Progression, remission, regression of chronic renal diseases

Innovative therapeutics for renoprotection: Where we are

Chronic kidney disease (CKD) has become highly prevalent worldwide, with major implications for public health, including increased risk of progression to kidney failure, cardiovascular events, and mortality. Up to a decade ago, renin-angiotensin system inhibitors, that is angiotensin-converting enzyme inhibitors and angiotensin II type 1 receptor blockers, were the only available pharmacological interventions to slow kidney function loss and limit the associated cardiovascular morbidity and mortality in this context. More recently, landmark trials have demonstrated the ability of novel therapeutics to significantly ameliorate kidney and cardiovascular outcomes in patients with CKD, when added on top of optimized renin-angiotensin system blockade. These include sodium-glucose cotransporter-2 inhibitors in patients with diabetic and nondiabetic kidney disease, as well as the nonsteroidal mineralcorticoid receptor antagonist finerenone and the glucagon-like peptide-1 receptor agonist semaglutide in patients with diabetic kidney disease. We herein review the evolving scenario and the latest evidence for the treatment of CKD, mainly focusing on proteinuric CKD. We started with a presentation of established and more recently approved classes of kidney protective drugs, followed by a discussion of therapeutic interventions under clinical investigation to slow CKD progression. Finally, we underscore the added value of personalized and multidrug interventions, which are becoming increasingly more feasible with the availability of a growing number of kidney protective agents, and are likely to stand as the most powerful tools to safely slow, or even prevent, the progression of proteinuric CKD. SIGNIFICANCE STATEMENT: Chronic kidney disease (CKD) is highly prevalent globally, and is associated with substantial morbidity and mortality. This review provides a comprehensive overview of the currently approved and emerging therapeutic options for the treatment of proteinuric CKD. As novel kidney protective agents have recently become available, the outcomes of patients with CKD could hopefully improve over the few decades ahead.

Comparing Long-Term Outcomes in Glomerular Disease Patients Presenting with Nephrotic Syndrome Versus Nephrotic Range Proteinuria

BACKGROUND

Despite extensive research on proteinuria's impact on chronic kidney disease progression, there is no direct comparison of outcomes in biopsy-diagnosed glomerular disease (GD) patients with nephrotic syndrome (NS) or nephrotic range proteinuria (NRP). Our study addresses this gap, comparing long-term outcomes between NS and NRP.

METHODS

We conducted a retrospective study on 240 kidney biopsy-proven GD patients, tracked from 2010 to 2015 until end-stage kidney disease (ESKD), death, or the study end in January 2022.

RESULTS

The median follow-up was 8.8 years. Diagnoses were predominantly nonproliferative (53%), proliferative (25%) nephropathies, diabetic nephropathy (12%), and paraprotein diseases (10%). NS was observed in 141 (59%) patients, presenting more frequently with arterial hypertension, higher eGFR, increased proteinuria, and dyslipidemia than NRP patients. NRP patients often had proliferative GD and diabetic nephropathy; their renal chronicity score was higher. The ESKD endpoint occurred in 35% NS and 39% NRP patients (p 0.4). The cohort's mean kidney survival time was 8.2 years. In a multivariate analysis, NS, lower eGFR, a higher renal chronicity score, and diabetic nephropathy were associated with ESKD. A total of 64 patients (27%) died, 73% post-kidney replacement therapy initiation, and mostly from cardiovascular disease (63%). Mortality between proteinuria forms showed no difference. The multivariate analysis found lower eGFR, a higher Charlson comorbidity score, and diabetic nephropathy associated with mortality.

CONCLUSIONS

Our study found no difference in all-cause mortality between NS and NRP in glomerular diseases. However, an adjusted analysis revealed poorer kidney survival for NS patients, emphasizing the need for personalized management to improve renal prognoses.

Proteinuria and Progression of Renal Damage: The Main Pathogenetic Mechanisms and Pharmacological Approach

The integrity of the glomerular filtration barrier maintains protein excretion below 150 mg/day. When urinary proteins increase, this indicates damage to the filtration barrier. However, proteinuria is not only a marker of kidney damage but also exacerbates it through various mechanisms involving the glomerular and tubulointerstitial compartments. Therefore, it is essential to intervene with renoprotective action that reduces the proteinuria. In this context, Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are cornerstone treatments. Recent advancements include sodium-glucose cotransporter 2 inhibitors, initially used for glycemic control, now recognized for their renoprotective properties in both diabetic and non-diabetic populations. Another drug, Finerenone, a selective non-steroidal mineralocorticoid receptor antagonist, has emerged as a promising agent, offering anti-inflammatory and antifibrotic benefits with fewer side effects than traditional steroidal options. Finally, dual inhibition of angiotensin II and endothelin-1 receptors through agents like Sparsentan presents a novel approach with significant antiproteinuric effects in IgA nephropathy and focal segmental glomerulosclerosis. This brief review summarizes the mechanisms by which proteinuria promotes kidney damage and the renoprotective therapeutic approaches available, which can be combined with lifestyle modifications and specific treatments for underlying diseases to mitigate the progression of chronic kidney disease.

Comprehensive Clinical Profile and Hemodialysis Outcomes in Patients Attending a Tertiary Care Hospital

Background Chronic kidney disease (CKD) can lead to serious conditions such as anemia and cardiovascular disease, posing a growing global health challenge. End-stage renal disease (ESRD) requires treatments such as dialysis or kidney transplantation. Despite the widespread impact and rising prevalence of CKD and ESRD, comprehensive data remains limited in India. This study seeks to investigate the clinical, socio-demographic, and etiological profiles of CKD patients undergoing hemodialysis at a tertiary care hospital, with the goal of enhancing understanding and improving patient care. Methodology This retrospective cohort study, conducted at a tertiary care center, included 500 CKD patients undergoing hemodialysis, with comprehensive medical records. Data collected covered demographics (age, sex, education, and occupation), CKD etiology, disease duration, hemodialysis duration, viral marker status, blood transfusions, and vascular access details. With continuous variables reported as mean ± standard deviation (SD) and categorical variables as counts (percentages), statistical analysis was carried out using SPSS version 21 (IBM Corp., Armonk, New York, USA). The connections were examined using the Pearson Chi-square test, with P≤0.05 being deemed significant. Results The study revealed that hypertension was the primary cause of CKD in 58% of patients, followed by diabetes mellitus in 13%. A significant 93% of patients tested negative for viral markers such as human immunodeficiency virus (HIV), hepatitis C virus (HCV), and hepatitis B surface antigen (HBsAg). Hemodialysis duration varied, with 68% of patients undergoing dialysis for one to five years. Most patients had two (40%) or three (58%) dialysis sessions per week, and 84% had only one arteriovenous (AV) fistula surgery. Blood transfusions were common, with 62% of patients receiving between one and five transfusions. The gender distribution showed more males (372) than females (201), and the majority of patients were aged between 41 and 60 years. Conclusion This study highlights the importance of early detection and management of CKD, emphasizing preventive health measures, enhanced diagnostic capabilities, and sufficient resource allocation to reduce the disease burden. It also calls for further research into unknown CKD causes and strategies to improve patient care and outcomes.

Mendelian Randomization Analysis of Systemic Iron Status and Risk of Different Types of Kidney Disease

With rapid increases in incidence, diverse subtypes, and complicated etiologies, kidney disease remains a global public health problem. Iron, as an essential trace element, has pleiotropic effects on renal function and the progression of kidney diseases. A two-sample Mendelian randomization (MR) analysis was implemented to determine the potential causal effects between systemic iron status on different kidney diseases. Systemic iron status was represented by four iron-related biomarkers: serum iron, ferritin, transferrin saturation (TfSat), and total iron binding capacity (TIBC). For systemic iron status, 163,511, 246,139, 131,471, and 135,430 individuals were included in the genome-wide association study (GWAS) of serum iron, ferritin, TfSat, and TIBC, respectively. For kidney diseases, 653,143 individuals (15,658 cases and 637,485 controls), 657,076 individuals (8160 cases and 648,916 controls), and 659,320 individuals (10,404 cases and 648,916 controls) were included for immunoglobulin A nephropathy (IgAN), acute kidney disease (AKD), and chronic kidney disease (CKD), respectively. Our MR results showed that increased serum iron [odds ratio (OR): 1.10; 95% confidence interval (95% CI): 1.04, 1.16; p < 0.0042], ferritin (OR: 1.30; 95% CI: 1.14, 1.48; p < 0.0042), and TfSat (OR: 1.07; 95% CI: 1.04, 1.11; p < 0.0042)] and decreased TIBC (OR: 0.92; 95% CI: 0.88, 0.97; p < 0.0042) were associated with elevated IgAN risk. However, no significant associations were found between systemic iron status and AKD or CKD. In our MR study, the genetic evidence supports elevated systemic iron status as a causal effect on IgAN, which suggests a potential protective effect of iron chelation on IgAN patients.

Serum soluble LYVE1 is a promising non-invasive biomarker of renal fibrosis: a population-based retrospective cross-sectional study

Diagnosis of renal fibrosis can only be verified by kidney biopsy, but biomarkers for non-invasive evaluation remain unsatisfactory. Patients with fibrosis often have abnormalities of the lymphatic vascular system and associated immune function. We describe here a lymphatic marker as a candidate biomarker for fibrosis. After assessing and grading the fibrosis scores, testing serum soluble lymphatic vessel endothelial hyaluronan receptor1 (sLYVE1) level, and collecting clinical information, the association between sLYVE1 and renal fibrosis was analyzed. Logistic regression analysis was used to screen variables. Diagnosis models with or without sLYVE1 were built, and nomograms were plotted. Calibration curve, C-index, and DCA were performed to assess the models. A total of 298 patients were enrolled in the study, of which 199 were included in the training cohort and 99 patients in the validation cohort. Serum sLYVE1 levels markedly elevated with increasing fibrosis grade (p<0.05). ROC analysis of sLYVE1 showed an AUC of 0.791 and 0.846 with optimal cut-off value of 405.25 ng/mL and 498.55 ng/mL for the prediction of moderate-to-severe renal fibrosis (MSF) and severe renal fibrosis (SF), respectively. The diagnostic nomogram model without sLYVE1 (model 1) included traditional clinical determinants (C-index: 0.658 for MSF; 0.603 for SF). A combination of model 1 and sLYVE1 (model 2) improved predictive performance (C-index: 0.847 for MSF; 0.856 for SF). Calibration curve and DCA demonstrated a better consistency accuracy and clinical benefit of model 2 than model 1. Serum sLYVE1 may be identified as a potential biomarker of renal fibrosis. Models incorporating sLYVE1 may be beneficial for a more accurate non-invasive diagnosis of renal fibrosis.

