Nephron最新文献

Background: Fluid overload is a common manifestation of chronic kidney disease (CKD) and is associated with increased hospitalizations and death. However, severe symptomatic fluid overload is potentially preventable with early recognition of mild fluid overload and timely institution of appropriate pharmacotherapy and fluid restriction. We implemented and evaluated the outcomes of a nurse-led clinic that incorporated objective fluid volume assessment using body impedance analysis (BIA) into structured patient education and action plan coaching to patients with CKD and fluid overload.

Methods: Single-center prospective pre- post implementation study of adults who participated in the program (Table 1) between August 2022 and April 2024. Patients were eligible if they had CKD not requiring dialysis and had fluid overload and/or systolic blood pressure (BP) >160 mmHg or diastolic BP >100 mmHg. The clinical effectiveness outcomes were symptoms and signs of fluid overload and improvement in blood pressure. The patient-reported effectiveness outcomes were chronic disease self-management assessed using the Partner in Health (PIH) questionnaire and health-related quality of life (HrQOL) assessed by the EuroQOL-5 Dimension (EQ5D5L) survey. The clinical safety outcomes were hypotension and worsening kidney function.

Results: Among 107 patients referred to the nurse-led program, 96 attended the first visit. median age was 68.5 (IQR 60.2, 77.3) years and eGFR was 21.6 (14.0, 39.7) ml/min/1.73 m2. Almost all participants (93.8%) had symptoms of fluid overload within the past 1 month before the first review. BIA was performed for 52 (54.2%) patients and the median overhydration was 2.4 (1.3, 3.6) liters. The second and third visits were attended by 38 (39.6%) and 28 (29.2%) patients, respectively. At program completion, patients had reduced symptoms and signs of fluid overload and had improved systolic BP [137 (121, 143) versus 151 (132, 166) mmHg, p=0.03] and self-management [PIH score 96 (89, 104) versus 72 (57, 88), p=0.001] compared to their baseline visit. EQ5D5L scores were significantly different. None experienced hypotension (systolic BP <90 mmHg) and kidney function did not change significantly during follow-up.

Conclusions: A nurse-led program that incorporated objective fluid volume assessment, structured patient education and action plan coaching for patients with CKD and fluid overload improved BP and self-management.

Introduction: Autosomal dominant polycystic kidney disease (ADPKD) is a prevalent hereditary kidney disease and the fourth most common cause of kidney failure. Patients may be aware of their condition from an early age or discover it unexpectedly, with varying levels of familial knowledge about the disease. This chronic condition presents significant challenges for healthcare professionals. The study aimed to investigate how people with ADPKD experience their participation in a dedicated ADPKD clinic and to investigate their support needs in managing their disease in everyday life.

Methods: A qualitative phenomenological descriptive study was conducted, involving semi-structured telephone interviews with patients who attended a newly established dedicated ADPKD clinic between March and April 2023. The data were analyzed using Malterud's principles of systematic text condensation.

Results: In total, 18 out of 22 patients agreed to participate in the interviews. Six themes emerged from the interviews. Participants expressed feelings of uncertainty about their future and highlighted the necessity for personalized care tailored to their individual circumstances. They reported challenges in coping with emotions associated with the disease and sought assistance in making difficult decisions. Maintaining control over their health and illness was a significant theme, alongside a desire for increased knowledge about their condition.

Conclusion: Our study supports existing knowledge in this area. In this study, the participants experienced satisfaction with the dedicated ADPKD clinic, feeling well informed, listened to, and more at ease after the check-up. Investing in a dedicated ADPKD clinic could help alleviate the uncertainty that many people with ADPKD experience.

Background: Traditional biomarkers, such as estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (uACR), have long been central to chronic kidney disease (CKD) diagnosis and management, leading to a standardized CKD classification system. However, these biomarkers are non-specific and fail to capture the heterogeneity within CKD and the nuances of an individual's disease mechanism, limiting personalized treatment approaches. There is an increasing need for novel biomarkers that reflect the diverse pathophysiological processes underlying CKD progression, enabling more precise risk prediction and treatment strategies.

Summary: This review examines the limitations of current CKD biomarkers and classification systems, highlighting the need for a precision medicine approach. While traditional markers like eGFR and uACR are foundational, they inadequately capture CKD's complexity. Emerging biomarkers offer insights into specific disease processes, such as inflammation, oxidative stress, fibrosis, and tubular injury, which are crucial for personalized care. The article discusses the potential benefits of integrating these novel biomarkers into clinical practice, including more accurate risk prediction, tailored treatments, and personalized clinical trial designs, as well as the barriers to their implementation. Furthermore, advancements in multi-omics and high-throughput techniques offer opportunities to identify novel causative proteins with druggable targets, pushing CKD care towards greater precision.

