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Effectiveness and safety of apixaban and rivaroxaban vs warfarin in patients with atrial fibrillation and chronic kidney disease 阿哌沙班和利伐沙班对比华法林治疗心房颤动和慢性肾病患者的有效性和安全性
Pub Date : 2023-12-25 DOI: 10.5527/wjn.v12.i5.132
Sylvie Perreault, Laurie-Anne Boivin Proulx, A. Lenglet, Ziad A Massy, M. Dorais
BACKGROUND Randomized controlled trials (RCTs) of direct oral anticoagulants (DOACs) included a low proportion of atrial fibrillation (AF) patients with chronic kidney disease (CKD), and suggested that DOACs are safe and effective in patients with mild-to-moderate CKD. In a metanalysis of RCTs and observational studies, DOACs were associated with better efficacy (vs warfarin) in early CKD and had similar efficacy and safety profiles in patients with stages IV-V CKD. But few studies have provided data on the safety and effectiveness of each DOAC vs warfarin in patients with stage III CKD. The effectiveness and safety of DOACs in those patients are still subject to debate. AIM To assess and compare the effectiveness and safety of apixaban and rivaroxaban vs warfarin in this patient population. METHODS A cohort of patients with an inpatient or outpatient code for AF and stage III CKD who were newly prescribed apixaban and rivaroxaban was created using the administrative databases from the Quebec province of Canada between 2013 and 2017. The primary effectiveness outcome was a composite of ischemic stroke, systemic embolism, and death, whereas the primary safety outcome was a composite of major bleeding within a year of DOAC vs warfarin initiation. Treatment groups were compared in an under-treatment analysis using inverse probability of treatment weighting and Cox proportional hazards. RESULTS A total of 8899 included patients filled out a new oral anticoagulation therapy claim; 3335 for warfarin and 5564 for DOACs. Compared with warfarin, 15 mg and 20 mg rivaroxaban presented a similar effectiveness and safety composite risk. Apixaban 5.0 mg was associated with a lower effectiveness composite risk [Hazard ratio (HR) 0.76; 95% confidence interval (CI): 0.65-0.88] and a similar safety risk (HR 0.94; 95%CI: 0.66-1.35). Apixaban 2.5 mg was associated with a similar effectiveness composite (HR 1.00; 95%CI: 0.79-1.26) and a lower safety risk (HR 0.65; 95%CI: 0.43-0.99. Although, apixaban 5.0 mg was associated with a better effectiveness (HR 0.76; 95%CI: 0.65-0.88), but a similar safety risk profile (HR 0.94; 95%CI: 0.66-1.35). The observed improvement in the effectiveness composite for apixaban 5.0 mg was driven by a reduction in mortality (HR 0.61; 95%CI: 0.43-0.88). CONCLUSION In comparison with warfarin, rivaroxaban and apixaban appear to be effective and safe in AF patients with stage III CKD.
背景直接口服抗凝药(DOACs)的随机对照试验(RCTs)中,慢性肾脏病(CKD)房颤(AF)患者的比例较低,这表明 DOACs 对轻度至中度 CKD 患者安全有效。在一项对研究性临床试验和观察性研究的荟萃分析中,DOACs 在早期 CKD 患者中具有更好的疗效(与华法林相比),在 IV-V 期 CKD 患者中具有相似的疗效和安全性。但很少有研究提供数据,说明每种 DOAC 与华法林相比,对 III 期 CKD 患者的安全性和有效性。DOACs 对这些患者的有效性和安全性仍存在争议。目的 评估和比较阿哌沙班和利伐沙班与华法林在这类患者中的有效性和安全性。方法 利用加拿大魁北克省 2013 年至 2017 年间的行政数据库,建立了一组新处方阿哌沙班和利伐沙班的房颤住院或门诊病人和 III 期 CKD 患者队列。主要有效性结局是缺血性卒中、全身性栓塞和死亡的复合结果,而主要安全性结局是DOAC与华法林开始治疗后一年内大出血的复合结果。在治疗不足分析中,采用逆治疗概率加权法和 Cox 比例危险度法对治疗组进行了比较。结果 共有 8899 名患者填写了新的口服抗凝疗法申请表;其中 3335 人使用华法林,5564 人使用 DOAC。与华法林相比,15 毫克和 20 毫克利伐沙班具有相似的有效性和安全性综合风险。阿哌沙班 5.0 毫克的有效性综合风险较低[危险比 (HR) 0.76;95% 置信区间 (CI):0.65-0.88],安全性风险相似(HR 0.94;95% 置信区间 (CI):0.66-1.35)。阿哌沙班 2.5 毫克与相似的有效性综合结果(HR 1.00;95%CI:0.79-1.26)和较低的安全性风险(HR 0.65;95%CI:0.43-0.99)相关。阿哌沙班 5.0 毫克的有效性更高(HR 0.76;95%CI:0.65-0.88),但安全风险相似(HR 0.94;95%CI:0.66-1.35)。所观察到的阿哌沙班 5.0 毫克疗效综合指标的改善是由于死亡率的降低(HR 0.61;95%CI:0.43-0.88)。结论 与华法林相比,利伐沙班和阿哌沙班似乎对 III 期慢性肾脏病房颤患者有效且安全。
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引用次数: 0
Cryptococcosis in kidney transplant recipients: Current understanding and practices 肾移植受者中的隐球菌病:当前的认识和实践
Pub Date : 2023-12-25 DOI: 10.5527/wjn.v12.i5.120
P. Meena, V. Bhargava, Kulwant Singh, Jasmine sethi, Aniketh Prabhakar, Sandip Panda
