Clinical Kidney Journal最新文献

Background: Autonomic neuropathy (AN) is prevalent in diabetes and chronic kidney disease. The Composite Autonomic Symptom Score 31 (COMPASS 31) is a self-assessment test developed to determine not only cardiac AN but also AN of other organs, including the vasomotor, pupillomotor, secretomotor, and gastrointestinal systems. As yet there are no data on the effects of combined AN-scores of a variety of affected organ systems on mortality in dialysis patients.

Methods: In 119 patients undergoing hemodialysis therapy, symptoms of AN were documented using COMPASS 31. After 5 years, survival rates were calculated depending on AN scores and other parameters. After this 5-year period, AN scores were assessed for a second time and correlated with those obtained 5 years earlier.

Results: Survival rates for patients with lower AN scores were better than for those with higher AN scores. Patients with lower C-reactive protein levels showed better survival compared to those with higher values. Dialysis patients with diabetes had a lower survival rate compared to non-diabetic patients. In women, survival rates were better than in men. AN scores remained unchanged over the 5-year period.

Conclusion: AN is frequently observed in dialysis patients and can be identified through the COMPASS 31 questionnaire. Patients with higher AN scores exhibit poorer survival rates compared to those with lower scores. This observation is applicable not only for cardiac AN but also to AN scores reflecting changes in other organ systems. Therefore, AN scores can be used effectively to detect various AN symptoms in dialysis patients and identify their increased risk of mortality.

Background: Acute kidney injury (AKI), a rapid decrease in kidney function, is associated with increased risk of adverse outcomes including development and progression of CKD. Kidney fibrosis is one of the pathological processes central to this AKI-to-CKD transition. Here we investigate the association of biomarkers of collagen type III turnover with adverse outcome following AKI.

Methods: We measured three biomarkers reflecting collagen type III (PRO-C3) formation and degradation (C3M and C3C) in plasma samples collected 1 year after an episode of AKI in 800 patients (392 patients with AKI and 408 non-AKI controls) from the prospective AKI Risk in Derby (ARID) study. Patients were followed until 3 years after the episode of AKI and the following outcomes were assessed: kidney disease progression, mortality, heart failure, cardiovascular events, and hospital readmission.

Results: PRO-C3 levels were elevated in the AKI group compared with the controls (P < .001), whereas C3M and C3C levels were not different between groups. In multivariate models including common risk factors, PRO-C3 was prognostic for kidney disease progression and mortality in the AKI group and for heart failure in the control group. C3M and C3C were not prognostic for any of the investigated outcomes.

Conclusions: Circulating PRO-C3, a biomarker of fibroblast activity, was prognostic for kidney disease progression and mortality when measured 1 year after an episode of AKI. Biomarkers of fibroblast activity may help patient stratification after an episode of AKI by identifying patients at higher risk of kidney disease progression.

Threaded online medical education first emerged on X (formerly Twitter) in early 2018 following the introduction of a threading feature in December 2017, with nephrologists quickly becoming enthusiastic adopters. However, changes like paid features and weakened content moderation have led many nephrologists and allied professionals to migrate to other platforms, which offer the potential for a more suitable environment for learning and discussion. The 2024 US presidential election and growing disillusionment with X has accelerated this shift. By late November 2024, Bluesky appears to have reached critical mass, and we propose that it will become a major social media platform in nephrology. To this end, we provide 10 tips to compose educational material for use on Bluesky. We suggest a clean break with regards to terminology and propose the term 'skytorial'. Starter packs can help rebuild networks on Bluesky. Skytorials need to be planned with thought given to audience and scope. The first post is important: like a hook in fishing, it needs to interest the audience and establish contact. Emojis and visual content can be used to generate interest. Skytorials need to be concise and less is often more. Tagging and the use of hashtags is important, as is a good take-home message. Finally, it is important to check the entire skytorial before posting it. The arena of social media is constantly evolving and the future is difficult to predict. However, given the rapidly growing popularity of Bluesky, we believe nephrologists should now explore the opportunities of the new platform.

Acute kidney injury (AKI) is a heterogeneous syndrome associated with worse clinical outcomes. Many treatments and procedures in the hospitalized patient can cause AKI. Hence, the incidence of iatrogenic AKI is expected to be high. In this review we provide 10 practical tips on how to manage and avoid iatrogenic AKI. We cover identification of vulnerable patients by epidemiological data and recommend the usage of renal stress biomarkers for enhanced screening of high-risk patients. Further, we discuss the limitations of current diagnostic criteria of AKI. As a key takeaway, we suggest the implementation of novel damage biomarkers in clinical routine to identify subclinical AKI, which may guide novel clinical management pathways. To further reduce the incidence of procedure-associated AKI, we advocate certain preventive measures. Foremost, this includes improvement of hemodynamics and avoidance of nephrotoxic drugs whenever possible. In cases of severe AKI, we provide tips for the implementation and management of renal replacement therapy and highlight the advantages of regional citrate anticoagulation. The furosemide stress test might be of help in recognizing patients who will require renal replacement therapy. Finally, we discuss the progression of AKI to acute and chronic kidney disease and the management of this growing issue. Both can develop after episodes of AKI and have major implications for patient co-morbidity and long-term renal and non-renal outcomes. Hence, we recommend long-term monitoring of kidney parameters after AKI.

