher with lower eGFR across all four measures. The c-statistics for the stroke prediction scores were lower in those with an eGFR <60 mL/min/1.73 m compared with eGFR ≥ 60 mL/min/1.73 m in both cohorts. The lowest discrimination for ischemic stroke was seen with the RCHADS risk score (ranging from 0.53-0.61) with a c-statistic of 0.57 for the eGFR <30 mL/min/1.73m category in both cohorts. The c-statistics for ATRIA (range 0.59 to 0.64) and CHADS-VASc (range 0.55 to 0.61) were also modest across lower eGFR categories compared with eGFR >60 mL/min/1.73 m. The discrimination for the HAS-BLED bleeding risk score for intracranial bleeding was also low in those with lower eGFR categories (ranging from 0.51 to 0.56). Calibration varied by risk score and eGFR level. LIMITATIONS: Observational study. CONCLUSIONS: Performance of clinically used stroke and bleeding risk prediction scores was modest among those with CKD, particularly at advanced CKD. More accurate risk scores are needed to improve decision-making. PLAIN-LANGUAGE SUMMARY: This retrospective analysis evaluated the predictive accuracy of standard clinical risk scores for ischemic stroke (ATRIA, CHADS-VASc and RCHADS) and intracranial hemorrhage (HAS-BLED) in patients with atrial fibrillation (AF) and varying degrees of kidney function. Utilizing data from two large cohorts, Kaiser Permanente and an Ontario-based registry, the study focused on how baseline estimated glomerular filtration rate (eGFR) influenced the discrimination and calibration of these models. The study revealed a significant inverse relationship between kidney function and model reliability. While mean risk scores were higher in patients with lower eGFR, the c-statistics and calibration decreased significantly in more advanced stages of kidney disease. The results suggest that the pathophysiological complexities of advanced kidney disease limit the utility of tools to predict stroke and bleeding designed for the general population with AF. Development of kidney-specific risk models is needed to better inform anticoagulation strategies and clinical decision-making.
DePasquale N, Powell CJ, Hammond FA
… +3 more, Alvarez JM, Hall RK, Bowling CB
Am J Kidney Dis
· 2026 May · PMID 42140343
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RATIONALE & OBJECTIVE: The number of older adults requiring dialysis is increasing. Yet, many patients remain unprepared for this life-altering transition and its profound impacts. Care partners play a pivotal role in as...RATIONALE & OBJECTIVE: The number of older adults requiring dialysis is increasing. Yet, many patients remain unprepared for this life-altering transition and its profound impacts. Care partners play a pivotal role in assisting with dialysis that influences their life experiences but which are often overlooked in preparedness efforts. This study characterized the lived experiences of older adults receiving maintenance dialysis and their care partners. STUDY DESIGN: Descriptive qualitative study. SETTING & PARTICIPANTS: Adults in the Duke Health system aged ≥ 65 years receiving in-center hemodialysis for ≤ 1 year and their primary care partner. Each individual completed a semi-structured interview and survey. ANALYTICAL APPROACH: Hybrid deductive-inductive thematic analysis of interview transcripts. RESULTS: Thirty-three patients and thirty-six care partners completed interviews. Two identified themes described advice for patients: You determine whether your treatment journey is good or bad and maintain good health to facilitate smooth dialysis sessions. Two themes described advice for care partners: Prepare for a major commitment with role demands and consequences and putting yourself on the backburner is counterproductive. Three themes described advice relevant for patients and care partners: The care dyad should reflect a strong, collaborative, and supportive relationship; gain knowledge about dialysis before and after starting treatment to improve your experience; and plan ahead and organize yourself to effectively manage life on dialysis. LIMITATIONS: Patients all cared for in a single health system. CONCLUSIONS: Older patients receiving dialysis and their care partners provided advice affirming the importance of person- and family-centered approaches to care. This advice may inform clinical care models for maintenance dialysis. PLAIN-LANGUAGE SUMMARY: Dialysis unpreparedness is common among older adults. Family and friends who help with dialysis (i.e., care partners) also experience unpreparedness for their roles as caregivers, creating stress and, potentially, other adverse outcomes. Research has shown patients and care partners value and benefit from learning from others about lived experiences related to the same medical condition. This study asked older adults and their care partners in their first year of in-center hemodialysis to offer advice for peers initiating this treatment. This advice emphasized acceptance and positivity, self-care, promoting caregiver readiness, self-prioritization, strong patient-care partner relationships, treatment knowledge, and organizational skills. These findings highlight peer sharing as a potential resource for dialysis preparedness and person- and family-centered approaches to clinical care.