Impact of moderate to vigorous intensity physical activity on change in renal function in patients after acute myocardial infarction

Acute myocardial infarction (AMI) is associated with a decline in renal function. This study aimed to investigate the impact of engaging in moderate to vigorous intensity physical activity (MVPA) for more than 30 min per day on changes in renal function during the first 3 months after AMI onset. A prospective, observational study was conducted, enrolling 87 patients (75 men; average age, 65.2 ± 12.5 years) who had experienced AMI. The cystatin C-based estimated glomerular filtration rate (eGFRcys) was collected at and 3 months after discharge. Daily MVPA was measured using triaxial accelerometers at a threshold of 3.0 Metabolic equivalent of the task for 3 months. Generalized estimating equations (GEE) were applied to evaluate the longitudinal association between the number of days per week of MVPA for 30 min or more and within-patient changes in eGFRcys. The patients were categorized into three groups based on their MVPA engagement days: 0 days (n = 20), 1-2 days (n = 14), and 3-7 days (n = 53) groups. After adjusting for potential confounding variables, GEE analysis revealed that the eGFRcys slope over 3 months was significantly higher in the 3-7 days group than in 0 days group (B = 2.9, (95% confidence interval: 1.5-4.2), p < 0.001). Similar results were obtained when MVPA time thresholds were set to 40 and 60 min. These findings suggest a significant positive effect of engaging in MVPA for 30 min or more for 3-7 days per week in the improvement of renal function after AMI onset.

Osteoprotegerin and Inflammation in Incident Peritoneal Dialysis Patients

Objectives: Osteoprotegerin (OPG) is a member of the tumor necrosis factor receptor family involved in processes in many inflammatory states. OPG concentration is enhanced in the majority of chronic kidney disease (CKD) patients and those undergoing renal replacement therapy. The aim of the study was to assess the relation of OPG and chronic inflammation in peritoneal dialysis (PD) patients and to evaluate whether OPG concentrations in plasma and dialysate were related to plasma and dialysate levels of proinflammatory mediators (interleukin 6 (IL-6), high-sensitivity C-reactive protein (hsCRP), interleukin 33 (IL-33) and interleukin 1 receptor-like 1IL-1RL1 (IL-1RL1, sST2)). Methods: The study included 37 patients of the Peritoneal Dialysis Center, Department of Nephrology, Transplantology and Internal Medicine, Szczecin, Poland, 4-6 weeks after the onset of peritoneal dialysis therapy. During a peritoneal equilibration test, plasma (at 2 h) and dialysate (at 4 h) OPG, IL-33, 1IL-1RL1 (sST2), IL-6 and hsCRP concentrations were determined. Results: Plasma concentration of OPG did not correlate with dialysate OPG level (Rs = 0.04, p = 0.8). There was a strong positive correlation between plasma OPG concentrations and plasma IL-1RL1 (sST2) (Rs = 0.41; p = 0.01), plasma IL-6 (Rs = 0.38; p = 0.01) and plasma hsCRP (Rs = 0.35; p = 0.02). Dialysate OPG concentrations were positively associated with dialysate IL-1RL1 (sST2) (Rs = 0.37; p = 0.02) and dialysate IL-6 levels (Rs = 0.44; p = 0.005). Multivariate analysis showed that higher IL-1RL1 (sST2) (ß = +0.38, p = 0.006), higher plasma hsCRP (ß = +0.32, p = 0.02) and older age (ß = +0.35, p = 0.01) were independent determinants of higher plasma OPG concentration and that higher concentrations of dialysate IL-6 (ß = +0.37, p = 0.02) were independent determinants of higher dialysate OPG concentration. Conclusions: Both plasma and dialysate OPG levels are associated with the severity of systemic and local inflammation illustrated by the plasma and dialysate concentrations of IL-1RL1 (sST2), hsCRP and IL-6, suggesting that OPG might have a pivotal role in explaining the milieu of systemic and intraperitoneal inflammation.

Predictive performance of the sequential organ failure assessment score for in-hospital mortality in patients with end-stage kidney disease in intensive care units: A multicenter registry in Japan

INTRODUCTION

There is limited evidence regarding whether the performance of the Sequential Organ Failure Assessment (SOFA) score differs between patients with and without end-stage kidney disease (ESKD) in intensive care units (ICUs).

METHODS

We used a multicenter registry (Japanese Intensive care Patient Database) to enroll adult ICU patients between April 2018 and March 2021. We recalibrated the SOFA score using a logistic regression model and evaluated its predictive ability in both ESKD and non-ESKD groups. The primary outcome was in-hospital mortality.

RESULTS

128 134 patients were enrolled. The AUROC of the SOFA score was lower in the ESKD group than in the non-ESKD group [0.789 (95% CI, 0.774-0.804) vs. 0.846 (95% CI, 0.841-0.850)]. The calibration plot revealed good performance in both groups. However, it overestimated in-hospital mortality in ESKD groups.

CONCLUSION

The SOFA score demonstrated good predictive ability in patients with and without ESKD, but it overestimated the in-hospital mortality in ESKD patients.

The association between trypsin-like protease activity in the oral cavity and kidney function in Japanese workers

AIM

To evaluate the association between trypsin-like protease (TLP) activity in the oral cavity as an indicator of periodontal health status and kidney function in Japanese workers.

MATERIALS AND METHODS

This cross-sectional study included 1117 Japanese workers (mean age = 43.8 years). Tongue-swab TLP activity was quantified as a* value (the redness intensity of the matrix disc of the TLP activity assessment kit; a larger value indicates more intense enzymatic activity in the samples and poorer periodontal health status). Kidney function was assessed using the estimated glomerular filtration rate (eGFR; a lower value indicates poorer kidney function). We performed ordinal logistic regression analyses to assess the association of the a* value with three eGFR categories: ≥90, 60-89 and <60 mL/min/1.73 m2 .

RESULTS

The prevalence for each eGFR category was as follows: ≥90 (31.6%), 60-89 (63.8%) and <60 mL/min/1.73 m2 (4.6%). After adjusting for potential confounders, the a* value was found to be significantly associated with reduced kidney function. The multivariable-adjusted odds ratio (95% confidence interval) for reduced kidney function was 1.12 (1.02-1.22) per unit increase in the a* value.

CONCLUSIONS

Higher TLP activity was associated with reduced kidney function in Japanese workers.

Comprehensive advancements in the prevention and treatment of diabetic nephropathy: A narrative review

Diabetic nephropathy (DN) is a common and severe complication of diabetes mellitus and is the leading cause of chronic kidney disease (CKD) worldwide. Despite current treatments, many individuals with DN progress to end-stage renal disease (ESRD), requiring dialysis or kidney transplantation. The advancement in our understanding of the pathogenesis of diabetic nephropathy has led to the development of new prevention and treatment strategies. We comprehensively reviewed the literature on advances in the prevention and treatment of DN. We searched PubMed, Scopus, and Web of Science databases for articles published between 2000 and 2023, using keywords such as "diabetic nephropathy," "prevention," "treatment," and "recent advances." The recent advances in the prevention and treatment of DN include novel approaches targeting inflammation and fibrosis, such as inhibitors of the nuclear factor kappa-B (NF-kB) pathway, inhibitors of the transforming growth factor-beta (TGF-beta) pathway, and anti-inflammatory cytokines. Other promising strategies include stem cell therapy, gene therapy, and artificial intelligence-based approaches, such as predictive models based on machine learning algorithms that can identify individuals at high risk of developing DN and guide personalized treatment strategies. Combination therapies targeting multiple disease pathways may also offer the most significant potential for improving outcomes for individuals with DN. Overall, the recent advances in the prevention and treatment of DN represent promising avenues for future research and clinical development. Novel therapies targeting inflammation and fibrosis, stem cell and gene therapies, and artificial intelligence-based approaches all show great potential for improving outcomes for individuals with DN.

Peak exercise oxygen uptake and changes in renal function in patients after acute myocardial infarction

BACKGROUND

The impact of exercise tolerance on renal function change after acute myocardial infarction (AMI) is not clear.

OBJECTIVES

The present study aimed to elucidate the effect of peak exercise oxygen uptake (VO₂) levels on longitudinal changes in renal function up to 1 year after onset of AMI.

METHODS

This retrospective longitudinal study enrolled 198 AMI patients. Symptom-limited cardiopulmonary exercise testing was performed at completion of early Phase II cardiac rehabilitation, and peak VO₂ levels were defined as the primary exposure factor. The estimated glomerular filtration rates (eGFRs) at baseline, 3 months, 6 months and 1 year were collected. Generalized estimating equation (GEE) models were used to test the longitudinal effect of peak VO₂ levels on within-patient changes in eGFR.

RESULTS

Patients were stratified into tertile groups (Low group, 12.3 ± 1.3 mL/kg/min; Mid group, 15.3 ± 0.7 mL/kg/min; and High group, 19.1 ± 2.3 mL/kg/min) according to peak VO₂ levels. The slopes of eGFR over 1 year in the Low (p = 0.024) and Mid groups (p = 0.037) were lower compared to the High group. The Low group had a significantly higher odds ratio of experiencing rapid renal function decline than the High group (odds ratio, 2.87; p = 0.012).

CONCLUSIONS

There was a significant effect of lower peak VO₂ on rapid decline in renal function after AMI. Our findings suggest that the coexistence of exercise intolerance may be a novel risk factor for rapid decline in renal function after AMI.

