Frontiers in nephrology最新文献

Background: Contrast-Associated Acute Kidney Injury (CA-AKI) is a major cause of acute kidney injury in hospitalized patients, which is triggered by the administration of iodinated contrast agents during computed tomography scans and angiographic procedures. It significantly elevates cardiovascular risk and stands as a major complication of coronary angiography, contributing to a marked deterioration in patient prognosis with elevated rates of morbidity and mortality.

Aim: Our main goal was to assess the predictive factors of CA-AKI and investigate a possible association between pre-existing endothelial dysfunction and the occurrence of CA-AKI following Percutaneous Coronary Interventions (PCI). We also intended to explore possible preventive measures of CA-AKI.

Methods: We conducted a prospective observational longitudinal study enrolling patients with an indication for PCI. Patients underwent an assessment of renal function (baseline creatinine, 24h and 48-72h after administration of contrast agent). We also evaluated renal function at one month as a secondary endpoint. Then, we analyzed Endothelial Quality Index (EQI) by Finger Thermal Monitoring (FTM) with E4 diagnosis Polymath.

Results: We enrolled 187 patients (134 males, 53 females) in our study with a mean age of 61.1± 11.8 years. Over half (56.7%) were type 2 diabetes. A total of 60 cases of CA-AKI were reported (33.7%). The mean EQI was 0.86 ± 0.61. The vast majority of our study population (n=178; 95.2%) had endothelial dysfunction (EQI<2), and a significant proportion (n=142; 75.9%) had severe endothelial dysfunction (EQI<1). In our study, CA-AKI incidence was significantly associated with severe endothelial dysfunction (p=0.007). It was also strongly correlated to the rescue PCI (p=0.002), contrast media volume>100ml (p=0.015) and the presence of a two-vessel coronary artery disease (p=0.008). In multivariate analysis, severe endothelial dysfunction (OR = 5.46; p = 0.014), rescue PCI (OR = 5.77; p = 0.04) and contrast medica volume equal or over 140 ml (OR = 6.96; p = 0.036) were independent risk factors of CA-AKI. We found that pre- and post-hydration with isotonic saline solution and that patients whose baseline treatment includes statins, were significantly prevented from developing CA-AKI. (p=0.007 and 0.008 respectively).

Conclusion: Our study showed a significant association between the presence of severe endothelial dysfunction, assessed non-invasively by FTM, and the risk of developing CA-AKI. These results appear to be relevant considering that EQI is a low-cost, non-invasive and easily reproducible marker of endothelial dysfunction.

Obesity has been a systemic disease that has been underrecognized for years. Obesity-related chronic kidney disease (Ob-CKD) is a multifaceted disorder that affects patients with CKD to varying degrees. Among the structural changes associated with obesity, obesity-related glomerulopathy (ORG) stands out (glomerular hypertrophy, podocytopathy, mesangial matrix expansion, focal segmental glomerulosclerosis, tubulointerstitial fibrosis, vascular lesions, and tubular atrophy) associated with other kidney diseases. There are direct and indirect mechanisms that affect the kidneys of obese patients. Among the direct mechanisms, several effects may occur: hyperfiltration, activation of the renin-angiotensin-aldosterone system (RAAS), inflammation, lipotoxicity, and neurohormonal activation. This is a narrative review that will detail the inflammatory and lipotoxicity mechanisms involved in the genesis of Ob-CKD.

Introduction: The prevalence of bone disease in peritoneal dialysis patients has been recently shown to exceed 54%, including patients with parathormone (PTH) levels within the theoretical adequate target, yet demonstrating low bone turnover on histomorphometry. Moreover, bone disease is often associated with abnormalities in calcium and phosphate metabolism, leading to tissular deposits such as extraosseous calcifications.

Case presentation: We present a 22-year-old female patient managed on peritoneal dialysis with persistent swelling of all four extremities, including the fingers, hands, and feet, accompanied by a marked decrease in PTH. Many extraosseous calcifications in the hands were seen in the X-ray images, prompting a switch from peritoneal dialysis to conventional high-flow haemodialysis and intravenous sodium thiosulphate (STS) therapy. The patient showed adequate treatment tolerance, with most calcifications disappearing after 3 months of therapy.

Conclusions: Our experience suggests that the treatment of extraosseous calcifications requires timely and multi-angle intervention. At the same time, treatment with STS has proven effective and well tolerated in this patient.

