World journal of nephrology最新文献

Sodium-glucose cotransporter-2 (SGLT2) inhibitors suppress glucose reabsorption in the kidney proximal tubule through the SGLT2 protein, leading to glucosuria and osmotic diuresis. Randomized placebo-controlled clinical trials show that SGLT2 inhibitors increase long-term estimated glomerular filtration rate (GFR), calculated with serum creatinine-based equations. However, this effect of SGLT2 inhibitors may not reflect an improvement of kidney function. Investigations conducted in healthy volunteers and patients with chronic kidney disease and population-based studies reveal a positive association between urinary osmolality and GFR, either measured or estimated, indicating that glucosuria and osmotic diuresis are associated with glomerular hyperfiltration. Further, glomerular hyperfiltration is magnified by animal meat consumption. Therefore, the elevation of estimated GFR observed in patients receiving SGLT2 inhibitors may represent an adaptive response to glucosuria and osmotic diuresis driven by these drugs rather than an improvement of kidney function. Additionally, SGLT2 inhibitors have been consistently associated with loss of skeletal muscle mass. Reduction of muscle mass lowers serum creatinine. Serum creatinine-based equations to evaluate GFR overestimate kidney function in patients with reduced muscle mass. In patients receiving SGLT2 inhibitors, estimation of GFR using serum creatinine formulas may yield misleading high values of GFR that do not reflect a beneficial effect on kidney function.

Point-of-care ultrasonography (POCUS) is increasingly recognized as a valuable extension of the physical exam, offering real-time bedside insights to support clinical decision-making. In nephrology, lung ultrasound (LUS) is gaining prominence for its ability to assess extravascular lung water and guide fluid management, especially in patients with end-stage renal disease. This narrative review highlights current applications, technical aspects, and limitations of LUS in nephrology. Studies such as the Lung Water by Ultrasound-Guided Treatment in Haemodialysis Patients trial indicate that LUS-guided ultrafiltration may help improve blood pressure control, reduce pulmonary congestion and acute heart failure events in dialysis patients. Simplified approaches like the 8-zone protocol have shown diagnostic accuracy comparable to the traditional 28-zone method, improving feasibility in clinical practice. Nonetheless, limitations exist, including reduced specificity in non-cardiogenic lung conditions and under recognition of right-sided congestion when used in isolation. A comprehensive hemodynamic assessment requires integrating LUS with inferior vena cava ultrasound, focused cardiac ultrasound, and venous Doppler. Successful implementation depends on structured training and an understanding of potential interpretation challenges. Looking ahead, streamlined protocols, multimodal integration, and standardized training will be key to establishing POCUS as a core tool in nephrology.

Kidney transplantation remains the best treatment option for patients with end-stage kidney disease, offering superior outcomes and improved quality of life. However, as in the general population, cardiovascular disease remains the leading cause of mortality among kidney transplant recipients. While traditional cardiovascular risk factors-such as hypertension, diabetes, dyslipidemia, and tobacco use-are prevalent in this population, they are often compounded by transplant-specific and non-traditional risk factors unique to the post-transplant setting. This review aims to explore these non-traditional and transplant-related cardiovascular risk factors, including allograft dysfunction and acute rejection episodes. Moreover, we will provide an overview of the cardiovascular implications of immunosuppressive therapy, including its association with opportunistic infections such as cytomegalovirus. Finally, we will touch upon considerations for special populations of kidney transplant recipients based on our current understanding of these non-traditional cardiovascular risks with the currently available data.

Background: Laparoscopic nephrectomy is a preferred surgical approach due to its minimally invasive nature and faster recovery times. However, effective management of postoperative pain remains a significant challenge. Several traditional methods, including opioid-based analgesia, are commonly used but are associated with side effects such as nausea, vomiting, sedation, and delayed recovery. In recent years, the erector spinae plane block (ESPB) has gained attention as an ultrasound-guided regional anesthesia technique offering promising results in various surgical procedures by reducing opioid requirements and enhancing patient comfort.

Aim: To evaluate the efficacy and safety of ESPB in comparison to conventional pain management strategies in patients undergoing laparoscopic nephrectomy.

Methods: Following PRISMA guidelines, we searched PubMed, EMBASE, Web of Science, and the Cochrane Register for randomized controlled trials (RCTs) comparing ESPB with control for laparoscopic nephrectomy. The Cochrane Risk of Bias tool was employed for quality assessment. The primary outcome was total patient-controlled analgesia (PCA) consumption. Secondary outcomes included hospital discharge time and the incidence of postoperative nausea and vomiting. A random-effects meta-analysis was conducted to calculate pooled mean differences (MD) and odds ratios (OR) with 95%CIs.

Results: Nine RCTs involving a total of 643 patients (ESPB group = 320; control group = 323) were included in the analysis. ESPB significantly reduced PCA opioid consumption compared to controls (MD: -14.24, 95%CI: -20.66 to -7.83, P < 0.0001). Subgroup analysis showed reduced PCA use with ESPB vs morphine (MD: -8.78, 95%CI: -15.34 to -2.22, P = 0.009), and a non-significant effect compared to other analgesics (MD: -48.26, 95%CI: -143.60 to 47.09). No statistically significant differences were observed in discharge time or the incidence of nausea and vomiting.

