Clinical nephrology最新文献

Background: Acute kidney injury (AKI) is a common complication of critically ill COVID-19 patients which is associated with adverse outcomes. We examined clinical factors associated with hospital mortality in critically ill adult COVID-19 patients with AKI who required continuous renal replacement therapy (CRRT).

Materials and methods: We conducted a multicenter retrospective cohort study including data from two large academic medical centers. Adult (age ≥ 18 years) patients with AKI and requiring CRRT admitted from March 2020 to April 2021 were included in the study. Patients with end-stage kidney disease or renal transplantation were excluded. Multivariable Poisson regression analyses were used to identify clinical predictors of hospital mortality.

Results: A total of 178 patients were included. Patients were predominantly men (68.2%), 13.1% were Black, and 57.9% White. Median hospital and ICU length of stay were 20 days and 14 days, respectively. Mechanical ventilation and extracorporeal membrane oxygenation were utilized in 97.2% and 17.4% of patients, respectively. Overall, 130 (73.0%) patients died in the hospital (mortality rate of 2.7 per 100 person-days). In multivariable analyses, SOFA score ≥ 12 at ICU admission (MRRadj = 1.88; 95% CI 1.17 - 3.01) was associated with increased risk of mortality, while Black race (MRRadj = 0.56; 95% CI 0.31 - 1.01) was associated with a decreased risk of mortality.

Conclusion: More than two-thirds of critically ill adult COVID-19 patients with AKI requiring CRRT died during hospitalization. SOFA score ≥ 12 at ICU admission was an independent predictor of hospital mortality, and Black patients had a lower risk of mortality.

Introduction: Computed tomography peritoneography (CTp) is pivotal for evaluating peritoneal dialysis (PD)-related complications, yet it comes with drawbacks, specifically exposure to iodinated contrast media (ICM). This study aimed to explore the feasibility of reducing ICM dosage utilizing spectral detector CT (SDCT).

Materials and methods: 35 rabbits were strategically divided into 7 groups (A - G) according to the ICM concentration ratio in the injection protocol, with respective doses of 10, 15, 20, 25, 30, 40, and 50 mL/2L. The CTp injection protocol involved a 300-mL mixture of non-ionic ICM omnipaque (350 mgI/mL) and peritoneal dialysate (1.5% lactate, 2 L), followed by scans using dual-layer SDCT. Virtual monoenergetic images (VMIs) at 4 distinct energy levels (40 - 70 keV, in 10-keV steps), iodine maps (IMs), and effective atomic number (Zeff) maps were subsequently reconstructed. Both quantitative and qualitative image assessments were conducted, and the parameters from these analyses were compared across images from groups A - G and traditional 50 mL/2L 120-kVp images. In post-determination of the optimal concentration and reconstructions, we illustrated their applications in patients with suspected PD-related complications.

Results: The quantitative image quality (IQ) of 15 mL/2L VMIs at 40 keV surpassed that of the 50 mL/2L 120-kVp images (p < 0.05). Furthermore, the diagnostic performance utilizing 15 mL/2L VMIs40 keV, when combined with IMs and Zeff maps, was found to be optimal.

Conclusion: The employment of SDCT in CTp allows for a substantial reduction in the ICM dose by 70%, compared to the benchmark concentration of 50 mL/2L, without compromising diagnostic precision.

Background: Calciphylaxis is a rare and serious complication in patients with kidney disease. It has few treatment options and poor prognosis. Hyperbaric oxygen therapy (HBOT) may improve wound healing and was added to our conventional care in 2012.

Materials and methods: Data from all calciphylaxis patients treated from 2012 to 2022 were retrieved from hospital records. HBOT was added to our multidisciplinary care of calciphylaxis, which included sodium-thiosulphate, dialysis if indicated, medical optimization of calcium-phosphate homeostasis, substitution of vitamin K2, withdrawal of warfarin, iron and vitamin D, and minimization of systemic steroids. In addition, weight- and nutritional status was optimized, and wound care was thoroughly performed.

Results: 25 patients received a total number of 1,493 HBOT treatments in addition to conventional care in the study period. Median HBOT per patient was 45 (range 1 - 267). One year after diagnosis, 18 out of 25 patients were alive. 15 out of the 18 patients alive 1 year after diagnosis had completely resolved wound lesions. Seven patients died within the first year after diagnosis due to cardiovascular disease (n = 3), infection (n = 3), and cancer (n = 1).

Conclusion: Our results suggest that HBOT is well-tolerated and may be associated with beneficial effects on survival and wound-healing when combined with multidisciplinary care.

