Novel pharmacological approaches to lowering blood pressure and managing hypertension

Hypertension is the leading cause of death globally, primarily due to its strong association with cardiovascular disease. The global prevalence of hypertension has surged over the past three decades, driven by rising rates of diabetes mellitus and obesity. Despite current antihypertensive therapies, only a small proportion of patients with hypertension achieve adequate blood pressure control, necessitating novel therapeutic strategies. In this Review we explore the challenges and emerging opportunities in hypertension management. Aprocitentan, a dual endothelin receptor antagonist, is the first agent from a novel class of antihypertensive drug to be licensed since 2007 and exemplifies innovative treatments on the horizon. Here we also address the complex factors contributing to poor hypertension control, including genetic influences, lifestyle factors, therapeutic inertia and poor patient adherence. We discuss the limitations of existing therapies and highlight promising new pharmacological approaches to hypertension management. Integrating these novel treatments alongside current pharmaceuticals combined with improved diagnostic and management strategies could substantially reduce the global burden of hypertension and associated cardiovascular disease.

Health-related quality of life and its predictors among chronic kidney disease patients: A hospital-based cross-sectional study

Chronic kidney disease (CKD) has a significant impact on the health-related quality of life (HRQoL) of affected individuals due to its progressive and disabling nature. The aim of this study was to evaluate the HRQoL and its predictors among CKD patients. A cross-sectional study was carried out at kidney foundation Hospital and research Institute at Dhaka, Bangladesh. Kidney Disease Quality of Life (KDQoL™ -36) questionnaire were used to measure the HRQoL of CKD patients. The study also used kidney-targeted KDQoL-36 Summary Score (KSS). Socio-demographic and medical records were also collected. Descriptive statistics, and multiple linear regression were performed. Out of 430 patients, 77.9% were in moderate to advanced stage of CKD. Patients aged, occupation, income, co-morbidities such as diabetes or hypertension, medication used, and serum hemoglobin were found significantly (p <0.05) associated at different stages of CKD. The mean domain scores of physical component summary (PCS), mental component summary (MCS), burden of kidney disease (BKD), effect of kidney disease (EKD), symptoms and problems of kidney disease (SPKD) subscales were 37.19, 45.94, 31.49, 63.95, and 73.35, respectively. The KSS was 63.24. The stage of CKD has been documented as an important predictor of HRQoL of all subscales of KDQoL-36 as well as KSS. The older age group also showed a clear link with a lower HRQoL in all subscales of KDQoL-36, except SPKD. In multiple linear regression analysis, stage of CKD, patients age, employment status and use of medication were found significant predictors of KSS. Further, higher levels of education, being married, absence of diabetes and heart disease were all independent predictors of a higher MCS. Whereas retirement, low duration of CKD and the use of three or more drugs strongly linked to worse scores of PCS. By addressing the determinants of poor HRQoL, healthcare providers can tailor treatment plans to better meet the needs of these individuals and ultimately enhance their overall well-being.

Association between self-reported sleep apnea and albuminuria among middle age and elderly population: Results from National Health and Nutrition Examination Survey

The prevalence of both obstructive sleep apnea (OSA) and albuminuria increase with advanced age. The data on the association between OSA and albuminuria in subjects with advanced age were limited. Hence, the present study aimed to assess the association between sleep apnea (SA) and albuminuria in middle age and elderly population. Data on participants with age ≥ 40 years during 2005 to 2008 and 2015 to 2020 National Health and Nutrition Examination Survey were analyzed. SA was evaluated based on the sleep questionnaire and albuminuria was assessed by albumin-to-creatinine ratio. The independent relationship between SA and albuminuria was explored by using multivariate logistic regression. A total of 13,902 subjects with 11,788 cases of normoalbuminuria and 2114 cases of albuminuria were included for data analysis. The proportion of albuminuria increased as SA severity aggravation. Univariate logistic analysis showed that frequently SA was positively associated with albuminuria (OR = 1.301, 95% CI = 1.089-1.547, P = .003). In multivariate logistic analysis, frequently SA was independently associated with increased risk of albuminuria after adjusting for confounding factors (OR = 1.309, 95% CI = 1.010-1.683, P = .039). The present study suggested that self-reported frequently SA was independently associated with increased risk of albuminuria in middle age and elderly population.

Association between triglyceride-glucose index and clinical outcomes among patients with chronic kidney disease: a meta-analysis

PURPOSE

To identify the relationship of triglyceride-glucose (TyG) index with clinical outcomes in chronic kidney disease (CKD) patients based on current available evidence.

METHODS

PubMed, EMBASE, Web of Science and CNKI databases were searched up to August 31, 2024. Primary outcome was the all-cause mortality. Secondary outcomes included the coronary artery disease (CAD) mortality, CKD progression, risk of severe coronary artery stenosis (SCAS), major adverse cardiovascular event (MACE), coronary artery calcification (CAC) progression, end-stage renal disease (ESRD), and nonalcoholic fatty liver disease (NAFLD). The hazard ratio (HR) and odds ratio (OR) with 95% confidence interval (CI) were combined to assess the predictive role of TyG index for above clinical outcomes among CKD patients. All statistical analysis was performed by STATA 15.0 version.

RESULTS

Twelve studies with 26,530 cases were included. Pooled results indicated that elevated TyG index was significantly related to increased risk for all-cause mortality (HR = 1.22, 95% CI: 1.13-1.31, P<0.001). Besides, high TyG index was also associated with the CAD mortality (HR = 1.19, 95% CI: 1.04-1.36, P = 0.011), occurrence of CKD progression (HR = 1.52, 95% CI: 1.36-1.70, P<0.001), SCAS (OR = 1.79, 95% CI: 1.13-2.83, P = 0.013), MACE (OR = 1.68, 95% CI: 1.11-2.54, P = 0.014), CAC progression (OR = 1.55, 95% CI: 1.06-1.76, P = 0.02), CAD (OR = 2.865, 95% CI: 1.681-4.885, P<0.001), ESRD (OR = 1.49, 95% CI: 1.12-1.99, P = 0.006) and NAFLD (OR = 4.903, 95% CI: 3.046-7.893, P<0.001).

CONCLUSION

High TyG index predicts poor clinical outcomes and might serve as a novel prognostic indicator among CKD patients. However, more studies are still needed to verify above findings.

Atrasentan in Patients with IgA Nephropathy

BACKGROUND

Patients with IgA nephropathy and severe proteinuria have a high lifetime risk of kidney failure. The efficacy and safety of the selective endothelin type A receptor antagonist atrasentan in reducing proteinuria in patients with IgA nephropathy are incompletely understood.

METHODS

We are conducting a phase 3, multinational, double-blind, randomized, controlled trial involving adults with biopsy-proven IgA nephropathy, a total urinary protein excretion of at least 1 g per day, and an estimated glomerular filtration rate of at least 30 ml per minute per 1.73 m2 of body-surface area. Patients were randomly assigned to receive atrasentan (0.75 mg per day) or matched placebo for 132 weeks. The primary outcome, assessed at a prespecified interim analysis of data from the first 270 patients in the main stratum, was the change in the 24-hour urinary protein-to-creatinine ratio from baseline to week 36; the change was estimated with the use of a repeated-measures model. (An exploratory stratum of patients who were receiving a sodium-glucose cotransporter 2 inhibitor were included in a separate analysis.) Safety analyses were based on adverse events across the entire main stratum.

RESULTS

A total of 340 patients were recruited into the main stratum. Among the first 270 patients in the main stratum (135 per trial group) who completed the week 36 visit, the geometric mean percentage change in the urinary protein-to-creatinine ratio relative to baseline was significantly greater with atrasentan (-38.1%) than with placebo (-3.1%), with a geometric mean between-group difference of -36.1 percentage points (95% confidence interval, -44.6 to -26.4; P<0.001). The percentage of patients with adverse events did not differ substantially between the two groups. Fluid retention was reported by 19 of 169 patients (11.2%) in the atrasentan group and in 14 of 170 (8.2%) in the placebo group but did not lead to discontinuation of the trial regimen. No apparent cases of cardiac failure or severe edema occurred.

CONCLUSIONS

In this prespecified interim analysis, atrasentan resulted in a significant and clinically meaningful reduction in proteinuria as compared with placebo in patients with IgA nephropathy. (Funded by Novartis; ALIGN ClinicalTrials.gov number, NCT04573478.).

Combination therapy as a new standard of care in diabetic and non-diabetic chronic kidney disease

Combination therapy, involving the use of multiple medications together, is becoming a new standard of care for chronic kidney disease (CKD). For people with CKD, combination therapy offers the promise of preventing kidney failure and reducing the risk of heart problems. This approach is appealing because different drugs target distinct mechanisms involved in CKD progression. For instance, some target immune responses, others reduce kidney inflammation and scarring, while others improve blood pressure within the kidneys. Data from large clinical trials suggest that each treatment works effectively on its own, regardless of other medications people are taking. Combining therapies can also reduce the risk of side effects of individual medications. This review highlights the evidence for combination therapy in CKD, explores how to improve its use, and discusses how future studies may answer remaining questions.

ABSTRACT

A range of therapies now exists to reduce the risk of kidney failure and cardiovascular events in people with type 2 diabetes, including renin-angiotensin system blockade, sodium-glucose cotransporter 2 (SGLT2) inhibitors, non-steroidal mineralocorticoid receptor antagonists, and glucagon-like peptide-1 receptor agonists. With multiple clinical trials underway, it is likely that at least some of these therapies-as well as additional agents such as endothelin receptor antagonists-will further demonstrate kidney-protective effects in people with CKD who do not have diabetes in the near future. For conditions such as IgA nephropathy, several therapies have recently been approved or are being evaluated in late phase trials. Thus combination therapy is emerging as a new standard for diabetic and non-diabetic chronic kidney disease (CKD). This approach is supported by randomized data suggesting that each therapeutic class offers independent and additive benefits in diabetic kidney disease, regardless of background therapy. Notably, the reduction in hyperkalaemia and fluid retention with SGLT2 inhibitors may enhance the tolerability and safety of other treatments. In this review, we present the rationale for combination therapy with evidence-based kidney therapies in diabetic and non-diabetic CKD. We also summarize randomized evidence supporting a multi-medicine approach, address safety considerations, review ongoing trials, and propose frameworks for implementing treatments aligned with patient risk to optimize person-centred care and reduce long-term risks of kidney failure and related complications.

