Clinical Kidney Journal最新文献

Background: Diabetes is the leading cause of end-stage kidney disease (ESKD) worldwide. In particular, whether diabetes has a negative effect on the risk of transfer to haemodialysis (HD) remains controversial. This study was conducted to provide updated data on outcomes of patients with diabetes on peritoneal dialysis (PD).

Methods: This was a retrospective cohort study using data from the French Language Peritoneal Dialysis Registry, including patients starting PD between 2008 and 2018; the end of the study was 31 December 2021. Cox and Fine-Gray models examined associations between diabetes and mortality, transfer to HD, a composite outcome of death and HD transfer and kidney transplantation. In addition, the causes of transfer to HD were analysed separately. Mediation analyses were performed to assess the indirect effects of early peritonitis and assisted PD on HD transfer.

Results: Of 10 412 PD patients, 3473 (33%) were diabetics. Diabetes was associated with an increased risk of HD transfer {cause-specific hazard ratio [cs-HR] 1.69 [95% confidence interval (CI) 1.36-2.11]}, death [cs-HR 1.32 (95% CI 1.21-1.43)] and the composite outcome [cs-HR 1.23 (95% CI 1.15-1.31)] in Cox and Fine-Gray models [HD transfer subdistribution HR (sd-HR) 1.18 (95% CI 1.07-1.31); death sd-HR 1.25 (95% CI 1.15-1.35)]. Diabetic patients were less likely to receive a kidney transplant [cs-HR 0.52 (95% C: 0.41-0.66); sd-HR 0.44 (95% CI 0.35-0.56)]. At a 5% false discovery rate, diabetes was significantly associated with an increased risk of transfer to HD due to inadequate dialysis, other PD-related causes and non-PD-related causes. Mediation analyses showed no significant indirect effects via early peritonitis or assisted PD.

Conclusion: Diabetes has a higher risk of transfer to HD that was not explained by early peritonitis or not being assisted. Diabetic PD patients have a greater mortality risk and lower access to transplantation.

Despite advances and therapeutic progress, nephrotic syndrome (NS) in childhood remains challenging due to its heterogeneous presentation, variable response to treatment and the potential of adverse long-term kidney outcomes. The recently published KDIGO 2025 clinical practice guideline for the management of NS in children refines the definitions of relapse, infrequently- and frequently-relapsing NS and steroid-resistant NS. Herein we describe the revised definitions, summarize the key updates of the KDIGO 2025 guidelines and comment on the new treatment algorithm from a European viewpoint, highlighting the need for individualized approaches to minimize toxicity and optimize long-term kidney outcomes in NS in children.

Background: Patients undergoing hemodialysis frequently experience stress, physical discomfort, depressive symptoms and prolonged immobility during lengthy treatment sessions. Immersive virtual reality (VR) has shown promise as a non-pharmacological intervention to improve wellbeing in various clinical settings. However, no multicenter study has examined personalized immersive VR in dialysis patients. This study therefore aimed to assess the tolerability and effects of a single personalized VR session on wellbeing, pain and physiological parameters in patients undergoing hemodialysis.

Methods: In this pre-post single group pilot study, 148 participants from 12 dialysis centers (10 outpatient, 2 in-hospital) were enrolled. Each patient completed one personalized 20-min VR session, selecting from 20 immersive 360° options. Emotional wellbeing and pain were assessed before and after VR exposure, while treatment tolerance, perceived quality and feasibility were assessed post-session. Physiological parameters (blood pressure, heart rate, oxygen saturation) were recorded before, during and after exposure.

Results: Of the 148 enrolled participants, 143 completed the intervention (mean age 62.2 ± 14.5 years; 64.9% male and 35.1% female). Wellbeing improved significantly; among participants reporting pain, scores decreased by ∼50%. Systolic blood pressure declined from 135 to 128 mmHg and diastolic from 72 to 69 mmHg during VR exposure, with heart rate decreasing from a mean of 72 to 67 bpm (P < .0001 for all); values returned toward baseline afterwards. No serious adverse events were reported.

Conclusion: Personalized VR was well tolerated and produced measurable psychological and physiological benefits in dialysis patients, supporting its potential as a feasible non-pharmacological adjunct to routine care.

