Clinical nephrology最新文献

Introduction: To assess the efficacy and safety of a consistent percutaneous procedure for peritoneal dialysis (PD) catheter placement in initiating immediate-start PD in patients with end-stage kidney disease (ESKD).

Materials and methods: In this single-center prospective observational study, we enrolled patients with ESKD who were willing to undergo long-term PD. Tenckhoff catheters were placed under local anesthesia by a nephrologist, with the inner cuffs pushed underneath the anterior rectus fascia and purse-string sutures applied. Automated PD (APD) and continuous ambulatory PD (CAPD) were started within 1 hour following catheter placement. The primary outcomes were peri-catheter leakage, technique failure, and the need for hemodialysis during admission.

Results: APD was initiated in 12 patients, with a median initial dwell volume of 1,350 mL (range 1 - 2 L, 7 exchanges) and CAPD in 8 patients, with a median initial dwell volume of 1,500 mL (range 1 - 1.8 L, 4 exchanges). No cases of peri-catheter leakage, flow restriction, or hemodialysis inception occurred. There were 2 minor complications: 1 case of hemoperitoneum and 1 case of incisional bleeding, both of which were managed conservatively.

Conclusion: The use of purse-string suturing of the rectus fascia may allow for the immediate start of PD within 1 hour of catheter placement, with larger dwell volumes and a low risk of complications.

Aims: This study aims to investigate the relationship of blood pressure (BP) and systolic BP (SBP) variability with residual kidney function (RKF) loss in hemodialysis (HD) patients.

Materials and methods: The demographic and clinical information and data on RKF loss events in HD patients were collected. The baseline characteristics of the patients were compared among groups according to pre- and postdialysis SBP (< 120, 120 - 139, 140 - 159, and ≥ 160 mmHg) and diastolic BP (DBP) (< 80, 80 - 89, 90 - 99, and ≥ 1 00 mmHg). Participants were divided into two groups based on the mean intradialytic and interdialytic SBP variability. Kaplan-Meier analysis and Cox regression analysis were used to evaluate the risk of RKF loss.

Results: A total of 157 participants with an average HD vintage of 35.97 months were included. The group with the lowest predialysis SBP showed the longest duration of residual urine. However, Kaplan-Meier analysis and Cox regression analysis indicated that BP and SBP variability were not independent risk factors for RKF loss. Higher serum albumin levels showed protective effects against RKF loss, and diabetes mellitus (DM) and higher serum calcium were the independent risk factors for RKF loss.

Conclusion: BP and SBP variability were not independent risk factors for RKF loss in HD patients. DM, serum albumin, and calcium were independent factors related to RKF loss.

Uremic syndrome refers to the clinical manifestations of renal failure (acute or chronic) that results from the accumulation of several endogenous toxins normally excreted by the kidneys and can be fatal unless the primary cause is addressed and the toxins removed by dialysis. A historical description of the syndrome is traditionally believed to start in the 18^th - 19^th century through seminal works in the field of experimental medicine. This account, however, ignores the possibility of clinical apperception of this syndrome in ancient medical literatures. The Sushruta Samhita (SS), a Sanskrit text whose authorship is attributed to the legendary ancient Indian surgeon Sushruta (6^th century BC), is well known for its pioneering descriptions of several surgical procedures, even though its contribution to the fields of internal medicine and especially nephrology is detailed. Prameha, a term that first appears in the SS, and subsequently in later historical Ayurvedic (traditional Indian medicine) texts, denotes a multi-systemic disease syndrome impacting the neurological, cardiac, dermatological, and gastrointestinal systems that is recognized through its intimate association with urinary abnormalities such as hematuria, frothy urine, or glycosuria. This construct is highly consistent with uremic syndrome originating from multiple renal disease processes such as acute glomerulonephritis, nephrotic syndrome, diabetes mellitus, etc. Furthermore, medical treatment of prameha, as detailed in the original text, reflects several recently validated approaches to managing chronic kidney disease, supporting the hypothesis that this historical entity may be one of the earliest descriptions of uremic syndrome in medical history.

Ceftolozane-tazobactam (C/T) recommended dosing in patients undergoing renal replacement therapies (RRT) is lacking evidence. The objective of this study was to evaluate the clinical outcomes of C/T dosing in patients on RRT.

Materials and methods: A retrospective descriptive study conducted at our institution between May 1, 2017, and March 15, 2022. The primary endpoint was to determine the clinical cure for patients who received C/T for documented infection while on RRT. The secondary endpoints were the microbiologic cure, 30-day infection recurrence, and 30-day crude mortality.

Results: Of the 27 patients who met the inclusion criteria, 17 (63%) were males, median age was 69 (62 - 82) years, and weight 67 (57 - 79) kg. The majority of patients had pneumonia 19 (70.4%) followed by bacteremia 5 (18.5%). Multidrug resistant Pseudomonas spp. was the causative organism of infection in 22 subjects (81.5%). Clinical cure was achieved in 17 subjects (63%). Of the 14 subjects who had their culture repeated, 10 (71.4%) patients had microbiologic cure vs. 4 (28.5%) patients who had a microbiologic failure (p = 0.327). 30-day infection recurrence occurred in 6 (35.3%) patients of the clinical cure group and 2 (20%) patients in the clinical failure group (p = 0.362), while mortality occurred in 5 (29.4%) subjects vs. 7 (70%) in both groups, respectively (p = 0.049). The most frequently used doses of C/T were 1.5 g IV q8h while undergoing continuous venovenous hemodiafiltration and 0.75 g IV q8h while undergoing hemodialysis (p = 0.209). The median duration of therapy was 9 (4.5 - 13) days in the clinically cured group vs. 5 (3.75 - 5.5) days in those who had clinical failure (p = 0.038). There was no adverse event reported using these doses during the study period.