Selective endothelin A receptor antagonism in chronic kidney disease: improving clinical application

Endothelin-1 (ET-1) is a peptide that is involved in various chronic diseases including cardiovascular and kidney disease. ET-1 can bind to two receptors, endothelin A (ETA) and endothelin B (ETB), which are found in different organs and tissues. When ET-1 binds to the ETA receptor, it causes blood vessels to narrow, while binding of ET-1 to the ETB receptor causes blood vessels to widen. These receptors help regulate fluid and electrolyte balance in the kidneys, as well as the kidney's ability to filter various substances out of the body. Overactivation of ET-1 can occur in people with diabetes or obesity, which can damage the structure and function of the kidney.Studies in mice and humans with kidney disease have shown that blocking the ETA receptor improves kidney health. As a result, medicines that specifically block the ETA receptor, known as endothelin receptor antagonists (ERAs), are a promising option for treating these kidney diseases. The first ERA (sparsentan) is now available for use in patients with immunoglobulin A (IgA) nephropathy, a specific type of kidney disease. It should be noted that ERAs can cause side effects. Fluid retention, which can increase the risk of heart failure, is a side effect that is particularly observed in patients with type 2 diabetes and severe kidney disease. This side effect is less often observed in patients with IgA nephropathy or patients without diabetes.Treatment strategies to optimize safe and effective use of ETA blockers are being developed. Overall, these insights offer hope for better care of patients with kidney disease.

ABSTRACT

Endothelin-1 (ET-1) is a 21-amino acid peptide involved in numerous cardiovascular and renal processes. ET-1 can bind to endothelin receptor A (ETA) and endothelin receptor B (ETB), which are found in various organs and tissues. In general, binding of ET-1 to the ETA receptor causes vasoconstriction, whereas activation of the ETB receptor leads to vasodilation. In the kidney, endothelin receptors regulate fluid and electrolyte balance, regional blood flow and glomerular filtration rate. In pathological conditions, ET-1 promotes kidney injury through adverse effects on the endothelial glycocalyx, podocytes and mesangial cells, and stimulating inflammation and fibrosis in the tubules. In experimental and clinical studies, inhibition of the ETA receptor has been shown beneficial in a variety of kidney diseases. These include diabetic kidney disease, immunoglobulin A nephropathy, focal segmental glomerulosclerosis and Alport syndrome. Accordingly, selective ETA endothelin receptor antagonists (ERA) may prove a viable therapeutic option in these diseases. However, clinical application is challenged by the occurrence of fluid retention which can lead to heart failure, in particular in patients with severe CKD. Concomitant use of sodium-glucose cotransporter 2 inhibitors (SGLT2i) may mitigate these adverse effects through their diuretic actions. The development of highly selective ETA antagonists, such as atrasentan and zibotentan, and the opportunities of combining these with SGLT2i, holds promise to optimize efficacy and safety of ERAs in clinical practice.

Design considerations for future renoprotection trials in the era of multiple therapies for chronic kidney disease

In the last 5-10 years, several large high-quality research trials testing new treatments versus a dummy treatment in patients with kidney disease have provided new discoveries, particularly among people with diabetes. Some of these trials included patients with a wide variety of kidney diseases and therefore provided important information on how effective the treatment is, and whether it is safe to use for many people (and not just those with a specific type of kidney disease). The findings are particularly important as they suggest that, once established, kidney disease progresses in similar ways regardless of the initiating cause. These new treatments importantly slow kidney disease progression but, even when used together, do not arrest the loss of kidney function. New research is still needed to test new potential treatments. Now that we have several drugs that can be used to treat kidney disease, there are new challenges when designing and conducting new trials. These include the reduced risk of kidney disease progression and heart disease (because of the new treatments available). Future research trials need to include a sufficiently large number of patients to be able to answer research questions reliably. In addition, different types of people and diseases should be included. In an age of increasing regulation and bureaucracy, conducting such trials is challenging. Simplifying the design and conduct of future trials by focusing only on the necessary components needed to answer the research key question(s) is important. Such trials reduce the burden of participation for patients and busy clinical staff, whilst still ensuring careful focus on patient safety and data quality. We hope more high-quality trials that are sufficiently large, inclusive and simple will be conducted in the future, so that kidney teams can offer better care to their patients.

ABSTRACT

Nephrology has benefited from conducting increasingly large high-quality trials in the last 5-10 years. In addition to the long-standing known benefits of renin-angiotensin system inhibitors, we now have multiple pharmacotherapies that provide kidney and/or cardiovascular protection for certain types of patient with chronic kidney disease (CKD). These include sodium-glucose co-transporter 2 inhibitors (SGLT2i), a non-steroidal mineralocorticoid receptor antagonist and a glucagon-like peptide-1 receptor agonist. Trials of SGLT2i have had particularly important impact, as wide eligibility criteria in pivotal trials have enabled safety and efficacy across a wide range of causes of CKD to be demonstrated. These findings support the concept of final common pathways of CKD progression and should encourage similar trial designs recruiting broad ranges of patients at risk of CKD progression. This is important as these new drugs do not completely arrest CKD progression nor do they mitigate the full excess of cardiovascular disease. In the current era of multiple therapies to manage risk of CKD progression, trial design and conduct also need to consider new challenges. These include falling event rates, establishing standard of care for participants pre-randomization and improving the inclusion of trial participants understudied in previous trials. Streamlining trial design and conduct and reducing participation burden for patients and clinicians is increasingly important to facilitate larger sample sizes and to optimize adherence to study interventions and follow-up. Potential other solutions include maintaining a focus on wide generalizability (to include understudied patient groups) and empowering patients to volunteer for trials (through public and patient involvement and large-scale invitation methods), as well as innovations in trial design (including use of pre-randomization run-in periods to implement standard of care and factorial or platform trials to assess multiple treatments simultaneously).

Atherogenic index of plasma and cardiovascular disease risk in cardiovascular-kidney-metabolic syndrome stage 1 to 3: a longitudinal study

Background

Cardiovascular disease (CVD) remains a major contributor to the global disease burden. Previous studies have established a link between the atherogenic index of plasma (AIP) and CVD. However, it remains unclear whether cumulative AIP and AIP control influence the future incidence of CVD in individuals with Cardiovascular-Kidney-Metabolic (CKM) syndrome. This study aims to explore the association between cumulative AIP, AIP control levels, and the risk of CVD in individuals with CKM syndrome from stages 1 to 3.

Methods

Participants with CKM syndrome were drawn from the China Health and Retirement Longitudinal Study (CHARLS). Cumulative AIP was calculated using triglycerides (TG) and high-density lipoprotein cholesterol (HDL-C), while AIP control levels were categorized into four groups via k-means clustering. CVD was defined by self-reported heart disease or stroke. Multivariable logistic regression and restricted cubic spline analysis were employed to examine the association between AIP and incident CVD in individuals with CKM syndrome.

Results

A total of 793 participants (18.84%) developed CVD. After adjusting for confounders, cumulative AIP were associated with the developing CVD (OR=1.139, 95% CI: 1.017-1.275, P=0.0245). Compared to group 1 (best AIP control), the OR (95% CI) for incident CVD were 1.278 (0.959-1.702) for group 2, 1.329 (1.076-1.641) for group 3, and 1.195 (0.974-1.465) for group 4. Restricted cubic spline regression indicated the relationship between cumulative AIP and CVD risk is linear (P for nonlinear = 0.3377).

Conclusions

In middle-aged and elderly individuals with CKM syndrome, higher cumulative AIP and poorer AIP control were associated with an elevated incidence of CVD. These findings suggest that enhanced assessment of the AIP index could inform targeted prevention strategies for CVD in the context of CKM syndrome.

Heart failure events in randomized controlled trials for adults receiving maintenance dialysis: a meta-epidemiologic study

BACKGROUND AND HYPOTHESIS

Heart failure is characterized as cardiac dysfunction resulting in elevated cardiac filling pressures with symptoms and signs of congestion. Distinguishing heart failure from other causes of similar presentations in patients with kidney failure is challenging but necessary, and is needed in randomized controlled trials (RCTs) to accurately estimate treatment effects. The objective of this study was to review heart failure events, their diagnostic criteria, and adjudication in RCTs of patients with kidney failure treated with dialysis. We hypothesized that heart failure events, diagnostic criteria, and adjudication were infrequently reported in RCTs in dialysis.

METHODS

We conducted a meta-epidemiologic systematic review of RCTs from high-impact medical, nephrology, and cardiology journals from 2000 to 2020. RCTs were eligible if they enrolled adults receiving maintenance dialysis for kidney failure and evaluated any intervention.

RESULTS

Of 561 RCTs in patients receiving dialysis, 36 (6.4%) reported heart failure events as primary (10, 27.8%) or secondary (31, 86.1%) outcomes. Ten of the 36 (27.8%) RCTs provided heart failure event diagnostic criteria and five of these (50%) adjudicated heart failure events. These 10 RCTs included event diagnostic criteria for heart failure or heart failure hospitalizations, and their criteria included dyspnoea (5/10), oedema (2/10), rales/crackles (4/10), chest X-ray pulmonary oedema or vascular redistribution (4/10), treatment in an acute setting (6/10), and ultrafiltration or dialysis (4/10). No study explicitly distinguished heart failure from volume overload secondary to non-adherence or underdialysis.

CONCLUSION

Overall, we found that heart failure events are infrequently reported in RCTs in dialysis and are heterogeneously defined. Further research is required to develop standardized diagnostic criteria that are practical and meaningful to patients and clinicians.

The road ahead: emerging therapies for primary IgA nephropathy

Primary IgA nephropathy (IgAN) is the most common form of primary glomerulopathy. A slowly progressive disease presenting in the young to middle-aged, most patients with reduced eGFR or proteinuria will progress to end-stage kidney disease (ESKD) in their lifetimes. The pathogenesis involves increased production of galactose-deficient IgA1 (Gd-IgA1) that forms immune complexes that deposit in the glomerulus, eliciting mesangial cell proliferation, inflammation, and complement activation. The backbone of therapy is supportive, including lifestyle modifications, strict blood pressure control, and renin-angiotensin system inhibition targeting proteinuria < 300 mg/day. Sodium-glucose transporter 2 inhibitors are indicated for persisting proteinuria or declining eGFR. Sparsentan is indicated for persisting proteinuria. Immunosuppression should be considered for all patients at risk for progression (persisting proteinuria and/or declining eGFR). To reduce Gd-IgA1 production, targeted-release budesonide is approved. Agents targeting B cell survival factors APRIL or BAFF/APRIL have significantly reduced Gd-IgA1 production and proteinuria in phase 2 trials but await phase 3 data for approval. To reduce inflammation, high-dose steroids are ineffective and toxic in Caucasian patients, although lower-dose regimens may be effective in Chinese patients. Complement inhibition is being actively studied. The factor B inhibitor iptacopan has conditional approval. The terminal pathway inhibitors cemdisiran and ravulizumab show promise in phase 2 studies. Our current approach for those requiring immunosuppression involves combining the reduction of Gd-IgA1 (nefecon) with suppressing the effects of inflammation (iptacopan). The optimal duration of such therapy is uncertain. Clearly, there is more to be learned with many trials underway.