Background: The administration of an adequate dialysis dose is a critical aspect for ensuring the effectiveness of hemodialysis (HD) treatment and improving survival. Kt is a key indicator to evaluate the dose, with two targets: based on sex (Kt-Sx) and body surface area (Kt-BSA).

Methods: This retrospective study (2022-23) was conducted across 15 HD centers analyzed 1829 prevalent patients and 317 842 HD sessions.

Results: It was found that 65.9% met both Kt targets, 21.2% met only Kt-Sx and 12.9% met neither. Failure to meet both of the targets was associated with being male, older age, shorter time on HD, higher comorbidity, low body mass index, use of a catheter, shorter sessions, conventional HD, low flow rates and small membranes. Meeting at least the Kt-Sx target was associated with a 41.6% reduction in 24-month mortality risk, and an even more favorable association was observed when both targets were met, reducing the risk by 61.7%.

Conclusions: These findings highlight the importance of personalizing dialysis considering both sex and BSA, particularly in overweight or obese patients, to improve survival.

Background: Patients with chronic kidney disease (CKD) are frequently hospitalized for heart failure. Sodium-glucose co-transporter 2 (SGLT2)-inhibitors improve cardiorenal outcomes in CKD and heart failure, at least in estimated glomerular filtration rate (eGFR) ranges 20-60 ml/min/1.73 m², possibly through direct cardiac effects. In the cardiac imaging sub-studies of the Renal Lifecycle Trial, we aim to establish the effects of SGLT2-inhibition on cardiac structure and function in patients with advanced CKD, kidney failure and in kidney transplant recipients.

Methods: In the Renal Lifecycle Trial, patients with advanced CKD (eGFR ≤25 ml/min/1.73 m²), those treated with hemodialysis or peritoneal dialysis (PD) or kidney transplant recipients (eGFR ≤45 ml/min/1.73 m²), are randomized to receive either dapagliflozin or placebo. The echocardiography sub-study (acronym: STOP-HF-in-PD) will enroll 100 PD-treated patients, who undergo echocardiography at baseline, and at 6 and 12 months post-randomization. In the cardiac magnetic resonance imaging (MRI) sub-study, 250 Renal Lifecycle Trial participants across all three groups (i.e. advanced CKD, dialysis, kidney transplant recipients), including a subset of STOP-HF-in-PD participants, will undergo cardiac MRI at baseline, and at 12 months post-randomization. The primary endpoint of STOP-HF-in-PD is the difference in left ventricular global longitudinal strain, a measure of cardiac function, after 6-months of dapagliflozin compared to placebo. For the cardiac MRI sub-study, the primary endpoint is the difference of indexed left ventricular mass after 12 months of dapagliflozin compared to placebo.

Conclusions: The Renal Lifecycle Trial cardiac imaging sub-studies will generate novel data on the effects of SGLT2-inhibition on cardiac structure and function in a population with advanced CKD, in whom SGLT2-inhibitor induced cardiovascular protection remains to be established.

Clinical trial registration: The Renal Lifecycle Trial and its sub-studies are registered at ClinicalTrials.gov under registration number NCT05374291.

Tenapanor, a selective inhibitor of the sodium/hydrogen exchanger isoform 3 (NHE3), was initially developed for the treatment of irritable bowel syndrome with constipation. Subsequent preclinical and clinical studies revealed its ability to reduce gastrointestinal phosphate absorption, leading to effective serum phosphate control with minimal pill burden in patients with kidney failure undergoing dialysis therapy. However, the precise mechanisms underlying NHE3 inhibition, its impact on phosphate handling and the primary site of action within the gastrointestinal tract remain incompletely understood. This review explores the hypothesis that tenapanor-induced NHE3 inhibition elevates the luminal pH via enhanced bicarbonate secretion in the colon, thereby altering phosphate speciation. Phosphate exists in the body as monovalent (H₂PO₄⁻) and divalent (HPO₄²⁻) anions, with the latter predominating under alkaline conditions. Although divalent anions are theoretically more prone to be absorbed from the gut lumen via the paracellular transport route because of the lumen-negative transepithelial potential, on the contrary recent studies have provided evidence that monovalent species are transported more efficiently and that paracellular phosphate permeability is suppressed at high luminal pH. We now propose that the net negative electrostatic environment within the paracellular pore pathway of tight junctions may selectively hinder divalent phosphate transport. This hypothesis aligns with prior findings that tenapanor does not alter the expression of tight junction proteins, suggesting a physicochemical rather than a structural basis for reduced permeability. Further investigations are warranted to determine whether the electrostatic properties of the paracellular pathway contribute to the phosphate-lowering effect of tenapanor.

