Clinical nephrology最新文献

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.

Aims: No English-language research papers have reported on the clinical use of upacicalcet, a novel intravenous calcimimetic agent for the treatment of secondary hyperparathyroidism (SHPT) in hemodialysis patients. Therefore, this study aimed to investigate the outcomes of switching from etelcalcetide to upacicalcet.

Materials and methods: The subjects included 37 hemodialysis patients with SHPT treated with etelcalcetide before switching to upacicalcet. This study was a single-center retrospective study conducted in Japan. Serum levels of corrected calcium (Ca), phosphorus (P), intact parathyroid hormone (iPTH), and the dose of maxacalcitol were assessed at 3 and 6 months after switching to upacicalcet.

Results: As a result of the switch from etelcalcetide to upacicalcet, the serum corrected Ca level remained unchanged, from 8.9 ± 0.6 to 9.1 ± 0.7 mg/dL (p = 0.104) at 3 months and to 9.0 ± 0.6 mg/dL (p = 0.197) at 6 months. Meanwhile, the serum P level decreased from 6.3 ± 1.5 to 5.8 ± 1.5 mg/dL (p = 0.069) at 3 months and to 5.9 ± 1.9 mg/dL (p = 0.039) at 6 months. The iPTH level increased slightly, from 153.8 ± 100.3 pg/mL to 176.4 ± 124.6 pg/mL (p = 0.337) at 3 months and to 206.5 ± 168.7 pg/mL (p = 0.017) at 6 months. Multiple regression analysis revealed that the change in iPTH was related to the change in P levels.

Conclusion: These findings suggested that upacicalcet may be a useful option for managing serum P levels in hemodialysis patients with SHPT.

Background: BK virus nephropathy (BKVN) in native kidneys following lung transplantation is an exceptionally rare occurrence. This case report highlights a unique instance where BKVN developed in a patient's native kidney post lung transplantation, emphasizing its rarity and the importance of considering BKVN in differential diagnoses for patients presenting with acute kidney injury (AKI) after such transplants.

Case presentation: A 67-year-old male patient who had undergone bilateral lung transplantation 3 years prior presented with worsening creatinine levels following an angiogram. The patient's history included no exposure to toxic medications or other known triggers for kidney disease. The worsening renal function was initially investigated through an angiogram, which was followed by the onset of hematuria and a progressive rise in creatinine levels. To determine the cause of the AKI, a kidney biopsy was performed. The biopsy of the left kidney revealed polyoma nephropathy. Confirmatory tests, including positive staining for simian virus 40 (SV40), confirmed the diagnosis of BKVN in the patient's native kidney.

Conclusion: The occurrence of BKVN in the native kidney following lung transplantation is a rare phenomenon. This case underscores the necessity of considering BKVN in the differential diagnosis of AKI in patients with a history of lung transplantation. Early recognition and diagnosis are crucial for appropriate management and potential modification of immunosuppressive therapy to prevent further kidney damage.

Background: This systematic review evaluates existing risk prediction models for intradialytic hypotension (IDH) in maintenance hemodialysis (MHD) patients, aiming to inform the development of high-quality predictive tools for clinical use.

Materials and methods: Retrieve studies on the construction of predictive models for IDH risk in patients undergoing maintenance hemodialysis in CNKI and other databases. The search time frame is from the establishment of the databases to November 13, 2024. Two researchers independently screened the literature and extracted data according to the Predictive Model Study Data Extraction Form and bias risk assessment tools. The bias risk and applicability of the included literature were evaluated.

Results: A total of 21 studies were included, with 16 undergoing internal validation, and 8 reporting calibration. IDH incidence ranged from 7.3 to 51.0%. The overall applicability of the studies included in the research is good, but the overall risk of bias is high, mainly due to unreasonable sample size, lack of performance evaluation, and single-center studies.

Conclusion: The research on predictive models for IDH risk in patients undergoing maintenance hemodialysis is still in its early stages. The included studies exhibit an overall high risk of bias, and there is a lack of clinical application. In the future, it may be beneficial to utilize interpretable machine learning methods to construct predictive models with good performance and simplicity, aiming for practical clinical applications.

