Contributions to nephrology最新文献

Clinical Background: Older age has been associated with higher prevalence and progression of chronic kidney disease (CKD). The presence of CKD leads to an increased risk of end-stage renal disease, cardiovascular diseases, and death. Epidemiology: Progressive aging of the population is accompanied by an increase in the prevalence of CKD worldwide. The high prevalence of CKD in the aged population would result in a considerably greater social burden. Challenges: Structural and functional changes are often observed in the aged kidney. The main pathological feature of the aged kidney is nephrosclerosis such as arteriosclerosis, glomerulosclerosis, tubular atrophy, and interstitial fibrosis. As a consequence of renal aging, the nephron number decreases. A lower nephron number approximately parallels with the decline in glomerular filtration rate (GFR), and GFR declines with aging. Recent studies have highlighted several pathological mechanisms involved in renal aging, that can serve as targets for intervention. Decreased renal oxygen levels, mitochondrial dysfunction, and inflammation drive renal fibrosis, one of the hallmarks of renal aging. Prevention and Treatment: Novel therapeutic approaches that target these functional changes are now being developed to prevent an aging-associated inevitable loss of renal function. For example, calorie restriction, Sirtuin 1 activator and peroxisome proliferator-activated receptor-γ agonists have the potential to ameliorate renal deterioration. This chapter provides an overview of the aged kidney and summarizes the current knowledge on therapeutic strategies to attenuate renal aging.

Clinical Background: Cigarette smoking is one of the leading causes of preventable deaths, including cardiovascular diseases and cancer. However, the effects of tobacco use on chronic kidney disease (CKD) are less widespread. Epidemiology: Smoking tobacco is associated with proteinuria and attenuation of glomerular filtration rate in the general population of different ethnicities. Smoking also accelerates the progression of established CKD and aggravates proteinuria along the wide spectrum of causes determining kidney disease. Furthermore, smoking worsens the survival of kidney transplant recipients and shortens graft survival. Most of the effects of tobacco exposure are dose and time dependent and could be ameliorated with smoking cessation. Challenges: In the last decades, tobacco use policies and regulations were implemented around the world obtaining a global 6% reduction in smoking prevalence. However, the reduction was not proportionally equal in all the geographical areas around the world. The region of Americas experimented the most positive result in reducing smoking prevalence. Smoking trends in South East Asian and Eastern Mediterranean regions show minor decrease or increased rates. The World Health Organization projected reaching a global target prevalence of 15% by 2025. Prevention and Treatment: The results showing smoking cessation slows the progression of kidney disease in smokers should drive our effort to help our patients quit smoking. Smoking prevention at the population level, and particularly in those at risk of CKD or with established CKD should be part of health policies and regulations all around the world.

Clinical Background: The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) rapidly spread globally from late 2019, reaching pandemic proportions. Epidemiology: The related disease, COVID-19, exacerbates and progresses due to patients' abnormal inflammatory/immune responses, widespread endothelial damage, and complement-induced blood clotting with microangiopathy. COVID-19 manifests mainly as a respiratory illness. In cases of severe viral pneumonia, it may lead to acute respiratory distress syndrome, respiratory failure, and death. Challenges: Many extrapulmonary manifestations commonly occur, and a substantial proportion of patients with severe COVID-19 exhibit signs of kidney damage. Clinically, kidney involvement ranges from mild/moderate proteinuria and hematuria to acute kidney injury (AKI) requiring renal replacement therapy (RRT). The pathophysiologic mechanisms of kidney damage and AKI in patients with COVID-19 remain unclear but are known to be multifactorial. Current knowledge implies direct SARS-CoV-2-dependent effects on kidney cells (tubular epithelial cells and podocytes) and indirect mechanisms through the systemic effect of viral infection secondary to the critical pulmonary illness and its management. Prevention and Treatment: Standard-of-care strategies apply, as there is no specific evidence to suggest that COVID-19 AKI should be managed differently from other types in severely ill patients. If conservative management fails, RRT should be considered. The choice of RRT approaches and sequential extracorporeal therapies depends on local availability, resources, and expertise. The focus should now be on the long-term follow-up of COVID-19 patients, especially those who developed kidney injury and dysfunction. This represents an opportunity for integrated multidisciplinary research to clarify the natural history of COVID-19 renal sequelae and the best therapeutic interventions to mitigate them.

Obstetric-related acute kidney injury (obstetric AKI) is an important and complex public health problem; its early recognition and proper treatment are key in preventing maternal and fetal adverse outcomes. While the incidence of obstetric AKI has drastically declined in some developing countries due to reduction of sepsis-related causes, the opposite has been observed in other developed nations in the last decade due to advanced maternal age and the presence of comorbidities. The diagnosis of obstetric AKI has been made difficult by the physiologic decrease in serum creatinine of pregnancy as well as the absence of a uniform definition for AKI in this population. The most common causes of obstetric AKI include pre-renal etiologies such as hyperemesis gravidarum and post-abortal sepsis, intra-renal causes which comprise the thrombotic microangiopathies (preeclampsia/HELLP, thrombotic thrombocytopenic purpura, pregnancy associated-hemolytic uremic syndrome, lupus nephritis), and post-renal causes due to obstruction from kidney stones or iatrogenic injuries during delivery. A kidney biopsy is rarely required and should be reserved for cases where the diagnosis will change management, preferably before the third trimester. A multidisciplinary approach with the maternal-fetal-medicine specialist and nephrologist, along with the intensivist and hematologist may be needed. In this review, we will present the latest updates on the global epidemiology, focus on the most challenging thrombotic microangiopathy diagnoses, summarize treatment recommendations, and delineate the ongoing challenges as well as novel strategies to tackle this public health burden which does not seem to be disappearing.

