Journal of Nephrology最新文献

Background: Healthcare contributes significantly to global carbon dioxide equivalent emissions, with kidney care contributing disproportionately to this. Renal medicine was one of the first specialities to actively develop a "green" community. This paper is a retrospective review of a series of comprehensive and impactful green initiatives across various aspects of kidney care delivery in a kidney unit from 2007 to 2024.

Methods: The interventions include using e-consultations and virtual clinics, online priming of haemodialysis machines, upgrade of water treatment systems, centralised dialysate acid delivery, use of 1:44 acid concentrate, use of dialysate autoflow function, installation of energy-efficient lighting, and incremental and decremental dialysis practices. Financial and environmental saving estimates for the haemodialysis-related interventions were calculated based on a 40-bed haemodialysis unit. A hybrid carbon footprinting approach was utilised to calculate the greenhouse gas and financial savings.

Results: The cumulative estimated greenhouse gas and financial savings exceed 1,000 tonnes of carbon dioxide equivalent and £2.8 million, respectively. Among sustainable initiatives in haemodialysis, online priming, use of central acid delivery, dialysate autoflow facility, and incremental and decremental haemodialysis showed the most significant savings.

Conclusions: Interventions to facilitate environmental sustainability may require upfront funding and staff investment of time and effort, but the dividend is long-term environmental protection, financial savings, enhanced quality of care, greater staff satisfaction and enhanced service resilience. Sharing these experiences may help other institutions to integrate green initiatives into everyday service planning.

Immunoglobulin A nephropathy (IgAN) is one of the most common forms of primary glomerulonephritis which can lead to kidney failure requiring kidney replacement therapy via dialysis or transplantation. Unfortunately, IgAN can recur within the allograft. For treatment of primary IgAN, a targeted-release formulation of budesonide that acts specifically within the ileum can be used to prevent disease progression. The use of targeted-release budesonide in the setting of recurrent IgAN after transplantation has not yet been studied in detail. We here report a 28-year-old female with IgAN recurrence after transplantation, treated by targeted release budesonide for 9 months. Prior to treatment initiation in April 2023, estimated glomerular filtration rate (eGFR) drastically decreased, reaching  24 ml/min/1.73 m² within 10 months. With treatment, the eGFR decrease slowed down considerably (- 6 ml/min/1.73 m² within 12 months). The urine protein-to-creatinine-ratio (UPCR) likewise decreased from 4.55 g/g creatinine before therapy start to 1.30 g/g 12 months after therapy start. Despite episodes of poorly controlled hypertension and edema during treatment that were related to interruption of medications, blood pressure was stable at 122/77 mmHg after 9 months and 133/83 mmHg after 12 months. Compared to the beginning of the therapy, the patient lost 3 kg of body weight. There were no serious infections, nor was an increased susceptibility to infections observed. No other serious adverse events occurred. Although the patient experienced corticosteroid-related side effects, treatment was not interrupted. After therapy, the side effects subsided and the patient reports general wellbeing.

Deceased donor kidneys are a scarce national resource, and principles of utilitarianism and justice govern allocation. Kidney transplant recipients with a prior history of cancer show an increased risk of malignancy- and non-malignancy-related mortality compared to their counterparts without a previous history of malignancy. The inferior survival of a recipient with pre-transplant malignancy questions the allocation of a scarce resource to a population at anticipated poorer patient and graft survival. However, patient survival has significantly improved with advances in therapeutics for hematological malignancies, which led to an updated consensus expert opinion by the American Society of Transplantation in 2019. Nevertheless, the candidacy of patients with pre-transplant hematological malignancies in countries with a scarcity of deceased donor kidneys and a prolonged wait time may warrant specific considerations. This review details the basis for evaluation and candidacy recommendations for patients with a history of hematological malignancy for waitlist placement for deceased donor kidney transplantation, while optimizing scarce deceased donor organ supply in  Singapore. It considers the available evidence in countries where organ scarcity is a distinct challenge; thus, this consensus report is tailored to these constraints and may not be fully generalizable to other countries or transplant allocation algorithms.

Background: Diabetes-driven impaired autonomic nervous system function might contribute to increased mortality in hemodialysis patients. Our study aimed to validate heart rate turbulence as a long-term predictor of mortality in this vulnerable cohort.

Methods: Heart rate turbulence is a non-invasive, 24 h electrocardiography-Holter-based assessment of cardiovascular autonomic responses. Hemodialysis patients of the "rISk strAtification in end-stage Renal disease" (ISAR) study, a prospective, multicenter observational study, were followed up for six years. Mortality hazard, and correlations between clinical characteristics and mortality, were assessed using Cox regression models.

