Current Opinion in Nephrology and Hypertension最新文献

Purpose of review: Acute metabolic acidosis is a common complication in critically ill patients and is associated with increased morbidity and mortality. Management of acute metabolic acidosis varies widely in clinical practice, with limited randomized trial data to support a standardized approach. This review will provide an overview of the literature regarding the management of acute metabolic acidosis and the potential risks associated with these therapies.

Recent findings: Correction of metabolic acidosis with sodium bicarbonate has not been associated with a reduction in mortality, although does reduce the need for kidney replacement therapy in high-risk patients with coexisting moderate to severe acute kidney injury. Additionally, there is not a clear association between correction of acidosis and improvement in overall hemodynamics in critically ill patients. The risks of sodium bicarbonate therapy and kidney replacement therapy are not insignificant and must be thoughtfully weighed against the benefits of correcting a metabolic acidosis.

Summary: The management of acute metabolic acidosis should be tailored to the individual patient, with careful consideration of the risks and benefits associated with sodium bicarbonate use and kidney replacement therapy discussed in this review. Additional randomized human trials are needed to better define the role for these therapies in critically ill patients.

Purpose of review: Acute tubulointerstitial nephritis (ATIN) is a common cause of acute kidney injury (AKI) that requires diagnosis specific management. Currently available diagnostic tests lack accuracy to distinguish ATIN from various other etiologies of AKI increasing reliance on kidney biopsy for diagnosis, which is associated with procedural risks and possible diagnostic and interventional delays. This review highlights the recent efforts focused on identifying diagnostic biomarkers and addressing this important clinical challenge.

Recent findings: Numerous research groups have harnessed the increasing knowledge of inflammatory proteins and cytokines upregulated in ATIN to identify reliable diagnostic biomarkers, these include C-X-C motif ligand 9, tumor necrosis factor alpha, interleukin-9, urinary regulated on activation normal T cell expressed and secreted, among others. Parallel work has also focused on identifying imaging and pathological markers associated with ATIN as well as a diagnostic model that combines currently available clinical tests for ATIN diagnosis.

Summary: Biomarkers have shown promise as diagnostic tools for ATIN; however, most studies have limitations such as small sample sizes, and lack of external validation. Future progress will rely on larger collaborative efforts to identify the most accurate biomarker or combination of biomarkers for integration into diagnostic workup of ATIN.

Purpose of review: To reposition kidney stone disease within the cardiovascular-kidney-metabolic continuum and synthesize recent evidence on therapeutics, clinician-supervised digital monitoring, and value-based care implementation to modernize prevention and follow-up.

Recent findings: Epidemiology shows a rise in kidney stone disease prevalence across cardiovascular-kidney-metabolic stages independent of demographics. Comparative-effectiveness analyses suggest fewer stone events with sodium-glucose cotransporter-2 inhibitor(s) vs. active comparators, while early randomized data demonstrate meaningful reductions in urinary supersaturation in phenotype-matched stone formers. Digital hydration programs using validated connected bottles and just-in-time prompts increase 24-h urine output in feasibility studies; at-home urine pH and urine conductivity measurement offer pragmatic proxies for day-to-day risk. However, clinical validation, privacy governance, and regulatory readiness of software-as-a-medical-device remain variable.

Summary: Embedding kidney stone disease prevention within a cardiovascular-kidney-metabolic program supports value-based outcomes. A hybrid "Care, Remote Monitoring, Medication optimization, Nudges pathway" links early risk identification to telemonitoring and titration. Integrating urinary lithogenic profiling into cardiovascular-kidney-metabolic screening flags asymptomatic patients with lithogenic profiles before a first stone, enabling prevention of stones and chronic kidney disease progression. Priorities consist in validation of digital urinary biomarkers (time-in-target volume/pH) and deployment of hybrid care. This patient-centred hybrid model can shift current episodic procedures to anticipatory, measurable, and scalable prevention within routine cardiovascular-kidney-metabolic care.

