Nephron最新文献

Background The management of kidney failure in older adults has increasingly adopted patient-centered approaches, with conservative kidney management (CKM) recognized as a valid alternative to dialysis in selected cases. Structured counselling is commonly used to support informed decision-making and align treatment with patient goals. However, evidence on its structured application and impact on treatment decisions in this population remains limited. This study evaluates the clinical characteristics, treatment choices, decision stability, and outcomes of older adults with kidney failure who, after a structured counselling session ("Welcome Meeting") at La Paz University Hospital, chose either CKM or dialysis.

Methods: This prospective, observational, single-center cohort study (April 2015-December 2019) included participants aged >75 years with CKD-EPI <12 mL/min (<15 mL/min for those with diabetes), Charlson Comorbidity Index >5, and functional impairment (Barthel Index <95 or Palliative Performance Scale <60). All participants received a structured counselling session to support treatment decision-making. Participants then chose either dialysis or CKM. Predictors included treatment choice, clinical outcomes, symptom burden, and healthcare utilization. Decision stability was defined as sustained adherence to the initial treatment choice over the course of follow-up. Analyses were adjusted for potential confounders including age, sex, comorbidity, and functional status. Data were analyzed using SPSS version 27.

Results: A total of 103 participants were included (mean age: 84.9 ± 5.5 years); 72% chose CKM and 28% opted for dialysis. CKM participants were older, more often female (p=0.009), and had greater functional and cognitive impairment (p<0.001). They also reported more weakness or lack of energy (p=0.03), constipation (p=0.03), and poor mobility (p<0.001) at baseline At the standardized follow-up assessment, depressive symptoms measured with the IPOS-Renal scale showed a significant reduction in the dialysis group (p = 0.043), while vomiting (p = 0.021) and sore or dry mouth (p = 0.049) increased significantly in the CKM group. Healthcare utilization was higher among dialysis participants. Of the 69 deaths, 65 occurred in the CKM group. Decision stability revealed only 5% of CKM participants switching later to dialysis, with no treatment transitions observed in the dialysis group.

Conclusion: After a structured counselling session, elderly kidney failure participants who chose CKM were older, female, and presented greater cognitive and functional impairment. This approach supported informed choices and was associated with a high adherence to the initial treatment decision. Further studies are needed to expand this line of research.

Introduction: The number of spousal donor transplantation (SDT) has increased since the early 1990s. Although the SDT is performed successfully today, several concerns remain regarding compatibility. In particular, in husband-to-wife donations, donor-specific antibodies (DSAs) positivity may develop as a consequence of previous pregnancies, thereby posing a risk to graft survival. However, data on outcomes in recipients with a history of pregnancy and the development of DSA are limited. In this study, we aimed to compare the outcomes of transplantation between high-risk spouses and transplantation from living donors.

Methods: This study was conducted in our nephrology and transplantation department. It involved 59 spousal donors and 72 living-related donors with DSAs who were older than >18 years of age. We evaluated the consecutive patients who had kidney transplantation between 2010 and 2020.

Results: We analyzed data from 59 SDTs with 72 living-related donor transplants (LRDTs) with DSA positivity. Within the first year after transplantation, the acute rejection rate was highest in the husband-to-wife (H-to-W) group (p = 0.01). Compared with LRDT, H-to-W transplants were associated with an increased risk of acute rejection (OR [95% CI]: 4.231 [1.122-15.957], p = 0.03). Cox regression analysis demonstrated a higher risk of rejection in kidney transplants from H to W within the first year of kidney transplantation (HR: 3.734 [95% CI: 1.087-12.825], p = 0.03). There was no increase in creatinine doubling time between groups and no increase in risk of rejection in 5 years. During the follow-up period, graft loss was reported in 3 patients, comprising 2 in the LRDT group and 1 in the W-to-H group.

Conclusion: SDT, particularly when DSA has developed, appears to be associated with a higher risk of rejection during the first year compared with LRDT with similar DSA. Nevertheless, similar graft survival suggests that H-to-W spousal transplants appear to be safe in the long term.

Introduction: Type IV collagen trimers are major structural components of the kidney glomeruli and tubules. Several loss-of-function COL4A1 and COL4A2 variants have been reported to cause cerebral small vessel disease. However, there is little evidence to suggest that loss-of-function variants in these genes can cause kidney disease.

Case presentation: Here we report a case of a patient with thin basement membrane nephropathy and chronic kidney disease (CKD) who was found to bear a 1.9 Mb heterozygous contiguous gene deletion of chromosome 13q33.3-q34 that includes COL4A1 and a large region of COL4A2.

Conclusion: We propose that haploid expression of COL4A1 in combination with COL4A2 can lead to thin basement membrane nephropathy and CKD.

