Clinical nephrology最新文献

Objective: Research on autoimmune diseases has revealed multi-organ interactions, including thyroid-renal associations. This study aims to investigate the clinical features of primary nephrotic syndrome (PNS) patients with thyroid dysfunction, assess the impact of thyroid autoantibodies (anti-TPO Ab and anti-Tg Ab) on renal damage, and identify risk factors for thyroid dysfunction to facilitate early clinical intervention.

Materials and methods: A total of 175 PNS patients diagnosed between January 2023 and June 2024 were enrolled. Thyroid function and autoantibodies were measured upon admission. Comparisons were made between groups with normal and abnormal thyroid function, and between autoantibody-positive and double-negative patients. Logistic regression was used to analyze risk factors for thyroid dysfunction.

Results: A total of 134 patients were identified with thyroid dysfunction. The abnormal group showed higher total cholesterol, triglycerides, low-density lipoprotein cholesterol, and 24-hour urinary protein (UP), and lower total protein, albumin (ALB), calcium, immunoglobulin G, and immunoglobulin A. Autoantibody-positive patients had higher TSH, 24-hour UP, and urinary albumin-to-creatinine ratio, and lower FT4 (p < 0.05), though renal pathology did not differ significantly. Logistic regression analysis identified reduced ALB (OR = 0.900, 95% CI 0.815 - 0.993, p = 0.036) and elevated 24-hour UP (OR = 1.192, 95% CI 1.040 - 1.368, p = 0.012) as independent risk factors.

Conclusion: Thyroid dysfunction is common in PNS and is associated with more severe proteinuria and hypoalbuminemia, though not with specific pathological types. Thyroid autoimmunity was not an independent predictor; however, antibody-positive patients had significantly higher TSH and proteinuria levels. Routine thyroid function and antibody screening are recommended for early intervention in PNS patients.

Introduction: Fournier gangrene (FG) is a severe acute necrotizing fasciitis affecting the genitalia and carries a high mortality. Patients with end-stage kidney disease (ESKD) are an overlooked but potentially vulnerable subgroup given their high burden of comorbidities. As such, we aimed to study FG in those with and without ESKD.

Materials and methods: We conducted a retrospective analysis of all adult male FG hospitalizations from 2017 - 2021 in the National Inpatient Sample (NIS) database. We sought to identify independent predictors of in-hospital mortality. Univariable logistic regression analyses were used to calculate unadjusted odds ratios (OR) for an outcome of in-hospital death. All variables with p-values ≤ 0.2 were included in a multivariable logistic regression model. P-values ≤ 0.05 were considered significant in the multivariable analysis.

Results: Among 35,415 adult hospitalizations with FG in the NIS database, 2,210 (6.2%) had ESKD. Those with FG and ESKD, compared to those without ESKD, had higher rates of diabetes mellitus (DM) (85.3 vs. 65.1%; p < 0.001), higher in-hospital mortality (13.4 vs. 5.3%; p < 0.001), greater median length of stay (LOS) (10 vs. 8 days; p < 0.001), and greater median total hospital charges (USD 119,402 vs. 89,108; p < 0.001). The prevalence of sepsis was very high but similar between the groups (59.7 vs. 56.8%; p = 0.230). Multivariable analysis revealed the following factors were independently associated with higher odds of in-hospital death: age (OR 1.04; 95% CI: 1.033 - 1.055), alcohol abuse (OR 2.31; 95% CI: 1.622 - 3.278), and ESKD (OR 3.14; 95% CI: 2.279 - 4.331).

Conclusion: Patients with ESKD represent a distinct and high-risk subgroup, characterized by longer hospital LOS, increased total hospital charges, and over three-fold increased odds of in-hospital death. Comorbid DM was found in the majority of cases suggesting it was a strong FG risk factor, but DM itself did not independently increase the odds of in-hospital death. Sepsis was a very common complication and the most frequent cause of death. These findings underscore the need for targeted management strategies and early recognition of high-risk features in FG patients, particularly those with underlying ESKD, to improve outcomes in this severe and complex condition.

