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Klinkhammer BM, Boor P. Kidney fibrosis: Emerging diagnostic and therapeutic strategies. Mol Aspects Med 2023; 93:101206. [PMID: 37541106 DOI: 10.1016/j.mam.2023.101206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 07/25/2023] [Indexed: 08/06/2023]
Abstract
An increasing number of patients worldwide suffers from chronic kidney disease (CKD). CKD is accompanied by kidney fibrosis, which affects all compartments of the kidney, i.e., the glomeruli, tubulointerstitium, and vasculature. Fibrosis is the best predictor of progression of kidney diseases. Currently, there is no specific anti-fibrotic therapy for kidney patients and invasive renal biopsy remains the only option for specific detection and quantification of kidney fibrosis. Here we review emerging diagnostic approaches and potential therapeutic options for fibrosis. We discuss how translational research could help to establish fibrosis-specific endpoints for clinical trials, leading to improved patient stratification and potentially companion diagnostics, and facilitating and optimizing development of novel anti-fibrotic therapies for kidney patients.
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Affiliation(s)
| | - Peter Boor
- Institute of Pathology, RWTH Aachen University Hospital, Aachen, Germany; Electron Microscopy Facility, RWTH Aachen University Hospital, Aachen, Germany; Division of Nephrology and Immunology, RWTH Aachen University Hospital, Aachen, Germany.
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Garimella PS, Katz R, Waikar SS, Srivastava A, Schmidt I, Hoofnagle A, Palsson R, Rennke HG, Stillman IE, Wang K, Kestenbaum BR, Ix JH. Kidney Tubulointerstitial Fibrosis and Tubular Secretion. Am J Kidney Dis 2022; 79:709-716. [PMID: 34571064 PMCID: PMC8973399 DOI: 10.1053/j.ajkd.2021.08.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 08/13/2021] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Tubular secretion plays an important role in the efficient elimination of endogenous solutes and medications, and lower secretory clearance is associated with risk of kidney function decline. We evaluated whether histopathologic quantification of interstitial fibrosis and tubular atrophy (IFTA) is associated with lower tubular secretory clearance in persons undergoing kidney biopsy. STUDY DESIGN Cross-sectional. SETTINGS & PARTICIPANTS The Boston Kidney Biopsy Cohort is a study of persons undergoing native kidney biopsies for clinical indications. EXPOSURES Semiquantitative score of IFTA reported by 2 trained pathologists. OUTCOMES We measured plasma and urine concentrations of 9 endogenous secretory solutes using a targeted liquid chromatography/mass spectrometry assay. We used linear regression to test associations of urine-to-plasma ratios (UPRs) of these solutes with IFTA score after controlling for estimated glomerular filtration rate (eGFR) and albuminuria. RESULTS Among 418 participants, mean age was 53 years, 51% were women, 64% were White, and 18% were Black. Mean eGFR was 50mL/min/1.73m2, and median urinary albumin-creatinine ratio was 819mg/g. Compared with individuals with≤25% IFTA, those with>50% IFTA had 12%-37% lower UPRs for all 9 secretory solutes. Adjusting for age, sex, race, eGFR, and urine albumin and creatinine levels attenuated the associations, yet a trend of lower secretion across groups remained statistically significant (P<0.05 for trend) for 7 of 9 solutes. A standardized composite secretory score incorporating UPR for all 9 secretory solutes using the min-max method showed similar results (P<0.05 for trend). LIMITATIONS Single time point and spot measures of secretory solutes. CONCLUSIONS Greater IFTA severity is associated with lower clearance of endogenous secretory solutes even after adjusting for eGFR and albuminuria.
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Affiliation(s)
- Pranav S Garimella
- Division of Nephrology-Hypertension, University of California San Diego, La Jolla; Kidney Health, Research and Innovation Hub of San Diego, San Diego, CA.
