Journal of Nephrology最新文献

Background: Chronic kidney disease (CKD) is a common comorbidity among patients with tricuspid regurgitation, yet its impact on tricuspid regurgitation outcomes is underexplored. This study examines how CKD affects the relationship between severe tricuspid regurgitation and overall survival.

Methods: This is a retrospective cohort study of all adult patients (> 18 years old) evaluated at the Sheba Medical Center, between 2007 and 2022, who underwent transthoracic echocardiographic evaluation. It is based on the SHEBAHEART big data registry. Sheba Medical Center is the largest hospital in Israel with approximately 115,000 admissions per year. The echocardiographic reports together with the electronic medical records of all patients are the source for this study. Patients with missing creatinine data within one month of their echocardiography study, as well as those who underwent tricuspid regurgitation intervention, were excluded from the study. Patients were categorized into four groups, according to the presence and severity of tricuspid regurgitation and stratified by CKD stage. The primary outcome was all-cause mortality.

Results: The study included 78,147 patients (median age 67, IQR 55-78), with 2989 (4%) having severe tricuspid regurgitation and 19,910 (25%) with an estimated glomerular filtration rate [eGFR] < 60 mL/min/1.73 m². Over a median 4-year follow-up, 28,112 patients (36%) died. Both tricuspid regurgitation severity and CKD stage were associated with increased mortality risk (log-rank p < 0.001 for both). Adjusted models showed that compared to the none/trivial group, patients with mild, moderate, and severe tricuspid regurgitation had a 6%, 12%, and 35% higher risk of death, respectively (p < 0.001 for all). The association of tricuspid regurgitation with poor survival was CKD-dependent, with increased mortality risk of 56% vs. 23% among patients with eGFR < 60 vs. eGFR ≥ 60 (p for interaction < 0.001). The interaction analysis was no longer significant when right ventricular function was incorporated into the multivariable model. Subanalysis, limited to patients with isolated tricuspid regurgitation, yielded consistent results.

Conclusions: The association between severe tricuspid regurgitation and poor survival is stronger in advanced CKD patients and may be modulated through right ventricular function.

Background: Significant differences in kidney disease-related mortality persist among Italian regions, even after adjusting for age and education level, suggesting a role of contextual factors. The study aimed to assess whether these differences are attributable to the availability of economic and structural resources for healthcare.

Methods: Retrospective longitudinal cohort study conducted on the Italian population recorded in the 2011 Census and followed up to 2019. Deaths from kidney diseases were retrieved by record linkage with the Causes of Death Register. Regional information on age-adjusted prevalence of kidney disease (indicator of demand for care), current healthcare expenditure per capita, and number of nurses and beds in dialysis units (indicators of renal care supply) per million residents were selected as contextual variables. Regional differences in kidney disease-related mortality taking or not into account these contextual indicators were evaluated using a multilevel approach.

Results: Age-adjusted kidney disease-related mortality rates were higher than the national average for males and females in the largest southern regions. When adding to the models the prevalence of kidney disease, healthcare expenditure, and number of nurses and beds in dialysis units, regional differences in kidney disease-related mortality became non-significant compared to the national average. Significant heterogeneity persisted across regions, both in males and females, although its magnitude strongly decreased when regional-level covariates were considered.

Conclusions: Regional differences in kidney disease-related mortality decreased markedly after considering the general expenditure for healthcare and the number of nurses in dialysis units, suggesting that resources dedicated to caring for kidney disease patients may play an important role in decreasing their mortality.

Background: Arteriovenous fistulas (AVF) and arteriovenous grafts (AVG) are the preferred options for establishing vascular access in adult patients undergoing haemodialysis treatment. Although various official recommendations exist for AVF and AVG cannulation, a comprehensive, personalised approach to cannulation has yet to be proposed. This systematic review highlights existing knowledge gaps and identifies best practices by synthesising quality evidence on all components involved in AVF and AVG cannulation for haemodialysis.

Methods: A search was conducted across the PubMed, CINAHL, Cochrane, Scopus and Web of Science databases for studies published between January 2016 and January 2023. This review followed the PRISMA statement and was registered with PROSPERO (CRD42024293288).