Association Between a New Model of Insulin Sensitivity and Hypertension in Patients With Type 2 Diabetes: A Cross-Sectional Study

Type 2 diabetes (T2D) and hypertension often coexist, and insulin resistance (IR) plays an important role in their pathological progression. An increasing number of studies have focused on the relationship between different IR indices and hypertension. A natural log transformation of the glucose disposal rate (loge GDR) has been proposed as a new model for insulin sensitivity in patients with T2D. The study aimed to explore the relationship between loge GDR and hypertension in T2D patients. This cross-sectional study included 1544 Chinese T2D patients. Clinical and biochemical characteristics were collected. The loge GDR was calculated based on triglycerides, urinary albumin to creatinine ratio, gamma-glutamyl transferase, and body mass index. Patients were categorized into hypertension and nonhypertension groups stratified by gender. Among both females and males, compared with the nonhypertension group, the level of loge GDR was significantly decreased in the hypertension group (both p < 0.001). As the loge GDR increased, the levels of systolic and diastolic blood pressure, and the prevalence of hypertension were obviously increased (all p < 0.001). Univariate analysis displayed that loge GDR was negatively related to hypertension (correlation coefficient: -0.243, p < 0.001 in females; correlation coefficient: -0.181, p < 0.001 in males). Furthermore, the logistic regression analysis showed that loge GDR was independently associated with hypertension (OR: 0.456; 95% CI: 0.224-0.927 in females; OR: 0.544; 95% CI: 0.314-0.941 in males). This study revealed that loge GDR was closely related to hypertension, which might help monitor and manage hypertension in T2D patients.

Metabolite pathway alterations identified by magnetic resonance metabolomics in a proximal tubular epithelial cell line treated with TGF-β1

Tubulointerstitial fibrosis is a characteristic hallmark of chronic kidney disease (CKD). Metabolic perturbations in cellular energy metabolism contribute to the pathogenesis of CKD, but the chemical contributors remain unclear. The aim of this investigation was to use two dimensional 1H-nuclear magnetic resonance (2D-COSY) metabolomics to identify the chemical changes of kidney fibrogenesis. An in vitro transforming growth factor-β1 (TGF-β1)-induced model of kidney fibrogenesis with human kidney-2 (HK-2) proximal tubular epithelial cells (PTEC) was used. The model was validated by assaying for various pro-fibrotic molecules, using quantitative PCR and Western blotting. 2D-COSY was performed on treated cells. Morphological and functional changes characteristic of tubulointerstitial fibrosis were confirmed in the model; expression of fibronectin, collagen type IV, smooth muscle actin, oxidative stress enzymes increased (p < 0.05). NMR metabolomics provided evidence of altered metabolite signatures associated with glycolysis and glutamine metabolism, with decreased myo-inositol and choline, and metabolites of the oxidative phase of the pentose phosphate pathway with increased glucose and glucuronic acid. The altered PTEC cellular metabolism likely supports the rapid fibrogenic energy demands. These results, using 2D-COSY metabolomics, support development of a biomarker panel of fibrosis detectable using clinical magnetic resonance spectroscopy to diagnose and manage CKD.

Improved porosity promotes reendothelialization and smooth muscle remodeling in decellularized tissue-engineered vascular grafts

Decellularized tissue-engineered vascular grafts (dTEVGs) exhibit superior biocompatibility, anti-infection properties and repair potential, contributing to better patency and making them a more ideal choice for arteriovenous grafts (AVGs) in hemodialysis compared to chemically synthesized grafts. However, the unsatisfactory reendothelialization and smooth muscle remodeling of current dTEVGs limit their advantages. In this study, we investigated the use of elastase to improve the porosity of elastic fiber layers in dTEVGs, aiming to promote cell infiltration and achieve superior reendothelialization and smooth muscle remodeling. Our findings revealed that elastase treatment induced scattered cracks and holes in the elastic fiber layers of dTEVGs. Porous dTEVGs demonstrated increased cell infiltration in rat subcutaneous tissue. In the rat AVG models, mildly elastase-treated dTEVGs significantly improved cell infiltration and graft remodeling, including adequate smooth muscle cell (SMC) repopulation, impressive reendothelization and regeneration of the extracellular matrix, without stenosis, dilation or disintegration of the grafts. This study demonstrates that porous dTEVGs promote reendothelization, smooth muscle remodeling and extracellular matrix regeneration while retaining a stable graft structure, enhancing durability and puncture resistance in hemodialysis.

The Effect of Heparin on Bone Metabolism and Orthodontic Tooth Movement in Rats

OBJECTIVES

Various attempts have been made to increase the rate of orthodontic tooth movement (OTM). The aim of this study was to determine the effect of different doses of heparin on OTM and paraclinical factors related to bone metabolism in rats.

METHODS AND MATERIALS

A total of 24 Sprague-Dawley rats were randomly divided into three groups of 8 animals each and injected with 0 (control), 3000, and 6000 U/Kg/d heparin sulfate for 4 weeks. Radiographs were obtained at the initiation and at the end of the study period. Orthodontic forces were applied on Day 14 and continued for the next 2 weeks, after which, OTM, optical density, parathyroid hormone (PTH) level, and histologic variables were assessed for each rat. The latter was performed on hematoxylin/eosin-stained sections of the mesial roots of the first molar and included calculation of the osteoclast number, and resorption lacunae depth and number. One-way analysis of variance, the Tukey test, and a paired-t-test were used for statistical analysis (p < 0.05).

RESULTS

A significant increase in OTM, the number of resorptive lacunae, and PTH secretion was observed in the group that received 6000 U/Kg/d compared with both the other groups. There was no significant difference in optical density, and, therefore, bone density, among the study groups (p > 0.05).

CONCLUSION

Heparin injection affects bone metabolism in rats, as shown by the increases in OTM and PTH and its impact on histologic parameters. These effects seem to be dose-dependent and may be a factor that should be taken into consideration during orthodontic treatment planning.

The effect of the endothelin receptor antagonist atrasentan on insulin resistance in phenotypic clusters of patients with type 2 diabetes and chronic kidney disease

AIMS

Type 2 diabetes (T2D) patients with a clinical phenotype characterized by a high degree of insulin resistance are at increased risk of chronic kidney disease (CKD). We previously demonstrated that the endothelin receptor antagonist (ERA) atrasentan reduced insulin resistance in T2D. In this study, we compared the effect of atrasentan on insulin resistance across different phenotypic clusters of patients with T2D.

MATERIALS AND METHODS

We performed a post hoc analysis of the SONAR trial, a randomized, placebo-controlled trial of the ERA atrasentan in patients with T2D and CKD. Patients were stratified into four previously identified phenotypic clusters: severe insulin-deficient diabetes (SIDD), severe insulin-resistant diabetes (SIRD), mild obesity-related diabetes (MOD) and mild age-related diabetes (MARD). Changes in insulin resistance, assessed by HOMA-IR, were compared between the phenotypic clusters using a mixed effects model.

RESULTS

In total, 931 patients were included in the analysis. In the overall population, atrasentan compared to placebo reduced HOMA-IR by 12.9% [95%CI 3.5,21.4]. This effect of atrasentan was more pronounced in clusters characterized by insulin resistance or deficiency: (SIRD cluster 26.2% [95% CI 3.8,43.3] and SIDD cluster 18.5% [95%CI -3.8,35.9]), although the latter did not reach statistical significance. The effect of atrasentan compared to placebo was less pronounced in the other two clusters (MARD 12.2% [95% CI -1.7,24.12] and MOD -5.3% [95% CI -28.9,13.9]).

CONCLUSIONS

Atrasentan significantly improved insulin sensitivity in patients with T2D and CKD, especially in those characterized by high insulin resistance (SIRD cluster). Further studies are warranted to investigate the long-term clinical outcomes of atrasentan treatment in these distinct phenotypic clusters.

Targeted metabolomics identified novel metabolites, predominantly phosphatidylcholines and docosahexaenoic acid-containing lipids, predictive of incident chronic kidney disease in middle-to-elderly-aged Chinese adults

BACKGROUND

Evidence is limited regarding the association of circulating metabolites with decline of kidney function, letting alone their value in prediction of development of chronic kidney disease (CKD).

METHODS

This study included 3802 participants aged 64.1 ± 7.4 years from the Dongfeng-Tongji cohort, among whom 3327 were CKD-free at baseline (estimated glomerular filtration rate [eGFR] > 60 ml/min per 1.73 m2). We measured baseline levels of 211 metabolites with liquid chromatography coupled with mass spectrometry, including 25 amino acids, 12 acyl-carnitines, 161 lipids, and 13 other metabolites.

RESULTS

The mean (SD) absolute annual change in eGFR was -0.14 ± 4.11 ml/min per 1.73 m2 per year, and a total of 472 participants who were free of CKD at baseline developed incident CKD during follow-up of 4.6 ± 0.2 years (14.2 %). We identified a total of 22 metabolites associated with annual eGFR change and survived Bonferroni correction for multiple testing, including seven metabolites associated with eGFR increase (six being docosahexaenoic acid [DHA]-containing lipids) and 15 associated with eGFR decline (nine being phosphatidylcholines [PCs]). Among them, eight metabolites obtained non-zero coefficients in least absolute shrinkage and selection operator (LASSO) regression on incident CKD, indicating predictive potential, including one amino acid (arginine), one acyl-carnitine (C2), one lysophosphatidylcholine (LPC 22:6), two PCs (32:1 and 34:3), one triacylglycerol (TAG 56:8 [22:6]) and two other metabolites (inosine, niacinamide), and the composite score of these eight metabolites showed an odds ratio (OR) of 8.79 (95 % confidence interval [CI]: 7.49, 10.32; P < 0.001) per SD increase in association with incident CKD. The addition of the metabolite score increased the c-statistic of the reference model of traditional risk factors (including baseline eGFR) by 0.065 (95 % CI: 0.046 to 0.084; P = 3.39 × 10-11) to 0.765 (0.742 to 0.788) in 1000 repetitions of 10-fold cross-validation, while the application of two advanced machine learning algorithms, random forest (RF), and extreme gradient boosting (XGBoost) models produced similar c-statistics, to 0.753 (0.729 to 0.777) and 0.778 (0.733 to 0.824) with increases of 0.074 (0.055 to 0.093; P = 4.11 × 10-14) and 0.073 (0.032 to 0.114; P = 4.00 × 10-4), respectively.

CONCLUSIONS

In this study, we identified 22 metabolites associated with longitudinal eGFR change, nine of which were PCs and six were DHA-containing lipids. We screened out a panel of eight metabolites which improved prediction for the development of CKD by 9 % beyond traditional risk factors including baseline eGFR. Our findings highlighted involvement of lipid metabolism in kidney function impairment, and provided novel predictors for CKD risk.

Identification and Prioritization of Canadian Society of Nephrology Clinical Practice Guideline Topics

Introduction

Nephrology clinical practice guideline topics are routinely determined by clinicians and researchers, without extensive engagement of people with lived experience (PWLE) of kidney disease and their caregivers. The Canadian Society of Nephrology (CSN) Clinical Practice Guidelines Committee (CPGC) completed this modified Delphi study to incorporate diverse stakeholder perspectives in identifying and prioritizing future guideline topics.

