Journal of Nephrology最新文献

The European Union (EU)-funded KitNewCare consortium aims to create and manage a comprehensive EU-wide programme focusing on sustainability in Kidney Care. Around 850 million people have chronic kidney disease (CKD) worldwide and by 2030, 6 million will need kidney replacement therapy, mainly haemodialysis. As the world population gets older, projections for the end of the century worsen. From a sustainability perspective, healthcare systems contribute around 5-11% of total carbon emissions. Kidney care is one of the most resource-intensive specialties. In addition to energy, haemodialysis and peritoneal dialysis require transportation of patients and personnel to and from facilities, use large volumes of water and generate significant plastic waste. Overall, current dialysis is not sustainable in the medium term. Primary prevention, early diagnosis and treatment of CKD and transplantation will decrease the need for dialysis, but this will take time and will not prevent the need for dialysis in millions of persons. There is a need to improve knowledge around the environmental and financial cost of kidney care and social and health outcomes of each patient pathway including using holistic tools such as life cycle assessment. This knowledge will allow workflow optimisations, organisational transformations and technological innovations across Europe, learning from different clinical sites. KitNewCare will build a European-wide knowledge base for sustainability in kidney care, develop and introduce a novel 4-factor database for comprehensive impact analysis, implement optimised processes and organisational transformations in four European clinical sites. It will also pilot innovations from small- and medium-sized high-tech enterprises with a focus on kidney care, and establish a network for continuous monitoring, benchmarking, and implementation of sustainable solutions across healthcare sectors. This paper presents the rationale behind selecting kidney disease as a focal point, summarises the current state of knowledge, and outlines the foundational statement underlying KitNewCare's operational framework.

Background: Cystinuria is a rare genetic disease characterized by impaired tubular transport of cystine. Clinical features of cystinuria mainly include nephrolithiasis and its complications, although cystinuric patients may present with other comorbidities. There are currently no data on bone features of patients with cystinuria. Our aim is to characterize bone mineral density (BMD) in cystinuria.

Methods: Our study included adult cystinuric patients with estimated glomerular filtration rate (eGFR) ≥ 60 mL/min/1.73 m² followed at 3 specialized outpatient clinics in Italy (Rome, Naples and Verona). Markers of bone turnover were analyzed in a centralized laboratory. Clinical, biochemical and dual-energy X-ray absorptiometry (DEXA) data were collected from September 2021 to December 2022. Linear regression models were used to evaluate statistically significant deviations from zero of Z-scores.

Results: Twenty-seven patients were included in the study. Mean (SD) age was 37 (15) years, 41% were women. Mean estimated glomerular filtration rate was 99 mL/min/1.73 m². Serum parameters associated with bone turnover (parathyroid hormone, FGF23, calcium and phosphate) were all in the normal range, with only 4 patients showing mild hypophosphatemia. Prevalence of low bone mineral density, defined as Z-score ≤  - 2 at any site, was 15%. Average Z-scores were negative across most sites.

Conclusions: Our study suggests that cystinuric patients have lower bone mineral density compared with individuals of the same sex and age, even when their kidney function is normal.

Background: Decreased lean body mass or muscle mass is associated with decreased bone mineral density in individuals with preserved renal function. However, the association between muscle mass and bone mineral density in chronic kidney disease (CKD) patients is not well known. The aim of this study was to assess the relationship between muscle mass estimated from urine creatinine (UCr) and bone mineral density in Korean CKD patients.

Methods: This cross-sectional study analyzed 1872 participants from the Korean Cohort Study for Outcome in Patients With Chronic Kidney Disease (KNOW-CKD) cohort. Participants underwent UCr (g/day) and bone mineral density measurements, which were measured at the lumbar spine, total hip, and femoral neck by dual-energy X-ray absorptiometry. Patients were divided into three groups according to the tertiles of 24 h UCr (T1-T3).

Results: The mean values for 24 h urine creatinine of T1, T2, and T3 were 0.83 ± 0.23 g, 1.18 ± 0.24 g, and 1.55 ± 0.38 g, respectively. A total of 172 patients were diagnosed with osteoporosis. The number of patients in each group was 92 (14.4%) in T1, 45 (7.3%) in T2, and 35 (5.7%) in T3. The odds ratio (95% confidence interval) for osteoporosis was 0.37 (0.20-0.69) for 1 g/day increase of UCr. Compared with T1, the odds ratios (95% confidence interval) for osteoporosis were 0.58 (0.39-0.87) for T2 and 0.51 (0.32-0.80) for T3.

Conclusion: Low 24-h UCr was associated with low bone mineral density. Low 24 h UCr was significantly and independently associated with osteoporosis in Korean pre-dialysis CKD patients. Further research is warranted to verify the influence of muscle mass on bone health in CKD.

Background: Ambulatory blood pressure monitoring is essential for understanding blood pressure patterns beyond clinical visits, aiding in risk assessment, treatment evaluation, and managing hypertension. This retrospective cohort study aimed to identify risk factors for all-cause mortality and major cardiovascular events in patients who underwent ambulatory blood pressure monitoring.

Methodology: Eligible participants aged 18 or older, with an estimated glomerular filtration rate (eGFR) > 60 ml/min/1.73 m², who underwent ambulatory blood pressure monitoring for various reasons, were included in the study. Data were gathered through telephone interviews, electronic health records, and the national health record system. Descriptive analysis and classification and regression tree modeling were used to uncover significant risk factors related to all-cause mortality and cardiovascular events, and to assess the model's performance compared to traditional Cox survival analysis.

