BMC Nephrology最新文献

Background: Post-operative acute kidney injury (AKI) remains a major complication in paediatric surgery. Serum creatinine is an insensitive marker, that increases only after significant impairment. Neutrophil gelatinase-associated lipocalin (NGAL) has emerged as an early biomarker capable of detecting tubular injury before functional decline. This study aimed to determine the incidence of clinical AKI and subclinical AKI in paediatric spine surgery using plasma NGAL levels and to evaluate the associations of intraoperative hypotension with kidney injury.

Methods: In this prospective single-centre study, 66 children (mean age 15.2 ± 1.7 years) who underwent elective posterior spinal instrumentation were enrolled. Plasma NGAL was measured after induction (T1, baseline), and subsequently at 6 and 24 h after induction (T2 and T3, respectively). Clinical AKI was defined by the KDIGO criteria. ROC analysis was used to determine NGAL cut-off values; patients with NGAL above the the cut-off but without KDIGO-AKI were classified as having subclinical AKI. Potential risk factors, particularly intraoperative hypotension, were analysed.

Results: Clinical AKI occurred in 12% of patients. The NGAL-T2 cut-off for AKI was 86 ng/mL (AUC = 0.817; sensitivity = 100%; specificity = 63.8%). Twenty-nine patients exceeded this cut off; 8 developed clinical AKI and 21 (31.8%) had subclinical AKI. In multivariable analyses, intraoperative hypotension exposure remained independently associated with kidney injury. Durations of MAP < 70 and < 65 mmHg were significantly longer in the clinical AKI and subclinical AKI groups than in the non-AKI group, whereas time spent below MAP < 60 mmHg was significantly prolonged only in the clinical AKI group compared with both the subclinical AKI and non-AKI groups.

Conclusions: Although 12% of the children developed clinical AKI, approximately one-third had subclinical AKI detectable only by NGAL. Plasma NGAL at the 6th hour demonstrated excellent sensitivity for predicting AKI, with a threshold of 86 ng/mL. Intraoperative hypotension was a major predictor, with a MAP < 70 mmHg linked to tubular damage whereas deeper hypotension (MAP < 60 mmHg) was linked to clinical AKI. This study is the first to define NGAL cut-off values and intraoperative MAP thresholds for postoperative AKI in paediatric non-cardiac surgery.

Background: This study aimed to evaluate the anatomical localization and distribution of parathyroid glands following total parathyroidectomy (TPTx) and bilateral cervical thymectomy (BCTx) in chronic hemodialysis patients with medically refractory secondary hyperparathyroidism (SHPT).

Methods: A retrospective study on 154 consecutive SHPT patients with a mean hemodialysis duration of 109.3 ± 63.3 months was conducted.The study focused on the distribution of parathyroid glands within defined anatomical zones identified during surgery. Preoperative imaging methods (ultrasound and technetium-99 m sestamibi scintigraphy) provided limited diagnostic value, successfully localizing glands in only 34.6% and 31% of cases, respectively. Intraoperative parathyroid hormone (iPTH) measurement was not performed in any patient undergoing TPTx and BCTx.

Results: Postoperative success was defined by the normalization of iPTH levels, with 76.6% of patients achieving normal iPTH levels on postoperative day one (mean: 12.2 ± 14.1 pg/mL). Persistent SHPT was identified in 36 patients, leading to five complementary parathyroidectomies. The study demonstrated that the anatomical zones defined for parathyroid gland localization are reliable, exhibiting higher accuracy compared to preoperative imaging.

Conclusions: The findings support the feasibility of achieving high success rates with TPTx for SHPT, even when preoperative diagnostic tools are limited or ineffective. Knowledge of parathyroid gland distribution within these anatomical zones can significantly assist endocrine surgeons, particularly those who approach this condition with hesitation.

Background: Pulmonary hypertension (PH) frequently complicates end-stage kidney disease, contributing significantly to cardiovascular morbidity and mortality. Some of the pathophysiologic effects of PH may persist even after kidney transplantation (KT). We investigated the association between pre-transplant PH and long-term major adverse cardiovascular events (MACE) after KT.