Methods

We recruited nephrology clinicians, researchers, PWLE of kidney disease or their caregivers for this study. We collated literature-derived guideline topics from international and national guideline organizations that had relevance to nephrology, in addition to suggestions from participants. Consenting participants were taken through a 3 round Delphi survey process, where items were ranked on a 9-point Likert scale in terms of their importance. Based on predetermined consensus criteria, items were accepted as a priority or excluded from further consideration. We ranked the prioritized topics and compared the median ranking between clinicians or researchers and PWLE in the round where consensus was reached.

Results

Of the 85 consenting participants, 76 to 78 completed each Delphi round. From the initial list of 100 topics for consideration, 12 were priorities. All stakeholder groups felt it was important for PWLE to be included in topic prioritization and guideline development. The 3 most highly prioritized topics were de novo guidelines on novel therapeutics to prevent or slow progression of chronic kidney disease (CKD), recommendations for primary care, and patient-oriented guidelines on diet and exercise in kidney disease. There were no statistical differences in the median ranking between stakeholder groups (P > 0.05).

Conclusion

This study will inform the future nephrology guidelines and commentaries developed by the CSN.

Clinicopathological characteristics of patients with low titer anti-phospholipase A2 receptor antibodies verified by indirect immunofluorescence assay

OBJECTIVE

Laboratory extensively applied enzyme-linked immunosorbent assay (ELISA) to measure anti-phospholipase A2 receptor antibodies (PLA2R-abs) since its diagnostic significance on PLA2R related primary membranous nephropathy (PLA2R-related pMN) was discovered. However, PLA2R-abs determined by ELISA (PLA2R-ELISA) could infrequently yield inconclusive results, specifically a grey-zone defined as PLA2R-abs ranging from 2 to 20 RU/mL. Recently, researchers suggested that double-check grey-zone PLA2R-abs by indirect immunofluorescence (IIF) could improve diagnostic accuracy. We evaluated the diagnostic performance of PLA2R-IIF in assessing PLA2R-related pMN and summarized clinicopathological characteristics of grey-zone population to provide more evidence for clinical practice.

METHODS

Data on demographics, serology and pathology of patients with PLA2R-ELISA grey-zone results and a native kidney biopsy at Peking Union Medical College Hospital from September 2020 to April 2023 were reviewed. Grey-zone samples were analyzed using PLA2R-IIF. Negative results were defined as no fluorescence and positive results were graded according to fluorescence intensity.

RESULTS

This study included a total of 52 grey-zone patients divided into pMN group (n = 36, 69 %) and non-pMN group (n = 16, 31 %) according to renal pathology reports. The pMN patients had higher PLA2R-abs and lower serum creatinine compared to the non-pMN patients (P = 0.003, P < 0.001). No statistically significant differences were observed in 24-hour urine protein and albumin between the two groups. Multiple pathological types were identified in the non-pMN group. The sensitivity and specificity of PLA2R-IIF in PLA2R-ELISA grey-zone population were 72 % and 88 %, respectively, with a total consistent rate of 77 % and a positive predictive value of 93 %.

CONCLUSION

Both pMN and non-pMN patients presented grey-zone PLA2R-ELISA results. It was necessary to perform PLA2R-IIF to assist in the diagnosis of patients with PLA2R-ELISA grey-zone results.

Prevalence and Treatment Patterns of Anaemia in Individuals With Chronic Kidney Disease Across Asia: A Systematic Review and Meta-Analysis

AIM

Anaemia is a significant complication of chronic kidney disease (CKD). However, its prevalence and treatment patterns in Asia are poorly understood. We sought to quantify prevalence of anaemia and its treatment in people with CKD across the region.

METHODS

MEDLINE and Embase (inception to 2023) were systematically searched for observational studies of adults with CKD conducted in Asia that reported the prevalence of anaemia or its treatment. Additional relevant unpublished data were obtained from national experts. Summary estimates of the prevalence of anaemia and its treatment were determined using a random-effects meta-analysis according to country and study-specific CKD inclusion criteria.

RESULTS

Eighty-six studies from 10 Asian countries reported data on 1 342 121 participants. The overall prevalence of anaemia in individuals with CKD was 42% (95% CI 33%-52%), with wide variation (12%-57% in studies including all CKD stages; 21%-96% in studies limited to individuals with kidney failure). Anaemia prevalence progressively increased with more advanced CKD (80% in Stage 5). Studies reporting data on anaemia treatment, particularly in early CKD, were limited. The prevalence of erythropoietin-stimulating agents (ESAs) and iron therapy was 40% (95% CI 24%-58%) and 21% (95% CI 14%-31%), respectively (ESA: 7%-29% in CKD, 63%-95% in kidney failure; iron: 6%-26% in CKD, 15%-88% in kidney failure).

CONCLUSION

Our findings indicate a significant, but widely varying, prevalence of anaemia and its treatment in people with CKD in Asia. Substantial variability in data availability and collection highlights the need for standardised reporting to facilitate the development of regionally relevant strategies for anaemia management in CKD.

Systematic, Pretransplant Screening by Aortoiliac CT Angiography: Impact on Surgical Decision-making and Clinical Outcomes

Background

Aortoiliac screening before kidney transplantation is suggested by some guidelines to select patients for transplantation and to assist surgical planning. We investigated the clinical outcomes of systematic screening for aortoiliac disease in potential kidney transplant candidates.

Methods

In this observational study, 470 potential kidney transplant candidates underwent aortoiliac computed tomography angiography. Patients were characterized by the presence of peripheral artery disease and calcification of iliac arteries and aortoiliac arteries. The risk of graft loss and graft function at 1 y posttransplant were examined and clinical decisions based on the vascular findings were assessed.

Results

Clinically diagnosed peripheral artery disease was present in 66 patients (14%), circular calcifications in 101 patients (21%), and aortoiliac stenosis in 77 patients (16%). In 326 patients undergoing kidney transplantation, circular calcification or aortoiliac stenosis was not associated with an increased risk of graft loss (P = 0.45 and P = 0.28) or estimated glomerular filtration rate (P = 0.23 and P = 0.76) at 1 y posttransplant. When evaluated for transplantability, clinical decision-making based on vascular findings was recorded in 67 of 429 patients (16%), including rejection for transplantation in 7 patients (2%) and laterality for surgical implantation in 52 patients (12%).

Conclusions

Systematic screening by aortoiliac computed tomography angiography may assist in surgical planning but seems of limited clinical value in assessing the risk of future graft loss and graft function in patients undergoing kidney transplantation.

Traditional, alternative, and emerging therapeutics for focal segmental glomerulosclerosis

INTRODUCTION

Segmental focal glomerulosclerosis is a histological lesion characterized by podocyte damage. It may be a primary disease linked to an unknown circulating factor, secondary to viral infections, drug toxicity, or a disadaptive response to the loss of nephrons, or it may depend on gene mutations or have an indeterminate cause. The treatment of the primary form involves immunosuppressors. Additional pharmacotherapies for residual proteinuria are used, and emerging therapies are being studied to target other pathological pathways.

AREAS COVERED

This paper covers the treatment of FSGS, focusing on traditional and emerging therapeutic strategies. It is based on the KDIGO 2021 guidelines and supplemented by a literature search conducted on PubMed.

EXPERT OPINION

Treating FSGS is challenging due to its heterogeneity. Immunosuppression is adequate for primary FSGS but harmful in genetic or secondary forms. Key strategies include targeting the underlying cause and using agents that affect renal hemodynamics. Antifibrotic drugs can help slow kidney damage by addressing chronic inflammation and fibrosis. Alongside pharmacological treatments, managing blood pressure and restricting dietary salt are crucial. Finally, personalized treatment requires stratifying patients based on clinical, genetic, and histological data to improve clinical trial design and outcomes.

Exposure to perchlorate and cardiovascular disease in China: A community-based cross-sectional study and benchmark dose estimation

The association between exposure to perchlorate, which inhibits thyroidal iodine uptake, and cardiovascular disease (CVD) is unclear in China. Moreover, the point of departure (POD) for perchlorate based on observed adverse health effect in Chinese populations remains absent. A total of 2355 adults (mean age 50.4 years and 39.2% male) from four communities in Shenzhen were included in analyses. Spot urine specimens were collected to measure urinary perchlorate concentrations, which were applied to estimate daily intakes of perchlorate. Multivariable logistic regression model was applied to examine the association between perchlorate and CVD. The roles of cardiometabolic risk factors, including obesity, abdominal obesity, hypertension, diabetes, and hyperlipidemia, were evaluated with mediation analyses. We further employed Bayesian benchmark dose (BMD) modeling to derive the POD for risk assessment. Comparing extreme tertiles, subjects in the highest perchlorate tertile had a significantly elevated risk of prevalent CVD (OR: 2.16; 95% CI: 1.28, 3.65). Multivariable-adjusted ORs for hypertension, diabetes, and hyperlipidemia associated with per doubling in urinary perchlorate concentration were 1.11 (95% CI: 1.01, 1.21), 1.15 (95% CI: 1.02, 1.28), and 1.11 (95% CI: 1.01, 1.20), respectively. Hypertension, diabetes, and hyperlipidemia partially mediated the perchlorate-CVD association (mediated proportion ranged from 7.75% to 11.30%). Given a benchmark response of 5% and 10%, the model-averaged BMD lower bounds (BMDLs) of perchlorate exposure on CVD were 0.15 and 0.40 μg/kg-bw day, respectively. Our estimated POD for perchlorate was lower than those recommended by other groups. These findings call for stricter regulations on perchlorate contamination to promote cardiovascular health in China.

Urinary concentrations of arsenic species in older Dutch adults and risk of chronic kidney disease

Chronic exposure to arsenic (As) is associated with various cancers and nephrotoxicity. It occurs in different chemical forms which vary in toxicological potential. Human biomonitoring (HBM) is used to measure internal (all-route) exposure to different As species. To assess the risk of internal As exposure, toxic relevant arsenic (TRA) (sum of arsenite (As(III)), arsenate (As(V)), and their methylation metabolites, monomethylarsonate (MMA) and dimethylarsinate (DMA)) in urine should be used. Morning urine samples of 288 Dutch adults (aged 52-91 years) were analysed for As(III), As(V), MMA, DMA, arsenobetaine (AsB) and total As using ICP-MS. The risk of chronic kidney disease (CKD) related to TRA exposure in participants was assessed. The estimated daily intake (EDI) of inorganic As (iAs) was calculated for each participant using food consumption and occurrence data, and the correlation between EDIs and urinary TRA concentrations was investigated. The detection frequency of the individual As species in urine was high (59-100 %). The median and 95th percentile concentrations (middle bound) were 0.24 and 0.77 µg As(III)/g creatinine, 0.12 and 0.74 µg As(V)/g creatinine, 0.96 and 2.54 µg MMA/g creatinine, 8.09 and 63.82 µg DMA/g creatinine and 8.69 and 166.15 µg AsB/g creatinine, respectively. For total As, the detection frequency was 93 %, with median and 95th percentile concentrations of 10.96 and 131.53 µg/g creatinine, respectively. For calculated TRA, the median and 95th percentile concentrations were 5.75 and 35.53 µg/g creatinine, with DMA being the major contributor (85 %). A human biomonitoring-toxicological value (HBM-TV) of 13.7 µg TRA/g creatinine in urine was derived to assess the risk of CKD, and the risk could not be excluded in approximately 11 % of participants. A weak positive association was found between participants' iAs EDIs and urinary TRA concentrations (ρ = 0.16-0.24). This study has generated novel concentration data of As species in morning urine samples of older Dutch adults. The risk assessment results indicate potential concern based on the current exposure in this group of participants. Such findings could be confirmed in a more comprehensive study with a larger and more geographically diverse group of Dutch adults.