Purpose of review: Hypertension remains a leading modifiable risk factor for cardiovascular and renal conditions and dementia. Given its rising global prevalence and economic burden, artificial intelligence offers promising solutions across the care continuum, from diagnosis to monitoring. This review highlights recent advances in artificial intelligence-driven diagnosis and monitoring, risk stratification, and predictive modelling of hypertension-related outcomes.

Recent findings: Using artificial intelligence-based technologies, validated wearable cuffless monitors are developed, which use electrocardiography, heart sounds, and thoracic impedance data and provide continuous blood pressure (BP) monitoring. Artificial intelligence-generated algorithm have shown promising response to accurately predict BP. The Extreme Gradient Boost has consistently performed as the best algorithms. Additionally, these models have been used in predicting hypertension impact on cardiovascular, renal, and retinal conditions, and in predicting treatment strategies. Emerging applications of Large Language Models are being developed to provide personalized care based on individual patient characteristics.

Summary: Artificial intelligence has the potential to transform hypertension management through improved diagnosis, monitoring, and personalized care and prediction of its systemic consequences. However, challenges of model validation, interpretability, generalizability, and ethics persist. Robust prospective trials and equitable implementation strategies can help realise the potential of artificial intelligence in improving hypertension outcomes.

Purpose of review: This review provides a comprehensive examination of the current inequities and ethical challenges in kidney transplantation and highlights some of the most urgent issues related to organ allocation and emerging technologies.

Recent findings: Several recent news and media reports have significantly undermined public trust in the organ transplantation and allocation process. This review discusses some of these controversies and proposes strategies to restore confidence in the system. With advancements in gene editing, xenotransplantation is becoming a tangible reality, bringing forth new ethical challenges explored in this paper. Likewise, as artificial intelligence continues to permeate medicine and moves closer to integration within transplantation, proactive preparation and ethical foresight are essential.

Summary: In conclusion, we aim to draw attention to pressing ethical dilemmas in kidney transplantation and suggest actionable steps to restore trust.

Purpose of review: The purpose of this review is to discuss antineutrophil cytoplasmic antibody (ANCA) vasculitis (microscopic polyangiitis and granulomatosis with polyangiitis) and how we have arrived at our current guidelines and treatment methods. The goal is to offer a greater understanding of major clinical trials in the field, and how they have enabled treatment options which have led to reduced morbidity and improved survival for patients.

Recent findings: Our understanding and treatment of ANCA vasculitis has changed tremendously over the past 40 years, from a condition with a high mortality without significant treatment options, to a treatable condition. We have moved from the use of more toxic therapies such as Cyclophosphamide towards more common use of rituximab for both induction and maintenance regimens. More recently, the focus has been on attempting to reduce steroid burden and toxicity. The approval of avacopan (a C5a inhibitor) enables a more rapid steroid taper regimen along with usual induction therapy with rituximab or cyclophosphamide. Readers will have the chance to learn about new targets being evaluated for the treatment of ANCA vasculitis.

Summary: ANCA Vasculitis is complex with varying presentations. Through collaboration among multiple specialists, including nephrologists, rheumatologists, pulmonologists, ENT specialists, and neurologists, we are able to achieve a diagnosis and offer organ and life-saving treatments for our patients.

Purpose of review: The 2023 CONVINCE trial demonstrated improved survival with high-dose hemodiafiltration (HDF), prompting discussions about widespread adoption. However, this clinical advancement occurs amid growing awareness of healthcare's environmental impact, particularly dialysis treatments that consume extensive water and energy resources. This review examines the environmental implications of HDF adoption, synthesizing recent evidence on resource consumption and emerging sustainability solutions in the context of the climate crisis facing nephrology.

Recent findings: Life cycle assessments indicate HDF has a carbon footprint 30-40% higher than conventional hemodialysis, consuming an additional 10 300 L of water per patient annually. However, recent technological innovations show promise: expanded hemodialysis (HDx) using medium cut-off membranes reduces water usage by >20% and energy consumption by >30% compared to HDF while potentially achieving similar clinical outcomes. Water conservation technologies, including reverse osmosis, reject water reuse and reduced dialysate flow protocols, can decrease environmental impact by 30-50% without any difference in patient outcomes.

