Clinical Kidney Journal最新文献

Background: Dipeptidyl peptidase 4 inhibitors (DPP4is) are considered safe for use in patients with diabetes mellitus and kidney dysfunction. We explored whether usage of DPP4is in patients who recovered from dialysis-requiring acute kidney injury (AKI) could reduce the risk of future cardiac and kidney events.

Methods: We used the TriNetX platform to investigate whether the use of DPP4is in diabetes mellitus patients within 90 days of discharge from acute kidney disease could reduce the risk of all-cause mortality, major adverse kidney events (MAKEs), major adverse cardiovascular events (MACEs), and re-dialysis. The patients were followed for 5 years or until the occurrence of significant outcomes, with cohort data collected from 1 January 2016 to 30 September 2022.

Results: The cohort utilizing DPP4is comprised 7348 patients with acute kidney disease, while the control group encompassed 229 417 individuals. After applying propensity score matching, 7343 patients (age 66.2 ± 13.4 years; male, 49.9%) who used DPP4is showed a significant reduction in the risk of all-cause mortality [adjusted hazard ratio (aHR) 0.89; E-value 1.50 , MAKEs (aHR 0.86; E-value 1.59), MACEs (aHR 0.91; E-value 1.44), and re-dialysis (aHR 0.73; E-value 2.10) after a median follow-up of 2.4 years.

Conclusions: We demonstrated that in diabetes mellitus patients concurrently experiencing acute kidney disease, DPP4i usage could decrease the risk of mortality, MAKEs, MACEs, and re-dialysis. These findings emphasize the pivotal role of tailored treatment strategies involving DPP4i for acute kidney disease patients.

The management of CKD in older patients presents a significant challenge in modern medicine. As the global population ages, the prevalence of CKD among older adults is increasing, which demands effective and safe treatment strategies. The introduction of sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists has revolutionized the treatment of CKD, offering potential benefits beyond traditional therapies. However, their use in the older population raises essential questions about safety and efficacy, given the unique physiological changes and comorbidities associated with aging. In this CKJ controversy paper, Roberto Minutolo (PRO) and Sophie Liabeuf (CON) debate on the use of SGLT2 inhibitors and GLP-1 receptor agonists in older patients with CKD. Roberto Minutolo advocates the benefits of these medications, highlighting their role in improving cardiovascular outcomes and slowing CKD progression in older patients. He emphasizes the importance of personalized treatment plans based on the patient's cardio-renal risk profile and preferences. In contrast, Sophie Liabeuf expresses concerns about the safety of these drugs in older adults, citing risks such as fractures, acute kidney injury, and urinary tract infections. She argues that treatment decisions should be guided by patient frailty rather than chronological age, as frail individuals are more vulnerable to adverse drug effects. Both contenders agree on the need for more inclusive clinical trials to better understand the impact of these treatments on older populations. While Roberto Minutolo and Sophie Liabeuf present differing perspectives on the use of SGLT2 inhibitors and GLP-1 receptor agonists in older patients with CKD, their views can be seen as complementary rather than strictly opposing. Minutolo's focus on the benefits of these drugs underscores their potential to improve outcomes. Liabeuf's emphasis on caution and the consideration of frailty highlights the need for careful patient assessment. Both agree on the importance of personalized treatment and the inclusion of older patients in future clinical trials, suggesting a shared goal of optimizing care for this vulnerable population. Their debate underscores the complexity of treatment decisions and the necessity of balancing risks and benefits in managing CKD in older adults.

Background: Serum magnesium disturbances are common in patients with cardiovascular disease (CVD). However, the well-established link between low serum magnesium and nutritional or inflammatory disorders has limited its consideration as a non-traditional risk factor for mortality. This study aims to elucidate the relationship between serum magnesium concentrations and mortality due to fatal heart failure (HF), coronary heart disease (CHD) and stroke in non-dialysis patients with chronic kidney disease (CKD) stages 4 and 5.

Methods: A cohort of 1271 non-dialysis patients with CKD stages 4 and 5 was followed from 2008 to 2018. Patients with prior major adverse cardiovascular events (MACE) were excluded. Serum magnesium levels were stratified into tertiles and the primary outcomes were incidence rates of fatal HF, CHD and stroke. Secondary outcomes included composite MACE and all-cause mortality. Hazard ratios (HRs) were calculated using multivariate Cox regression, adjusting for demographics, comorbidities and biochemical parameters. E-values were used to assess the robustness of the results.