Cryptococcosis is the third most commonly occurring invasive fungal disease in solid organ transplant recipients (SOT). It is caused by encapsulated yeast, Cryptococcus species, predominantly Cryptococcus neoformans and Cryptococcus gattii. Though kidney transplant recipients are at the lowest risk of cryptococcosis when compared to other solid organ transplant recipients such as lung, liver or heart, still this opportunistic infection causes significant morbidity and mortality in this subset of patients. Mortality rates with cryptococcosis range from 10%-25%, while it can be as high as 50% in SOT recipients with central nervous system involvement. The main aim of diagnosis is to find out if there is any involvement of the central nervous system in disseminated disease or whether there is only localized pulmonary involvement as it has implications for both prognostication and treatment. Detection of cryptococcal antigen (CrAg) in cerebrospinal fluid or plasma is a highly recommended test as it is more sensitive and specific than India ink and fungal cultures. The CrAg lateral flow assay is the single point of care test that can rapidly detect cryptococcal polysaccharide capsule. Treatment of cryptococcosis is challenging in kidney transplant recipients. Apart from the reduction or optimization of immunosuppression, lipid formulations of amphotericin B are preferred as induction antifungal agents. Consolidation and maintenance are done with fluconazole; carefully monitoring its interactions with calcineurin inhibitors. This review further discusses in depth the evolving developments in the epidemiology, pathogenesis, diagnostic assays, and management approach of cryptococcosis in kidney transplant recipients.
隐球菌病是实体器官移植受者(SOT)中第三大常见的侵袭性真菌疾病。它是由隐球菌属包裹酵母引起的,主要是新生隐球菌和加特隐球菌。虽然与肺、肝或心脏等其他实体器官移植受者相比,肾移植受者患隐球菌病的风险最低,但这种机会性感染仍会给这部分患者带来严重的发病率和死亡率。隐球菌病的死亡率在10%-25%之间,而在中枢神经系统受累的SOT受者中,死亡率可高达50%。诊断的主要目的是查明播散性疾病是否累及中枢神经系统,还是仅有局部肺部受累,因为这对预后和治疗都有影响。检测脑脊液或血浆中的隐球菌抗原(CrAg)是非常值得推荐的检测方法,因为它比印度墨水和真菌培养更敏感、更特异。CrAg 侧流试验是唯一能快速检测隐球菌多糖胶囊的护理检测点。肾移植受者隐球菌病的治疗具有挑战性。除了减少或优化免疫抑制外,两性霉素 B 的脂质制剂是首选的诱导抗真菌药物。氟康唑可用于巩固和维持治疗,但需谨慎监测其与钙神经蛋白抑制剂的相互作用。本综述进一步深入探讨了肾移植受者隐球菌病的流行病学、发病机制、诊断方法和管理方法的发展变化。
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引用次数: 0
Heterogeneity in cardiorenal protection by Sodium glucose cotransporter 2 inhibitors in heart failure across the ejection fraction strata: Systematic review and meta-analysis 葡萄糖钠共转运体 2 抑制剂在不同射血分数阶层对心力衰竭患者心肾保护的异质性:系统回顾和荟萃分析
Pub Date : 2023-12-25 DOI: 10.5527/wjn.v12.i5.182
Saeed Taheri
BACKGROUND Gliflozins or Sodium glucose cotransporter 2 inhibitors (SGLT2i) are relatively novel antidiabetic medications that have recently been shown to represent favorable effects on patients’ cardiorenal outcomes. However, there is shortage of data on potential disparities in this therapeutic effect across different patient subpopulations. AIM To investigate differential effects of SGLT2i on the cardiorenal outcomes of heart failure patients across left ventricular ejection fraction (LVEF) levels. METHODS Literature was searched systematically for the large randomized double-blind controlled trials with long enough follow up periods reporting cardiovascular and renal outcomes in their patients regarding heart failure status and LVEF levels. Data were then meta-analyzed after stratification of the pooled data across the LVEF strata and New York Heart Associations (NYHA) classifications for heart failure using Stata software version 17.0. RESULTS The literature search returned 13 Large clinical trials and 13 post hoc analysis reports. Meta-analysis of the effects of gliflozins on the primary composite outcome showed no significant difference in efficacy across the heart failure subtypes, but higher efficacy were detected in patient groups at lower NYHA classifications (I 2 = 46%, P = 0.02). Meta-analyses across the LVEF stratums revealed that a baseline LVEF lower than 30% was associated with enhanced improvement in the primary composite outcome compared to patients with higher LVEF levels at the borderline statistical significance (HR: 0.70, 95%CI: 0.60 to 0.79 vs 0.81, 95%CI: 0.75 to 0.87; respectively, P = 0.06). Composite renal outcome was improved significantly higher in patients with no heart failure than in heart failure patients with preserved ejection fraction (HFpEF) (HR: 0.60, 95%CI: 0.49 to 0.72 vs 0.94, 95%CI: 0.74 to 1.13; P = 0.04). Acute renal injury occurred significantly less frequently in heart failure patients with reduced ejection fraction who received gliflozins than in HFpEF (HR: 0.67, 95%CI: 51 to 0.82 vs 0.94, 95%CI: 0.82 to 1.06; P = 0.01). Volume depletion was consistently increased in response to SGLT2i in all the subgroups. CONCLUSION Heart failure patients with lower LVEF and lower NYHA sub-classifications were found to be generally more likely to benefit from therapy with gliflozins. Further research are required to identify patient subgroups representing the highest benefits or adverse events in response to SGLT2i.
