International Journal of Nephrology and Renovascular Disease最新文献

Background: Cisplatin is a cornerstone chemotherapeutic agent used widely to treat various solid malignancies. Despite its efficacy, the usage of cisplatin is limited by its dose-dependent nephrotoxicity causing cisplatin-induced acute kidney injury (AKI) in up to 45% of treated patients. Current preventive strategies are limited to supportive measurement resulting in questionable clinical outcomes. N-acetylcysteine (NAC), a thiol-containing compound with antioxidant and anti-inflammatory properties, is already known for its safety.

Purpose: This review aims to explore the mechanisms of cisplatin-induced AKI, the role of NAC in its prevention, and the current evidence.

Methods: A narrative review has been conducted of several literature, including preclinical and clinical studies evaluating NAC's efficacy in preventing cisplatin-induced AKI.

Results: Cisplatin has cytotoxic effect via DNA structures disruption, leading to impairment of cell repair mechanism, triggering apoptosis that works effectively against cancer cells. However, cisplatin also accumulates in renal proximal tubular epithelial cells, disrupting DNA structures, increasing reactive oxygen species (ROS), inducing mitochondrial dysfunction and inflammation, all leading to apoptosis. NAC can counteract these mechanisms by scavenging ROS directly via its thiol group and indirectly by replenishing glutathione. Preclinical studies have demonstrated consistent NAC nephroprotective effects. However, findings from clinical studies remain inconsistent due to limited sample sizes, varied dosing regimens, and differences in administration routes, making comparison between studies difficult to conduct.

Conclusion: NAC exhibits strong nephroprotective properties through antioxidant, anti-inflammatory, and cytoprotective mechanisms as consistently shown in preclinical studies. Despite the limited current clinical evidence supporting these findings, NAC remains a promising agent for cisplatin-induced AKI prevention. Future research should focus on large-scale, well-designed, standardized clinical trials with optimized dosing strategies to validate NAC's efficacy and establish its clinical role.

Background: Autosomal dominant polycystic kidney disease (ADPKD), the most common inherited kidney disorder, is frequently accompanied by hypertension, with each condition potentially exacerbating the other. This study employs a bidirectional Mendelian randomization (MR) design to investigate the causal relationship between PKD and hypertension, alongside bioinformatics analyses to explore underlying genetic mechanisms.

Methods: Genetic data for PKD and hypertension were obtained from the International Epidemiology Unit (IEU) Genome-Wide Association Study (GWAS) database. A bidirectional MR analysis was performed using nucleotide polymorphisms (SNPs) strongly associated with PKD and hypertension. Genetic annotation and enrichment analysis of SNPs were conducted using the Functional Mapping and Annotation (FUMA) platforms. Gene expression differences between PKD and controls were studied using the GEO database and single-cell data analysis tools. Quantitative PCR analysis of ARL13B mRNA levels in normal renal tubular epithelial cells (RCTEC), renal cystic epithelial cells (WT9-12), and ADPKD kidney tissues.

Results: MR analysis demonstrated a causal effect of PKD on hypertension (IVW: P=0.038; OR=1.011; 95% CI: 1.001-1.021) and a reverse causal effect of hypertension on PKD (IVW: P=0.042; OR=1.195; 95% CI: 1.007-1.420). No significant heterogeneity or pleiotropy was detected. Genetic annotation identified 27 PKD genes closely associated with hypertension. Among them, functional enrichment analysis indicated ARL13B was involved in cilia morphology and dysfunction. Notably, RT-PCR results showed that ARL13B mRNA expression was significantly elevated in human ADPKD kidneys (P<0.001) and WT9-12 cells (P<0.05).

Conclusion: Our bidirectional MR study demonstrated a causal effect of PKD on hypertension and a reverse influence of hypertension on PKD progression. Elevated ARL13B expression in ADPKD suggested a possible involvement of cilia-related pathways in the development of renal hypertension.

Purpose: To evaluate the effect of a novel follow-up mode integrating specialist nurse-led care and an intelligent platform on fluid volume management in patients with end-stage renal disease (ESRD) undergoing peritoneal dialysis (PD).

Patients and methods: A pre- and post-observational clinical cohort of 80 PD patients (Shanghai General Hospital South, Mar 2020-Mar 2021) evaluated the 12-month impact of the novel mode on fluid volume overload (FVL), cardiac function, laboratory indicators (including biochemical parameters and electrolytes), and clinically relevant complications (peritonitis, exit-site/tunnel infection and catheter displacement).