Conclusion: ESPB demonstrates the potential of reducing PCA in laparoscopic nephrectomy patients; however, its impact on secondary outcomes remains inconclusive. Large-scale RCTs are needed to confirm ESPB's benefits and explore long-term effects.

Background: Percutaneous nephrolithotomy (PNL) is the standard treatment for medium-sized and large kidney stones. Many potential complications of PNL may warrant hospital readmission (HR) after discharge, threatening patient safety and increasing the costs.

Aim: To estimate the rate of unplanned HR after PNL and identify its urological and nursing-related predictors.

Methods: One hundred sixty-one patients were prospectively studied for HR after PNL from April 2022 to December 2022. The relevant urological and nursing-related characteristics of patients with and without unplanned HR after PNL were studied for association with HR, using univariate and multivariate analyses. Variables such as the demographic characteristics, comorbidities, laboratory and imaging characteristics, dietary status, operative time, number of kidney punctures, blood loss, urinary tract infections, and the receipt of instructions for catheter care and activities of daily living were included. A risk score was created.

Results: The mean age of patients with HR (44.4 ± 12.7 years) and without HR (43.9 ± 12.6 years) was similar (P = 0.847). The overall stone-free rate was 88.8%. The total complication rate was 32.3% (52 patients), and the highest grade was IIIa, according to the modified Clavein grading system, resulting in an HR rate of 22.4%. History of preoperative pyuria (P = 0.001), hydronephrosis (P = 0.001) and mean stone size (P = 0.012), multiple renal punctures (P < 0.001), double J stent (P = 0.033), total operative time (P = 0.001), intraoperative injury (P = 0.011), postoperative urinary tract infection (P < 0.001), and inadequate instructions for urethral catheter (P = 0.001) and activity daily living (P = 0.048) were significantly associated with HR after PNL. On multivariate analysis, only preoperative pyuria (P = 0.004), intraoperative injury (P = 0.001), and inadequate instructions on urethral catheter care (P = 0.035) were associated with HR. The risk score of the independent predictors was 0-17; 0-4 (low risk), 5-9 (moderate risk), and 10-17 (high risk).

Conclusion: The rate of unplanned HR after PNL was relatively high (22.4%). The presence of pus cells in the preoperative urine analysis, intraoperative injury, and receiving inadequate instructions on urethral catheter care were independent predictors of HR after PNL. Combined studying of the urological and nursing-related predictors may promote the implementation of enhanced recovery protocols after PNL.

Background: Tacrolimus is a key immunosuppressive agent used to prevent allograft rejection in kidney transplant recipients. Due to its narrow therapeutic index, careful monitoring is essential to avoid adverse effects, particularly neurotoxicity and nephrotoxicity. Hepatic metabolism is an important part of tacrolimus pharmacokinetics. This case report highlights the impact of liver resection on tacrolimus pharmacokinetics in a kidney transplant recipient.

Case summary: A 61-year-old male with end-stage kidney disease underwent a living-unrelated donor kidney transplant at age 46 and has maintained a stable tacrolimus regimen for 15 years. He was later diagnosed with hepatocellular carcinoma and underwent an open wedge liver resection. Despite stable preoperative tacrolimus levels, he developed acute kidney injury and neurotoxicity (manifested as new-onset tremors and headache) postoperatively. Tacrolimus levels rose from 3.4 ng/mL before surgery to 19.5 ng/mL postoperatively, despite no changes in dosage. This increase was most likely due to reduced liver mass and function following resection, in addition to ischemic injury of the remaining liver parenchyma, leading to impaired drug metabolism and acute toxicity. Liver function tests showed transient abnormalities postoperatively, with transaminase levels peaking at 30 times the normal range before gradually returning to normal, coinciding with the decline in tacrolimus levels. The patient's symptoms and acute kidney injury improved as tacrolimus concentration returned to normal.

Conclusion: This is the first reported case of acute tacrolimus neurotoxicity and nephrotoxicity in a kidney transplant recipient following liver resection. It highlights the critical need for vigilant therapeutic drug monitoring of tacrolimus after liver surgery to prevent severe adverse effects.

Urinary tract infections (UTIs) are the most common bacterial infections. Escherichia coli is the most common cause of UTIs, accounting for 50% of hospital-reported and 90% of community-reported cases. Also, this includes species of Klebsiella, Proteus, Acinetobacter, Pseudomonas, Staphylococcus, Streptococcus, and Enterococcus. Patients experience cystitis, polyuria, and dysuria. If untreated, this affects the kidneys, further leading to septicemia. UTIs majorly affect adult females (40%-60%). Microbiological culture has been proven to be the standard method. However, it takes 48-72 hours for the tests to be reported. In cases of recurrent UTI, it is mandatory to have a quick, sensitive, and specific diagnostic procedure. Dipstick tests are considered early methods for diagnosing UTIs; however, they have limitations. Recently, biomarkers are being used to assess the severity of the disease. To achieve the United Nations Sustainable Development Goals 3 and 8, the expertise from General Medicine, Biotechnology, and Microbiology come together in achieving the set targets by 2030. In addition to diagnosis of UTI, resistance to antibiotics should not be neglected. This review aimed to examine the clinical relevance of biomarkers such as neutrophil gelatinase-associated lipocalin, kidney injury molecule-1, interleukin (IL) 6, IL-8, heparin-binding protein, procalcitonin, lipopolysaccharide-binding protein, xanthine oxidase, cell-free DNA, and transrenal DNA.