Am J Kidney Dis
· 2026 May · PMID 42140342
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Glucagon-like peptide-1 (GLP-1) receptor agonists are revolutionizing the treatment of obesity and related illnesses, including kidney disease. While it is widely believed that the benefits of GLP-1 receptor agonists on...Glucagon-like peptide-1 (GLP-1) receptor agonists are revolutionizing the treatment of obesity and related illnesses, including kidney disease. While it is widely believed that the benefits of GLP-1 receptor agonists on the kidney are primarily driven by weight loss, data from randomized trials in humans are less supportive of this viewpoint. This mini-review presents an alternative hypothesis positing that the kidney protective benefits of GLP-1 receptor agonists are largely independent of weight loss. In doing so it presents supportive data, reviews the clinical implications, and describes additional research that is needed to confirm the hypothesis.
The Kidney Disease Outcomes Quality Initiative (KDOQI) convened a work group to review the 2025 KDIGO (Kidney Disease: Improving Global Outcomes) Clinical Practice Guideline for the Management of Immunoglobulin A Nephrop...The Kidney Disease Outcomes Quality Initiative (KDOQI) convened a work group to review the 2025 KDIGO (Kidney Disease: Improving Global Outcomes) Clinical Practice Guideline for the Management of Immunoglobulin A Nephropathy (IgAN) and Immunoglobulin A Vasculitis (IgAV). The KDOQI work group reviewed the KDIGO guideline statements and practice points and provided perspective for implementation within the context of clinical practice in the United States. Our understanding of the pathophysiology of IgAN has led to several treatment options that are new to this clinical practice guideline. With many ongoing studies on agents with novel therapeutic mechanisms of action, the KDOQI work group acknowledges the challenges in selecting the appropriate disease modifying agents for such a heterogenous disease. In this commentary, the work group addresses the importance of risk stratification of IgAN while emphasizing the novel therapeutic options that are now available to prevent disease progression.
The prevalence of anemia is high in people with chronic kidney disease (CKD) and increases as the disease advances. The Kidney Disease Outcomes Quality Initiative (KDOQI) convened a work group to review the Kidney Diseas...The prevalence of anemia is high in people with chronic kidney disease (CKD) and increases as the disease advances. The Kidney Disease Outcomes Quality Initiative (KDOQI) convened a work group to review the Kidney Disease: Improving Global Outcomes (KDIGO) 2026 clinical practice guideline for the management of anemia in CKD. The previous KDIGO anemia guideline was published in 2012; in 2019 and 2021 KDIGO convened conferences addressing controversies in iron management and hypoxia-inducible factor-prolyl hydroxylase inhibitor (HIF-PHI) use, respectively. The KDOQI work group provides perspective for implementation of the KDIGO 2026 anemia guideline within the context of clinical practice in the United States. The KDOQI work group agrees with most of the KDIGO recommendations, particularly the proactive use of intravenous (IV) iron in hemodialysis patients and the preference for erythropoiesis stimulating agents (ESAs) over HIF-PHIs for first-line anemia therapy, due to greater familiarity with safety of the former. Specific issues regarding recommendations and practice points for providers in the United States include higher serum ferritin targets and mean levels among people receiving hemodialysis than in the rest of the world; the availability of a single HIF-PHI product with approval only for patients receiving dialysis for ≥3 months; and payment barriers that may drive the choice of therapeutic agents. Additional commentary is provided on topics including IV iron therapy in people receiving hemodialysis and an iron-based phosphate binder, the incidence and significance of hypophosphatemia among people with CKD not on dialysis but receiving IV iron therapy, the physiologic importance of iron repletion in people with CKD and iron deficiency without anemia, possible therapeutic benefits of HIF-PHIs compared with ESAs, and assessing risk versus harm of red blood cell transfusions.
