Frontiers in nephrology最新文献

Background: Septic shock with acute kidney injury (AKI) carries high mortality in resource-limited settings. The oXiris^® membrane enables continuous renal replacement therapy (CRRT) with endotoxin and cytokine adsorption, but data from low- and middle-income countries are scarce.

Methods: We conducted a single-center retrospective cohort of adults with septic shock and KDIGO stage 2-3 AKI treated with CRRT using oXiris^® in a Colombian public tertiary hospital (January 2021-March 2023). The primary outcome was renal recovery, defined as dialysis independence at discharge. Secondary outcomes included in-hospital mortality, vasopressor trajectories and hemodynamics over 72 hours, intensive care unit (ICU) length of stay, and outcomes stratified by COVID-19 status.

Results: Fifty patients were analyzed (median age 56.5 [IQR 46.0-66.0] years; 32% male); 21 (42%) had confirmed SARS-CoV-2 infection. Norepinephrine requirements fell from 0.303 to 0.000 µg/kg/min over 72 hours (p<0.001), and vasopressin use declined to zero (p<0.001), while mean arterial pressure increased from 74.5 to 83.0 mmHg. In-hospital mortality was 62% (31/50) and was higher in patients with greater baseline severity (APACHE II 21.5 vs 14.5 in survivors; p=0.023). ICU length of stay was 14.0 days [5.0-22.5] and was longer in survivors than non-survivors (21.0 vs 8.0 days; p<0.001). Among survivors, 63% (12/19) were dialysis-independent at discharge. COVID-19 septic shock was associated with higher crude mortality (76% vs 52%) and lower renal recovery among survivors (9.5% vs 34%) compared with non-COVID sepsis.

Conclusions: In a resource-limited ICU, oXiris^®-based CRRT was associated with rapid vasopressor de-escalation and clinically meaningful kidney recovery among survivors, but overall mortality remained high and severity-dependent. COVID-19 septic shock showed a distinct profile, with higher baseline severity, a trend toward higher mortality, and impaired renal recovery. These data support feasibility and safety of hemoadsorptive CRRT in constrained settings and justify prospective comparative evaluation.

Introduction: Early kidney transplant failure has significant negative impact for individuals and healthcare systems. Contemporary data investigating early allograft failure are lacking. We undertook a retrospective observational cohort study of adult patients who underwent kidney transplantation at a single European centre.

Methods: We determined causes of allograft failure between 1 and 5 years after transplant and explored clinical variables present at 1 year that predicted allograft loss.

Results: 591 patients (median age 50 years, 64.1% male, and 44% white) were included; 531 (89.8%) had graft survival and 60 (10.2%) had graft loss between 1- and 5-years. Rejection was the primary cause of graft failure in 24 (40%) cases and 54% had undetectable tacrolimus levels prior to failure event. Female sex, serum creatinine at 1 year, the occurrence of rejection, and undetectable tacrolimus levels were associated with increased odds of graft loss. In subsequent analysis of 787 patients alive with a functioning graft at 1 year, recipient age, serum creatinine, proteinuria, any rejection episode, and tacrolimus intrapatient variability (IPV) at 1 yearwere associated with an increased hazard of graft loss.

Discussion: Hence, graft losses were predominantly alloimmune mediated, often associated with non-adherence, and were predicted by tacrolimus IPV at 1 year.

Background: Sarcopenia has emerged as one of the major complications in end-stage kidney disease (ESKD), leading to greater disability and poor long-term outcomes. This study aimed to compare quadriceps muscle sonoelastographic parameters between ESKD patients with and without sarcopenia.

Materials and methods: We prospectively enrolled 50 ESKD patients with sarcopenia and 50 ESKD patients without sarcopenia as controls. All participants underwent clinical and laboratory evaluation, sonoelastography of the quadriceps muscle, and dual-energy X-ray absorptiometry (DXA) for muscle mass assessment. Sarcopenia was diagnosed according to the revised European Working Group on Sarcopenia in Older People (EWGSOP2, 2019), which emphasizes muscle strength as the principal determinant. Handgrip strength, gait speed, and appendicular skeletal muscle mass (ASM/height²) by DXA were assessed. The elastography ratio was calculated as the stiffness of the quadriceps muscle relative to the overlying subcutaneous tissue. Comparisons were made between the sarcopenia and non-sarcopenia groups.

Results: A total of 100 ESKD patients were included: 50 with sarcopenia (mean age, 63.0 ± 12.7 years) and 50 without sarcopenia (mean age, 58.3 ± 14.9 years). The sarcopenia group demonstrated a lower quadriceps-to-subcutaneous tissue elastography ratio compared with the control group. Multivariate logistic regression identified the quadriceps-to-subcutaneous tissue ratio, muscle hardness, and body mass index (BMI) as independent predictors of sarcopenia (p < 0.05). Lower BMI was associated with an increased risk of sarcopenia. The optimal quadriceps-to-subcutaneous tissue elastography ratio cut-off value was 0.885 (sensitivity 82.4%; specificity 66.7%).