Introduction: Choosing the treatment for kidney failure, whether dialysis or kidney conservative care, is challenging. Many adults may experience regret about this decision, leading to poor quality of life. This review aims to determine the proportion of patients who report decisional regret after making treatment choices for kidney failure, as well as to identify the factors that contribute to it.

Methods: This systematic review was conducted in accordance with PRISMA guidelines. A comprehensive search was performed through the databases PubMed, Web of Science, Scopus, APA PsycINFO, and through websites. The search strategy included terms of three main categories: adults with kidney failure or estimated glomerular filtration rate less then 30 ml/min/1.73 m², kidney failure treatment and decisional regret.

Results: Studies examining decisional regret in adults undergoing kidney replacement therapy, those in the pre-dialysis phase, or those receiving conservative kidney management were included. Initially, 1712 articles were found by the reported research, and 22 of them were selected. The proportion of regret ranged from none to 62% and the factors most related to it were the lack of information, lack of patient autonomy, social and physical burden, and decisional conflict.

Conclusions: Decisional regret is a common experience among adults facing treatment choices for kidney failure, particularly when patient autonomy is compromised, or information is inadequate. Regret is also associated with decisional conflict, and with emotional, social and physical burden, impacting quality of life. Effective communication between healthcare professionals and patients plays a vital role in reducing decisional regret, leading to improved outcomes and greater patient satisfaction. Additionally, practical tools such decision aids can enhance shared decision-making and empower patients to make informed and autonomous choices.

Background: There are considerable sex and gender differences in the epidemiology of chronic kidney disease (CKD), with CKD stage 3, defined as a glomerular filtration rate (GFR) below 60, being more prevalent in women. This raises questions about whether sex differences in age-related GFR decline contribute to this paradox. Only a few studies have investigated this issue, and most of these studies used estimated GFR (eGFR) based on creatinine (eGFRcrea) or cystatin C.

Summary: This article reviews studies examining age-related GFR decline in men and women from the general population. The conflicting findings on sex differences in GFR decline are likely influenced by variations in study populations, including differences in comorbidities, as well as the methods used to assess GFR. Further research is essential to accurately address trajectories of GFR decline in men and women.

Key messages: Sex and gender differences in GFR levels and age-related GFR decline rates may influence the observed differences in CKD prevalence between men and women. Possible differences in age-related GFR decline between men and women may stem from a combination of biological factors, including sex hormones, different methods to assess GFR, and differences in the prevalence and impact of risk factors. Current eGFR equations may not accurately capture sex differences in measured GFR decline. Further research is needed to better understand these differences and their clinical implications.

Background: Diabetic kidney disease (DKD) is a serious complication arising from long-term diabetes, disproportionately affecting historically marginalized populations, such as racial and ethnic minority groups, populations with low socioeconomic status, or a lower level of education. This review explores the causes of these disparities and barriers to accessing DKD therapies and proposes solutions.

Summary: Socioeconomic factors like lack of health insurance, low income, and limited health literacy significantly hinder access to DKD therapies for marginalized communities. Additionally, inadequate access to healthcare services further exacerbates the issue. Clinical factors also contribute to the inequity. Under-recognition of DKD, under-prescription of effective medications, and a lack of a patient-centered healthcare environment are prominent concerns. Implicit bias among healthcare professionals may also play a role. Patient factors include limited awareness of DKD, challenges with treatment adherence, and frequent healthcare interruptions. Policy interventions like the Inflation Reduction Act, expanding health insurance coverage, and increasing reimbursement for DKD therapies can improve affordability and access. Additionally, a shift toward preventive care models is crucial. Clinical interventions focus on improving early detection, accurate diagnosis, and proper management of DKD. Educating healthcare providers about the benefits of DKD therapies and implementing value-based kidney care programs are essential steps. Patient interventions involve raising awareness about DKD, implementing culturally appropriate educational programs, and fostering community-based support systems.

Key messages: Addressing these disparities requires a multipronged approach involving policy changes, improved healthcare delivery, and patient education. This collaborative effort can ensure equitable access to DKD therapies and improve health outcomes for all populations.

Introduction: Oxalate nephropathy, characterized by calcium oxalate crystal deposition in renal tissue, represents an underrecognized etiology of acute and chronic kidney injury. Secondary hyperoxaluria can emerge from diverse pathogenetic mechanisms, including excessive oxalate precursor intake, augmented intestinal absorption, or iatrogenic interventions. The therapeutic potential of glucocorticoids in managing this condition remains incompletely elucidated.