| | - Ronit Katz
- Departments of Obstetrics and Gynecology, University of Washington, Seattle, WA
| | - Sushrut S Waikar
- Section of Nephrology, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA
| | - Anand Srivastava
- Division of Nephrology and Hypertension, Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Insa Schmidt
- Section of Nephrology, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA
| | | | - Ragnar Palsson
- Division of Nephrology, Landspitali-The National University Hospital of Iceland, Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland
| | - Helmut G Rennke
- Department of Pathology, Brigham and Women's Hospital, Boston, MA
| | - Isaac E Stillman
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Ke Wang
- Department of Medicine, Division of Nephrology, University of Washington, Seattle, WA; Kidney Research Institute, Seattle, WA
| | - Bryan R Kestenbaum
- Department of Medicine, Division of Nephrology, University of Washington, Seattle, WA; Kidney Research Institute, Seattle, WA
| | - Joachim H Ix
- Division of Nephrology-Hypertension, University of California San Diego, La Jolla
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Abstract
An exploration of the normal limits of physiologic responses and how these responses are lost when the kidney is injured rarely occurs in clinical practice. However, the differences between "resting" and "stressed" responses identify an adaptive reactiveness that is diminished before baseline function is impaired. This functional reserve is important in the evaluation of prognosis and progression of kidney disease. Here, we discuss stress tests that examine protein-induced hyperfiltration, proximal tubular secretion, urea-selective concentration defects, and acid retention. We discuss diseases in which these tests have been used to diagnose subclinical injury. The study and follow-up of abnormal functional reserve may add considerable understanding to the natural history of CKD.
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Affiliation(s)
- Armando Armenta
- Department of Nephrology, National Institute of Cardiology “Ignacio Chavez,” Mexico City, Mexico
| | - Magdalena Madero
- Department of Nephrology, National Institute of Cardiology “Ignacio Chavez,” Mexico City, Mexico
| | - Bernardo Rodriguez-Iturbe
- Department of Nephrology, National Institute of Cardiology "Ignacio Chavez," Mexico City, Mexico .,Department of Nephrology and Mineral Metabolism, National Institute of Health Sciences and Nutrition "Salvador Zubirán," Mexico City, Mexico
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Ix JH, Shlipak MG. The Promise of Tubule Biomarkers in Kidney Disease: A Review. Am J Kidney Dis 2021; 78:719-727. [PMID: 34051308 PMCID: PMC8545710 DOI: 10.1053/j.ajkd.2021.03.026] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 03/10/2021] [Indexed: 12/23/2022]
Abstract
For over 70 years, serum creatinine has remained the primary index for detection and monitoring of kidney disease. Tubulointerstitial damage and fibrosis are highly prognostic for subsequent kidney failure in biopsy studies, yet this pathology is invisible to the clinician in the absence of a biopsy. Recent discovery of biomarkers that reflect distinct aspects of kidney tubule disease have led to investigations of whether these markers can provide additional information on risk of chronic kidney disease (CKD) progression and associated adverse clinical end points, above and beyond estimated glomerular filtration rate and albuminuria. These biomarkers can be loosely grouped into those that mark tubule cell injury (eg, kidney injury molecule 1, monocyte chemoattractant protein 1) and those that mark tubule cell dysfunction (eg, α1-microglobulin, uromodulin). These kidney tubule biomarkers provide new opportunities to monitor response to therapeutics used to treat CKD patients. In this review, we describe results from some unique contributions in this area and discuss the current challenges and requirements in the field to bring these markers to clinical practice. We advocate for a broader assessment of kidney health that moves beyond a focus on the glomerulus, and we highlight how such tools can improve diagnostic accuracy and earlier assessment of therapeutic efficacy or harm in CKD patients.
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Affiliation(s)
- Joachim H Ix
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, San Diego, California; Nephrology Section, Veterans Affairs San Diego Healthcare System, La Jolla, California; Kidney Research Innovation Hub of San Diego, San Diego, California.
| | - Michael G Shlipak
- Kidney Health Research Collaborative, San Francisco Veterans Affairs Medical Center and University of California, San Francisco, California; Division of General Internal Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California
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Chen JJ, Chang CH, Huang YT, Kuo G. Furosemide stress test as a predictive marker of acute kidney injury progression or renal replacement therapy: a systemic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:202. [PMID: 32381019 PMCID: PMC7206785 DOI: 10.1186/s13054-020-02912-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 04/22/2020] [Indexed: 12/16/2022]
Abstract
Background The use of the furosemide stress test (FST) as an acute kidney injury (AKI) severity marker has been described in several trials. However, the diagnostic performance of the FST in predicting AKI progression has not yet been fully discussed. Methods In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched the PubMed, Embase, and Cochrane databases up to March 2020. The diagnostic performance of the FST (in terms of sensitivity, specificity, number of events, true positive, false positive) was extracted and evaluated. Results We identified eleven trials that enrolled a total of 1366 patients, including 517 patients and 1017 patients for whom the outcomes in terms of AKI stage progression and renal replacement therapy (RRT), respectively, were reported. The pooled sensitivity and specificity results of the FST for AKI progression prediction were 0.81 (95% CI 0.74–0.87) and 0.88 (95% CI 0.82–0.92), respectively. The pooled positive likelihood ratio (LR) was 5.45 (95% CI 3.96–7.50), the pooled negative LR was 0.26 (95% CI 0.19–0.36), and the pooled diagnostic odds ratio (DOR) was 29.69 (95% CI 17.00–51.85). The summary receiver operating characteristics (SROC) with pooled diagnostic accuracy was 0.88. The diagnostic performance of the FST in predicting AKI progression was not affected by different AKI criteria or underlying chronic kidney disease. The pooled sensitivity and specificity results of the FST for RRT prediction were 0.84 (95% CI 0.72–0.91) and 0.77 (95% CI 0.64–0.87), respectively. The pooled positive LR and pooled negative LR were 3.16 (95% CI 2.06–4.86) and 0.25 (95% CI 0.14–0.44), respectively. The pooled diagnostic odds ratio (DOR) was 13.59 (95% CI 5.74–32.17), and SROC with pooled diagnostic accuracy was 0.86. The diagnostic performance of FST for RRT prediction is better in stage 1–2 AKI compared to stage 3 AKI (relative DOR 5.75, 95% CI 2.51–13.33). Conclusion The FST is a simple tool for the identification of AKI populations at high risk of AKI progression and the need for RRT, and the diagnostic performance of FST in RRT prediction is better in early AKI population.