Conclusion: Sonoelastography provides a reliable and non-invasive assessment of quadriceps muscle stiffness and demonstrates good predictive value for detecting sarcopenia in ESKD patients. Given its accessibility, low cost, and ease of use, sonoelastography may serve as a valuable adjunct to conventional DXA in evaluating muscle quality in this high-risk population.

Introduction: To verify whether rituximab (RTX) monotherapy is noninferior to glucocorticoids in inducing and maintaining remission in adults with minimal change disease (MCD).

Method: We retrospectively analyzed the clinical data of 60 patients with minimal change disease (MCD) who were diagnosed with MCD by renal pathology biopsy and electron microscopy before their first visit to the Department of Nephrology of Shandong Provincial Hospital between 01/2020 and 01/2024, and were diagnosed with MCD at the first visit without acute kidney injury (AKI). Patients were divided into a RTX treatment group (RTX group, 20 cases) and glucocorticoids (GC) treatment group (GC group, 40 cases). None of the patients had previously received steroid/immunosuppressive therapy. The RTX group received rituximab monotherapy. At the 6-month follow-up, the RTX group received additional rituximab infusions as maintenance therapy. The primary endpoints were the time to induced remission, 12-month remission, and relapse rates in each group; the secondary endpoints were the safety and incidence of side effects.

Results: After treatment during the 12-month follow-up period, 57 out of 60 patients (95%) achieved remission, of which 48 (80%) achieved complete remission; and 9 (15%) patients relapsed during the follow-up period. A total of 24 (40%) patients experienced adverse events while receiving treatment. 19 (95%) patients in the RTX group and 38 (95%) patients in the GC group achieved remission within 12 months of follow-up, respectively [the difference in rates between the two groups was 0%, 95% confidence interval (0.08, 11.73)]. In the RTX group, 14 (70%) achieved complete remission. In the GC group, 34 (85%) achieved complete remission (p=0.304). In the RTX group, 2 (10%) patients relapsed, and in the GC group 7 (18%) patients relapsed (p=0.701). 1 (5%) patient in the RTX group and 23 (58%) patients in the GC group experienced adverse events (p=0.000), none of which were severe.

Conclusion: Adequate RTX monotherapy is noninferior to adequate glucocorticoids in inducing and maintaining remission in adult MCD patients without AKI, with fewer adverse effects and better adherence, and may be considered as a first-line treatment option for adult MCD patients without AKI.

Continuous glucose monitoring (CGM) is used more frequently among patients with chronic kidney disease (CKD), including those undergoing haemodialysis and peritoneal dialysis. However, there is a lack of information and evidence regarding CGM use in kidney transplantation (KT). Dysglycaemia is commonly observed in the transplant setting; often complicated by impaired kidney function with fluctuating glomerular filtration rates and competing influences of diabetogenic immunosuppressants, perioperative surgical stress and transplant-related complications. This narrative review, the first of its kind, examines the utility, accuracy, efficacy and clinical outcomes of CGM in KT patients. It also addresses specific transplant-related issues that may necessitate future CGM usage and highlights knowledge gaps to inform future research directions.

Background: Filtration slit proteins are important for maintaining the integrity of the glomerular filtration barrier. Genetic mutations and environmental factors can disrupt their structure and functions, leading to proteinuria and kidney diseases. This scoping review aims to synthesize the available information on the genetic and environmental factors that affect the slit proteins to enhance our understanding of the (patho)physiology of glomerular filtration.

Methods: Online databases such as Wiley and PubMed were used. Relevant studies were selected focusing on genetic variations, environmental influences, and their impact on filtration slit proteins. Data extraction and synthesis were conducted to highlight key themes and knowledge gaps.

Results: We summarized at least 20 proteins and their genes, including nephrin, podocin, phospholipase C Epsilon 1 (PLCE1), CD2-Associated Protein (CD2AP), ITGA 3, synaptopodin, myosin 1E (MYO1E), flotillin-2 (Flot2), podocalyxin, FAT1, Apo Hemoglobin-Haptoglobin (Apo Hb-Hp), spermidine, P-Cadherin, ephrin B1, Zo- 1 (Zona Occluden), MAGI 1&2 (MAGUK inverted), Par- complex, IP-10 (interferon-inducible protein), neurexin 1, and liver type fatty acid binding protein. We also reported at least 8 environmental factors, including oxidative stress, inflammation, heavy metals, air-bone pollutants, high-fat diets, vitamins and micronutrient deficiency, mechanical stretch, and nephrotoxic agents.

Conclusion: This review highlights various filtration slit proteins and the mechanisms of their alterations by genetic and environmental factors. It contributes to efforts toward personalized therapeutic strategies for disorders of glomerular filtration.