Results: After 12 months of follow-up using the novel mode, significant improvements were observed compared to the traditional follow-up approach. Specifically, levels of B-type natriuretic peptide (BNP) (144.12±14.21 vs 631.01±104.21 pg/mL, P < 0.001), systolic blood pressure (SBP) (136.99±12.04 vs 145.34±15.22 mmHg, P < 0.001), and diastolic blood pressure (DBP) (79.03±6.35 vs 84.87±8.17 mmHg, P < 0.01) were significantly lower in patients managed with the novel mode. Additionally, blood calcium (2.24±0.52 vs 2.18±0.02 pg/mL, P < 0.05), phosphorus (1.96±0.07 vs 1.80±0.06 mmol/L, P < 0.01), parathyroid hormone (PTH) (409.28±43.49 vs 250.84±23.26 pg/mL, P < 0.001), and albumin (38.89±0.60 vs 36.25±0.51 pg/mL, P < 0.001) levels were higher following implementation of the novel mode. FVL and cardiac function also showed significant improvement over the 12-months follow-up period. Notably, compared with the preceding 12-month control period, the platform-based follow-up reduced clinically relevant infectious complications from 10.3% to 3.8% (McNemar mid-p = 0.077).

Conclusion: The novel follow-up mode effectively reduced fluid volume overload and improved cardiac function, offering clinical benefits for PD patients.

Uric acid nephropathy (UAN), driven by sustained hyperuricemia, is an underrecognized but increasingly prevalent contributor to chronic kidney disease (CKD) progression. Mitochondrial oxidative stress and vascular remodeling are central to its pathogenesis. Excess mitochondrial reactive oxygen species (ROS) cause renal tubular injury, impair mitophagy, and activate pro-apoptotic signaling pathways. In parallel, ROS disrupt endothelial homeostasis, promote phenotypic switching of vascular smooth muscle cells, and induce pathological structural changes in the renal microvasculature. These processes are mutually reinforcing, thereby exacerbating inflammation, hypoxia, and fibrosis. This review synthesizes emerging mechanistic insights into the mitochondrial-vascular axis in UAN and discusses therapeutic strategies targeting mitochondrial dysfunction and vascular pathology. Particular emphasis is placed on mitochondria-targeted antioxidants and inhibitors of key signaling pathways as potential interventions to interrupt the ROS-remodeling cycle. We also highlight the need for biomarker development and clinical translation. A more comprehensive understanding of mitochondrial-vascular crosstalk may ultimately enable the development of effective strategies to slow or halt UAN progression.

Purpose: Unhealthy behaviors can accelerate the progression of chronic kidney disease (CKD). This study aimed to evaluate the effectiveness of a community-based integrated care program in modifying key unhealthy behaviors among CKD patients in rural Thailand and to assess the impact of these behaviors on the rate of kidney function decline.

Patients and methods: This is a post-hoc analysis of the ESCORT-2 trial, which is a 3-year prospective cohort study that enrolled 914 patients with CKD stages 3-4 in rural Thailand. Participants received an integrated care program involving hospital-based multidisciplinary teams and home-based community care networks. Seven unhealthy behaviors were assessed annually: usage of herbal medicines, analgesics, and non-steroidal anti-inflammatory drugs (NSAIDs); being overweight; lack of regular exercise; moderate-to-high salt intake; and high protein intake. Data were collected through patient interviews and standardized questionnaires. Changes in the prevalence of these behaviors were analyzed over three years, and the association between persistent unhealthy behaviors and the rate of eGFR decline was examined.

Results: Over the 3-year study period, the integrated care program led to significant and sustained reductions in the use of herbal medicines (23.3% to 5.0%), analgesics (34.9% to 7.8%), and NSAIDs (4.3% to 1.3%) (all p<0.0001). Moderate-to-high salt intake also significantly decreased (22.1% to 14.1%, p<0.0001). However, no significant improvement was observed in the prevalence of overweight or high protein intake. While individual persistent unhealthy behaviors did not significantly correlate with the rate of estimated glomerular filtration rate (eGFR) decline, patients with a baseline accumulation of three or more unhealthy behaviors exhibited a significantly faster eGFR decline compared to those with fewer unhealthy behaviors (-2.04 vs -1.02 mL/min/1.73 m², p<0.001).

Conclusion: An integrated care model implemented in a primary care setting can effectively reduce medication- and dietary-related unhealthy behaviors in CKD patients. However, fostering sustained improvements in complex lifestyle behaviors such as weight control and regular exercise remains a significant challenge.

