Clinical nephrology最新文献

Introduction: After kidney transplantation, persistent hyperparathyroidism commonly occurs, often alongside increased serum calcium levels. It is reasonable to infer that kidney transplant recipients (KTRs) with hypercalcemia related to persistent hyperparathyroidism are more susceptible to developing anemia. However, reports suggest that hypercalcemia could be a contributing factor to erythrocytosis. Our aim was to assess the effect of persistent hypercalcemia on the trajectory of hemoglobin levels after transplantation.

Materials and methods: We conducted a retrospective cohort study investigating the trajectory of hemoglobin in 385 KTRs with and without persistent hypercalcemia (free Ca > 5.2 mg/dL). We performed mixed-model analyses adjusting for potential confounders.

Results: Persistent hypercalcemia was present in 62% KTRs (56% male, median age 36 (IQR 28 - 48) years, median follow-up 4.1 (IQR 1 - 8.2) years). Compared to KTRs without hypercalcemia, KTRs with persistent hypercalcemia had a mean positive difference in hemoglobin levels of +0.76 g/dL/year (95% CI +0.45 - +1.08, p < 0.001) throughout the follow-up period. Specifically, the change slope was +0.80 (95% CI +0.32 - +1.27, p < 0.001) g/dL/year for males and +0.36 (95% CI +0.16 - +1.08, p < 0.001) g/dL/year for females. Persistent hypercalcemia was significantly associated with post-transplant erythrocytosis according to the WHO (47 vs. 24%, OR 2.8, 95% CI 1.8 - 4.4) and altitude-adjusted criteria (22 vs. 10%, OR 2.5, 95% CI 1.2 - 4.5). The effect of hypercalcemia on hemoglobin levels was consistent after adjusting for confounders, except in KTRs who developed an estimated glomerular filtration rate < 45 mL/min/1.73m² after transplantation.

Conclusion: Persistent hypercalcemia after kidney transplantation was significantly associated with higher hemoglobin levels and an increased risk of developing post-transplant erythrocytosis.

Background: No drug has been shown to be effective in preventing cardiac surgery-associated acute kidney injury (CSA-AKI). In different clinical settings, sodium-glucose transporter 2 (SGLT2) inhibitors confer renal protection and may be promising drug candidates. We examined the association between preoperative dapagliflozin use and the incidence and prognosis of CSA-AKI.

Materials and methods: Data were obtained for consecutive patients undergoing cardiac surgery with cardiopulmonary bypass between December 2020 and November 2022 at a large teaching hospital in Eastern China. The exposure was preoperative dapagliflozin use, and the primary outcome was the incidence of AKI within seven days following cardiac surgery. The secondary outcomes included dialysis, death, AKI recovery, and length of hospitalization. The association between the exposures and outcomes was determined by various logistic regression models with propensity scores.

Results: A total of 1,424 patients were included, of which 201 (14.1%) received dapagliflozin preoperatively, and 321 (22.5%) developed CSA-AKI. Patients with dapagliflozin use developed CSA-AKI more frequently than those without (32.3 vs. 20.9%, unadjusted odds ratio 1.81; 95% CI, 1.30 - 2.50). However, the association became non-significant in the multivariate model (adjusted odds ratio, 1.11; 95% CI, 0.73 - 1.68), in the adjusted model with inverse probability weighting (odds ratio, 1.21; 95% CI, 0.76 - 1.93), or in the propensity-score-matched model (odds ratio, 1.09, 95% CI, 0.68 - 1.73). Furthermore, there was no significant association between preoperative dapagliflozin use and secondary outcomes.

Conclusion: Results from this study suggest that preoperative dapagliflozin use was not associated with a lower risk of CSA-AKI.

Introduction: Hemodialysis patients need long-term frequent use of parenteral anticoagulants, and the side effects need to be taken seriously. This study aimed to assess the reporting of adverse drug reactions (ADRs) following administration of unfractionated heparin (UFH), low molecular weight heparins (LMWHs), fondaparinux, and danaparoid, in relation to their usage in European Economic Area (EEA).

Materials and methods: The total number of ADRs of each anticoagulant between 2017 to 2021 was collected using data from the EudraVigilance database. The number of hemorrhages, thrombocytopenia, injection-site reaction, liver injury, hypersensitivity and bone disorder were collected, respectively. Usage of these anticoagulants was estimated using sales data from the IQVIA MIDAS database. The reporting rates of ADRs were calculated and compared using χ²-test.

Results: Between 2017 and 2021 in the EEA, the overall ADRs reporting rates per 10,000,000 standard units (SU) of UFH, enoxaparin, nadroparin, dalteparin, fondaparinux, and danaparoid were 12.3, 40.8, 23.6, 36.5, 91.4, and 430.0, respectively. There were significant differences among these drugs (χ² = 7,239.26, p < 0.001). Specifically, hemorrhage and thrombocytopenia were reported at higher rates, ranging from 2.8 to 140.1, and 2.0 to 115.9 per 10,000,000 SU among different anticoagulants. Injection-site reactions and hypersensitivity came in second, between 0.2 - 29.0 and 0.1 - 53.1 per 10,000,000 SU, respectively. The reporting rates for liver injury and bone disorder were reported at low rates.

