Since its introduction in 1985, Kt/V urea has played a pivotal role as a marker of "dialysis adequacy." Over the decades, multiple clinical practice guidelines have adopted and subsequently relaxed Kt/V targets, which we...Since its introduction in 1985, Kt/V urea has played a pivotal role as a marker of "dialysis adequacy." Over the decades, multiple clinical practice guidelines have adopted and subsequently relaxed Kt/V targets, which were then transformed into quality metrics in various health care systems, including the United States. In this perspective, we explore the historical origins of Kt/V, focusing on its adaptation to peritoneal dialysis. We critically examine literature linking Kt/V to patient outcomes and explore the limitations of Kt/V-including reliance on urea removal alone as a surrogate for the clearance of all uremic toxins, the flawed assumption of equivalence between residual kidney and dialytic urea clearances, and the challenges in estimating the volume of distribution of urea. We propose alternative quality metrics that may better reflect meaningful patient outcomes such as preserving residual kidney function, optimizing nutrition and volume status, minimizing dialysis-related infections, and maintaining quality of life. Ultimately, we call for a shift away from Kt/V-centric quality frameworks and the concept of "adequate" dialysis, advocating instead for a more holistic model of high-quality, person-centered dialysis care, a model in which kidney care practitioners are empowered to provide high-quality peritoneal dialysis care without the constraints of Kt/V.
Massengill SF, Andreoni KA, Bellovich KA
… +7 more, Courtlandt C, Derebail VK, Feldman DL, Oh GJ, Sleasman JW, Bryant KA, Improving Vaccination in CKD Working Group
Am J Kidney Dis
· 2026 Mar · PMID 41443538
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People with chronic kidney disease (CKD) are particularly vulnerable to vaccine-preventable infections. Therefore, the National Kidney Foundation organized a multidisciplinary working group, including people with CKD and...People with chronic kidney disease (CKD) are particularly vulnerable to vaccine-preventable infections. Therefore, the National Kidney Foundation organized a multidisciplinary working group, including people with CKD and family care partners, to develop recommendations to improve vaccination rates, vaccination effectiveness, and health care for the CKD population. A modified Delphi process was used to achieve consensus on the recommendations. Recommendations on vaccination in CKD patients were organized into these categories: (1) patient preferences; (2) assessing the vaccination status of patients with CKD; (3) assessing vaccine response in patients with CKD; (4) vaccination of immunocompromised patients; (5) vaccination in posttransplant patients; (6) vaccinations in patients with CKD before international travel; (7) vaccination of household contacts of patients with CKD; (8) assessing vaccine efficacy and safety in clinical trials with patients with CKD; (9) training and resources for health care teams; (10) training of health care teams for discussions with patients; (11) role of technology in promoting and improving vaccination; and (12) advocacy and policy considerations for promoting and improving vaccination rates. The working group's recommendations should improve communication between patients and health care clinicians, inclusion of people with CKD in vaccine trials, and use of existing clinical guidelines as well as generate educational resources and training materials for CKD patients of all ages and health care professionals.
Hudson JQ, Chang AR, Condon Martinez AJ
… +3 more, Maxson R, Meaney CJ, St Peter WL
Am J Kidney Dis
· 2026 Mar · PMID 41443537
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Comprehensive medication management (CMM) is the standard of care that ensures that medications are individually assessed to determine that each medication is appropriate, effective for the medical condition, safe given...Comprehensive medication management (CMM) is the standard of care that ensures that medications are individually assessed to determine that each medication is appropriate, effective for the medical condition, safe given the patient's comorbidities and other medications, and able to be taken by the patient as intended. CMM helps improve all aspects of health care quality and is essential for individuals with chronic kidney disease. It specifically addresses the complexity of medication regimens in patients with multiple comorbid conditions that often lead to medication therapy problems. The provision of CMM is best optimized with a multidisciplinary team that includes a pharmacist. The importance of interprofessional and multidisciplinary practice in the care of individuals with kidney disease has been emphasized by nephrology organizations and within chronic kidney disease-related guidelines. The shift toward pay for performance and value-based care models within nephrology has created more opportunities for pharmacist integration into care teams. Other health care providers should view the inclusion of pharmacists in the kidney care team as a valuable opportunity to enhance patient support, reduce work-related stress, and improve outcomes through collaborative teamwork. The Advancing Kidney Health through Optimal Medication Management initiative supports the involvement of pharmacists across practices and health care systems to ensure the successful implementation of CMM for individuals with kidney disease.