Diet quality patterns and chronic kidney disease incidence: a UK Biobank cohort study

BACKGROUND

Only a few studies have investigated the role of diet on the risk of chronic kidney disease (CKD) in European populations and have mainly focused on the Mediterranean diet. This is the first study to evaluate the association between various diet quality indices and CKD incidence in British adults.

OBJECTIVE

To study the relationship between a set of 6 different diet quality indices and CKD incidence among British adults.

METHODS

A prospective cohort with 106,870 participants from the UK Biobank, followed from 2009 to 2012 through 2021. Food consumption was obtained from ≥2 24-h dietary assessments. Dietary patterns were assessed using previously established indices: Alternate Mediterranean Index (aMED), Alternative Healthy Eating Index 2010, dietary approaches to stop hypertension (DASH), healthful plant-based diet index (hPDI), unhealthful plant-based diet index (uPDI), and dietary inflammatory index (DII). Incident CKD was obtained from clinical records, death registries, and self-reports. Analyses were performed with Cox regression models and adjusted for the main confounders.

RESULTS

After a median follow-up of 9.27 y, 2934 cases of CKD were ascertained. Hazard ratios (95% confidence interval) of CKD for the highest compared with lowest tertile of adherence to each diet score were 0.84 (0.76, 0.93) for aMED, 0.94 (0.85, 1.03) for alternative healthy eating index 2010, 0.77 (0.70, 0.85) for DASH, 0.79 (0.72, 0.87) for hPDI, 1.27 (1.16, 1.40) for uPDI, and 1.20 (1.18, 1.33) for DII. The results were robust in sensitivity analyses.

CONCLUSIONS

In British adults, higher adherence to the aMED, DASH, and hPDI patterns was associated with lower risk of CKD, whereas greater adherence to the uPDI and DII patterns was associated with greater risk.

Kidney Biopsy-Proven Diabetic and Non-Diabetic Kidney Diseases and Outcomes in Patients With Type 2 Diabetes Receiving Dialysis: The REIN Registry

Rationale & Objective

Chronic kidney disease (CKD) in patients with diabetes does not always equate to diabetic kidney disease (DKD). This study aims to delineate and compare the clinical characteristics, survival rates, and access to kidney transplantation among patients with type 2 diabetes commencing dialysis, who were classified by kidney biopsy as having either DKD or non-diabetic kidney disease (non-DKD).

Study Design

We used the comprehensive French Renal Epidemiology and Information Network registry to analyze baseline clinical characteristics at dialysis inception and outcomes defined as death and access to kidney transplantation.

Outcomes & Analytical Approach

We employed a multivariate Cox proportional hazards model and the Fine-Gray competing risk model to assess the probabilities of mortality and transplantation.

Settings & Participants

Adults in the Renal Epidemiology and Information Network registry in France with a diagnosis of type 2 diabetes who initiated kidney replacement therapy from January 2009 to December 2015 and had a previous native kidney biopsy.

Results

We analyzed data from 2,869 patients with diabetes, 45% of whom had a biopsy-confirmed diagnosis of DKD. Among these patients, half presented additional histopathological findings indicative of nephroangiosclerosis and focal segmental glomerulosclerosis. The clinical profiles of patients with DKD and non-DKD were largely comparable. There were no significant differences in dialysis survival rates or kidney transplantation access between the groups, even after adjusting for confounding variables and considering competing risks. At the 6-year mark, the mortality rate was 60.3% (95% CI: 55.5-64.5) for the DKD group and 60.3% (95% CI: 55.9-64.3) for the non-DKD group. Multivariable Cox analysis revealed no significant difference in mortality risk between the DKD and non-DKD groups.

Limitations

The study limitations include potential residual confounders, lack of predialysis data, kidney biopsies possibly outdated, nonrandom biopsy indications, and survival bias because of analysis at dialysis inception.

Conclusions

In patients with diabetes initiating dialysis, clinical characteristics and outcomes following dialysis initiation were similar in biopsy-proven DKD versus non-DKD. Our results suggest that the diabetic milieu has a more significant impact on outcomes in patients with diabetes treated with dialysis than the underlying pathological kidney diagnosis.

Chronic kidney disease

Chronic kidney disease (CKD) is defined by persistent abnormalities of kidney function or structure that have consequences for the health. A progressive decline of excretory kidney function has effects on body homeostasis. CKD is tightly associated with accelerated cardiovascular disease and severe infections, and with premature death. Kidney failure without access to kidney replacement therapy is fatal - a reality in many regions of the world. CKD can be the consequence of a single cause, but CKD in adults frequently relates rather to sequential injuries accumulating over the life course or to the presence of concomitant risk factors. The shared pathomechanism of CKD progression is the irreversible loss of kidney cells or nephrons together with haemodynamic and metabolic overload of the remaining nephrons, leading to further loss of kidney cells or nephrons. The management of patients with CKD focuses on early detection and on controlling all modifiable risk factors. This approach includes reducing the overload of the remaining nephrons with inhibitors of the renin-angiotensin system and the sodium-glucose transporter 2, as well as disease-specific drug interventions, if available. Hypertension, anaemia, metabolic acidosis and secondary hyperparathyroidism contribute to cardiovascular morbidity and reduced quality of life, and require diagnosis and treatment.

Information needs in vascular access decision-making: A qualitative study of patient and clinical stakeholder perspectives

BACKGROUND

The information and decision support needs required to embed a patient-centred strategy are challenging, as several haemodialysis vascular access strategies are possible with significant differences in short- and long-term outcomes of potential treatment options. We aimed to explore and describe stakeholder perspectives on information needs when making decisions about vascular access (VA) for haemodialysis.

METHODS

We performed thematic analysis of seven (six online, one in person) focus group discussions including transcripts, post-it phrases and text responses with 14 patients and 12 vascular access professionals (four nephrologists, three surgeons and five nurses - Vascular access nurse specialists/Education and dialysis nurses) who participated in at total of six online and one in person focus group.

RESULTS

All patients had experience of haemodialysis and 50% had experience with at least one other modality of RRT. Ten patients had experience of more than one VA modality and 4/14 had experience of AVG, 13/14 had experience of AVF and 8/14 had experience of TCVC. We identified four semantic themes and two latent themes. The themes and their subthemes reflected information needs of patients when making vascular access decisions: Knowledge, Risks and Benefits of Relevant options, long-term treatment strategy and Personal Impact of VA. The latent themes, identified across all stakeholders, were of the need for consistent and trustworthy information.

DISCUSSION

All recent vascular access guidelines propose a shared decision-making approach to vascular access. The ability to implement this in practice carries an information need for both patients and clinicians. This study describes a framework model which can be applied during co-design and assessment of vascular access educational resources to facilitate a patient centred perspective.

Association between vitamin D deficiency and major depression in patients with chronic kidney disease: a cohort study

Background

Patients with chronic kidney disease (CKD) have an elevated risk of both vitamin D deficiency (VDD) and depression. However, the relationship between VDD and the risk of depression in this population remains unclear.

Methods

Using the TriNetX network database (2010-2019), we conducted a propensity score-matched cohort study of CKD patients aged ≥50 years. Patients were categorized into VDD (≤20 ng/mL) and control (≥30 ng/mL) groups based on measurements within 3 months of CKD diagnosis. The primary outcome was the incidence of major depression within 1 year of follow-up.

Results

Among 17,955 matched pairs, VDD was associated with increased depression risk at 1 year (hazard ratio [HR]: 1.929; 95% confidence interval [CI]: 1.52-2.448; p < 0.0001). This association persisted through 3 years of follow-up. The relationship remained consistent across CKD stages, with similar risks in early (HR:1.977; 95% CI: 1.382-2.829) and CKD stage 3-5 (HR:1.981; 95% CI: 1.533-2.559). Males with VDD showed higher depression risk (HR: 2.264; 95% CI: 1.498-3.421) compared to females (HR:1.761; 95% CI: 1.307-2.374). Even vitamin D insufficiency (20-30 ng/mL) increased depression risk compared to normal levels (HR:1.667; 95% CI: 1.318-2.11). In patients with VDD, cerebrovascular disease, malnutrition, and ischemic heart disease are risk factors for depression.

Conclusion

VDD is independently associated with increased depression risk in patients with CKD, particularly in males. These findings suggest that maintaining adequate vitamin D levels might be important for mental health in patients with CKD, although randomized trials are needed to confirm whether supplementation can prevent depression in this population.

A Core Outcome Set for Trials in CKD: Report of the Standardized Outcomes in Nephrology-Chronic Kidney Disease (SONG-CKD) Stakeholder Workshops

Omitting outcomes of importance to patients with chronic kidney disease (CKD) and their caregivers from trials can impede decision making based on patient-centered outcomes. As part of the global Standardized Outcomes in Nephrology-Chronic Kidney Disease (SONG-CKD) initiative, we established a consensus-based set of core outcomes for trials in CKD (prior to the need for kidney replacement therapy). To finalize the proposed set of core outcomes that were identified through focus groups and an international Delphi survey, we convened 2 international stakeholder workshops in English and Spanish languages that involved 61 patients/caregivers and 75 health professionals from 18 countries. Participants were asked to discuss and endorse the potential core outcomes (mortality, kidney function, life participation, and cardiovascular disease), and to provide suggestions for implementing the core outcomes. The discussions were summarized into 4 themes: reflecting a comprehensive approach to health, facilitating patient empowerment in their own care, ensuring applicability to broad geographic areas and populations, and feasibility for implementation. Patients, caregivers, and health professionals agreed that mortality, kidney function, life participation, and cardiovascular disease should be established as core outcomes for trials in CKD.

The mechanism of enterogenous toxin methylmalonic acid aggravating calcium-phosphorus metabolic disorder in uremic rats by regulating the Wnt/β-catenin pathway

BACKGROUND

Uremia (UR) is caused by increased UR-related toxins in the bloodstream. We explored the mechanism of enterogenous toxin methylmalonic acid (MMA) in calcium-phosphorus metabolic disorder in UR rats via the Wnt/β-catenin pathway.

METHODS

The UR rat model was established by 5/6 nephrectomy. The fecal bacteria of UR rats were transplanted into Sham rats. Sham rats were injected with exogenous MMA or Salinomycin (SAL). Pathological changes in renal/colon tissues were analyzed. MMA concentration, levels of renal function indicators, serum inflammatory factors, Ca2+/P3+, and parathyroid hormone, intestinal flora structure, fecal metabolic profile, intestinal permeability, and glomerular filtration rate (GFR) were assessed. Additionally, rat glomerular podocytes were cultured, with cell viability and apoptosis measured.