Introduction: Fibroblast growth factor inhibitors (FGFRi) are novel cancer drugs that offer new hope for patients with advanced biliary tract cancers and metastatic urothelial tumors. Despite their effectiveness, they often cause hyperphosphatemia.

Materials and methods: We investigated the incidence and characteristics of hyperphosphatemia in patients treated with FGFRi at Northwell Health, comparing findings with clinical trials and the FDA Adverse Event Reporting System database.

Results: 94% of patients in our series developed hyperphosphatemia, predominantly grade 2. The time-to-onset of hyperphosphatemia was longer than noted in clinical trials. Patients on erdafitinib showed a higher-than-expected incidence and grade of hyperphosphatemia.

Conclusion: Collaboration between nephrologists and oncologists is crucial for optimizing treatment benefits and managing side effects. Further research is warranted to refine management strategies and to understand the clinical implications of hyperphosphatemia.

Aims: Reliable national estimates for the incidence and prevalence of immunoglobulin A nephropathy (IgAN) in the United States (U.S.) are needed. We performed a national survey with pathologists and used insurance claims data to estimate IgAN frequency nationwide.

Materials and methods: An online survey with pathologists was conducted between November and December 2021 to obtain data on the number and types of biopsies evaluated and the proportion with IgAN confirmed. Biopsy data were extrapolated to two different claims databases to estimate incidence and prevalence. Results were validated against a separate dataset of electronic health records.

Results: A total of 43 pathologists from across U.S. regions reported evaluating a mean of 169 kidney biopsies (standard deviation 179.1) in the past 12 months. Of the 7,267 total biopsies evaluated, 632 (8.7%) were IgAN. Based on the respective claims databases, annual incidence rates of 2.1 and 2.2 per 100,000 and prevalence rates of 59.9 and 62.7 per 100,000 were estimated. Results from the validation dataset were similar, with an incidence of 1.9 per 100,000 and prevalence of 54.2 per 100,000.

Conclusion: This study estimated incidence and prevalence of IgAN. Extrapolating the findings to the U.S. population for 2021, total prevalence was 198,887 - 208,184 persons.

Background: Left ventricular (LV) diastolic dysfunction is frequently observed in patients with end-stage kidney disease (ESKD) and a significant risk factor for the development of cardiovascular events in those patients. We hypothesized that the ratio of early diastolic peak mitral flow velocity to early mitral annulus velocity (E/e' ratio), the widely used non-invasive LV diastolic dysfunction index, would show improvements following kidney transplantation (KT).

Materials and methods: A total of 192 KT recipients who underwent echocardiography before KT and 2 years after KT were included this analysis. Moreover, 137 patients with ESKD on dialysis, waiting for deceased donor were included as a control group. Multiple linear regression analysis was used to identify the factors related to changes in the E/e' ratio.

Results: The median duration between conducting the two echocardiographies was 809 days for the KT recipients and 798 days for the controls. The mean E/e' ratio showed a significant decrease in KT recipients (10.9 vs. 9.8, respectively; p = 0.002), but not in the controls (11.7 vs. 11.9, respectively; p = 0.605). In multiple linear regression, KT (standardized β (SB) = -0.156; p = 0.009) and administration of β blocker (BB) at enrollment (SB = -0.130; p = =0.034) and at 2 years (SB = 0.206, p = 0.001) were significant predictors of the change in the E/e' ratio.

Conclusion: LV diastolic dysfunction showed a noticeable improvement in the patients after KT compared to those on the waiting list and undergoing dialysis. Further studies, including patients with volume status and major cardiovascular events, may be helpful for validating these findings.

Acute kidney injury (AKI) is a frequent, severe complication of hematopoietic stem cell transplantation (HSCT) and is associated with an increased risk of morbidity and mortality. Recent advances in artificial intelligence (AI) and machine learning (ML) have showcased their proficiency in predicting AKI, projecting disease progression, and accurately identifying underlying etiologies. This review examines the central aspects of AKI post-HSCT, veno-occlusive disease (VOD) in HSCT recipients, discusses present-day applications of artificial intelligence in AKI, and introduces a proposed ML framework for the early detection of AKI risk.

Background: Our aim was to systematically evaluate the efficacy and safety of rituximab (RTX) in patients with lupus nephritis (LN).

Materials and methods: PubMed, Embase, China National Knowledge Infrastructure (CNKI), Cochrane Library, and Wanfang Databases were searched to collect literature on the efficacy and safety of RTX in patients with LN. Odds ratios (ORs), weighted mean differences (WMDs), and standardized mean differences (SMDs) were used to represent treatment efficacy and overall outcome. The outcomes included complete renal remission rate, proteinuria, Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) scores, serum creatinine, any adverse events and serious adverse events. We explored the heterogeneity with I2 and assessed publication bias with funnel plot and Egger's test.