Focal segmental glomerulosclerosis (FSGS) is not a single disease. Instead, it is a histopathological entity that is the manifestation of a wide range of clinical insults that injure the podocyte, a key structural elemen...Focal segmental glomerulosclerosis (FSGS) is not a single disease. Instead, it is a histopathological entity that is the manifestation of a wide range of clinical insults that injure the podocyte, a key structural element in the glomerular filtration barrier. The current classification of FSGS includes 4 subtypes: primary immune-mediated, genetic, secondary, and undetermined cause. Based on this scheme, patients are treated empirically with a combination of nonspecific renoprotective drugs and immunosuppressive agents in an effort to reduce proteinuria and preserve kidney function. However, there are no medications approved by the US Food and Drug Administration for FSGS. Moreover, current therapy is successful in achieving disease remission in less than a quarter of patients, and all of the available options are associated with significant side effects that limit their use in practice. Ongoing research using a full array of muti-omics analytical tools-including genomic, transcriptomic, proteomic, and metabolomic assessment-suggest that patients with FSGS can be characterized mechanistically by the primary process(es) initiating and promoting disease progression. This work is summarized in this review and raises the potential to individualize therapy for each patient with FSGS. This would usher in the potential for precision medicine to be applied in the treatment of those affected by this rare but serious glomerular disease.
Am J Kidney Dis
· 2026 Mar · PMID 41423086
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IgA nephropathy (IgAN) is the most common immune-mediated glomerular disease worldwide. Advanced understanding of the role of complement in IgAN pathogenesis has motivated the development of complement inhibition as a th...IgA nephropathy (IgAN) is the most common immune-mediated glomerular disease worldwide. Advanced understanding of the role of complement in IgAN pathogenesis has motivated the development of complement inhibition as a therapeutic strategy. Iptacopan, a complement factor B inhibitor, is the first approved complement inhibitor for IgAN. Several other complement inhibitors are being studied in phase 2/3 clinical trials. How best to integrate complement inhibition into the evolving treatment paradigm for IgAN remains a challenge. This review provides an overview of the role of complement in the pathogenesis and progression of IgAN and summarizes current and emerging complement-targeted IgAN therapies.
Am J Kidney Dis
· 2026 Feb · PMID 41389078
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Exercise triggers complex effects on kidney physiology that vary with intensity, duration, and environmental conditions. While moderate physical activity improves cardiovascular and renal outcomes, intense or prolonged e...Exercise triggers complex effects on kidney physiology that vary with intensity, duration, and environmental conditions. While moderate physical activity improves cardiovascular and renal outcomes, intense or prolonged exertion, particularly in endurance sports, can lead to acute kidney injury. Adaptations in kidney physiology during exercise include reduced plasma flow, altered glomerular filtration, and hormone-mediated fluid retention. These changes are protective but may become maladaptive with dehydration, heat stress, or excessive fluid intake. High-intensity exercise increases oxidative stress and proteinuria, while ultramarathon participation may cause transient creatinine elevation from muscle breakdown, complicating acute kidney injury diagnosis. Prevention strategies include individualized hydration plans, electrolyte replacement, and avoidance of nonsteroidal anti-inflammatory drugs. In special populations, such as children with chronic kidney disease or patients receiving dialysis, structured exercise enhances quality of life and physical function when implemented safely. Clinicians must balance the benefits of exercise with kidney-related risks, promote safe training practices, and recognize early signs of exertional complications to optimize renal and overall health in physically active individuals. This core curriculum reviews the physiology of exercise on kidney function and provides evidence-based strategies for patient counseling and risk reduction.