背景 Gliflozins 或葡萄糖钠共转运体 2 抑制剂(SGLT2i)是一种相对新型的抗糖尿病药物,近来已被证明对患者的心肾功能有良好的影响。然而,关于不同患者亚群在这种治疗效果上的潜在差异,目前还缺乏相关数据。目的 探讨不同左心室射血分数(LVEF)水平的 SGLT2i 对心衰患者心肾功能预后的不同影响。方法 系统地检索了具有足够长随访期的大型随机双盲对照试验的文献,这些试验报告了心衰状态和 LVEF 水平下患者的心血管和肾脏疗效。然后使用 Stata 软件 17.0 版对 LVEF 分层和纽约心脏协会(NYHA)心衰分类的汇总数据进行分层后进行元分析。结果 文献检索结果显示有 13 项大型临床试验和 13 项事后分析报告。格列酮嗪对主要综合结果影响的 Meta 分析表明,不同心衰亚型的疗效无显著差异,但在 NYHA 分级较低的患者组中发现了更高的疗效(I 2 = 46%,P = 0.02)。对 LVEF 分层进行的 Meta 分析显示,与 LVEF 水平较高的患者相比,基线 LVEF 低于 30% 的患者的主要复合结局改善程度更高,但在统计学上有边缘显著性(HR:0.70,95%CI:0.60 至 0.79 vs 0.81,95%CI:0.75 至 0.87;分别为 P = 0.06)。与射血分数保留的心衰患者(HFpEF)相比,无心衰患者的综合肾功能改善率明显更高(HR:0.60,95%CI:0.49 至 0.72 vs 0.94,95%CI:0.74 至 1.13;P = 0.04)。与 HFpEF 相比,射血分数降低的心衰患者接受格列酮类药物治疗后,急性肾损伤的发生率明显降低(HR:0.67,95%CI:51 至 0.82 vs 0.94,95%CI:0.82 至 1.06;P = 0.01)。所有亚组患者对 SGLT2i 的反应中,血容量耗竭持续增加。结论 LVEF 较低和 NYHA 分级较低的心衰患者一般更容易从格列奈类治疗中获益。还需要进一步研究,以确定哪些亚组患者服用 SGLT2i 后获益最大,哪些亚组患者服用 SGLT2i 后不良反应最多。
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引用次数: 0
Seeing through the myths: Practical aspects of diagnostic point-of-care ultrasound in nephrology 看穿神话:肾脏病学护理点超声诊断的实用方面
Pub Date : 2023-12-25 DOI: 10.5527/wjn.v12.i5.112
Abhilash Koratala, A. Kazory
Point of care ultrasonography (POCUS) is emerging as an invaluable tool for guiding patient care at the bedside, providing real-time diagnostic information to clinicians. Today, POCUS is recognized as the fifth pillar of bedside clinical examination, alongside inspection, palpation, percussion, and auscultation. In spite of growing interest, the adoption of diagnostic POCUS in nephrology remains limited, and comprehensive training beyond kidney ultrasound is offered in only a few fellowship programs. Moreover, several misconceptions and barriers surround the integration of POCUS into day-to-day nephrology practice. These include myths about its scope, utility, impact on patient outcomes and legal implications. In this minireview, we address some of these issues to encourage wider and proper utilization of POCUS.
护理点超声波检查(POCUS)正在成为床旁指导病人护理的重要工具,为临床医生提供实时诊断信息。如今,POCUS 与检查、触诊、叩诊和听诊一样,被认为是床旁临床检查的第五大支柱。尽管人们对 POCUS 的兴趣与日俱增,但肾脏内科对 POCUS 诊断的采用仍然有限,只有少数研究员课程提供肾脏超声以外的综合培训。此外,在将 POCUS 纳入日常肾脏病学实践方面还存在一些误解和障碍。其中包括对其范围、效用、对患者预后的影响以及法律影响的误解。在本小视图中,我们将讨论其中的一些问题,以鼓励更广泛、更适当地使用 POCUS。
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引用次数: 0
Bleeding complications after percutaneous kidney biopsies – nationwide experience from Brunei Darussalam 经皮肾活检术后出血并发症--文莱达鲁萨兰国的全国经验
Pub Date : 2023-12-25 DOI: 10.5527/wjn.v12.i5.147
Chiao Yuen Lim, Sai Laung Khay
BACKGROUND Kidney biopsy serves as a valuable method for both diagnosing and monitoring kidney conditions. Various studies have identified several risk factors associated with bleeding complications following the procedure, but these findings have shown inconsistency and variation. AIM To investigate the risk of bleeding complications following percutaneous kidney biopsy in Brunei Darussalam. We sought to explore the relevant clinical and pathological risk factors associated with these complications while also considering the findings within the broader international literature context. METHODS We conducted a retrospective study of all adult patients who underwent kidney biopsy in Brunei Darussalam from October 2013 to September 2020. The outcomes of interest were post-biopsy bleeding and the need for blood transfusions. Demographics, clinical, laboratory and procedural-related data were collected. Logistic regression analysis was used to identify predictors of outcomes. RESULTS A total of 255 kidney biopsies were included, with 11% being performed on transplanted kidneys. The majority of biopsies were done under ultrasound guidance (83.1%), with the rest under computer tomography guidance (16.9%). The most common indications for biopsy were chronic kidney disease of undefined cause (36.1%), nephrotic syndrome (24.3%) and acute kidney injury (11%). Rate of bleeding complication was 6.3% – 2% frank hematuria and 4.3% perinephric hematoma. Blood transfusion was required in 2.8% of patients. No patient lost a kidney or died because of the biopsy. Multivariate logistic regression identified baseline hemoglobin [odds ratio (OR): 4.11; 95% confidence