Results: Over the 10-year follow-up, 186 patients died. Higher serum magnesium levels were significantly associated with reduced mortality risk from HF [HR 0.49 (95% CI 0.27-0.89) for T2; HR 0.31 (95% CI 0.16-0.60) for T3] compared with the lowest tertile. Similar trends were observed for CHD and stroke mortality. The incidence rate of MACE per 1000 person-years was reduced from 68.2 in tertile 1 to 26.2 in tertile 2 and 16.8 in tertile 3. Secondary endpoints, including all-cause mortality and composite MACE, followed trends similar to the primary outcomes.

Conclusions: Higher serum magnesium concentrations were associated with lower risks of death from fatal HF, CHD and stroke in non-dialysis patients with CKD stages 4 and 5.

Background: Chronic kidney disease (CKD) is mainly managed in primary care, but detailed information on these patients is limited. This study describes CKD patients and the disease management and referrals by general practitioners (GPs) in Denmark in order to identify opportunities for improved care.

Methods: Patients with CKD, defined by at least two abnormal estimated glomerular filtration rate (eGFR) or urinary albumin/creatinine ratio (UACR) measurements ≥90 days apart during 2019-2020, were followed until May 2023 utilizing electronic health records.

Results: Among 1316 patients with one abnormal eGFR or UACR test, 993 (75%) had a second abnormal test within a median of 10.8 months, which confirmed CKD. Most patients (62%) were G-stage 3a, 89% had cardiovascular disease and 34% had diabetes. A UACR test was performed in 52% of patients around time of index. The use of renin-angiotensin-aldosterone system inhibitors was high (67%), whereas sodium-glucose cotransporter 2 inhibitors was low at inclusion (5%), although increasing during follow-up (15%). Patients had a median of 13.5 GP contacts/year, 1-2 eGFR and 0-1 UACR tests/year, and only 2.7% were referred to a nephrologist. The median decline in eGFR was modest; however, 15% experienced a drop of >5.0 mL/min/1.73 m² during 3-years of follow-up.

Conclusions: The findings indicate a high likelihood of CKD following one abnormal measurement. CKD patients constitute a significant burden to primary care with frequent GP contacts, yet more focus on UACR testing and new treatment adaptation to improve CKD prognosis is warranted.

Background: Resting heart rate is a potent predictor of various renal outcomes. However, the decline rate of renal function in ischemic stroke patients is not well defined. We tested the association of heart rate with estimated eGFR decline and the composite renal outcomes in patients with recent ischemic stroke.

Methods: The data of 9366 patients with ischemic stroke with an eGFR of ≥30 mL/min/1.73 m² were retrieved from the Chang Gung Research Database. Mean initial in-hospital heart rates were averaged and categorized into 10-beats-per-minute (bpm) increments. The outcomes were the annualized change in eGFR across the heart rate subgroups and composite renal outcomes, namely a ≥40% sustained decline in eGFR, end-stage renal disease, or renal death. Generalized estimating equation models were used to determine the annualized change in eGFR and Cox proportional hazards regression models were used to estimate the relative hazard of composite renal outcomes by referencing the subgroup with a heart rate of <60 bpm.

Results: The annual eGFR decline in the patients with a mean heart rate of <60, 60-69, 70-79, 80-89, and ≥90 bpm was 2.12, 2.49, 2.83, 3.35, and 3.90 mL/min/1.73 m², respectively. Compared with the reference group, the adjusted hazard ratios for composite renal outcomes were 1.17 [95% confidence interval (CI), 0.89-1.53), 1.54 (95% CI, 1.19-2.00), 1.72 (95% CI, 1.30-2.28), and 1.84 (95% CI, 1.29-2.54] for the patients with a heart rate of 60-69, 70-79, 80-89, and ≥90 bpm, respectively. In the subgroup analysis, the associations between higher heart rate and both eGFR decline and composite renal outcomes were more evident and statistically significant in patients without atrial fibrillation.

