Clinical Kidney Journal最新文献

Immunoglobulin A nephropathy (IgAN) remains the most common primary glomerulonephritis globally. Advances in mucosal immunology have illuminated the role of dysregulated B cell activity, galactose-deficient IgA1 (Gd-IgA1) and Gd-IgA1-specific antibody formation in driving disease pathogenesis. Therapeutic targeting of the mucosal immune system and, more specifically, B cell survival and differentiation pathways have entered late-stage development, offering a mechanistically guided approach to disease modification. Targeting of the gut-associated lymphoid tissue of the terminal ileum, B cell activating factor and/or a proliferation-inducing ligand antagonists and CD38-targeted agents have all demonstrated efficacy in reducing proteinuria and preserving kidney function. Emerging cellular and bispecific platforms, although early in development, raise the prospect of deeper immunologic remodelling. Precision tools such as Gd-IgA1 quantification, single-cell transcriptomics and pharmacogenomics are being explored to optimise treatment selection and duration. As real-world data and long-term safety outcomes accumulate, B cell-directed therapies are likely to become a commonly used treatment option in IgAN.

Background: Over the last 30 years, with increasing comorbidity and frailty among people with end-stage kidney disease, there is recognition that dialysis may carry little benefit in some patient groups. We examined the utility of the electronic frailty index (eFI), modelling the survival time of patients starting dialysis at a single renal unit in northern England, hypothesising this would give useful prognostic survival information.

Methods: Two datasets describing the same population of patients receiving dialysis over a 226-month period (2000-2019) at a single dialysis unit were used (n = 599 and 553 participants). One dataset was derived from primary care (linked to UK Renal Registry submissions) and the other from the UK Renal Registry (linked with primary care data to facilitate eFI calculation). Retrospective survival analysis was undertaken with hazard ratios for the impact of eFI and other covariates on survival.

Results: The frailty score at dialysis start has a strong effect on subsequent survival time using either the primary care-derived or UK Renal Registry dataset, but there were differences in overall survival and the relation between eFI score and survival between datasets.

Conclusions: This represents the first study of eFI utility within tertiary renal care, demonstrating a strong association between frailty measured by eFI and survival time for patients on dialysis. However, significant differences between primary care-derived and UK Renal Registry-derived survival at different frailty scores were demonstrated. These differences indicate a need for greater understanding and analysis of large datasets before using them to discuss patient treatment choices, service planning and delivery.

Rhabdomyolysis is a clinical syndrome characterized by the breakdown of skeletal muscle, leading to the release of creatine kinase (CK), myoglobin and electrolytes into the circulation. This can result in acute kidney injury and other complications. Common etiologies include trauma, medications and metabolic disorders. We report a case of semaglutide-associated rhabdomyolysis in a 36-year-old obese male who presented with bilateral lower extremity pain, cramping and dark urine 6 days after increasing his weekly dose from 1.7 mg to 2.4 mg. The dose had been titrated weekly from 0.25 mg to 1.0 mg, then to 1.7 mg, and finally to 2.4 mg. Laboratory evaluation revealed markedly elevated CK (16 202 U/L; normal: 20-200 U/L) and liver enzymes (aspartate aminotransferase: 279 U/L, alanine aminotransferase: 77 U/L), consistent with rhabdomyolysis. After excluding other common causes through clinical assessment and diagnostic workup, this case underscores the importance of recognizing this rare but potentially serious adverse effect of semaglutide.

Background: Efficacy studies have demonstrated the benefits of intradialytic exercise. However, real-world effectiveness trials are lacking. This study evaluated a nationwide clinical implementation of intradialytic exercise settled as a routine practice. Implementation of intradialytic exercise and its effectiveness regarding safety, physical function and body composition were investigated.

Methods: This was a retrospective analysis of the first year of implementation using the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation and Maintenance). For effectiveness outcomes, participants (n = 347) were compared with patients who refused the intervention (n = 394), except for physical function in which a pre-post design was performed. Physical function tests included the 8-foot up and go, 30-s sit-to-stand, 5 times sit-to-stand, single leg stance and hand dynamometer. Body composition was determined by multifrequency bioimpedance.

Results: Adoption: 20 hemodialysis units adopted the intervention (55.6%). Reach: 1270 patients were eligible (55.8%). The main reason for non-eligibility was physical/cognitive incapacity (50.8%). Of those eligible (n = 1270), 811 (63.9%) started the intervention and 459 (36.1%) refused. Maintenance: attrition rate was 57.2%. Implementation: patients completed 86.3 ± 29.0 min/week of aerobic exercise and adherence was 75.0% ± 19.7%. Effectiveness: there was a lower incidence of cramps in the exercise group (P < .001). No significant differences were found for other adverse events. A significant improvement was observed for all physical function tests, except for handgrip strength. For body composition, significant differences favorable to the exercise group were found for lean tissue mass (P = .045), lean tissue index (P = .013) and body cell mass (P < .001).

