Clinical Kidney Journal最新文献

Background: Published studies have suggested a link between chronic kidney disease (CKD) and sleep disorders, although the exact nature of this association has not been uniformly described. Clarifying this relationship may facilitate evidence-based interventions that address the interplay between these disease entities. Such interventions could prevent obstructive sleep apnea (OSA) from worsening CKD and improve the quality of life for CKD patients by reducing the risk of developing OSA. Therefore, the objective of this meta-analysis is to assess the bidirectional association between sleep disorders and CKD.

Methods: Following a PROSPERO-registered protocol, three blinded reviewers conducted a systematic review of the Medline/PubMed, Embase, Cochrane Library and Cumulative Index of Nursing and Allied Health (CINAHL) databases for observational studies pertaining to the relationship between sleep disorders and CKD. A meta-analysis was conducted in risk ratios (RRs).

Results: From 63 studies (26 777 524 patients), OSA [RR 1.68; 95% confidence interval (CI) 1.45 to 1.93], albuminuria (RR 1.54; 95% CI 1.18 to 1.99), restless leg syndrome (RLS) (RR 1.88; 95% CI 1.48 to 2.38) and insomnia (RR 1.24; 95% CI 1.01 to 1.54) were significantly associated with CKD. There was a significant association between OSA (RR 1.77; 95% CI 1.56 to 2.01) with incident CKD. There was a significant association of OSA (RR 1.74; 95% CI 1.55 to 1.96), RLS (RR 1.73; 95% CI 1.32 to 2.25) and insomnia (RR 1.14; 95% CI 1.03 to 1.27) in patients with CKD compared with healthy controls. CKD was also significantly associated with incident OSA (RR 1.60; 95% CI 1.35 to 1.89).

Conclusion: The bidirectional associations of obstructive sleep apnea with CKD remained consistent across different stages of CKD, modes of diagnosis of sleep disorder and geographical region. A bidirectional association was observed between CKD and obstructive sleep apnea, RLS and insomnia. The treatment of sleep disorders may reduce the risk of CKD, and vice versa.

[This corrects the article DOI: 10.1093/ckj/sfae194.].

Background: Sodium-glucose cotransporter 2 inhibitors (SGLT2i) lower ambulatory blood pressure (ABP) in patients with type 2 diabetes mellitus; whether the same holds true in diabetic kidney disease (DKD) is unknown. This information is critical to the knowledge of mechanisms of nephroprotection and safety of this therapy.

Methods: This multicenter prospective study evaluates the changes in ABP after 12 weeks of dapagliflozin 10 mg/day in a cohort of patients with type 2 DKD and glomerular filtration rate (GFR) >25 mL/min/1.73 m². Primary endpoint was the change of nighttime systolic blood pressure (SBP). Changes of daytime SBP, prevalence of normal dipping (day/night SBP ratio <0.9) and changes in ABP patterns, that is, sustained uncontrolled hypertension (SUCH), white coat uncontrolled hypertension (WUCH), masked uncontrolled hypertension (MUCH) and controlled hypertension (CH) were secondary endpoints.

Results: Eighty-three of 96 patients completed the study [age 68.7 ± 8.9 years, 73.5% males, GFR 49 ± 17 mL/min/1.73 m², median albuminuria: 0.18 (interquartile range 0.10-0.38) g/24 h]. After 12 weeks of dapagliflozin, nighttime SBP declined by -3.0 mmHg (95% confidence interval -5.2/-0.8 mmHg; P = .010) with an improvement of nighttime SBP goal (<110 mmHg) from 18.0% to 27.0% (P < .001). Similarly, the prevalence of normal dipping increased (from 31.3% to 50.6%, P = .005). A decrease in daytime (-2.4 mmHg; P = .046) and office (-7.9 mmHg; P = .009) SBP was also found. The decline of ambulatory and office SBP was associated with increased prevalence of CH (from 6.0% to 18.0%) and significant improvement of SUCH, WUCH and MUCH (P = .009). Albuminuria decreased (P < .001), whereas eGFR did not change (P = .297). Urinary tract infection (4.2%) and acute kidney injury (3.6%) were the main causes of drop-out. Only one patient showed a drop of nighttime SBP below 90 mmHg.

Conclusions: Dapagliflozin is associated with improvement in circadian blood pressure rhythm with no major safety signal related to excessive blood pressure decrease.

Background: Allograft loss is the most feared outcome of kidney transplant recipients. We aimed to develop a dynamic Bayesian model using estimated glomerular filtration rate (eGFR) trajectories to predict long-term allograft and patient survivals.