Hiraoka A, Sakaguchi Y, Kadono H
… +11 more, Kawaoka T, Oka T, Doi Y, Kawano Y, Kishimoto H, Saito T, Yamamoto R, Matsui I, Mizui M, Kaimori JY, Isaka Y
Am J Kidney Dis
· 2026 May · PMID 41371386
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RATIONALE & OBJECTIVE: Sedentary behavior is common among hemodialysis patients although large-scale data on physical activity (PA) objectively measured by accelerometers are scarce. We (1) compared PA levels between hem...RATIONALE & OBJECTIVE: Sedentary behavior is common among hemodialysis patients although large-scale data on physical activity (PA) objectively measured by accelerometers are scarce. We (1) compared PA levels between hemodialysis patients and community-dwelling adults, 2) estimated annual PA changes, and 3) determined associations between PA levels and mortality in hemodialysis patients. STUDY DESIGN: Prospective cohort study. SETTING & PARTICIPANTS: 1,030 Japanese hemodialysis patients enrolled for PA measurements between June 2019 and July 2020 and followed for 3 years. PA data in community-dwelling adults were obtained from the Dazaifu-City Survey in Japan. EXPOSURE: Light-intensity PA, moderate-intensity PA, vigorous-intensity PA, and steps measured by triaxial accelerometers after enrollment and 1 year later, defined based on 10-second epoch-averaged metabolic equivalents (METs) of 1.6-2.9, 3.0-5.9, and ≥6.0, respectively. OUTCOME: All-cause death. ANALYTICAL APPROACH: Cox proportional hazards models with least absolute shrinkage and selection operator (LASSO). RESULTS: The median light-intensity PA, moderate-intensity PA, vigorous-intensity PA, and steps were 192 (IQR, 128-263) minutes/day, 70 (IQR, 26-169) minutes/week, 0 (IQR, 0-0) minutes/week, and 1,832 (IQR, 680-3,822)/day, respectively. Age- and sex-adjusted geometric means of light-intensity PA, moderate-to-vigorous intensity PA, and steps were 42%, 77%, and 73% lower among hemodialysis patients than community-dwelling adults. The least-squares mean annual changes in light-intensity PA, moderate-intensity PA, and steps were -12.4 minutes/day, -10.7 minutes/week, and -215 steps/day, respectively. The lowest hazard was observed at 216-262 minutes/day for light-intensity PA, 239-291 minutes/week for moderate-intensity PA, and 4,294-6,045/day for steps. LASSO identified light-intensity PA on nondialysis days as the parameter most strongly associated with survival. The lowest mortality risk was observed at about 300 minutes/day of light-intensity PA on nondialysis days compared with about 200 minutes/day on dialysis days. LIMITATIONS: Observational study design precludes causal inference. CONCLUSIONS: Light-intensity PA on nondialysis days, even for short durations, was associated with better survival in hemodialysis patients. PLAIN-LANGUAGE SUMMARY: Sedentary behavior is prevalent in hemodialysis patients. Although current guidelines recommend 150-300 minutes/week of moderate-intensity physical activity (PA) (eg, brisk walking, cycling at a moderate pace, jogging) or 75-150 minutes/week of vigorous-intensity PA (eg, running, sprinting), it is uncertain whether these targets are applicable to hemodialysis patients who have a high prevalence of frailty. In this 3-year prospective cohort study involving 1,030 Japanese hemodialysis patients, light-intensity PA (eg, casual walking, light household activities, gardening, tai-chi) on nondialysis days was most closely associated with better survival among various PA parameters. The lowest mortality risk was observed at about 300 minutes/day of light-intensity PA on nondialysis days. Light-intensity PA, even for short durations, may be associated with favorable outcomes among hemodialysis patients.
Laslandes M, Lorent M, Brilland B
… +12 more, Boulay H, Golbin L, Barbet C, Grellier J, Dujardin A, Larmet D, Testa A, Pfirmann P, Thierry A, Ville S, Dantal J, Masset C
Am J Kidney Dis
· 2026 May · PMID 41360256
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RATIONALE & OBJECTIVE: Rituximab effectively limits the number of relapses in childhood idiopathic nephrotic syndromes (INS) and reduces exposure to corticosteroids and other immunosuppressants. However, few data are ava...RATIONALE & OBJECTIVE: Rituximab effectively limits the number of relapses in childhood idiopathic nephrotic syndromes (INS) and reduces exposure to corticosteroids and other immunosuppressants. However, few data are available on the risk of relapse after an initial dose of rituximab or the benefit of a maintenance therapy in adults with INS. STUDY DESIGN: Multicenter retrospective cohort study. SETTING & PARTICIPANTS: All adult patients with minimal change disease (MCD) or primary focal segmental glomerulosclerosis (FSGS) treated in 10 French centers who received a first dose of rituximab between January 2009 and June 2023. EXPOSURE: Maintenance therapy with rituximab. OUTCOME: Disease relapse, change in proteinuria, and occurrence of infectious complications ascertained using clinical, biological, and histological data collected from disease onset until up to 4 years after the first rituximab dose. ANALYTICAL APPROACH: Marginal structural models of rituximab redosing and, as time-varying covariates, proteinuria, use of steroids, and other immunosuppressant drugs. RESULTS: The study included 134 patients (MCD = 66.4%) who were followed for a median of 36 months after the first dose of rituximab (baseline). In a subgroup of patients followed for at least 2 years after baseline (n = 65), rituximab was associated with a significant reduction in the frequency