interval (95%CI): 1.12-15.1; P = 0.03 for hemoglobin ≤ 11 g/dL vs. > 11 g/dL) and the presence of microscopic hematuria (OR: 5.24; 95%CI: 1.43-19.1; P = 0.01) as independent risk factors for post-biopsy bleeding. Furthermore, low baseline platelet count was identified as the dominant risk factor for requiring post-biopsy transfusions. Specifically, each 10 109/L decrease in baseline platelet count was associated with an 12% increase risk of needing transfusion (OR: 0.88; 95%CI: 0.79-0.98; P = 0.02). CONCLUSION Kidney biopsies were generally well-tolerated. The identified risk factors for bleeding and transfusion can help clinicians to better identify patients who may be at increased risk for these outcomes and to provide appropriate monitoring and management.
背景 肾活检是诊断和监测肾脏状况的重要方法。多项研究发现了与手术后出血并发症相关的几个风险因素,但这些研究结果并不一致,而且存在差异。目的 调查文莱达鲁萨兰国经皮肾活检术后出血并发症的风险。我们试图探索与这些并发症相关的临床和病理风险因素,同时在更广泛的国际文献背景下考虑这些研究结果。方法 我们对 2013 年 10 月至 2020 年 9 月期间在文莱达鲁萨兰国接受肾活检的所有成年患者进行了回顾性研究。我们关注的结果是活检后出血和输血需求。研究人员收集了人口统计学、临床、实验室和手术相关数据。采用逻辑回归分析确定结果的预测因素。结果 共纳入 255 例肾脏活检,其中 11% 的活检是在移植肾上进行的。大部分活检在超声引导下进行(83.1%),其余在计算机断层扫描引导下进行(16.9%)。活组织检查最常见的适应症是病因不明的慢性肾病(36.1%)、肾病综合征(24.3%)和急性肾损伤(11%)。出血并发症的发生率为 6.3% - 2% 为良性血尿,4.3% 为肾周血肿。2.8%的患者需要输血。没有患者因活检而失去肾脏或死亡。多变量逻辑回归确定了基线血红蛋白[几率比(OR):4.11;95% 置信区间(P<0.05)]:4.11;95% 置信区间 (95%CI):1.12-15.1;P = 0.03(血红蛋白≤ 11 g/dL 与 > 11 g/dL)和出现镜下血尿(OR:5.24;95%CI:1.43-19.1;P = 0.01)是活检后出血的独立危险因素。此外,低基线血小板计数被认为是活组织检查后需要输血的主要风险因素。具体而言,基线血小板计数每降低 10 109/L,需要输血的风险就会增加 12%(OR:0.88;95%CI:0.79-0.98;P = 0.02)。结论 肾活检的耐受性总体良好。已确定的出血和输血风险因素可帮助临床医生更好地识别可能会增加这些后果风险的患者,并提供适当的监测和管理。
{"title":"Bleeding complications after percutaneous kidney biopsies – nationwide experience from Brunei Darussalam","authors":"Chiao Yuen Lim, Sai Laung Khay","doi":"10.5527/wjn.v12.i5.147","DOIUrl":"https://doi.org/10.5527/wjn.v12.i5.147","url":null,"abstract":"BACKGROUND\u0000 Kidney biopsy serves as a valuable method for both diagnosing and monitoring kidney conditions. Various studies have identified several risk factors associated with bleeding complications following the procedure, but these findings have shown inconsistency and variation.\u0000 AIM\u0000 To investigate the risk of bleeding complications following percutaneous kidney biopsy in Brunei Darussalam. We sought to explore the relevant clinical and pathological risk factors associated with these complications while also considering the findings within the broader international literature context.\u0000 METHODS\u0000 We conducted a retrospective study of all adult patients who underwent kidney biopsy in Brunei Darussalam from October 2013 to September 2020. The outcomes of interest were post-biopsy bleeding and the need for blood transfusions. Demographics, clinical, laboratory and procedural-related data were collected. Logistic regression analysis was used to identify predictors of outcomes.\u0000 RESULTS\u0000 A total of 255 kidney biopsies were included, with 11% being performed on transplanted kidneys. The majority of biopsies were done under ultrasound guidance (83.1%), with the rest under computer tomography guidance (16.9%). The most common indications for biopsy were chronic kidney disease of undefined cause (36.1%), nephrotic syndrome (24.3%) and acute kidney injury (11%). Rate of bleeding complication was 6.3% – 2% frank hematuria and 4.3% perinephric hematoma. Blood transfusion was required in 2.8% of patients. No patient lost a kidney or died because of the biopsy. Multivariate logistic regression identified baseline hemoglobin [odds ratio (OR): 4.11; 95% confidence interval (95%CI): 1.12-15.1; P = 0.03 for hemoglobin ≤ 11 g/dL vs. > 11 g/dL) and the presence of microscopic hematuria (OR: 5.24; 95%CI: 1.43-19.1; P = 0.01) as independent risk factors for post-biopsy bleeding. Furthermore, low baseline platelet count was identified as the dominant risk factor for requiring post-biopsy transfusions. Specifically, each 10 109/L decrease in baseline platelet count was associated with an 12% increase risk of needing transfusion (OR: 0.88; 95%CI: 0.79-0.98; P = 0.02).\u0000 CONCLUSION\u0000 Kidney biopsies were generally well-tolerated. The identified risk factors for bleeding and transfusion can help clinicians to better identify patients who may be at increased risk for these outcomes and to provide appropriate monitoring and management.","PeriodicalId":23745,"journal":{"name":"World Journal of Nephrology","volume":"46 8","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-12-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138943832","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Antihypertensive prescribing patterns in non-dialysis dependent chronic kidney disease: Findings from the Salford Kidney Study 非透析依赖型慢性肾病患者的抗高血压处方模式:索尔福德肾脏研究结果
