World Journal of Nephrology最新文献

Background: Hypercalciuria is the most common metabolic risk factor for calcium urolithiasis and is associated with bone loss in adult patients. Reduced bone mineral density (BMD) was already described in idiopathic hypercalciuria (IH) children, but the precise mechanisms of bone loss or inadequate bone mass gain remain unknown. Life-long hypercalciuria might be considered a risk to change bone structure and determine low bone mass throughout life. The peak of bone mass should occur without interferences. A beneficial effect of citrate formulations and thiazides on bone mass in adult and pediatric patients with IH have been shown.

Aim: To evaluate whether pharmacological therapy has a beneficial effect on bone mass in children and adolescents with IH.

Methods: This retrospective cohort study evaluated 40 hypercalciuric children non-responsive to lifestyle and diet changes. After a 2-mo run-in period of citrate formulation (Kcitrate) usage, the first bone densitometry (DXA) was ordered. In patients with sustained hypercalciuria, a thiazide diuretic was prescribed. The second DXA was performed after 12 mo. Bone densitometry was performed by DXA at lumbar spine (L2-L4). A 24-h urine (calcium, citrate, creatinine) and blood samples (urea, creatinine, uric acid, calcium, phosphorus, magnesium, chloride, hemoglobin) were obtained. Clinical data included age, gender, weight, height and body mass index.

Results: Forty IH children; median age 10.5 year and median time follow-up 6.0 year were evaluated. Nine patients were treated with Kcitrate (G1) and 31 with Kcitrate + thiazide (G2). There were no differences in age, gender, body mass index z-score and biochemical parameters between G1 and G2. There were no increases in total cholesterol, kalemia and magnesemia. Calciuria decreased in both groups after treatment. Lumbar spine BMD z-score increased after thiazide treatment in G2. There was no improvement in G1.

Conclusion: Results point to a beneficial effect of thiazide on lumbar spine BMD z-score in children with IH. Further studies are necessary to confirm the results of the present study.

Background: Chronic kidney disease (CKD) is a common medical condition that is increasing in prevalence. Existing published evidence has revealed through regression analyses that several clinical characteristics are associated with mortality in CKD patients. However, the predictive accuracies of these risk factors for mortality have not been clearly demonstrated.

Aim: To demonstrate the accuracy of mortality predictive factors in CKD patients by utilizing the area under the receiver operating characteristic (ROC) curve (AUC) analysis.

Methods: We searched Ovid MEDLINE, EMBASE, and the Cochrane Library for eligible articles through January 2021. Studies were included based on the following criteria: (1) Study nature was observational or conference abstract; (2) Study populations involved patients with non-transplant CKD at any CKD stage severity; and (3) Predictive factors for mortality were presented with AUC analysis and its associated 95% confidence interval (CI). AUC of 0.70-0.79 is considered acceptable, 0.80-0.89 is considered excellent, and more than 0.90 is considered outstanding.

Results: Of 1759 citations, a total of 18 studies (n = 14579) were included in this systematic review. Eight hundred thirty two patients had non-dialysis CKD, and 13747 patients had dialysis-dependent CKD (2160 patients on hemodialysis, 370 patients on peritoneal dialysis, and 11217 patients on non-differentiated dialysis modality). Of 24 mortality predictive factors, none were deemed outstanding for mortality prediction. A total of seven predictive factors [N-terminal pro-brain natriuretic peptide (NT-proBNP), BNP, soluble urokinase plasminogen activator receptor (suPAR), augmentation index, left atrial reservoir strain, C-reactive protein, and systolic pulmonary artery pressure] were identified as excellent. Seventeen predictive factors were in the acceptable range, which we classified into the following subgroups: predictors for the non-dialysis population, echocardiographic factors, comorbidities, and miscellaneous.

Conclusion: Several factors were found to predict mortality in CKD patients. Echocardiography is an important tool for mortality prognostication in CKD patients by evaluating left atrial reservoir strain, systolic pulmonary artery pressure, diastolic function, and left ventricular mass index.

