BMC Nephrology最新文献

Background: The impact of protein-bound uremic toxins, specifically indoxyl sulfate (IS) on peritoneal dialysis (PD) complications remains controversial. This study aimed to explore the link between serum total IS (tIS) levels, proinflammatory cytokines in serum and peritoneal dialysis effluent (PDE), and PD technique survival.

Methods: In this prospective cohort study, 84 patients were followed up for three years and analyzed. Stratification into low-tIS (< 22.6 µmol/L) and high-tIS (≥ 22.6 µmol/L) groups was based on the median serum tIS concentration. Logistic regression, Kaplan-Meier, receiving operation characteristic, and Cox regression analyses assessed associations between tIS levels, cytokine concentrations (IL-6, MCP-1, TNF-α), and PD technique failure.

Results: Patients in the high-tIS group were older and had a higher prevalence of diabetes, a greater incidence of PD-related peritonitis, elevated diastolic blood pressure, and lower HDL cholesterol compared to those in the low-tIS group. They also exhibited higher peritoneal transport characteristics, lower dialysis adequacy, and reduced peritoneal creatinine clearance. Elevated tIS levels significantly correlated with higher PDE cytokine levels, without a corresponding rise in serum cytokine levels. Serum tIS levels ≥ 50 µmol/L predicted PD technique failure with 70.4% sensitivity and 87.9% specificity (p < 0.0001). The association between high tIS levels and PD technique failure remained significant after adjusting for confounders identified in logistic regression, including peritoneal weekly creatinine clearance, the D/P creatinine ratio, high peritoneal transport status, and PDE IL-6 and MCP-1 concentrations (HR 2.9, 95% CI 1.13; 8.21).

Conclusion: Our findings are the first to demonstrate a link between elevated tIS levels, peritoneal inflammation, and an increased risk of PD technique failure. Monitoring tIS levels in PD patients could be clinically relevant for risk assessment and personalized management, potentially improving long-term PD outcomes. Future research should explore interventions targeting tIS reduction to alleviate peritoneal inflammation and improve PD prognosis.

Background: The prevalence of chronic kidney disease (CKD) is increasing, reflecting the rising incidence of chronic diseases. With the continuous growth of the global geriatric population, a significant portion of individuals with CKD consists of those aged over 65. Regardless of the chosen treatment method, protein-energy loss in patients undergoing renal replacement therapy (RRT) has been associated with elevated morbidity and mortality rates.

Methods: This is a retrospective, single-center study of incident adult PD patients on peritoneal dialysis (PD) from 1998 to 2022. We aimed to compare the survival outcomes of geriatric patients on PD with changing BMI measurements.

Results: In the geriatric patient group exhibiting a reduced BMI after dialysis initiation, BMI significantly and negatively influenced survival (p = 0.01). The negative effect of BMI on survival was independent of known risk factors such as diabetes mellitus, a history of cardiovascular disease, gender, residual renal function, and history of hemodialysis before peritoneal dialysis (HD before PD) (p = 0.04).

Conclusion: Although BMI is easy and extensively measured, it is not considered the perfect monitoring parameter for dialysis patients. However, regular follow-up of BMI, especially in geriatric cases, can be a guiding tool for estimating patients' prognoses.

Background: To compare the efficacy and safety of rituximab (RTX), calcineurin inhibitor (CNI) and cyclophosphamide (CTX) plus glucocorticoids in the treatment of primary membranous nephropathy (PMN).

Methods: Totally 478 biopsy-proven PMN patients in single center were retrospectively included. After 1:1 propensity score matching (PSM), 258 patients were included in RTX, CNI or CTX group (86 patients in each group).

Results: After PSM, there were no differences on serum creatinine, eGFR, serum albumin, urine protein, anti-PLA2R antibody levels among groups. The follow-up duration was 12 (10.5, 18) months in CNI group, 12 (12, 18) months in CTX group and 12 (12, 18) months in RTX group. Throughout entire follow-up period, 39 patients (45.3%) in CNI group, 47 patients (54.7%) in CTX group, and 59 patients (68.6%) in RTX group achieved total remission (TR, either complete remission or partial remission). The survival curve showed a higher rate of TR in RTX group than CNI group (p = 0.018). A relapse occurred in 15 of 39 (38.5%) patients in CNI group, significantly higher than CTX group (4.3%, p < 0.001) and RTX group (3.4%, p < 0.001). In CNI group, 36% patients had a ≥ 25% decline in eGFR.

Conclusions: RTX may be more effective than CNI in inducing remission in PMN and showed similar efficacy to CTX. CNI may have a high risk of proteinuria relapse and eGFR decline.

Background: POEMS syndrome with polyneuropathy, organomegaly, endocrinopathy, M protein, and skin changes is an uncommon plasma cell paraneoplastic syndrome involving multiple system. It is relatively rare in clinical practice, and renal involvement is a usual yet easily overlooked symptom.