Key messages: Current CKD classification systems, based on non-specific biomarkers, fail to capture CKD's heterogeneity. Incorporating biomarkers reflecting diverse pathophysiological mechanisms can enhance risk prediction, customized treatments, and personalized clinical trials. High-throughput multi-omic techniques present a promising path towards precision medicine in nephrology.

Background: Efficient arteriovenous vascular access (VA) surveillance is vital for early identification of dysfunctional access, allowing timely intervention to prevent thrombosis. This study compares the efficacy of adding remote software surveillance to standard clinical care across our units.

Methods: We conducted a 12-month prospective study on maintenance haemodialysis (HD) patients using Vasc-Alert software technology to assist clinical decision-making in 2 satellite HD units (group 1) and standard care in the remaining 3 HD units (group 2). Patients with Vasc-Alert-derived high Access Risk Score (ARS) (≥7) underwent clinical assessment and were referred for fistulogram based on relevant Kidney Disease Outcome Quality Initiative (KDOQI) criteria. Data on referrals for fistulogram, subsequent VA events, access abandonment, and complication-free days-extended (CFD-extended) were collected. VA survival analysis of post-intervention primary patency rate at 3 and 6 months was conducted.

Results: There were 23 (28.1%) pre-emptive correction of stenosis and 6 (7.3%) thrombosis episodes in group 1, compared to 40 (19.5%) and 21 (10.2%) in group 2 (p value 0.155, 0.587), respectively). Among the thrombotic episodes, 83% of cases in group 1 had been detected during surveillance and referred for diagnostic fistulogram ± angioplasty but developed thrombosis while awaiting elective intervention compared to 19% in group 2 (p = 0.004). Median time from fistulogram request to thrombosed VA was 26 days (interquartile range: 21-42 days). Group 1 exhibited better post-intervention primary patency rates and longer CFD compared to group 2 (p value <0.001, 0.002, respectively).

Conclusion: Incorporating Vasc-Alert technology into VA clinical surveillance pathway was associated with improved early detection of high-risk VA, higher primary patency rates, and longer CFD-extended compared to standard of care. Improving elective interventional radiology capacity for timely intervention (<3 weeks from referral) is crucial to materialise the benefits of enhanced surveillance in preventing acute thrombosis.

Introduction: With the increasing prevalence of membranous nephropathy (MN), the gut microbiome (GM) is increasingly implicated in its cause, yet the intricate mechanisms remain unclear. Whether changes in the diversity and richness of gut microbial populations among MN patients contribute to disease prevalence is still unanswered, necessitating further exploration into the potential causative link between the GM and MN.

Methods: We conducted a comprehensive bidirectional mendelian randomization (MR) study. We selected 211 bacterial taxa using genome-wide association study (GWAS) data provided by the MiBioGen consortium, while GWAS data relevant to MN were obtained from ebi-a-GCST010005. The inverse-variance weighted (IVW) method was the primary technique used to delineate the causal relationship between exposures and outcomes. To confirm the robustness of our results, we used additional methods, including MR-Egger, weighted median, simple mode, and weighted mode. Sensitivity analyses included tests for pleiotropy, heterogeneity, and leave-one-out sensitivity to ensure the integrity of our conclusions. Finally, reverse MR analyses were conducted to assess the likelihood of reverse causality.

Results: Using various analytical methods, including the IVW approach, MR-Egger, weighted median, simple mode, and weighted mode, our study identified six microbial taxa with a statistically significant causal link to MN, as indicated by p values <0.05. The implicated taxa are Butyrivibrio (OR = 1.25, 95% CI: 1.001-1.565, p = 0.048), Butyricicoccus (OR = 2.15, 95% CI: 1.005-4.621, p = 0.048), Catenibacterium (OR = 1.49, 95% CI: 1.043-2.134, p = 0.028), Ruminiclostridium 5 (OR = 1.78, 95% CI: 1.140-2.763, p = 0.03), Ruminococcaceae UCG-003 (OR = 1.78, 95% CI: 1.140-2.763, p = 0.011), and Bacillales (OR = 1.52, 95% CI: 1.135-2.025, p = 0.005). Each of these taxa has been established as a risk factor for MN. Notably, Ruminococcaceae UCG-003 and Bacillales were identified as having a bidirectional causal relationship with the disease.

Conclusion: Our MR study has revealed a causal link between six microbial taxa and MN, highlighting their potential involvement in the disease's development. These findings represent an initial step into this complex field and underscore the need for more in-depth research.

