Current Opinion in Nephrology and Hypertension最新文献

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.

Purpose of review: Cuffless blood pressure (BP) technologies have moved from concept to everyday wearables, spurred by consumer adoption and recent regulatory milestones. Yet clinicians face mixed signals on accuracy, calibration stability, and clinical use. This review synthesizes current evidence and emerging standards to clarify where cuffless data can add value.

Recent findings: Most devices estimate BP from surrogate signals and require periodic calibration, making outputs reliable for trends around the last calibration but less so for absolute values. New cuffless-specific validation frameworks mandate dynamic testing (position/hydrostatics, activity/exercise, awake-sleep, pharmacologic response, and prerecalibration drift). Professional bodies currently advise against diagnosis or drug titration using cuffless readings unless a device passes such protocols. Real-world studies show feasibility and patient preference but only moderate agreement with cuffs and limited outcomes data. Special populations (chronic kidney disease/dialysis, pregnancy, pediatrics/frail, diverse skin tones) introduce additional accuracy and equity concerns.

Summary: Cuffless wearables may be used as adjuncts to surface patterns and support engagement; diagnosis and treatment decisions must be confirmed with validated upper-arm measurements. A pragmatic "good-enough" checklist includes stable calibration over weeks, accuracy across dynamic states and subgroups, and transparent multisite validation. Priorities include harmonized standards, inclusive datasets, and trials linking cuffless monitoring to clinical outcomes.

Purpose of review: Medullary sponge kidney (MSK) is a congenital disorder of the distal nephron, characterized by cystic dilatation of the papillary and medullary tubules. It commonly presents with recurrent calcium nephrolithiasis and often, severe, life-altering chronic pain syndromes, often independent of urinary obstruction and of uncertain etiology. Management focuses on stone prevention and symptomatic care, but these measures are frequently inadequate. No studies of management of this pain syndrome in these patients have been performed. There are essentially no studies evaluating renal denervation in MSK specifically, although the technique has been utilized with some benefit in other disorders, underscoring a major therapeutic gap. In this review, we describe patients with MSK and chronic pain syndrome and review the role of renal denervation as a potential therapy.

Recent findings: Renal denervation may represent a promising strategy for chronic kidney pain syndrome. It could provide pain relief and improve quality of life in affected patients.

Summary: The optimal management strategy for chronic pain in MSK has not been elucidated. Renal denervation has recently been utilized and approved for the management of blood pressure. It could be useful for managing chronic kidney pain in this condition as well.

Purpose of review: There is growing evidence that personalisation of hypertension treatment leads to better blood pressure control. This review will explore current evidence for individualised treatment of hypertension, and application of this in future guidelines.

Recent findings: Recent studies demonstrate considerable inter-individual variability in responses to specific antihypertensives. Factors such as ethnicity, sex, age, BMI and genetics contribute to differences in blood pressure and cardiovascular risk. There is emerging ethnicity data that may help to support targeted pharmacotherapy. Advances in genetics, particularly through large-scale genome-wide association studies (GWAS), have given us insight into individual genetic determinants of blood pressure. The development of polygenic risk scores (PRS) also show promise for future precision-guided treatment. This review will examine both intra-individual and inter-individual variability in blood pressure control and treatment response using evidence to date.

Summary: Personalised hypertension care is an evolving field. Our review highlights the importance of refining clinical guidelines to better account for individual differences in blood pressure and treatment response.

Purpose of review: Provide an overview of the rationale for implementing time-limited dialysis trials (TLT-Ds) in critically ill older adults with acute kidney injury treated with dialysis, the communication strategies required for proper implementation, and future research directions.

Recent findings: AKI-D is linked to high mortality, reduced renal recovery, and a substantial chance of discharge to nursing homes in older adults. Many older people value independence and quality of life over longevity. Yet acute dialysis often remains the reflexive treatment option, while patients and families face prognostic uncertainty in the face of mortality. A TLT-D is an ethically sound, person-centered approach that aligns with many patients' preferences. Its benefits include providing a structured opportunity for clinicians, families, and patients to assess the biomedical efficacy of dialysis while allowing time for deliberation, prognostic clarity, and emotional processing. This can inform whether to continue acute dialysis or transition to comfort care or chronic dialysis within prespecified or evolving goals.

Summary: Acute dialysis decision-making for critically ill older adults needs improvement. Reflexive initiation followed by automatic transition to chronic dialysis may not align with many patients' goals. TLT-Ds can promote goal-concordant care. Further research is needed to guide their implementation and evaluate person-centered outcomes.

Purpose of review: Long-term kidney allograft survival remains limited by chronic rejection and the toxicities of lifelong immunosuppression. Donor-specific tolerance, the acceptance of the graft without continuous pharmacological therapy, has long been considered the ultimate goal of transplantation. This review summarizes recent clinical advances in tolerance-inducing strategies and outlines future directions for clinical translation.

