Predicting chronic kidney disease outcomes: are two estimated glomerular filtration rates better than one?

The National Kidney Foundation's (NKF) Kidney Disease Outcomes Quality Initiative (KDOQI) definition of chronic kidney disease (CKD), stages 3-5, requires 2 estimated glomerular filtration rates (eGFRs) <60 ml/min/1.73 m(2) more than 3 months apart. By requiring 2 eGFRs, the NKF definition reduced identification of people without chronic disease, which may have decreased identification of individuals with early CKD, but increased identification of those who ultimately have progression of CKD or require renal replacement therapy (RRT). Our objective was to determine whether 2 eGFR tests were better than 1 eGFR as a predictor of RRT, CKD progression, or death. This retrospective incident cohort study evaluates outcomes in adults with an initial eGFR <60 ml/min/1.73 m(2) and a second eGFR after 90 days by examining a third follow-up eGFR. For the 2086 patients in this study, the mean initial eGFR was 50.7 ml/min/1.73 m(2) and the mean second eGFR was 59.3 ml/min/1.73 m(2). More than 40% of the population (925) did not have CKD based upon their second eGFR. The initial eGFR was the best predictor of the third eGFR. There was no material difference in the ability to predict outcome measures between 1 versus 2 eGFR tests, regardless of eGFR value or associated comorbidities. Identifying patients with CKD is a critical step when beginning to implement population management strategies for those patients. Our findings illustrate some of the trade-offs in strategies inherent in methods that might be used to identify patients with CKD; 1 eGFR will identify patients about 5 months sooner, allowing additional time for nephrologist and other therapeutic intervention, but approximately doubles the population to be managed.     

Mobility and HIV care engagement: a research agenda

Introduction

Mobility is common and an essential livelihood strategy in sub-Saharan Africa (SSA). Mobile people suffer worse outcomes at every stage of the HIV care cascade compared to non-mobile populations. Definitions of mobility vary widely, and research on the role of temporary mobility (as opposed to permanent migration) in HIV treatment outcomes is often lacking. In this article, we review the current landscape of mobility and HIV care research to identify what is already known, gaps in the literature, and recommendations for future research.

Discussion

Mobility in SSA is closely linked to income generation, though caregiving, climate change and violence also contribute to the need to move. Mobility is likely to increase in the coming decades, both due to permanent migration and increased temporary mobility, which is likely much more common. We outline three central questions regarding mobility and HIV treatment outcomes in SSA. First, it is unclear what aspects of mobility matter most for HIV care outcomes and if high-risk mobility can be identified or predicted, which is necessary to facilitate targeted interventions for mobile populations. Second, it is unclear what groups are most vulnerable to mobility-associated treatment interruption and other adverse outcomes. And third, it is unclear what interventions can improve HIV treatment outcomes for mobile populations.

Conclusions

Mobility is essential for people living with HIV in SSA. HIV treatment programmes and broader health systems must understand and adapt to human mobility, both to promote the rights and welfare of mobile people and to end the HIV pandemic.