Results: Nine studies involving 723 patients (254 in the RTX group and 469 in the control group) were included in our systematic review and meta-analysis. RTX resulted in a higher complete renal remission rate (OR: 2.62; 95% CI 1.43 - 4.79, p = 0.024, I² = 54.7%) than the control group. It significantly decreased SLEDAI scores (WMD = -3.79, 95% CI: -5.78 to -1.8, p < 0.001, I² = 94.7%) as well as proteinuria (WMD = -0.9, 95% CI: -1.6 to -0.2, p < 0.001, I² = 97.6%). There were no significant differences in any adverse events and serious adverse events between the RTX group and control group.

Conclusion: RTX was an effective therapeutic agent in patients with LN, and it did not increase the risk of adverse events compared to the control group.

Background and objectives: Chronic kidney disease (CKD) is associated with increased cardiovascular risk, which may be mediated by vascular calcification. Based on evidence that bisphosphonates inhibit vascular calcification, we hypothesized use of bisphosphonates in CKD would be associated with lower incident cardiovascular disease (CVD), CVD-related mortality, and all-cause mortality.

Materials and methods: This was a longitudinal observational study including 2,593 Framingham Offspring participants. We used propensity score-adjusted Cox regression models to determine the association between bisphosphonate use and outcomes: time to incident CVD, time to CVD-related mortality, and time to all-cause mortality. The data were stratified by presence or absence of CKD, defined as estimated glomerular filtration rate < 60 mL/min/1.73m². The propensity score included age, sex, hypertension, smoking status, diabetes, total cholesterol, high-density lipoprotein, and self-reported history of fracture.

Results: In unadjusted and propensity score-adjusted analyses, those with CKD using bisphosphonates had a trend toward increased incident CVD risk (adjusted hazard ratio (HR) 1.66 (95% CI, 93 - 2.97)) compared to those with CKD not using bisphosphonates. Those with CKD using bisphosphonates also had increased risk of cardiovascular mortality in the propensity score-adjusted model (adjusted HR 2.20 (95% CI, 1.12 - 4.32)). There was no significant association between bisphosphonate use and all-cause mortality in participants with CKD. Among individuals without CKD, bisphosphonate use was significantly associated with an increase in all-cause mortality in the propensity-score adjusted analysis (adjusted HR 1.59 (95% CI, 1.27 - 1.98)). However, there was no significant association between bisphosphonate use and incident CVD events (adjusted HR 0.85 95% CI, 0.63 - 1.16) or CVD-related death (adjusted HR 0.70 (95% CI 0.36 - 1.37) in those without CKD.

Conclusion: Contrary to our hypothesis, bisphosphonate use was associated with a trend toward increased incident CVD and a two-fold higher risk of CVD mortality in CKD.

Background: Among hemodialysis patients, left ventricular hypertrophy (LVH) is a prevalent cardiac abnormality. The uremic toxin indole-3-acetic acid (IAA) is elevated in uremia patients, but the connection between IAA and LVH in individuals undergoing hemodialysis remains uncertain. Hence, the objective of this research was to examine the correlation between blood IAA levels and LVH in individuals undergoing hemodialysis.

Materials and methods: In total, 205 individuals undergoing hemodialysis were chosen and categorized into two groups, with (143 patients) and without LVH (62 patients). Patient clinical data were collected, and serum creatinine, calcium, phosphorus, hemoglobin, and IAA levels were measured.

Results: Compared to the non-LVH group, the LVH group had higher IAA and serum phosphorus but lower hemoglobin. The serum IAA concentration was positively correlated with both left ventricular mass (LVM) and left ventricular mass index (LVMI) but negatively correlated with both left ventricular ejection fraction (LVEF) and the ratio of left ventricular transmitral early peak flow velocity to left ventricular transmitral late peak flow velocity (E/A). Logistic regression analysis indicated that increased IAA levels are a risk factor for LVH and are not influenced by other factors. In addition, we exposed primary neonatal cultured mouse cardiomyocytes to varying concentrations of IAA in a controlled environment. Cardiomyocyte hypertrophy was induced by IAA in a concentration-dependent manner.

Conclusion: Serum IAA is correlated with alterations in both the function and structure of the left ventricle. The serum IAA concentration is an independent risk factor for LVH. IAA may be a novel biomarker of LVH in hemodialysis patients.