RESULTS

Intestinal flora richness and diversity in UR rats were decreased, along with unbalanced flora structure. Among the screened 133 secondary differential metabolites, the MMA concentration rose, showing the most significant difference. UR rat fecal transplantation caused elevated MMA concentration in the serum and renal tissues of Sham rats. The intestinal flora metabolite MMA or exogenous MMA promoted intestinal barrier impairment, increased intestinal permeability, induced glomerular podocyte loss, and reduced GFR, causing calcium-phosphorus metabolic disorder. The intestinal flora metabolite MMA or exogenous MMA induced inflammatory responses and facilitated glomerular podocyte apoptosis by activating the Wnt/β-catenin pathway, which could be counteracted by repressing the Wnt/β-catenin pathway.

CONCLUSIONS

Enterogenous toxin MMA impelled intestinal barrier impairment in UR rats, enhanced intestinal permeability, and activated the Wnt/β-catenin pathway to induce glomerular podocyte loss and reduce GFR, thus aggravating calcium-phosphorus metabolic disorder.

Chronic kidney disease progression in patients with previous type 2 diabetes and/or hypertension: a population-based cohort study from primary care in Spain

OBJECTIVES

To evaluate whether between hypertension and type 2 diabetes (T2D)-established drivers of chronic kidney disease (CKD) progression-one might be more strongly associated with CKD progression than the other.

DESIGN

Cohort study using a primary care database (electronic health records).

SETTING

Primary care in Catalonia, Spain.

PARTICIPANTS

438 273 patients with CKD identified from the Information System for Research in Primary Care database in Catalonia (2007-2017) and stratified into four mutually exclusive groups based on the presence/absence of hypertension and/or T2D. Distribution of the CKD study cohort was as follows: CKD with hypertension (51.1%), CKD with T2D (3.9%), CKD with hypertension and T2D (32.8%), CKD without hypertension and T2D (12.2%).

PRIMARY AND SECONDARY OUTCOME MEASURES

Patients were followed up to identify the occurrence of severe kidney impairment (SKI) and kidney failure (kidney replacement therapy/estimated glomerular filtration rate (eGFR) <15 mL/min/1.73 m2). Subdistributional hazard ratios (sHRs) were estimated using Cox regression adjusted for confounders.

RESULTS

Compared with the CKD without hypertension and T2D group, adjusted sHRs (95% CIs) for SKI/kidney failure were 1.77 (1.65 to 1.89) for CKD with hypertension and T2D, 1.50 (1.41 to 1.59) for CKD with hypertension and 1.21 (1.09 to 1.34) for CKD with T2D, and for kidney failure were 1.24 (1.10 to 1.39) for CKD with hypertension, 0.74 (0.61 to 0.90) for CKD with T2D and 1.09 (0.96 to 1.24) for CKD with hypertension and T2D. The strongest risk factors for CKD progression were low eGFR and albuminuria, even at mild-moderate levels.

CONCLUSIONS

Hypertension could be associated with an equal/greater risk of CKD progression as T2D. Efforts to slow CKD progression should target both patients with hypertension and T2D, focusing on the identification, close monitoring and effective management of albuminuria and reduced eGFR.

Comprehensive Review of Lipid Management in Chronic Kidney Disease and Hemodialysis Patients: Conventional Approaches, and Challenges for Cardiovascular Risk Reduction

Background/Objectives: Lipid disorders are very prevalent in patients with chronic kidney disease (CKD) and end-stage kidney disease (ESKD), leading to heightened cardiovascular risk. This review examines the effectiveness of lipid-lowering agents in these populations and explores gaps in the current research. The goal of this review is to assess the efficacy of lipid-lowering therapies in CKD and ESRD patients and identify future research needs. It aims to provide a clearer understanding of how these treatments impact cardiovascular risk in high-risk populations. Methods: We conducted a literature search in Embase, PubMed, Cochrane, and Google Scholar databases using keywords including but not limited to: chronic kidney diseases, dialysis, hemodialysis, dyslipidemia, statins, ezetimibe, and lipid-lowering drugs. Findings from included studies were synthetized to provide an overview of the current management of dyslipidemia in ESRD and HD. Results: Statins show mixed results in CKD and ESRD, with limited benefits in reducing cardiovascular events in dialysis patients. Agents like PCSK9 inhibitors show promising results but require further research, while non-statin therapies like fibrates and omega-3 fatty acids have limited evidence for use in this population. Conclusions: The review underscores the need for further research into lipid-lowering agents in CKD and ESRD patients, highlighting the need for tailored lipid management strategies in vulnerable patients with unique risk factors. More studies are needed to refine treatment strategies and assess the role of exercise and accurate risk calculators in managing cardiovascular outcomes.

Gender differences in the prognostic impact of uric acid in patients with heart failure and preserved ejection fraction

BACKGROUND

Uric acid has been identified as an independent predictor of poor outcomes in patients with heart failure with preserved ejection fraction (HFpEF). However, the impact of gender differences on this association is not fully explored.

METHODS

This retrospective cohort study included hospitalized patients with HFpEF from June 2018 to October 2022. The primary outcome was a composite endpoint, defined as the occurrence of all-cause mortality and heart failure readmission. Kaplan-Meier survival analysis and stratified Cox regression examined the combined effect of gender and uric acid on the composite endpoint, and restricted cubic spline curves were applied to visualize the relationship.

RESULTS

The study included 547 patients, with 267 females and 280 males. In the entire cohort, each mg/dL increase in uric acid was associated with a 4% increase in the risk of the composite endpoint (HR: 1.04, 95%CI:1.01-1.09). This association was more pronounced in females, with a 9% increase in the risk of the composite endpoint per mg/dL increase in uric acid (95%CI: 1.02-1.17). Restrict cubic spline curves analysis demonstrated a significant linear correlation between increasing uric acid levels and higher risk of the composite endpoint in female patients (P = 0.028). Kaplan-Meier analysis revealed higher survival probabilities for females compared to males (P = 0.002). However, survival rates for females with high uric acid levels were similar to those for males with high uric acid levels.

CONCLUSIONS

Baseline serum uric acid levels are significantly associated with the composite endpoint in patients with HFpEF, particularly among females.

The association between body roundness index and new-onset hyperuricemia in Chinese population: the Kailuan cohort study

BACKGROUND

This study aimed to investigate the potential relationship between the newly defined adiposity metric, the Body Roundness Index (BRI), which assesses central obesity, and the development of new-onset hyperuricemia.

METHODS

In the Kailuan cohort study from 2006 to 2019, 91,804 eligible participants were included. A multivariate Cox regression model was used to test the correlation between BRI and hyperuricemia. At the same time, the restricted cubic spline was applied to solve the dose-response relationship between BRI and the risk of hyperuricemia.Then, stratified analysis was carried out using multivariate Cox regression according to age, sex, hs-CRP level, TG level, education level, smoking status and hypertension status.

RESULTS

The results showed that the risk of new-onset hyperuricemia was significantly increased in the highest quartile compared with the lowest quartile. After adjusting for confounders, compared with Q1, the HR (95% CI) for new-onset hyperuricemia was 1.24 (1.18-1.30), 1.32 (1.25-1.40), and 1.40 (1.29-1.52) for Q2, Q3, and Q4, respectively. Restricted cubic spline analysis showed a J-curve relationship between baseline BRI levels and new-onset hyperuricaemia. Age, sex, hs-CRP level, TG level, income level, education level, smoking, and hypertension each had a multiplicative interaction with BRI at baseline.

CONCLUSION

We found that elevated BRI increased the risk of developing new-onset hyperuricaemia. In addition, the association between elevated BRI and the risk of new-onset hyperuricemia showed dependency on age, sex, hs-CRP level, TG level, education level, smoking status and hypertension status.

Salivary proteomics profiling reveals potential biomarkers for chronic kidney disease: a pilot study

Introduction

Chronic kidney disease (CKD) is a global public health problem, and the absence of reliable and accurate diagnostic and monitoring tools contributes to delayed treatment, impacting patients' quality of life and increasing treatment costs in public health. Proteomics using saliva is a key strategy for identifying potential disease biomarkers.

Methods

We analyzed the untargeted proteomic profiles of saliva samples from 20 individuals with end-stage kidney disease (ESKD) (n = 10) and healthy individuals (n = 10) using liquid chromatography-tandem mass spectrometry (LC-MS/MS) to identify potential biomarkers for CKD. A volcano plot was generated using a p-value of ≤0.05 and a fold change (FC) ≥ 2.0. Multivariate analysis was performed to generate the orthogonal partial least squares discriminant analysis (OPLS-DA) model and the variable importance in projection (VIP) scores. The accuracy of candidate biomarker proteins was evaluated using receiver operating characteristic (ROC) curves.

Results

In total, 431 proteins were identified in the salivary proteomic profile, and 3 proteins were significantly different between the groups: apoptosis inhibitor 5 (API5), phosphoinositide phospholipase C (PI-PLC), and small G protein signaling modulator 2 (Sgsm2). These proteins showed good accuracy based on the ROC curve and a VIP score of >2.0. During pathway enrichment, PI-PLC participates in the synthesis of IP3 and IP4 in the cytosol. Gene ontology (GO) analysis revealed data on molecular functions, biological processes, cellular components, and protein classes.

Conclusion

We can conclude that the salivary API5, PI-PLC, and Sgsm2 can be potential biomarker candidates for CKD detection. These proteins may participate in pathways related to renal fibrosis and other associated diseases, such as mineral and bone disorders.

Catheter replacement combined with antiplatelet therapy in hemodialysis catheter-related right atrial thrombus: a potential treatment approach

BACKGROUND

Catheter-related right atrial thrombus (CRAT) is a severe complication in hemodialysis patients that can lead to catheter dysfunction and pulmonary embolism (PE). However, no standardized treatment strategy currently exists for hemodialysis-related CRAT. This study aims to investigate the efficacy of catheter replacement and antiplatelet therapy in managing hemodialysis CRAT.

METHODS

We conducted a retrospective cohort study on patients at West China Hospital diagnosed with catheter dysfunction caused by right atrial thrombosis between May 2019 and March 2022. All CRAT were asymptomatic and underwent catheter replacement (either guidewire exchange or insertion at a new site), with the new catheter tip repositioned away from the original location and closer to the right atrium. Antiplatelet therapy with dipyridamole was initiated post-procedure. We analyzed the efficacy of catheter replacements and antiplatelet therapy in hemodialysis-related CRAT.

RESULTS

Among the 178 patients with CRAT who underwent catheter replacement, the success rate was 98.9%. Preoperative examinations detected asymptomatic PE in 10 patients (5.6%). During follow-up, 3 patients (1.9%) developed new asymptomatic PE post-operation, and no fatal PE occurred. The catheter primary patency rates at 3, 6, and 12 months were 87.0%, 62.6%, and 36.7%, respectively. The secondary patency rates were 91.7%, 75.7%, and 52.3% at 3, 6, and 12 months, respectively. No patients died due to PE or other thrombotic complications.

