Frontiers in nephrology最新文献

Background: Although medical guidelines for chronic kidney disease (CKD) clearly recommend measures such as blood pressure control, dietary changes, regular physical activity, and consistent medication adherence, individuals frequently encounter challenges in implementing these behavioral modifications. In medical practices, there is a lack of time and resources to comprehensively support CKD patients and low-threshold (digital) interventions aimed at enhancing patient activation are needed. This paper analyzes the acceptance and usage intention (Study 1) and the contribution to health literacy and behavioral change (Study 2) of a m-health program for CKD ("Oska"). The Oska program combines personal counseling via video calls with app-based support and is theoretically grounded in the Health Action Process Approach (HAPA), with a strong emphasis on fostering self-efficacy and promoting implementation in daily routines.

Method: Study 1: An online survey was conducted with N = 401 individuals with CKD and/or hypertension, obesity, type 2 diabetes, or coronary heart disease (age: 50-89 years, M = 64.1, 49% female). Participants were recruited via the provider Appinio and presented with a vignette illustrating the Oska program and answered questionnaires on usage intention, desired support, compatible health benefits, health literacy, and perceived usefulness. Study 2: N = 109 participants with CKD, who already took part in the Oska program for an average of 4.7 months (age: 29-84 years, M = 62.3, 64% female, BMI: M = 29.6), completed established questionnaires on working alliance, kidney-specific health literacy, and behavior change. The analysis was conducted using structural equation models and linear regression analyses.

Results: Acceptance and usage intention in study 1 were high and predominantly explained by compatible health benefits, health literacy, and perceived usefulness, but largely independent of sociodemographic factors and health-related variables. In study 2, higher health literacy was primarily fostered by longer program participation and, most notably, by a positive trust relationship (working alliance) (R²_adj = .48) Successful behavior change (across all guideline areas) was primarily attributed to a positively evaluated working alliance and Oska's contribution to health literacy, rather than sociodemographic factors or the number and type of diagnoses (R²_adj = .14).

Discussion: Digitally delivered coaching combined with app-based support is not only acceptable but may be particularly effective for CKD patients with low health literacy and multiple comorbidities. Relevant determinants include a trusting coaching relationship and a focus on health literacy as well as self-efficacy in implementing measures in everyday life.

Anti-glomerular basement membrane (anti-GBM) disease is a rare autoimmune disorder characterized by circulating autoantibodies targeting type IV collagen, leading to rapidly progressive glomerulonephritis. We report a case of a 44-year-old African American female with a history of hypertension who presented with acute kidney injury, hematuria, and shortness of breath. She tested positive for COVID-19 and received antiviral therapy; however, her renal function rapidly deteriorated, with serum creatinine rising from 3.4 to 10 mg/dL. Serologic testing ruled out common autoimmune conditions, but elevated CH50 levels suggested ongoing immune activation. Renal biopsy demonstrated diffuse necrotizing crescentic glomerulonephritis with linear IgG staining, consistent with anti-GBM disease. Despite aggressive therapy, including plasmapheresis, corticosteroids, and dialysis, renal recovery was not achieved. Immunosuppressive therapy was deferred in light of her active COVID-19 infection and the risk of immunosuppression-related complications. This case highlights a potential association between COVID-19 and anti-GBM disease, suggesting viral-induced endothelial injury and aberrant immune activation as possible mechanisms. Given emerging reports of autoimmune kidney diseases following COVID-19, further research is needed to clarify this relationship and guide optimal management. This is particularly important for patients who present with severe renal dysfunction in the context of an active infection.

Introduction: Myonecrosis is a rare but serious complication of diabetes, particularly in patients with end-stage kidney disease (ESKD), characterized by ischemic necrosis of the skeletal muscles. Its diagnosis is often delayed due to overlapping presentations with cellulitis or deep vein thrombosis. Treatment is traditionally limited to supportive measures such as rest and pain control, which remains the cornerstone. The role of corticosteroids remains controversial in this condition as its effectiveness and utility are not widely understood. This case highlights the unconventional use of corticosteroids in the management of refractory diabetic myonecrosis, emphasizing their potential in mitigating inflammation and promoting recovery.