Pub Date : 2023-12-25 DOI: 10.5527/wjn.v12.i5.168
R. Chinnadurai, Henry H L Wu, Jones Abuomar, Sharmilee Rengarajan, D. New, D. Green, Philip A Kalra
BACKGROUND Hypertension is commonly observed in patients living with chronic kidney disease (CKD). Finding an optimal treatment regime remains challenging due to the complex bidirectional cause-and-effect relationship between hypertension and CKD. There remains variability in antihypertensive treatment practices. AIM To antihypertensive prescribing patterns amongst CKD patients. METHODS The Salford Kidney Study is an ongoing prospective study that has been recruiting CKD patients since 2002. All patients are followed up annually, and their medical records including the list of medications are updated until they reach study endpoints [starting on renal replacement therapy or reaching estimated glomerular filtration rate (eGFR) expressed as mL/min/1.73 m2 ≤ 10 mL/min/1.73m2, or the last follow-up date, or data lock on December 31, 2021, or death]. Data on antihypertensive prescription practices in correspondence to baseline eGFR, urine albumin-creatinine ratio, primary CKD aetiology, and cardiovascular disease were evaluated. Associations between patients who were prescribed three or more antihypertensive agents and their clinical outcomes were studied by Cox regression analysis. Kaplan-Meier analysis demonstrated differences in survival probabilities. RESULTS Three thousand two hundred and thirty non-dialysis-dependent CKD patients with data collected between October 2002 and December 2019 were included. The median age was 65 years. A greater proportion of patients were taking three or more antihypertensive agents with advancing CKD stages (53% of eGFR ≤ 15 mL/min/1.73m2 vs 26% of eGFR ≥ 60 mL/min/1.73m2, P < 0.001). An increased number of patients receiving more classes of antihypertensive agents was observed as the urine albumin-creatinine ratio category increased (category A3: 62% vs category A1: 40%, P < 0.001), with the upward trends particularly noticeable in the number of individuals prescribed renin angiotensin system blockers. The prescription of three or more antihypertensive agents was associated with all-cause mortality, independent of blood pressure control (hazard ratio: 1.15; 95% confidence interval: 1.04-1.27, P = 0.006). Kaplan-Meier analysis illustrated significant differences in survival outcomes between patients with three or more and those with less than three antihypertensive agents prescribed (log-rank, P < 0.001). CONCLUSION Antihypertensive prescribing patterns in the Salford Kidney Study based on CKD stage were consistent with expectations from the current United Kingdom National Institute of Health and Care Excellence guideline algorithm. Outcomes were poorer in patients with poor blood pressure control despite being on multiple antihypertensive agents. Continued research is required to bridge remaining variations in hypertension treatment practices worldwide.
背景慢性肾脏病(CKD)患者常会出现高血压。由于高血压与 CKD 之间存在复杂的双向因果关系,因此寻找最佳治疗方案仍具有挑战性。降压治疗方法仍存在差异。目的 了解 CKD 患者的降压处方模式。方法 索尔福德肾脏研究是一项正在进行的前瞻性研究,自 2002 年以来一直在招募 CKD 患者。所有患者每年都会接受随访,包括用药清单在内的医疗记录会不断更新,直到他们达到研究终点[开始接受肾脏替代治疗或估计肾小球滤过率(eGFR)达到 mL/min/1.73 m2 ≤ 10 mL/min/1.73 m2,或最后一次随访日期,或数据锁定在 2021 年 12 月 31 日,或死亡]。评估了与基线 eGFR、尿白蛋白-肌酐比值、原发性 CKD 病因和心血管疾病相对应的降压处方数据。通过 Cox 回归分析研究了处方三种或三种以上降压药的患者与其临床结果之间的关系。Kaplan-Meier 分析显示了生存概率的差异。结果 共纳入 3230 名非透析依赖型 CKD 患者,数据收集时间为 2002 年 10 月至 2019 年 12 月。中位年龄为 65 岁。随着 CKD 阶段的增加,服用三种或三种以上降压药的患者比例增加(eGFR ≤ 15 mL/min/1.73m2 的患者为 53% vs eGFR ≥ 60 mL/min/1.73m2 的患者为 26%,P < 0.001)。随着尿白蛋白-肌酐比值类别的增加,接受更多类别降压药物治疗的患者人数也在增加(A3 类别:62% vs A1 类别:40%,P <0.001),其中肾素血管紧张素系统阻滞剂处方人数的上升趋势尤为明显。处方三种或三种以上降压药与全因死亡率有关,与血压控制无关(危险比:1.15;95% 置信区间:1.04-1.27,P = 0.006)。Kaplan-Meier 分析显示,使用三种或三种以上抗高血压药物的患者与使用三种以下抗高血压药物的患者在生存率方面存在显著差异(对数秩,P < 0.001)。结论 索尔福德肾脏研究中基于 CKD 分期的抗高血压处方模式与英国国家健康与护理优化研究所现行指南算法的预期一致。尽管使用了多种降压药,但血压控制不佳的患者预后较差。需要继续开展研究,以弥合全球高血压治疗实践中仍然存在的差异。
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引用次数: 0