Background: Sepsis-associated acute kidney injury (S-AKI) represents a critical complication with high mortality rates in intensive care units. Current risk stratification tools lack precision and interpretability for clinical decision-making. This study aimed to develop and validate interpretable machine learning models for predicting hospital mortality in S-AKI patients.

Methods: This retrospective cohort study utilized five international critical care databases: Medical Information Mart for Intensive Care (MIMIC)-IV (n = 12 966), MIMIC-III-CareVue (n = 2209), eICU (n = 8210), Northwestern University Intensive Care Unit (NWICU) (n = 2207) and Salzburg Intensive Care database (SICdb) (n = 1893). Adult patients with S-AKI meeting sepsis-3.0 and acute kidney injury criteria were included. Feature selection used the Boruta algorithm on MIMIC-IV, MIMIC-III and eICU databases. Eleven machine learning algorithms were trained using MIMIC-IV data with external validation on all other datasets. Performance was evaluated using receiver operating characteristic (ROC) curve analysis, calibration plots and decision curve analysis. SHapley Additive exPlanations (SHAP) analysis provided model interpretability.

Results: Among 27 485 S-AKI patients, hospital mortality was 27.5%. Boruta identified 21 consensus features including severity scores [Simplified Acute Physiology Score II (SAPS II), Sequential Organ Failure Assessment (SOFA), OASIS], vital signs and laboratory parameters. Gradient Boosting Machine emerged as optimal with area under the curve (AUC) values of 0.770 (training), 0.731 (internal validation) and 0.732-0.778 across four external validation cohorts. The model demonstrated excellent calibration and minimal overfitting (3.9% AUC difference). Decision curve analysis revealed superior clinical utility across probability thresholds of 4%-82%. SHAP analysis identified SAPS II as the most important predictor, with scores >60 and SOFA >15 associated with substantially increased mortality risk. Complete case analysis confirmed model robustness (AUC 0.766-0.847).

Conclusions: The interpretable machine learning model demonstrated excellent performance and robust generalizability for S-AKI mortality prediction across five international databases. SHAP analysis provided clinically meaningful insights supporting personalized risk stratification and evidence-based clinical decision-making.

Background: Renal thrombotic microangiopathy (TMA) remains a challenge for lupus nephritis (LN) patients. The purpose of this study was to determine the prognostic significance of renal TMA in patients with LN.

Methods: Patients were recruited from the LN database (http://ln.medidata.cn) of the First Affiliated Hospital of Sun Yat-Sen University between 2001 and 2023. To assess the association between renal TMA and kidney recovery outcomes, propensity score matching (PSM), and Cox proportional hazards regression analysis were used.

Results: 5.17% LN patients had kidney biopsies showing TMA. After PSM, patients with renal TMA exhibited lower scores on the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) and the Activity Index (AI) scores in renal biopsies. Renal TMA was independently associated with deteriorated renal function recovery compared with non-renal TMA [hazard ratio (HR) 0.62; 95% confidence interval (CI) 0.42-0.94, P = .022). This association remained significant after PSM (HR: 0.50; 95% CI: 0.31-0.82, P = .004). Additionally, renal TMA was independently associated with higher risk of renal replacement therapy (RRT) (HR: 6.90; 95% CI: 3.57-13.30, P < .001) in LN patients. The proportion of glomerulosclerosis is a predictive factor for renal function recovery in LN patients with renal TMA (HR: 0.62; 95% CI: 0.40-0.95, P = .027).

Conclusions: Renal TMA is strongly associated with poorer renal function recovery in LN patients. Furthermore, a higher degree of glomerulosclerosis is a significant risk factor for impaired recovery in these patients.