Journal of Nephrology最新文献

Background: Despite efforts to increase its use, home dialysis remains underutilized as a modality for kidney replacement therapy (KRT). Home dialysis may offer an advantage in rural areas. We evaluated the role of a rural outreach program on the use of home dialysis as incident KRT modality in West Virginia.

Methods: This is a retrospective cohort study of patients with end-stage kidney disease (ESKD). Data on KRT were collected using the United States Renal Data System (USRDS) database from 1965 to 2020.

Results: Of the total 22,408 West Virginia patients who started KRT with a dialysis modality between 1965 and 2020, 3203 (14.3%) patients started with a home modality. Among patients from counties served by a rural outreach clinic providing kidney care, 896 (18%) patients started with home dialysis compared to 2306 (13%) patients from other counties. Patients from counties served by a rural outreach clinic were more likely to be White (96 vs 90%), have comorbid illness, and live in a rural community (90 vs 56%), but less likely to be unemployed (11 vs 14%), all p < 0.001. In a multivariable model, after adjusting for comorbid medical conditions and rurality, the odds of starting dialysis with a home modality were greater for patients from counties served by a rural clinic than for patients from counties without such clinics (OR 1.4, 95% CI 1.15-1.7).

Conclusion: Patients with ESKD from West Virginia counties served by rural outreach clinics were more likely to initiate KRT by a home-based modality than patients from other counties in West Virginia.

Background: The management of patients with non-dialysis dependent chronic kidney disease (NDD-CKD) is challenging due to coexisting diseases, competing risks and uncertainties around optimal transition planning. Such clinical challenges are further exacerbated by physician shortage, coupled with rising service demands, which may hinder timely medical access due to long waiting times. Accurate progression risk assessment may help optimize resource allocation and adapting care based on individual patients' needs. This study validated the Prognostic Reasoning System for Chronic Kidney Disease Progression (PROGRES-CKD) in an Italian public hospital and compared its potential impact on waiting list optimization against physician-based protocols.

Methods: First we first validated PROGRES-CKD by assessing its accuracy in predicting kidney replacement therapy (KRT) initiation within 6 months and 24 months in a historical cohort of patients treated at the San Gerardo Hospital (Italy) between 01-01-2015 and 31-12-2019. In a second study we compared PROGRES-CKD to attending nephrologists' prognostic ratings and simulated their potential impact on a waiting list management protocol.

Results: We included 2005 patients who underwent 11,757 outpatient nephrology visits in 4 years. Most visits occurred for NDD-CKD stage 4 patients; the incidence of KRT onset was 10.8 and 9.32/100 patient-years at the 6 and 24-month prediction horizon cohorts, respectively. PROGRES-CKD demonstrated high accuracy in predicting KRT initiation at 6 and 24 months (AUROC = 0.88 and AUROC = 0.85, respectively). Nephrologists' prognostic performance was highly operator-dependent, albeit always significantly lower than PROGRES-CKD. In the simulation exercise, allocation based on PROGRES-CKD resulted in more follow-up visits for patients progressing to end-stage kidney disease (ESKD) and fewer visits for non-progressing patients, compared to allocation determined by nephrologists' prognosis.

Conclusions: PROGRES-CKD showed high accuracy in a real-world application. Waiting list simulation suggests that PROGRES-CKD may enable more efficient allocation of resources.

Background: Prevalence data indicates that chronic kidney disease (CKD) affects approximately 15% of people worldwide, and chronic kidney disease of unknown etiology (CKDu) is highly prevalent in Sri Lanka. Food and water contamination are factors that were suggested as associated with CKDu. This systematic review aimed to summarize evidence on the patterns in quality and sources of food and water consumed by people with CKDu in Sri Lanka.

Methods: MEDLINE, EMBASE, PsycINFO, and SLJOL databases were searched from inception to August 2024 for studies investigating the quality and sources of food and water consumed by the people with CKDu in Sri Lanka. Studies assessing children below 18 years, pregnant women and dialysis patients were excluded. Studies not specifically investigating CKDu were likewise excluded from the review. Two independent reviewers completed the screening, and the conflicts were resolved by consensus. Extracted data were presented as a narrative summary.

Results: Of 1067 studies, 57 were eligible for the final analysis. Commonly investigated food sources were contaminated with heavy metals, while water sources were contaminated with heavy metals, toxic anions and cations, agrochemicals, fertilizers, herbicides, glyphosate, and aminomethylphosphonic acid (AMPA).

Conclusion: Nephrotoxic heavy metals and fluoride contamination alter the quality of food and water, and pose high risks with regard to the kidney function of the people in Sri Lanka. Appropriate strategies to reduce the contamination of heavy metals, agrochemicals, and major ions that afftect the quality of water and food, should be implemented to lower the burden of CKDu in Sri Lanka.