CONCLUSIONS

Catheter replacement combined with antiplatelet therapy may be a potential treatment approach for patients with hemodialysis-related CRAT < 6 cm, without other complications except from catheter dysfunction.

Association of cumulative health status with subsequent mortality in patients with acute heart failure

AIMS

We aim to examine the association between long-term cumulative health status and subsequent mortality among patients with acute heart failure (HF).

METHODS AND RESULTS

Based on a national prospective cohort study of patients hospitalized for HF, we measured health status by Kansas City Cardiomyopathy Questionnaire (KCCQ)-12 at four time points, i.e. admission and 1, 6 and 12 months after discharge. Cumulative health status was interpreted by cumulative KCCQ-12 score and cumulative times of good health status. Outcomes included subsequent all-cause and cardiovascular mortality. Multivariable Cox proportional hazard models were performed to examine the association between cumulative health status and subsequent mortality. Totally, 2328 patients {36.7% women with median age 66 [interquartile range (IQR): 56-75] years} were included, and the median follow-up was 4.34 (IQR: 3.93-4.96) years. Compared with quartile 4, the lowest quartile 1 had the highest hazard ratio (HR) for all-cause mortality [2.96; 95% confidence interval (CI): 2.26-3.87], followed by quartile 2 (1.79; 95% CI: 1.37-2.34) and quartile 3 (1.62; 95% CI: 1.23-2.12). Patients with zero times of good health status had the highest risk of all-cause mortality (HR: 2.41, 95% CI: 1.69-3.46) compared with patients with four times of good health status. Similar associations persisted for cardiovascular mortality.

CONCLUSION

A greater burden of cumulative health status indicated worse survival among patients hospitalized for HF. Repeated KCCQ measurements could be helpful to monitor long-term health status and identify patients vulnerable to death.

Association of the abdominal aortic calcification with all-cause and cardiovascular disease-specific mortality: Prospective cohort study

BACKGROUND

Abdominal aortic calcification (AAC) is a prevalent form of vascular calcification associated with adverse cardiovascular outcomes. While previous studies on AAC and cardiovascular risk exist, many have limitations such as small sample sizes and limited clinical significance outcomes. This study aims to prospectively investigate the association between AAC and all-cause and cardiovascular disease (CVD)-specific mortality rates in a nationally representative sample of adults in the United States, using data from the National Health and Nutrition Examination Survey (NHANES).

METHODS

The study, conducted on NHANES participants aged 40 years or older during the 2013-2014 cycle, assessed AAC using the Kauppila scoring system. Demographic characteristics, mortality data, and comorbid factors such as age, gender, diabetes, and hypertension were considered. Statistical analyses, including weighted percentages, Kaplan-Meier survival curves, and multivariable Cox proportional hazards regression models, were employed to evaluate the associations between AAC and mortality risks.

RESULTS

After analyzing a final sample of 2717 participants, the study found a significant association between severe AAC (SAAC) and higher all-cause mortality risk (HR 1.70, 95% CI 1.17-2.48). The dose-response relationship indicated an increased risk with higher AAC scores. However, no independent association was observed between AAC and cardiovascular mortality. Stratified analysis revealed variations in the AAC-all-cause mortality association based on gender and hypertension.

CONCLUSION

This population-based study provides valuable insights into the prospective association between AAC and all-cause mortality, emphasizing the potential role of AAC assessment in identifying individuals at higher risk.

Lipidomics-based natural products for chronic kidney disease treatment

Chronic kidney disease (CKD) is by far the most prevalent disease in the world and is now a major global public health problem because of the increase in diabetes, hypertension and obesity. Traditional biomarkers of kidney function lack sensitivity and specificity for early detection and monitoring of CKD progression, necessitating more sensitive biomarkers for early diagnostic intervention. Dyslipidemia is a hallmark of CKD. Advancements in mass spectrometry (MS)-based lipidomics platforms have facilitated comprehensive analysis of lipids in biological samples and have revealed changes in the lipidome that are associated with metabolic disorders, which can be used as new biomarkers for kidney diseases. It is also critical for the discovery of new therapeutic targets and drugs. In this article, we focus on lipids in CKD, lipidomics methodologies and their applications in CKD. Additionally, we introduce novel biomarkers identified through lipidomics approaches and natural products derived from lipidomics for the treatment of CKD. We believe that our study makes a significant contribution to literature by demonstrating that natural products can improve CKD from a lipidomic perspective.

A network meta-analysis of therapies for hyperphosphatemia in CKD based on randomized trials

To update the efficacy and safety of different drugs for the treatment of patients with hyperphosphatemia in chronic kidney disease, we conducted a network meta-analysis of 22 therapies for the treatment of uncontrolled hyperphosphatemia in patients with chronic kidney disease (CKD). All randomized controlled trials on hyperphosphatemia published from January 2013 to November 2023 were searched from CNKI, VIP database, Wanfang database, PubMed, Scopus, and Cochrane databases. Meta-analysis was used to evaluate the serum phosphorus, calcium levels, total effective rate and adverse events of patients with chronic kidney disease (CKD). Data collection and quality evaluation were carried out by three evaluators, RevMan (5.5.3) and Stata (1.3.0). A total of 71 RCTs, and 22 treatment strategies were included in this NMA. The results showed that all treatment strategies were effective in improving patients' blood phosphorus levels. Among them, SL + CT, CA + CC, SL and TCM had higher overall efficacy, RT, TCM and SL + CT had lower blood phosphorus levels, SL + CT, SL and NAM had lower blood calcium levels, and OAC, CC, NAM and SL had higher safety. Among them, SL + CT seems to be the most recommended treatment strategy. In addition, multidrug combination strategies usually have a higher efficacy and safety profile.

The burden of chronic kidney disease attributable to high sodium intake: a longitudinal study in 1990-2019 in China

Objective

Elevated sodium consumption is associated with increased risk for chronic kidney disease (CKD) and data for this disease burden attributable to high sodium intake in China from 1990 to 2019 are scarce in China. Our study aims to estimate and present the national burden of CKD attributable to high sodium intake, as well as its profile.

Methods

The regional disease burden data from the China Center for Food Safety Risk Assessment (CFSA) from 1990 to 2019 were compiled based on the methodology of GBD 2019. CKD burden [deaths and disability-adjusted life years (DALYs)] was quantified according to population group (age, gender) and regions categories (province, SDI). The estimated annual percentage change (EAPC) in age-standardized mortality rate (ASMR) and age-standardized DALYs rate (ASDR) were calculated to describe long-term trends.

Results

Totally, the number of deaths of CKD attributable to high sodium intake reached 95,000, with DALYs amounting to 2.59 million person-years in 2019, while the trends of ASMR (EAPC: -0.31, 95%CI: -0.46, -0.17%) and ASDR (-0.33, 95%CI: -0.48, -0.18%) were down during the observation period. The age-specific numbers and rates of deaths, as well as DALYs increase with age are higher in males than in females. Significant disparities in CKD burden attributable to high sodium intake were observed across provinces and SDI regions. In both 1990 and 2019, the number of deaths and DALYs were higher in middle SDI regions, while low-middle SDI regions had highest ASMR and ASDR. The EAPC of ASDR was found to be significantly negatively correlated with the 1990 ASDR (ρ = -0.393, p = 0.024), and the EAPC of ASMR and ASDR were also significantly negatively correlated with the 2019 SDI (ASMR:ρ = -0.571, p < 0.001; ASDR:ρ = -0.368, p = 0.035).

Conclusion

High sodium intake accounted for a sizeable burden of disease from 1990 to 2019 in China, also presents sexual and geographic variations. Despite a slight decreasing trend exists, the absolute number increased as much as twofold, particularly among males and seniors. Targeting to reduce sodium intake remains a priority, and progress requires systematic monitoring and evaluation, particularly in middle SDI regions that are experiencing rising trends and low-middle SDI regions being susceptible to approaches.

Accelerated aging as a mediator of the association between co-exposure to multiple air pollutants and risk of chronic kidney disease

BACKGROUND

The association between co-exposure to multiple air pollutants and the occurrence of chronic kidney disease (CKD) was not well-established, and the mediating role of accelerated aging in this association remained uncertain.

METHODS

Using a cohort of 313,908 participants without CKD at baseline from the UK Biobank, we examined the potential association between co-exposure to multiple air pollutants, including PM2.5, PM10, PM2.5-10, NO2 and NOx, and the incidence of CKD by calculating an air pollution score. Mediation analyses were performed to examine the mediating role of accelerated aging (PhenoAgeAccel or KDM-BioAgeAccel) in this association.

RESULTS

During the median follow-up time of 12.9 years, 11,117 participants developed CKD. The results showed that per interquartile range (IQR) increment in air pollution score led to an approximately 9.0 % (6.6-11.4 %) elevated risk of occurring CKD. Compared to the first quartile (Q1) of air pollution score, those in the highest quartile (Q4) had a 21.2 % (14.8-27.9 %) higher risk of developing CKD (Ptrend<0.001). Mediation analyses suggested that PhenoAgeAccel and KDM-BioAgeAccel significantly mediated 1.5 % and 5.7 % of the association between air pollution score and incident CKD, respectively.

CONCLUSION

Co-exposure to multiple air pollutants could increase the risk of developing CKD, with accelerated aging serving as a partial mechanism in the relationship between air pollution and CKD. These findings highlight the importance of reducing air pollution, and suggest a possible mechanism from air pollution to CKD through accelerated aging.

Global, regional, and national burden inequality of chronic kidney disease, 1990-2021: a systematic analysis for the global burden of disease study 2021

Background

Chronic kidney disease (CKD) is a significant global health issue, often linked to diabetes, hypertension, and glomerulonephritis. However, aggregated statistics can obscure heterogeneity across subtypes, age, gender, and regions. This study aimed to analyze global CKD trends from 1990 to 2021, focusing on age, gender, socio-demographic index (SDI), and regional variations.

Methods

Data were extracted from the Global Burden of Disease (GBD) 2021 database, covering prevalence, incidence, mortality, and disability-adjusted life years (DALYs). These were presented as counts per 100,000 population and age-standardized rates, with uncertainty intervals (UIs) to highlight variability. Joinpoint regression was used to assess trends over the 30-year period.

Results

In 2021, global CKD prevalence was 359 million, with 11.13 million new cases, 1.53 million deaths, and 44.45 million DALYs-up 92, 156, 176, and 114% since 1990. While prevalence slightly declined, incidence, mortality, and DALYs increased significantly. CKD burden varied by region and age, with notable gender disparities.

Conclusion

The study highlights a dramatic rise in CKD burden linked to population growth and aging, emphasizing the need for targeted treatment and effective global healthcare policies.