Case report: We present a 31-year-old woman with ESKD on hemodialysis and a history of type 1 diabetes who presented with recurrent, debilitating pain and swelling in the right lower extremity. Despite a comprehensive workup, including MRI and a muscle biopsy confirming myonecrosis, the patient's symptoms persisted despite conventional supportive care. Following a multidisciplinary discussion, corticosteroid therapy was initiated, resulting in dramatic symptom resolution within 48 h. The patient experienced significant pain reduction, improved mobility, and decreased swelling, allowing for discharge on a tapered steroid regimen. Notably, a subsequent recurrence of myonecrosis in a different muscle group also responded favorably to corticosteroid treatment, further underscoring its therapeutic potential in the management of patients with this condition.

Discussion/conclusion: This case underscores the importance of considering corticosteroids as an adjunctive therapy in refractory diabetic myonecrosis, particularly in patients who fail to respond to standard care. A detailed workup, a high degree of suspicion, distinct clinical findings, and imaging such as MRI, along with muscle biopsy, can accurately diagnose this condition. While corticosteroids are not routinely used due to their potential risks, their dramatic effect in this patient highlights the need for further research to better understand their role and to refine treatment strategies. By expanding the therapeutic approach to diabetic myonecrosis, this case provides valuable insights for improving outcomes in this rare and challenging condition. This case opens the door for the exploration of corticosteroids as an adjunctive therapy in similar diabetic patients with ESKD and refractory myonecrosis.

Tertiary hyperparathyroidism (THPT) is a severe complication of uncontrolled secondary hyperparathyroidism, typically associated with advanced-stage chronic kidney disease (CKD). We present the case of a Honduran patient with a long-standing history of CKD secondary to severe preeclampsia, who developed THPT following the discontinuation of her treatment due to financial constraints and the COVID-19 pandemic. The patient exhibited severe maxillofacial deformities, functional limitations, and widespread skeletal abnormalities. Despite initial management with medications such as paricalcitol and alfacalcidol, the lack of access to appropriate therapies and the postponement of a planned parathyroidectomy worsened her condition. This case highlights the importance of early diagnosis and timely intervention, particularly in resource-limited settings, emphasizing the urgent need for kidney transplant programs and improved preventive strategies in developing countries.

Background: Acute Kidney Injury (AKI) is a common yet preventable complication among surgical patients, contributing to increased morbidity, prolonged hospital stays, and higher healthcare costs. Early detection is critical; however, the absence of a standardized nursing-led risk assessment tool for AKI limits proactive intervention in clinical practice.

Objective: This study aimed to develop and evaluate the Nursing Risk Assessment for Acute Kidney Injury tool, integrating the Fuzzy Logic Model (FLM) to enhance interpretive accuracy and improve nursing-led AKI risk detection and decision-making.

Methods: A Design and Development Research (DDR) framework was employed in three phases. Phase 1 involved a needs analysis using a focus group discussion to explore the necessity of AKI assessment among surgical nurses. Phase 2 focused on tool development through expert consensus (surgeon, nephrologist, nursing academician, and experienced nurse) and evidence synthesis via a systematic literature review. In Phase 3, the Nursing Risk Assessment-AKI tool was evaluated through a quasi-experimental design at Hospital Canselor Tuanku Muhriz (HCTM), Kuala Lumpur, involving 75 surgical nurses assessing 200 patients.

Results: Post-intervention analysis indicated increased nursing confidence, with 95.7% expressing positive perception of tool use. The FLM-supported tool demonstrated a predictive accuracy of 81.3%; however, the potential for false positives or negatives remains, especially given the single-center context. Fuzzy logic stratified patients into risk groups: at risk (33.5%), borderline (20.5%), and no risk (46.0%). ANOVA analysis revealed significant differences (p < 0.05) between AKI risk and factors such as age, gender, comorbidities, clinical/laboratory parameters, surgery types, and nephrotoxic agent usage.

Conclusion: While initial findings support the usability and clinical feasibility of the NURA-AKI tool, further multicenter validation is needed. The tool is designed to complement nurse judgment, promoting early AKI detection and structured risk communication in surgical care without replacing clinical autonomy.

