Frontiers in nephrology最新文献

Background: Artificial intelligence (AI) is increasingly recognized for its potential to enhance nephrology training and practice. However, the integration of AI into fellowship training remains inadequately explored. This study aimed to assess current AI utilization, perceptions, and educational needs among nephrology fellows at Mayo Clinic.

Methods: A structured online survey was administered to 23 fellows-including those specializing in kidney transplantation and onco-nephrology-across three Mayo Clinic sites (Minnesota, Arizona, and Florida). The survey addressed domains such as current AI usage, perceived relevance of AI in clinical practice, interest in formal AI training, self-assessed comfort with AI integration, and barriers to adopting AI technologies in nephrology education.

Results: A total of 21 fellows (91% response rate) participated in the survey. 76% of respondents rated AI as moderately to highly relevant to nephrology. Similarly, 76% indicated a moderate to very high interest in receiving targeted AI training. Despite these favorable perceptions, 76% had rarely or never used AI in their clinical or research activities, and none reported any formal AI education. Interactive workshops emerged as the preferred modality for AI training (52%), with limited knowledge cited as the primary barrier to adoption. Optimism was especially high regarding AI applications in predictive modeling (86%) and diagnostic imaging (81%), while confidence in AI for direct clinical decision-making remained cautious.

Conclusion: There is significant interest among nephrology fellows in AI, along with a critical need for formal education and training. The enthusiasm for AI's potential contrasts with a cautious perspective towards its current use in clinical decision-making. Our study highlights the necessity for educational initiatives that bridge the knowledge gap and foster confidence in the appropriate use of AI technologies in Nephrology fellowship.

Catastrophic antiphospholipid syndrome (CAPS) leads to organ dysfunction due to thrombotic microangiopathy (TMA). Complement may play a role in CAPS, and its blockade could prevent antiphospholipid syndrome (APS) complications after kidney transplantation (KT). Here, we report a case of APS recurrence after KT in a 38-year-old woman with early acute cortical kidney allograft necrosis despite preventive eculizumab treatment, probably because of insufficient complement blockade. The patient had recurrent but controlled CAPS for years with renal dysfunction, leading to preemptive KT. Anticoagulation and eculizumab were administered to prevent thrombosis and TMA after KT. She developed acute kidney injury (AKI) with incomplete biological TMA. Imaging revealed cortical necrosis in the renal allograft. In the absence of donor-specific anti-HLA antibodies, we concluded a relapse. Additional doses of eculizumab and plasma exchange allowed the normalization of biological tests and improvement of kidney allograft function. A retrospective complement analysis showed an incomplete blockade at the time of AKI. One year after KT, the renal allograft function was impaired. This suggests that inadequate complement blockade leads to a relapse of APS in the renal allograft with cortical necrosis and dysfunction. Our case highlights the importance of monitoring complement activity and adjusting the dose of eculizumab or ravulizumab.

Introduction: Renal vasculitis is a rare disease, the incidence of which increased markedly during the COVID-19 pandemic in our center. The aim of this study is to compare the incidence and the clinical and histopathological characteristics of anti-neutrophil cytoplasm antibodies (ANCA)-associated vasculitis patients before and during the COVID-19 pandemic.

Methods: A single-center observational retrospective analysis of 61 patients with ANCA-associated vasculitis who were divided into two groups according to date of diagnosis: pre-pandemic from 2008 to 2020 (n=37) and during the pandemic from 2020 to the middle of 2022 (n=24). The annual incidence rate was compared, as were characteristics such as age, gender, Birmingham Vasculitis Activity Score (BVAS) score, renal clinic, organ involvement, and ANCA serotype. Biopsy findings, such as optical microscopy glomerular characteristics, crescents, interstitium, immunofluorescence, and electron microscopy findings, were analyzed. Mortality and renal replacement therapy needs were also compared.

Results: The annual incidence rate was higher in the pandemic group compared to the pre-pandemic group, with 9.6 cases per year vs. 3.1 cases per year [incidence rate ratio (IRR)=3.11, 95% CI 1.86 to 5.20]. No significant differences between the groups were found for clinical characteristics, except for greater hemoptysis frequency in the pandemic group. Significant differences in immunofluorescence and electronic microscopy were observed, with a higher IgG deposit and C3 in the pandemic group (37.5% vs 8.1%, p=0.0064; 43.5% vs 10.8%, p=0.009, respectively), whereas the incidence of pauci-immune patterns was higher in the pre-pandemic group (81.1% vs 54.1%, p=0.016). Mortality and the need for renal replacement therapy were significant higher in the pandemic group (IRR=3.56, CI 95% 1.27-9.98 and IRR=4.24, CI 95% 2.08-8.65, respectively).

Conclusion: The incidence of ANCA vasculitis increased during the COVID-19 pandemic and was associated with higher rates of IgG deposit and C3 in the immunofluorescence findings and with higher rates of deaths and dialysis in the pandemic group compared with the pre-pandemic group.

Recipients of kidney transplants often outlive the function of the renal allograft will need ESRD management. Patients face a higher risk of mortality in the period of transition from failing allograft to dialysis. Long term risk of cardiovascular complications and risk of infections and cancer with use of long-term immune suppression contribute to poor outcomes. Patients with failing transplants appear to have poorer control of CKD complications and are more likely to initiate hemodialysis using a catheter. Outcomes of peritoneal dialysis in the setting of the failing allograft in general are equivalent to hemodialysis. Management of these patients in transplant center clinics specifically focused on patients with failing allografts may have benefit, but maximal utility has yet to be demonstrated. Patients with failed transplants can have a survival benefit with retransplant, even in older patients. There may not be a benefit to retransplant in patients older than 70 years of age. Patients with failing renal grafts should be assessed as to whether they are potential candidates for retransplant prior to needing to start dialysis to allow for identification of a living kidney donor or to be listed as soon a possible on the kidney transplant wait list as to minimize the wait time on dialysis. Decisions regarding reduction of immunosuppression once the patient has started dialysis should be made with guidance from the transplant center in the context of patient-centric factors such as candidacy for retransplant and minimizing complications of long-term immunosuppression.

