Current Opinion in Nephrology and Hypertension最新文献

Purpose of review: Sulfate is essential for the sulfation of proteoglycans to maintain cell function. The mechanisms regulating the 'ins and outs' of systemic sulfate balance remain incompletely understood. SLC26A1 is an anion exchanger expressed in the kidney. It has recently been identified as a key regulator of plasma sulfate homeostasis in humans. This review summarizes current insights into SLC26A1 function and its role in human diseases.

Recent findings: Slc26a1-knockout mouse models exhibit reduced plasma sulfate and abnormal sulfate and oxalate homeostasis, accompanied by augmented susceptibility to acetaminophen-induced liver injury and kidney stone disease, although findings on oxalate homeostasis are inconsistent. In humans, rare and common SLC26A1 variants are associated with hyposulfatemia, musculoskeletal abnormalities, and, in some cases, nephrolithiasis. Functional assays confirm disrupted sulfate and oxalate transport of damaging variants. However, the knockout mouse models have been incompletely characterized, and few patients with damaging SLC26A1 variants have been characterized regarding sulfate and oxalate homeostasis and associated diseases.

Summary: SLC26A1 emerges as a key regulator of sulfate homeostasis, with potential roles in hepatic detoxification, skeletal integrity, and kidney stone disease. Additional mouse models with tissue-specific gene deletion are needed to delineate the role of SLC26A1 in sulfate and oxalate homeostasis as well as disease pathogenesis. Identification of additional patients with damaging variants in SLC26A1 as well as larger population studies may help to elucidate causal relationships of SLC26A1 activity with clinical outcomes.

Purpose of review: Acute kidney injury requiring dialysis (AKI-D) is a growing global health problem with high mortality. This perspective re-evaluates the role of acute peritoneal dialysis in the modern management of AKI-D, challenging the prevailing extracorporeal paradigm and highlighting its potential in various clinical scenarios.

Recent findings: We review the current evidence comparing peritoneal dialysis to other renal replacement therapies, demonstrating comparable outcomes in many cases. We discuss the advantages of peritoneal dialysis, including hemodynamic stability, avoidance of anticoagulation, and cost-effectiveness, which make it an ideal choice for specific patient populations and in resource-limited settings. We explore the history of underutilization and provide concrete guidance on prescribing acute peritoneal dialysis.

Summary: Peritoneal dialysis is a versatile and effective therapy for AKI-D that deserves renewed consideration. A paradigm shift is needed to integrate acute peritoneal dialysis into mainstream clinical practice through enhanced education, robust research, and the development of standardized protocols.

Purpose of review: Diabetic kidney disease (DKD) is the leading cause of chronic kidney disease (CKD) and end-stage renal disease (ESRD) worldwide, disproportionately affecting underserved and safety-net populations.

Recent findings: Los Angeles County Department of Health Services (LAC-DHS) Kidney Health Workgroup has developed pragmatic population health frameworks and Expected Practices for DKD co-management with primary-care providers: pragmatic definitions of low kidney function (LKF, <50% of normal) and very low kidney function (VLKF, <25%), and proteinuria severity classification as early (>150 mg/g), heavy (>1 g/g), and massive (>7 g/g) to guide referral urgency; biopsy-agnostic diagnosis of DKD when four out of five criteria are met, including diabetes history or A1c more than 6%, LKF, proteinuria, diabetic microangiopathy, and larger kidney length (>12 cm) or faster CKD progression (>25 ml/min/year); Kidney Disease Integrated Therapy (KDIT) combining four medication categories (RAAS blockade, SGLT2 inhibitors, GLP-1 agonists, nonsteroidal mineralocorticoid antagonist) and renal nutrition and lifestyle medicine (PLADO/PLAFOND diets), adequate hydration, and exercise; and eConsults to support timely detection, dialysis vascular access placement, shared decision-making, and ESRD care coordination.

Summary: The DKD management model demonstrates that resource-limited systems can deliver innovative, high-quality kidney care and provide a scalable framework for equity-focused and pragmatic kidney care in municipal health systems.

Purpose of review: Heart failure and chronic kidney disease are frequently comorbid, with both characterized by salt and water retention that lead to clinical deterioration. Peritoneal dialysis can effectively treat fluid overload and maintain euvolemia but remains underutilized. This review addresses the use of peritoneal dialysis in heart failure, including its potential advantages and also its challenges.

