Anticoagulation in chronic kidney disease: current status and future perspectives

Direct oral anticoagulant failure in patients with venous thromboembolism-why and what next?

Management of recurrent thrombotic events in patients taking a direct oral anticoagulant can be challenging. In this review, we consider causes of so-called direct oral anticoagulant failure, from poor adherence, malabsorption, and drug interactions to the presence of undiagnosed antiphospholipid syndrome, cancer-associated thrombosis, severe thrombophilia, vasculitis, and other rare causes. We discuss the known or potential pathogenesis of venous thromboembolism recurrence in these situations and provide practical guidance to assist clinicians faced with these challenging cases.

Dual-specificity phosphatases: Potential targets for cognitive impairment induced by chronic kidney disease

The aim of this review is to systematically explore the critical role of dual-specific phosphatases (DUSPs) in CKD-associated cognitive impairment and their therapeutic potential. Chronic kidney disease (CKD) is a global health burden, and the cognitive impairment it induces seriously affects patients' quality of life. Studies have shown that DUSPs are involved in pathological processes such as inflammation, oxidative stress, fibrosis, and neuronal apoptosis through the regulation of signaling pathways such as MAPK, which in turn affects the cognitive function of CKD patients. Specifically, downregulation of DUSP1 and DUSP6 expression in brain tissues of CKD patients is associated with cognitive impairment, whereas upregulation of DUSP8 and DUSP16 exacerbates cognitive deficits by promoting neuroinflammation. In addition, uremic toxins (e.g., indolephenol sulfate) can further deteriorate cognitive function by altering the activity of DUSPs and interfering with central nervous system signaling. Although there are currently no clinical drugs targeting DUSPs, small molecule inhibitors, gene modulation techniques, and natural compounds have demonstrated the potential to improve cognitive function by modulating DUSPs. Future studies need to focus on optimizing the specificity and selectivity of DUSPs inhibitors and conducting rigorous clinical validation. In-depth elucidation of the mechanism of action of DUSPs in the renal-brain axis will provide an important theoretical basis for the development of novel intervention strategies for CKD-associated cognitive impairment.

Effects of dyadic psychoeducational interventions for haemodialysis patients and their family caregivers: a randomised controlled trial

BACKGROUND

Haemodialysis may affect the changes in the patient's relationship with the family, and eventually cause some psychological distress to the patient and affect the health-related quality of life. This study examines the effectiveness of the dyadic psychoeducational intervention on patients' quality of life and psychosocial health, as well as caregiver burden and psychosocial outcomes among caregivers.

METHODS

This is a parallel, two-arm, assessor-blind, randomised controlled trial with a repeated-measures design. A total of 80 haemodialysis dyads (patient and family caregivers) randomly assigned to the intervention group or control group with usual care (N = 40 dyads per group). The intervention included 4-week dyadic psychoeducational intervention. At before intervention (T0), immediately after intervention (T1), 1 month after intervention (T2) and 3 months after intervention (T3), patients' quality of life ana caregiver burden (primary outcomes), and other secondary outcomes (i.e., dyads' coping, depression and anxiety symptoms, and social support) were evaluated. Generalized Estimated Equation was used to test the intervention effect of the dyadic psychoeducation intervention, and intentional-to-treat analysis was used for all analyses.

RESULTS

Effects of dyadic psychoeducational intervention: The result of adjusting the GEE model shows that dyadic psychoeducational intervention can effectively improve patients' quality of life (T1: β = 8.51, p < 0.001; T2: β = 9.03, p < 0.001; T3: β = 8.82, p < 0.001), patients' anxiety (T1: β = -2.35, p = 0.022; T2: β = -2.84, p = 0.002; T3: β = -2.85, p = 0.001) and caregivers' anxiety (T2: β = -1.67, p = 0.012; T3: β = -2.57, p = 0.004), patients' depression (T2: β = -2.39, p = 0.017; T3: β = -2.71, p = 0.006), caregiver burden (T2: β = -6.95, p = 0.007; T3: β = -6.34, p = 0.008), caregiver depression (T2: β = -2.01, p = 0.015; T3: β = -1.85, p = 0.015).

CONCLUSIONS

The dyadic psychoeducational intervention can improve the psychosocial outcomes of haemodialysis dyads. This intervention provides effective ways and measures for the relevant psychological education intervention and provides new ideas and evidence for clinical nursing research.

TRIAL REGISTRATION

This study was retrospectively registered as a randomized controlled trial in the ClinicalTrials Registry. Registration Date: April 16, 2024.

REGISTRATION NUMBER

NCT06203730.

Interaction between chronic kidney disease and atrial fibrillation on incident stroke and all-cause mortality: Matched cohort study of 49,594 patients

BACKGROUND AND AIMS

The interaction between full-spectrum chronic kidney disease (CKD) and atrial fibrillation (AF) on ischemic stroke and all-cause mortality risk, particularly in stage 4 and 5 CKD, remains undetermined.

METHODS

This matched cohort study identified incident AF patients using the International Classification of Disease codes and electrocardiograms from the Clinical Research Data Repository of China Medical University Hospital between 2003 and 2020. For each AF patient, we selected four controls without AF and matched them by age, sex, eGFR within 10 mL/min/1.73 m2, end-stage kidney disease (ESKD) vintage, and diagnosis year. Multivariable Cox proportional hazard models were utilized to assess the interaction between AF and CKD on three-year ischemic stroke and all-cause mortality outcomes.

RESULTS

Within a total of 10,155 patients and 39,439 controls, incidence rates were 3.03 % and 1.48 % for ischemic stroke and 15.6 % and 9.53 % for overall mortality, respectively. In AF, the stroke risk was the highest among patients with stage 4 and 5-ND (non-dialysis) CKD with adjusted hazard ratio (aHR) of 3.31 (95 % CI, 2.46-4.45) and 2.73 (1.88-3.96), respectively. The mortality risk difference varied between 45% and 177 % with the highest difference noted in ESKD (aHR 3.36 [95 % CI, 2.84-3.98] in AF vs. 1.59 [95 % CI, 1.28-1.96] in non-AF; interaction p < 0.001). Anticoagulation therapy significantly lowered the mortality risk among patients with AF and advanced CKD (3-way interaction p < 0.001).

CONCLUSIONS

The risk of ischemic stroke and overall mortality was particularly high among patients with concurrent AF and stage 4 and 5-ND CKD, underscoring the urgent evidence to optimize prognosis.

Targeting renal damage: The ACE2/Ang-(1-7)/mas axis in chronic kidney disease

The renin-angiotensin system (RAS) is a crucial factor in chronic kidney disease (CKD) progression, affecting renal function and contributing significantly to renal tissue inflammation and fibrosis. Activation of the classical ACE/Ang II/AT1 axis exacerbates renal damage, while the ACE2/Ang-(1-7)/Mas axis has shown promise in reducing CKD progression in numerous animal models. Recently, the ACE2/Ang-(1-7)/Mas axis has emerged as a promising target for CKD interventions. This review provides a comprehensive review of the pivotal role of this axis in CKD pathogenesis and systematically examines various molecules and pharmaceutical agents targeting this pathway. This review aims to elucidate potential strategies for delaying or halting CKD progression, offering patients more effective treatment options.