Kidney Research and Clinical Practice最新文献

Background: With the aging population and advancements in medical care worldwide, the number of older patients with end-stage kidney disease continues to rise. This study aimed to identify factors associated with osteoporosis and osteopenia in older patients undergoing incident hemodialysis and assess their impact on mortality.

Methods: We analyzed a large multicenter retrospective cohort of patients aged ≥70 years undergoing incident hemodialysis to identify factors associated with osteoporosis using logistic regression analysis and to assess the association of death with osteoporosis and osteopenia using Cox multivariable analysis.

Results: Among 710 patients, 39.0% and 19.6% had osteoporosis and osteopenia, respectively. Osteoporosis was significantly associated with female sex, a history of fractures, and the absence of phosphate binder use. During a median follow-up of 36.8 months, 348 participants (58.8%) died. Mortality rates were the highest in the osteoporosis group (79.8%), followed by the osteopenia (77.2%) and normal bone mineral density (BMD) groups (35.2%). Cox regression analysis revealed that even after adjusting for covariates, the osteoporosis group was significantly associated with a higher mortality risk than the normal BMD group. Osteoporosis at the start of hemodialysis was significantly associated with higher mortality.

Conclusion: We should consider the importance of bone health in patients undergoing incident hemodialysis and pay attention to the use of phosphate binders and fracture prevention.

Background: Immunoglobulin G4 (IgG4)-related disease (RD) is a newly recognized disease, and a few epidemiologic studies about this disorder have been published. This research aimed to demonstrate the clinical features and outcomes of IgG4-related kidney disease (RKD) and IgG4-related retroperitoneal fibrosis (RPF) compared to other organs' involvement.

Methods: Patients who were diagnosed with IgG4-RD from January 2009 to July 2019 at three medical institutions in South Korea were included. They were classified into three groups: RKD, RPF, and Others groups. The differences in symptoms, laboratory, histological and radiological findings, treatment, and outcomes among the three groups were evaluated.

Results: Of 94 patients, 13 (13.8%) and 22 patients (23.4%) were classified into the RKD and RPF groups, respectively. There were older (p = 0.004) and more asymptomatic patients (p = 0.02) in the RKD and RPF groups. In the RKD group, hypocomplementemia (p = 0.003) and eosinophilia (p = 0.001) were more frequently identified. In logistic regression analysis, hypocomplementemia (odds ratio [OR], 14.04; 95% confidence interval [CI], 1.38-142.95) and decreased renal function at the time of diagnosis (OR, 0.95; 95% CI, 0.91-0.98) were associated with renal involvement. Older age (OR, 1.05; 95% CI, 1.00-1.11), male (OR, 6.11; 95% CI, 1.41-26.61), and higher serum IgG4 levels (OR, 1.00; 95% CI, 1.00-1.00) were associated with retroperitoneal involvement. The treatment duration was longer in the RKD and RPF groups (p = 0.01) with glucocorticoids.

Conclusion: Renal and retroperitoneal involvement in IgG4-RD presented clinical features that distinguish it from other organs' involvement, such as incidental diagnosis, hypocomplementemia, eosinophilia, and the need for a longer duration of maintenance treatment.

Chronic kidney disease (CKD) is a progressive condition characterized by declining kidney function principally driven by diabetes mellitus, glomerulonephritis, and hypertension. Although renal biopsy is the gold standard for diagnosing CKD, its invasive nature restricts its use for early detection and routine clinical applications. Current noninvasive biomarkers, including the estimated glomerular filtration rate and albumin-to-creatinine ratio, are useful indicators of kidney dysfunction but fall short in specificity and sensitivity required to distinguish between CKD subtypes, including diabetic kidney disease and glomerulonephritis. Recently, urinary extracellular vesicles (uEVs), nano-sized lipid bilayer entities ranging from 30 to 1,000 nm in diameter and secreted by renal cells, have emerged as promising biomarkers for CKD. uEVs encapsulate a diverse array of proteins, nucleic acids, and lipids that mirror kidney pathophysiology, presenting a noninvasive means to assess disease progression, inflammation, fibrosis, and oxidative stress within the urinary system. Furthermore, uEVs offer a molecular fingerprint of kidney health, positioning them as potential tools for precision medicine. This review explores the diagnostic potential of uEVs, underscoring the need for standardization in urine collection, normalization techniques, and uEV isolation methodologies. We also highlight uEV-based biomarkers that distinguish various CKD subtypes and mirror pathological changes within the kidneys and urogenital system. As molecular proxies of their cells of origin, uEVs hold significant promise in enhancing CKD diagnostics to enable early detection, disease classification, and the development of novel therapeutic strategies.