Newborn infants who had neurogenic bladder dysfunction (NBD) have a normal upper urinary tract at birth. Most of them will develop deterioration of renal function and chronic kidney disease if they do not receive proper management. Children with NBD can develop renal damage at adolescence or earlier, which is due to high detrusor pressures resulted from poor compliance of the bladder, detrusor overactivity against a closed sphincter or detrusor sphincter dyssynergia. To preserve renal function and prevent deterioration of the kidneys, NBD must be treated immediately after being diagnosed. Over the last few years there was great progress in the treatment of children with the NBD. We searched PubMed and the Cochrane Library for peer-reviewed articles published in any language up to March 10, 2021, using the search term "neurogenic bladder children." Our search excluded diagnosis, pathophysiology, surgical treatment of spinal cord injury and spina bifida. The research identified the effectiveness of treatment regimens targeting prevention of chronic kidney disease and the indications of kidney transplantation. The results of the research showed that NBD in children should be diagnosed early in life, and the child should receive the proper management. The literature search concluded that the management of NBD in children would be personalized for every case and could be changed according to response to treatment, side effects, child compliance, availability of treatment modality and costs of treatment. The objectives of the study are to present the different options of management of NBD in children and the selection of the proper method in a personalized manner.

Gadolinium-based contrast agents (GBCAs) used in magnetic resonance imaging are vital in providing enhanced quality images, essential for diagnosis and treatment. Nephrogenic systemic fibrosis (NSF) with GBCAs has been a deterrent for the physician and has led to avoidance of these agents in patients with impaired kidney function. NSF is a progressive debilitating multisystem condition described classically in patients with renal insufficiency exposed to gadolinium contrast media. It is characterized by an induration and hardening of the skin. NSF is described to first involve the extremities and can imperceptibly involve internal organs. Lack of therapeutic interventions to treat NSF makes it more challenging and warrants deep insight into the pathogenesis, risk factors and treatment strategies.

Background: Low-molecular-weight dextran (LMWD) is considered a safe alternative to contrast media for blood displacement during optical coherence tomography (OCT) imaging.

Aim: To investigate whether the use of LMWD for OCT is protective against kidney injury in patients with advanced renal insufficiency.

Methods: In this retrospective cohort study, we identified 421 patients with advanced renal insufficiency (estimated glomerular filtration rate < 45 mL/min/1.73 m²) who underwent coronary angiography or percutaneous coronary intervention; 79 patients who used additional LMWD for OCT imaging (LMWD group) and 342 patients who used contrast medium exclusively (control group). We evaluated the differences between these two groups and performed a propensity score-matched subgroup comparison.

Results: The median total volume of contrast medium was 133.0 mL in the control group vs 140.0 mL in the LMWD group. Although baseline renal function was not statistically different between these two groups, the LMWD group demonstrated a strong trend toward the progression of renal insufficiency as indicated by the greater change in serum creatinine level during the 1-year follow-up compared with the control group. Patients in the LMWD group experienced worsening renal function more frequently than patients in the control group. Propensity score matching adjusted for total contrast media volume consistently indicated a trend toward worsening renal function in the LMWD group at the 1-year follow-up. Delta serum creatinine at 1-year follow-up was significantly greater in the LMWD group than that in the control group [0.06 (-0.06, 0.29) vs -0.04 (-0.23, 0.08) mg/dL, P = 0.001], despite using similar contrast volume.

Conclusion: OCT using LMWD may not be protective against worsening renal function in patients with advanced renal insufficiency.

Background: Coronavirus disease 2019 (COVID-19) is a highly contagious infection caused by the severe acute respiratory syndrome coronavirus 2 virus and has a unique underlying pathogenesis. Hemodialysis (HD) patients experience high risk of contamination with COVID-19 and are considered to have higher mortality rates than the general population by most but not all clinical series. We aim to highlight the peculiarities in the immune state of HD patients, who seem to have both immune-activation and immune-depression affecting their outcome in COVID-19 infection.

Case summary: We report the opposite clinical outcomes (nearly asymptomatic course vs death) of two diabetic elderly patients infected simultaneously by COVID-19, one being on chronic HD and the other with normal renal function. They were both admitted in our hospital with COVID-19 symptoms and received the same treatment by protocol. The non-HD sibling deteriorated rapidly and was intubated and transferred to the Intensive Care Unit, where he died despite all supportive care. The HD sibling, although considered more "high-risk" for adverse outcome, followed a benign course and left the hospital alive and well.

Conclusion: These cases may shed light on aspects of the immune responses to COVID-19 between HD and non-HD patients and stimulate further research in pathophysiology and treatment of this dreadful disease.