Results: The study included 1291 patients, primarily male (51.8%) with a mean age of 61.1 ± 15.2 years. During a mean follow-up of 46.9 months, 76 (5.9%) patients died of any cause, and 195 (15.1%) had a cardiovascular event. The highest survival rates were observed in patients with a diastolic blood pressure (BP) dipping percentage between - 2% and 29%, nighttime systolic BP variability below 32 mmHg, and age below 72. Conversely, smokers with a diastolic BP dipping percentage below - 10% showed the lowest survival rates. The best cardiovascular outcomes were observed in patients with diastolic BP dipping above - 11%, nighttime mean systolic BP < 144 mmHg, no statin use, normotensive status, and daytime mean heart rate ≥ 60 bpm. Conversely, the worst outcomes were seen in patients with diastolic BP dipping below - 11% and a morning surge ≥ 14 mmHg. In all-cause mortality and cardiovascular event analysis, the combined model demonstrated excellent calibration and predictive power, like the classification and regression tree model and traditional analysis.

Conclusion: These findings highlight the potential of a combined model for assessing mortality and cardiovascular event risk in patients who have undergone ambulatory blood pressure monitoring.

Background: Chronic kidney disease (CKD) increases cardiovascular risk, however, traditional cardiovascular risk factors cannot entirely explain it. A real-world investigation examined the concept that renal function decline is linked to carotid total plaque area progression, which strongly confirms cardiovascular risk. We analyzed CKD patients in stages 1-3 to find risk factor relationships before the onset of severe CKD.

Methods: We monitored 328 patients for 16 ± 5 months. Participants were classified at baseline by estimated glomerular filtration rate (eGFR) stage: G1 (≥ 90), G2 (60-89), and G3 (30-59 ml/min/1.73m²). Ultrasound-guided total plaque area tracked atherosclerosis. Age, sex, blood pressure, lipids, and HbA1c were covariates. Total plaque area and variables were measured on day 1 and at the conclusion of observation. We used a multilevel mixed effects model to assess biological and behavioral factors on total plaque area progression in the general population. For validation, this research was conducted on 73 CKD patients with optimal traditional cardiovascular risk factor management during 15 ± 5 months.

Results: Multiple analyses showed an inverse relationship between eGFR decline and total plaque area progression [β-exponent = 0.99 (95% CI = 0.98-0.99)], regardless of age, lipid profile, blood pressure, smoking, diabetes, or hypertension. The correlation remained significant in the 73-patient sample with optimal traditional cardiovascular risk factor management (β-exponent = 0.99; 95% CI 0.97-0.99). Although traditional cardiovascular risk factor management was excellent, total plaque area increased considerably in G2-G3 patients compared to G1.

Conclusions: CKD, total plaque area, and eGFR are inversely correlated, independent of traditional cardiovascular risk factors, suggesting that non-traditional mechanisms are responsible for resistant atherosclerosis. The combination of eGFR and total plaque area may be useful in identifying high-risk patients.

Background: The relationship between kidney and vascular health is acknowledged, but detailed information is still missing. This study examines the relationship of estimated glomerular filtration rate (eGFR) and carotid intima media thickness, providing insights into the association between atherosclerosis and kidney function.

Methods: Participants older than 50 years of age who were part of the PolyIran-L study, a trial nested in the Golestan Cohort Study, were included. The maximal intima media thickness of both common carotid arteries was evaluated using B-mode ultrasonography. Four different cut-off values for abnormal carotid intima media thickness were considered. Correlation of carotid intima media thickness and eGFR was assessed with linear correlation and multivariable binary logistic regression models after adjusting for several confounders.

Results: In total, 1562 participants (750 females, 48%) were included in this population-based study. Assuming the eGFR < 45 [mL/min/1.73 m²] group as reference in the crude analysis, those with eGFR ≥ 45 and < 60 [mL/min/1.73 m²] showed an association of being less likely to have carotid intima media thickness above the 0.8 cutoff. However, the fully adjusted analysis showed no significant statistical association between carotid intima media thickness and eGFR.

Conclusion: This study did not support the independent association of eGFR and different carotid intima media thickness cutoffs. This pattern may be different in patients with severely decreased eGFR, a subset of cases in which it should be further investigated.

Background: Acute kidney injury (AKI) is a common complication in chronic kidney disease (CKD) patients in the cardiac intensive care unit (cardiac ICU). In this study, we aimed to identify predictors of AKI in CKD patients treated in the cardiac ICU for cardiovascular diseases.

Methods: The MORCOR-TURK trial was conducted as a multicenter, prospective, cross-sectional, and noninterventional investigation. A total of 3157 patients treated in the cardiac ICU were enrolled from 50 centers over the course of one month. In this subgroup analysis, 615 patients with CKD treated in the cardiac ICU for cardiovascular disease were included in the study. The primary outcome of this study was the development of AKI. During hospitalization, patients who developed AKI were identified.

Results: AKI developed in 288 patients (46%). After multivariable analysis, decompensated heart failure (OR: 3.72, p = 0.005), primary percutaneous coronary intervention (OR: 3.75, p = 0.004), non-primary percutaneous coronary intervention (OR: 2.85, p = 0.033), troponin levels (OR: 1.04, p = 0.031), and need for mechanical ventilation (OR: 3.11, p < 0.001) were identified as independent predictors of AKI development in CKD patients.

Conclusion: Our efforts to identify AKI predictors in cardiac ICU patients with CKD have yielded directly applicable results in clinical practice. AKI can be prevented by developing personalized strategies to follow up and treat cardiac ICU patients with CKD who have decompensated heart failure, are undergoing percutaneous coronary intervention (primary and non-primary), have high troponin levels, and need mechanical ventilation.