Recent findings: The 2019 Advancing American Kidney Health initiative incentivized increased use of peritoneal dialysis in the United States. There is, therefore, growing recognition of peritoneal dialysis's appropriateness for heart failure, in that it can effectively remove volume, often with greater hemodynamic stability than intermittent hemodialysis. Peritoneal dialysis additionally avoids the risk of systemic bloodstream infection, which may be particularly high risk for patients with cardiac devices. System and logistic challenges remain for more widespread uptake of peritoneal dialysis in people with kidney failure and heart failure, including limited ability to urgently start peritoneal dialysis and clinician and hospital inexperience.

Summary: Peritoneal dialysis is an effective therapy for heart failure in individuals with kidney failure but remains underutilized. Strategies for increased uptake include provider education and greater structural and logistic support, particularly in the inpatient setting.

Purpose of review: Artificial intelligence (AI) and machine learning (ML) are rapidly transforming healthcare, but their adoption in nephrology and dialysis remains relatively limited.

Recent findings: This review highlights key applications of AI in kidney disease, including prognostic modeling, imaging, personalized anemia and fluid management, patient engagement, and research acceleration. While numerous studies demonstrate improved prediction accuracy and clinical insights, translation into routine practice is rare. Examples such as the Anemia Control Model (ACM) demonstrate that AI can simultaneously improve clinical outcomes and reduce costs, though widespread adoption will require rigorous validation, seamless integration into clinical workflows, regulatory approval, and above all, clinician trust.

Summary: AI in nephrology shows promise for personalized care and cost reduction, as demonstrated by tools like the Anemia Control Model. Yet, broad adoption requires rigorous validation, seamless workflow integration, regulatory clearance, and clinician trust. Future opportunities include digital twins, large language models, and multiomics integration, with AI poised to enhance both patient outcomes and system performance.

Purpose of review: Continuous renal replacement therapy (CRRT) is an essential support modality for patients with acute kidney injury (AKI) and hemodynamic instability. Circuit clotting remains a major limitation to efficacy. The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend regional citrate anticoagulation (RCA) as the preferred method of anticoagulation in CRRT for patients without contraindications. The guidelines also emphasize tailoring anticoagulation strategies to individual patient needs and institutional capabilities.

Recent findings: Strategies to prevent CRRT circuit clotting can be broadly categorized into nonpharmacological and pharmacological approaches after optimization of blood flow rate, catheter function and CRRT modality. Nonpharmacological methods include prefilter dilution and intermittent saline flushes. Pharmacological strategies include systemic heparin and RCA. Heparin remains the most widely used anticoagulant globally due to its availability and low cost; however, citrate is favored for its safety profile, including use in patients with liver failure in the absence of shock.Despite KDIGO recommendations, utilization of RCA remains limited in the United States. In a recent survey, only 28% of patients received citrate during CRRT, while 29% received no anticoagulation. Notably, U.S. nephrologists reported managing approximately 41% of CRRT patients without anticoagulation. Within our hospital network, prefilter dilution is the most common strategy for anticoagulation. We present case-based scenarios to illustrate practice variation and to support efficient decision-making when managing critically ill patients requiring urgent CRRT initiation.

Summary: Both heparin and RCA are effective anticoagulation strategies in CRRT, with RCA preferred for its favorable safety profile. Nonetheless, nearly half of U.S. nephrologists report providing CRRT without anticoagulation. In our practice, we typically initiate CRRT without anticoagulation and reserve pharmacological agents for cases complicated by frequent filter clotting.

Purpose of review: To examine recent developments in shared decision making (SDM) interventions for advanced chronic kidney disease (CKD) and end-stage kidney disease (ESKD). Given the complexity of treatment decisions and low patient engagement despite available options, SDM is a critical approach to improve treatment initiation and engagement.

Recent findings: Three recent SDM interventions were identified: DART (Decision-Aid for Renal Therapy), a decision support patient-centered video tool for older patients with stages 4-5 CKD that significantly reduced decisional conflict and improved treatment knowledge; YoDCA (Yorkshire Dialysis and Conservative Care Aid), a 28-page patient-centered decision support tool supporting dialysis versus conservative management decisions; and SIMPLIFY-HD (Stroke-Prevention Strategies in Patients With Atrial Fibrillation Receiving Maintenance Hemodialysis), an encounter-based decision aid for patient-provider use. These interventions demonstrated improved decision quality, reduced decisional conflict, and enhanced patient knowledge.

