KIReports
@KIReports · New York, USA · joined 27 Sep 2017
Kidney International Reports | Official journal of @ISNkidneycare | Tweets by KI Reports Social Media team | 👀https://t.co/I6LNofZoQ2
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@KIReports @AgavriloaeiB @assad_sm @DrAkshayaJ @ISNkidneycare @ISNeducation @sophia_kidney @MChanMD @brian_rifkin @CristinaDeReins I’m curious whether the vascular effect tracks citrate exposure itself or the transient drop in ionized Ca—does the study separate those mechanisms?
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18/ Thank you for reading!
This paper is a reminder that dialysis prescriptions can have biological effects we may not predict from short-term biochemical markers.
Read the full KI Reports paper and keep questioning the mechanism.
🧵@DrAkshayaJ
https://t.co/0Kf2DgxL4i https:
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16/ So, should we stop citrate dialysate? No.
This is a small, single-center study with a selected population and surrogate endpoint. But the signal is striking enough to justify larger studies with robust exposure assignment, imaging and clinical outcomes. https://t.co/3IOe0mXT
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15/ The study also challenges an interesting disconnect: citrate dialysate can improve short-term serum calcification propensity, yet this study found faster progression of vascular calcification.
A better biomarker does not automatically mean a better tissue-level outcome.
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14/ Limitations
5 patients may have had dialysate errors, based on unexpectedly ⬆️ citrate levels during the acetate arm
BAC is a surrogate
This study did not measure coronary/aortic Ca, calciphylaxis, CV events or mortality. We cannot conclude that citrate dialysate⬆️ CV risk
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13/ Why is this surprising?
Citrate is a calcium chelator and can inhibit calcium phosphate crystallization. But citrate is also abundant in bone and participates in biomineralization. So its biological effect may depend on context, concentration and tissue environment.
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12/ Then came the intriguing tissue finding. Citrate was detected in calcified human arterial segments. Citrate content correlated strongly with the amount of calcification (r=0.91). Estimated citrate content was ~0.8% of calcified tissue.
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11/ The striking biochemical difference was citrate itself.
Pre-HD citrate was similar, but post-HD citrate rose to 383 vs 187 μM with citrate vs acetate. That >3-fold rise makes citrate a plausible contributor, but does not prove causality. https://t.co/LqhRvWfsmO
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10/ Could Ca, phosphate or dialysis adequacy explain it?
Not really.
Pre-HD Ca and phosphate, dialysis time, Kt/V and dialysate Ca were similar. Citrate did lower post-HD ionized Ca and Mg, while HCO3 and PTH were slightly higher. https://t.co/wsGXACaW4O
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9/ The finding was also seen as % change from baseline: 40%/yr with citrate vs 21%/yr with acetate.
The effect was significant whether patients started with citrate or acetate, supporting consistency within the crossover design. https://t.co/1CN138vDKC
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8/ The headline result: BAC progressed much faster with citrate.
Median progression was 47 mm/yr with citrate vs 9 mm/yr with acetate. (P=0.0005)
22 of 28 patients had greater progression during citrate exposure. https://t.co/QYP9VmfrMI
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7/ The cohort was small and highly selected: all 28 were women and African American.
Of 54 who started, only 29 completed the protocol, and 28 had usable BAC progression data.
The attrition matters when interpreting the magnitude of the finding. https://t.co/m0I1ZKNAuS
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6/ Study design : This was a crossover study. 28 women on chronic HD with pre-existing BAC received citrate or acetate dialysate for ~1 year each, with mammograms at 6-month intervals.
Each patient therefore served as her own control. https://t.co/M6fbu3CNjf
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5/ The study used breast arterial calcification (BAC) as a marker of medial vascular calcification, answer “A”.
BAC is visible on routine mammography and reflects medial rather than atherosclerotic intimal calcification. https://t.co/rwJRUGFYWb
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4/ Poll : What is breast arterial calcification (BAC) most reflective of?
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3/ Our #Xtorial is by Akshaya J @DrAkshayaJ, adult nephrologist from @CMCNephrology - No COI
#MedTwitter
@ISNkidneycare
Check out #KIReportsCommunity educational #blogposts at https://t.co/AgY6mXQU75.
FOLLOW US at @KIReports https://t.co/jdjZqH5pw1
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2/ A new KI Reports study asks a provocative question : does citrate-containing dialysate affect vascular calcification in HD?
https://t.co/0Kf2DgxL4i
The answer was unexpected. Let’s look at the study, the signal, and what we should make of it. https://t.co/9lu2VmH0BO
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1/ Hey #NephX! 👋
We’re back with a fresh #Xtorial from KIReports
Citrate dialysate is often viewed as a friend in dialysis : it chelates Ca, and inhibits Ca/Phos crystallization, But what if the effect on the vessel wall is not so simple?
https://t.co/0Kf2DgxL4i https://t.co/R
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19/ We hope this #tweetorial improved your understanding of donor & recipient diabetes in KT. Please share! Thanks to @ManoleaA for authoring & @sophia_kidney for great feedback! @ISNkidneycare @KIReports
🔗https://t.co/V4jQZ0foqK
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18/ Based on this evidence, does this change your perspective on using kidneys from donors with diabetes for transplantation? Please comment!