Objectives: This study aimed to evaluate patient satisfaction with dialysis services provided across different healthcare sectors in Saudi Arabia, including governmental and private facilities, and to identify key determinants influencing satisfaction levels.

Methods: A cross-sectional observational study was conducted using secondary data from dialysis patients attending Ministry of Health, Diaverum, and DaVita facilities between January and December 2023. Patient satisfaction data were collected through the Press Ganey survey, a validated instrument assessing six domains: registration, care, dialysis, pharmacy, personal issues, and personal experience. Descriptive statistics summarized patient demographics and satisfaction scores, while regression analysis identified factors associated with satisfaction.

Results: A total of 5,472 patients were included, with an overall satisfaction score of 89.84 ± 14.25. The mean satisfaction score was highest in the personal experience domain (91.39 ± 17.02) and lowest in the dialysis domain (88.45 ± 18.65). Private facilities had statistically significant higher satisfaction scores (90.41 ± 13.31) compared to governmental hospitals (88.57 ± 16.08). Females reported significantly higher satisfaction than males (91.96 ± 12.15 vs. 88.91 ± 14.60), respectively. Pediatric patients demonstrated significantly higher satisfaction (age ≤18 years: 93.80 ± 11.42) compared to young adults (age = 19-29 years: 89.18 ± 14.62). Regional differences were observed, with the Southern region reporting the highest satisfaction (91.37 ± 14.18) and the Eastern region the lowest (88.60 ± 15.59). Regression analysis identified gender (B = 2.943, 95% CI [2.165, 3.722], p < 0.001) and facility type (B = 1.108, 95% CI [0.243, 1.973], p = 0.012) as significant predictors of satisfaction.

Conclusion: Patient satisfaction with dialysis services in Saudi Arabia is generally high, with statistically significant but modest differences across regions, facility types, age groups, and genders. Improving dialysis-related education, addressing regional disparities, and enhancing patient-centered care, particularly in governmental facilities, could further optimize satisfaction outcomes.

Background: Immunoglobulin A nephropathy (IgAN) is a leading cause of chronic kidney disease (CKD) worldwide. While racial and ethnic differences in disease progression are well documented, the Hispanic/Latinx populations remain understudied despite their elevated risk of kidney failure among other CKD populations.

Objective: This study aimed to evaluate the kidney function decline and progression in Hispanic/Latinx patients with biopsy-proven IgAN within a large, integrated healthcare system and to contextualize to other racial/ethnic groups.

Methods: We conducted a retrospective case series study of 259 Hispanic/Latinx adults with biopsy-proven IgAN from the Kaiser Permanente Southern California (KPSC) health system. Patients were followed from biopsy to ≥50% decline in the estimated glomerular filtration rate (eGFR), kidney failure, mortality, the study end date of November 30, 2022, or disenrollment. Annualized eGFR decline and the incidence of composite kidney outcomes were assessed.

Results: At diagnosis, Hispanic/Latinx patients had significant CKD and a high risk of progression to kidney failure, indicated by a median eGFR of 56 ml min^-1 1.73 m^-2 and a median urine protein/creatinine ratio of 1.8 g/g. Common treatments included immunosuppressive agents (41%), angiotensin-converting enzyme (ACE) inhibitors (48%), and angiotensin receptor blockers (ARBs; 20%). The mean annual eGFR decline was -4.5 ml min^-1 1.73 m^-2, and 30.9% experienced rapid decline (>5 ml min^-1 1.73 m^-2 per year). The composite kidney outcome occurred at 73.3 events per 1,000 patient-years, with a median time to event of 2.8 years and a median age at event of 46 years.

Conclusion: Hispanic/Latinx patients with IgAN demonstrate rapid kidney function decline and early-onset kidney failure. These findings underscore the need for earlier detection and targeted management in this underserved group.

Background: Proteinuria is a well-established and recommended biomarker for disease activity in patients with IgAN. In the most recent version of the KDIGO guideline, the target level of proteinuria changed from < 1.0 g/day to < 0.5 g/day. The objective of this systematic literature review (SLR) is to identify, synthesize, and critically evaluate the evidence from peer-reviewed publications that inform the significance of achieving different proteinuria levels.

Methods: We searched PubMed and Embase (2005-2025) for studies in adult patients diagnosed with IgAN that examined the relationship between proteinuria measured by any method (e.g., uPCR, 24-hour protein excretion) and key kidney outcomes. The review used an a priori protocol following established methodological guidance for systematic reviews. Additionally, the quality of all studies included in the SLR was assessed based on standardized appraisal tools. The evidence was narratively synthesized reporting frequencies and percentages.