The correlation of spot urinary protein-to-creatinine ratio with 24-h urinary protein excretion in various glomerulopathies 各种肾小球疾病的定点尿蛋白与肌酐比值与 24 小时尿蛋白排泄量的相关性
Pub Date : 2023-12-25 DOI: 10.5527/wjn.v12.i5.159
Amber Raza, S. Nawaz, Rahma Rashid, Ejaz Ahmed, Muhammed Mubarak
BACKGROUND Proteinuria is an important and well-known biomarker of many forms of kidney injury. Its quantitation is of particular importance in the diagnosis and management of glomerular diseases. Its quantification can be done by several methods. Among these, the measurement of 24-h urinary protein excretion is the gold standard method. However, it is cumbersome, time-consuming, and inconvenient for patients and is not completely foolproof. Many alternative methods have been tested over time albeit with conflicting results. Among the latter, the measurement of urine protein-to-creatinine ratio (uPCR) in single-voided urinary samples is widely used. The majority of studies found a good correlation between uPCR in single urine samples with 24-h urinary protein estimation, whereas others did not. AIM To investigate the correlation of spot uPCR with 24-h urinary protein estimation in patients suffering from different forms of glomerulopathies at a single large-volume nephrological center in Pakistan. METHODS This cross-sectional, observational study was conducted at the Department of Nephrology, Sindh Institute of Urology and Transplantation, Karachi, Pakistan from September 2017 to March 2018. All newly presenting adult patients with proteinuria who were being investigated for suspected glomerulonephritis and persistent proteinuria with ages between 18 to 60 years were enrolled. All patients were given detailed advice regarding 24-h urine collection starting at 7:00 AM for total protein and creatinine excretion estimations. A spot urine sample was collected the next day at the time of submission of a 24-h urine sample for measuring uPCR along with a blood sample. The data of patients were collected in a proforma. SPSS version 20.0 was used for statistical analysis. RESULTS A total of 157 patients were included. Their mean age was 30.45 ± 12.11 years. There were 94 (59.8%) males and 63 (40.2%) females. The mean 24-h urinary protein excretion was 3192.78 ± 1959.79 mg and the mean spot uPCR was 3.16 ± 1.52 in all patients. A weak but significant correlation was observed between spot uPCR and 24-h urinary protein excretion (r = 0.342, P = 0.01) among all patients. On subgroup analysis, a slightly better correlation was found in patients older than 47 years (r = 0.78), and those with body mass index > 25 kg/m2 (r = 0.45). The Bland and Altman's plot analysis comparing the differences between spot uPCR and 24-h protein measurement also showed a wide range of the limits of agreement between the two methods. CONCLUSION Overall, the results from this study showed a significant and weakly positive correlation between spot uPCR and 24-h urinary protein estimation in different forms of glomerulopathies. The agreement between the two methods was also poor. Hence, there is a need for careful interpretation of the ratio in an unselected group of patients with kidney disease.
背景 蛋白尿是许多形式肾损伤的重要且众所周知的生物标志物。蛋白尿的定量对于肾小球疾病的诊断和治疗尤为重要。蛋白尿的定量有多种方法。其中,测量 24 小时尿蛋白排泄量是金标准方法。然而,这种方法繁琐、耗时,给患者带来不便,而且并非完全万无一失。随着时间的推移,人们对许多替代方法进行了测试,尽管结果不尽相同。其中,在单排尿样本中测量尿蛋白与肌酐比值(uPCR)被广泛使用。大多数研究发现,单次尿液样本中的尿蛋白-肌酐比值与 24 小时尿蛋白估计值之间具有良好的相关性,而其他研究则没有发现。目的 研究巴基斯坦一家大型肾病中心对不同形式肾小球疾病患者进行的定点 uPCR 与 24 小时尿蛋白估测值之间的相关性。方法 这项横断面观察性研究于 2017 年 9 月至 2018 年 3 月在巴基斯坦卡拉奇信德泌尿外科和移植研究所肾脏内科进行。所有因疑似肾小球肾炎和持续性蛋白尿而接受检查的新发蛋白尿成年患者均被纳入研究范围,年龄在 18 岁至 60 岁之间。所有患者都得到了关于从早上 7:00 开始收集 24 小时尿液以估算总蛋白和肌酐排泄量的详细建议。第二天,在提交 24 小时尿样以测量 uPCR 时,收集点滴尿样和血液样本。患者的数据以表格形式收集。使用 SPSS 20.0 版进行统计分析。结果 共纳入 157 名患者。他们的平均年龄为(30.45 ± 12.11)岁。男性 94 人(59.8%),女性 63 人(40.2%)。所有患者的 24 小时尿蛋白平均排泄量为 3192.78 ± 1959.79 毫克,尿蛋白定点定量平均值为 3.16 ± 1.52。在所有患者中,定点 uPCR 与 24 小时尿蛋白排泄量之间存在微弱但明显的相关性(r = 0.342,P = 0.01)。在亚组分析中,年龄大于 47 岁的患者(r = 0.78)和体重指数大于 25 kg/m2 的患者(r = 0.45)的相关性稍好。布兰德和阿尔特曼图谱分析比较了定点 uPCR 和 24 小时蛋白质测量之间的差异,结果显示两种方法之间的一致性范围很广。结论 总体而言,本研究结果表明,在不同形式的肾小球疾病中,定点 uPCR 和 24 小时尿蛋白估计值之间存在显著的弱正相关。两种方法之间的一致性也很差。因此,有必要在未经选择的肾病患者群体中仔细解释该比率。
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引用次数: 0
Infection related membranoproliferative glomerulonephritis secondary to anaplasmosis: A case report. 无形体病继发于感染相关膜增生性肾小球肾炎1例。
Pub Date : 2023-05-25 DOI: 10.5527/wjn.v12.i3.66
Maulik K Lathiya, Praveen Errabelli, Salvatore Mignano, Susan M Cullinan

