Clinical nephrology最新文献

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: Mood disorders are common among patients with end-stage renal disease (ESRD) undergoing dialysis, with anxiety and depressive disorders being the most prevalent. The association of anxiety symptoms with sociodemographic and dialysis-related factors is less well understood in dialysis patients. The level of anxiety experienced during individual peritoneal dialysis (PD) remains unclear. This study examined the frequency and severity of anxiety and the association of anxiety symptoms with selected demographic and dialysis-related variables in patients receiving peritoneal dialysis in Isfahan, Iran.

Materials and methods: A cross-sectional study was conducted on 85 PD patients referred to Al-Zahra and Khorshid centers between October 2022 and April 2023, who had been undergoing PD for at least 3 months. Patients completed the Beck Anxiety Inventory questionnaire, which assessed the presence and severity of anxiety symptoms.

Results: The overall mean anxiety score was 10.65 ± 10.04. Minimal anxiety was reported by 50.6% of participants, 25.9% experienced mild anxiety, 14.1% had moderate anxiety, and 9.4% reported severe anxiety. No significant associations were found between anxiety and demographic or PD-related factors (p > 0.05).

Conclusion: According to this study, 50.6% of our participants reported minimal anxiety, and 49.4% had mild to severe anxiety. Early diagnosis and management of mood disorders in ESRD patients are crucial to improve their quality of life and prevent adverse outcomes. These findings underscore the need to plan and implement screening programs for mood disorders among high-risk chronic kidney disease patients to ensure timely and appropriate management.

Backgrounds: The present study aimed to explore the causal association between body composition indexes and primary membranous nephropathy (PMN) from a genetic perspective.

Materials and methods: A bidirectional two-sample Mendelian randomization (MR) analysis was conducted in the present study. Genetic data were obtained from published genome-wide association studies on PMN (n = 7,979) and body composition indexes, including weight (n = 797,859), body mass index (n = 461,460), body fat percentage (n = 454,633), waist circumference (n = 568,740), hip circumference (n = 336,601), and basal metabolic rate (n = 454,874) in European populations. The inverse variance weighted (IVW) random-effects MR method was performed as the main analysis, with MR-Egger and weighted median methods used as supplemental methods. Several sensitivity analyses were used to examine the reliability of the findings.

Results: The MR analysis results showed that weight (MRC-IEU: odds ratio (OR) = 1.578, 95% confidence interval (CI) = 1.047 - 2.379, and IVW p = 0.029; Neale Lab: OR = 1.745, 95% CI = 1.204 - 2.529, and IVW p = 0.003), body fat percentage (OR = 2.487, 95% CI = 1.349 - 4.583, and IVW p = 0.003), waist circumference (Neale Lab: OR = 1.700, 95% CI = 1.042 - 2.774, and IVW p = 0.034; GIANT: OR = 1.915, 95% CI = 1.030 - 3.559, and IVW p = 0.040), and hip circumference (OR = 1.410, 95% CI = 1.021 - 1.948, and IVW p = 0.037) were causally related to an increased risk of PMN. Sensitivity analysis verified and indicated the robustness of these results. Reverse MR analysis indicated no causal relationship between PMN and the body composition indexes.

Conclusion: The present study demonstrated causal relationships between body composition indexes and PMN, suggesting the potential value of these factors in helping to understand PMN and develop intervention strategies.

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.

The landmark ADVOCATE trial, which lead to the approval of Avacopan (AVP) as adjunctive treatment of ANCA-associated vasculitis (AAV), treated patients with AVP for 52 weeks. In the real-world, some patients are prescribed AVP for a longer duration. In this study, we performed a multi-center retrospective cohort study of 15 adult patients with new and relapsing AAV treated with AVP for a duration of 52 weeks or longer. During a mean follow-up period of 96 (21) weeks, 1/15 patients experienced AAV flare, and none progressed to end-stage kidney disease. On last follow-up, the mean estimated glomerular filtration rate (eGFR) rise from baseline was 16 mL/min/1.73m². Infections were the most reported adverse effects including 5 infections requiring hospitalization. No abnormal liver function tests were reported during these prolonged courses of AVP beyond 52 weeks. AVP therapy for AAV showed excellent remission rates with marked improvement of the eGFR at 26- and 52-weeks follow-up. By prolonging the treatment with AVP beyond 52 weeks, the improvement in eGFR was sustained during the additional AVP treatment period. Infection complications were the most observed adverse effects. Further data on the longer-term use of AVP is needed.