Immunoglobulin A Nephropathy (IgAN) is a prevalent form of glomerulonephritis that leads to chronic kidney disease (CKD), typically marked by ongoing proteinuria, even when treated with standard therapies such as renin-angiotensin-aldosterone system (RAAS) blockers and occasionally immunosuppression. Proteinuria is a modifiable risk factor crucial for disease advancement. Sparsentan, a dual endothelin receptor and angiotensin receptor blocker (DEARA), has been introduced as a novel therapeutic option focusing on proteinuria. We present a case series featuring seven patients - five diagnosed with IgAN and two with IgA vasculitis (IgAV) - with severe proteinuria who were treated with Sparsentan, sometimes in combination with other medications such as targeted-release formulation (TRF) budesonide, sodium-glucose cotransporter-2 (SGLT2) inhibitors, or mycophenolate. Notable reductions in proteinuria and improvements in blood pressure regulation were observed in these cases. Sparsentan was well-tolerated overall, with no significant hyperkalemia or hepatotoxicity reported in this group. These cases emphasize the real-world experience, promising efficacy and safety of Sparsentan in reducing proteinuria in patients with IgA-mediated glomerular disorders, including its application in combination therapies and patients with concurrent or prior immunosuppression.

The Banff classification for renal allograft rejection has evolved over time, increasing in complexity. For non-pathologists conducting retrospective studies, assigning Banff diagnostic categories across different eras presents a significant challenge. The Automated Diagnosis System (ADS) is a publicly available web-based tool designed to standardize Banff category diagnoses based on Banff scoring. We retrospectively evaluated ADS using 1,071 kidney biopsy results from 544 transplant recipients, including 146 ABO-incompatible cases performed at our institution. Overall concordance between ADS and pathologists was 69.8%, with high agreement in non-rejection (97.4%) and rejection (86.3%) cases. Among rejection cases, discrepancies were noted in 27 antibody-mediated rejection (AMR) and 22 T cell-mediated rejection (TCMR) cases. Discrepancies were frequently observed in AMR following ABO-incompatible transplantation and in chronic TCMR, highlighting challenges in standardizing these categories. Despite these limitations, ADS demonstrated acceptable concordance and potential utility for promoting global standardization in rejection diagnosis.

Introduction: Fatigue is a prevalent and burdensome symptom in Chronic Kidney Disease (CKD), with major impact on Health-Related Quality of Life (HRQoL). Physical activity has been linked to improvements in both fatigue and HRQoL. This study examined whether physical activity relates to HRQoL indirectly through fatigue and whether this relationship is moderated by sleep quality.

Methods: A total of 465 CKD patients (mean age = 53.78 years; 50% female) participated in the study. Fatigue, physical activity, HRQoL, and sleep quality were assessed and compared to general population norms and across treatment modalities using t-tests and ANCOVAs. Mediation, moderation, and moderated mediation analyses were conducted.

Results: CKD patients reported lower physical activity levels, HRQoL, and sleep quality, and higher fatigue than the general population (all ps <.001). Among treatment groups, transplant recipients showed the most favorable outcomes, while patients without renal replacement therapy reported the poorest. Higher levels of physical activity were associated with better HRQoL indirectly through fatigue, with small to moderate effect sizes. Stronger associations observed in those reporting better sleep quality.

Discussion: These findings indicate that physical activity is associated with better HRQoL in CKD patients through its relationship with fatigue, particularly among those with good sleep quality. Future research should explore fatigue across CKD stages to optimize interventions that target both physical activity and sleep.

Background: Focal xanthogranulomatous pyelonephritis (XGP) is a rare chronic renal inflammatory disorder in children that often mimics renal neoplasms, complicating diagnosis and management.

Methods: We describe two pediatric cases of focal XGP managed at our institution and provide a descriptive review of the literature (1975-2024), analyzing clinical presentation, imaging features, management strategies, and outcomes of this disease.

Results: Case 1: A 2-year-old boy presented with a febrile right flank mass and systemic inflammation. CT Scan revealed an 80 mm multilocular renal mass. Surgical drainage and biopsy confirmed focal XGP, and targeted antibiotics led to complete resolution with preserved renal function at two-year follow-up. Case 2: A 10-year-old girl presented with a 40 mm left renal mass and systemic inflammatory signs. CT-guided aspiration and histopathology confirmed focal XGP. She was managed conservatively with intravenous and oral antibiotics, achieving complete resolution and normal renal function at seven-year follow-up. Literature review of 34 pediatric XGP cases (median age 11.1 years) showed that 53% were focal lesions. Conservative management with antibiotics, with or without drainage, succeeded in 64% of cases, and overall outcomes were favorable, with stable renal function and no reported mortality.

Conclusion: This combined case series and descriptive literature review highlights that conservative, kidney-sparing management is a feasible and effective approach in selected pediatric focal XGP cases. Multicenter collaborations are needed to define standardized diagnostic and therapeutic protocols.