Current Opinion in Nephrology and Hypertension最新文献

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.

Purpose of review: Cardiovascular diseases (CVD) are the leading cause for morbidity and mortality, and hypertension (HTN) remain the most important modifiable risk factor for CVD with poor control rates. All guidelines recommend lower blood pressure (BP) target that has made BP control rates in the community even worse. There is high unmet clinical need for novel therapies in HTN that could help achieve lower BP targets consistently across all patient subgroups.

Recent findings: There have not been many novel therapies successfully developed for HTN in the last 30 years. Successful therapies such as renal denervation (RDN) or endothelin receptor antagonist aprocetantan have major limitations (poor response rate with RDN, fluid retention and modest BP reduction with aprocetantan) that restricts their use in large cohorts. Novel therapies including RNAi Zilebesiran and aldosterone synthase inhibitors (lorundrostat and baxdrostat) have demonstrated efficacy and safety in large, robust randomized controlled trials with good safety/tolerability and clinically significant BP reduction consistent across all sub-groups.

Summary: Novel therapies (Zilebesiran, lorundrostat, baxdrostat) have shown great potential in lowering BP that is clinically meaningful to help improve cardiovascular and renal outcomes. ASI therapies lorundrostat and baxdrostat are close to being licensed for HTN. Once commercially available and recommended in treatment guidelines, the next big challenge will be reimbursement and implementation model in different healthcare systems.

Purpose of review: Hypertension management is a gateway for cardiovascular risk reduction. The status of hypertension treatment and control is low in resource-limited lower income countries and similar settings in middle-income and high-income countries. Implementation of strategies for prevention and management of hypertension can lead to a substantial increase in its control and decline in associated cardiovascular mortality and disease burden.

Recent findings: Population-wide and clinical interventions that can be deployed in resource-limited settings globally to improve hypertension control have been summarized in the WHO's Global Report on Hypertension (2025). Focusing on social determinants (poverty, hunger, literacy, clean energy, economic growth, inequalities, sustainable cities, and climate action) can lead to primordial prevention, and risk factor control (such as salt reduction, physical activity, pollution, obesity, and a healthy diet) for primary prevention. Guidelines emphasize simplified medical treatment with algorithm-based single-pill combinations. Specific strategies that focus on nonphysician health worker-led interventions to promote identification and adherence to treatment in low-resource settings ae important. Technology-based interventions for the identification of hypertension and promotion of adherence need more studies.

Summary: Primordial and primary prevention of hypertension, combined with interventions that support clinical management and promote adherence to therapies, are important for resource-limited settings to reduce cardiovascular risk.

Purpose of review: Synthetic high-flux membranes are currently the most widely used dialyzers worldwide. In Japan, super high-flux membranes have been in widespread use for some time, but in recent years, S-type dialyzer membranes have also been reported to improve prognosis. Today, super high-flux membranes with a larger pore size make it possible to remove large-molecule toxins, such as α 1 -microglobulin. This review focuses on the prognostic benefit of super high-flux and S-type dialyzer membranes.

Recent findings: Until 2012, dialyzers in Japan were classified based on their β2-microglobulin (β2MG) clearance rate as type I (<10 ml/min), type II (≥10-30 ml/min), type III (≥30-50 ml/min), type IV (≥50-70), or type V (≥70 ml/min). It has been reported that type IV and V dialyzers are associated with a good prognosis. Dialyzers are now classified as type I-a, I-b, II-a, or II-b, based on a combination of β2MG clearance and the sieving coefficient for albumin. Moreover, the S-type dialyzer has been defined as having high biocompatibility, improving solute removal by adsorption, and having anti-inflammatory and antioxidant properties.

Summary: Type IV and V dialyzers with a β2MG clearance rate of ≥50 ml/min are considered to improve the prognosis of patients on dialysis. According to the present classification, super high-flux membranes with a β2MG clearance rate of ≥70 ml/min and S-type membranes contribute to a more favorable prognosis.

Purpose of review: This review provides a comprehensive overview of self-cannulation in home hemodialysis (HHD), highlighting key elements essential for successful implementation.

Recent findings: Despite policy support, self-cannulation is underutilized. Early patient education, patient-centered care, and shared decision-making can increase interest in self-care. Comprehensive support strategies, including needle-phobia assessment and management, cannulation aids, and effective training, build patient confidence and competence.

Summary: A multifaceted approach, including education, empowerment, and effective training, is crucial for successful self-cannulation. By incorporating individualized cannulation technique selection and comprehensive support, care providers can empower patients to adopt self-cannulation and HHD. Further research is needed to address knowledge gaps and promote best practices.

Purpose of review: The healthcare system is increasingly burdened by the rising number of patients with end-stage kidney disease (ESKD), alongside a parallel surge in obesity. However, use of peritoneal dialysis in patients with obesity has been met with caution despite increasing recognition of advantages of home dialysis. This review addresses these concerns and outlines evidence-based guidelines for effective management.