Background: Acute kidney injury (AKI) frequently complicates acute heart failure (AHF), predicting worse outcomes. Early risk identification is crucial. The stress hyperglycemia ratio (SHR), reflecting acute dysglycemia, may predict AKI, but its utility in AHF remains unestablished.

Materials and methods: We analyzed 1,241 AHF patients stratified by SHR. Associations with outcomes were assessed using logistic and Cox regression. The relationship between continuous SHR and AKI development was evaluated with restricted cubic splines (RCS). The primary endpoint was incident AKI during hospitalization.

Results: AKI occurred in 79.7% of patients. After multivariable adjustment, SHR demonstrated a linear association with AKI risk. For 28-day mortality, the relationship with SHR was U-shaped, with an inflection point at 0.841. An SHR > 0.841 was associated with significantly increased mortality (OR = 2.086; 95% CI: 1.368 - 3.182). An elevated SHR was consistently associated with higher AKI risk across all patient subgroups, with an overall adjusted OR of 1.60 (95% CI: 1.15 - 2.22).

Conclusion: The study demonstrates a linear association between the SHR and AKI, in contrast to a U-shaped relationship with 28-day in-hospital mortality among AHF patients. An SHR of 0.841 represents a critical threshold for evaluating in-hospital mortality risk.

Background: Patients on maintenance hemodialysis (MHD) face a dramatically elevated risk of cardiovascular death, which is 10 - 20 times higher than in the general population. To address this high risk, we developed and validated a prediction model to accurately estimate cardiovascular disease (CVD) mortality and guide preemptive clinical management.

Materials and methods: This study retrospectively collected data from MHD patients at the First Affiliated Hospital of Chengdu Medical College from 2016 to 2021 (Approval No. CYFYEC-C-005), including demographic characteristics, medical history, biochemical indicators, and echocardiogram indices. Variables were screened using univariate logistic regression and stepwise regression to construct a nomogram model. The dataset was randomly divided (6 : 4) into training and validation sets, and a classification and regression tree (CART) decision tree model was also constructed. Both models' discrimination, calibration, and clinical utility were evaluated.

Results: The nomogram identified systolic blood pressure, uric acid, total cholesterol, diabetes, myoglobin, serum albumin, and procalcitonin as predictors, with an AUC of 0.947 (95% CI: 0.903 - 0.991) and good clinical applicability. The CART model identified serum albumin, procalcitonin, and myoglobin as predictors, categorizing the population into four groups. AUC values were 0.933 (95% CI: 0.851 - 1.000) in the training set and 0.774 (95% CI: 0.612 - 0.936) in the validation set.

Conclusion: In conclusion, this study consistently identified serum albumin, procalcitonin, and myoglobin as key factors associated with CVD mortality risk in MHD patients. Both models demonstrated promising predictive performance in our cohort. These findings suggest the potential of such models to inform clinical risk assessment. However, external validation in larger, multi-center studies is necessary before these tools can be considered for direct clinical decision-making.

Introduction: IgA nephropathy (IgAN) is a common glomerulonephritis with varied clinical presentations across regions, showing more aggressive progression in Asians. However, its exact prevalence and clinicopathological profile in India remain unclear.

Materials and methods: The study included all patients of all age groups with primary IgAN on kidney biopsy from March 2016 to December 2023. Clinical and pathological parameters were noted. The MEST-C scores were correlated with the serum creatinine level, proteinuria, and hematuria.

