Clinical nephrology最新文献

Objective: This study explored factors and models to predict post-dialysis volume overload status in maintenance hemodialysis patients (MHD) based on pre-dialysis parameters using machine learning.

Materials and methods: Pre-dialysis clinical data, pre- and post-dialysis bioimpedance spectroscopy, and the ultrasound (US) assessment for the lung were involved. Intergroup comparisons, regression analysis, and the least absolute shrinkage and selection operator (LASSO) regularization algorithm were conducted to screen potential predictive factors. Seven machine learning algorithms (Random Forest, Naïve Bayes, Support Vector Machine, K-Nearest Neighbors, Decision Tree, Gradient Boosting, and Neural Networks) were applied to construct prediction models.

Results: This study included 120 MHD patients. The prevalence of post-dialysis volume overload status in participants was 31.67%. Regression analysis showed that age (p = 0.007), prescribed ultrafiltration volume (UFV)/weight ratio (p < 0.001), overhydration (OH) (p < 0.001), and pre-dialysis US B-lines (p = 0.015) were associated with post-dialysis volume overload status. After the LASSO regularization algorithm, prescribed UFV/weight ratio, OH, and pre-dialysis US-B lines were selected as the potential prediction factors for constructing prediction models. The best-performing model was the Random Forest with an area under the curve (AUC) of 0.96, accuracy of 91.67%, precision of 92.56%, recall of 91.67%, and F1 of 0.91.

Conclusion: Pre-dialysis parameters, including prescribed UFV/weight ratio, OH, and dialysis US-B lines, were predictive factors for post-dialysis volume overload status. The Random Forest model based on these parameters could predict the post-dialysis volume overload status with relative accuracy and may provide a helpful guide to optimal prescribed UFV.

Background: It is recognized that topiramate use may affect risk of stone disease, but large population-based and weighted evaluations are absent. Furthermore, the suspected increased odds of stone disease have remained unquantified. We leveraged the nationally representative National Health and Nutrition Examination Survey (NHANES) to perform a population-based assessment of the association of current topiramate use on occurrence of stones presenting within the year immediately preceding survey participation.

Materials and methods: We utilized the 2017 - 2020 (Pre-COVID-19) NHANES data to assess association between current topiramate use and incidence of kidney stones. Weights and strata provided by NHANES were employed, and analyses were performed using survey package for STATA v14.

Results: 843 participants met analysis criteria, weighted to represent a nationally representative population of 23,064,066 noninstitutionalized U.S. adults. Logistic regression was used to analyze the relationship between the incidence of kidney stone passage in the last 12 months and current topiramate use. It was found that current topiramate use was associated with a statistically significant 810% increase in the odds of stone passage in the last 12 months (OR: 8.1, 95% CI (1.04 - 63.06), p = 0.046). None of the investigated demographic or pharmaceutical covariates (age, diabetes status, body mass index, or concomitant use of diuretics, proton pump inhibitors, or H2-blockers) demonstrated statistically significant association with topiramate use and thus were not included as covariates.

Conclusion: Our results demonstrate that odds of a stone within the last 12 months is increased significantly with topiramate use. Additionally, we provide the initial quantification of the strength of this association, with an estimated 8-fold increase in odds of stone formation. These findings can allow improved risk counseling for patients considering topiramate use for providers.

Volume overload is a frequent complication in critically ill patients. Ultrafiltration (UF) uses a semipermeable membrane for removal of plasma water driven by a transmembrane pressure gradient. Employed outside dialysis, it is referred to as aquapheresis (AQ). This study is a retrospective review of our experience with AQ beyond management for congestive heart failure (CHF). The use of AQ was at the discretion of the nephrologist overseeing the case. The study population was categorized according to hospital unit and specific indications for AQ therapy. A total of 69 patients underwent AQ in various critical units: 23 in the cardiothoracic intensive care unit (ICU); 21 in both the cardiac ICU and medical ICU, and 4 patients in the surgical ICU. All patients had a component of kidney dysfunction and volume overload, ranging from non-oliguric acute kidney injury to end-stage renal disease (ESRD). The average UF volume was 6.4 L per patient, with an UF rate of 82 mL/h. The mean AQ duration was 78 hours per patient. 64% (n = 44), were receiving vasopressor support during AQ. Volume optimization remains a fundamental component of management in critically ill patients. AQ can be employed as an additional resource to accelerate fluid removal in a myriad of clinical settings. This analysis underscores the versatility of AQ as an effective treatment for managing fluid overload across diverse patient populations.

Objectives: The aim of this study was to determine the differential dose response of parathyroid hormone (PTH) and fibroblast growth factor (FGF23) to paricalcitol in patients with secondary hyperparathyroidism and end-stage renal failure on chronic intermittent hemodialysis.