Tight Blood Pressure Control in Chronic Kidney Disease

Hypertension affects over a billion people worldwide and is the leading cause of cardiovascular disease and premature death worldwide, as well as one of the key determinants of chronic kidney disease worldwide. People with chronic kidney disease and hypertension are at very high risk of renal outcomes, including progression to end-stage renal disease, and, even more importantly, cardiovascular outcomes. Hence, blood pressure control is crucial in reducing the human and socio-economic burden of renal and cardiovascular outcomes in those patients. However, current guidelines from hypertension and renal societies have issued different and sometimes conflicting recommendations, which risk confusing clinicians and potentially contributing to a less effective prevention of renal and cardiovascular outcomes. In this review, we critically appraise existing evidence and key international guidelines, and we finally formulate our own opinion that clinicians should aim for a blood pressure target lower than 130/80 in all patients with chronic kidney disease and hypertension, unless they are frail or with multiple comorbidities. We also advocate for an even more ambitious systolic blood pressure target lower than 120 mmHg in younger patients with a lower burden of comorbidities, to minimise their risk of renal and cardiovascular events during their lifetime.

Glomerular hyperfiltration

Circulating blood is filtered across the glomerular barrier to form an ultrafiltrate of plasma in the Bowman's space. The volume of glomerular filtration adjusted by time is defined as the glomerular filtration rate (GFR), and the total GFR is the sum of all single-nephron GFRs. Thus, when the single-nephron GFR is increased in the context of a normal number of functioning nephrons, single glomerular hyperfiltration results in 'absolute' hyperfiltration in the kidney. 'Absolute' hyperfiltration can occur in healthy people after high protein intake, during pregnancy and in patients with diabetes, obesity or autosomal-dominant polycystic kidney disease. When the number of functioning nephrons is reduced, single-nephron glomerular hyperfiltration can result in a GFR that is within or below the normal range. This 'relative' hyperfiltration can occur in patients with a congenitally reduced nephron number or with an acquired reduction in nephron mass consequent to surgery or kidney disease. Improved understanding of the mechanisms that underlie 'absolute' and 'relative' glomerular hyperfiltration in different clinical settings, and of whether and how the single-nephron haemodynamic and related biomechanical forces that underlie glomerular hyperfiltration promote glomerular injury, will pave the way toward the development of novel therapeutic interventions that attenuate glomerular hyperfiltration and potentially prevent or limit consequent progressive kidney injury and loss of function.

How does clinical profile and outcome differ in patients with Chronic Kidney Disease undergoing percutaneous coronary revascularization according to the severity of CKD? - CHANNEL Study

BACKGROUND

Chronic kidney disease (CKD) is an independent risk factor for the development of coronary artery disease. We evaluated outcomes amongst patients of CKD undergoing percutaneous coronary intervention (PCI) as assessed on severity of CKD based on estimated glomerular filtration rate (eGFR) at the time of PCI.

METHOD AND MATERIALS

We analyzed 100 consecutive CKD patients who underwent PCI and were followed up for 1 year; an observational, prospective, open-label study. Multivariate and Receiver operator characteristics (ROC) analysis was used to determine the cut point ofeGFR for predicting 4-P major adverse cardiac events (MACE) outcomes defined as the composite of Cardiovascular (CV) mortality, heart failure hospitalization (HHF), repeat revascularization and non-fatal MI over 1 year follow up.

RESULTS

According to eGFR cut-off value derived from ROC, patients were divided in to two groups based on eGFR cut-off of 36.25 mL/min/1.73 m². Majority of patients (79%) were in Group 1 (eGFR >36.25 mL/min/1.73 m²). Group 2 had Lower HbA1C, hemoglobin and elevated level of urea as compared to group:1 (p=0.002,<0.0001 respectively). All-cause mortality had trend forbeing higher (6.3 vs. 19%) in group:2, but statistically non-significant (p = 0.17). Lower baseline LVEF (39 ± 10.08%) across the cohort was independent predictor of higher risk for HHF. eGFR <36.25 mL/mim/1.73 m² was the most robust predictor of MACE, carrying a 3-fold increase in risk of 4-P MACE with significant association (0.69, CI 0.59 to 0.78, p = 0.0009).

CONCLUSIONS

Lower baseline eGFR was associated with higher incidence of 4 P MACE with best cut-off being eGFR <36.25 mL/min/1.73 m². Lower Baseline LVEF was independent predictor from HHF across the cohort.

An Evaluation of Socio-Demographic and Risk Factor Profile in End-Stage Renal Disease Patients: A Cross-Sectional Assessment

Background The global incidence and prevalence of chronic kidney disease (CKD) is skyrocketing. In Asia, the prevalence of CKD varies from 10%-18%. However, as Asia is largely populated by developing countries with nascent health care systems, there is a dearth of research and data. It is estimated that a large number of cases go unreported. As a result, the exact disease burden remains unclear. The knowledge about risk factors and their proportionate role in CKD is indispensable in regards to patient management and care.  Objective The early recognition of the most important risk factors for end-stage renal disease (ESRD) is key to early diagnosis, successful treatment, and general heightened awareness regarding CKD. In developing countries, the provision of medical services, in general, and nephrological services, in particular, is wholly inadequate. The insufficiency of solid and regularly updated data compounds the problem. This research study aims to partake in catering to that need. Methodology A structured questionnaire was used to obtain quantitative and categorical data from 119 ESRD patients in the nephrology ward, Allied Hospital, Faisalabad through non-probability sampling. Socio-demographic profile of the patients and information regarding the presence or absence of risk factors were collected. The resulting dataset was analyzed using R version 3.6.3 (R Foundation for Statistical Computing, Vienna, Austria) for data visualization and descriptive analysis. Results The most common age group for ESRD presentation was 46-60 years (52.1%). Among the 119 ESRD patients, the most frequent risk factor was hypertension with 85.7% of the patients presenting with the condition, followed by diabetes mellitus (DM) in 54.6%, renal calculi in 28.6%, glomerulonephritis (GN) in 31.1%, Family history of CKD in 24.4%, and polycystic kidney disease (PKD) in 5% of the patients. Gender-wise distribution of the patients shows that the proportion of patients with hypertension, renal calculi, and family history of CKD varied very little among the two groups. Conclusion In conclusion, our study has reinforced the existing body of knowledge and brought some fresh evidence regarding the prevalence of risk factors in ESRD to light. Hypertension and DM, together, represent the vast majority of cases with ESRD. However, hypertension far outpaces DM as the leading risk factor. Nephrolithiasis was also present in a considerable minority, with a figure much higher than previously reported. Finally, a relatively younger age group (45-60 years) formed the majority of the ESRD patients which is a concerning development. It points to early progression of CKD to ESRD. Long-term adequate control of these risk factors limits disease progression.

From Proteinuria to Fibrosis: An Update on Pathophysiology and Treatment Options

BACKGROUND

Proteinuria is a key biomarker in nephrology. It is central to diagnosis and risk assessment and the primary target of many important therapies. Etiologies resulting in pathological proteinuria include congenital and acquired disorders, as well as both glomerular (immune/non-immune mediated) and tubular defects.

SUMMARY

Untreated proteinuria is strongly linked to progressive loss of kidney function and kidney failure. Excess protein reaching the renal tubules is ordinarily resorbed by the tubular epithelium. However, when these mechanisms are overwhelmed, a variety of inflammatory and fibrotic pathways are activated, causing both interstitial fibrosis and glomerulosclerosis. Nevertheless, the specific mechanisms underlying this are complex and remain incompletely understood. Recently, a number of treatments, in addition to angiotensin system blockade, have been shown to effectively slow the progression of proteinuric chronic kidney disease. However, additional therapies are clearly needed. Key message: This review provides an update on the pathophysiology of proteinuria, the pathways leading to fibrosis, and an overview of current and emerging therapies.

Pathophysiology, diagnosis, and treatment of membranous nephropathy

Nephrotic syndrome is in adult patients mainly due to membranous nephropathy (MN) characterized by thickening of the glomerular basement membrane (GBM) and immune complex formation between podocytes and the GBM. Autoantibodies directed against the M-type phospholipase A2 receptor (PLA2R) and thrombospondin 1 domain-containing 7 A (THSD7A) can be used as diagnostic biomarkers. THSD7A seems to be of direct pathogenic significance as is suggested by experimental models and plasmapheresis in humans. Recently, further antigens like NELL-1 (neural tissue encoding protein with EGF-like repeats-1), exostosin 1 and 2 have been discovered. Thus, MN should be classified into antibody positive and antibody negative MN. More specific immunosuppressive treatments directed against B-cells and antibody production like rituximab have been introduced in addition to already existing immunosuppressive protocols including steroids, chlorambucil, cyclophosphamide, and calcineurin inhibitors. Antibody removal using immunoadsorption or plasmapheresis leads to short-term reduction in proteinuria and might be indicated only in patients with very severe proteinuria and complications. Studies are needed to identify a more specific immunosuppression directed against the production and effects of autoantibodies in order to protect the kidneys from autoimmune mediated tissue damage and to identify patients who require an immunosuppressive treatment, as the remission rate is high in patients with MN.

Association between physical activity and changes in renal function in patients after acute myocardial infarction: A dual-center prospective study

BACKGROUND

Acute myocardial infarction (AMI) causes a decline in renal function. This study aimed to elucidate the longitudinal association between physical activity levels and changes in renal function up to 6 months after the onset of AMI.

METHODS

In this dual-center prospective observational study, 73 AMI patients (67 men; average age, 65.0±11.7 years) were enrolled from 2017 to 2019. Blood biochemistry, urinalysis, and physical function tests were conducted at discharge and 3 and 6 months post-discharge. The renal function was evaluated based on cystatin C-based estimated glomerular filtration rate (eGFRcys). The number of steps was recorded for 6 months post-discharge. Generalized estimating equation (GEE) models were used to test the longitudinal association between physical activity levels and within-patient changes in eGFRcys. Both GEE models with a follow-up period of 3 and 6 months were constructed to assess the effects of the passage of time.