Background: Anaplasmosis is a tick-borne disease with a range of clinical manifestations, from a flu-like illness with fever and myalgias to a severe systemic disease with multisystem organ failure. Although renal involvement is not a common presentation, there have been few cases reporting acute kidney injury from Anaplasmosis.

Case summary: We present a 55-year-old female with anaplasmosis who developed acute kidney injury due to membranoproliferative glomerulonephritis (MPGN). The patient originally presented with cough and shortness of breath. She was admitted to the hospital with a diagnosis of community acquired pneumonia and received antibiotics. During the hospital course she developed severe acute renal failure. Initial serological work up didn't provide any conclusive diagnosis. Hence, she underwent kidney biopsy which showed MPGN pattern suggesting autoimmune, multiple myeloma or infectious etiology. Extensive work up was undertaken which was negative for autoimmune diseases, vasculitis panel, paraproteinemias but tested positive for IgG anaplasma with high titers indicating Anaplasmosis.

Conclusion: Our case shows a unique presentation of severe acute renal failure from MPGN from tick borne illness. MPGN is usually seen with autoimmune diseases, hepatitis C virus infections, paraproteinemias. Hence, we suggest that tick borne illness should also be considered when evaluating acute renal failure cases in tick borne prevalent regions.

背景:无形体病是一种蜱传疾病,具有一系列临床表现,从发烧和肌痛的流感样疾病到多系统器官衰竭的严重全身性疾病。虽然肾脏受累不是一个常见的表现,有少数病例报告急性肾损伤的无形体病。病例总结:我们报告一位55岁女性无形体病患者,因膜增生性肾小球肾炎(MPGN)而发展为急性肾损伤。病人最初表现为咳嗽和呼吸短促。她因诊断为社区获得性肺炎而入院,并接受抗生素治疗。在住院期间,她出现了严重的急性肾衰竭。最初的血清学检查没有提供任何结论性诊断。因此,她接受了肾活检,显示MPGN模式,提示自身免疫性、多发性骨髓瘤或感染性病因。开展了广泛的工作,自身免疫性疾病、血管炎、副蛋白血症均为阴性,但IgG无原体检测呈阳性,高滴度表明无原体病。结论:我们的病例显示了一个独特的表现严重急性肾功能衰竭的MPGN从蜱传疾病。MPGN常见于自身免疫性疾病、丙型肝炎病毒感染、副蛋白血症。因此,我们建议在蜱传流行地区评估急性肾衰竭病例时也应考虑蜱传疾病。
{"title":"Infection related membranoproliferative glomerulonephritis secondary to anaplasmosis: A case report.","authors":"Maulik K Lathiya,&nbsp;Praveen Errabelli,&nbsp;Salvatore Mignano,&nbsp;Susan M Cullinan","doi":"10.5527/wjn.v12.i3.66","DOIUrl":"https://doi.org/10.5527/wjn.v12.i3.66","url":null,"abstract":"<p><strong>Background: </strong>Anaplasmosis is a tick-borne disease with a range of clinical manifestations, from a flu-like illness with fever and myalgias to a severe systemic disease with multisystem organ failure. Although renal involvement is not a common presentation, there have been few cases reporting acute kidney injury from Anaplasmosis.</p><p><strong>Case summary: </strong>We present a 55-year-old female with anaplasmosis who developed acute kidney injury due to membranoproliferative glomerulonephritis (MPGN). The patient originally presented with cough and shortness of breath. She was admitted to the hospital with a diagnosis of community acquired pneumonia and received antibiotics. During the hospital course she developed severe acute renal failure. Initial serological work up didn't provide any conclusive diagnosis. Hence, she underwent kidney biopsy which showed MPGN pattern suggesting autoimmune, multiple myeloma or infectious etiology. Extensive work up was undertaken which was negative for autoimmune diseases, vasculitis panel, paraproteinemias but tested positive for IgG anaplasma with high titers indicating Anaplasmosis.</p><p><strong>Conclusion: </strong>Our case shows a unique presentation of severe acute renal failure from MPGN from tick borne illness. MPGN is usually seen with autoimmune diseases, hepatitis C virus infections, paraproteinemias. Hence, we suggest that tick borne illness should also be considered when evaluating acute renal failure cases in tick borne prevalent regions.</p>","PeriodicalId":23745,"journal":{"name":"World Journal of Nephrology","volume":"12 3","pages":"66-72"},"PeriodicalIF":0.0,"publicationDate":"2023-05-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/c5/fb/WJN-12-66.PMC10354567.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9847593","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Acute renal failure with severe loin pain and patchy renal ischemia after anaerobic exercise. 无氧运动后急性肾功能衰竭伴严重腰痛和局部肾缺血。
Pub Date : 2023-05-25 DOI: 10.5527/wjn.v12.i3.56
Hiroshi Tamura