of relapses (0.20 vs 1.02 per person-year; P < 0.001). Two-thirds of the 26 patients with baseline nephrotic proteinuria had decreased proteinuria within the first 6 months (median reduction of 70% [IQR, 46-94]). Among the 105 patients in remission at baseline, the median relapse-free survival was 38 months. Maintenance dosing of rituximab between 6 and 12 months after the first dose was associated with significantly lower risk of INS relapse during follow-up (HR, 0.35 [95% CI, 0.15-0.83], P = 0.02). Overall, the rate of severe infections was 7.24 per 100 person-years in the entire cohort. Treatment with rituximab after the first dose was not detectably associated with an increased risk of severe infections (HR, 0.48 [95% CI, 0.08-2.98], P = 0.4). LIMITATIONS: Retrospective, observational study. Variation in doses/timing of rituximab. Heterogeneous population. Lack of longitudinal CD19 monitoring. CONCLUSIONS: Rituximab reduced the risk for INS relapse, and maintenance treatment between 6 and 12 months was associated with further reduction in relapses. Prospective studies are required to better specify the benefit of rituximab maintenance therapy. PLAIN-LANGUAGE SUMMARY: Rituximab is effective in reducing relapses and the need for administration of steroids and other immunosuppressant drugs in childhood idiopathic nephrotic syndromes (INS). In adults, few data are available, particularly with regard to maintenance dosing. This study identified all adult patients with INS who received rituximab in 10 French clinical centers. These 134 patients were followed for a median of 36 months. Rituximab was associated with a reduction in the number of relapses and exposure to steroids and other immunosuppressants. Maintenance dosing of rituximab between 6 and 12 months was significantly associated with a lower risk of INS relapse without an increased risk of severe infections. The role of maintenance therapy with rituximab requires further evaluation in prospective studies.
Créon A, Faucon AL, Caldinelli A
… +5 more, Shin JI, Grams ME, Sjölander A, Fu EL, Carrero JJ
Am J Kidney Dis
· 2026 Apr · PMID 41360255
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RATIONALE & OBJECTIVE: Albuminuria is a predictor of adverse health outcomes. Early detection enables timely clinical management, yet little is known about how clinicians respond to newly detected albuminuria in routine...RATIONALE & OBJECTIVE: Albuminuria is a predictor of adverse health outcomes. Early detection enables timely clinical management, yet little is known about how clinicians respond to newly detected albuminuria in routine practice. This study characterized clinical care processes for patients with newly detected albuminuria. STUDY DESIGN: Retrospective, population-based cohort study. SETTING & PARTICIPANTS: 215,035 adults with newly detected albuminuria between 2010 and 2021 in Stockholm, Sweden. EXPOSURE: Albuminuria severity, categorized as moderate (≥30-299 mg/g), severe (300-999 mg/g), or very severe (≥1000 mg/g). All methods of albuminuria testing were considered: dipstick albuminuria or proteinuria tests as well as 24-hour and spot albumin concentrations. OUTCOME: Proportion of patients retested for albuminuria, frequency of the methods used for retesting, rates of nephrology referral, and rates of initiation of treatment with renin angiotensin system or sodium/glucose cotransporter 2 inhibitors. ANALYTICAL APPROACH: Descriptive analysis of proportions and cumulative incidence of outcomes based on time-to-event analysis accounting for the competing risks of death and kidney failure. RESULTS: We found 90% of participants had moderate, 8% had severe, and 2% had very severe albuminuria. Retesting rates within 1 year were 46%, ranging from 45% for moderate albuminuria to 70% for very severe albuminuria, with lower rates among individuals without diabetes. Only 28% of those with an indication were referred to a nephrologist, and renin angiotensin system and sodium/glucose cotransporter 2 inhibitor initiation rates at 1 year were 10%, 12%, and 37% for moderate, severe, and very severe albuminuria, respectively, with substantially lower rates in individuals without diabetes. LIMITATIONS: The findings are specific to Stockholm's health care system and may not be generalizable to other regions, health care models, or cultures. CONCLUSIONS: This study identified important care gaps in the Swedish management of albuminuria. A substantial proportion of individuals, including those with very severe albuminuria, lacked monitoring and failed to receive antiproteinuric treatments. Strategies to improve clinician awareness and adherence to guideline-recommended care may mitigate the long-term consequences of chronic kidney disease progression. PLAIN-LANGUAGE SUMMARY: Early signs of kidney damage, such as albuminuria (protein in the urine) may not always lead to the appropriate clinical follow-up that is recommended in clinical practice guidelines. This study characterized how patients with albuminuria were managed in Stockholm's health care environment. Between 2010 and 2021, 215,035 adults had elevated albuminuria detected for the first time, but many did not receive the recommended follow-up care, including a confirmation test, referral to a nephrologist when indicated, or initiation of kidney-protective medications. This study highlights the need for better strategies to improve care for individuals with albuminuria, ensuring earlier intervention that may prevent more severe health consequences of early indications of kidney damage.