RESULTS

Patients were stratified into the low (n=36; 2903±1187 steps/day) and high groups (n=37; 7988±3192 steps/day) based on the median number of steps. Both GEE models at the 3- (p=0.027) and 6-month follow-up (p=0.034) showed a significant positive association between the physical activity levels and within-patient changes in eGFRcys. The changes in eGFRcys at 6 months were -0.3 mL/min/1.73 m² and +4.4 mL/min/1.73 m² among the low and high group participants, respectively.

CONCLUSIONS

There was a significant positive association between physical activity and renal function changes after the onset of AMI, which persisted when the follow-up period was extended from 3 to 6 months. Our findings support the importance of interventions that enable maintaining high physical activity levels as a strategy for preserving renal function in AMI patients.

Dipeptidyl-Peptidase 4 Inhibitors did not Improve Renal Endpoints in Advanced Diabetic Kidney Disease

OBJECTIVE

The efficacy of dipeptidyl-peptidase 4 inhibitors (DPP4is) in advanced diabetic kidney disease (DKD) is unknown. We investigated whether DPP4is confer renal protective benefits in DKD patients.

METHODS

We conducted a retrospective cohort study between 2012 and 2018 in Taiwan. We only included type 2 diabetes patients with estimated glomerular filtration rate (eGFR) between 30 and 90 mL/min/1.73 m² and urine albumin to creatinine ratio between 300 and 5,000 mg/g. Patients with DPP4i prescriptions were selected as cases, while non-DPP4i users served as controls. We followed these patients until the presence of composite primary renal endpoints, which was defined by the earliest occur-rence of clinical renal outcomes.

RESULTS

A total of 522 patients were included in the analysis, comprising 273 patients with a DPP4i prescription who were selected as cases and 249 patients without DPP4i prescription who were assigned as controls. Median follow-up duration for DPP4i users and nonusers was 2.2 years and 3.4 years, respectively. At baseline, the mean glycated hemoglobin levels for DPP4i users and nonusers were 8.1% and 8.3%, respectively. Among patients with DPP4i prescriptions, there was no reduction in composite primary renal outcome, with a crude hazard ratio (HR) of 1.50 (95% confidence interval [CI], 0.95 to 2.36). Similar results were observed for the risk of persistent eGFR <15 mL/min/1.73 m², with a HR of 1.68 (95% CI, 0.90 to 3.13), doubling of serum creatinine level, with a HR of 1.05 (95% CI, 0.15 to 7.45), and end-stage renal disease, with a HR of 0.87 (95% CI, 0.14 to 5.19).

CONCLUSION

DPP4i prescription did not reduce the risk of composite renal endpoints in DKD patients.

ABBREVIATIONS

BMI = body mass index; CI = confidence interval; CVOT = cardiovascular outcomes trial; DPP4i = dipeptidyl-peptidase 4 inhibitor; DKD = diabetic kidney disease; eGFR = estimated glomerular filtration rate; ESRD = end-stage renal disease; HbA1c = glycated hemoglobin; HR = hazard ratio; SGLT2i = sodium-glucose cotransporter 2 inhibitor; T2D = type 2 diabetes; UACR = urine albumin to creatinine ratio.

Microvascular changes at different stages of chronic kidney disease

Patients with progressing chronic kidney disease (CKD) are more likely to experience cardio‐ and cerebrovascular events than progressing to end‐stage renal disease. The authors explored whether retinal microvascular calibers differed with the degree of renal impairment and between the standard and extended optic disk and may serve as a simple additional tool for risk stratification in this highly vulnerable patient cohort. The authors analyzed central retinal arteriolar and venular equivalent calibers (CRAE, CRVE) at different retinal zones (zone B&C) using digital retinal imaging in hypertensive patients with stage 2 (n = 66) or stage 3 CKD (n = 30). Results were adjusted for age, sex, HbA1c, and 24‐hour diastolic blood pressure. Mean eGFR was 77.7 ± 8.9 and 48.8 ± 7.9 ml/min/1.73 m² for stage 2 and 3 CKD, respectively. CRAE and CRVE in zones B and C were significantly lower in patients with stage 3 CKD compared to patients with stage 2 CKD (CRAE‐B:141.1 ± 21.4 vs. 130.5 ± 18.9 µm, p = .030; CRAE‐C:137.4 ± 19.4 vs 129.2 ± 18.2 µm, p = .049; CRVE‐B:220.8 ± 33.0 vs. 206.0 ± 28.4 µm, p = .004; and CRVE‐C:215.9 ± 33.0 vs. 201.2 ± 25.1µm, p = .003). In patients with stage 2 CKD, CRAE‐B was higher than CRAE‐C (141.1 ± 21.4 vs. 137.4 ± 19.4µm, p < .001). In contrast, such a difference was not found in patients with stage 3 CKD. CRAE of both retinal zones correlated with eGFR for the entire cohort. In patients with stage 3 CKD, retinal narrowing is more pronounced compared to patients with stage 2 CKD. Whether the novel observation of difference in arteriolar caliber between zones B and C in stage 2 CKD could serve as an early marker of CKD progression warrants further investigation.

Occupational risk factors for chronic kidney disease in Andhra Pradesh: 'Uddanam Nephropathy'

BACKGROUND

CKD of unknown etiology (CKDu) has been reported in several countries including India. We previously showed a prevalence of CKD in India to be 17.2% and we found a CKD epidemic in Andhra Pradesh (AP) to be 46.8%. We conducted this study to further explore the unexplained CKD epidemic in AP.

METHODS

We recruited 1201 adult participants through systematic random sampling from eight administrative divisions. Demographic, medical, and detailed occupational history was collected. Anthropometric measurements and blood pressure were taken and blood and urine samples were collected. Poisson regression model was used to identify potential predictors for CKD.

RESULTS

We analyzed data for 1184 individuals with mean age of 44.6 ± 14.0 years, of whom 44% were male. Prevalence of CKD was 32.2%. Working as a farmer had 20% more prevalence of CKD compared to non-farmers in the fully adjusted model (PR 1.2, 95% CI 1.01-1.42). Age, alcohol consumption, and chewing tobacco were also independent predictors of CKD. Gender, hypertension, and diabetes were not associated with CKD.

CONCLUSIONS

The prevalence of CKD in AP is 32.2%. Occupational exposure among farmers could play a potential role in this epidemic. Large longitudinal epidemiologic research studies are needed to trace the causes of this problem.

Short- and Long-Term Outcome of Chronic Dialyzed Patients Admitted to the ICU and Assessment of Prognosis Factors: Results of a 6-Year Cohort Study

OBJECTIVES

Data about end-stage kidney disease patients admitted to the ICU are scarce, dated, and mostly limited to short-term survival. The aim of this study was to assess the short- and long-term outcome and to determine the prognostic factors for end-stage kidney disease patients admitted to the ICU.

DESIGN

Prospective observational study.

SETTING

Medical ICUs in two university hospitals.

PATIENTS

Consecutive end-stage kidney disease patients admitted in two ICUs between 2012 and 2017.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

Renal replacement therapy variables, demographic, clinical, and biological data were collected. The requirement of mechanical ventilation and vasopressive drugs were also collected. In-ICU and one-year mortality were estimated and all data were analyzed in order to identify predictive factors of short and long-term mortality. A total of 140 patients were included, representing 1.7% of total admissions over the study period. Septic shock was the main reason for admission mostly of pulmonary origin. Median Simplified Acute Physiology Score II and Sequential Organ Failure Assessment score were at 63 and 6.7, respectively. In-ICU, hospital, and 1-year mortality were 41.4%, 46.4%, and 63%, respectively. ICU mortality was significantly higher as compared with ICU control group non-end-stage kidney disease (25% vs 41.4%; p = 0.005). By multivariate analysis, the short-term outcome was significantly associated with nonrenal Sequential Organ Failure Assessment score, and with the requirement of mechanical ventilation or/and vasoconstrictive agents during ICU stay. One-year mortality was associated with increased dialysis duration (> 3 yr) and phosphatemia (> 2.5 mmol/L), with lower albuminemia (< 30 g/L) and nonrenal Sequential Organ Failure Assessment greater than 8.

CONCLUSIONS

End-stage kidney disease patients presented frequently severe complications requiring critical care that induced significant short- and long-term mortality. ICU and hospital mortality depended mainly on the severity of the critical event reflected by Sequential Organ Failure Assessment score and the need of mechanical ventilation and/or catecholamines. One-year mortality was associated with both albuminemia and phosphatemia and with prior duration of chronic dialysis treatment, and with organ failure at ICU admission.

Chronic Kidney Disease among Middle-Aged and Elderly Population: A cross-sectional screening in a Hospital Camp in Varanasi, India

Chronic kidney disease (CKD) is no longer considered just a health burden, but a major health priority owing to its high treatment costs and poor outcome. The lack of community-based screening programs has led to the detection of CKD patients at advanced stages. This study aims to estimate the prevalence of CKD and patterns of known risk factors among the general population (middle-aged and elderly) attending a screening camp in a community-based setting. The study participants constituted a part of the general population of Varanasi (aged ≥45 years) who volunteered in a screening camp that was organized as part of the World Kidney Day Initiative at Opal Hospital. Information on age, sex, height, weight, smoking and drug history, history of diabetes, hypertension, and family history of kidney disease was extensively interrogated, while laboratory investigations such as urinalysis and serum creatinine levels were recorded. More than three-fifths of the participants were middle-aged adults (i.e., 45-64 years) and the remaining 34.8% were elderly population, i.e., ≥65 years. The overall prevalence of CKD in the 198 studied participants was 29.3%. Higher number of participants (40.6%) of elderly population had CKD (P = 0.011). The serum creatinine, albuminuria, and estimated glomerular filtration rate levels were strongly associated with CKD (P <0.05). Our study suggests that elderly individuals are at risk with higher serum creatinine levels and would benefit from early detection of CKD to prevent disease progression and associated morbidity and mortality.