Conclusions: A higher heart rate is associated with a faster rate of eGFR decline and an increased risk of composite renal outcomes after ischemic stroke, particularly in patients without atrial fibrillation. These results underscore the importance of heart rate monitoring and management in ischemic stroke patients in sinus rhythm to potentially mitigate renal function decline. Further studies are needed to explore this relationship in patients with atrial fibrillation and across different ethnic groups.

Background: Access to deceased donor kidney transplantation may be restricted in the event of resource limitation induced by extreme peaks in activity or local major incidents, which exceed centre capacity. An organ-sharing protocol was developed by the five London transplant units in 2019 to establish a system for safe transfer of organs and recipients between five regional kidney transplant units. We describe the activity and outcomes over the initial 20-month period.

Methods: National data on kidney transplants performed via the collaborative scheme were obtained from National Health Service Blood and Transplant. Outcomes data was collected locally and analysed.

Results: Sixteen recipients were transplanted between November 2020 and July 2022. The reasons for referral were theatre capacity and an information technology systems failure. Donor kidneys were from 10 brainstem death donors (62.5%) and six circulatory death donors (37.5%). Half of the donors fulfilled standard criteria. Twelve patients (75%) were first transplant recipients. Three (18.75%) were highly sensitized (calculated reaction frequency ≥85%). Three (18.75%) patients required arterial reconstruction. Seven patients (43.75%) had delayed graft function. Median creatinine at 12 months post-transplantation was 134 µmol/L. The median length of stay was 7.5 days. Three recipients (18.75%) died within the first year, two from SARS-CoV-2 infection.

Conclusions: This unique organ sharing collaborative scheme involving five hospitals in London enabled 16 transplants to proceed which otherwise would not have occurred. Although initially established for low-risk donors and recipients, the scheme has evolved to enable transplantation for a wide variety of recipients of varying complexity.

Diagnosing and managing antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) remain a challenge for many clinicians, due to the complexity of the disease manifestations and its treatment. There has been a paradigm shift in ANCA vasculitis management, where treatment incorporates both emergency life- and organ-saving procedures and longer-term care to manage relapse and co-morbidity risk and the complications of organ damage. Here, we highlight 10 key tips for the management of ANCA-associated vasculitis based on current evidence and clinical experience. First, we advise making the diagnosis as early as possible, emphasizing the importance of using high-quality ANCA assays. Second, we recommend the use of glucocorticoids in combination with rituximab and/or cyclophosphamide as induction therapy. Third, plasma exchange should be considered in patients with severe renal impairment and diffuse alveolar haemorrhage. We advise the use of rapidly reducing glucocorticoid regimens and advocate consideration of avacopan early in the disease course. We recommend the use of rituximab as maintenance therapy and routine monitoring of kidney function, proteinuria, ANCA and immunoglobulin levels at baseline and during follow-up. The use of prophylactic antibiotics in susceptible patients and timely vaccination schedules is discussed. Rituximab is the preferred immune suppressive for treatment of relapse. Finally, we recommend switching treatment modalities in patients whose vasculitis is refractory to induction therapy and to consider plasma exchange in selected patients. These key tips aim to provide the necessary guidance to improve patient outcomes and reduce adverse events.

Background: The shortage of applications for fellowships in nephrology is a worldwide challenge. This is the first survey to explore in Europe the reasons physicians choose (and do not choose) a career in nephrology.

Methods: An anonymous questionnaire was sent to the presidents of societies that are members of the European Renal Association (ERA), who invited trainees and nephrologists to respond. Statistical analysis was performed using SPSS v.26. (SPSS Inc., Chicago, IL, USA). Continuous variables were compared by Student's t-test or by one-way ANOVA.

Results: Responders included 516 (49%) females and 542 (51%) males. They comprised 278 (26%) trainees, and 780 (74%) nephrologists. The majority (64%) believe that students have an unfavourable perception of nephrology. For trainees, nephrology is not considered an attractive option due to 'chronically ill patients' (35%), 'lack of contact during undergraduate training' (37%), 'nephrology is too challenging' (38%), 'poor remuneration' (22%), 'negative role models' (15%), and 'long working hours' (14%). The factors with the greatest impact on choosing a career include a positive role model (46%), practical experience during medical school and early postgraduate training (42%).