RATIONALE & OBJECTIVE: Chronic kidney disease (CKD) is a global public health concern, but its burden in Africa is poorly defined. This study estimated CKD prevalence across the African continent. STUDY DESIGN: Systemati...RATIONALE & OBJECTIVE: Chronic kidney disease (CKD) is a global public health concern, but its burden in Africa is poorly defined. This study estimated CKD prevalence across the African continent. STUDY DESIGN: Systematic review and individual participant data meta-analysis. SETTING & STUDY POPULATION: Populations residing in Africa. SELECTION CRITERIA: Eligible studies enrolled ≥300 adults, were observational, used community-based designs, and reported CKD prevalence or data necessary to calculate it. SEARCH STRATEGY: Studies, both published and unpublished, through May 31, 2024, identified through systematic searches of major databases and through networks within the CKD-Africa Collaboration. DATA EXTRACTION: Data were systematically extracted and verified by the authors. Extracted information included study and publication details, CKD diagnostic criteria, and participant characteristics. ANALYTICAL APPROACH: Pooled prevalence estimates were calculated using random-effects meta-analysis. RESULTS: Sixty-seven studies, comprising 91,723 participants from 19 countries, were included. High- and moderate-quality studies accounted for 37% and 52%, respectively, and 6% were unpublished. Pooled CKD prevalence (stages 1-5) was 13.7% (95% CI, 11.0-16.4), and 5.1% (95% CI, 4.3-5.8) for stages 3-5. Regional variation was evident (I >98%; P < 0.001), with higher prevalence in western Africa compared to southern Africa. Estimates using aggregated data and individual participant data were consistent. LIMITATIONS: Variations in the quality of the study data and substantial heterogeneity in prevalence estimates. Lack of assessment of chronic CKD. Reliance on aggregated data for 55% of the sample. Gaps in geographic representation may limit the generalizability of findings. CONCLUSIONS: Approximately 14% of African adults had CKD, highlighting its public health burden. The precision of this finding was augmented by the use of individual participant data. REGISTRATION: Registered at Prospero with identification number CRD42019143370. PLAIN-LANGUAGE SUMMARY: Chronic kidney disease (CKD), a long-term condition in which the kidneys gradually lose their ability to filter waste and fluids from the blood, is an increasing health problem in Africa, but prevalence data have been limited. Previous studies relied on only summaries of studies' data. This analysis combined individual-level and summary data from multiple African countries to provide a more accurate and precise estimate of CKD prevalence. It found that CKD affects a substantial proportion of adults, with rates varying across regions. These findings highlight the potential value of early detection given the availability of effective clinical strategies to manage CKD.
RATIONALE & OBJECTIVE: The transition from chronic kidney disease (CKD) to kidney failure (KF) is life-changing. We explored the KF transition and dialysis start experiences of patients with varying degrees of prior neph...RATIONALE & OBJECTIVE: The transition from chronic kidney disease (CKD) to kidney failure (KF) is life-changing. We explored the KF transition and dialysis start experiences of patients with varying degrees of prior nephrology care and preparation. STUDY DESIGN: Convergent parallel mixed-methods study using surveys and interviews. SETTING & PARTICIPANTS: Data were collected from December 2018 to January 2020 among adults in metropolitan Philadelphia who had recently transitioned from CKD to KF and started dialysis. ANALYTICAL APPROACH: Participants were categorized as having had (1) some prior nephrology care and placement of an arteriovenous or peritoneal dialysis access, (2) minimal nephrology care (prior nephrology care, but no placement of a dialysis access), or (3) no prior nephrology care or placement of an access. Applied thematic analysis guided the qualitative analysis, and quantitative data were fully described. RESULTS: KF transition was tumultuous for all participants (N = 47) regardless of preparation (some prior care, n = 23 [48.9%]; minimal prior care, n = 13 [27.7%]; no prior care, n = 11 [23.4%]). Dialysis start occurred along a spectrum of urgency, with most (n = 44; 93.6%) initiating dialysis in a hospital, and nearly all (n = 46; 97.9%) were treated with in-center hemodialysis. Four additional themes emerged: (1) participants were unprepared to receive the KF diagnosis because they were unaware of the urgency of their medical situation; (2) the KF diagnosis communication environment was chaotic, but effective provider communication helped; (3) the first dialysis treatment was marked by intense apprehension and fear; and (4) participants prioritized making sense of their sudden new reality. LIMITATIONS: Limited geographic representation and the exclusion of non-English-speaking participants. CONCLUSIONS: Irrespective of prior preparation, participants experienced apprehension and fear during the transition from CKD to KF. Successfully addressing modifiable health system-level factors that affect this critical care transition and directly address the patient experience is needed to improve care and outcomes. PLAIN-LANGUAGE SUMMARY: The progression from chronic kidney disease to kidney failure and dialysis is a challenging time for patients. We sought to understand the experiences of patients-those who had received prior kidney disease care and those who had not-during this transition to kidney failure and dialysis treatment. We interviewed and surveyed 47 patients in metropolitan Philadelphia within 5 months of their dialysis initiation to understand and compare their experiences. Nearly all participants described this transition as traumatic and chaotic, even those who had received prior kidney disease care. This study underscores the need for patient-centered, health system-level programs that equip patients with the knowledge, resources, and support necessary to cope with this major life change and ultimately improve patient outcomes.