Case presentation: We successfully treated a patient with M protein-negative POEMS syndrome with membranoproliferative glomerulonephritis (MPGN) findings and thrombotic microangiopathic changes by comparing the level of Vascular endothelial growth factor (VEGF) in the serum and the changes in polyserositis before and after the patient's treatment.

Conclusion: POEMS syndrome clinically involves multiple systems and has complex symptoms. Because of the diversity of the disease manifestations, identification of atypical POEMS syndrome and timely intervention are important for patient survival and prognosis.

Post-transplant diabetes mellitus (PTDM) is a common complication following renal transplantation, and its incidence has been gradually increasing in recent years, posing a significant public health challenge. Managing PTDM is complex, as studies suggest that it involves changes in the microbial flora across multiple organs. Recent research highlights the critical role of gut flora metabolism in the development of diabetes among post-renal transplant patients. This paper reviews the alterations in gut flora observed in PTDM patients and explores how gut flora influences PTDM. These findings may offer new perspectives on targeting gut flora metabolites for the prevention and treatment of PTDM.

Background: The renal renin-angiotensin system (RAS) plays a vital part in the control of blood pressure and is known to be affected by aging. This study aimed to investigate the effects of intermittent fasting on age-related hypertension and the expression of local renal RAS components.

Methods: The Wistar rats were categorized into three main age groups (young, middle aged, and elderly) and three dietary treatment models, including ad libitum feeding (AL), every other day fasting (EOD), and one day per week of fasting (FW). After three months, blood pressure (BP) was assessed. Some genes and proteins of the renal RAS system were measured by using Real time PCR and Western blot. α-klotho and Ang II proteins were assessed by ELISA method.

Results: Old rats exhibited significantly increase in BP and Ang II (P < 0.001 vs. young rats) and a significant reduction in circulating levels of α-klotho and kidney AT2R protein (P < 0.001, P < 0.01, vs. young rats, respectively). Additionally, they respond to aging by increasing the AT1aR/AT2R proteins ratio (P < 0.05). Two model of feeding reduced BP in old rats and circulating Ang II in middle-aged and older rats. Moreover, by fasting, ACE2 protein expression was elevated in old rats. EOD fasting also significantly elevated the AT2 receptor protein and reduced the AT1aR/AT2R proteins ratio in the older rats (P < 0.001, P < 0.01, respectively).

Conclusion: Our findings suggest that fasting, particularly EOD, can attenuate age-related hypertension, partly through reset of the local renal RAS and increase of klotho protein expression.

Background: Contrast-induced acute kidney injury (CI-AKI) is a known complication after coronary angiography (CAG) or percutaneous coronary intervention (PCI). Clinical evidence suggests that trimetazidine (TMZ), an anti-ischemic drug, may prevent CI-AKI. We aimed to evaluate the role of trimetazidine in preventing CI-AKI in patients with pre-existing renal dysfunction undergoing CAG or PCI.

Methods: We searched PubMed, Cochrane Library, EBSCOhost, Web of Science, and Google Scholar databases from January 2004 to January 2024. We reviewed RCTs involving participants aged ≥ 18 years with pre-existing renal insufficiency who underwent CAG or PCI. Outcomes should include the incidence of CI-AKI, adverse events, and changes in serum creatinine (Scr) levels at different time intervals. Two reviewers independently extracted the data, evaluated the quality and relevance of the studies, and graded the strength of evidence for each study through consensus.

Results: Nine RCTs met the inclusion criteria and assessed the role of TMZ in patients with renal dysfunction who underwent CAG or PCI. All RCTs showed a significant decrease in the incidence of CI-AKI in the TMZ group compared to the control group (RR 0.36, 95% CI, [0.25, 0.52] P < 0.001). Changes in Scr at 24 h (SMD -0.33, 95% CI, [-0.56, -0.10], P = 0.01), at 48 h (SMD -0.27, 95% CI, [-0.46, -0.09], P = 0.01), and 72 h (SMD -0.32, 95% CI, [-0.56, -0.07], P = 0.01) were statistically significant in the TMZ group compared to the control group. However, the changes in Scr beyond 72 h following CAG or PCI were statistically insignificant in the TMZ group when compared to the control group (SMD -0.22, 95% CI, [-0.52, 0.09], P = 0.16). The incidence of adverse effects was lower in the TMZ group than in the control group, and the difference was statistically significant (RR 0.51, 95% CI, [0.29, 0.90]; P = 0.02).

Conclusion: The addition of TMZ to standard hydration protocols may offer a promising strategy for lowering the incidence of CI-AKI, adverse events, and postoperative SCr levels in patients with renal insufficiency within 72 h after CAG or PCI. However, large-scale RCTs are necessary to definitively establish the efficacy and safety of TMZ in patients with renal insufficiency after CAG or PCI.