Salivary creatinine as a diagnostic tool for evaluating patients with chronic kidney disease

BACKGROUND

Preliminary studies have shown the potential use of salivary creatinine concentration in the diagnosis of chronic kidney disease (CKD). For saliva to replace serum as a diagnostic tool, studies must be done to determine its effectiveness in the diagnosis and staging of CKD. The aim of the present study was to evaluate the use of salivary creatinine as a safe and non-invasive alternative for identifying patients with CKD.

METHODS

A cross-sectional study was conducted at Tygerberg Hospital in Cape Town, on 230 patients, across all stages of CKD. Ethical approval to conduct the study was obtained from the University of the Western Cape Biomedical Research Ethics Committee, and written informed consent was provided by each participant. Saliva and serum samples were collected for creatinine analysis and the correlation determined using Spearman's correlation. Receiver operating characteristics (ROC) analysis was used to determine the diagnostic ability of salivary creatinine. A cut-off value for optimal sensitivity and specificity of salivary creatinine to diagnose CKD with glomerular filtration rate (GFR) < 60 mL/min/1.73 m2 was obtained.

RESULTS

Serum creatinine values ranged from 46 μmol/L to 1581 μmol/L, with a median value of 134 μmol/L. Salivary creatinine values ranged from 3 μmol/L to 400 μmol/L, with a median of 11 μmol/L. There was a strong positive correlation (r = 0.82) between serum and salivary creatinine values. Linear regression analysis of serum and salivary creatinine for CKD patients was significant in all CKD stages, except for stage 1. Area under the curve for salivary creatinine was 0.839. A cut-off value of 8.5 μmol/L yielded a sensitivity of 78.3% and specificity of 74.0% for classifying patients as having CKD based on estimated GFR < 60 mL/min/1.73 m2.

CONCLUSIONS

The results support the potential of salivary creatinine as a non-invasive diagnostic tool for estimating GFR and identifying patients with CKD.

Real-world data on healthcare resource consumption and costs before and after kidney transplantation

End-stage renal disease (ESRD) is increasing worldwide as a consequence of population aging and increasing chronic illness. Treatment consists mostly of dialysis and kidney transplantation (KTx), and KTx offers advantages for life expectancy and long-term cost reductions compared with dialysis. This study uses the administrative database of the Lombardy Region to analyze the costs of a cohort of patients with ESRD receiving KTx, covering a time period of 24 months before transplant to 12 months after. During 2011, 276 patients underwent kidney transplantation (8.7% preemptive and 91.3% non-preemptive). In the period before transplantation, the main cost driver was dialysis (66.6% for the period from -24 to -12 months and 73.8% for the period from -12 to 0 months), while in the 12 months after KTx, the most relevant cost was surgery. The total cost -24 to -12 months pre-KTx was 35 049.2€; the cost -12 to 0 months was 36 745.9€; and the cost 12 months after KTx was 43 805.8€. Non-preemptive patients showed much higher costs both pre- and post-KTx than preemptive patients. This study highlights how KTx modifies the resource consumption and costs composition of patients with ESRD vs those undergoing dialysis treatment and how KTx may be economically beneficial, especially preemptive intervention.

Chronic Kidney Disease as a Risk Factor for Heart Failure With Preserved Ejection Fraction: A Focus on Microcirculatory Factors and Therapeutic Targets

Heart failure (HF) and chronic kidney disease (CKD) co-exist, and it is estimated that about 50% of HF patients suffer from CKD. Although studies have been performed on the association between CKD and HF with reduced ejection fraction (HFrEF), less is known about the link between CKD and heart failure with preserved ejection fraction (HFpEF). Approximately, 50% of all patients with HF suffer from HFpEF, and this percentage is projected to rise in the coming years. Therapies for HFrEF are long established and considered quite successful. In contrast, clinical trials for treatment of HFpEF have all shown negative or disputable results. This is likely due to the multifactorial character and the lack of pathophysiological knowledge of HFpEF. The typical co-existence of HFpEF and CKD is partially due to common underlying comorbidities, such as hypertension, dyslipidemia and diabetes. Macrovascular changes accompanying CKD, such as hypertension and arterial stiffening, have been described to contribute to HFpEF development. Furthermore, several renal factors have a direct impact on the heart and/or coronary microvasculature and may underlie the association between CKD and HFpEF. These factors include: (1) activation of the renin-angiotensin-aldosterone system, (2) anemia, (3) hypercalcemia, hyperphosphatemia and increased levels of FGF-23, and (4) uremic toxins. This review critically discusses the above factors, focusing on their potential contribution to coronary dysfunction, left ventricular stiffening, and delayed left ventricular relaxation. We further summarize the directions of novel treatment options for HFpEF based on the contribution of these renal drivers.

Usefulness of ambulatory blood pressure monitoring in chronic kidney disease: The moroccan experience

Among patients with chronic kidney disease (CKD), hypertension (HTN) is very common and widely recognized to accelerate the progression of CKD and increase the risk for cardiovascular events. Accumulated data indicate that ambulatory blood pressure monitoring (ABPM) is better in detecting HTN than office blood pressure (BP) measurement. The goal of this study is to describe the ABPM characteristics in a group of CKD and hypertensive patients. A transversal study was conducted over a period of six months, to evaluate the ABPM patterns among a group of hypertensive patients with CKD (Group 1) and compared the data with a control group (Group 2). ABPM was performed with measurement rate every 15 min during daytime and 30 min at night. Nondipping BP patterns were defined as the absence of fall in nocturnal systolic and diastolic BP >10% of daytime values. Masked HTN was defined as controlled office BP (<140/90 mm Hg) with an elevated overall average BP by 24-h ABPM (>125/75 mm Hg), and white-coat HTN was defined as association of elevated BP readings (>140/90 mm Hg) in a clinical setting and normal 24-h average BP levels (<130/80 mm Hg). Fifty patients were included in each group. HTN was much longer in duration among hypertensive patients with CKD and frequently associated with obesity, dyslipidemia, and diabetes (64% vs. 39.60%). Positive proteinuria was present in 82% of CKD patients with HTN. CKD patients with HTN received more antihypertensive drugs than Group 2 patients. HTN was much more uncontrolled among CKD patients (60% vs. 24%), more serious with higher daytime and nighttime SBP, and loss of physiologic dipping during nighttime BP measurement (80%). Out-of-office BP monitoring by ABPM may improve the assessment and the successful management of HTN in patients with CKD. Standardized definitions for the diagnosis of masked and white-coat HTN would facilitate research.

Effects of Sevelamer Carbonate in Patients With CKD and Proteinuria: The ANSWER Randomized Trial

RATIONALE & OBJECTIVE

Hyperphosphatemia is associated with increased risk for chronic kidney disease (CKD) progression and reduced antiproteinuric effects of renin-angiotensin system (RAS) blockers. We investigated whether the phosphate binder sevelamer carbonate may enhance the antiproteinuric effect of RAS inhibitors in patients with CKD.

STUDY DESIGN

Phase 2, randomized, controlled, open-label, crossover trial.

SETTING & PARTICIPANTS

Between November 2013 and December 2014, we enrolled 53 patients with CKD with estimated glomerular filtration rates (eGFRs)>15mL/min/1.73m² and residual proteinuria with protein excretion≥0.5g/24h despite maximal tolerated ramipril and/or irbesartan therapy from 2 nephrology units in Italy.

INTERVENTION

After stratification by serum phosphate level, ≤4 or>4mg/dL, patients were randomly assigned to 3 months of sevelamer (1,600mg thrice daily) treatment followed by 3 months without sevelamer separated by a 1-month washout period or 3 months without sevelamer followed by 3 months with sevelamer, also separated by a 1-month washout period.

OUTCOMES

The primary outcome was 24-hour proteinuria (n=49patients). Secondary outcomes included measured GFR (using iohexol plasma clearance), office blood pressure (BP), serum lipid levels, levels of inflammation and bone metabolism biomarkers, urinary electrolyte levels, and arterial stiffness.

RESULTS

Changes in proteinuria during the 3-month treatment with (from 1.36 [IQR, 0.77-2.51] to 1.36 [IQR, 0.77-2.60] g/24h) or without (from 1.36 [IQR, 0.99-2.38] to 1.48 [IQR, 0.81-2.77] g/24h) sevelamer were similar (P=0.1). Sevelamer reduced urinary phosphate excretion without affecting serum phosphate levels. Sevelamer reduced C-reactive protein (CRP), glycated hemoglobin, and total and low-density lipoprotein cholesterol levels and increased high-density lipoprotein cholesterol levels without affecting levels of office BP, measured GFR, fibroblast growth factor 23, klotho, intact parathyroid hormone, serum vitamin D, or other urinary electrolytes. Results were similar in the low- and high-phosphate groups. Sevelamer was well tolerated. Adverse events were comparable between treatment periods. One case of transient hypophosphatemia was observed during treatment with sevelamer.

LIMITATIONS

Short treatment duration, lower pretreatment proteinuria than expected.

CONCLUSIONS

3-month sevelamer treatment did not reduce proteinuria in patients with CKD on maximal RAS blockade. Amelioration of inflammation and dyslipidemia with sevelamer treatment raises the possibility that it may confer benefit in patients with CKD beyond reduction of proteinuria.

FUNDING

Sanofi (Milan, Italy).

TRIAL REGISTRATION

Registered at ClinicalTrials.gov with study number NCT01968759.

Association between physical activity and change in renal function in patients after acute myocardial infarction

BACKGROUND

Combined renal dysfunction worsens the subsequent prognosis in patients after acute myocardial infarction (AMI). Therefore, establishing a therapeutic modality to maintain or improve renal function in AMI patients is necessary. This study aimed to elucidate the association between physical activity level and change in renal function in such patients.

DESIGN

Prospective and observational study.

METHODS

We enrolled 41 patients (35 men; average age, 67.5 ± 12.6 years) after AMI onset. Blood biochemistry, urinalysis, and physical function tests were conducted at discharge and 3 months after discharge. Renal function was evaluated based on cystatin C based-estimated glomerular filtration rate (eGFRcys). The number of steps was recorded for 3 months post-discharge. Generalized estimating equations (GEE) was used to test the association between physical activity level and within-patient changes in eGFRcys.