Results: Twenty-four studies met the inclusion criteria and reported outcomes for 11,687 patients and 801 ward staff in 14 countries. Collectively, their results emphasized a person-centred approach, the importance of nurses' and patients' skills, and the need for continuous learning to enhance patient care. While recommendations varied, the implementation of the button-hole technique and innovative nurse-led devices such as plastic cannulas and point-of-care ultrasound guided cannulation were highly recommended.

Conclusion: This systematic review highlights the importance of adopting a person-centred approach to managing patients undergoing haemodialysis. It also recommends the systematic assessment of vascular access and the continuous training for nurses and patients. Further research is needed to evaluate the cost-effectiveness of innovative, nurse-led tools in haemodialysis units.

Background: Stage 3 chronic kidney disease (CKD) often remains undiagnosed until more severe symptoms appear. This study assessed awareness and management of CKD among Italian general practitioners (GPs), focusing on early detection and current practices.

Methods: A nation-wide, retrospective observational study was conducted using data from The Health Improvement Network (THIN®) database. Each participant was required to have had at least one interaction with a GP for either medical or administrative purposes (considering the index date), and to have a minimum of three years of retrospective data available  from January 2021 to June 2022. The study evaluated the proportion of individuals aged ≥ 40 years who underwent a second serum creatinine test after ≥ 90 days, referrals to nephrologists, and CKD diagnosis confirmation and categorization. Multivariable Poisson regression models analyzed data to identify associations between patient characteristics and outcomes, in both the overall cohort and in the sub-group with available urine albumin-to-creatinine ratio (uACR) measurement.

Results: Among 347,548 adults aged ≥ 40 years, 18,002 (5.2%) had an initial estimated glomerular filtration rate (eGFR) indicating possible stage 3 CKD (30-59 mL/min/1.73 m²), and 1495 of these had a concomitant uACR assessment. Data concerning follow-up testing and specialist referrals were inconsistent, and available only for 53.0% and 9.0% of the patients, respectively. Overall, 15.3% met the criteria for KDIGO stage 3 CKD, yet CKD ICD-9-CM diagnostic codes were recorded for only 905 (5.0%) patients. Factors associated with these outcomes were analyzed, including age, comorbidities, treatments, and laboratory values.

Conclusions: Substantial gaps in GP awareness and adherence to CKD management guidelines were identified, particularly in follow-up testing, referral practices, and diagnostic coding. Targeted educational interventions and standardized care protocols are needed to enhance CKD detection and management in primary care, improving patient outcomes and healthcare system performance.

Background: Gout, a disease already described in the "Anonymus Parisinus Darembergii sive Fuchsii", one of the two surviving Greek medical manuscripts of the first century CE, is reviewed in an effort to trace the timeline of the knowledge of the disease between the Corpus Hippocraticum and the Renaissance.

Methods: The treatise exists in four manuscripts of varying lengths: two are located in Paris, one in Vienna, and one in London. The study was conducted using the 1997 Leiden critical edition by Ivan Garofalo, which unifies all four manuscripts ("Anonymi Medici. De Morbis acutis et chronicis"), and was translated into English by Brian Fuchs. The treatise consists of 51 sections (a capite ad calcem, head to heel), in which the description of sixteen acute diseases precede that of thirty-five chronic diseases. The chapter on diseases affecting the joints precedes the last chapter, that describes elephantiasis. The text on gout consists of 945 words covering causes (46 words), signs (138 words) and therapy.

Results: The causes of gout are attributed to bilious humors and phlegm, as described by the "Ancients". The signs include inflammation and severe pain, typically beginning in the great toe (later known as podagra), but can extend to affect the entire leg, hands (referred to as cheiragra), or other joints, indicating a broader condition of arthritis. Pain is more tolerable when swelling coexists. Therapy is based on immediate bloodletting, dietary restrictions, and abstention from meat, wine and venery.

Conclusions: Gout in the "Anonymus Parisinus" allows a full understanding of gout in the centuries between the Corpus Hippocraticum and Galen.

Background: Atypical haemolytic uraemic syndrome (aHUS) leads to acute kidney injury, necessitating dialysis in about half of patients. A certain proportion of patients treated with C5 inhibitors discontinue dialysis; however, little is known about the patient characteristics and clinical courses relating to discontinuation.

