Current Opinion in Nephrology and Hypertension最新文献

Purpose of review: Blood pressure (BP) monitoring is crucial to detect and manage postdonation hypertension early; however, obtaining accurate BP readings and regular BP monitoring remains challenging.

Recent findings: While office BP (OBP) measurement is almost universal, implementing accurate OBP readings by utilizing automatic office BP (AOBP) can be challenging due to its time-consuming. Moreover, OBP cannot be performed regularly, especially in a telemedicine setting. Out-of-office BP (OOOBP) can overcome the challenges in obtaining accurate OBP readings and monitoring BP. While 24-h ambulatory BP monitoring remains the gold standard for diagnosing hypertension in living kidney donors (LKDs), its availability is limited. Since OOOBP relies on the patients' BP measurement technique, technologies can help facilitate and enable LKD to check their BP accurately and regularly, including self-measured BP monitoring (SMBPM) and automatic remote BP monitoring. Cuffless BP monitoring offers convenience to the patients; further validation is required. Utilizing technologies for BP measurement is a proposed intervention to increase adherence to BP measurement and monitoring.

Summary: While several BP measurement modalities can provide accurate BP readings, some facilitate better accuracy, especially unattended BP measurements and should be implemented for BP monitoring to mitigate cardiovascular outcomes in LKD.

Purpose of review: This review examines the role of indoxyl sulfate, a gut-derived uremic toxin, in the development of anemia in chronic kidney disease. It dissects the cellular and biochemical mechanisms through which indoxyl sulfate suppresses erythropoietin production, disrupts iron metabolism, and promotes oxidative stress and inflammation.

Recent findings: Indoxyl sulfate interferes directly with the hypoxia-inducible factor pathway, thereby reducing the transcriptional activation of erythropoietin. In parallel, indoxyl sulfate-induced oxidative stress damages red blood cells and accelerates premature cell death, while its stimulation of pro-inflammatory pathways further downregulates erythroid progenitor cell function. Therapeutic strategies such as dietary protein modulation, gut microbiota interventions, oral adsorbents, and enhanced dialysis modalities have shown promise in lowering indoxyl sulfate levels and, consequently, improving erythropoietin responsiveness and iron homeostasis in chronic kidney disease patients.

Summary: The review synthesizes evidence from clinical and experimental studies that position indoxyl sulfate as a central yet underappreciated mediator of anemia in chronic kidney disease. Indoxyl sulfate establishes a vicious cycle that exacerbates anemia and contributes to erytropoiesis-stimulating agent hyporesponsiveness. The article advocates for targeted interventions aimed at reducing indoxyl sulfate burden, which could transform anemia management in chronic kidney disease and pave the way for personalized treatment strategies.

Purpose of review: In April and May of 2024, the state of Rio Grande do Sul in southern Brazil faced one of the most devastating natural disasters in its history. Torrential rains caused catastrophic flooding, affecting over 2.4 million people and damaging critical infrastructure. Among the most vulnerable were individuals with chronic kidney disease, particularly those dependent on dialysis or immunosuppressive therapy following kidney transplantation. This narrative report describes the impact of the floods on nephrology services, highlights systemic vulnerabilities, and outlines the responses by the Brazilian Society of Nephrology, healthcare providers, government authorities and other stakeholders.

Recent findings: Drawing on field reports and institutional data, the article details breakdowns in transportation, communication, water and power supply, and the cascading challenges affecting dialysis provision. It also documents mitigation efforts, including patient relocation, resource reallocation, inter-institutional collaboration, and telemedicine deployment. Although no deaths due to lack of dialysis were reported, the crisis exposed the fragility of health service continuity in extreme events.

Summary: This event underscores the urgent need to incorporate disaster preparedness into nephrology service planning. Strategies must be tailored to the specific geographic and infrastructural contexts of each region and integrated into broader public health emergency frameworks. The lessons learned offer valuable insights for strengthening healthcare system resilience in the face of climate-related disasters.

Purpose of review: To describe the current evidence and emerging role of continuous glucose monitoring (CGM) and automated insulin delivery (AID) systems in the management of diabetes among individuals with advanced chronic kidney disease (CKD) undergoing dialysis.

Recent findings: Recent studies have shown that CGM provides accurate and clinically useful glucose data in people with advanced CKD requiring dialysis. CGM enables the detection of glycaemic variability and hypoglycaemia patterns that are often missed by traditional monitoring methods, such as capillary blood glucose testing and haemoglobin A1c. While observational studies show benefits, randomised controlled trial data are limited. Early trials and case series suggest that AID, especially fully closed-loop systems, may improve glycaemia in dialysis-dependent individuals with diabetes, though evidence is currently sparse and primarily focused on type 2 diabetes. Several ongoing and planned studies aim to address these knowledge gaps.

Summary: CGM represents a valuable tool for improving glucose management and safety in people with diabetes and advanced CKD, but barriers to widespread use, such as cost, access, and healthcare provider familiarity, remain significant. AID technologies show promise but require further evaluation in this population. Future research should prioritise long-term outcomes, cost-effectiveness, and patient-reported outcomes to support the integration of these technologies into routine care for this high-risk group.

Purpose of review: Children with kidney diseases are among the most vulnerable populations in disaster settings due to their age-specific physiological features, need for specialized care, and dependence on caregivers. This review highlights the importance of disaster preparedness tailored to pediatric kidney patients and proposes practical measures.