Conclusion: The reporting rates of ADRs for heparin and its derivates were all very low. In comparison, the reporting rate of ADRs for danaparoid and fondaparinux was relatively high. The most commonly reported ADRs were hemorrhage, thrombocytopenia, followed by injection-site reactions and hypersensitivity.

Dialysis initiation during an emergency hospital admission is associated with increased complications, more temporary access, and higher mortality. Even in patients known to nephrologists, more than one-third start dialysis in an unplanned fashion. This retrospective case-control study sought to identify features of the pre-dialysis period that are associated with unplanned dialysis initiation in patients known to nephrology services. 40 consecutive patients (median age 61, 85% male) who underwent unplanned dialysis initiation (cases) were individually matched by age and sex with patients who started dialysis in a planned fashion during a similar period (controls). Clinical and laboratory data were collected from electronic patient records and correspondence. Across the pre-dialysis year, cases had a faster estimated glomerular filtration rate (eGFR) decline, greater weight gain, missed more nephrology clinic appointments, and had more emergency hospital admissions compared to controls. In multivariable analysis, predictors of unplanned dialysis initiation were eGFR trajectory (OR 1.91 per -1 mL/min/1.73m²/month, 95% CI 1.10 - 3.30, p = 0.021), weight gain (OR 1.97 per +1%/month, 95% CI 1.33 - 2.93, p < 0.001), and clinic non-attendance (OR 1.54 per clinic, 95% CI 1.09 - 2.18, p = 0.015). The findings of this study suggest that to better identify individuals nearing dialysis who are at high risk for unplanned initiation, nephrologists need to move away from traditional markers of disease progression, such as latest eGFR and proteinuria, and instead look at trends in eGFR, trends in weight, and levels of patient engagement with pre-dialysis care.

Background: Chronic kidney disease (CKD) is a highly prevalent condition with complications such as constipation, inflammation, and dietary restrictions. Gut microbiota is an ecosystem of trillions of bacteria and other microorganisms such as viruses, fungi, and other eukaryotes. This review aimed to analyze the correlation between CKD and the microbiota.

Materials and methods: This is a literature review of recent articles published in the Medline database.

Results: As CKD progresses, there is a change in the composition of the gut bacteria colonies, with the production of gut-derived uremic toxins. Gut-impaired permeability facilitates the bacteria fragments' translocation, increasing the stimulus for producing inflammatory mediators. Many interventions have been suggested to modulate the gut composition, and the administration of substances to interact with bacteria or decrease inflammatory status is of central interest. Probiotics are live microorganisms that interact with the local microbiota, and prebiotics are non-digested compounds that reach the colon. Their administration reduces the production of uremic toxins and inflammatory substances but fails to protect against chronic kidney disease progression.

Conclusion: Curcumin decreases uremic compounds and inflammation. Physical exercise did not act as a gut microbiota modulator. Systematic reviews and metanalysis evaluating gut microbiota modulators revealed a lack of positive impact on renal deterioration but a good reduction in the production of uremic toxins.

Introduction: Free radical-mediated oxidative renal tubular injury secondary to hyperoxaluria is a proposed mechanism in the formation of calcium oxalate stones. Vitamin E, an important physiologic antioxidant, has been shown in rat models to prevent calcium oxalate crystal deposition. Our objective was to determine if low dietary vitamin E intake was associated with a higher incidence of stones.

Materials and methods: We analyzed data from the 2017 to 2020 National Health and Nutrition Examination Survey, a nationally representative sample (n = 7,707). A multivariable logistic regression model was used to assess the association between elevated dietary vitamin E intake (≥ 15 mg/day) and nephrolithiasis controlling for key demographic variables: water and nutrient intake (sodium, calcium, vitamin C), and diabetes mellitus.

Results: The incidence of nephrolithiasis was 1.66% (1.38% - 1.95%). In patients consuming < 15 mg/day vitamin E, the incidence was 1.8% compared to 0.8% in patients with vitamin E intake ≥ 15 mg/day (p = 0.024). In adjusted models, participants with low vitamin E intake had a significantly higher odds of reporting stone passage (aOR = 2.83, 95% CI (1.07 - 7.5)).

Conclusion: We found that low vitamin E intake is associated with a > 2.5× greater odds of stone passage. These data are consistent with animal models suggesting that vitamin E may play an important protective role in the pathogenesis of calcium oxalate stone formation. This is the first study assessing the relationship between vitamin E intake and nephrolithiasis in humans. Future investigation of vitamin E supplementation in stone formers may help further determine if vitamin E is useful in the management of calcium oxalate stones.