Methods: This retrospective cohort study included 468 adult KT recipients from an academic medical center between January 2015 and January 2024. We excluded patients who did not follow up at our institution and those with no adequate pre-transplant assessment of pulmonary artery (PA) pressures. Patients were stratified based on the presence of pre-transplant PH, defined as PA systolic pressure > 35 mmHg on echocardiography or mean PA pressure > 20 mmHg via right heart catheterization. The primary outcome was the occurrence of MACE after KT, defined as cardiovascular death, nonfatal myocardial infarction, stroke, or hospitalization for heart failure. Kaplan-Meier cumulative incidence curves and Multivariable Cox proportional hazards models were used.

Results: Of the 468 recipients who qualified for the study, 86 (18.4%) had pre-transplant PH. Over a mean follow-up of 54.7 ± 28.4 months, 89 patients (19.0%) experienced MACE. The incidence of MACE was significantly higher in the PH group at one- (8.1 vs 2.9%, p = 0.03) and five-year (22.0 vs 11.0%, p = 0.01). After adjusting for age, sex, and relevant confounders, PH remained independently associated with MACE (HR 2.15; 95% CI 1.25-3.70; p = 0.01).

Conclusions: In this retrospective single-center study, pre-transplant PH was independently associated with an increased risk for MACE following KT. These findings highlight the importance of identifying PH in KT candidates. Enhanced cardiovascular risk surveillance may be warranted in this population.

Trial registration: Not applicable as this is a retrospective cohort study.

Background: Patients undergoing hemodialysis (HD) experience reductions in cerebral blood flow (CBF) during treatment. It remains unclear whether these changes are more pronounced in individuals with arteriovenous fistula (AVF). The study aimed to quantify and compare cerebral and cardiovascular hemodynamic changes during HD sessions in patients with AVF versus those with high-flow catheters (CVC).

Methods: In this cross-sectional study, 25 AVF patients were matched to 25 CVC patients by age, sex, and HD vintage. CBF was measured using transcranial doppler ultrasound at 15, 120, and 240 min during a routine HD session. Cardiac output (CO) was estimated pre- and post-dialysis.

Results: All CBF parameters declined significantly during HD: peak systolic velocity of the middle cerebral artery decreased by 18 cm/s (p < 0.001), end-diastolic velocity of the middle cerebral artery by 8 cm/s (p < 0.001), and mean flow velocity of the middle cerebral artery (MFVMCA) by 12 cm/s (p < 0.001). Conversely, pulsatility and resistance indices progressively increased (+ 0.3, and + 0.07, respectively; p < 0.001 for both). The main determinant of CBF reduction was CO decline. Both access group exhibited MFVMCA reductions, more pronounced in the AVF (-30.6% vs. -22.4%, p = 0.17). Cognitive impairment (MoCA < 26) was present in 72% of patients and inversely correlated with age (r=-0.51, p < 0.001).

Conclusions: HD patients experience significant cerebral hemodynamic deterioration during treatment, irrespective of vascular access type, potentially contributing to the high prevalence of cognitive impairment.

Background: Amyloidosis is a group of heterogeneous diseases characterized by the deposition of amyloid fibrils in various organs and tissues. Membranous nephropathy (MN) is one of the most common causes of nephrotic syndrome in adults.

Case presentation: We report three cases of early-stage MN occurring concurrently with distinct types of renal amyloidosis: apolipoprotein A-I (AApoA-I) amyloidosis, leukocyte chemotactic factor 2 (ALECT2) amyloidosis, and monoclonal immunoglobulin light-chain (AL) amyloidosis. Each case represents a different pathogenic mechanism, therapeutic approach, and clinical prognosis.

Conclusions: These cases underscore the pivotal role of renal pathology in the accurate diagnosis of patients with coexisting amyloidosis and MN. Correct classification of renal amyloidosis is essential for guiding therapy and predicting outcomes. When amyloidosis coexists with MN or other potentially treatable renal diseases, therapeutic decisions should prioritize the condition with the greater potential for organ damage or the one most responsive to available treatment.