Brucellosis is known to impact multiple organ systems in humans, including the urogenital system; however, the occurrence of glomerular diseases is relatively uncommon. In this study, we present the case of a 45-year-old man with no prior history of renal disease who developed gross hematuria, proteinuria, acute kidney injury, anemia, hypoproteinemia, pleural effusion, arthralgia, and lymphadenopathy following an acute Brucella infection. Renal biopsy revealed mesangial proliferative immunoglobulin A (IgA) nephropathy with partial crescents, classified as M1E0S0T0C2 according to the Oxford classification, in conjunction with Brucella spondylitis. The patient achieved complete remission after 4 months of anti-brucellosis therapy with doxycycline, levofloxacin, and rifampicin. In this paper, we present a case study of IgA nephropathy complicated by cellular crescent lesions resulting from acute Brucella infection, which completely resolved following anti-Brucella therapy. In addition, we review previously documented cases of Brucella-associated glomerular disease confirmed through renal biopsy, aiming to offer a reference for clinical diagnosis and treatment.

Background: High-dose methotrexate (HDMTX) is central to treating primary central nervous system lymphoma but carries a risk of acute kidney injury (AKI), which can delay methotrexate (MTX) clearance and increase toxicity. Glucarpidase is the treatment of choice for MTX toxicity, but limited access in many countries may necessitate alternatives. We present the first reported adult case of combined high-flux hemodialysis (HFHD) and HA230 hemoadsorption for MTX clearance.

Case summary: A 66-year-old woman with newly diagnosed primary central nervous system lymphoma began induction chemotherapy including HDMTX. Forty-eight hours post-infusion, she developed KDIGO stage 3 AKI, with plasma MTX levels of 26.278 µmol/L despite maintained urine output and early supportive measures. On Day 3, MTX levels remained elevated at 15.567 µmol/L, accompanied by severe metabolic alkalosis. She was admitted to intensive care, where she underwent HFHD combined with post-filter HA230 hemoadsorption, followed by intravenous glucarpidase as soon as it became available. A second extracorporeal session occurred 48 hours later. MTX levels decreased by 91.93% (estimated elimination half-life ≈ 0.83 hours) and 71.02% (half-life ≈ 2.12 hours) after the first and second sessions, respectively. No significant rebound in MTX levels or dialysis-related complications occurred. The patient recovered renal function and completed further treatment without MTX.

Conclusions: This case demonstrates the effectiveness of combined HFHD and HA230 hemoadsorption as a bridging or alternative strategy when glucarpidase is delayed or unavailable. While evidence remains limited, it supports further investigation into extracorporeal MTX removal and contributes to the evolving field of Onconephrology.

Background: Chronic kidney disease (CKD) is a progressive condition affecting over 10% of the global population, with high sodium intake identified as a critical modifiable risk factor. This study investigated the global burden of CKD due to excessive sodium intake in 204 countries and territories from 1990 to 2021 and made the first future projections to 2040, addressing gaps in longitudinal analysis of sodium-related CKD trends and demographic differences.

Methods: Data from the Global Burden of Disease (GBD) 2021 database were analyzed to quantify CKD-related deaths and disability-adjusted life years (DALYs) linked to high sodium intake. Age-standardized mortality rates (ASMR) and DALY rates (ASDR), alongside the sociodemographic index (SDI), were used to assess regional and demographic variations. Statistical analyses in R included joinpoint regression to identify temporal inflection points and age-period-cohort (APC) modeling to disentangle age, period, and birth cohort effects. Future projections show that from 2021 to 2040, the global ASMR trend is stabilizing and ASDR is on the rise. Moreover, male ASMR and ASDR have been consistently higher than female ASMR. This gender difference is expected to continue for a long time, with men continuing to bear a greater burden of chronic kidney disease than women.