Case presentation: A 66-year-old man with no significant prior medical history developed acute kidney injury (AKI), manifesting as a profound serum creatinine elevation from 81 µmol/L to 1,140.4 µmol/L. The patient had consumed a "corn germ powder" supplement containing lactitol for five consecutive months, concurrently experiencing persistent diarrhea. Initial laboratory investigations revealed severe renal dysfunction without notable proteinuria or hematuria. Renal ultrasonography demonstrated normal kidney morphology and dimensions. Definitive kidney biopsy revealed extensive calcium oxalate crystal deposition within renal tubular structures, conclusively diagnosing oxalate nephropathy. Therapeutic intervention comprised prednisone (60 mg daily) and comprehensive supportive management. Following a 3-month treatment protocol with gradual corticosteroid dose reduction, the patient's renal function demonstrated substantial improvement, with serum creatinine declining to 118.2 µmol/L.

Conclusion: This case underscores lactitol-induced secondary oxalate nephropathy as a rare yet clinically significant contributor to AKI. Prompt diagnostic recognition and targeted therapeutic intervention, potentially incorporating glucocorticoid therapy, may substantially facilitate renal functional recovery. Clinicians should maintain heightened awareness of nephrotoxic risks associated with over-the-counter laxative supplements and consider oxalate nephropathy in cryptogenic renal dysfunction scenarios.

Introduction: Mitophagy is central to acute kidney injury (AKI) pathogenesis. Elucidating its molecular interplay with AKI is crucial for novel therapeutics.

Methods: This study is based on transcriptome sequencing combined with single-cell sequencing and applies bioinformatics analysis. Finally, it is verified by in vitro, in vivo, and clinical specimen experiments.

Results: In transcriptome analysis, combining protein-protein interaction mapping with machine intelligence algorithms, we screened out two mitophagy-related differentially expressed genes (MitoDEGs), solute carrier family 3 member 2 (SLC3A2) and thioredoxin (TXN). The immunological analysis revealed a notable rise in monocyte infiltration in the immune microenvironment of ischemia-reperfusion injury (IRI)-AKI. Spearman analysis indicated hub MitoDEGs were positively correlated with pro-inflammatory immune cell infiltration and negatively correlated with anti-inflammatory or regulatory immune cell infiltration. Based on the highest binding score, 506-26-3 CTD (gamma-linolenic acid) was determined to be the top promising therapeutic candidate. At the single-cell level, hub MitoDEGs were mainly expressed in proximal tubular. In cell experiments, mitophagy was inhibited after hypoxia-reoxygenation, SLC3A2 matched earlier results, while TXN was contrary to the previous analysis results. In the IRI-AKI rat experiments, the findings regarding hub MitoDEGs aligned with our prior analysis, revealing a decrease in the expression of genes associated with mitophagy. Consequently, we directed our attention to the expression levels of SLC3A2 in clinical cases of AKI, where we observed a notable increase.

Conclusion: Our research indicates that SLC3A2 could be a crucial target for enhancing IRI-AKI through the modulation of the mitophagy pathway.

Introduction: Pulmonary hypertension and right ventricular (RV) dysfunction are associated with an increase in mortality and worse prognosis in patients with end-stage kidney disease (ESKD), but pathophysiologic mechanisms underlying the progression of RV dysfunction remain incompletely understood. The present study aimed to understand right ventricular to pulmonary artery (RV-PA) coupling, which is an early indicator of transition to RV dysfunction, to better characterize adaptive RV response to increased afterload in ESKD patients and changes in RV-PA coupling following renal transplantation.

Methods: One hundred eleven patients with ESKD, including 49 patients scheduled for renal transplantation, underwent a detailed echocardiographic examination and measurement of tricuspid annular plane excursion to pulmonary artery systolic pressure (TAPSE/PASP) ratio, and a repeat examination was performed 6 months after the baseline examination.

Results: Patients with ESKD had significantly lower TAPSE/PASP ratio at baseline (1.02 [0.71-1.63] vs. 1.29 [1.09-1.96], p < 0.001). In 40 patients that underwent transplantation, TAPSE/PASP ratio increased significantly from (0.97 [0.72-1.42] to 1.30 [1.01-1.82], p = 0.03), while in 27 patients remained on dialysis, there was a nonsignificant reduction in TAPSE/PASP ratio (1.21 [0.71-1.62] vs. 0.84 [0.61-1.38], p = 0.44). The change in TAPSE/PASP ratio correlated significantly with the change in pulmonary vascular resistance (OR: 0.61, 95% CI: 0.51-0.72, p < 0.001) and left ventricular mass index (OR: 0.97, 95% CI: 0.96-0.99, p = 0.001) after adjustment.

Conclusions: Patients with ESKD had abnormal RV-PA coupling, as indicated by a reduced TAPSE/PASP ratio, which normalizes 6 months after renal transplantation.