RATIONALE & OBJECTIVE: Children in the United States receive priority for kidneys with a kidney donor profile index (KDPI) < 35%, although their priority falls below that of certain adult recipients. Recently, the KDPI w...RATIONALE & OBJECTIVE: Children in the United States receive priority for kidneys with a kidney donor profile index (KDPI) < 35%, although their priority falls below that of certain adult recipients. Recently, the KDPI was revised to include 8 donor characteristics instead of 10. We sought to (1) describe the allocation of these high-quality kidneys and (2) compare the characteristics of donors with a KDPI < 35% using the original KDPI (KDPI-10) versus the revised KDPI (KDPI-8) calculation. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: 60,587 deceased donors and their kidney recipients in the Organ Procurement and Transplantation Network registry between January 1, 2018, and December 31, 2023. EXPOSURE: KDPI calculated using KDPI-10 and KDPI-8 (without race and hepatitis C virus [HCV]). OUTCOME: The primary outcome was the use of kidneys with a KDPI < 35% overall. Secondary outcome was the utilization of kidneys from "ideal pediatric-quality donors" who were defined as having a KDPI < 35%, diagnosed with brain death, were aged <35 years, had a creatinine level ≤ 1.5 mg/dL, and had no infectious risk, diabetes, or hypertension. Additionally, we assessed the changes in characteristics of KDPI < 35% donors after revision to the KDPI. ANALYTICAL APPROACH: Descriptive statistics. RESULTS: During the study period, 23.4% of KDPI-10 < 35% and 34.3% of ideal pediatric-quality, KDPI-10 < 35% kidneys were transplanted into adults in allocation categories that receive more priority than children. Nearly three-quarters of these adults were multiorgan recipients. Compared with the KDPI-10 calculation, the donors with a KDPI < 35% using the KDPI-8 calculation were more often Black (15.3% vs 9.9%), HCV seropositive (11.1% vs 3.6%), and less frequently donated after circulatory death (12.7% vs 20.3%). The proportion of KDPI < 35% donors who are ideal pediatric-quality was similar (32.7% KDPI-10 vs 33.5% KDPI-8). LIMITATIONS: Extrapolation of KDPI-8 donor characteristics using a historical cohort. CONCLUSIONS: Many ideal pediatric-quality kidneys are allocated to adults, primarily multiorgan transplant recipients. We anticipate no meaningful change in the proportion of ideal pediatric-quality kidneys prioritized for children using the revised KDPI-8 calculation. PLAIN-LANGUAGE SUMMARY: Children with end-stage kidney disease are intended to have priority for kidneys from the best-quality kidney donors. However, their priority may fall below adult candidates who need multiple organs or are highly sensitized. Only about one-third of donors prioritized for children are ideal pediatric quality, meaning they come from young donors with minimal risk of kidney dysfunction. About one-third of these top-quality kidneys are transplanted into adults with more priority than children, most often transplanted into recipients receiving more than 1 organ transplant. Recently, the risk index used to determine which kidneys are prioritized for children was revised by excluding donor race and donor infection with hepatitis C. Our study suggests this change will not substantially affect the proportion of ideal pediatric-quality kidneys offered to children.