RESULTS

Patients were stratified into low (n = 21; number of steps, 2335 ± 1219 steps/day) and high groups (n = 20; number of steps, 7102 ± 2365 steps/day). eGFRcys significantly increased from baseline to after 3 months in the high group (76.5 ± 13.8 to 83.2 ± 16.0 mL/min/1.73 m2, q = 0.004), whereas no significant change was observed in the low group (65.1 ± 15.9 to 62.2 ± 20.2 mL/min/1.73 m2, q = 0.125). Result of GEE adjusted for potential confounding variables showed a significant positive association between physical activity level and within-patient changes in eGFRcys (p = 0.003). Changes in eGFRcys was -2.9 mL/min/1.73 m2 among low group versus +6.7 mL/min/1.73 m2 among high group.

CONCLUSIONS

Physical activity level was positively associated with changes in renal function, demonstrating that high physical activity may suppress renal function decline in patients after AMI.

Ethnic prevalence of anemia and predictors of anemia among chronic kidney disease patients at a tertiary hospital in Johannesburg, South Africa

INTRODUCTION

Anemia is a complication of chronic kidney disease (CKD) that can greatly impact on its prognosis. However, the risk factors for anemia, including the influence of ethnicity, are not well established among the CKD population in Johannesburg.

METHODS

This was a cross-sectional study of 353 adult CKD patients attending the renal outpatient clinic of the Charlotte Maxeke Johannesburg Academic Hospital (Johannesburg, South Africa) from June 1, 2016 to December 30, 2016. Sociodemographic and clinical characteristics were obtained using a proforma. Blood samples were collected for serum electrolytes and hematological parameters. Predictors of low hemoglobin and iron deficiency anemia (IDA) were evaluated using multivariable binary logistic regression.

RESULTS

The mean age and prevalence of anemia among the CKD participants were 55.3±15.0 years and 43.18% (95% CI: 38.1%-48.4%), respectively. Blacks had the highest prevalence of anemia (46.9%), while Indians/Asians had the lowest (18.2%). Although the odds of anemia was 3.8-fold higher (odds ratio =3.8, P-value =0.059) among CKD stage V participants as compared to CKD stage I, the relationship between anemia and stages of CKD was non-linear. Diabetes mellitus (odds ratio =2.31, P-value =0.005) had a strong association with anemia among the CKD participants.

CONCLUSION

Almost half of the CKD participants were anemic, and the odds of anemia did not increase linearly with increasing severity of CKD. There was a marked ethnic disparity in anemia prevalence. Our study highlights the need for risk-based management of anemia among CKD patients.

Hydrogen sulfide modulates SIRT1 and suppresses oxidative stress in diabetic nephropathy

DN is recognized as not only a leading cause of end stage renal disease (ESRD) but also an independent risk factor for cardiovascular disease (CVD). Novel therapeutic approaches to diabetic nephropathy (DN) are needed, or else, healthcare resources will be overwhelmed by the expected worldwide increase in associated cases of ESRD and CVD. Reactive oxygen species (ROS) and advanced glycation end product (AGE) are implicated in the development of DN. Hydrogen sulfide (H₂S) is known for its antioxidant and antiapoptotic characteristics. Simultaneously diabetics have lower H₂S levels. Thus, it is worth investigating the use of H₂S in treatment of DN. To investigate the potential therapeutic role of H₂S in DN. Sixty male rats were divided into four groups: control, DN, DN+NaHS30 µmol/kg/day and DN+NaHS100 µmol/kg/day. Fasting blood sugar (FBS), kidney function tests, SIRT1 activity, superoxide dismutase activity (SOD), malondialdehyde (MDA) and expression of caspase3 and p53 in renal tissues were assessed. Kidney was examined histopathologically. DN rats had higher FBS, renal dysfunction, decreased SIRT1 and SOD activity levels, increased caspase3 and p53 relative expression and increased MDA in renal tissues. NaHS increased SIRT1 and reversed biochemical, apoptotic, oxidant and pathologic parameters characteristic of DN, with better results using a dose of 100 µmol/kg/day. H₂S has a protective role against DN through decreasing FBS, ROS, apoptosis and upregulating SIRT1, thus preserving renal cells from further damage caused by DM.

The aftermath of acute kidney injury: a narrative review of long-term mortality and renal function

Acute kidney injury (AKI) is a frequent complication of hospitalization and is associated with an increased risk of chronic kidney disease (CKD), end-stage renal disease (ESRD), and mortality. While AKI is a known risk factor for short-term adverse outcomes, more recent data suggest that the risk of mortality and renal dysfunction extends far beyond hospital discharge. However, determining whether this risk applies to all patients who experience an episode of AKI is difficult. The magnitude of this risk seems highly dependent on the presence of comorbid conditions, including cardiovascular disease, hypertension, diabetes mellitus, preexisting CKD, and renal recovery. Furthermore, these comorbidities themselves lead to structural renal damage due to multiple pathophysiological changes, including glomeruloscleroses and tubulointerstitial fibrosis, which can lead to the loss of residual capacity, glomerular hyperfiltration, and continued deterioration of renal function. AKI seems to accelerate this deterioration and increase the risk of death, CDK, and ESRD in most vulnerable patients. Therefore, we strongly advocate adequate hemodynamic monitoring and follow-up in patients susceptible to renal dysfunction. Additionally, other potential renal stressors, including nephrotoxic medications and iodine-containing contrast fluids, should be avoided. Unfortunately, therapeutic interventions are not yet available. Additional research is warranted and should focus on the prevention of AKI, identification of therapeutic targets, and provision of adequate follow-up to those who survive an episode of AKI.

The incessant search for renal biomarkers: is it really justified?

PURPOSE OF REVIEW

This review summarizes the most recent and relevant findings in the search for novel biomarkers for the most common renal diseases.

RECENT FINDINGS

Unprecedented, fast-paced technical advances in biomedical research have offered an opportunity to identify novel and more specific renal biomarkers in several clinical settings. However, despite the huge efforts made, the molecules identified so far have generally failed to provide relevant information beyond what has already been generated by established biomarkers, such as serum creatinine and proteinuria, whereas the complexity and costs of these technology platforms hamper their widespread implementation.

SUMMARY

No novel renal biomarkers have added clear-cut additional value in clinical decision-making. The only exception is anti-phospholipase A2 receptor antibodies, which have been implemented successfully as a diagnostic and prognostic biomarker of membranous nephropathy. This achievement, along with the large number of ongoing collaborative projects worldwide, should lead the renal community to be quite confident regarding the successful qualification of novel and effective diagnostic, prognostic and therapeutic response biomarkers for kidney diseases, hopefully in the next few years.

Analysis of emergency Department Frequentation among patients with advanced CKD (chronic kidney disease): Lessons to optimise scheduled renal replacement therapy initiation

The decision to initiate renal replacement therapy (RRT) implies a wide margin of uncertainty. Glomerular filtration rate (GFR) tells us the magnitude of renal damage. Proteinuria indicates the speed of progression. However, nowadays more than 50% of patients are still initiating RRT hastily, and it is life threatening.

HYPOTHESIS

By analysing Emergency Department (ED) frequentation and causes of a hurried initiation, we can better schedule the timing of the start of RRT.

METHOD

Retrospective and observational study of all CKD patients in our outpatient clinic. ED frequentation and hospitalisation (Hos) time were reviewed during a 12-month period. We analysed: 1) time at risk, purpose (modality of RRT), previous comorbidity; 2) causes of ED frequentation and Hos; 3) type of initiation: «scheduled» vs. «non-scheduled», and within these «non-planned» vs. «potentially planned».

RESULTS

Of a total of 267 patients (time at risk 63.987 days, 70±13 years, 67% males, 38% diabetics), 68 (25%) patients came to hospital on 97 occasions: 39 only ED, 46 ED+Hos and 12 only Hos. ED frequentation was one patient every 4.3 days, and bed occupation was almost 3 per day. Main causes: 47% cardiopulmonary (1/3 heart failure), 11% vascular peripheral+cerebral, 11% gastrointestinal: 8/11 due to bleeding (all with anticoagulants/antiplatelet agents). Thirty-one (12%) patients initiated RRT: of these, 14 (45%) were scheduled (6 PD, 6 HD, and 2 living donor RTx), and 17 (55%) were not scheduled or were rushed, all with venous central catheter. Following the objectives of this study, the non-scheduled group were itemised into 2 groups: 9 non-planned (initial indication of conservative management or patient's refusal to undergo dialysis, and diverse social circumstances not controllable by the nephrologist) and 8 were considered potentially planned (6 heart failure, one gastrointestinal bleeding and one peripheral vascular complication). This last group (potentially planned), when compared with the 14 patients who started treatment in a scheduled manner, had significant differences in that they were older, with more previous cardiac events, and GFR almost double that of the other group. All of them started treatment in the ED.

CONCLUSION

This analysis provides us with knowledge on those patients who may benefit from an earlier preparation in RRT. We suggest that patients with previous cardiac events, especially with a risk of gastrointestinal bleeding, should start the preparation for RRT even with GFR rates of 20^-25ml/min. In spite of the retrospective nature of this study, and taking into account the difficulties of carrying out clinical trials in this population, we propose this suggestion as complementary to the current recommendations for a scheduled start using this technique.