Background: Chronic kidney disease-associated pruritus (CKD-aP) is a debilitating symptom that can significantly impact patients' daily activities and quality of life. This systematic review aimed to assimilate the latest evidence on the relationship between CKD-associated pruritis and patient-centred outcomes.

Methods: A comprehensive search was conducted to identify relevant studies in PubMed, Medline and Embase via OVID, CINAHL, and Web of Science from 2000 to June 2024. Quality appraisal and subsequent data extraction were performed using the Joanna Briggs Institute (JBI) tools and a modified extraction form derived from JBI.

Results: The review included 29 studies with a total of 147,174 CKD patients, including those on haemodialysis (HD) and peritoneal dialysis (PD). The most frequently reported patient-centred outcomes included quality of life (n = 21), sleep quality (n = 17), anxiety/depression (n = 11) and mortality (n = 7). There was a paucity of data on patients in the pre-dialysis stages, those undergoing PD, and following a conservative (non-dialytic) pathway. The impact of CKD-associated pruritus on outcomes was contingent on the severity of CKD-associated pruritus. There was an association between increased medication usage, decreased compliance with HD treatments and higher rates of hospitalisation in patients experiencing severe pruritus.

Conclusion: Our review underscores the pernicious impact of CKD-associated pruritus on patient outcomes and emphasises the importance of effective management to improve patient-centred outcomes. Additional investigations are warranted among patients undergoing PD, those in pre-dialysis stages, and on conservative (non-dialytic) pathways, to achieve a more comprehensive understanding of the impact of CKD-associated pruritus in these patient groups.

Background: Little is known about the association of health-related quality of life (HRQOL) with, and level of, patient activation among patients with chronic kidney disease (CKD) in Japan.

Methods: We conducted a cross-sectional observational study using a questionnaire targeting patients with CKD across Japan from 2021 to 2023. The primary outcome was low HRQOL assessed using the short form 8 (SF-8). The risk of low HRQOL was evaluated by patient activation (using the Patient Activation Measure 13 (PAM-13)).

Results: In total, 1427 patients with CKD were included in this study. Mean age was 61.9 (standard deviation (SD) 12.7) years and 891 (62.4%) were men. Among the participants, 948 (66.4%) were treated without dialysis or kidney transplantation, 304 (21.3%) underwent hemodialysis, 72 (5.1%) underwent peritoneal dialysis, and 103 (7.2%) underwent kidney transplantation. Regarding patient activation, those belonging to higher activation groups were less likely to have low physical HRQOL compared with those belonging to lower activation groups (adjusted odds ratio (OR) 0.73, 95% confidence interval (CI) 0.55-0.96 for medium; adjusted OR 0.53, 95% CI 0.41-0.70 for high; adjusted OR 0.42, 95% CI 0.29-0.61 for the highest activation group). When stratified by type of treatment for CKD, among participants with kidney transplantation the highest activation group tended to have more low mental HRQOL participants compared with the low activation group (adjusted OR 2.44, 95% CI 0.51-12.5).

Conclusion: Among Japanese patients with CKD, lower patient activation is associated with lower physical and mental HRQOL in a dose-dependent manner. However, the highest activation may be associated with low mental HRQOL among patients undergoing kidney transplantation.

Background: Membranous nephropathy (MN) is a common cause of nephrotic syndrome in adults, with high risk of progression to end-stage kidney disease when untreated. Rituximab is commonly used in its treatment however many patients do not respond. Obinutuzumab is a novel anti-CD20 monoclonal antibody for which there is increasing observational evidence in treatment-resistant membranous nephropathy. The majority of evidence for its use relates to anti-phospholipase A2 receptor-(PLA2R) associated membranous nephropathy.

Methods: This was a single-centre case-series of all patients at a tertiary nephrology centre in Melbourne, Australia, treated with Obinutuzumab for membranous nephropathy, between January 2023 and June 2024. All patients who received Obinutuzumab were included in this case-series, irrespective of PLA2R status.

Results: Out of 5 patients with treatment-resistant membranous nephropathy, 3 had PLA2R-associated membranous nephropathy which had previously been refractory to, or relapsed on Rituximab therapy. All 3 patients with PLA2R-positive membranous nephropathy achieved complete immunological and clinical remission after receiving Obinutuzumab. The case of secondary PLA2R-negative membranous nephropathy only achieved partial remission after Obinutuzumab before unexpectedly dying from another cause. The case of recurrent PLA2R-associated membranous nephropathy in a renal allograft did not respond to Obinutuzumab.

Conclusion: This case-series supports the existing evidence in favour of Obinutuzumab for treatment-resistant PLA2R-associated membranous nephropathy. To our knowledge it is the first reported use of Obinutuzumab in sarcoidosis-associated membranous nephropathy.