The coronavirus disease-19 (COVID-19) pandemic has been a wake-up call in which has forced us to react worldwide. Health policies and practices have attracted particular attention in terms of human and financial cost. Before COVID-19, chronic kidney disease was already considered a risk multiplier in patients with diabetes and hypertension, the two now being the major risk factors for COVID-19 infection and adverse outcome. In contrast to the urgent need for action, the nephrology field is considered to be in a state of stagnation regarding the management of chronic kidney disease patients who still experience unacceptably high morbidity and mortality. Ironically and paradoxically in a field lacking robust clinical trials, clinical practice is driven by guidelines-based medicine on weak evidence. The Emperor's syndrome, referring to Hans Christian Andersen's fairy tale, has been described in medicine as voluntary blindness to an obvious truth, being a weak evidence-based therapeutic intervention or weak health care. A promising positive example of improving heart and kidney outcomes is the emerging treatment with sodium-glucose cotransporter 2 inhibitors. COVID-19 could boost actions for patient-centered care as a positive shift in nephrology care.

Coronavirus disease 2019 has spread across the world and has been classified as a pandemic. It has overwhelmed the healthcare systems. Specifically, it has overstretched the intensive care units and renal replacement therapy services in many countries. In this paper, we discuss the reconfiguration of nephrology services in the State of Qatar during the current pandemic. We highlight the key strategies that have been implemented to ensure that renal replacement therapy capacity is not constrained in either the intensive care or ambulatory setting. Some innovative approaches for the safe delivery of ambulatory care to dialysis and kidney transplant patients are also discussed.

Coronavirus disease 2019 (COVID-19) continues to affect millions of people around the globe. As data emerge, it is becoming more evident that extrapulmonary organ involvement, particularly the kidneys, highly influence mortality. The incidence of acute kidney injury has been estimated to be 30% in COVID-19 non-survivors. Current evidence suggests four broad mechanisms of renal injury: Hypovolaemia, acute respiratory distress syndrome related, cytokine storm and direct viral invasion as seen on renal autopsy findings. We look to critically assess the epidemiology, pathophysiology and management of kidney injury in COVID-19.

Background: Contrast-induced nephropathy (CIN) is a reversible form of acute kidney injury that occurs within 48-72 h of exposure to intravascular contrast material. CIN is the third leading cause of hospital-acquired acute kidney injury and accounts for 12% of such cases. Risk factors for CIN development can be divided into patient- and procedure-related. The former includes pre-existing chronic renal insufficiency and diabetes mellitus. The latter includes high contrast volume and repeated exposure over 72 h. The incidence of CIN is relatively low (up to 5%) in patients with intact renal function. However, in patients with known chronic renal insufficiency, the incidence can reach up to 27%.

Aim: To examine the association between renal enhancement pattern on non-contrast enhanced computed tomographic (CT) images obtained immediately following hepatic artery embolization with development of CIN.

Methods: Retrospective review of all patients who underwent hepatic artery embolization between 01/2010 and 01/2011 (n = 162) was performed. Patients without intraprocedural CT imaging (n = 51), combined embolization/ablation (n = 6) and those with chronic kidney disease (n = 21) were excluded. The study group comprised of 84 patients with 106 procedures. CIN was defined as 25% increase above baseline serum creatinine or absolute increase ≥ 0.5 mg/dL within 72 h post-embolization. Post-embolization CT was reviewed for renal enhancement patterns and presence of renal artery calcifications. The association between non-contrast CT findings and CIN development was examined by Fisher's Exact Test.

Results: CIN occurred in 11/106 (10.3%) procedures (Group A, n = 10). The renal enhancement pattern in patients who did not experience CIN (Group B, n = 74 with 95/106 procedures) was late excretory in 93/95 (98%) and early excretory (EE) in 2/95 (2%). However, in Group A, there was a significantly higher rate of EE pattern (6/11, 55%) compared to late excretory pattern (5/11) (P < 0.001). A significantly higher percentage of patients that developed CIN had renal artery calcifications (6/11 vs 20/95, 55% vs 21%, P = 0.02).

Conclusion: A hyperdense renal parenchyma relative to surrounding skeletal muscle (EE pattern) and presence of renal artery calcifications on immediate post-HAE non-contrast CT images in patients with low risk for CIN are independently associated with CIN development.