Conclusion: Trainees emphasize that work-life balance is very important for the younger generation. A strong mentorship along with early engagement is associated with a higher likelihood of pursuing a career in nephrology. It is crucial to create a strategy that will provide a positive experience, renew the interest in nephrology careers and ensure enough nephrologists to treat the growing number of patients with kidney disease.

Background: The outcomes of patients with infective endocarditis (IE)-associated acute kidney injury (AKI) are poorly understood.

Methods: This retrospective cohort study was conducted in a tertiary hospital in China to analyze the short- and long-term outcomes among patients with IE-associated AKI. The risk factors for 90-day mortality, long-term outcomes and kidney non-recovery were analyzed via multivariable logistic regression, the Cox regression, and the Fine-Gray competing risk model, respectively.

Results: Among 294 patients with IE-associated AKI, 14.3% died within 90 days, and the risk factors for 90-day mortality were similar to those identified in the general IE population. Among the 230 AKI survivors in whom 90-day kidney recovery could be assessed, 17.4% did not recover kidney function at 90 days. Kidney non-recovery at 90 days was associated with an increased risk of the long-term composite outcome of mortality, end-stage renal disease or sustained doubling of serum creatinine [hazard ratio (HR) 3.00, 95% confidence interval (CI) 1.19-7.59]. Five variables were related to kidney non-recovery: low baseline estimated glomerular filtration rate (eGFR) (HR 2.52, 95% CI 1.73-3.65), stage of AKI (HR 3.03, 95% CI 2.07-4.42 for stage 3), shock (HR 5.56, 95% CI 3.02-10.22), glomerulonephritis-related AKI (HR 3.04, 95% CI 1.93-4.77) and drug-related AKI (HR 2.77, 95% CI 1.86-4.13).

Conclusion: Patients with IE-associated AKI had a high 90-day mortality, and a substantial proportion of survivors did not recover kidney function at 90 days. Kidney non-recovery at 90 days was associated with adverse long-term outcomes. Low baseline eGFR, severe AKI, shock, drug-related AKI and glomerulonephritis-related AKI were risk factors for kidney non-recovery.

Background: Kidney complications associated with anticancer drug therapy have greatly increased recently. We aimed to investigate the real-world clinical outcomes of anticancer drug therapy-associated renal complications in Japan using the national kidney biopsy database, Japan Renal Biopsy Registry (J-RBR).

Methods: From 2018 to 2021, 449 cases from 49 facilities identified as 'drug-induced' histopathology in the J-RBR were screened, of which a total of 135 were confirmed as anticancer drug-related cases and included in the analysis. Overall survival rates were estimated using the Kaplan-Meier method and compared by logrank test. The Cox regression model was used to evaluate the association between variables and deaths.

Results: The most common primary sites of malignancies were the lung (33.3%), followed by gastrointestinal (16.3%) and gynaecological (11.1%) cancers. Tubulointerstitial nephritis (TIN; 47.4%) and thrombotic microangiopathy (TMA; 35.6%) were the most frequent diagnoses. All immunoglobulin A nephropathy, minimal change disease and crescentic glomerulonephritis (CrGN) cases were immune checkpoint inhibitor related. All CrGN cases were anti-neutrophil cytoplasmic antibody negative. Antibiotics were most frequently used concomitantly with anticancer drugs in TMA cases among subgroups (TMA versus others: 62.5 versus 27.5%; P < .001). Among TMA cases, the serum lactate dehydrogenase level tended to be higher in cytotoxic agent-associated TMA (CTx-TMA) than in other TMAs, but was not significant between groups (415.5 versus 219.0 U/l; P = .06). Overall survival was worse in CTx-TMA than in other TMAs (P = .007). The Cox model demonstrated proton pump inhibitor (PPI) use (hazard ratio 2.49, P = .001) as a significant prognostic factor, as well as the presence of metastasis and serum albumin level.

Conclusions: Our registry analysis highlighted various presentations of biopsy-proven kidney complications associated with anticancer drug therapy. Clinicians should be aware of worse outcomes associated with CTx-TMA and the prognostic role of PPI use.