Conclusion: The used doses of C/T in this study were higher than those approved by the U.S. FDA, while clinical success is uncertain. Larger outcomes and pharmacokinetics studies are needed to establish effective dosing and therapy duration.

Purpose: Alterations in skin structure and function are very common in uremic patients, but still there is no unifying hypothesis for uremic skin disorders. Fibroblast growth factor-23 (FGF-23) deficiency has been linked to skin disorders in non-uremic animals. We aimed to study alterations in FGF-23 and fibroblast growth factor-23 receptor 1 (FGFR1) expression in uremic rat skins.

Material and methods: Wistar albino rats were divided into two groups: sham group (SG, n = 8) and uremic group (UG, n = 8). Uremia was induced by reduction of the total kidney mass in the UG. Animals were sacrificed after 14 weeks of the follow-up.

Results: Serum creatinine and blood urea nitrogen levels in the UG increased significantly, compared to the SG, at the end of the experiment (0.69 ± 0.08 vs. 0.3 ± 0.04 Mann-Whitney U test (MWU), p = 0,003 and 55.2 ± 8.9 vs. 29.6 ± 6.8 MWU, p = 0.002, respectively). Serum FGF-23 level in the UG was increased non-significantly, compared to the SG (53.5 ± 20.9 vs. 37.2 ± 9.7 MWU, p = 0.072), whereas serum 1,25(OH)₂D₃ level was significantly lower in the UG (149.4 ± 33.5 vs. 213.8 ± 43.8 MWU, p < 0.05). Expression of FGF-23 in UG skins, assessed by western blot, was significantly higher than that in the SG (186.3 ± 16.8 vs. 148.9 ± 25.9, MWU, p < 0.01). FGFR1 expression was increased in almost all parts of the uremic skin. Receptor expression was most dense at the epidermis and hair follicles. Normal skin appendages and cells either expressed no receptor, or expressed it very weakly.

Conclusion: This study shows increased FGF-23 levels and FGFR1 expression in uremic rat skins. It deserves further study to fully place this finding in the pathophysiology and clinical picture of uremic skin diseases.

In patients receiving hemodialysis, infective endocarditis (IE) may present in a similar way to other causes of bacteremia, which may delay early diagnosis and can lead to worse outcomes. In this study, we aimed to identify the risk factors for IE in hemodialysis patients with bacteremia. This study was conducted on all patients diagnosed with IE and receiving hemodialysis between 2005 and 2018 in Salford Royal Hospital. Patients with IE were propensity score matched with similar hemodialysis patients with episodes of bacteremia between 2011 and 2015 (non-IE bacteremic (NIEB)). Logistic regression analysis was used to predict the risk factors associated with infective endocarditis. There were 35 cases of IE, and these were propensity matched with 70 NIEB cases. The median age of the patients was 65 years with a predominance of males (60%). The IE group had higher peak C-reactive protein compared to the NIEB group (median, 253 mg/L vs. 152, p = 0.001). Patients with IE had a longer duration of prior dialysis catheter use than NIEB patients (150 vs. 28.5 days: p = 0.004). IE patients had a much higher 30-day mortality rate (37.1% vs. 17.1%, p = 0.023). Logistic regression analysis showed previous valvular heart disease (OR: 29.7; p < 0.001), and a higher baseline C-reactive protein (OR: 1.01; p = 0.001) as significant predictors for infective endocarditis. Bacteremia in patients receiving hemodialysis through a catheter access should be actively investigated with a high index of suspicion for infective endocarditis, particularly in those with known valvular heart disease and a higher baseline C-reactive protein.

Vedolizumab, which is used to effectively treat ulcerative colitis (UC), is a humanized monoclonal antibody that specifically inhibits α4β7 integrin on lymphocytes and prevents lymphocyte migration into the intestinal tissues. Herein, we report a case of acute tubulointerstitial nephritis (ATIN) probably caused by vedolizumab in a kidney transplant recipient (KR) with UC. Approximately 4 years after kidney transplantation, the patient developed UC and was treated initially with mesalazine. Treatment continued with the addition of infliximab later; however, he was hospitalized because of poor symptom control and treated with vedolizumab. His graft function declined rapidly after vedolizumab was administered. Allograft biopsy revealed ATIN. Since no evidence of graft rejection was found, vedolizumab-associated ATIN was diagnosed. The patient was treated with steroids, and his graft function improved. Unfortunately, he finally underwent total colectomy considering that UC was refractory to medical treatment. Previously, cases of vedolizumab-induced acute interstitial nephritis have been reported; however, none were associated with KRs. This is the first report of ATIN in KR which was possibly induced by vedolizumab.