Objective: A growing body of research has shown a connection between chronic pain and chronic kidney disease (CKD). However, it is unclear if these correlations point to a cause-and-effect link. Our goal is to investigate the causal link between renal function or CKD and chronic pain.

Materials and methods: Using genome-wide association study (GWAS) datasets on these traits, we performed bidirectional two-sample Mendelian randomization (MR) analyses in this work to evaluate genetic linkages and possible causal links between chronic pain and CKD or renal function. The CKD Genetics Consortium provided the GWAS data for CKD symptoms, estimated creatinine-based glomerular filtration rate (eGFRcrea) and cystatin C-based GFR (eGFRcys). A sizable biomedical database of GWAS provided summary statistics for both chronic widespread musculoskeletal pain (CWP) and multisite chronic pain (MCP).

Results: MR analysis revealed that MCP was significantly associated with an increased risk of CKD (OR = 1.52; 95% CI: 0.97 - 2.40; p = 0.037) and eGFRcys decline (OR = 0.97; 95% CI: 0.95 - 0.99; p = 0.014). The reliability of the MR analysis was demonstrated by sensitivity analysis. However, MR analysis did not find a significant association between CWP and CKD or renal function decline. Additionally, this study did not discover a link between renal function decline or CKD and chronic pain.

Conclusion: Our research revealed a substantial correlation between MCP and a higher risk of CKD and renal function deterioration.

Objective: Chronic kidney disease (CKD) is prevalent among Veterans and is strongly associated with cardiovascular disease (CVD) and mortality. Fruit and vegetable intake may help manage CKD and CVD. However, the relationships of dietary intake of kidney-impacting nutrients from plant-based foods with vascular function, oxidation, and inflammation in CKD is uncertain.

Materials and methods: We conducted a post-hoc analysis of the Phosphate Lowering in CKD Trial evaluating the association of unprocessed, plant-based energy and nutrient intake with pulse wave velocity (PWV), flow meditated dilation (FMD), and markers of oxidative stress and inflammation. Participants had stage 3b - 4 CKD and serum phosphorus of 2.8 - 5.5 mg/dL. Linear regression models were adjusted for age, sex, body mass index, blood pressure, diabetes, CVD, and kidney function.

Results: Participants (n = 42) were aged 66 ± 7 years with estimated glomerular filtration rate 36.2 ± 10.1 mL/min/1.73m²; 88% were male. Diets comprised large proportions of animal and processed foods. Higher daily intake of unprocessed plant-based energy, potassium, phosphorus, and protein were each significantly associated with lower PWV in fully adjusted models: -1.11 cm/s (95% CI: -1.98, -0.25 cm/s), -0.49 cm/s (95% CI: -0.86, -0.12 cm/s), -312.4 cm/s (95% CI: -514.5, -110.3 cm/s), and -280.3 cm/s (95% CI: -484.4, -76.2 cm/s), respectively. However, unprocessed, plant-based nutrient intakes were not associated with FMD or markers of oxidation or inflammation.

Conclusion: Despite overall low diet quality, higher consumption of unprocessed, plant-based energy and nutrients was associated with lower arterial stiffness. Future studies are needed to explore these associations in larger cohorts with CKD and the effects of diet quality interventions.

Aims: Longitudinal trajectory analysis can provide important insights into the optimal levels of metabolic factors in chronic kidney disease (CKD). This study evaluated the association between longitudinal trajectories of metabolic disturbances and prognosis in CKD.

Materials and methods: We used data from the National Health Insurance Service-National Health Screening Cohort, which comprises data from 514,866 subjects randomly selected from the 2002 and 2003 health screening participants, who were aged between 40 and 79 years. Subjects were classified into trajectory groups using K-means clustering - an algorithm that assigns individual data points to groups according to similarity of the data - based on metabolic parameters, including blood pressure (BP), total cholesterol, triglycerides, low-density lipoprotein cholesterol (LDL-C), and body mass index (BMI). Subjects were classified into groups with similar trajectories based on the central value with the minimum distance. The optimal number of clusters was selected using the Calinski-Harabasz index. Outcomes were a decline in renal function and all-cause mortality.

