Clinical nephrology最新文献

Introduction: The prevalence of hypertension in lupus nephritis varies according to studies and can be as high as 74%. The aim of this study was to determine the prevalence of hypertension in lupus nephritis and to search for factors associated with hypertension and the occurrence of major adverse cardiovascular events (MACE).

Materials and methods: This was a multicenter, retrospective, descriptive, and analytical study over a 10-year period from January 1, 2012, to December 31, 2022. It targeted patients followed for lupus nephritis confirmed by anatomo-pathological examination in three nephrology departments in Dakar. We compared hypertensive and non-hypertensive patients to identify hypertension-associated factors.

Results: During the study period, 73 cases of lupus nephritis were collected. In the study population, the mean age was 33.90 years, with a sex ratio of 0.30. The prevalence of hypertension was 40.1%. 23 patients were class III, 25 class IV, and 19 class V. Among hypertensive patients, mean creatinine was 33.7 mg/L, and renal failure was present in 56.66% of patients. Mean proteinuria was 5.42 g/24h. Hypertension-associated factors were age (OR = 1.15, 95% CI: 1.05 - 2.25; p = 0.001), renal failure (OR = 12.872, 95% CI: 2.23 - 74.28; p = 0.004), and proliferative class (OR = 18.83, 95% CI: 1.91 - 185.25; p = 0.012). For the cardiovascular events, there were 3 cases of stroke, 0 cases of heart attack, and 0 cardiovascular deaths.

Conclusion: Hypertension in lupus nephritis is common in our setting. Hypertension-associated factors were related to advanced age and severity of lupus nephritis. Long-term follow-up would be necessary to better detect cardiovascular events.

Background: Roxadustat is used for treating chronic kidney disease (CKD) patients, particularly those on hemodialysis with comorbid cancer. Some studies suggest a link between roxadustat and cancer progression, but the mechanisms remain unclear, highlighting the need for further investigation into potential causal links.

Materials and methods: We employed a two-sample Mendelian randomization (MR) analysis to explore associations between genetic variations in Roxadustat targets and 14 cancer types. Single-nucleotide polymorphisms (SNPs) in the Egl-9 family hypoxia inducible factor 1 (EGLN1) and Egl-9 family hypoxia inducible factor 2 EGLN2 genes, related to hemoglobin levels, were chosen as instrumental variables. Analyses used inverse variance-weighted (IVW)-MR and summary data-based MR (SMR) approaches, assessing horizontal pleiotropy with Mendelian randomization Egger (MR-Egger) and Mendelian Randomization Pleiotropy RESidual Sum and Outlier (MR-PRESSO), and using the heterogeneity in dependent instrumental variables (HEIDI) test for SMR.

Results: Summary statistics were derived from three UK studies involving 172,925 individuals. IVW-MR revealed a positive association between EGLN1 variants and breast cancer (OR = 1.644) and lung adenocarcinoma (OR = 2.117), while negative associations were found for malignant non-melanoma skin cancer and kidney cancer. SMR confirmed the links to breast cancer and a decrease in skin cancer risk. EGLN2 expression was positively associated with prostate and lung cancers and negatively with estrogen receptor (ER)- breast and brain cancers.

Conclusion: Our findings support a potential causal relationship between the inhibition of EGLN1 and EGLN2 and the development of specific cancer types.

This review analyzes the pivotal but underrecognized contribution of Thomas Willis (1621 - 1675) to the foundations of kidney function in the 17^th century. By comparing his early work De Urinis (1659), which interpreted urinary diagnosis through humoral traditions, with his subsequent Pharmaceutice Rationalis (1674 - 1675) we document a paradigm shift: progress from considering the kidney a passive filter to proposing it as an active regulatory organ that balanced urinary salts through tubular function. Building on the cardiac pump and blood circulation model of William Harvey and the tubular structure of the kidney of Lorenzo Bellini, Willis rejected the Galenic physiology that the kidney attracted blood because it was in its nature to do so in favor of a mechanical model of "straining or percolation" driven by the force of circulating blood. Willis also considered diabetes a blood disorder rather than a kidney disease, noting that diabetic urine differed from imbibed fluids being sweet "as it were imbued with Honey or Sugar". These conceptual advances - developed without microscopic evidence or chemical analysis - reveal a remarkable inductive reasoning. Documented by subsequent observations, Willis' work established three critical principles: the blood-clearing function of the kidney depends on circulatory dynamics, tubules modify urine composition, and urinary changes reflect systemic physiology rather than just renal pathology. His renal model, though incomplete, provided the first systematic framework for homeostasis that would be developed in the 19^th century. His writings clearly mark the initial but fundamental first steps in the evolution of our current understanding of kidney function.