Recent findings: Natural and man-made disasters continue to disrupt healthcare globally, often leading to poor outcomes in patients with chronic diseases. Despite international efforts, preparedness for pediatric kidney patients - including those with chronic kidney disease not on dialysis, those on hemodialysis or peritoneal dialysis, and transplant recipients - remains limited. Disasters frequently cause medication shortages, treatment interruptions, underdialysis, and increased risk of infection. Pediatric patients face unique logistical and clinical challenges, such as lack of age-appropriate dialysis supplies and trained personnel.

Summary: Disaster preparedness strategies at the unit, regional, and national levels are essential to reduce risks and improve outcomes for pediatric kidney patients during disasters. These strategies must include pediatric-specific resources, trained personnel, caregiver education, and integration with broader emergency systems and official authorities. International nephrology societies and humanitarian organizations can also provide valuable support.

Purpose of review: Kidney diseases affect around 850 million people globally and are a growing public health burden, with high rates of associated cardiovascular mortality and no major decline in age-standardized mortality compared to other noncommunicable diseases. Climate change is an inequitable driver of kidney diseases, and climate-related disasters can disrupt access to life-sustaining kidney replacement therapies. Conversely, the care of patients with kidney diseases contributes to greenhouse gas emissions, pollution, and generates large amounts of waste.

Recent findings: Environmentally sustainable kidney care planning is pursuing kidney care practices and innovations that minimize environmental harm while remaining patient-centered and cost-effective. An adaptation and mitigation framework (a structured approach to developing adaptation strategies, policies, and measures) to guide this is lacking.

Summary: We propose the 'PASIGE' framework to guide climate science integration in kidney care planning -> Prevent: approaches to prevent kidney disease, its progression to kidney failure, and complications; Adopt: sustainable lifestyle, practices and therapies; Screen: targeted population screening for early detection and identification of kidney disease; Innovate: technology, manufacturing, procurement, energy sources and transportation; Generate: sustainably powered and produced low-impact net zero waste kidney replacement therapies resilient to climate threats; and Enhance: patient engagement, care quality, and system resiliency.

Purpose of review: This review examines the impact of earthquakes on nephrology services and patients, highlighting the urgent need for integrated disaster preparedness in renal care. With earthquakes increasing in frequency and affecting densely populated regions, the relevance of this topic to both clinical practice and policy has never been greater.

Recent findings: Earthquakes disrupt dialysis infrastructure, impede access to care, and create surges in acute kidney injury (AKI) due to crush syndrome. Hemodialysis (HD) services are highly vulnerable to power, water, and transportation failures, whereas peritoneal dialysis (PD) offers greater resilience but faces hygiene and supply challenges. Special populations - pediatric patients, transplant recipients, and displaced persons - face unique vulnerabilities. Global experiences demonstrate that flexible modalities, patient education, and coordinated international responses can mitigate risks. Despite this, PD remains underutilized and disaster-specific planning is often lacking.

Summary: Earthquakes expose critical weaknesses in nephrology systems but also provide lessons in resilience. Proactive strategies - including PD-first policies, interoperable patient registries, emergency kits, and mobile dialysis units - are essential to protect kidney patients during future disasters. Integrating nephrology into disaster frameworks is both a clinical imperative and a humanitarian necessity.

Purpose of review: The purpose of this review is to describe recent and important updates in acute kidney injury (AKI) phenotyping that help us to move beyond the clinical syndrome of AKI.

Recent findings: Recent studies reinforce the utility of damage biomarker positivity in AKI classification and have found that biomarker positivity (specifically NGAL) adds prognostic information regardless of classification of the AKI according to RIFLE or KDIGO criteria, and regardless of cut-off selection methodology. Novel methodologies for identifying AKI phenotypes and subphenotypes are currently being developed and integrated subclassification approaches e.g. combining biomarker and transcriptomic approaches, have been found to be more informative than using a single approach alone to identify AKI phenotypes. Consortiums have developed in partnership between academia and industry to identify consensus endotypes for critically ill adults and children.

Summary: There are prognostic and treatment benefits to AKI phenotyping and subphenotyping which allow us to provide a customized approach to AKI care. Challenges currently exist to implementation of AKI phenotyping at the bedside but ongoing projects are already seeking solutions for feasible bedside identification of subphenotypes using machine-learning or point-of-care biomarker assays. Future research in this area will focus on the ability to recognize and link endotypes, subphenotypes and phenotypes in AKI.

Purpose of review: To examine the disruption of kidney care services in Sudan following the 2023 conflict, highlighting the compounded risks faced by dialysis and transplant patients during crises, and offering evidence-based strategies for future emergency preparedness.

Recent findings: The conflict in Sudan exposed deep systemic weaknesses in an already under-resourced nephrology infrastructure. Hemodialysis centers were damaged or shut down, supply chains collapsed, and patient displacement became widespread. Over 70% of patients experienced treatment interruption and many died due to missed dialysis sessions or transplant rejection. Emergency responses were delayed and uncoordinated. In contrast, experience from Ukraine and Gaza disasters illustrate how registry-based evacuation and cross-border planning can save lives. Egypt's subsequent collaboration with WHO and KSrelief (King Salman Humanitarian Aid and Relief Center) offered a late but instructive model for regional support.

Summary: Sudan's crisis demonstrates how kidney patients suffer disproportionately from adverse effects of disasters when health systems collapse. Displacement may become a survival tactic in the absence of formal evacuation or support plans. Embedding kidney care into disaster response-through registries, mental health support, cross-border agreements, and sustainable NCD programming-is urgently needed. Global momentum, such as WHA78's kidney resolution, must now translate into national preparedness for fragile settings.