Summary: The adoption of HDF represents a critical test case for sustainable healthcare innovation. While the potential benefits should not be ignored, technology is not static and, if confirmed, additional sustainability work and comprehensive policy frameworks integrating environmental impact assessments into technology evaluation are urgently needed. The nephrology community must balance clinical excellence with planetary stewardship through technological innovation, resource optimization, and evidence-based environmental guidelines that benefit, not compromise, patient care.

Purpose of review: As the health impacts of climate change intensify, health systems globally are transitioning to net zero greenhouse gas emissions and climate resiliency. Kidney care has high environmental impact, and both a coordinated sectoral approach as well as provider-level quality care improvements are needed. Updated, evidence-based strategies for operationalizing environmentally sustainable kidney care are provided.

Recent findings: As Earth warms, rising temperatures are adversely impacting kidney health, and both the prevalence and severity of kidney diseases are projected to worsen. Kidney care providers seek ways to implement planetary healthcare, and a framework of improved education, ongoing research activities, enhanced sustainability performance metrics reporting and accountability is described. Optimized disease prevention through nonpharmacologic as well as pharmacologic strategies, ensuring appropriateness of care [some examples include stewardship of laboratory testing and dialysis prescriptions, increased transplantation (preferably live donor) for those living with kidney failure], and lower impact care through technological improvements and better waste management are described.

Summary: Environmentally sustainable kidney care is high-quality care that is implementation-ready in diverse settings.

Purpose of review: Optimal blood pressure control is essential for managing chronic kidney disease (CKD), as it can reduce cardiovascular risk and mortality. However, recent updates in major international guidelines present differing recommendations for blood pressure targets in CKD, contributing to clinical uncertainty. This review summarizes studies to clarify the benefits and risks associated with lower blood pressure targets in patients with CKD.

Recent findings: Recent randomized trials and meta-analyses show that targeting lower systolic blood pressure (<120 mmHg) reduces cardiovascular events and all-cause mortality in nondialysis CKD, with benefits similar to those in the general population. Importantly, these trials used standardized blood pressure measurements that typically yield lower readings than routine office measurements. Lower blood pressure targets may increase the risk of incident CKD and acute kidney disease (AKI). Benefits for slowing CKD progression are mostly seen in patients with significant proteinuria. Patients with advanced CKD and heavier proteinuria remain underrepresented in the trials.

Summary: Lower blood pressure targets, measured via standardized techniques, confer important cardiovascular benefits in CKD. However, kidney outcomes and safety concerns require individualized blood pressure target selection, especially in frail or other high-risk subgroups that were often excluded from trials. Clinical practice should continue to balance the benefits of lower blood pressure goals with risks of acute kidney injury and other adverse events.

Purpose of review: The prevalence of both obesity and hypertension is increasing in childhood, with considerable overlap in disease and causative factors. Evidence from studies over the past decade suggests both obesity and hypertension have summative effects on both cardiac remodelling in childhood and major adverse cardiovascular events in adulthood.

Recent findings: We highlight recent high-quality evidence reporting epidemiology of obesity, hypertension and hypertension-mediated organ damage (HMOD) in those with obesity-related hypertension. We discuss the early life influences on BP and BMI trajectory and the clustering of cardiovascular risk factors (CVRFs) seen in obesity hypertension. We discuss management options highlighting key contributors to compounding risk for obesity-associated hypertension across the first two decades of life, with potential windows for both individual and population-level intervention.

Summary: Currently, a large and expanding cohort of young people with multiple CVRFs is progressing toward adulthood, where they are likely to experience disproportionate cardiovascular morbidity when compared with age-matched healthy peers. These trends underscore the urgent need for co-ordinated healthcare responses to manage affected children and for robust governmental and public-health interventions to mitigate the environmental and societal drivers of this convergent epidemic.