A comparison of the effectiveness of cyclophosphamide, leflunomide, corticosteroids, or conservative management alone in patients with IgA nephropathy: a retrospective observational study

To compare the long-term efficacy of corticosteroids (P) alone or in combination with cyclophosphamide (CTX), leflunomide (LEF), or Angiotensin-convertase inhibitors or angiotensin II receptor blockers (ACEI/ARB) in treatment for IgA nephropathy (IgAN), 311 patients with IgAN were identified. Therapeutic effectiveness (including progression, partial remission, complete remission) and combined renal endpoint (defined as 30% reduction in eGFR or ESRD) were compared based on different therapies. After immunosuppressive and ACEI/ARB treatment, the levels of eGFR, proteinuria and albumin were significantly improved at the last follow-up, the extent of improvement of eGFR, proteinuria, and albumin was more notable in P + CTX group and P + LEF group. 41%, 52.2%, 55.3% and 55.2% in P + CTX, P + LEF, P and ACEI/ARB group achieved complete remission, respectively. Multivariate regression analysis indicated that only proteinuria (Relative risk (RR) 0.82(0.72-0.94), P = 0.004) and tubular atrophy/interstitial fibrosis (RR 0.26(0.13-0.57), P = 0.001) were predictors for complete remission. The optimal cutoffs of eGFR was 47.085 ml/min/1.73 m2 predicting renal function recovery in P + CTX therapy. In conclusion, tubular atrophy/interstitial fibrosis and massive proteinuria were poor predictors for complete remission in IgAN, it appears as though patients may have benefited from immunosuppressive treatment but that comparison to a well-matched contemporary control group or, ideally, a randomized controlled clinical trial, would be required to show this.

Swimming exercise demonstrates advantages over running exercise in reducing proteinuria and glomerulosclerosis in spontaneously hypertensive rats

Experimental studies in animal models have described the benefits of physical exercise (PE) to kidney diseases associated with hypertension. Land- and water-based exercises induce different responses in renal function. Our aim was to evaluate the renal alterations induced by different environments of PE in spontaneously hypertensive rats (SHRs). The SHRs were divided into sedentary (S), swimming exercise (SE), and running exercise (RE) groups, and were trained for 8 weeks under similar intensities (60 min/day). Arterial pressure (AP) and heart rate (HR) were recorded. The renal function was evaluated through urinary volume at each week of training; sodium and potassium excretions, plasma and urinary osmolarities, glomerular filtration rate (GFR), levels of proteinuria, and renal damage were determined. SE and RE rats presented reduced mean AP, systolic blood pressure, and HR in comparison with S group. SE and RE rats showed higher urine osmolarity compared with S. SE rats showed higher free water clearance (P < 0.01), lower urinary density (P < 0.0001), and increased weekly urine volume (P < 0.05) in comparison with RE and S groups. GFR was increased in both SE and RE rats. The proteinuria of SE (7.0 ± 0.8 mg/24 h) rats was decreased at the 8th week of the PE in comparison with RE (9.6 ± 0.8 mg/24 h) and S (9.8 ± 0.5 mg/24 h) groups. The glomerulosclerosis was reduced in SE rats (P < 0.02). SE produced different response in renal function in comparison with RE, in which only swimming-trained rats had better profile for proteinuria and glomerulosclerosis.

Chronic kidney disease in patients at high risk of cardiovascular disease in the United Arab Emirates: A population-based study

Chronic kidney disease has become an increasingly significant clinical and public health issue, accounting for 1.1 million deaths worldwide. Information on the epidemiology of chronic kidney disease and associated risk factors is limited in the United Arab Emirates. Therefore, this study aimed to evaluate the incidence and causes of chronic kidney disease stages 3-5 in adult United Arab Emirates nationals with or at high risk of cardiovascular disease. This retrospective study included 491 adults with or at high risk of cardiovascular disease (diabetes mellitus or associated clinical disease) who attended outpatient clinics at a tertiary care hospital in Al-Ain, United Arab Emirates. Estimated glomerular filtration rate was assessed every 3 months from baseline to June 30, 2017. Chronic kidney disease stages 3-5 were defined as an estimated glomerular filtration rate < 60 mL/min/1.73 m2 for ≥ 3 months. Multivariable Cox's proportional hazards analysis was used to determine the independent risk factors associated with developing chronic kidney disease stages 3-5. The cumulative incidence of chronic kidney disease stages 3-5 over a 9-year period was 11.4% (95% confidence interval 8.6, 14.0). The incidence rate of these disease stages was 164.8 (95% confidence interval 121.6, 207.9) per 10,000 person-years. The independent risk factors for developing chronic kidney disease stages 3-5 were older age, history of coronary heart disease, history of diabetes mellitus, and history of smoking. These data may be useful to develop effective strategies to prevent chronic kidney disease development in high-risk United Arab Emirates nationals.

Effects of S-1-propenylcysteine, a sulfur compound in aged garlic extract, on blood pressure and peripheral circulation in spontaneously hypertensive rats

OBJECTIVES

This study was designed to investigate the antihypertensive effect of S-1-propenylcysteine, a characteristic sulfur compound in aged garlic extract, using a hypertensive rat model.

METHODS

The blood pressure and tail blood flow of both spontaneously hypertensive rats and control Wistar Kyoto rats were measured by the tail-cuff method and the noncontact laser Doppler method, respectively, at various times after single oral administration of a test compound for 24 h.

KEY FINDINGS

Treatment with S-1-propenylcysteine (6.5 mg/kg BW) significantly decreased the systolic blood pressure of spontaneously hypertensive rat approximately 10% at 3 h after administration, and thereafter, the systolic blood pressure gradually returned to the baseline level in 24 h. The effect of S-1-propenylcysteine was dose-dependent and was maximal at the dose of 6.5 mg/kg BW at 3 h. However, the other compounds such as S-allylcysteine and S-allylmercaptocysteine in aged garlic extract were ineffective. In addition, S-1-propenylcysteine had no effect on systolic blood pressure of control Wistar Kyoto rats. Furthermore, S-1-propenylcysteine significantly increased the blood flow at 3 h after administration at the dose of 6.5 mg/kg BW.

CONCLUSIONS

S-1-propenylcysteine is a key constituent of aged garlic extract responsible for its antihypertensive effect, and the effect of S-1-propenylcysteine involves the improvement in peripheral circulation.

The Effects of Momordica balsamina Methanolic Extract on Kidney Function in STZ-Induced Diabetic Rats: Effects on Selected Metabolic Markers

BACKGROUND

Studies suggest that Momordica balsamina (intshungu) possesses hypoglycaemic effects. The effects of Momordica balsamina on diabetic complications such as DN, however, have not been established. Accordingly, this study seeks to investigate the effects of M. balsamina on kidney function in STZ-induced diabetic rats.

METHODS

Methanolic extracts (ME) of M. balsamina's leaves were used in this study. Short-term effects of M. balsamina methanolic extract on kidney function and MAP were studied in STZ-induced diabetic rats treated twice daily with M. balsamina methanolic extract (250 mg/kg), insulin (175 μg/kg, s.c.), and metformin (500 mg/kg) for 5 weeks.

RESULTS

M. balsamina methanolic extract significantly increased Na⁺ excretion outputs in STZ-induced diabetic rats by comparison to STZ-diabetic control rats. M. balsamina methanolic extract significantly increased GFR in STZ-diabetic rats with a concomitant decrease in creatinine concentration and also reduced kidney-to-body ratio, albumin excretion rate (AER), and albumin creatinine ratio (ACR). M. balsamina methanolic extract significantly reduced MAP in STZ-diabetic animals by comparison with STZ-diabetic control animals. These results suggest that M. balsamina methanolic extract not only lowers blood glucose but also has beneficial effects on kidney function and blood pressure.

CONCLUSION

These findings suggest that M. balsamina may have beneficial effects on some processes that are associated with renal derangement in STZ-induced diabetic rats.

[Exercise as a protective cardiovascular and metabolic factor in end stage renal disease patients]

OBJECTIVE

The aim of the study was to test the effectiveness of Physical Activity (PA) during haemodialysis as a protective treatment against cardiovascular (CV) diseases.

METHODS

Eighty volunteer patients were included in this multicentric prospective study and followed for two years: 40 patients in the Exercise group (EX), 40 patients in the Control group (Ctrl). CV risk factors: Total Cholesterol, HDL Cholesterol (HDL-c), LDL cholesterol (LDL-c), Triglycerides (TG) and Hemoglobin (Hb), and Prealbumin, Albumin, Parathormon, 25-OH Vitamin D, were checked at Month 0 (M0) and Month 24 (M24). The number of antihypertensive treatments and the Erythropoietin Stimulating Agent (ESA) required doses were collected. We noted for each group during the follow-up the number of hospitalizations for CV reasons. After two years, we compared 31 patients in EX and 35 in Ctrl.

RESULTS

We observed a significant decrease of total cholesterol EX group: 1.86±0.49g/L at M0 versus 1.64±0.38g/L at M24 (P<0.05). HDLc and but LDL-c remained stable in both groups. TG decreased significantly in EX: 1.76±0.89g/L vs 1.44±0.69g/L (P<0.05). The number of antihypertensive drugs per patient decreased significantly (P<0.05) in the EX group between M0 and M24 (1.61±1.28 at M0 and 0.74±0.85 at M24). The EX patients were three times less frequently hospitalized for cardiovascular reasons. There were five hospital stays versus 14 for the Ctrl group.

CONCLUSION

Our study demonstrates that an intradialytic aerobic cycling training program promotes beneficial effects on cardiovascular protection. Physical activity reduced the number of CV events in our population during two years follow-up.

The Prevalence and Risk Factors of Renal Insufficiency among Korean HIV-Infected Patients: The Korea HIV/AIDS Cohort Study

BACKGROUND

Renal disease is one of the leading causes of morbidity and mortality among people infected with human immunodeficiency virus (HIV). However, there are very few published studies about renal insufficiency in HIV-infected persons in Asia, especially in South Korea.

MATERIALS AND METHODS

A cross-sectional study was performed to investigate the prevalence and risk factors of renal insufficiency, defined as <60 mL/min/1.73 m², in subjects in the Korea HIV/AIDS Cohort Study enrolled from 19 institutions between December 2006 and July 2013. Data at entry into the cohort were analyzed.