Methods: We used data from the Australian and New Zealand Dialysis and Transplant registry and included all adult kidney transplant recipients (1980-2017) in Australia (derivation cohort) and New Zealand (NZ, validation cohort). Using a joint model, the temporal changes of eGFR trajectories were used to predict patient and allograft survivals.

Results: The cohort composed of 14 915 kidney transplant recipients [12 777 (86%) from Australia and 2138 (14%) from NZ] who were followed for a median of 8.9 years. In the derivation cohort, eGFR trajectory was inversely associated with allograft loss [every 10 ml/min/1.73 m² reduction in eGFR, adjusted hazard ratio [HR, 95% credible intervals (95%CI) 1.31 (1.23-1.39)] and death [1.12 (1.10-1.14)]. Similar estimates were observed in the validation cohort. The respective dynamic area under curve (AUC) (95%CI) estimates for predicting allograft loss at 5-years post-transplantation were 0.83 (0.75-0.91) and 0.81 (0.68-0.93) for the derivation and validation cohorts.

Conclusion: This straightforward model, using a single metric of eGFR trajectory, shows good model performance, and effectively distinguish transplant recipients who are at risk of death and allograft loss from those who are not. This simple bedside tool may facilitate early identification of individuals at risk of allograft loss and death.

Background: Cognitive impairment (CI) is a critical complication in peritoneal dialysis (PD) patients, associated with decreased quality of life and increased hospitalization. Despite its significant impact, the prevalence, risk factors, and consequences of CI in PD patients are not well understood. We aimed to determine the prevalence, risk factors, and outcomes of CI in PD patients.

Methods: We performed systematic reviews in OVID Medline, Embase, and Cochrane databases until February 2024 to identify cross-sectional and cohort studies on prevalence of CI (identified by cognitive assessment scales) in PD patients. The Newcastle-Ottawa Scale was used to assess risk of bias. A pooled meta-analysis of CI prevalence in PD and a subgroup analysis comparing the risk of CI between PD and non-PD settings were performed using a random-effects model.

Results: A total of 19 studies were identified, involving 2882 PD patients. The pooled prevalence of CI in PD patients was 47.7% (95%CI: 35.8-59.9%). CI in patients undergoing PD appears to be associated with older age, female gender, lower levels of education, and is linked to higher rates of hospitalization and peritonitis, compared to those without CI. However, it is not associated with increased mortality. Compared to hemodialysis, PD showed a trend toward a lower risk of CI (OR 0.64, 95%CI 0.39-1.03; P = .068).

Conclusion: CI is highly prevalent and associated with several adverse clinical outcomes in PD patients. These findings could contribute to facilitate the development of screening and early intervention strategies to reduce the burden of disease in this population.

Background and hypothesis: The prevalence of antiphospholipid antibody (aPL) is high among hemodialysis (HD) patients compared to the general population and is inconsistently associated with arteriovenous fistula (AVF) thrombosis or stenosis. The association with maturation failure has never been investigated. This study aims to evaluate native AVF complications (thrombosis, stenosis, and maturation failure) and primary patency in aPL positive HD patients.

Methods: We retrospectively identified 116 HD patients with native AVF. We collected the aPL profiles, the clinical and biological data potentially involved in AVF maturation failure, thrombosis, and stenosis, and investigated the association of these complications and aPL positivity. Kaplan-Meier survival analysis was performed.

Results: In our cohort, the prevalence of aPL persistent positivity was 32.7% and this was strongly associated with AVF maturation failure defined by ultrasound. aPL persistent positivity was a strong predictor in multivariate analysis and this association was independent of AVF stenosis or thrombosis during maturation process. There was no association with primary and functional primary patency, and stenosis. However, aPL persistent positivity according to ACR/EULAR classification criteria was associated with thrombosis when compared to strictly negative aPL patients.

Conclusions: In our cohort, aPL persistent positivity was significantly associated with AVF maturation failure and thrombosis but not with AVF stenosis. To our knowledge, we report for the first time, a statistically significant association between aPL positivity and delay or absence of native AVF maturation.

Background: Although hepatic production of FGF23 has been suggested in chronic settings, there are no data indicating hypophosphatemia resulting from acute hepatic FGF23 production. Based on two clinical observations of profound hypophosphatemia in the setting of acute hepatitis, our study investigates the hypothesis of acute FGF23 liver expression.

Methods: Retrospective analyses were conducted to estimate FGF23 liver expression both qualitatively (in situ hybridization) and quantitatively (relative FGF23 gene expression and protein production) on histological specimens of human and murine acute hepatitis livers, compared with controls of hepatic fibrosis or healthy liver.