Results: Twenty-one unique studies were included (representing 13,006 patients with IgAN). The studies captured in the SLR were mostly observational and they encompassed diverse patient populations, timing of proteinuria assessment, methods of proteinuria measurement and classification, and clinical management strategies, reflecting real-world heterogeneity in IgAN. Despite the differences in individual study methods, results across studies consistently found that lower proteinuria was associated with better kidney outcomes. Specifically, it was clearly established that <0.5 g/day achieved better outcomes than higher proteinuria thresholds.

Conclusion: The evidence identified in this SLR affirms the updated KDIGO recommendation to achieve at least a proteinuria level of < 0.5 g/day.

Systematic review registration: https://www.crd.york.ac.uk/prospero/, identifier CRD420251062821.

Rationale and objectives: Depression has been associated with worse clinical outcomes in individuals with chronic kidney disease (CKD), yet its influence on kidney disease progression in earlier CKD stages remains underexplored. Thus, this study investigates the role of depression on CKD progression by stages, and bidirectional relationship using real-world data.

Methods: This was a retrospective cohort analysis. Data was extracted from the TriNetX EMR database from 2007 to 2022. Patients (>18 years of age) with diagnosis of CKD were selected for the study. Key independent variables were diagnosis of depression or anxiety, identified by ICD codes, for the primary objective, and CKD stages (i.e., >3, 4, and 5) defined by KDIGO for the secondary objective. Primary outcome was progression to kidney disease (eGFR < 60 ml/min/bsa and > 40% decline in eGFR from the initial screening), and the secondary outcome was diagnosis of depression. Kaplan-Meier analysis and Cox proportional hazards model were used to evaluate the relationship between the dependent and independent variables while adjusting for covariates (sex, race, ethnicity, and age).

Results: Depression was significantly associated with a higher risk of kidney disease progression (HR = 1.94 [1.77-2.11], p<0.001). Among patients with CKD, patients with CKD stages 4 and 5 had significantly higher risks (HR = 1.26 [1.17-1.35] and 1.38 [1.23-1.54], p<0.001) of new diagnosis of depression than those in stage ≤3, respectively. These associations remained statistically significant after matching and adjusting for age, sex, race, and comorbidities.

Conclusion: Depression significantly accelerates CKD progression and patients with stage 5 CKD had the highest risk of developing depression. Our study advocates for integrating frequent mental health screenings for patients with CKD. This could improve patient outcomes and minimize negative consequences associated with depression.

Background: High-sensitivity cardiac troponin T (hs-cTnT) is widely used in the diagnosis of acute coronary syndrome (ACS) because it is a marker of myocardial damage. Most patients with end-stage kidney disease (ESKD) on renal replacement therapy have elevated plasma hs-cTnT levels at baseline. The impact of hemodialysis (HD) on hs-cTnT levels remains unclear. This study aimed to determine the effect of HD in patients with ESKD and hypervolemia on plasma hs-cTnT levels.

Methods: We conducted a retrospective study of ESKD patients admitted to two community hospitals over a three-year period (from January 1, 2020, to December 31, 2022). All patients had hypervolemia on admission. Plasma hs-cTnT levels were measured at admission and repeated 5.5 ± 0.75 hours after HD. Over the study period, 20 patients with ESKD and hypervolemia fulfilled the inclusion criteria. Two patients were diagnosed with ACS.

Results: Pre-HD and post-HD hs-cTnT were elevated in 85% of patients. The data did not follow normal distribution. The median and interquartile range (IRQ) for pre-HD hs-cTnT was 126 (154) ng/L, and for post-HD hs-cTnT was 155 (234) ng/L. Following a single HD session with a high-flux dialyzer, hs-cTnT levels increased in 80% of the cohort, with a mean rise of 25.6% (p = 0.0042). Mean volume removal was 2.4 L, range (1-5 L). Two patients were diagnosed with ACS. Mortality over the study period was 40%, with cardiovascular disease as the leading cause of death.

Conclusion: In ESKD patients with hypervolemia, a single HD session using a high-flux dialyzer significantly increased hs-cTnT plasma level. Pre-dialysis hs-cTnT measurements should be used as a clinical baseline when evaluating for ACS, and post-dialysis elevations should be interpreted with caution. Serial measurements may improve diagnostic accuracy. Further prospective studies are needed to clarify the mechanisms and clinical implications of these findings.

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.