Journal of Nephrology最新文献

Background: This study aims to evaluate the diagnostic ability of quantitative renal echogenicity for chronic kidney disease (CKD) using ultrasounds.

Methods: Between September 2018 and December 2019, patients with kidney disease at our hospital underwent ultrasound imaging and serum creatinine tests. Five radiologists assessed patient ultrasound image echogenic characteristics for CKD diagnosis. Novel quantitative imaging measurements were also collected. Estimated glomerular filtration rate (eGFR) was used to classify patients into CKD or non-CKD groups. The diagnostic accuracy of the radiologists' assessment and quantitative measurements was analyzed using Receiver Operating Characteristic (ROC) curves.

Results: In our study, 339 patients participated. Radiologists' visual analysis showed low accuracy (42.5-46.9%) for CKD diagnosis. Conversely, bilateral mid-renal cortex echogenicity and echogenicity difference value showed a strong correlation with eGFR. We identified two effective CKD indicators: the Echogenicity Difference Value between Right Renal Sinus and Right Renal Cortex, which achieved 0.838 AUC (area under the curve), 77.90% accuracy, 68.45% sensitivity, and 87.13% specificity; and the Echogenicity Difference Value between Left Renal Sinus and Left Renal Cortex, which showed 0.805 AUC, 75.22% accuracy, 70.24% sensitivity, and 80.12% specificity.

Conclusions: The radiologists' visual analysis of renal echogenic characteristics is insufficient for CKD diagnosis. Quantitative echogenicity analysis using the proposed echogenicity difference values is more objective and effective for diagnosing CKD.

Background: Peritoneal dialysis catheter malfunction compromises dialysis adequacy. Standard imaging methods in the case of peritoneal catheter malfunction include abdominal X-ray, fluoroscopic catheter peritoneography, and computed tomography. Ultrasound has only recently been utilized to evaluate the intraperitoneal part of the catheter. In clinical routine, catheter function is assessed by the time needed to fill or drain a defined quantity of peritoneal dialysis fluid. Visual functional testing of the catheter can be performed by fluoroscopy or by contrast-enhanced ultrasound. We developed and tested a color Doppler ultrasound technique for dynamic imaging of the peritoneal catheter based on signal generation by dialysis fluid flow.

Methods: The feasibility of the color Doppler approach was evaluated utilizing a phantom. Furthermore, the technique was applied in 28 peritoneal dialysis patients, most of whom presented peritoneal catheter malfunction.

Results: Color Doppler examination improved the catheter visualization, especially in cases in which the catheter is embedded between the intestinal loops. Furthermore, this technique highlighted catheter side hole occlusions by adhesions or intraluminal thrombi. The examination can be performed either during filling or draining of dialysis fluid.

Conclusions: The color Doppler ultrasound technique appears to be helpful in identifying problem-solving strategies in malfunctioning peritoneal catheters.

Background: Mortality of patients > 75 years of age initiating dialysis is high. Late referral to a nephrologist prior to dialysis initiation is associated with poor outcomes. Herein, we report the outcomes of patients initiating dialysis according to their age and timing of referral.

Methods: We reviewed a prospective cohort of patients initiating dialysis from 2000 to 2022 at a single university center. Primary outcome was one-year all-cause mortality. Secondary outcomes were overall all-cause mortality and one-year hospitalization days. Late referral was defined as dialysis initiation < 1 month after a first consultation with a nephrologist.

Results: We included 906 patients, including 246 (27%) aged over  75 years. Late referral was more common in elderly patients compared to younger ones, with rates of 26% and 34%, respectively (p = 0.027). Regarding one-year mortality, considering patients aged over 75 years with early referral as the reference, patients aged > 75 years with late referral were at higher risk (Hazard Ratio [HR] 2.30, p = 0.001), while patients aged < 75 years with either early or late referral were at similar risk. Regarding overall mortality, patients aged > 75 years with late referral were at higher risk (HR 1.56, p = 0.002), while patients aged < 75 years with either early (HR 0.65, p < 0.001) or late referral (HR 0.62, p = 0.001) were at lower risk. Finally, patients aged over 75 years with late referral had more hospitalization days per year (coef 0.09, p < 0.001), while patients < 75 years with either early (coef - 0.07, p < 0.001) or late referral (coef - 0.05, p < 0.001) had fewer hospitalization days per year.

Conclusions: Late referral of elderly patients prior to dialysis initiation is common and adversely associated with short- and long-term mortality as well as hospitalization days. Conversely, early referral of elderly patients is associated with a favorable short-term prognosis that is comparable to that of younger patients.

Background: The COVID-19 pandemic led to concerns about disruptions in the follow-up of chronic diseases, including chronic kidney disease (CKD). Here, we assessed the COVID-19 pandemic impact on healthcare use by patients with CKD in France.

Methods: We used the French National Health Data System (SDNS) that contains data on outpatient and inpatient healthcare of the whole French population. Using a validated algorithm, we identified two CKD cohorts based on their healthcare utilization: (i) the 2019 cohort (pandemic-exposed) and (ii) the 2017 cohort (comparator). We followed these cohorts for 2 years and compared consultations (in-person and teleconsultation) with a general practitioner (GP) and a nephrologist and all-cause hospitalizations (excluding COVID-19 as primary diagnosis). We stratified comparisons by age group and sex.