Results: The index clinical case involves acute alcoholic hepatitis complicated by profound hypophosphatemia due to phosphate diabetes, revealing a major production of both FGF23 C-terminal fraction (cFGF23) and bio-intact form (iFGF23, 39 751 RU/mL, N: 21-91; and 228.6 pg/mL, N: 22.7-93.1, respectively). A second case of acute hepatitis related to erythrocytic protoporphyria also exhibited comparable abnormalities. In both cases, no other cause of renal phosphate wasting was identified, and the hydroelectrolytic disorders disappeared in parallel with normalization of the liver balance and FGF23 levels. Histological data of acute hepatitis compared with cirrhosis and healthy liver confirmed our hypothesis of hepatic FGF23 overproduction. Furthermore, mouse models showed a significant increase in FGF23 mRNA relative liver expression in acute hepatitis and a moderate increase in cirrhosis, compared with healthy liver (respectively 60.55 ± 16.75 and 3.70 ± 0.87 vs 1.00 ± 0.65, both P < .05). These findings were also confirmed at the protein level.

Conclusion: This translational study raises the hypothesis of renal phosphate wasting induced by excessive hepatic production of FGF23 in case of acute hepatitis.

Background: Metabolic surgery is recognized for its effectiveness in weight loss and improving outcomes for individuals with type 2 diabetes mellitus (T2DM). However, its impact on renal function, especially in multi-ethnic Asian populations, remains underexplored. This study investigates mid- and long-term renal outcomes following metabolic surgery in Asian patients with T2DM.

Methods: This retrospective cohort study utilized data from the Asian Diabetes Surgery Study (ADSS), involving T2DM patients aged 20-79 who underwent metabolic surgery from 2008 to 2015. The primary outcome was the change in estimated glomerular filtration rate (eGFR) at 1, 3, and 5 years post-surgery, with adjustments for confounders. Secondary outcomes included changes in chronic kidney disease (CKD) stages and the relationship between weight loss and eGFR changes. Data were analyzed using univariate and multivariable regression analyses, along with the McNemar test.

Results: The study included 1513 patients with a mean age of 42.7 years. The results revealed that a significant improvement in eGFR was observed at 1-year post-surgery (112.4 ± 32.0 ml/min/1.73 m², P < .001), with a shift toward less severe CKD stages. However, this improvement was not sustained at 3 and 5 years. No significant correlation was found between weight loss and eGFR changes at 1-year follow-up.

Conclusion: Metabolic surgery significantly improves renal function at 1 year postoperatively in Asian individuals with T2DM, highlighting its potential benefits beyond glycemic control and weight loss. The long-term effects on renal function require further investigation.

Background: Anti-phospholipid antibodies nephropathy (aPL-N) is a complex feature of anti-phospholipid syndrome due to microvascular lesions. Renal prognosis and predictors of outcome are not yet known.

Methods: We performed a systematic review of the literature (February 2006-January 2024) using the PubMed, Scopus, Cochrane Library and EMBASE databases. Two reviewers independently conducted literature screening and data extraction in a blinded, standardized manner. A random effects model was used to pool odds ratios (ORs) [with 95% confidence interval (CI)] for the primary analysis, the risk of kidney failure. Subgroup analyses were performed for clinical and laboratory features that predicted renal outcomes. Heterogeneity was assessed by I².

Results: Six records involving 709 patients were included in the meta-analysis. Biopsy-proven aPL-N was found in 238/832 (28.6%) patients. Acute kidney injury (AKI) was present at diagnosis in 20/65 (30.8%), while 73/233 (31.3%) patients with aPL-N developed chronic kidney disease (CKD)/end-stage kidney disease (ESKD) at follow-up. aPL-N was associated with an increased risk of CKD/ESKD [OR 6.89 (95% CI 2.42-19.58)] and AKI [OR 2.97 (95% CI 1-4-6.29)]. Arterial hypertension and positivity for lupus anticoagulant, anti-cardiolipin antibodies and anti-β2 glycoprotein I antibodies were associated with an increased risk of developing aPL-N [OR 3.7 (95% CI 1.9-7.23), OR 4.01 (95% CI 1.88-8.53), OR 2.35 (95% CI 1.31-4.21) and OR 19.2 (95% CI 2.91-125.75), respectively].

Conclusion: aPL-N is associated with poor renal outcomes. High blood pressure and aPL positivity have been identified as predictors of adverse renal outcomes. This up-to-date knowledge on renal outcomes and predictors of renal outcomes in aPL-N enables a personalized follow-up and therapeutic approach.