We present a case of a 19-year-old who developed nephrotic syndrome with preserved renal function. Renal biopsy confirmed focal segmental glomerular sclerosis (FSGS). No remission was achieved despite 2 years of treatment with glucocorticoids, mycophenolate mofetil, tacrolimus, and cyclophosphamide. After transfer to our center, we performed re-examination of renal pathology by electron microscope (EM), chromosomal karyotype, and gene analysis. EM revealed uneven thickness of the glomerular basement membrane without obvious stratification or fracture. Gene analysis revealed a splice mutation (1447+1G>A) in IVS9 and chromosomal karyotype was (46, XY), confirming the diagnosis of Frasier syndrome, which was consistent with primary amenorrhea overlooked by local nephrologists. Cyclosporin A was prescribed to reduce the proteinuria, but serum creatinine increased to 152 μmol/L.

Objective: Utilizing expression data of clear cell renal cell carcinoma (ccRCC) genes from the Cancer Genome Atlas (TCGA) database, this study employs weighted gene co-expression network analysis (WGCNA) and Cox regression analysis to identify genes associated with the occurrence and development of ccRCC, thereby providing a scientific basis for its treatment.

Materials and methods: Differentially expressed genes between tumor and control groups were identified by preprocessing and batch correction of ccRCC transcriptome data in the TCGA database using the Wilcoxon test. Prognostic prediction models were established through a combination of WGCNA analysis, univariate Cox regression analysis, and multivariate Cox regression analysis. The reliability of these prognostic models was evaluated by plotting Kaplan-Meier survival analysis and receiver operating characteristic (ROC) curves and by further analyzing the relationship between model gene expression levels, tumor staging, and tumor grading.

Results: Post-batch correction, M2-type macrophage infiltration was pronounced in tumor tissue, and 13 out of 290 screened relevant differential genes were included in the prognostic model. The Kaplan-Meier survival curves indicated that the 3- and 5-year overall survival rates were significantly higher in the low-risk group compared with the high-risk group (83.7 vs. 69.1%; 75.7 vs. 52.6%, p = 1.169e-08). The area under the ROC curve was 0.732, signifying strong predictive power for the survival curve. In this model, the expression levels of 11 genes were positively correlated with tumor stage and pathological grade, whereas the remaining 2 genes were negatively correlated.

Conclusion: This model can predict the overall survival of patients with ccRCC and has the potential to become an important therapeutic target.

Background: Sodium-glucose co-transporter-2 (SGLT-2) inhibitors have been added to the mainstay of treatment for chronic heart failure. Recent studies suggest that empagliflozin may also reverse cardiac remodeling in heart failure by reducing N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels. In our study, we wanted to show the decrease in NT-proBNP levels, which is an indicator of poor prognosis in heart failure, and to see if there was a decrease in the rate of renal progression in patients with HF after empagliflozin use.

Materials and methods: Patients with type 2 diabetes mellitus and heart failure using empagliflozin were selected from the system and 456 patients were found. Patients were divided into two groups: heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF). The patients were divided into two groups according to their NT-proBNP levels at the beginning of the drug and on the 90^th day. The laboratory data were analyzed at the time of drug initiation and at day 90.

Results: There was a statistically significant difference between baseline and day 90 HbA1C and NT-proBNP levels (p < 0.001), (p < 0.001). NT-proBNP and creatinine levels at baseline and day 90 were significantly higher in patients with HFrEF than in those with HFpEF (p < 0.001). According to the multivariate analysis, patients with HFrEF were 11.42 times more likely to have an NT-proBNP change above 300 pg/mL than patients with HFpEF (OR: 11.42, p = 0.028).

Conclusion: In our study, a significant reduction in NT-proBNP and HbA1C levels was observed, while renal function was preserved.

Background: To evaluate the safety and efficacy of low-dose roxadustat combined with low-dose recombinant human erythropoietin (rhEPO) for the treatment of renal anemia in hemodialysis patients.

Materials and methods: We retrospectively reviewed the medical records of hemodialysis patients with moderate renal anemia between December 2019 and July 2023 from two medical centers. Patients were classified into 3 groups: rhEPO (150 - 300 IU/kg/week), roxadustat (1.5 - 2.5 mg/kg thrice weekly), and combination therapy (low-dose (≤ 1.5 mg/kg thrice weekly) roxadustat in addition to low-dose (≤ 150 IU/kg per week) rhEPO. After 24 weeks of treatment, the efficacy therapeutic endpoints and the safety endpoints were evaluated.

Results: Overall, a total of 158 patients were included: 53 in the rhEPO group, 52 in the roxadustat group, and 53 in the combination group. The median time to achieve Hb response in the combination therapy group was 20 days, which was shorter than that in the roxadustat group (20 vs. 25.5 days, log-rank p = 0.027) and the rhEPO group (20 vs. 27 days, log-rank p = 0.004). The mean rate of increase in Hb (g/L/month) during the first month of the treatment period was significantly greater in the combination group than in the roxadustat group (15.4 ± 4.7 vs. 11.1 ± 5.7, p = 0.038) or in the rhEPO group (15.4 ± 4.7 vs. 10.5 ± 4.3, p = 0.026). The incidence and frequency of adverse events were similar among the 3 groups.

Conclusion: The combination of low-dose roxadustat and rhEPO appears to have better effects in treating hemodialysis patients with moderate anemia by shortening the hemoglobin response time with minimal adverse effects.