Results: Of a total of 3,811 native renal biopsies, 218 (5.72%) revealed IgAN, out of which 183 (4.8%) had more than 8 viable glomeruli, allowing MEST-C scoring to be done. The mean age was 32.84 ± 14.22 years, and the male-to-female ratio was 1.5 : 1. At presentation, 53.2% had hypertension, 90% had microscopic hematuria, and 5% had gross hematuria. The mean proteinuria was 3.87 ± 3.67 g/day, with 52% showing nephrotic-range proteinuria and 48% showing nephrotic syndrome manifestation. Oxford MEST-C scoring revealed M1 in 97.8%, E1 in 30.1%, S1 in 60.1%, T1 in 46.4%, T2 in 3.8%, and crescents in 27.8% of biopsies. The mean serum creatinine was significantly higher in cases with E1, S1, T1/2, and C1/2 scores (p < 0.05). Hematuria was significantly higher (p < 0.05) with E1 scores. On follow-up (mean 35 months), patients who presented early with only mesangial hypercellularity had good prognosis while those with endocapillary hypercellularity, crescents, tubular atrophy, and interstitial fibrosis at the time of biopsy had poor prognosis.

Conclusion: IgAN affects young individuals with diverse symptoms and rapid progression. In Western India, most patients present late, highlighting the need for early diagnosis and routine screening to improve outcomes.

Renal clear cell carcinoma (RCC), the predominant subtype of kidney cancer, is characterized by paraneoplastic syndromes, of which membranous nephropathy (MN) represents the most common paraneoplastic glomerulonephritis. While phospholipase A2 receptor (PLA2R) antibodies indicate primary MN, the concurrent presence of light-chain amyloidosis may further complicate the clinical manifestations in malignancy-associated cases. A rare case of RCC concurrent with phospholipase A2 receptor PLA2R-positive MN and light chain amyloidosis is reported in this paper. An elderly male patient presented with nephrotic syndrome and a right renal mass. The patient underwent a nephrectomy after admission. Pathological examination confirmed the diagnosis of right kidney renal clear cell carcinoma. Renal biopsy revealed PLA2R-positive MN and AL amyloidosis. Interestingly, in this case, glomerular light chain staining showed no monoclonal restriction, but λ light chain deposition was found in the vessels. However, the nephrotic syndrome showed no improvement after tumor resection. The patient achieved remission following sequential treatment with bortezomib, dexamethasone, daratumumab, and rituximab. This case illustrates the complex interplay among RCC, PLA2R-positive MN, and AL amyloidosis, complicating patient management. Future research should focus on the immunological mechanisms of PLA2R antibody production in malignancy and the pathophysiological links among these conditions. Clinicians should remain vigilant for secondary causes of nephrotic syndrome in renal malignancy patients and adopt comprehensive, multidisciplinary approaches to improve outcomes.

Objective: To identify factors linked to systemic inflammation and evaluate the predictive value of novel inflammatory biomarkers in peritoneal dialysis (PD) patients.

Materials and methods: We enrolled 111 maintenance PD patients, stratified by C-reactive protein (CRP) into a normal group (CRP < 3 mg/L) and an inflammation group (CRP ≥ 3 mg/L). We compared clinical characteristics, laboratory parameters, and novel inflammatory biomarkers. Analyses included group comparisons, Spearman correlations between CRP and clinical parameters, multiple linear regression relating novel biomarkers to CRP, and binary logistic regression with receiver operating characteristic (ROC) analysis for predictive value.

Results: The inflammation group had significantly lower urine volume, hemoglobin (HGB), prealbumin (pre-ALB), potassium (K), magnesium (Mg), and transferrin saturation (TSAT), but higher serum ferritin (SF) and white blood cell count (WBC) (p < 0.05). CRP positively correlated with age, neutrophils, monocytes, WBC, SF, glucose, glycated hemoglobin A1c (HbA1c), triglycerides, β2-microglobulin, and novel indices include systemic immune inflammation index (SII), platelet-lymphocyte ratio (PLR), platelet-albumin ratio (PAR), systemic inflammation response index (SIRI), albumin-prealbumin ratio (APR), and aggregate index of systemic inflammation (AISI) (p < 0.05). Negative correlations existed with HGB, pre-ALB, residual urea clearance index (Kt/V), residual creatinine clearance (CCr), residual glomerular filtration rate (GFR), and electrolytes (Na, Cl, Mg) (p < 0.05). Multiple linear regression identified AISI and APR as independent predictors of CRP levels. ROC analysis showed that the combination of AISI and APR had superior diagnostic utility for systemic inflammation compared to individual indices.