Background: Clearance of circulating myoglobin is crucial to prevent further damage in patients with rhabdomyolysis (RM) and acute kidney injury (AKI). The objective of the present study was to evaluate the efficacy and safety of haemoadsorption (HA) combined with continuous renal replacement therapy (CRRT) in critically ill patients with RM and AKI.

Methods: Patients with RM and AKI who received CRRT + HA or CRRT with concomitant creatine kinase (CK) >10 000 IU/l in our intensive care unit (ICU) between May 2021 and December 2023 were retrospectively included. The primary outcome was 90-day mortality; secondary outcomes were kidney function recovery and CK decline rate. Adverse events were also evaluated, including hypotension, circuit clotting, albumin leakage and blood loss. Propensity score matching and Cox retrospective analysis were performed.

Results: A total of 111 RM patients with AKI were ultimately included. The ICU and in-hospital mortality were significantly lower in the CRRT + HA group compared with the CRRT group (ICU mortality: 18% versus 42%, P = .025; in-hospital mortality: 21% versus 42%, P = .048). However, the CRRT + HA group only showed a non-significant reduction in 90-day mortality compared with the CRRT group (47% versus 68%, P = .063). After treatment for 90 days, the number of patients with kidney function recovery was not significantly different between the CRRT + HA and CRRT groups (95% versus 84%, P = .639). Moreover, the incidence of hypotension and circuit clotting events did not increase during CRRT + HA treatment. In addition, the CRRT + HA group also appeared to have a higher rate of CK reduction and reduction of CK than the CRRT group at 24 and 48 hours after the initiation of CRRT. A multivariate Cox regression model demonstrated that CRRT + HA {hazard ratio [HR] 0.477 [95% confidence interval (CI) 0.234-0.972], P = .042}, mean arterial blood pressure [per 1 mmHg; HR 0.967 (95% CI 0.943-0.992), P = .009] and CRRT treatment duration [per 1 h; HR 0.995 (95% CI 0.992-0.998), P = .002] played a favourably important role in the survival prognosis of RM and AKI patients. In contrast, serum phosphate before RRT [per 1 mmol/l; HR 1.531 (95% CI 1.113-2.106), P = .009] and McMahon score [per 1 score; HR 1.15 (95% CI 1.006-1.313), P = .04] were independent risk factors for 90-day mortality.

Conclusions: CRRT combined with HA therapy reduced ICU and in-hospital mortality in patients with RM and AKI and also had a cleansing effect on creatine kinase without significant adverse events.

Background: Hemodialysis (HD) can lead to left ventricular (LV) transient regional wall motion abnormalities (RWMAs), due to segmental hypoperfusion, better known as myocardial stunning. Repeated episodes of HD-induced ischemia contribute directly to the development of heart failure and increased mortality in patients receiving HD. Intradialytic exercise (IDE) training is capable of exerting favorable effects on the cardiovascular system. However, its impact on HD-induced myocardial stunning remains currently unknown.

Methods: In this prospective controlled study, 31 patients participating in an intradialytic aerobic and resistance training program (3/week for 16 weeks) were compared with 30 patients receiving usual care. Two-dimensional echocardiography was performed at baseline and follow-up both just before HD onset (T₀) and at peak stress of HD (T_peak). LV longitudinal strain from an 18-segment model were used to assess the presence of RWMAs.

Results: Training resulted in a significant reduction of RWMAs at T_peak between groups [-2.22 segments; 95% confidence interval (CI) -0.49/-3.96; P = .01]. Compared with usual care, trained patients demonstrated also a greater reduction in the decline of global longitudinal strain during HD (-1.45%; 95% CI -0.24/-2.66; P = .01). There were significant reductions in LV mass (-23.3 g; 95% CI -8.7/-37.9; P = .002) and improvements in LV ejection fraction (4%; 95% CI 1.5/6.6; P = .002) between groups favoring IDE. Correlations were found between change in RWMAs with change in LV mass and ejection fraction over the study period.

Conclusion: IDE training is cardioprotective, improving LV remodeling and reducing HD-induced myocardial stunning.

Nucleoporins, as major components of nuclear pore complex, have been recently discovered to participate in organ development. Here, we report a young female patient with nephrotic proteinuria resistant to immune suppressant treatment and congenital ovarian insufficiency. Renal pathology confirmed focal segmental glomerulosclerosis and whole-exome sequencing revealed compound heterozygous mutations in Nucleoporin 160 (NUP160), NM_015231.2 c.4154C>T (p.Pro1385Leu) and c.1102-9T>G. Notably, NUP160 mutations have been associated with congenital nephropathy in four families. We also ruled out competing genetic variants implicated in focal segmental glomerulosclerosis and ovarian dysgenesis. Our identification of two novel NUP160 mutations associated with congenital nephropathy and ovarian insufficiency simultaneously contributes to a deeper understanding of nuclear pore complex function in the urogenital system.