Recent findings: Clinical progress has accelerated in the past decade. Mixed hematopoietic chimerism protocols have matured from single-center feasibility studies to a recent phase 3 randomized trial in human leukocyte antigen (HLA)-identical recipients, achieving sustained immunosuppression-free survival with improved safety outcomes regulatory T cell therapies, tested across multiple early-phase trials, have consistently demonstrated safety, biological activity, and scalability in multicenter settings, with new approaches entering clinical development.

Summary: Tolerance in kidney transplantation is transitioning from conceptual aspiration to clinical feasibility. Landmark chimerism trials confirm that operational tolerance is possible in selected populations. Future priorities include refining conditioning regimens to reduce toxicity and extending eligibility to higher-risk recipients. Together, these developments suggest that tolerance-based strategies may ultimately transform kidney transplantation from chronic immunosuppression to durable immune re-education.

Purpose of review: High-dose methotrexate (HDMTX) is an integral component of treatment for multiple malignancies. However, preventive strategies often fail, resulting in renal impairment and delayed methotrexate elimination (DME), which increases the risk of systemic toxicity. This review aims to summarize past, current, and emerging strategies for the management of HDMTX-related toxicity.

Recent findings: Recent research has identified host genetic factors, hypoalbuminemia, and larger body surface area as contributors to DME. Animal studies have explored potential nephroprotective agents, including synthetic 1,3,4-oxadiazole (5b) and repurposed drugs such as empagliflozin and amlodipine. The preferred mitigation agent, glucarpidase, continues to demonstrate improved clinical and financial outcomes, with higher odds of renal recovery even at lower doses. Early therapeutic drug monitoring has shown promise as a biomarker for predicting acute kidney injury. In addition, the web-based clinical tool MTXPK.org now integrates population pharmacokinetic models with patient-specific data to guide interpretation and management of DME.

Summary: Identification of emerging risk factors, advances in pharmacogenomics, and timely methotrexate monitoring, combined with patient-specific pharmacokinetic modeling, underscore the importance of personalized therapeutic strategies to reduce renal toxicity and DME.

Purpose of review: High blood pressure is the leading risk factor for premature death and disability globally. Despite availability of effective treatment, prevention, and control of high blood pressure remain suboptimal worldwide. This review examines trends in hypertension prevalence, awareness, treatment, and control and highlights evidence-based strategies to improve hypertension care.

Recent findings: Hypertension awareness, treatment, and control remain inadequate globally. Recent evidence suggests that universal healthcare facility-based screening, increased accessibility and affordability of fixed-dose combination therapies, and team-based care approaches can improve the management of hypertension along the care cascade.

Summary: To prevent death and disability globally, the implementation of evidence-based strategies and policy recommendations targeting the multifactorial barriers to hypertension management and control is essential.

Purpose of review: Chronic kidney disease (CKD) remains one of the costliest conditions in healthcare, yet value-based payment (VBP) reforms have produced limited improvements in cost or quality. Existing renal payment models rely on annual benchmarks that fail to reflect the longitudinal reality of CKD care. This precludes the possibility of observing a dose-response relationship in clinician-level interventions, effectively invisible in current VBP structures.

Recent findings: Advances in clinical informatics and predictive modeling demonstrate the feasibility of sub-annual, patient-level risk estimation for CKD outcomes and costs. Standardized electronic health record and claims data enable longitudinal, clinician-level analysis. This can transform retrospective, aggregate VBP into dynamic forecasting systems reflecting real-world care delivery. Short-horizon prediction reveals temporal, dose-response relationships between guideline-aligned interventions and downstream events that remain obscured by annualized VBP frameworks.

Summary: CKD is a clinically and economically compelling testbed for next-generation VBP design. Patient-level modeling with sub-annual risk prediction is the next step in modernizing payment frameworks to align incentives. Future VBP policy should shift models beyond static, annual metrics toward EHR-native, temporally precise evaluation frameworks that reward meaningful preventive care for patients, clinicians, and payers.

Purpose of review: Microvascular inflammation (MVI) is a central feature of allograft rejection, traditionally associated with antibody-mediated rejection (AMR), but its mechanisms and clinical impact extend beyond this framework. This review highlights recent updates in the Banff classification, insights into the mechanisms underlying MVI, and how these developments may refine diagnostic approaches and guide the development of therapeutic strategies.

Recent findings: The spectrum of MVI has been refined, with DSA-negative C4d-negative MVI and probable AMR now recognized as distinct entities associated with adverse graft outcomes. Mechanistic studies highlight the complementary roles of non-HLA antibodies, NK-cell-driven alloreactivity, and T-cell mediated injury. Molecular diagnostics have advanced our understanding of rejection phenotypes, while donor-derived cell-free DNA has emerged as the most robust and noninvasive biomarker of active microvascular injury. Novel therapies, particularly CD38-directed treatments such as felzartamab, have shown promising results in AMR but their efficacy across all MVI phenotypes remains to be established.

Summary: MVI represents a heterogeneous spectrum of alloimmune injuries that extends beyond the traditional AMR framework. Combining histology with emerging artificial intelligence tools, molecular diagnostics, and noninvasive biomarkers, will offer a more integrated approach to diagnosis, risk stratification, and development of novel therapies.