Summary: While recent advances show promise for enhancing patient knowledge and decision-making among older adults with kidney disease, significant gaps remain. Limited real-world testing, narrow focus on older populations with late-stage disease, and insufficient integration of multimorbidity present implementation challenges. Future research should prioritize rigorous randomized controlled trials, broader patient inclusion, multimorbidity integration, clinician training, and assessment of long-term clinical outcomes to achieve patient-centered kidney care.

Purpose of review: Postoperative acute kidney injury (PO-AKI) is a common complication associated with increased morbidity and mortality. Despite its frequency, guidelines for the prevention of PO-AKI are relatively recent and still based on weak or contradictory evidence. This review aims to summarize large recent studies published in the past 2 years that have attempted to address these gaps.

Recent findings: While the POST-CABGDM and Stop-or-Not trials have provided additional evidence on the preoperative prescription of RAAS and SGLT2 inhibitors in selected surgical settings, future research must integrate preoperative risk profiling to personalize therapy. Likewise, although the POISE-3 trial seems to suggest that maintaining a mean arterial pressure of at least 60 mmHg is crucial in noncardiac surgery, it does not explore how targets might be personalized. In cardiac surgery, both the SIRAKI02 trial (i.e., extracorporeal blood purification membrane connected to the cardiopulmonary bypass) and the PROTECTION trial (i.e., intraoperative amino-acid infusion) demonstrated benefit only for mild AKI, raising questions about their mechanistic basis and clinical significance.

Summary: "Prevention is better than cure," a principle that holds particularly true for PO-AKI, a common complication that still lacks effective curative treatments. Although the recent abovementioned trials have yielded important findings, they concurrently underscore the significant obstacles in conducting clinical trials on PO-AKI and in formulating robust recommendations based on their outcomes.

Purpose of review: Remote monitoring in peritoneal dialysis and its practical implementation is an important technology to leverage in optimizing automated peritoneal dialysis delivery. The more advanced our remote monitoring capabilities become, the greater the urgency to implement protocols to appropriately utilize and leverage the technology for the betterment of patient care. Debates about its utility tend to center around two main issues: responsibility and skepticism around the findings of studies that examined its utility, owing to a combination of hyperbolic claims and methodology variations. This review discusses the theory behind remote monitoring, the available data and capabilities, and a path forward towards adopting remote monitoring in peritoneal dialysis.

Recent findings: Numerous clinical studies have demonstrated the association of remote monitoring protocol implementation with reduced hospitalization rates, shorter hospital stays, decreased automated peritoneal dialysis technique failure, and longer time on peritoneal dialysis.

Summary: There is a need for standardized remote monitoring in peritoneal dialysis protocols. Fewer reported hospitalization rates, shorter hospital stays, and lower automated peritoneal dialysis (APD) technique rates are some of the findings demonstrated in remote monitoring studies. While it is more costly to implement than traditional automated peritoneal dialysis, the reported benefits of remote monitoring outweigh the cost burden. Patients have an overall positive perception and experiences with remote monitoring-APD. Remote patient monitoring provides an additional invaluable resource to enhance the quality of care delivered to.

Purpose of review: Staff-assisted peritoneal dialysis (PD) is commonly used in many countries but remains largely unavailable in the United States. This limits access to PD for patients with physical, cognitive, and psycho-social barriers to self-care - the group of patients who may benefit the most from home dialysis. This review explores the global experiences, the limited U.S. implementations, and proposes a pathway for national adoption.

Recent findings: Published reports demonstrate that assisted PD is safe and effective. It is comparable to self-care PD and in-center hemodialysis in outcomes such as peritonitis, hospitalization, and mortality. Assisted PD facilitates PD uptake and retention, thus increasing PD utilization and supporting growth of home dialysis. International models vary in scope, services, and staffing, showing flexibility in design. In the United States, limited programs have demonstrated feasibility. Widespread adoption faces barriers including reimbursement and regulatory challenges. Using the diffusion of innovations lens, assisted PD is still at the "innovator" stage, hindered by perceived complexity, limited trialability, and lack of visibility.

Summary: Assisted PD is supported by strong clinical evidence and allows more equitable care. Demonstration projects, standardized templates, supportive reimbursement models, and leadership from nephrology societies and policy makers are critical to help the US nephrology community move from evidence to practice.