RESULTS

Of 454 enrolled subjects, 24 (5.3%) showed renal insufficiency at entry into the cohort. The mean age of patients in the renal insufficiency group was 5.28 years and the majority were male subjects (91.7%). All the patients were receiving antiretroviral agents, mostly protease inhibitor-based regimens (76.4%), for an average of 19 months. In univariate analysis, older age (P = 0.002), diabetes mellitus (DM) (P = 0.0002), unknown route of transmission (P = 0.007), and taking indinavir (P = 0.0022) were associated with renal insufficiency. In multivariable analysis, older age [odds ratio (OR) 1.07, 95% confidence interval (CI) 1.03-1.12, P = 0.002], DM [OR 3.03, 95% CI 1.17-7.82, P = 0.022], unknown route of transmission [OR 6.15, 95% CI 1.77-21.33, P = 0.004], and taking indinavir [OR 3.07, 95% CI 1.17-8.05, P = 0.023] were independent risk factors of renal insufficiency.

CONCLUSION

The prevalence of renal insufficiency in HIV-infected subjects in this study was relatively low, similar to that in other countries. Aging, DM, and taking indinavir were significantly associated with decreased glomerular filtration rate. Furthermore, unknown route of transmission was an independent risk factor, which was interpreted as a reflection of patient compliance. Further studies on the incidence and risk factors of renal insufficiency during HIV infection using follow-up cohort data are necessary.

The Ameliorative Effect of Pectin-Insulin Patch On Renal Injury in Streptozotocin-Induced Diabetic Rats

BACKGROUND/AIMS

Renal damage and dysfunction is attributed to sustained hyperglycaemia in overt diabetes. Subcutaneous insulin injections are beneficial in delaying the progression of renal dysfunction and damage in diabetics. However, the current mode of administration is associated with severe undesirable effects. In this study, we evaluated the ameliorative effects of pectin-insulin dermal patches on renal dysfunction in diabetes.

METHODS

Pectin-insulin patches (20.0, 40.8 and 82.9 µg/kg) were applied on the skin of streptozotocin-induced diabetic rats, thrice daily for 5 weeks. Blood glucose concentration, blood pressure and urine output volume were recorded on week 5 after which the animals were sacrificed after which the kidneys and plasma were collected. Kidney nephrin expression and urinary nephrin concentration, albumin excretion rate (AER), creatinine clearance (CC) and albumin creatinine ratio (ACR) were assessed.

RESULTS

Patch application resulted in reduced blood glucose concentration and blood pressure. Furthermore, pectin-insulin patch treatment resulted in increased kidney nephrin expression and reduced urinary nephrin concentration. AER, CC ACR were also reduced post patch application.

CONCLUSIONS

The application of pectin-insulin patch limited diabetes associated kidney damaged and improved kidney function. These observations suggest that pectin-insulin patches may ameliorate kidney dysfunction that is associated with chronic subcutaneous insulin administration.

Treatment of membranous nephropathy: time for a paradigm shift

In patients with membranous nephropathy, alkylating agents (cyclophosphamide or chlorambucil) alone or in combination with steroids achieve remission of nephrotic syndrome more effectively than conservative treatment or steroids alone, but can cause myelotoxicity, infections, and cancer. Calcineurin inhibitors can improve proteinuria, but are nephrotoxic. Most patients relapse after treatment withdrawal and can become treatment dependent, which increases the risk of nephrotoxicity. The discovery of nephritogenic autoantibodies against podocyte M-type phospholipase A2 receptor (PLA₂R) and thrombospondin type-1 domain- containing protein 7A (THSD7A) antigens provides a clear pathophysiological rationale for interventions that specifically target B-cell lineages to prevent antibody production and subepithelial deposition. The anti-CD20 monoclonal antibody rituximab is safe and achieves remission of proteinuria in approximately two-thirds of patients with membranous nephropathy. In those with PLA₂R-related disease, remission can be predicted by anti-PLA₂R antibody depletion and relapse by antibody re-emergence into the circulation. Thus, integrated evaluation of serology and proteinuria could guide identification of affected patients and treatment with individually tailored protocols. Nonspecific and toxic immunosuppressive regimens will fall out of use. B-cell modulation by rituximab and second-generation anti-CD20 antibodies (or plasma cell-targeted therapy in anti-CD20 resistant forms of disease) will lead to a novel therapeutic paradigm for patients with membranous nephropathy.

ACE and SGLT2 inhibitors: the future for non-diabetic and diabetic proteinuric renal disease

Most chronic nephropathies progress relentlessly to end-stage kidney disease. Research in animals and humans has helped our understanding of the mechanisms of chronic kidney disease progression. Current therapeutic strategies to prevent or revert renal disease progression focus on reduction of urinary protein excretion and blood pressure control. Blockade of the renin-angiotensin system (RAS) with angiotensin-converting enzyme inhibitors and/or angiotensin II type 1 receptor blockers is the most effective treatment to achieve these purposes in non-diabetic and diabetic proteinuric renal diseases. For those individuals in which nephroprotection by RAS blockade is only partial, sodium-glucose linked cotransporter-2 (SGLT2) inhibitors could be a promising new class of drugs to provide further renoprotective benefit when added on to RAS blockers.

Screening and management practices for renal disease in the HIV-positive patient population of an inner metropolitan sexual health service

Renal disease is an important and commonly encountered co-morbidity in HIV infection. Despite this, few data are available concerning renal disease in this patient group. A retrospective review was conducted of all HIV-positive patients of an inner metropolitan sexual health service who attended from 1 August 2013 to 31 July 2014 for HIV management. One hundred eighty-eight HIV-positive patients attended the clinic during the study period. The majority were male (96%), Caucasian (70%) and 30-39 years of age (37%). There was a high prevalence of renal risk factors in the population, including potentially nephrotoxic antiretroviral therapy (61%), smoking (38%), hypertension (12%), dyslipidemia (11%) and hepatitis C co-infection (7%). In the previous year, measurements of estimated glomerular filtration rate were performed in all patients, but measurements of lipid profiles, urinary protein and serum phosphate were performed within the last year in only 48%, 33% and 30% of patients, respectively. These are the first comprehensive data regarding renal disease, associated risk factors and screening and management practices in the HIV-positive patient population of a specialized sexual health service in Australia. This patient population demonstrates a particularly high prevalence of risk factors for renal disease. Despite this, screening investigations were not performed as recommended. This represents a potential area to improve patient care.

Out of Africa: Complete and partial remissions as a combined outcome in patients with idiopathic membranous glomerulonephritis in Cape Town

AIM

Remission outcomes among patients with idiopathic membranous glomerulonephritis is unknown in Africa. We sought to determine remission outcomes in a cohort of South African adult patients with IMGN.

METHODS

This was a retrospective review of patients with biopsy-proven IMGN over a 10 year period. Secondary causes of MN were excluded. Demographic, clinical, biochemical and histological records were retrieved for analysis. The trends in biochemical parameters from baseline were determined. The primary outcome was the attainment of a complete or partial remission (CR / PR) at the last follow-up.

RESULTS

Fifty-six patients met the criteria for inclusion and 43 had subsequent follow-up care with a median duration of follow-up of 23.0 (13.0-48.0) months. Sixteen patients (37.2%) were treated with immunosuppression (corticosteroids and cyclophosphamide) and 81.4% received anti-proteinuric agents. There were no significant differences in demographic and clinical features of patients categorized by immunosuppression (ISP) use. Changes in level of proteinuria and estimated glomerular filtration rate (eGFR) were also not significantly different between the two groups. Eighteen patients (41.9%) reached CR or PR at the last visit. The median times-to-remission of patients according to ISP status were similar at 48.6 and 48.7 months respectively (P = 0.104) while the proportions of patients not reaching CR/PR at 12 and 24 months were 94.6% and 80.8% respectively. Gender and race did not predict remission status (P > 0.05). Predictors of CR/PR at last visit were eGFR [OR 1.01 (95%CI: 1.00 - 1.02); P = 0.041], and systolic BP (OR 0.97 [95%CI: 0.95 - 0.99); P = 0.036].

CONCLUSION

Remission outcomes in this African IMGN cohort are delayed and poor.

Achieving remission of proteinuria in childhood CKD

BACKGROUND

A multidrug treatment strategy that targets urinary proteins with an angiotensin-converting enzyme (ACE) inhibitor and angiotensin receptor blocker (ARB) up-titrated to the respective maximum tolerated dose combined with intensified blood pressure (BP) control has been found to prevent renal function loss in adults with proteinuric nephropathies. Herein, we investigated the effects of this treatment protocol in the pediatric patient population.

METHODS

From May 2002 to September 2014 we included in this observational, longitudinal, cohort study 20 consecutive children with chronic nephropathies and 24-h proteinuria of >200 mg who had received ramipril and losartan up-titrated to the respective maximum approved and tolerated doses [mean (standard deviation) dose:2.48 (1.37) mg/m² and 0.61 (0.46) mg/kg daily, respectively]. The primary efficacy endpoint was a >50 % reduction in 24-h proteinuria to <200 mg (remission). Secondary outcomes included changes in proteinuria, serum albumin, BP, and glomerular filtration rate (GFR).

RESULTS

Mean (± standard deviation) patient age at inclusion was 13.8 ± 2.8 years, and the median [interquartile range (IQR)] serum creatinine level and proteinuria were 0.7 (0.6-1.0) mg/dl and 690 (379-1270) mg/24 h or 435 (252-711) mg/m²/24 h, respectively. Proteinuria significantly decreased by month 6 of follow-up, and serum albumin levels increased over a median follow-up period of 78 (IQR 39-105) months. In the nine children who achieved remission, proteinuria reduction persisted throughout the whole follow-up without rebounds. The GFR improved in those children who achieved remission and worsened in those who did not. The mean GFR slopes differed significantly between these two groups (p < 0.05), being positive in those children with remission and negative in those without remission (+0.023 ± 0.15 vs.-0.014 ± 0.23 ml/min/1.73 m²/month, respectively), whereas BP control was similar between the two groups. Hyperkalemia was observed in two children.

CONCLUSIONS

Combination therapy with maximum approved doses of ACE inhibitors and ARBs is a safe strategy which may achieve proteinuria remission with kidney function stabilization or even improvement in a substantial proportion of children with proteinuric nephropathies.