Background: The optimal treatment for profound hyponatraemia remains uncertain. Recent clinical studies have demonstrated that a standardized bolus of hypertonic saline is effective, but relying solely on this approach may not fully address the individual variability of hyponatraemia among patients. We evaluated the effectiveness of rapid bolus (RB) administration of hypertonic saline followed by predictive correction (PC) using an infusate and fluid loss formula identical to the Barsoum-Levine formula based on the Edelman equation (RB-PC) for managing profound hyponatraemia.

Methods: In this retrospective observational cohort study, we evaluated 276 patients aged >18 years with s[Na] levels ≤120 mEq/L (January 2014-December 2023). Using propensity score matching (PSM), we assessed s[Na] elevations at 6 h post-treatment initiation and the rate of appropriate hyponatraemia correction between the RB-PC and PC groups. We defined the appropriate correction as a change in s[Na] in the range of 4-10 mEq/L within the first 24 h and ≤18 mEq/L within the first 48 h following corrective treatment initiation.

Results: Among 276 patients with profound hyponatraemia (s[Na] ≤120 mEq/L), 49 and 108 underwent treatment with RB-PC therapy and with PC therapy without RB, respectively. Post-PSM, 84 patients were selected and allocated to the RB-PC (n = 42) or PC group (n = 42). In PSM analysis, patients with RB-PC experienced a higher elevation in s[Na] at 6 h after treatment initiation than PC (4.0 vs 2.4 mEq/L, P < 0.001). The rate of appropriate correction was similar between the RB-PC and PC groups (90.5% vs 90.5%, P = 1).

Conclusions: RB-PC can quickly elevate s[Na] levels and achieve appropriate correction of s[Na] in patients with profound hyponatraemia.

The European Renal Association (ERA) Registry collects data on kidney replacement therapy (KRT) in patients with end-stage kidney disease (ESKD). This paper summarizes the ERA Registry Annual Report 2022, with a special focus on comparisons by sex. The supplement of this paper contains the complete ERA Registry Annual Report 2022. Data was collected from 53 national and regional KRT registries from 35 countries. Using this data, incidence, and prevalence of KRT, kidney transplantation rates, survival probabilities, and expected remaining lifetimes were calculated. In 2022, 530 million people of the European general population were covered by the ERA Registry. The incidence of KRT was 152 per million population (pmp). In incident patients, 54% were 65 years or older, 64% were male, and the most common primary renal disease (PRD) was diabetes mellitus (22%). At KRT initiation, 83% of patients received haemodialysis, 12% received peritoneal dialysis, and 5% underwent pre-emptive kidney transplantation. On 31 December 2022, the prevalence of KRT was 1074 pmp. In prevalent patients, 48% were 65 years or older, 62% were male, the most common PRD was of miscellaneous origin (18%), 56% of patients received haemodialysis, 5% received peritoneal dialysis, and 39% were living with a functioning graft. In 2022, the kidney transplantation rate was 40 pmp, with most kidneys coming from deceased donors (66%). For patients starting KRT between 2013 to 2017, 5-year survival probability was 52%. Compared with the general population, the expected remaining lifetime was 66% and 68% shorter for males and females, respectively, receiving dialysis, and 46% and 49% shorter for males and females, respectively, living with a functioning graft.

Background and hypothesis: Cardiovascular diseases are a leading cause of morbidity and mortality in patients with chronic kidney disease (CKD). Acute kidney injury (AKI) has been increasingly recognized as a potential exacerbating factor for cardiovascular events in these patients. The CKD-REIN study aims to explore the relationship between AKI and the risk of major adverse cardiovascular events (MACE) in a cohort of CKD patients. We hypothesize that AKI is a significant and independent predictor of MACE in patients with CKD, and that the severity of AKI correlates with the risk of subsequent cardiovascular events.

Methods: This prospective cohort study included 3033 adult CKD patients from 40 outpatient nephrology clinics in France. Patients were followed for a median of 5.2 years. AKI episodes were identified and staged based on the KDIGO-AKI criteria. Cardiovascular events, including myocardial infarction, stroke, heart failure hospitalization, and cardiovascular death, were systematically recorded. The association between AKI and MACE was analyzed using a multivariable Cox model, adjusting for confounders such as demographic characteristics, medical history, and baseline kidney function.

Results: During the follow-up, 530 patients experienced at least one episode of AKI. The cumulative incidence of MACE at 1 year post-AKI was 8.1%. Patients with AKI had a significantly increased risk of MACE, with an adjusted hazard ratio (HR) of 5.78 (P < .001). The risk was consistent across different MACE components and was independent of age, sex, CKD stage, or comorbidities. The risk of MACE was higher for more severe AKI stages and for AKI events requiring hospitalization or associated with incomplete renal recovery.

Conclusion: The findings of this study confirm that AKI is a significant independent predictor of MACE in CKD patients, demonstrating a strong severity-response relationship. These results underscore the importance of vigilant cardiovascular monitoring and preventive strategies in CKD patients following AKI episodes. Understanding the mechanisms linking AKI to cardiovascular outcomes is crucial for developing targeted interventions to mitigate these risks.