Materials and methods: The multicenter, randomized, double-blind, prospective, crossover study comprised a total of 43 hemodialysis patients (average age 64 years, female 30%) with 31 complete patient data sets, and with PTH levels between 200 and 600 pg/mL, serum calcium < 2.55 mmol/L, phosphorus ≤ 2.1 mmol/L, and 25 OH-vitamin D > 20 ng/mL as inclusion criteria (Eudract 2007-006606-16).

Results: Mean intact PTH at baseline was 319 pg/mL (standard deviation (SD) 141, normal 11.3 - 42.4 pg/mL; ECLIA; Roche, Basel, Switzerland) and FGF23 651.25 RU/mL (SD 1,099.98; normal 21 - 424 RU/mL; c-terminal, 2^nd generation ELISA kit, Immutopics, San Clemente, CA, USA) at baseline. The initial oral dose of paricalcitol was 2 μg/day, adjusted to a mean dosage of 1.9 μg/day at week 6 and 1.5 μg/day at week 12, guided by PTH response. PTH levels remained significantly suppressed at both 6 (189 pg/mL; SD 95) and 12 weeks (164 pg/mL; SD 95), both p < 0.001 as compared to baseline. FGF23 levels showed a significant increase at 6 weeks (1,442.1 RU/mL, SD 1,860.2; p = 0.002) but returned at 12 weeks to levels not significantly different from baseline (1,150.7 RU/mL, SD 1,509.3; p = 0.24).

Conclusion: Treatment with paricalcitol resulted in a significant reduction in PTH levels at both 6 and 12 weeks compared to placebo. The suppression of PTH levels with paricalcitol was possible without elevating FGF23 within the restrictions of this short duration study, at least if over-suppression of PTH is avoided by dose adaption. Our findings suggest a cautious lower oral paricalcitol starting dose to mitigate the initial spike in FGF23 while effectively managing PTH levels.

Objective: This is a single-center retrospective cohort study on the demographics and clinical outcomes including the response to therapy of patients with primary membranous nephropathy (PMN) over the past decade. With the spread of diverse therapeutic agents available today, this study seeks to present an interesting array of varied responses.

Materials and methods: All histology-proven PMN cases diagnosed between 2008 and 2018 were analyzed for their clinical, laboratory, and histological characteristics including treatment that could influence disease progression and renal outcome.

Results: There were two sub-groups of patients, those with nephrotic syndrome and those without nephrotic syndrome. All secondary causes of secondary membranous nephropathy were excluded. The response to therapy including RAS blockers, steroids, and immunosuppressants all showed a consistent reduction of proteinuria with therapy for the whole cohort, nephrotic as well as non-nephrotic syndrome with only 10% of the 102 patients in end-stage renal disease (ESRD) at 10 years.

Conclusion: Our data show that membranous nephropathy is a disease responsive to most forms of therapy with decreasing proteinuria. The progression of the disease is slow with a gradual decline to ESRD.

Objective: Renal survival is crucial in patients with idiopathic membranous nephropathy (IMN). Our aim was to identify baseline clinical and histopathological predictors of long-term renal survival in patients with IMN.

Materials and methods: In this retrospective, single-center cohort study, we reviewed 50 adults with biopsy-proven IMN (January 2009 - February 2019) who completed at least 60 months of follow-up. We recorded baseline age, sex, serum creatinine, serum albumin, 24-hour proteinuria, and the total renal chronicity score (Mayo Clinic Chronicity Score). Chronicity was classified as minimal (score 0 - 1) or non-minimal (score ≥ 2). The renal endpoint was defined as a ≥ two-fold increase in serum creatinine from baseline or the initiation of renal replacement therapy (RRT). Predictors of renal survival were assessed using univariate and multivariate Cox regression; renal survival probability was illustrated with Kaplan-Meier analysis.

Results: During the 5-year follow-up, 20 out of 50 patients (40%) reached the renal endpoint. Kaplan-Meier curves demonstrated a significant divergence: only 1 out of 30 patients (3.3%) in the minimal-chronicity group progressed, while 19 out of 20 patients (95%) with non-minimal chronicity experienced either a doubling of creatinine or required RRT (log-rank p < 0.001). In univariate analysis, older age, higher serum creatinine, lower serum albumin, albumin levels below 3 g/dL, and non-minimal chronicity were associated with poor outcomes. Multivariate Cox regression confirmed three independent predictors: baseline serum creatinine (HR 2.38, 95% CI 1.37 - 4.11, p = 0.02), serum albumin (HR 0.43, 95% CI 0.23 - 0.80, p = 0.008), and non-minimal chronicity score (HR 14.4, 95% CI 3.2 - 64.6, p < 0.001).

Conclusion: In IMN, a high total renal chronicity score on biopsy, elevated baseline serum creatinine, and hypoalbuminemia (< 3 g/dL) independently predict poor 5-year renal survival. Early recognition of non-minimal chronicity may facilitate timely therapeutic intervention and closer monitoring to mitigate progression to end-stage kidney disease.

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.