Background: Acute kidney injury (AKI) is a prevalent and severe medical condition that is frequently observed in the intensive care unit (ICU). Although numerous biomarkers have been identified to predict the prognosis of AKI, the lactate dehydrogenase to albumin ratio [LDH/ALB ratio (LAR)] has not been extensively investigated. The principal objective of this study was to assess the relationship between LAR and all-cause mortality in patients with AKI.

Methods: A total of 6,831 AKI patients were included in this study, divided into survival (n = 5,152) and non-survival groups (n = 1,679). The association between LAR and mortality was examined through restricted cubic spline (RCS) analysis and Cox regression analysis. Subgroup analysis was used to search for interactive factors. Additionally, the prognostic capability of LAR was further evaluated using receiver operating characteristic (ROC) curve analysis.

Results: The LAR was remarkably higher in the non-survival group (p < 0.001). RCS indicated a non-linear correlation between LAR and ICU death (p for non-linearity < 0.001). A LAR of 10.4 was used as the cutoff point to generate the high-LAR and low-LAR subgroups, and the Kaplan-Meier curves revealed that the ICU cumulative survival rate for patients with AKI was significantly lower in the high-LAR group (log-rank p < 0.001). The LAR's prediction of ICU mortality in AKI patients yielded an area under the ROC curve of 0.65.

Conclusion: Our research suggests that LAR monitoring may be promising as a prognostic marker among patients with AKI. Higher LAR is associated with greater ICU mortality.

This Festschrift in honor of Dr. Jeffrey Hymes, a distinguished leader in nephrology and a pioneer in the field of dialysis care. Dr. Hymes' career has been marked by his unwavering commitment to improving patient outcomes through innovative approaches and data-driven insights. His contributions have not only advanced the practice of nephrology but have also had a profound impact on the lives of countless patients.

Cardiovascular diseases are a leading cause of mortality in Saudi Arabia, accounting for approximately 42% of deaths. The "triple whammy" phenomenon-which combines angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, diuretics, and non-steroidal anti-inflammatory drugs-increases the risk of acute kidney injury, particularly in hypertensive patients. This study, which was conducted in small-scale hospitals in Jeddah from 2017 to 2022, assessed the incidence of the triple whammy phenomenon and the awareness of healthcare professionals of this condition. Of 5,654 patient records, 1,899 met the inclusion criteria, with 2.7% experiencing the triple whammy. A survey of 56 healthcare professionals revealed 75% unawareness, with pharmacists and dentists being the most affected. Access to over-the-counter non-steroidal anti-inflammatory drugs and gaps in training likely drive the incidence and awareness deficits. This phenomenon can lead to acute kidney injury, with mortality rates as high as 50%-80% in critically ill patients, and imposes significant costs, representing 5% of hospital budgets and 1% of the overall health expenditure. Interventions including education, pharmacist roles, and non-steroidal anti-inflammatory drug regulation are proposed. Limitations include the small-scale focus and the low survey sample, necessitating national studies to accurately measure incidence and to improve patient safety.

A 67-year-old male patient with limited-stage diffuse large B-cell lymphoma was on an R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone) chemotherapy regimen. His Eastern Cooperative Oncology Group (ECOG) Performance Scale score was zero, indicating functional independence for activities of daily living. The patient was admitted to the intensive care unit (ICU) with septic shock in the presence of febrile neutropenia progressing to acute kidney injury, hypoxemic respiratory failure, and systemic arterial hypotension, in addition to the already established hematological dysfunction with thrombocytopenia. During his 32-day ICU stay, he required invasive mechanical ventilation, renal replacement therapy (RRT) and vasopressor drugs, with a focus on control of the infection. The patient was discharged from the ICU with sarcopenia and a serum creatinine level of 2.3 mg/dL, indicating a clearance rate of 24 ml/min/1.73 m². Oxygen supplementation was needed. What impact did critical illness, more specifically renal dysfunction, have on the planning of onco-hematological treatment in this patient?

Glomerular diseases represent a significant global health challenge, complicated by the intricate management required for their treatment. We examine the treatment burden associated with the immunosuppressive therapies used to manage these conditions, focusing on the efficacy, side effects, and financial implications of commonly used medications such as glucocorticoids, mycophenolate mofetil (MMF), cyclophosphamide, calcineurin inhibitors and Rituximab. Immunosuppressive treatments, while effective in controlling disease activity, can result in a variety of adverse effects ranging from gastrointestinal symptoms and bone marrow suppression to increased infection risks, necessitating careful monitoring and dose adjustments to mitigate these risks. Hence, the need for a balanced approach in therapy management, incorporating regular monitoring and potential dose modifications to enhance patient outcomes while minimizing side effects. Additionally, these treatments have an economic impact, particularly in lower-income regions where access to medication and the cost of medication can limit patient outcomes. There have been certain advancements in treatment modalities, such as the use of enteric-coated formulations and tailored dosing schedules, which aim to improve drug tolerability and adherence. By addressing these critical aspects, we aim to shed light on the ongoing challenges and developments in the management of glomerular diseases, emphasizing the need for continued research and innovation in therapeutic strategies to reduce the overall treatment burden and improve the quality of life for affected individuals.