Background: Immune checkpoint inhibitors (ICIs) have revolutionized cancer treatment and have become an essential part of therapy, but their use is associated with immune-related adverse events (irAE). Specifically, nephrotoxicity is well documented in adult populations but data regarding irAEs are limited in pediatric populations. This review examines the renal manifestations of ICIs and relevant clinical measures and treatments.

Materials and methods: A comprehensive review of existing literature was conducted to assess the incidence, pathophysiology, and management of ICI-associated renal injuries in pediatric and adult populations.

Results: The most common renal irAE associated with ICIs is acute kidney injury; however, ICIs have been implicated in transplant rejection and electrolyte disturbances including hyponatremia, hyperkalemia, hypophosphatemia, and metabolic acidosis. Pediatric ICI manifestation patterns are similar to those in adults, but research suggests earlier onset compared to adults. Though corticosteroids are the primary treatment for irAEs, standardized pediatric management guidelines require further improvement.

Conclusion: ICIs carry concerning risks in pediatric populations, yet research in this area is lacking. This warrants further research into the recognition, treatment, and prevention of renal irAEs, particularly for the improvement of long-term outcomes.

Background: In the United States (U.S.), economically disadvantaged populations have reduced access to subspecialty care. To improve accessibility to nephrology care early in the clinical course of chronic kidney disease (CKD), we designed a feasibility pilot study for electronic consults (eCons).

Materials and methods: This retrospective cohort study evaluated eCons referral patterns, patient demographics, comorbidities, and rates of in-person visits following eCons. Our suggested referral criteria included CKD stages 1 - 3a with a urine albumin-creatinine ratio (UACR) < 300 mg/g, resistant hypertension, abnormal kidney imaging or urine sediment, electrolyte abnormalities, and nephrolithiasis.

Results: A total of 103 patients completed eCons over a 12-month period. 98% self-identified as African Americans, and 2% as Caucasians. The rates of subsequent in-person visits for patients with CKD stages 2, 3a, 3b, 4, and 5 were 5/9 (56%), 8/28 (29%), 34/38 (90%), 11/14 (79%), and 9/9 (100%), respectively. Among the 103 patients, 40 (39%) had macroalbuminuria (UACR > 300 mg/g), and 51 (50%) had diabetes mellitus. The rates of subsequent in-person visits for patients with macroalbuminuria and diabetes mellitus were 87.5% and 76%, respectively. Patients with macroalbuminuria had greater odds of subsequent in-person visits than did those without macroalbuminuria, adjusted for age and sex (AOR, 6.15; 95% confidence interval (CI), 2.08 - 18.16; p = 0.001). Patients with diabetes mellitus were also more likely to have subsequent in-person visits than were those without diabetes mellitus (OR, 2.38; 95% CI, 1.02 - 5.57; p = 0.04).

Conclusion: Electronic consultations are beneficial in the early CKD stages and in patients without diabetes or macroalbuminuria. In addition, both macroalbuminuria and diabetes influence the need for subsequent in-person evaluation.

Background: Double-positive patients exhibit both anti-glomerular basement membrane antibody and anti-neutrophil cytoplasmic antibody. Its initial treatment includes induction cyclophosphamide, glucocorticoids, and plasmapheresis, followed by maintenance therapy similar to that for anti-neutrophil cytoplasmic antibody-associated vasculitis. However, some patients suffer from refractoriness and intolerance to cyclophosphamide, creating an unmet need for second-line therapy. Moreover, no guidance has been provided on the choice of immunosuppressant agents for maintenance therapy.

Case presentation: A 55-year-old Asian woman presented with post-prandial vomiting and a persistent high fever for 1 month. She was diagnosed as a double-positive patient after developing rapidly progressive glomerulonephritis, with a creatinine level of 332 μmol/L. She received induction therapy with cyclophosphamide, glucocorticoids, and plasmapheresis soon after diagnosis. However, worsening renal function and severe nausea and vomiting occurred after 3 monthly doses of cyclophosphamide. Four weekly doses of re-induction rituximab at 375 mg/m², followed by maintenance rituximab 500 mg every 6 months, were administered. The patient had a stable creatinine level of 208 μmol/L 17 months after diagnosis.