Recent findings: Contemporary analysis of peritoneal dialysis cohorts demonstrates that catheter-related complications are not higher in patients with obesity compared to normal weight using basic or advanced laparoscopic methods, and even percutaneously placed catheters can achieve good outcomes using technical advancements. A meticulously identified and well placed exit site facilitates infection free peritoneal dialysis delivery in patients with obesity. It is important to recognize that adipocytes have a significantly lower water content; therefore, adjusted body weight is proposed to estimate the volume of distribution and the clearance of small solutes more accurately. The practice of incremental dialysis and use of Icodextrin for long dwells help limit glucose exposure and manage related metabolic complications. Recent evidence does not support the notion that peritoneal dialysis modality alters the impact of obesity on likelihood of transplantation or overall survival.

Summary: Obesity is associated with adverse outcomes in dialysis patients; however, these effects are comparable between hemodialysis and peritoneal dialysis, and are not more pronounced in peritoneal dialysis. With careful technical and clinical considerations, peritoneal dialysis therapy can be effectively delivered to patients with obesity without imposing undue burden. Therefore, obesity should not be viewed as a contraindication to peritoneal dialysis.

Purpose of review: In patients with advanced chronic kidney disease (CKD), risk factor reversals occur where obesity and elevated LDL cholesterol paradoxically associate with improved survival. This review synthesizes recent advances in understanding these obesity and lipid paradoxes, integrating insights from body composition, inflammation, and metabolism.

Recent findings: Observational studies have shown stage-specific survival advantages of obesity, mainly in hemodialysis populations and among patients with inflammation. The lipid paradox is also largely explained by the confounding effects of inflammation, which suppresses cholesterol levels. Beyond quantitative assessment, emerging evidence emphasizes that assessments of body composition and lipid quality are stronger predictors of clinical outcomes. For severely obese patients, integrative strategies using lifestyle, nutritional therapy, and pharmacologic agents may modulate inflammation, reducing the risk of protein-energy wasting. Weight loss from GLP-1 receptor agonists or bariatric surgery may improve kidney transplant eligibility but requires careful individual assessment to balance this benefit with the risk of malnutrition.

Summary: The obesity and lipid paradoxes in CKD are not merely anomalies nor statistical fallacies to be adjusted for, but manifestations of CKD's distinct metabolic milieu. Their recognition highlights the need for individualized approaches beyond conventional risk factor modification. By integrating assessment of body composition, nutrition, and inflammation, precision nephrology can provide tailored interventions that improve prognosis.

Purpose of review: C3 glomerulopathy is a complex, relatively recently elucidated topic with many diagnostic and therapeutic developments over the last 10 years. The authors aim to update the general, glomerular disease, and transplant nephrology audience regarding these new discoveries.

Recent findings: C3 glomerulopathy (C3G) includes a spectrum of disorders both etiologically, and morphologically, like dense deposit disease. Further developments in related glomerular pathologies like immune complex mediated membranoproliferative glomerulonephritis (ICMPGN), C3 monoclonal immunoglobulin deposition disease (C3-MIDD), and post infectious glomerulonephritis (PIGN) are emerging. Increases in molecular testing have revealed genetic links to alternative complement and acquired nephritic and anticomplement antibodies as playing an etiologic role. This alongside new pharmaceutical developments have moved the field forward significantly. There are also two new pivotal pharmacological agents approved by the United States Food and Drug Administration (USFDA). The new pharmacological pathways involve Factor B blockade (iptacopan) and C3 blockade (pegetacoplan).

Summary: The new diagnostic, genetic, and molecular developments are discussed; changes in nomenclature and taxonomy are reviewed. Finally, landmark trials (such as the APPEAR-C3G and VALIANT, respectively) are reviewed to provide clinicians and clinician researchers with a timely update of new events in C3G.

Purpose of review: Home dialysis remains variable and underused globally despite clinical and quality of life benefits for patients. Due to low patient volumes in many centers, it is challenging for nephrology trainees to gain adequate clinical exposure to achieve competency and comfort in patient management. In this review, we highlight the University of Toronto-affiliated University Health Network (UHN) and St. Michael's Hospital (SMH) Home Dialysis Fellowship as an educational model to improve competency and comfort in home dialysis.

Recent findings: The UHN/SMH Home Dialysis Fellowship offers diverse clinical exposure with over 300 patients on peritoneal dialysis and home hemodialysis. Trainees achieve competency through repetitive exposure to a large volume of patients. The fellowship leverages continuity and longitudinal follow-up across all stages of a patient's chronic kidney disease journey. The program fosters interprofessional collaboration to develop comprehensive patient management plans. The attending physicians are leading world experts and support the varied trainee academic and career goals through mentorship and sponsorship.

Summary: The UHN/SMH Home Dialysis Fellowship program combines evidence-based medical education principles with high volume, diverse, and complex patient populations to offer trainees an exceptional learning experience and the foundations to become the next generation of home dialysis experts.