Patient-physician communication in advanced kidney disease: a narrative review

The increasing prevalence of kidney failure highlights the crucial need for effective patient-physician communication to improve health-related quality of life and ensure adherence to treatment plans. This narrative review evaluates communication practices in the context of advanced kidney disease, focusing on the frameworks of shared decision-making, advanced care planning, and communication skills training among nephrologists. The findings highlight the significant gaps in patient-physician communication, particularly in the domains of advanced care planning, shared decision-making, and dialysis withdrawal. When communication in such situations falls short, it affects patient satisfaction and outcomes. Effective communication is essential for managing advanced kidney disease, requiring a patient-centered approach that includes patients, families, and healthcare providers in care planning. This review advocates for a more integrated, empathic approach to healthcare interactions, emphasizing the importance of including patients, their families, and healthcare providers in a collaborative model based on goals of care. Moreover, it highlights the role of patient-reported outcome measures and patient experience of care in assessing the quality of care in dialysis settings. Here, we call for enhanced training programs regarding communication skills for physicians and emphasize the need for systemic changes to foster patient-centered communication.

DEPDC1B, CDCA2, APOBEC3B, and TYMS are potential hub genes and therapeutic targets for diagnosing dialysis patients with heart failure

Introduction

Heart failure (HF) has a very high prevalence in patients with maintenance hemodialysis (MHD). However, there is still a lack of effective and reliable HF diagnostic markers and therapeutic targets for patients with MHD.

Methods

In this study, we analyzed transcriptome profiles of 30 patients with MHD by high-throughput sequencing. Firstly, the differential genes between HF group and control group of patients with MHD were screened. Secondly, HF-related genes were screened by WGCNA, and finally the genes intersecting the two were selected as candidate genes. Machine learning was used to identify hub gene and construct a nomogram model, which was verified by ROC curve and RT-qPCR. In addition, we further explored potential mechanism and function of hub genes in HF of patients with MHD through GSEA, immune cell infiltration analysis, drug analysis and establishment of molecular regulatory network.

Results

Totally 23 candidate genes were screened out by overlapping 673 differentially expressed genes (DEGs) and 147 key module genes, of which four hub genes (DEPDC1B, CDCA2, APOBEC3B and TYMS) were obtained by two machine learning algorithms. Through GSEA analysis, it was found that the four genes were closely related to ribosome, cell cycle, ubiquitin-mediated proteolysis. We constructed a ceRNA regulatory network, and found that 4 hub genes (TYMS, CDCA2 and DEPDC1B) might be regulated by 4 miRNAs (hsa-miR-1297, hsa-miR-4465, hsa-miR-27a-3p, hsa-miR-129-5p) and 21 lncRNAs (such as HCP5, CAS5, MEG3, HCG18). 24 small molecule drugs were predicted based on TYMS through DrugBank website. Finally, qRT-PCR experiments showed that the expression trend of biomarkers was consistent with the results of transcriptome sequencing.

Discussion

Overall, our results reveal the molecular mechanism of HF in patients with MHD and provide insights into potential diagnostic markers and therapeutic targets.

Effectiveness of Virtual Reality Training in Improving Outcomes for Dialysis Patients: Systematic Review and Meta-Analysis

BACKGROUND

Virtual reality (VR) training uses computer-generated simulations that enable users to engage with immersive virtual environments, simulating real-world activities or therapeutic exercises. This technology is increasingly recognized as a promising intervention to address the physical and psychological challenges faced by dialysis patients, who frequently experience diminished physical function, social isolation, and emotional distress associated with prolonged treatment regimens. Given the increasing prevalence of dialysis patients and the limitations of conventional rehabilitation approaches, VR presents a novel, interactive method that has the potential to enhance patient well-being and improve quality of life.

OBJECTIVE

This meta-analysis aimed to evaluate the effectiveness of VR training interventions for dialysis patients, with a focus on assessing their impact on motor abilities, psychological symptoms (specifically anxiety and depression), social functioning, and self-efficacy. This analysis also explores whether VR can offer comprehensive benefits to support both the physical and mental health of dialysis patients.

METHODS

The meta-analysis was conducted following Cochrane guidelines. Comprehensive searches were performed across major databases, including China National Knowledge Infrastructure, Wanfang database, China Science and Technology Journal Database, China Biomedical Literature database, Cochrane library, Web of Science, PubMed, and Embase, encompassing all studies up to December 2023. Inclusion criteria targeted studies assessing VR's impact on motor performance, psychological well-being, social functioning, and self-efficacy in dialysis patients. Two reviewers independently extracted data and assessed methodological quality using Cochrane's risk of bias criteria, ensuring data synthesis reliability.

RESULTS

A total of 12 studies, involving 625 dialysis patients in total, met the inclusion criteria. The meta-analysis demonstrated that VR training led to significant improvements across multiple domains. VR interventions were associated with improved physical capacity, evidenced by higher scores in the 6-minute walk test (standardized mean difference [SD]=29.36, 95% CI 14.32-44.4, P<.001, I2=46%). VR training was associated with significant reductions in depression (SD=-6.30, 95% CI -7.14 to -5.47, P<.001, I2=96%) and anxiety (SD=-8.91, 95% CI -9.69 to -8.14, P<.001, I2=95%). In addition, VR interventions enhanced social functioning (SD=16.20, 95% CI 14.49-17.9, P<.001, I2=72%), and improved self-efficacy (SD=20.47, 95% CI 18.55-22.39, P<.001, I2=99%). However, VR training did not yield significant differences in gait speed, balance, or functional tests (Ten Sit-to-Stand Test, Five Sit-to-Stand Test, Sixty Sit-to-Stand Test, Timed Up and Go Test, and fatigue) compared with control groups.

CONCLUSIONS

The findings suggest that VR training is a promising intervention for dialysis patients, providing benefits in physical endurance, social engagement, and psychological well-being. Despite these advantages, VR remains underused among peritoneal dialysis patients compared with hemodialysis patients. Further studies with larger sample sizes and more refined experimental designs are recommended to validate these results and support VR as a complementary tool in the holistic care of dialysis patients.

Association between normal weight obesity and comorbidities and events of cardiovascular diseases among adults in South China

BACKGROUND

The increased risks for cardiovascular comorbidities and cardiovascular diseases (CVD) in populations with normal weight obesity (NWO) have not been well-identified. We aimed to study their associations in an adult population in South China.

METHODS

Based on the CVD prevalence of 4% in Shenzhen and a calculated sample size of 6,000, a cross-sectional study with a multi-stage stratified cluster sampling method was conducted in Shenzhen City. The cardiovascular comorbidities being studied were abdominal obesity (AO), diabetes, hypertension, dyslipidemia, metabolic syndrome, and chronic kidney disease, while the CVD events were occurrences of myocardial infarction and strokes. Questionnaire surveys, physical examinations, and laboratory tests were performed. NWO was defined as a condition with the highest tertile of body fat percentage (BF%) among the normal body mass index (BMI) range (18.5-23.9 kg/m2). Continuous data were reported as mean [standard deviation (SD)] and categorical data as percentages (%). CVD comorbidities and CVD events and their detection rates in different groups were compared using ANONA analysis and Chi-squared test. Spearman's correlation coefficients between BF% and cardiometabolic abnormalities were calculated by partial correlation analysis. Multivariate logistic regression models were used to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) for BF%, CVD comorbidities, and CVD events, adjusted for multiple confounders.

RESULTS

Among the total 6,240 subjects who completed the study and had BMI and BF% data available, 3,086 had normal BMI. The prevalence of NWO was 16.36%, with 13.15% for men and 19.54% for women. With confounders adjusted, the risks of AO (OR = 6.05, 95%CI = 3.40-10.75), essential hypertension (OR = 1.56, 95%CI = 1.09-2.22), dyslipidemia (OR = 1.85, 95%CI = 1.49-2.29), and metabolic syndrome (OR = 4.61, 95%CI = 2.32-9.18) were significantly increased in the populations with NWO compared with the population without NWO (P < 0.05). BF% was not significantly associated with the risk of CVD events in the total (OR = 1.56, 95%CI = 0.83-2.93), male (OR = 1.00, 95%CI = 0.44-2.30), and female populations (OR = 2.53, 95%CI = 0.91-7.06).

CONCLUSION

NWO was found to be positively associated with CVD comorbidities but not with CVD events. The current study provides a ground to conduct further studies on whether body fat affects the risk of occurrence of CVD events and the underlying mechanisms in the future.

Correlation analysis of estimated pulse wave velocity and severe abdominal aortic calcification: based on the National Health and Nutrition Examination Survey database

Objective.To investigate how severe abdominal aortic calcification (SAAC) and estimated pulse wave velocity (ePWV) relate to each other and to all-cause and cardiovascular disease (CVD) mortalities.Approach.National Health and Nutrition Examination Survey 2013-2014 data were analyzed. ePWV, computed using age and mean blood pressure, served as an independent variable. Dependent variable SAAC (AAC score >6) was quantified using dual-energy x-ray absorptiometry and Kauppila grading. A weighted logistic regression model, interaction terms, and restricted cubic spline analysis examined relationship between ePWV and SAAC. Kaplan-Meier curves were drawn among SAAC people. A weighted Cox regression model was built to examine associations of ePWV with all-cause and CVD mortalities.Main results.2849 individuals were included. A strong positive connection (odds ratio (OR) > 1,P< 0.05) was seen between ePWV and SAAC risk. Interaction termP-value indicated that only ethnicity (P< 0.05) had an impact on this link but smoking, alcohol use, age, sex, body mass index, or hypertension did not. SAAC patients showed greater ePWV, all-cause and CVD mortalities (P< 0.05) than non-SAAC subjects. Greater ePWV (>12.00 m s-1) was associated with higher risks of all-cause and CVD mortalities in SAAC participants (hazard ratio (HR) > 1,P< 0.05). Significance.This study, for the first time based on the NHANES database, reveals a positive correlation between ePWV and SAAC, and identifies ePWV as an independent predictor of all-cause and cardiovascular mortality risk in patients with SAAC, providing a new biomarker for the prevention and early intervention of cardiovascular diseases.

Search for surrogate markers to predict end stage kidney disease in long term lithium users

BACKGROUND

A surrogate marker (a substitute indicator of the true outcome) is needed to predict subgroups of long-term lithium users at risk of end-stage kidney disease (ESKD). In this narrative review the aim is to determine the optimal surrogate endpoint for ESKD in long-term lithium users in a scientific context. MAIN: In a literature search in long-term lithium users, no studies on surrogate measurements on ESKD were identified. Therefore, comparable ESKD populations were sought, based on baseline eGFR, age, somatic comorbidity and sex. Articles were scored on comparability and risk of bias. Seventeen studies were included; ten studies evaluated a percentual decline (between 20 and 50% decline in eGFR) and seven studies focused upon a declining slope (from 1.63 to 6 ml/min/1,73m2 decline per year), using an interval of one to five years. Study populations mostly included patients with cardiovascular disease and chronic kidney disease.

CONCLUSION

Currently, the most appropriate marker for ESKD in long term lithium users appears a 30% decline in eGFR in at least one year. In order to confirm this hypothesis, further research in a cohort of long-term lithium users is needed. Better feasible research on lithium induced nephropathy could result in more knowledge about the risk on kidney function decline in lithium users and guide clinical decision making on lithium use.