Background: There are two known types of exercise-induced acute renal failure. One is the long-known myoglobinuria-induced acute renal failure due to severe rhabdomyolysis, and the other is the recently recognized non-myoglobinuria-induced acute renal failure with mild rhabdomyolysis. Exercise-induced acute renal failure was first reported in 1982. Non-myoglobinuria-induced acute renal failure is associated with severe low back pain and patchy renal vasoconstriction, and it is termed post-exercise acute renal failure because it usually occurs hours after exercise. It is also called acute renal failure with severe loin pain and patchy renal ischemia after anaerobic exercise (ALPE).

Aim: To makes a significant contribution to medical literature as it presents a study that investigated a not-widely-known type of exercise-induced acute renal failure known as ALPE.

Methods: We performed a database search selecting papers published in the English or Japanese language. A database search was lastly accessed on September 1, 2022. The results of this study were compared with those reported in other case series.

Results: The study evaluated renal hypouricemia as a key risk factor of ALPE. The development of ALPE is due to the sum of risk factors such as exercise, hypouricemia, nonsteroidal anti-inflammatory drugs, vasopressors, and dehydration.

Conclusion: In conclusion, hypouricemia plays a key role in the development of ALPE and is often associated with anaerobic exercise. The development of ALPE is a result of the cumulative effects of risk factors such as exercise, hypouricemia, NSAIDs, vasopressors, and dehydration.

背景:已知有两种类型的运动引起的急性肾功能衰竭。一种是众所周知的由严重横纹肌溶解引起的肌红蛋白尿引起的急性肾功能衰竭,另一种是最近发现的由轻度横纹肌溶解引起的非肌红蛋白尿引起的急性肾功能衰竭。1982年首次报道了运动性急性肾衰竭。非肌红蛋白尿引起的急性肾功能衰竭与严重的腰痛和局部性肾血管收缩有关,由于通常在运动后数小时发生,故称为运动后急性肾功能衰竭。它也被称为急性肾功能衰竭,伴有严重的腰痛和无氧运动(ALPE)后的局部肾缺血。目的:对医学文献做出重大贡献,因为它提出了一项研究,调查了一种不广为人知的运动引起的急性肾衰竭,称为ALPE。方法:我们进行数据库检索,选择以英语或日语发表的论文。最后一次访问数据库是在2022年9月1日。本研究的结果与其他病例系列报道的结果进行了比较。结果:本研究认为肾性低尿酸血症是ALPE的关键危险因素。ALPE的发展是由运动、低尿酸血症、非甾体抗炎药、血管加压药和脱水等危险因素共同作用的结果。结论:总之,低尿酸血症在ALPE的发展中起着关键作用,通常与无氧运动有关。ALPE的发展是运动、低尿酸血症、非甾体抗炎药、血管加压药和脱水等危险因素累积作用的结果。
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引用次数: 0
Preemptive living donor kidney transplantation: Access, fate, and review of the status in Egypt. 先发制人的活体肾移植:在埃及的途径、命运和现状的回顾。
Pub Date : 2023-05-25 DOI: 10.5527/wjn.v12.i3.40
Rabea Ahmed Gadelkareem, Amr Mostafa Abdelgawad, Ahmed Reda, Nashwa Mostafa Azoz, Mohammed Ali Zarzour, Nasreldin Mohammed, Hisham Mokhtar Hammouda, Mahmoud Khalil

Background: Preemptive living donor kidney transplantation (PLDKT) is recommended as the optimal treatment for end-stage renal disease.

Aim: To assess the rate of PLDKT among patients who accessed KT in our center and review the status of PLDKT in Egypt.

Methods: We performed a retrospective review of the patients who accessed KT in our center from November 2015 to November 2022. In addition, the PLDKT status in Egypt was reviewed relative to the literature.

Results: Of the 304 patients who accessed KT, 32 patients (10.5%) had preemptive access to KT (PAKT). The means of age and estimated glomerular filtration rate were 31.7 ± 13 years and 12.8 ± 3.5 mL/min/1.73 m2, respectively. Fifty-nine patients had KT, including 3 PLDKTs only (5.1% of total KTs and 9.4% of PAKT). Twenty-nine patients (90.6%) failed to receive PLDKT due to donor unavailability (25%), exclusion (28.6%), regression from donation (3.6%), and patient regression on starting dialysis (39.3%). In multivariate analysis, known primary kidney disease (P = 0.002), patient age (P = 0.031) and sex (P = 0.001) were independent predictors of achievement of KT in our center. However, PAKT was not significantly (P = 0.065) associated with the achievement of KT. Review of the literature revealed lower rates of PLDKT in Egypt than those in the literature.

Conclusion: Patient age, sex, and primary kidney disease are independent predictors of achieving living donor KT. Despite its non-significant effect, PAKT may enhance the low rates of PLDKT. The main causes of non-achievement of PLDKT were patient regression on starting regular dialysis and donor unavailability or exclusion.

背景:先发制人的活体肾脏移植(PLDKT)被推荐为终末期肾脏疾病的最佳治疗方法。目的:了解我院住院患者PLDKT的发生率,了解埃及PLDKT的现状。方法:我们对2015年11月至2022年11月在我中心接受KT治疗的患者进行回顾性分析。此外,对埃及PLDKT的现状进行了文献综述。结果:304例获得KT的患者中,32例(10.5%)患者有抢先获得KT (PAKT)。平均年龄为31.7±13岁,肾小球滤过率为12.8±3.5 mL/min/1.73 m2。59例患者有KT,其中仅3例为pldkt(占总KT的5.1%和PAKT的9.4%)。29例(90.6%)患者未能接受PLDKT,原因包括供体不可用(25%)、排斥(28.6%)、捐赠退行(3.6%)和患者开始透析退行(39.3%)。在多变量分析中,已知的原发性肾脏疾病(P = 0.002)、患者年龄(P = 0.031)和性别(P = 0.001)是本中心实现KT的独立预测因素。然而,PAKT与KT的实现无显著相关(P = 0.065)。回顾文献显示,埃及PLDKT的发生率低于文献中的发生率。结论:患者年龄、性别和原发肾脏疾病是实现活体供者KT的独立预测因素。尽管其作用不显著,但PAKT可能提高PLDKT的低发生率。未达到PLDKT的主要原因是患者在开始常规透析时出现倒退和供体缺乏或排斥。
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引用次数: 3
期刊
World Journal of Nephrology
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