Clinical Background: Although chronic kidney disease (CKD) and smoking are both associated with high rates of morbidity and mortality, the interplay between the two is not widely understood. Epidemiology: The incidence of CKD progression has been shown to be significantly higher among current and former smokers, and continued smoking thereafter has been associated with a nearly twofold higher risk of death. Challenges: Because it is a silent disease, CKD is often diagnosed in advanced stages, which underscores the importance of targeted, active screening for CKD. When CKD progresses to stage 5, life expectancy is drastically shortened unless life-saving renal replacement therapy (dialysis or kidney transplantation) is initiated. The treatment of smoking, which is a risk factor for CKD, also poses a challenge. Less than 10% of adults who want to quit smoking succeed in doing so, and those who do quit typically succeed only after making multiple attempts. In addition, many smokers have limited access to smoking cessation services, are unaware of available resources, or have misconceptions about smoking cessation therapies. Prevention and Treatment: There is evidence that quitting smoking may help prevent the development of CKD. However, glomerular filtration rates have been found to be higher in smokers than in nonsmokers, which could confound efforts to recognize smoking as a major risk factor for kidney disease. Efforts should continue to focus on the prevention of smoking, and nephrologists should promote smoking cessation as a means to prevent CKD progression.

Clinical Background and Epidemiology: Low physical activity is a common phenotype in individuals living with chronic kidney disease (CKD). It increases as renal function declines and is associated with adverse clinical outcomes and a poor quality of life (QOL). Both behavioral and disease-related factors contribute to the low physical activity levels in CKD. CKD has profound negative effects on skeletal muscle structure and function that are related to impairments in mitochondrial function, inflammation, oxidative stress, metabolic acidosis, and other uremia-related factors. These factors promote muscle protein catabolism and wasting, and impair strength, physical performance, and cardiorespiratory fitness. Moreover, the high burden of comorbid disease contributes to patient fatigue, fear of injury, and poor exercise self-efficacy. All of these factors reinforce patient's sedentary behavior, leading to a vicious cycle of disease and disability that further compromises their health and QOL. Data from both observational studies and exercise interventions indicate that increasing levels of physical activity may provide a range of benefits in CKD patients, including attenuating declines in renal function, and improving markers of physical function, cardiovascular disease risk, and QOL. Unfortunately, these results have not led to widespread implementation of exercise programs in CKD, and physical inactivity and poor physical function remain hallmarks of the disease worldwide. Challenges and Solutions: There are many frequently cited barriers to implementing exercise programs in CKD. These include: a lack of training and knowledge about physical activity/exercise prescriptions and interventions among health professionals; inadequate time to implement exercise programs due to other clinical responsibilities; a lack of specific funding and incentives to develop these programs; and a poor quality of the data demonstrating efficacy of exercise. Many CKD patients also are unmotivated to incorporate exercise into their daily lives due to time constraints, depression, and other comorbid diseases, and poor self-efficacy for exercise. Given these barriers, it is not surprising that physical activity/exercise programs have not become a component of standard of care for CKD patients. We discuss several potential solutions to address these barriers, including: (1) providing better education and training for healthcare professionals who provide exercise advise and counselling to individuals with CKD; (2) providing incentives to reimburse payers to develop and maintain exercise programs in CKD; and (3) providing more personalized approaches to exercise prescription and implementation of exercise programs that consider the unique circumstances of individual CKD patients. In summary, low physical activity levels in CKD patients result from a combination of many factors that adversely impact patient's health and QOL. Addressing this problem will require comprehe

Digital health is an area that emerges from the association between health needs and technological solutions. With the growing access of people to the internet and the ease of acquiring equipment that allows internet connection, we are observing an exponential increase in the strategies that use technology to connect patients and healthcare providers. Telenephrology is a channel of communication that facilitates the access to the nephrologist for both primary care physicians and patients and has been implemented in several countries. Applications for smartphones are frequently used by both patients and healthcare providers, and these tools are changing the way we practice nephrology and medicine in general. Social networks emerge as an important way of communicating between healthcare professionals and patients and a source of connection for people with the same interests. Artificial intelligence, big data, and other technological solutions, including wearable devices that measure and monitor different health parameters, are revolutionizing healthcare and the field of nephrology. Implantable devices are in development, including devices to monitor electrolytes in dialysis patients, systems to track medication intake, wearables to monitor exercises, monitoring of blood pressure, heart rate, arrhythmia, and peripheral oxy-hemoglobin saturation, among others. The wearable artificial kidney, a device which would perform renal function during ambulation and social activities outside of the hospital, has been under investigation for many years. In this chapter, we highlight the most recent advances in digital health applied to nephrology.

Kidney disease is frequently described as a public health problem. This chapter will unpack what we mean by "public health" and by "taking a public health approach." We will consider the global burden of kidney diseases and their determinants, with a focus on chronic kidney disease. We will explore the aetiology of chronic kidney disease across the life course and the way in which kidney health frequently reflects inequities in societal health, therefore requiring a public health response. We will describe some of the public health endeavours that help address these problems and then introduce epidemiology as the core science of public health. We will describe the common epidemiological study designs with a focus on observational studies and explore the role of the various study designs in addressing different types of research question, and thereby contributing to distinct aspects of disease understanding. We will introduce concepts of primary and secondary prevention and explore the ways in which the application of different epidemiological study designs has contributed to the knowledge and understanding of kidney diseases. We will discuss the strengths and weaknesses of different study designs and explain how epidemiological methods allow for the quantification of public health problems.