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Affiliation(s)
- Jia-Jin Chen
- Department of Nephrology, Chang Gung Memorial Hospital, No 5 Fu-shin Street, Taoyuan City, 333, Taiwan
| | - Chih-Hsiang Chang
- Department of Nephrology, Chang Gung Memorial Hospital, No 5 Fu-shin Street, Taoyuan City, 333, Taiwan.,Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Taoyuan City, 333, Taiwan
| | - Yen-Ta Huang
- Division of Experimental Surgery, Department of Surgery, Buddhist Tzu Chi General Hospital, Hualien County, 970, Taiwan.,Department of Pharmacology, School of Medicine, Tzu Chi University, Hualien County, 970, Taiwan
| | - George Kuo
- Department of Nephrology, Chang Gung Memorial Hospital, No 5 Fu-shin Street, Taoyuan City, 333, Taiwan.
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Coca A, Aller C, Reinaldo Sánchez J, Valencia AL, Bustamante-Munguira E, Bustamante-Munguira J. Role of the Furosemide Stress Test in Renal Injury Prognosis. Int J Mol Sci 2020; 21:E3086. [PMID: 32349337 PMCID: PMC7247682 DOI: 10.3390/ijms21093086] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 04/23/2020] [Accepted: 04/24/2020] [Indexed: 02/02/2023] Open
Abstract
Risk stratification and accurate patient prognosis are pending issues in the management of patients with kidney disease. The furosemide stress test (FST) has been proposed as a low-cost, fast, safe, and easy-to-perform test to assess tubular integrity, especially when compared to novel plasma and urinary biomarkers. However, the findings regarding its clinical use published so far provide insufficient evidence to recommend the generalized application of the test in daily clinical routine. Dosage, timing, and clinical outcomes of the FST proposed thus far have been significantly different, which further accentuates the need for standardization in the application of the test in order to facilitate the comparison of results between series. This review will summarize published research regarding the usefulness of the FST in different settings, providing the reader some insights about the possible implications of FST in clinical decision-making in patients with kidney disease and the challenges that research will have to address in the near future before widely applying the FST.
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Affiliation(s)
- Armando Coca
- Department of Nephrology, Hospital Clinico Universitario de Valladolid, 47003 Valladolid, Spain; (A.C.); (C.A.); (J.R.S.); (A.L.V.)
| | - Carmen Aller
- Department of Nephrology, Hospital Clinico Universitario de Valladolid, 47003 Valladolid, Spain; (A.C.); (C.A.); (J.R.S.); (A.L.V.)
| | - Jimmy Reinaldo Sánchez
- Department of Nephrology, Hospital Clinico Universitario de Valladolid, 47003 Valladolid, Spain; (A.C.); (C.A.); (J.R.S.); (A.L.V.)
| | - Ana Lucía Valencia
- Department of Nephrology, Hospital Clinico Universitario de Valladolid, 47003 Valladolid, Spain; (A.C.); (C.A.); (J.R.S.); (A.L.V.)
| | - Elena Bustamante-Munguira
- Department of Intensive Care Medicine, Hospital Clinico Universitario de Valladolid, 47003 Valladolid, Spain;
| | - Juan Bustamante-Munguira
- Department of Cardiac Surgery, Hospital Clinico Universitario de Valladolid, 47003 Valladolid, Spain
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