Background: Background diabetic nephropathy (DN), a major complication of diabetes, is linked to gut microbiota dysbiosis. Elevated trimethylamine N-oxide (TMAO), a microbiota-derived metabolite, plays a central role in inducing renal injury during DN pathogenesis.

Aim: To investigate the role of TMAO in renal dysfunction and intestinal microbiota alterations associated with DN, hypothesizing that TMAO exacerbates renal injury and fibrosis through gut microbiota-dependent mechanisms.

Methods: A DN model was successfully established using Zucker diabetic fatty (ZDF) rats. Blood samples were analyzed for renal function parameters, and serum TMAO levels were quantified via high-performance liquid chromatography-tandem mass spectrometry. Renal tissue morphology and fibrosis were assessed using hematoxylin and eosin and Masson staining, respectively. Additionally, 16S rRNA sequencing was employed to profile fecal bacterial communities in rats with diabetes and DN. Fecal microbiota transplantation was conducted to verify alterations in TMAO production capacity in the gut microbiota of DN rats.

Results: After 8 weeks of modeling, the ZDF rat model group exhibited blood glucose levels surpassing 16.7 mmol/L, and compared to the control group, renal function indicators, including β2-microglobulin, cystatin C, uric acid, and creatinine, were significantly elevated (P < 0.05). Renal fibrosis was more pronounced in the ZDF model group, accompanied by heightened P-smad3 expression, in contrast to the TMAO inhibition group. Although Masson staining results did not reach statistical significance (P > 0.05), notable alterations in intestinal flora structure were observed in DN rats, and fecal microbiota transplantation led to increased TMAO production within the intestinal flora of DN rats compared to controls (P > 0.05).

Conclusion: DN is associated with gut microbiota alterations that potentiate TMAO generation, contributing to renal injury and fibrotic progression. While TMAO's role in fibrosis warrants further validation, these findings implicate the gut-kidney axis in DN pathogenesis.

Left ventricular diastolic dysfunction is frequently noticed in patients with chronic kidney disease. Echocardiography is used to determine the presence and severity of diastolic dysfunction. In left ventricular diastolic dysfunction the ventricular diastolic distensibility, filling or relaxation is abnormal; however, the left ventricular ejection fraction may be normal or decreased. In heart failure with preserved ejection fraction, the patients have symptomatic pulmonary congestion even though the systolic ejection fraction is more than 50%. This condition is commonly associated with ventricular diastolic dysfunction. Increased incidence of major adverse cardiovascular events has been reported in surgical patients having grade III diastolic dysfunction. Peri-operatively haemodynamic instability and fluid overload in this set of patients is known to generate pulmonary oedema.

Background: Immunoglobulin A nephropathy is a leading cause of primary glomerulonephritis globally. Predicting disease progression using clinical markers alone is often inadequate. Integrating the Oxford classification may enhance kidney survival predictions, though its relevance in Pakistan remains unexplored.

Aim: To determine the correlation between MEST-C scores and clinical parameters, as well as their utility in predicting long-term kidney outcomes.

Methods: A retrospective analysis was conducted on biopsy-confirmed immunoglobulin A nephropathy cases diagnosed from 1998 to 2019 at the Sindh Institute of Urology and Transplantation, with a minimum follow-up of 12 months.

Results: Among 118 patients (mean age: 29.03 ± 10.58 years), median proteinuria was 2.13 g/day, and mean estimated glomerular filtration rate (eGFR) was 67.82 ± 44.60 mL/minute/1.73 m². Upon admission, 26.4% required kidney replacement therapy. Oxford classification components (E1, T1/T2, C1/C2) were significantly linked to proteinuria and eGFR decline (P = 0.00). Remission rates were 79.6%, 77.9%, 77.1%, 49.3%, and 33.3% at 6 months, and at 1 year, 2 years, 5 years, and 10 years, respectively. End-stage kidney disease progression increased over time, reaching 20.3%, 22%, 22.8%, 31.3%, and 33.8% at 6 months, 1 year, 2 years, 5 years, and 10 years, respectively. Three (2.5%) patients died. The median follow-up was 3.5 years; kidney survival rates were 79.6%, 77.9%, 77.1%, 49.3% and 33.3% at 6 months and at 1 year, 2 years, 5 years, and 10 years, respectively. Higher MEST-C scores and lower baseline eGFR were associated with poorer kidney survival (log-rank P = 0.00), while no significant correlation was observed with the degree of proteinuria (log-rank P = 0.26).

Conclusion: The E1, T1/2, and C1/C2 components of the MEST-C score showed strong correlations with baseline clinical markers. Delayed diagnosis has led to poor long-term kidney outcomes.