Background: This study was performed to evaluate the prognostic utility of a positive T wave in lead augmented vector right (TaVR) and elevated E/e' ratio in predicting major adverse cardiovascular events (MACE) in patients receiving maintenance hemodialysis.

Methods: We retrospectively examined 296 adults on thrice-weekly hemodialysis with baseline electrocardiography and transthoracic echocardiography (October 2018-April 2024). TaVR positivity was T-wave amplitude, >0 mV and high E/e', ≥19. Primary outcome was the first MACE-cardiovascular death, myocardial infarction, stroke, heart-failure admission, or revascularization. Multivariable Cox models adjusted for clinical covariates; incremental value was gauged with Harrell's C-index, integrated discrimination improvement (IDI), and continuous net reclassification improvement (NRI). Sensitivity analysis was performed using a guideline-recommended E/e' threshold of ≥15 to assess robustness.

Results: Over 56.5 months (1,325 patient-years), 118 MACE occurred (8.9/100 patient-years). Incidence was higher with TaVR positivity than negativity (16.0/100 patient-years vs. 3.7/100 patient-years; log-rank p < 0.001). Adjusted hazard ratios were 3.19 (95% confidence interval [CI], 2.00-5.08) for TaVR and 2.92 (95% CI, 1.71-4.96) for high E/e'. Adding both markers to the clinical model increased the C-index from 0.65 to 0.75 (Δ 0.10) and improved IDI (0.10) and NRI (0.16) (all p < 0.01). A significant negative interaction (hazard ratio, 0.21; p = 0.01) indicated complementary but partly overlapping information. Sensitivity results were similar.

Conclusion: TaVR positivity is a strong independent electrocardiography predictor of cardiovascular events in hemodialysis. Combining TaVR with E/e' adds prognostic value and supports a pragmatic two-step strategy- electrocardiography triage followed by focused echocardiography-for cardiovascular risk stratification in this high-risk population.

Background: Obesity is a well-known risk factor for chronic kidney disease and its progression. However, the impact of obesity on the renal function of the elderly population is uncertain. We investigated the association between obesity and renal outcomes in the elderly.

Methods: We analyzed 130,504 participants from the Korean National Health Insurance Service-Senior cohort. Obesity was classified according to body mass index (BMI), sex-specific waist circumference (WC), and the presence of metabolic syndrome. The primary outcome was renal function decline, defined as a decline in the estimated glomerular filtration rate (eGFR) of at least 50% from baseline or new-onset end-stage renal disease.

Results: During a follow-up period of 559,531.1 person-years (median, 4.3 years), 2,486 participants (19.0%; incidence rate of 4.44 per 1,000 person-years) showed renal function decline. A multivariate Cox proportional hazards model revealed that BMI/WC was not associated with renal function decline. However, the group with metabolic syndrome had a significantly increased risk of renal function decline compared to the group without metabolic syndrome (adjusted hazard ratio [HR], 1.24; 95% confidence interval [CI], 1.13-1.36). Compared with the non-metabolic syndrome group, the adjusted HRs (95% CI) for participants with one through five components were 0.96 (0.84-1.11), 1.10 (0.96-1.27), 1.24 (1.06-1.45), 1.37 (1.12-1.66), and 1.99 (1.42-2.79), respectively (p for trend < 0.001).

Conclusion: In elderly Korean adults, metabolic syndrome and the number of its components were associated with a higher risk of renal function decline, but BMI or WC was not significant.

Background: Intradialytic hypotension (IDH) is a critical complication related to worse outcomes in patients undergoing maintenance hemodialysis. Herein, we addressed the impact of IDH on mortality and other outcomes in patients with severe acute kidney injury (AKI) requiring intermittent hemodialysis.