Results: Between 1990 and 2021, global CKD deaths attributed to high sodium intake surged 1.68-fold (26,072 to 69,954), while DALYs increased by 135% (741,197 to 1,705,325). ASMR and ASDR rose markedly in high-income regions (20.73% and 6.77%, respectively), with Latin America and the Caribbean reporting the highest burdens (ASMR: 1.49/100,000; ASDR: 33.21/100,000). Men exhibited consistently higher burdens than women, peaking in the 65-79 age group. Low SDI regions showed declining trends, contrasting with widening inequalities in medium SDI areas.

Conclusion: The global CKD burden attributable to high sodium intake has escalated dramatically over three decades, driven by aging populations, dietary shifts, and regional disparities. Urgent, targeted interventions-such as sodium reduction policies, gender-specific health strategies, and enhanced healthcare access-are critical to curbing this trend, particularly in high-risk demographics and high-income regions.

Background: Calcimimetics are a group of medications that increase the sensitivity of the calcium receptors to extracellular calcium ions and inhibit the release of parathyroid hormone (PTH) in patients with chronic kidney disease (CKD).

Objectives: The aim of this study was to analyze the global trends in the publication of articles on calcimimetics through bibliometric analysis of the Web of Science and Scopus databases, as well as to identify the most highly cited articles from 1997 to 2024.

Methods: Systematic and thematic analyses were performed to provide substantial insights into calcimimetic research. Data were analyzed using VOS viewer (var1.6.6) and the Biblioshiny tool.

Results: A total of 3,500 documents were identified for analysis. There was an exponential growth in calcimimetic-associated publications (from 57 documents in 2004 to 258 in 2021). The mean of the total citations per article showed a decrease from 226 in 1998 to 0 in 2024. The United States was the most productive country. Goodman W. emerged as the most prolific author, with high-level metrics [n = 45, total number of citations (TNC) = 4,768, h_index = 27]. Fukazawa M. showed the longest research activity in the field, with 97 published documents in 25 years. Nephrology Dialysis Transplantation was the most published journal, with 112 documents and with an h_index of 43. The thematic KeyWords Plus analysis identified three key domains, including pharmacological targets (CaSR and cinacalcet) reported in niche themes and central CKD and mineral bone disorder (MBD) pathway (hemodialysis, vascular calcification, and vitamin D) case reports in emerging/declining themes. The small correlation between "diabetes" and "mineral metabolism" (despite shared CKD complications) suggests a critical research gap. While our thematic map highlighted robust research on the pathophysiology of CKD-MBD, critical clinical outcomes remain underexplored. Future trials should highlight these gaps, particularly in high-risk subgroups such as diabetic patients with CKD.

Conclusion: The results of this review offer a summary of the global landscape, the key research areas, and possible future directions in calcimimetic research. This information can assist researchers in exploring the knowledge structure and understanding future trends in calcimimetic research, as well as in supporting collaboration toward advanced global research on calcimimetics.

Background: Percutaneous renal biopsy (PRB) provides valuable information to guide treatment decisions in patients with metastatic renal cell carcinoma (mRCC) who develop acute kidney injury (AKI) after systemic anticancer therapy (SACT). The rising incidence of renal cell carcinoma (RCC) and the substantial impact of SACT on overall survival suggest a higher prevalence of RCC patients with reduced nephron mass and a solitary kidney (SK) requiring PRB for AKI. However, safety data on SK biopsies are scarce, and the potential for dialysis-requiring complications may deter clinicians.

Methods: This retrospective case series reports the safety of 13 PRBs in 12 mRCC patients with reduced nephron mass who developed AKI during SACT as well as six PRBs in six patients with metastatic solid malignancies and AKI, which developed during SACT.

Results: Eleven biopsies in mRCC patients and five biopsies in patients with metastatic solid malignancies were uneventful. One patient with mRCC experienced a major bleeding event due to an arteriovenous (AV) fistula seven days post-procedure, while another mRCC patient developed macrohematuria within 24 hours. In the group of patients with metastatic solid malignancies, one patient experienced a small perinephric hematoma during the observational period. Despite the small sample size, individual chart reviews and direct management of adverse events allowed assessment of the association between biopsy and complications.

Conclusion: Until further data become available, a longer observation period is recommended for these patient cohorts compared to the general population. Further studies are needed to develop consensus guidelines for PRB in mRCC patients with reduced nephron mass.