Results: We identified 4,866,096 individuals with CKD in 2017 and 5,089,706 in 2019. During the first year of follow-up, 95.2% and 6.4% of patients in the 2017 cohort had at least one consultation with a GP and with a nephrologist, respectively, versus 94% and 6.3% in the 2019 cohort. Teleconsultations compensated for the reduction of in-person GP and nephrologist consultations throughout the lockdown periods in 2020 and 2021 (40.5% of patients in the 2019 cohort had at least one in-person consultation and 52.5% an in-person or tele-consultation with a GP). Hospitalizations ≥ 24 h decreased in 2020 and 2021 (-10%).

Conclusions: In France, outpatient care for CKD was maintained during the 2 years following the COVID-19 pandemic, thanks to teleconsultations. The persistently lower inpatient care utilization warrants further investigation.

Background: Early CKD may affect pregnancy outcomes, but identifying women at most risk remains challenging. We aimed to understand the predictive role of clinical parameters in early-mid pregnancy in women with early stage CKD.

Methods: Women with CKD stage 1-3 with a pregnancy > 20 weeks gestation between 2018 and 2023 were evaluated for 'red flag' markers previously linked with risk of adverse pregnancy outcomes: failure of ≥ 10% fall in serum creatinine; urinary protein: creatinine ratio (uPCR) ≥ 30 mg/mmol in second trimester; lack of physiological fall in blood pressure by mid-pregnancy. The relationship between these red flags and a composite adverse pregnancy outcome of gestational age < 37 weeks, birth weight < 2500 g and pre-eclampsia was determined.

Results: Of 38 mothers with 47 deliveries, 72% of pregnancies were in women with stage 1 CKD, 38% had hypertension and 19% had pre-eclampsia. Infants had median birth weight 2895 g (IQR: 2460-3170) and median gestational age 37.3 weeks (IQR 35.8-38). Serum creatinine did not fall ≥ 10% in 66% (n = 27/41) of women, uPCR was ≥ 30 mg/mmol in 69% (n = 24/35) and blood pressure did not fall in 73% (n = 24/33). Eighty-six percent had one or more 'red flags'. The composite adverse pregnancy outcome occurred in 49% (n = 22/45). Women exhibiting any early-mid pregnancy red flags did not have increased rates of composite adverse pregnancy outcome (no creatinine fall, composite adverse pregnancy outcome n = 15, p = 0.176; proteinuria n = 15, composite adverse pregnancy outcome p = 0.066; no blood pressure fall, composite adverse pregnancy outcome n = 12, p = 1.00).

Conclusions: The high rate of composite adverse pregnancy outcome in early stage CKD was not associated with traditional mid-pregnancy red flags. Best models of care for this cohort remain uncertain.

Background: While significant sociodemographic disparities in the burden of chronic kidney disease (CKD) are well established, less is known about how area-level socioeconomic status interacts with these disparities.

Methods: This study used data from the Centers for Disease Control and Prevention Wide-Ranging Online Database for Epidemiologic Research (CDC WONDER) Underlying Cause of Death Database to identify deaths from CKD among people aged 45 and older in the United States from 1999-2020. We used county-level Social Vulnerability Index data to examine the relationship between Social Vulnerability Index and CKD-associated mortality for the overall population and for sociodemographic subgroups.

Results: The age-adjusted mortality rate for the overall population was 73.56 (95% CI 67.74-79.39). Mortality from CKD was significantly higher in the 4th quartile of Social Vulnerability Index, representing the most vulnerable areas (age-adjusted mortality rate = 81.39, 95% CI 75.77-87.00), compared to the 1st quartile, representing the least vulnerable areas (age-adjusted mortality rate = 66.07, 95% CI 59.02-73.12). For both the overall population and all sociodemographic subgroups, higher Social Vulnerability Index was associated with a higher risk of CKD-associated mortality. Within each Social Vulnerability Index quartile, Black Americans and males had higher CKD-associated mortality than White Americans and females, respectively.

Conclusion: The burden of CKD-associated mortality in the United States is rising, with people living in more socially vulnerable counties facing a higher risk of CKD death. Racial disparities in CKD-associated mortality persist even within counties of similar social vulnerability, indicating the urgent need to address these health disparities.

Background: Atrial fibrillation and chronic kidney disease mutually interact, presenting distinct clinical dilemmas where the optimal risk-benefit profile of antithrombotic therapy remains undefined.

Methods: This study was conducted using the Korean Health Insurance Review and Assessment Service database in patients with atrial fibrillation undergoing hemodialysis. The primary outcomes included thromboembolism and intracranial hemorrhage rates, while major bleeding and all-cause death were secondary outcomes. Selecting patients not taking antithrombotics as a reference, Kaplan-Meier and Cox proportional hazard analyses were performed for those taking antiplatelets, direct oral anticoagulants (DOACs), and warfarin. The net clinical benefit was obtained by balancing the efficacy and safety of each antithrombotic therapy.

Results: There were 13,311 patients on hemodialysis recorded as with atrial fibrillation, the mean age was 63.1 ± 12.8 years, with the mean CHA₂DS₂-VASc score of 3.3 ± 1.6. One-fifth of the patients received antithrombotic therapy, with 67.1% using antiplatelet drugs. Warfarin was associated with an increased thromboembolic risk (HR 1.25; 95% CI, 1.01-1.56), while findings for DOACs remain inconclusive. In net clinical benefit analysis, with warfarin demonstrated the most unfavorable profile, and DOACs exhibited comparable net clinical benefit to antiplatelet agents (0.57; 95% CI, - 0.56-1.70).

Conclusion: This study provides real-world evidence on the use of antithrombotic therapy in atrial fibrillation patients undergoing hemodialysis. The findings highlight the profound complexity and uncertainty in managing this high-risk population, underscoring the importance for comprehensive assessment, individualized treatment approaches, and further dedicated research to establish optimal prevention and treatment strategies.