Background: Intradialytic hypotension (IDH) remains a significant and distressing complication of hemodialysis, often reducing the efficiency of the dialysis procedure and leading to adverse clinical outcomes. IDH is strongly associated with increased morbidity and mortality rates among hemodialysis patients. This study aimed to evaluate the impact of an educational intervention on nurses' knowledge and practices regarding the prevention and management of IDH at Kiruddu National Referral Hospital (KNRH) and Mulago National Referral Hospital (MNRH).

Methodology: A quasi-experimental study was conducted in the dialysis units of KNRH and MNRH between May and July 2024, involving 25 dialysis nurses. Data were collected using semi-structured questionnaires to assess knowledge and an observation checklist to evaluate practices, both administered pre- and post-intervention.

Results: The study recruited 25 nurses with a mean age of 33.1 years, including 13 males. The majority had 1-4 years of dialysis experience. The mean knowledge score significantly increased from 5.3 before the intervention to 13.1 after the intervention (p < 0.05). Similarly, the mean practice score improved from 12 to 20, with the difference also being statistically significant (p < 0.05).

Conclusion: The baseline knowledge of nurses was generally low. The educational intervention significantly enhanced nurses' knowledge and practices in the prevention and management of IDH, highlighting the importance of continuous training to improve patient outcomes in hemodialysis care.

Background: Residual kidney function (RKF) plays a crucial role in maintaining biochemical balance in hemodialysis patients. Frailty, commonly observed in end-stage renal disease (ESRD) patients, is associated with metabolic derangements, inflammation, and fluid overload. However, the relationship between RKF and frailty in this population remains unclear.

Purpose: This study aimed to investigate the association between RKF and frailty in ESRD patients undergoing hemodialysis. Secondary objectives included assessing the prevalence of frailty and sarcopenia, and identifying clinical correlates.

Patients and methods: A cross-sectional study was conducted involving 110 adult ESRD patients undergoing maintenance hemodialysis for ≥6 months at an urban teaching hospital in Bangkok, Thailand between October 2023 and February 2024. RKF was assessed by 24-hour urine volume, with <100 mL defined as absent RKF. Frailty was evaluated using the Thai version of the FRAIL scale, and sarcopenia was diagnosed based on the 2019 Asian Working Group for Sarcopenia (AWGS) criteria. Demographic, clinical, and laboratory data were analyzed using chi-squared tests, logistic regression, and multivariable models.

Results: Among 110 participants, 78 (70.91%) had no RKF. Frailty prevalence was 13.64%, and sarcopenia prevalence was 65.45%. Frailty was associated with a history of cerebrovascular accident [adjusted odds ratio (OR) 10.303; P = 0.036] and lower total iron-binding capacity (TIBC) (adjusted OR 0.972; P = 0.047). Sarcopenia was linked to advanced age (adjusted OR 1.054; P = 0.020) and lower Kt/V values (adjusted OR 0.417; P = 0.002). RKF was not significantly associated with frailty.

Conclusion: While RKF was not directly associated with frailty, this study highlights other significant factors, such as cerebrovascular accidents and low TIBC, contributing to frailty and advanced age associated with sarcopenia. These findings emphasize the need for comprehensive frailty screening and tailored interventions to improve outcomes in ESRD patients.

Background and aims: The prevalence of insomnia among patients with end-stage kidney disease undergoing hemodialysis is high. Insomnia in patients undergoing hemodialysis may reduce their quality of life. The purpose of this study was to estimate the prevalence of insomnia and to examine the risk factors associated with insomnia among patients with end-stage kidney disease undergoing hemodialysis.

Subject and methods: This cross-sectional study included 216 patients with end-stage kidney disease undergoing hemodialysis at 175 Military Hospital, Ho Chi Minh City, Vietnam. Psychiatrists evaluated insomnia using clinical criteria of The Diagnostic and Statistical Mental Disorders, 5th Edition (DSM5). Participants were recruited using convenience sampling at 175 Military Hospital in Vietnam, with all eligible patients invited. Descriptive statistics (counts, percentages, means, standard deviations) were used to describe population characteristics and insomnia prevalence. Data were collected on patients' sociodemographic factors such as sex, age, marital and economic status; clinical factors including duration of end-stage kidney diseases, duration of hemodialysis, number of hemodialysis sessions per week, co-morbidities (diabetes, hypertension…) and environmental factors (eg, excessive noisy or light bedrooms). Logistic regression analysis model was used to analyze the factors associated with insomnia disorders in patients with end-stage kidney disease undergoing hemodialysis.