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17/ Limitations
👎 Observational registry study, with potential residual confounding
👎 Relatively small D+/R+ group (n=189)
👎 No data on diabetes severity, duration, treatment or HbA1c
👎 Lack of kidney biopsy data to assess diabetic kidney changes
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16/ Summary
⚡ Donor diabetes status alone did not worsen graft or patient survival
⚡ D+/R+ had the poorest graft and patient survival
⚡ eGFR was only slightly lower, with no difference in rejection
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15/ Results: 2° Outcomes
⚕️ No significant difference in rejection between groups
⚕️ Diabetic donor kidneys were associated with only a minor reduction in eGFR
📉 The difference was small during the first 5 years post-transplant
📈 D−/R− recipients had the best eGFR over time https
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14b/ Results: Graft Survival
👤 Diabetic recipients had reduced overall graft survival
📊 D+/R+: aHR 1.52 (95% CI 1.16–1.98)
📊 D−/R+: aHR 1.19 (95% CI 1.03–1.36) https://t.co/7GsxJebN3i
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14a/ Results: Patient Survival
🫘 Death-censored graft survival was similar for most donor–recipient combinations
🫘 D+/R+ had significantly worse patient survival
📊 aHR 1.70 (95% CI 1.15–2.51)
🫘 D−/R+ had reduced patient survival
📊 aHR 1.38 (95% CI 1.18–1.61) https://t.co/rtkYEGur
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13/ Results: Cohort & Follow-up
💊 11,343 kidney transplant recipients included
💊 Median follow-up: 6.16 years
💊 3,427 graft losses and 2,532 deaths
💊 Only 124 patients were lost to follow-up
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12/ Results: Clinical Characteristics
The D+/R+ group was:
🔬 Older
🔬 More often male
🔬 Higher BMI
🔬 More cardiovascular & peripheral vascular disease
🔬 Mostly T2DM
For diabetic donors:
🫘 Older and higher BMI
🫘 More hypertension
🫘Similar terminal creatinine https://t.co/GlDCuRZh9
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10b/ Methods
🎗️ Inclusion: First-time adult (≥18 years) recipients of a deceased-donor kidney transplant
❌ Exclusion: Living-donor, repeat, and multi-organ transplants; missing donor or recipient diabetes status
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11/ Outcomes
🎯Primary: Death-censored graft survival
➕ Secondary: Patient survival, overall graft survival, acute rejection at 12 months, and post-transplant eGFR over time
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10a/ Methods
💽 Data: Australia and New Zealand Dialysis and Transplant Registry (ANZDATA)
🕐2003–2022
🫘 11,343 first-time adult recipients of deceased-donor kidney transplants
🔄 Compared 4 donor–recipient diabetes combinations: D−/R−, D−/R+, D+/R−, D+/R+
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Against accounts of the same size
41 posts from the last 90 days, next to the 10K–100K follower range. reaches fewer people than peers, but engages them much harder.
Median views61this account949median for 10K–100K
Reach, %0.43%this account3.31%median for 10K–100K
Engagement, %6.12%this account1.88%median for 10K–100K
| Metric | This account | Median for 10K–100K | Ratio |
|---|---|---|---|
| Median views per post | 61 | 949 | 0.06× |
| Reach (views ÷ followers) | 0.43% | 3.31% | 0.13× |
| Engagement rate | 6.12% | 1.88% | 3.25× |
Others in this range → Compare with another account → How these benchmarks are built →
Growth & engagement
How the posts we collected actually performed: views and reaction rate post by post, what the audience did with them, and where the follower count goes.
Views per post
1006 Sep
26
25
30
92
103
99
101
98
22
23
251
143
16
Last 14 collected posts, oldest on the left. The scale is logarithmic: one post can outrun the rest a hundred times over.
Engagement rate per post
7.00%6 Sep
11.54%
20.00%
10.00%
5.43%
5.83%
5.05%
5.94%
6.12%
13.64%
17.39%
2.79%
1.40%
0.00%
Reactions — likes, reposts, replies and quotes — divided by views. Median for 10K–100K accounts is 1.88%.
What the audience does
Likes58.1%86 in total
Reposts18.2%27 in total
Replies18.9%28 in total
Quotes2.7%4 in total
Bookmarks2.0%3 in total
Share of every reaction we collected for this account. Replies mean argument, reposts mean endorsement, bookmarks mean the post was worth keeping.
The follower curve appears once this account has two daily snapshots — we take one a day, and this one is on its first.
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