Methods: We compared the characteristics and clinical courses of patients with aHUS on dialysis at the initiation of eculizumab during post-marketing surveillance in Japan, stratified by those who did (Group A) and did not (Group B) discontinue dialysis within 26 weeks of eculizumab treatment.

Results: Of 38 included patients, 21 (55.3%) and 17 (44.7%) were placed in Groups A and B, respectively. No patient re-started dialysis. Hypertension was less frequent in Group A than in Group B (6/21 [28.6%] vs. 11/17 [64.7%], p = 0.022). Both the duration of dialysis before eculizumab initiation (6 vs. 17 days, p = 0.011) and the time from thrombotic microangiopathy onset to eculizumab initiation (9 vs. 25 days, p = 0.008) were shorter in Group A. A duration of less than 15 days from thrombotic microangiopathy onset to eculizumab initiation was associated with dialysis discontinuation. Kidney function improvement and normalisation of platelet count and lactate dehydrogenase levels were achieved earlier in Group A than in Group B (p = 0.050, 0.014, and < 0.001, respectively). Five (29.4%) of 17 patients in Group B discontinued dialysis after 27 weeks of eculizumab treatment, including one patient who underwent kidney transplantation.

Conclusions: Early initiation of eculizumab was significantly correlated with dialysis discontinuation.

Background: IgA nephropathy is a disease with a highly variable natural history, for which there is an increasing understanding of the role of complement activation in its pathogenesis and progression. We aimed to assess the clinical and prognostic implications of C4d staining in the kidney biopsy of IgA nephropathy patients.

Methods: This was a retrospective observational study wherein the medical records of IgA nephropathy patients were reviewed and baseline characteristics, kidney biopsy findings, treatment response and follow-up data were noted. We aimed to estimate the prevalence of C4d staining and assess its correlation with clinical presentation, MEST-C scoring as well as its predictive value on renal outcomes.

Results: A total of 131 kidney biopsies were studied in which the prevalence of C4d staining was 63.36%. C4d positivity was significantly associated with hypertension (P = 0.005), greater degree of proteinuria (P = 0.013) and lower estimated glomerular filtration rate (eGFR) (P = 0.04) at presentation. MEST-C score analysis revealed significant association of Segmental sclerosis (S1), Tubular atrophy and Interstitial Fibrosis (T1, T2) and a greater degree of glomerulosclerosis with C4d staining (P value < 0.001). On follow-up, lesser rates of complete remission, higher serum creatinine and lower eGFR were seen in the C4d positive group (P < 0.001). C4d positivity independently predicted progression to kidney failure [HR: 2.42; 95% CI:1.11-5.26 (P = 0.026)] with 5-year kidney survival of 58% (P < 0.001).

Conclusion: Mesangial C4d deposition is associated with adverse clinical and pathological characteristics and is an independent risk factor for progression to kidney failure in patients with IgA nephropathy. Thus, C4d staining could be integrated into routine kidney biopsy analysis as a potentially useful biomarker for prognostication and targeted complement-based therapies.

Background: Atypical hemolytic uremic syndrome (aHUS) usually results from an overactivation of the alternative complement pathway. As large clinical trials are scarce, patient registries can partially fill the knowledge gap on patient characteristics, management, and outcomes. We here describe the baseline clinical and genetic characteristics as well as the management of all Belgian patients enrolled in the Global aHUS Registry at data cut-off.

Methods: This observational study prospectively and retrospectively collected data (data cut-off: December 26, 2022) from patients of all ages with a clinical diagnosis of aHUS, irrespective of treatment.

Results: A total of 121 Belgian patients were registered in the Global aHUS Registry, resulting in a prevalence of 10.4 aHUS patients per million inhabitants, with a higher proportion of females affected (57.9% vs 42.1% of males). Among the 109 patients tested for at least one variant and/or anti-complement factor H (CFH) antibodies, 36 were positive for a pathogenic complement gene variant associated with aHUS (n = 29) and/or seropositive for anti-CFH antibodies (n = 14). The most common variants affected CFH, C3 and CD46. The higher proportion of complement gene variants in treated women versus men was not related to a specific gene.

Conclusions: This study strengthens the real-world evidence on aHUS and adds to previously published Global aHUS Registry data. In addition, it provides insights into the differential epidemiology of the disease in Belgium and demonstrates the increased susceptibility of women to aHUS across the whole spectrum of recognized complement gene variants.