Conclusions: Large-scale intradialytic exercise implementation is realistic, safe and effective. Nevertheless, implementation outcomes were limited, and complementary interventions may be needed.

Patients with advanced cardiovascular kidney metabolic syndrome generally face a high risk of cardiovascular complications. Guideline-directed medical therapies (GDMT) are critical for mitigating cardiovascular risk and improving prognosis. However, patients with more advanced kidney disease have frequently been excluded from the foundational cardiovascular outcome trials, leaving clinicians with a paucity of evidence with regards to the cardiovascular benefits and potential risks involved in initiating or maintaining GDMT for cardiovascular diseases in patients with chronic kidney disease stages 4 and 5. Numerous studies have demonstrated a systematic underutilization of GDMT among patients with advanced chronic kidney disease (CKD), likely caused by a combination of clinical inertia and a legitimate fear of potential side-effects such as hyperkalemia and rises in creatinine, which may necessitate repeat laboratory monitoring, dose adjustment, and additional potassium-lowering treatment. In this clinical review, we aim to summarize the accumulating evidence with regards to the use of key cardiovascular drugs among patients with advanced CKD, with an emphasis on GDMT in patients with heart failure, and outline the treatment approach used in our integrated heart-nephrology-diabetes clinic. Since the evidence is not always clear and our patients are generally both older, frailer, and have more multimorbidity than those included in clinical trials, sound clinical judgment, individual patient tolerability as well as shared decision-making are key. We also address the need to continuously align treatment goals with patient preferences across different phases of life and adjusting GDMT in the face of increasing frailty.

Autosomal dominant polycystic kidney disease (ADPKD) is a complex, multisystemic disorder exhibiting notable sex-related differences in clinical presentation, progression and complications. While the disease affects both sexes, disease expression and complications differ significantly between men and women. This review explores the biological, hormonal and psychosocial sex differences in ADPKD across multiple clinical domains. Men tend to experience faster kidney growth, earlier onset of hypertension and slightly younger age at kidney replacement therapy. Women, in contrast, are more susceptible to polycystic liver disease (PLD), often exacerbated by oestrogen exposure, especially during pregnancy or hormonal treatments. Although urinary tract infections are more prevalent among women, cyst infections show no major sex-based difference in incidence, although men may respond less favourably to antibiotic therapy. Cardiovascular complications, intracranial aneurysms and reproductive health risks also show sex-related patterns. Fertility and reproductive counselling must be individualized, as reproductive challenges and risks differ markedly between men and women. Pregnancy in women with ADPKD, especially those with reduced renal function or PLD, carries increased risks and requires specialized care. Fertility in men with ADPKD is usually preserved, although sometimes it may be impaired due to seminal vesicle cysts and sperm morphological abnormalities. However, assisted reproductive techniques generally achieve outcomes comparable to those of unaffected individuals. Psychosocial aspects such as pain, emotional burden and quality of life are also influenced by sex and require integrated management strategies. While tolvaptan slows disease progression in both sexes, pharmacodynamic responses may differ slightly. Incorporating sex-specific insights into ADPKD care, including hormonal and reproductive considerations, is critical to advancing personalized medicine. Understanding these differences will optimize management and improve quality of life for individuals living with ADPKD.

Background: Hyponatraemia is one of the most common electrolyte disorders. While hyponatraemia can cause severe neurological symptoms, its clinical predictors remain poorly defined. This study aimed to identify factors associated with neurological involvement in patients with severe hyponatraemia.

Methods: This retrospective cohort study included patients with severe hyponatraemia (serum sodium level ≤120 mEq/L) at admission or during hospitalization between January 2014 and June 2024 in two tertiary centres. Neurological symptoms were defined as vomiting, deep somnolence, seizures, coma or cardiopulmonary arrest. Risk factors were evaluated using multivariable logistic regression analysis.

Results: Among 834 patients included in the analysis, the median (interquartile range) age was 73 (62-82) years, 382 (46%) were female and the median serum sodium level was 118 (116-119) mEq/L. Neurological symptoms were observed in 221 (26%). Low serum potassium [<4.0 mEq/L; odds ratio (OR) 1.53; 95% confidence interval (CI) 1.05-2.23] was independently associated with an increased risk of neurological symptoms, together with low serum sodium (<115 mEq/L; OR 2.23; 95% CI 1.49-3.33). Compared with chronic onset, both acute onset (OR 3.92; 95% CI 2.36-6.51) and uncertain onset (OR 2.05; 95% CI 1.40-2.99) also showed significant association with their occurrence.

Conclusion: Low serum potassium, low serum sodium and onset pattern were independent predictors of neurological symptoms in patients with severe hyponatraemia. Particularly in those with these risk factors, careful assessment and individualized management of sodium imbalance may be appropriate to achieve favourable outcomes.