Conclusion: Systemic inflammation in PD patients is associated with impaired nutrition, anemia, and reduced residual renal function. AISI and APR strongly correlate with CRP, and their combination significantly enhances prediction of systemic inflammation, providing a valuable clinical tool for risk stratification.

Background: Simultaneous liver-kidney (SLK) transplant is the ideal therapeutic option for patients with chronic liver and kidney failure (CLKF), but the shortage of organs leaves many patients dialysis dependent. Hemodialysis is frequently utilized but is poorly tolerated due to exacerbation of preexisting intravascular instability. Peritoneal Dialysis (PD) may pose several advantages: providing hemodynamic stability, and ascites management.

Materials and methods: This was a retrospective observational study that included all patients with CLKF who initiated PD from July 2002 to December 2022 at the University of Texas Southwestern Medical Center/DaVita Dialysis Center. Medical charts were reviewed for demographics, clinical outcomes, laboratory values, and censoring events.

Results: 27 patients with CLKF initiated PD during this period. The mean MELD-3.0 score was 25. A total of 23 patients had clinical ascites requiring frequent large-volume paracentesis prior to PD initiation. Mean follow-up was 42.4 + 39 months. Peritonitis rates were 0.21 episodes per patient-year on PD. Six patients died with an annualized mortality of 63/1,000 patient-years. The hospitalization rate was 0.82 per patient-year. Six patients received an SLK transplant, and 1 received liver transplant followed by a kidney transplant. Six patients remained on the waiting list, and 2 were in the transplant work-up by the study end. Ten patients were deemed ineligible for SLK transplant. It is noteworthy that none of these patients required large-volume paracentesis after PD initiation.

Discussion: In this single-center study on PD patients with CLKF, we observed excellent outcomes, with mortality, hospitalizations, and peritonitis rates comparable to those of the general PD population. Furthermore, by providing continuous drainage of ascites, PD alleviated the need for large-volume paracentesis. In addition, PD did not affect the candidacy for SLK transplant. Hence, PD should be considered a viable dialysis modality in patients with CLKF.

We conducted a retrospective chart review of adult kidney transplant recipients (KTxR) with type 2 diabetes treated with a glucagon-like peptide-1 receptor agonist (GLP-1RA). A total of 211, 207, 161, and 92 KTxR were followed for 6, 12, 36, and 60 months, respectively. Over 5 years, we observed statistically significant reductions in the primary endpoints of weight, HbA1c, and major adverse cardiovascular events (MACE). The mean weight reduction was as follows: 1.17 kg at 6 months (p < 0.006), 1.2 kg at 12 months (p < 0.03), 3.7 kg at 36 months (p < 0.0001), and 4.1 kg at 60 months (p = 0.001) compared to baseline. The HbA1c levels showed reductions of 0.6 mmol/mol at 6 months (p < 0.0001), 0.5 mmol/mol at 12 months (p = 0.0004), 0.3 mmol/mol at 36 months (p = 0.04), and 0.35 mmol/mol at 60 months (p = 0.35). MACE rates fell from 45.5% at GLP-1RA initiation to 18.9% during follow-up (OR 3.6 (2.3 - 5.6), p < 0.0001). Insulin requirements decreased from 50 to 27 units over 5 years. Kidney function reduces over time in KTx, likely secondary to hemodynamic or vascular-mediated risk factors, chronic immunosuppressive agents, treatment for rejections, and solitary transplanted kidney. In our study, estimated glomerular filtration rate (eGFR) not only stayed stable but also showed a trend towards improvement (eGFR improved from 50 to 53 mL/min/1.73m²). Further prospective randomized trials are needed to assess GLP-1RA efficacy and safety in KTxR.