Results: A total of 24,094 CKD patients were included in the trajectory analysis. After clustering, BP, triglycerides, and LDL-C were divided into low and high categories, while BMI was classified into 6 categories according to the distribution of participants. Logistic regression analysis showed that a high systolic BP trajectory and underweight trajectory were associated with all-cause mortality, while high systolic BP, low diastolic BP, and high triglyceride trajectories were associated with a decline in renal function.

Conclusion: This study demonstrated the association between longitudinal trajectories of metabolic disturbances and the prognosis of CKD. Using trajectories of metabolic parameters could be helpful for predicting renal outcomes and mortality in CKD.

Aims: To evaluate if the association between anemia and mortality is affected by blood glucose levels in hemodialysis patients.

Materials and methods: A total of 818 consecutive patients who started hemodialysis between January 2013 and December 2016 were included in this study, followed until December 2022. Patients were categorized into five HbA1c groups (< 5%, 5 - 5.9%, 6 - 6.9%, 7 - 7.9%, and ≥ 8%) and six hemoglobin (Hb) groups (< 9, 9 - 10, 10 - 11, 11 - 12, 12 - 13, and > 13 g/dL). Kaplan-Meier survival analysis and multivariate Cox regression were performed to evaluate the association between Hb levels and all-cause mortality, adjusting for confounders.

Results: There were 310 (37.9%) deaths during a maximum follow-up of 120 months. Lower Hb levels were significantly associated with increased mortality risk (p for trend < 0.01). However, subgroup analysis revealed a significant interaction between Hb and HbA1c levels (p for interaction < 0.01). In patients with HbA1c < 5% and 5 - 5.9%, lower Hb levels (< 11 g/dL) were associated with a higher risk of mortality (p for trend < 0.05). In contrast, in patients with HbA1c ≥ 6%, Hb levels were not significantly associated with mortality risk (p for trend > 0.05).

Conclusion: The association between anemia and mortality in hemodialysis patients varies across HbA1c levels. Lower Hb levels were associated with increased mortality risk in patients with HbA1c < 6%, whereas this association was not observed in those with HbA1c ≥ 6%.

Objective: To evaluate the efficacy and safety of fluoroscopic-guided repositioning of peritoneal dialysis (PD) catheter using guidewire manipulation in our center in Hong Kong.

Materials and methods: All patients underwent fluoroscopic-guided PD catheter repositioning in our institution between November 1, 2017 to December 31, 2022 were reviewed. Patients fulfilling the selection criteria were identified, with their clinical notes, relevant radiological reports, interventional images, and operative records retrospectively reviewed. The success rate was evaluated, with the technical success defined as improved free contrast flow or return of continuous steady stream after test injection of normal saline immediately after repositioning; clinical success defined as functional peritoneal dialysis catheter at 30 days post-repositioning. Logistic regression models were applied to evaluate the variables associated with successful manipulation. Post-manipulation complications and the PD time gained after successful manipulation were also reviewed.

Results: 46 patients were identified and 54 procedures were performed over the study period. 35 of the interventions (64.8%) resulted in technical success, and 25 cases (46.3%) resulted in clinical success. The median extra PD time gained after successful manipulation was 619 days (IQR, 313.5 - 1,007; range, 110 - 1,872). The median for number of days of hospital stay after the procedure was 2.5 days (IQR, 2 - 5; range, 1 - 65). Seven cases (13.0%) developed immediate complications, with most cases being peritonitis (n = 5), and all were successfully treated with intraperitoneal antibiotics. There was no associated mortality.

Conclusion: Fluoroscopic-guided repositioning of the PD catheter was found to be a useful and safe treatment option for malfunctioning PD catheter and could potentially spare patients from the conventional operative intervention.