Background: The recurrence of primary glomerulonephritis (GN) following kidney transplantation poses a significant threat to graft survival. To enhance kidney transplant outcomes, we must lessen the burden of recurrence. In recent years, there has been progress in understanding the incidence, risk factors for recurrence, pathophysiology, biomarkers, and therapeutics, making it worthwhile to conduct an update on primary GN that may recur following kidney transplantation.

Summary: We conducted a narrative review of the literature on the novel discoveries of primary GN that can recur following kidney transplantation. To summarize, developing a broad consensus on recurrence diagnosis would greatly advance our understanding, and its development would be a valuable collaborative effort. The key risk factors for recurrence have been better understood, particularly in individuals with complement-related or monoclonal gammopathy-related recurrent membranoproliferative GN. Furthermore, we can identify better recurrent IgA nephropathy patients who are more likely to experience graft loss. New biomarkers for membranous nephropathy (anti-PLA2R-Ab) and focal and segmental glomerulosclerosis (anti-nephrin-Ab) can assist in identifying and monitoring patients at risk of recurrence. Regarding therapy, the focal and segmental glomerulosclerosis consensus will enhance recurrence treatment. Some complement inhibitors and anti-CD38 monoclonal antibodies are already promising in treating and healing recurrent C3 glomerulopathy and focal and segmental glomerulosclerosis, respectively. Finally, new drugs developed specifically to treat IgA nephropathy in the native kidney will also change the outcome of IgA nephropathy recurrence.

Key messages: Although there has been progress in understanding the recurrence of primary GN following kidney transplantation, a worldwide effort should be undertaken to gather research that will allow for improved diagnosis, monitoring, and management of these patients.

Introduction: The efficacy of telitacicept treatment in reducing proteinuria in patients with IgA nephropathy (IgAN) was indicated in a phase II clinical trial with small sample size. In this study, we conducted a large multicenter retrospective study to explore the efficacy and safety of telitacicept in patients with IgAN.

Methods: This study recruited patients with IgAN from 19 sites from China who were treated with telitacicept and had been followed up at least once or with side effect reported, since April 1, 2021, to April 1, 2023. The primary outcomes of the study were the changing in proteinuria and eGFR over time.

Results: A cohort of 97 patients with IgAN who were treated with telitacicept were recruited, with a median follow-up duration of 3 months. The median baseline proteinuria was 2.3 [1.3, 3.9] g/day and eGFR was 45.0 [26.8, 73.7] mL/min/1.73 m2. There was a significant reduction of proteinuria at 2, 4, 6 months when compared with baseline (2.3 [1.5, 4.1] vs. 1.5 [0.8, 2.3] g/day; 2.3 [1.1, 3.7] vs. 1.1 [0.6, 1.9] g/day; 2.1 [1.0, 2.7] vs. 0.9 [0.5, 1.7] g/day, all p values <0.01). The level of eGFR were comparable between at the baseline and 2, 4, 6 months of follow-up time (41.5 [29.7, 72.0] vs. 42.5 [28.8, 73.3] mL/min/1.73 m2; 41.0 [26.8, 67.7] vs. 44.7 [31.0, 67.8] mL/min/1.73 m2; 33.7 [24.0, 58.5] vs. 32.6 [27.8, 57.5] mL/min/1.73 m2, all p values >0.26). Telitacicept was well tolerated in the patients.

Conclusions: This study indicates that telitacicept alone or on top of steroids therapy can significantly and safely reduce proteinuria in patients with IgAN. The long-term kidney protection still needs to be confirmed in large phase III trial.

Introduction: Acute kidney injury (AKI) is associated with adverse outcomes, including death and dialysis. The goal of this study was to identify prognostic biomarkers of AKI that could be used across multiple phenotypes of AKI and across different species.

Methods: Liquid chromatography/tandem mass spectrometry analysis of urine samples from three species (human, rat, and mouse) and four etiologies of AKI identified five potential biomarkers, of which two were validated, complement C3 and vitamin D-binding protein, in a cohort of 157 patients that developed AKI following cardiothoracic surgery. We studied the relationship between the biomarker's concentration in the urine and the development of a composite primary endpoint (stage 3 AKI within 10 days or death within 30 days).

Results: Of the 153 patients who developed AKI following cardiovascular surgery, 17 met the combined primary outcome. The median concentration of urine complement C3 adjusted to urine creatinine had the best predictive value and was significantly higher in the primary outcome group than in the controls. Similarly, the median concentration of vitamin D-binding protein was higher in the primary outcome group.

Conclusions: The studies provide proof in principle that cross-species discovery analyses could be a valuable tool for identifying novel prognostic biomarkers in AKI. Urine complement C3 and vitamin D-binding protein could be promising early predictors of adverse outcomes in patients who develop AKI after cardiac surgery.