Kidney360最新文献

Nepal has made significant strides in nephrology, progressing from no dialysis services to offering comprehensive kidney care, including dialysis and transplantation. The journey began in the 1980s with the establishment of the first nephrology unit at Bir Hospital and has since grown to encompass over 60 dialysis centers and multiple transplant facilities. Government initiatives, such as financial subsidies and health insurance schemes, have increased accessibility, yet disparities persist due to workforce shortages, uneven infrastructure distribution, and inconsistent quality control in dialysis services. Predialysis care remains underdeveloped, and challenges in adopting peritoneal dialysis persist due to socioeconomic and logistical barriers. The kidney transplant program, primarily reliant on living donors, has shown steady growth. Critical care nephrology and interventional services are gradually emerging. To advance, addressing workforce shortages, improving care quality, and expanding equitable access through strategic investments and global partnerships are essential.

People with cirrhosis of the liver are at increased risk of developing kidney dysfunction because of portal hypertension-induced splanchnic vasodilation which decreases effective arterial blood volume. This can lead to hepatorenal syndrome, which manifests clinically as ascites that is refractory to diuretics, a rise in creatinine, and hyponatremia. Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure that shunts blood directly from the portal vein to the hepatic vein, bypassing the high-pressure system of the cirrhotic liver. Among patients with diuretic-resistant ascites, TIPS decreases recurrence of ascites and improves kidney function. However, because less blood is passing through the hepatic sinusoids, postprocedure risks of TIPS, including worsening hepatic encephalopathy and liver ischemia, increase with the severity of liver disease. The model for end-stage liver disease score quantifies this risk using the international normalized ratio, bilirubin, and serum creatinine as variables and has been used to exclude high-risk patients from TIPS. The flaw in this method is that although serum creatinine can indicate worse hepatic function, it is a parameter of this composite score that may improve with TIPS. This review discusses the physiologic changes that occur after TIPS and recommends an individualized approach to TIPS selection in patients with kidney disease.

Artificial intelligence (AI) promises significant advancements in nephrology. While current use of AI in clinical nephrology practice is limited, there is scope for application in transplant allocation, remote dialysis monitoring, and CKD management. Yet, despite its potential, the use of AI in nephrology raises important ethical issues. Challenges include concerns about trustworthiness and reliability of AI systems, accountability for inaccurate results, injustice from the perpetuation or exacerbation of individual and systemic biases and inequities, and risks to patient privacy arising from the need for AI to access to sensitive health data. In addition, there are unresolved questions about the application of current disclosure and informed consent practices for patients when AI is used in their care and about the environmental and sustainability effect of this energy-hungry technology in an already resource intensive specialty. This article explores these ethical challenges and gives recommendations for addressing them, both at an individual clinician and health care system level.