Conclusion: Rituximab may be a viable alternative as an induction therapy for double-positive patients when first-line cyclophosphamide is not effective or is not tolerated. Moreover, rituximab may be an effective maintenance therapy for double-positive patients. This case study demonstrates not only the efficacy of rituximab in double-positive patients but also reports the first Asian case of the disorder treated successfully with rituximab.

Background: Studies have suggested that colorectal cancer (CRC) and membranous nephropathy (MN) could be associated with each other. However, the existing conventional research methods fail to establish a conclusive relationship between the two conditions.

Materials and methods: The genome-wide association data for CRC and MN were obtained from previously published genome-wide association studies (GWAS). Inverse variance weighted (IVW), weighted median, weighted mode, and Mendelian randomization (MR)-Egger regression, were employed to analyze the data. Sensitivity analyses were conducted using the heterogeneity test, pleiotropic test, and leave-one-out test. Additionally, a reverse MR analysis was conducted to evaluate any potential reverse causal effects.

Results: The IVW analysis provided strong evidence supporting a causal link between CRC and MN (odds ratio (OR), 1.485; 95% confidence interval (CI), 1.131 - 1.951, p = 0.004). Similar findings were obtained from the weighted median analysis (OR, 1.515; 95% CI, 1.120 - 2.051, p = 0.007) and the weighted mode (OR, 1.572; 95% CI, 0.996 - 2.480, p = 0.084). The MR-Egger regression results indicated that the presence of horizontal pleiotropy was unlikely to bias the findings (intercept, -0.047; p = 0.611). MR-Egger regression did not show any causal association between CRC and MN (OR, 2.075; 95% CI, 0.584 - 7.373, p = 0.292). Reverse MR analysis suggested that MN is not a causative factor for CRC. Cochran's Q test, the funnel plot, and leave-one-out sensitivity analysis demonstrated the robustness of the MR study.

Conclusion: Based on the genetic evidence obtained from this MR study, it can be concluded that CRC may serve as a risk factor for the development of MN. These findings will facilitate a future understanding of the mechanisms underlying MN.

Oxalate nephropathy refers to the deposition of calcium oxalate crystals within the renal parenchyma. The subsequent tubular-interstitial inflammation results in acute kidney injury and/or chronic kidney disease. This condition occurs in the setting of hyperoxaluria or increased urinary excretion of oxalate. Enteric hyperoxaluria is an increasingly recognized cause of secondary hyperoxaluria in which fat malabsorption promotes increased absorption of dietary oxalate. In the context of increasing utilization of bariatric procedures to address obesity, those who have undergone biliopancreatic diversions represent a growing subset of patients who later develop oxalate nephropathy. Presently, management options for affected individuals are limited to dietary interventions, and renal outcomes are poor. We present a case of stage III acute kidney injury from oxalate nephropathy in a bariatric patient who demonstrated renal recovery after decreasing serum oxalate levels through an early, intensive dialysis regimen.

Introduction: Chronic kidney disease (CKD) and end-stage kidney disease (ESKD) are critical public health issues in South Korea, with an increasing number of dialysis patients. Cardiovascular outcomes, significantly affected by dyslipidemia, remain the leading cause of morbidity and mortality. This study explores the age and sex-specific impacts of dyslipidemia treatment on mortality in elderly hemodialysis patients.

Materials and methods: We conducted a retrospective cohort study with 2,736 newly diagnosed hemodialysis patients aged 70 years and older from 16 Korean hospitals (January 2010 to December 2017). The impact of statin therapy on mortality was assessed considering baseline characteristics, comorbidities, and lipid profiles. Statistical analyses included Kaplan-Meier survival curves and Cox proportional hazards models with covariate adjustments.

Results: Statin use significantly reduced all-cause mortality in both men and women (hazard ratio (HR), 0.76 (0.66 - 0.87) in men; HR, 0.85 (0.73 - 0.99) in women). This benefit was not statistically significant in patients aged 80 and above, especially among females. An inverse relationship between low-density lipoprotein (LDL) levels, and mortality was observed in men, while a U-shaped relationship was noted in females. The unfavorable effects associated with lower LDL levels were more pronounced in the female group.

Conclusion: Dyslipidemia treatment improves survival in elderly hemodialysis patients, particularly in males, though benefits diminish in those aged 80 and above. Effective patient outcomes require addressing malnutrition and inflammation alongside lipid levels. Further research is necessary to refine treatment guidelines for this demographic.