Methods: We retrospectively reviewed 1,009 patients who underwent intermittent hemodialysis due to severe AKI. IDH was defined as either dialysis discontinuation due to hemodynamic instability or a decrease in systolic blood pressure (BP) of ≥30 mmHg, with or without a nadir systolic BP of <90 mmHg during the first session. The primary outcome was all-cause mortality, and transfer to the intensive care unit (ICU) due to unstable status was additionally analyzed. Hazard ratios (HRs) of outcomes were calculated using a Cox regression model after adjusting for multiple variables. Risk factors for IDH were evaluated using a logistic regression model.

Results: IDH occurred in 449 patients (44.5%) during the first hemodialysis session. Patients with IDH had a higher mortality rate than those without IDH (40% vs. 23%; HR, 1.30; 95% confidence interval [CI], 1.02-1.65). The rate of ICU transfer was higher in patients experiencing IDH than in those without IDH (17% vs. 11%; HR, 1.43; 95% CI, 1.02-2.02). Factors such as old age, high BP and pulse rate, active malignancy, cirrhosis, and hypoalbuminemia were associated with an increased risk of IDH episodes.

Conclusion: The occurrence of IDH is associated with worse outcomes in patients with AKI requiring intermittent hemodialysis. Therefore, careful monitoring and early intervention of IDH may be necessary in this patient subset.

Background: The optimal frequency for hemodialysis in older adults with end-stage kidney disease (ESKD) has not been established. This study aims to investigate whether a twice-weekly dialysis schedule using an incremental approach can reduce hospitalization rates in the elderly with incident dialysis, compared with conventional thrice-weekly dialysis.

Methods: We have designed a pragmatic randomized controlled trial to compare the effects of twice-weekly versus thrice-weekly hemodialysis in 428 ESKD individuals (dropout rate 20%) aged 60 years or older with residual kidney function (urine output, >500 mL/ day). The trial will be conducted across 18 referral hospital-based dialysis centers in Korea. Individual participants will be randomized to either a twice-weekly (with incremental approach) or thrice-weekly dialysis group and will be followed up for 24 months. The primary outcome of the study is all-cause hospitalization rate, while secondary outcomes include dialysis-specific hospitalization rates, mortality, quality of life, frailty, and cost-effectiveness. Participants have the flexibility to transfer to other dialysis centers as needed. The decision to increase dialysis frequency will be made by the treating physicians. The study is ongoing and will be completed in May 2026.

Conclusion: This study will provide valuable insights into the benefits and risks of twice-weekly dialysis with an incremental approach in elderly with residual kidney function compared to thrice-weekly dialysis.

Background: Acute kidney injury (AKI) is a major global public health concern. However, a major challenge in addressing the AKI burden is the lack of global data on AKI-related mortality and its predictions, leaving significant limitations in understanding its trends over time. Therefore, we aimed to estimate AKI-related mortality rate trends and forecast future deaths.

Methods: We evaluated the temporal trends in age-standardized AKI-related mortality from 1996 to 2021 across 43 countries using the World Health Organization Mortality Database, with future projections through to 2050. Temporal trends were assessed based on age-standardized mortality rates, and future projections up to 2050 were calculated using a predictive model that considered attributable risk factors from the Global Burden of Disease Study 2021.

Results: Age-standardized AKI-related mortality rate per 1,000,000 people remained stable from 1996 to 2021 (10.47 [95% confidence interval (CI), 8.84-12.11] to 9.94 [95% CI, 8.32-11.57]). Although age-standardized mortality rates were lower in high-income countries (HICs) compared to low- and middle-income countries (LMICs), HICs exhibited a modest but statistically significant increasing trend (from 5.83 per 1,000,000 people [95% CI, 4.21-7.46] to 7.30 [95% CI, 5.66-8.95]), whereas LMICs showed a declining trend (from 19.66 [95% CI, 16.78-22.53] to 15.33 [95% CI, 12.37-18.29]). Projections indicate that mortality will rise to 11.36 per 1,000,000 population (95% CI, 10.65-12.07) by 2050, primarily attributable to population aging.

Conclusion: This global time-series modeling study highlights rising AKI-related mortality in HICs and/or aging populations. These findings underscore the need for targeted interventions to mitigate future AKI-related deaths.