Results: The prevalence of insomnia among patients with end-stage kidney disease was 48.1%. Multivariate logistic regression showed diabetes (OR=0.331 for no diabetes, 95% CI: 0.148-0.738, p<0.01), daytime napping (OR=2.122, 95% CI: 1.159-3.885, p=0.02, excessive noisy or light bedrooms (OR=0.251 for no exposure, 95% CI: 0.074-0.854, p=0.03) were significantly associated with insomnia.

Conclusion: The prevalence of insomnia in patients with end-stage kidney disease was high. These results may help clinicians in the dialysis department pay more attention to insomnia symptoms in patients with end-stage kidney disease on dialysis and consider collaboration with psychiatrists to explore treatment strategies is also recommended.

Purpose: Urokinase thrombolysis is a feasible method for salvage of thrombosed arteriovenous fistulas (AVFs). The impact of optimizing thrombolysis outcomes on improving the efficacy of subsequent angioplasty remains unclear. This study is aimed to investigate the impact of thrombolysis outcomes and to identify the prognostic factors of thrombolysis.

Patients and methods: The patients were divided into a complete lysis (CL) group of 336 treatments, an incomplete lysis (IL) group of 83 treatments, and a lysis failure (LF) group of 206 treatments. The efficacy data of the subsequent angioplasty and the patency before the next intervention were compared. Demographics, fistula characteristics, and baseline serum parameters were compared to screen for prognostic factors of thrombolysis outcomes.

Results: As the degree of thrombolytic therapy decreased, the complication rate significantly increased (CL, 14.6%; IL, 21.7%; LF, 30.6%; trend P < 0.001), whereas the clinical success rate of angioplasty decreased (CL, 97.0%; IL, 94.0%; LF, 82.3%; trend P < 0.001). However, no difference was noted in the patency interval before the next intervention among the three groups (log-rank P = 0.562). Elbow AVF and hemoglobin < 115 g/L were risk factors of poor lysis outcomes. The complete lysis rate of patients with both factors was 24.2%, whereas the rates of patients with one or neither factor were significantly higher (all > 50% and P = 0.001).

Conclusion: Complete thrombolysis is beneficial for improving the efficacy of recanalization procedures for thrombosed AVFs. Non-elbow AVFs and hemoglobin ≥115 g/L are predictors of an increased complete lysis rate.

Background: Severely ill patients are vulnerable to developing Acute Kidney Injury (AKI), with variable incidence, but limited data from LMICs. We evaluated the incidence, predictors, treatment, and outcomes of AKI among very ill adult patients at a public tertiary hospital in southwestern Uganda.

Methods: This prospective cohort study categorized patients who had a NEWS-2 above 5 as critically ill. We used the "Kidney Disease Improving Global Outcomes (KDIGO)" definition of AKI as a 0.3 mg/dl increase in serum creatinine within 48 hours. Participants were followed up until day 7 of admission, death or discharge, whichever occurred first. STATA version 13 was used for data analysis. Predictors of AKI were determined by logistic regression.

Results: Of 161 critically ill patients, the median age was 48 years (IQR: 31-65). The incidence of AKI was 70 (95% CI 55-90) per 1000 person days of observation. About, 39.1% (127) drugs used during hospitalization were deemed potentially nephrotoxic, and 60% (96) of participants were exposed to at least one nephrotoxic drug. Penicillins and loop diuretics were the most commonly used nephrotoxic drugs. Predictors of AKI included: previous hospitalization in the last 3 months (aOR 2.56, 95% CI: 1.08-6.06, P=0.032), admission to the surgical ward (aOR 4.32, 95% CI: 1.22-15.24, P=0.023), elevated baseline creatinine (>1.2 mg/dl) (aOR 2.44, 95% CI: 1.13-5.27, P=0.023) and elevated baseline WBC count (>12 × 10⁹/µL) (aOR 2.57, 95% CI: 1.21-5.46, P=0.014). Most AKI patients were managed conservatively; 25% of patients with stage 3 received hemodialysis, and 25% of those with incident AKI died in the hospital.

Conclusion: We found a high prevalence of AKI among critically ill patients (70 per 1000 person days). Previous hospitalization in the past 3 months, high baseline creatinine, high baseline WBC count and admission to the surgical ward were independently associated with AKI.