Results: Heart rate turbulence measurement at baseline was available in 290 hemodialysis patients, 99 (34%) with diabetes mellitus. In a multivariable analysis, abnormal heart rate turbulence was associated with a 2.1-fold (95% CI: 1.4-3.2; p < 0.001) increased risk for all-cause and 3.1-fold (95% CI: 1.5-6.2; p = 0.001) increased risk for cardiovascular mortality. The co-occurrence of abnormal heart rate turbulence and diabetes mellitus represented the strongest risk constellation, increasing all-cause mortality risk to a hazard ratio of 5.8 (95% CI: 3.3-10.4; p < 0.001) and cardiovascular mortality risk to 6.1 (95% CI: 2.5-15.1; p < 0.001). This association with mortality risk remained significant after multivariate adjustment. The interaction term between the two comorbidities indicated an approximately additive effect on mortality risk.

Conclusions: Heart rate turbulence significantly contributed to the prediction of long-term mortality risk in hemodialysis patients. Diabetes mellitus is a major driver of cardiovascular autonomic dysfunction, which plays a crucial role in mortality among dialysis patients. Heart rate turbulence measurement identifies high-risk patients in the dialysis setting, enhancing precision in risk prediction and stratification, and allowing an opportunity for personalized monitoring and prevention.

Background: Intradialytic hypotension is associated with increased morbidity, and mortality. Several machine learning (ML) algorithms have been recently developed to predict intradialytic hypotension. We systematically reviewed ML models employed to predict intradialytic hypotension, their performance, methodological integrity, and clinical applicability.

Methods: We conducted this systematic review with a pre-established protocol registered at the International Prospective Register of Systematic Reviews (PROSPERO ID: CRD42022362194). Six databases, from their inception to July 20, 2023, were comprehensively searched. Two independent investigators reviewed the articles, extracted data, and evaluated the risk of bias using the Prediction model Risk of Bias Assessment Tool (PROBAST).

Results: Out of 84 screened articles, 16 studies with 14,500 adult patients on hemodialysis were included in the review. Fourteen studies (87.5%) were found to have a high risk of bias. The intradialytic hypotension prevalence in the population investigated was between 1.2 and 51%. A diverse range of predictive ML tools were used to predict intradialytic hypotension, with various neural networking models being the most frequent, appearing in 13 studies (AUROC ranges: 0.684-0.978). One study performed both internal and external validation.

Conclusions: Researchers have made a concerted effort to develop ML tools to predict intradialytic hypotension. Despite their significant efforts, the lack of thorough external and clinical validation, and heterogeneity among the models and settings have resulted in a substantial challenge to offering ML tools as a global intradialytic hypotension prevention and management solution. Future studies should focus on external and clinical validation of these models to enhance the chances of clinically relevant changes in clinical practices.

Background: Aortic calcification is a predictor of cardiovascular events. Several studies have shown an association between zinc deficiency and aortic calcification in patients with chronic kidney disease (CKD). We therefore investigated the associations between serum zinc levels and aortic arch calcifications in incident patients on dialysis.

Methods: We analyzed data from 773 patients who started dialysis at our hospital between January 2013 and December 2023. Aortic arch calcification was graded 0-3 on chest X-ray, as follows: grade 0, no visible calcification; grade 1, < 50% calcification in the arch; grade 2, 50% calcification; or grade 3, circumferential calcification. We defined grades 2-3 as severe calcification. We stratified patients into tertiles of serum zinc levels.

Results: Median serum zinc levels were 51, 47 and 44 μg/dL in patients with grade 0, 1 and 2-3 aortic arch calcification, respectively (p < 0.001). In multivariate analysis, low serum zinc level was independently associated with aortic arch calcification (OR 3.12, 95% CI 1.84-5.27; p < 0.001), particularly with severe aortic arch calcification (OR 6.91, 95% CI 3.11-15.40; p < 0.001). Adding serum zinc level to a model with established risk factors for aortic arch calcification ameliorated net reclassification (0.308; p < 0.001) and integrated discrimination improvement (0.018; p = 0.0074). More robust findings for net reclassification improvement (0.427; p < 0.001) and integrated discrimination improvement (0.035; p < 0.001) were observed with severe aortic arch calcifications.

Conclusion: Low serum zinc level was independently associated with aortic arch calcification, and in particular, with severe aortic arch calcifications, among patients who started dialysis.