Background: Although Proton pump inhibitors (PPIs) were mostly prescribed for gastrointestinal (GI) disease widely, there were numerous studies about PPIs and adverse renal outcome. Most evidence was to evaluate the risk of PPIs in patients with normal renal function and in the absence of the moderate to advanced chronic kidney disease (CKD). This study focuses on the accelerated progression of renal function following proton pump inhibitors (PPIs) use, and the increased risks of acute kidney injury (AKI) among moderate to advanced CKD (pre-ESRD) patients.

Patients and methods: A retrospective cohort study was conducted by including adult patients with chronic kidney disease (CKD) stages 3b to 5 who initiated PPI or H2 blocker (H2B) therapy between 2011 and 2018. The risk of renal events was assessed using the Cox proportional hazard model to estimate the adjusted hazard ratio (HR) and 95% confidence interval (CI). Sensitivity analyses were performed, including propensity score matching, as-treated analysis, and subgroup analysis.

Results: The cohort comprised 83,432 pre-ESRD patients, with 5,138 treated with H2B and 1,051 with PPIs. The progression to ESRD was significantly more likely in patients using PPIs compared to those using H2B (adjusted HR, 1.495; 95% CI: 1.198-1.867). Specifically, omeprazole (adjusted HR, 1.784; 95% CI: 1.079-2.951) and esomeprazole (adjusted HR, 1.847; 95% CI: 1.332-2.561) were associated with a notably higher risk of ESRD and AKI.

Conclusions: The study highlights the significance of the accelerated renal risk, especially for moderate to advanced CKD patients, when prescribing PPIs and to implicate the clinicians prescribed PPIs and H2B in pre-ESRD patients.

Objective: Metabolic dysfunction-associated fatty liver disease (MAFLD) has been used to characterize patients with fatty liver and metabolic dysfunction. The association between MAFLD and chronic kidney disease (CKD) remains undefined. We present high-quality evidence obtained from cohort studies examining if MAFLD leads to an increased risk of CKD.

Methods: PubMed, CENTRAL, Embase, Scopus, and Web of Science were searched from the earliest possible date to 17th May 2024 for cohort studies examining the link between MAFLD and CKD.

Results: Eight studies with nine cohorts were included. Pooled analysis of all nine cohorts showed that MAFLD was an independent predictor of CKD (HR: 1.38 95% CI: 1.24, 1.53 I² = 95%). No change in results was noted on sensitivity analysis. We also noted no change in the significance of effect size on subgroup analysis based on study design (prospective or retrospective), country of origin (China, Korea, Japan, or UK), the incidence of CKD in the cohort (> 10% or ≤ 10%) and if the study adjusted for cardiovascular disease, diabetes, hypertension, and smoking status. Further, meta-analysis showed that MAFLD was still a risk factor for CKD in men (HR: 1.38 95% CI: 1.22, 1.56 I² = 86%), women (HR: 1.51 95% CI: 1.25, 1.82 I² = 87%), overweight (HR: 1.41 95% CI: 1.20, 1.66 I² = 89%) and non-overweight cohorts (HR: 1.35 95% CI: 1.20, 1.53 I² = 9%).

Conclusion: MAFLD is an independent predictor of CKD. The association seems persistent irrespective of sex, body mass index, and other CKD risk factors.

Background: Cognitive impairment is common in haemodialysis patients with no known beneficial interventions. Cooler dialysate slows brain white-matter changes, but its effect on cognition is unknown. This feasibility trial was performed to inform a fully-powered, randomised trial to assess this.

Methods: We aimed to randomise (1:1) 90 haemodialysis patients to this double-blinded, randomised controlled feasibility trial to standard care (dialysate-temperature 36.5 °C) or intervention (35 °C). Eligible patients were adult chronic haemodialysis recipients with no established diagnosis of dementia or psychiatric disease. The primary outcome was change in Montreal Cognitive Assessment (MoCA) score at 12-months. Secondary outcomes included recruitment and attrition rates, reasons for non-recruitment, intradialytic hypotension, depression, patient burden, computerised cognition test battery, and quality of life.

Findings: Of 334 patients screened, 160 were eligible. 99 declined mainly for the extra non-dialysis day study visits. Sixty-one patients consented, 43 randomised - 20 in standard care, 23 in intervention arms; 13 withdrew for non-dialysis day visits and 5 without reason before randomisation. 27 patients (12 standard care, 15 intervention) completed the trial - 5 died, 1 transplanted, 4 withdrew consent, and 6 could not attend due to the pandemic. Low temperature dialysis was well tolerated. There was no difference in change in MoCA from baseline to 12 months between the standard and intervention arms; 1.0 (-2.8-3.0, p = 0.755) and - 2.0 (-1.0 - -4.0, p = 0.047) respectively. There were no differences between groups on any secondary measures. There were no significant adverse events reported.

Discussion: The trial was significantly affected by the COVID-19 pandemic contributing to an attrition rate of 27%. The non-dialysis day research visits were mainly responsible for low recruitment and consent withdrawal. There are several learning points, described in the article, which will inform design of definitive trials in this area in the future.

Trial registration: ClinicalTrials.gov Identifier NCT03645733. Registration date 24/08/2018.