2019 World Kidney Day Editorial - burden, access, and disparities in kidney disease

Efficacy of resistance exercise during hemodialysis on improving lower limb muscle strength in patients with chronic kidney disease: a meta-analysis of randomized clinical trials

INTRODUCTION

Patients with chronic kidney disease (CKD) on hemodialysis (HD) have muscle weakness in addition to a high risk of falls, motor impairment and immobilization.

OBJECTIVE

To conduct a systematic review with meta-analysis of randomized clinical trials regarding the effectiveness of resistance exercises on muscle strengthening and lower limb endurance in patients with CKD on HD.

METHODOLOGY

The study was conducted in the PubMed, EMBASE, SciELO, LILACS and Cochrane databases, without linguistic restrictions or year of publication.

RESULTS

Of the 824 studies found, only 6 were included for analysis. Studies were allocated to some concern or high risk of bias regarding the reporting of outcomes. The low quality of outcome evidence can mainly be observed due to the severe level of inconsistency owing to the high degree of heterogeneity. A significant reduction in heterogeneity was observed after the sensitivity analysis, demonstrating an improvement in the muscle strength of the lower limbs (p = .002).

CONCLUSION

It is concluded that most studies demonstrate benefits in carrying out resistance training programs in increasing muscle strength of the lower limbs, however, it is necessary that randomized clinical trials (RCTs) with greater methodological rigor are performed to confirm these findings.

Determination of drug-related problems according to PAIR criteria in dialysis patients: a cross-sectional study in tertiary care hospital

BACKGROUND

Dialysis patients are at high risk for drug-related problems (DRPs), which have significant consequences for their morbidity, mortality, and quality of life. Improved clinical outcomes can be achieved by preventing, identifying, and resolving these problems.

METHODS

This is a retrospective observational study. In this study, the PAIR instrument (Pharmacotherapy Assessment in Chronic Renal Disease) was validated for use in Turkish. Validation consisted of three stages: translation back-translation with expert panel evaluation, reliability analysis using the test-retest method, and conceptual validity with both Pharmaceutical Care Network Europe (PCNE) and PAIR used to determine DRPs prevalence.

RESULTS

In total, 104 patients (mean ± SD age, 54.1 ± 15.8 years; 53.8% male) were included in the study. An expert panel evaluated the items in the criterion based on their intelligibility, service of purpose, differentiation, and cultural suitability during the translation stage. Content validity index (CVI) score was found to be 0.95. The reliability analysis was performed by applying the test-retest method and calculating correlation coefficient on 30 randomly selected patients one month later. Correlation coefficient (p) was found to be 0.8. To evaluate conceptual validity, 104 patients' pharmacotherapy plans were assessed using both the PAIR and PCNE criteria. The prevalence of DRPs according to PAIR criteria (100.0%) and PCNE (73.1%) were statistically significantly different (p < 0.001).

CONCLUSIONS

As a result, PAIR criteria can identify clinically relevant DRPs in patients with CKD and is a new, validated tool to be used in Turkey, but may not be adequate for patients receiving dialysis. Therefore, it needs to be reviewed and updated for dialysis patients.

Effects of periodontal treatment on the C-reactive protein levels in hemodialysis patients: A systematic review and meta-analysis

AIM

This systematic review provides a summary of the scientific evidence concerning effects of periodontal treatment on the C-reactive protein (CRP) levels in hemodialysis patients.

MATERIAL AND METHODS

Eight databases were accessed until May 2020 for interventional studies which evaluated CRP levels in hemodialysis patients before and after periodontal treatment. Inclusion criteria were studies involving hemodialysis patients with gingivitis or periodontitis, without restriction of year, language, and publication status. Random effects meta-analysis was performed. The risk of bias in eligible studies was assessed using the Joanna Briggs Institute's Critical Appraisal tools for use in systematic reviews. Certainty of evidence was also evaluated using GRADE approach.

RESULTS

The search in the databases resulted in 326 records, from which only seven met the eligibility criteria and therefore were submitted to qualitative evaluation. The meta-analysis revealed that, in general, the reduction in CRP levels had moderate and statistically significant effect size (standardized mean difference [SMD] = 0.45; confidence interval [CI] 95% = 0.25, 0.65; p < .001). Statistical heterogeneity was low (I2  = 0.0%; p = .771). Most studies showed moderate risk of bias.

CONCLUSION

Based on low certainty of evidence, the results suggest that periodontal treatment can significantly contribute to reduce CRP levels among hemodialysis patients. However, more randomized clinical studies, with follow-up longer than 12 months, using standardized diagnostic methods and controlling confounding factors, should be performed to strengthen the evidence.

Effects of intradialytic exercise on functional capacity in patients with end-stage chronic kidney disease: a systematic review and meta-analysis

The study aimed to investigate the effect of intradialytic exercise training programmes on the submaximal functional capacity of patients with kidney failure. We searched for randomized clinical trials that assessed submaximal functional capacity using the 6-min walk test (6 MWT) in adult patients on maintenance haemodialysis submitted to intradialytic physical training. The search was performed on 15 October 2021, in different databases. Random-effect, multivariate meta-regression adjusted for multiplicity were performed to examine the relationship between exercise effect and covariates. Intradialytic physical exercise induced greater changes in 6MWT distance (k = 18; n = 1,458; WMD: 37.0; 95% CI 29.3; 50.6 metres) than control groups, with substantial heterogeneity (I2 = 78.3%). Aerobic, strength, and combined exercise promoted an average increase of 48.7 (95%CI 30.9; 66.4 metres), 16.9 (95%CI 7.6; 26.3 metres), and 75.8 (95%CI 55.1; 96.6 metres) metres, respectively. Strength training resulted in inferior gains in 6MWT distance compared to aerobic training (WMD: -25.0; 95%CI: -49.1; -0.9). Intervention length shorter than 11 weeks (WMD: 37.0; 95%CI: -5.4; 79.3 metres) did not induce greater changes in 6MWT compared to control groups. There was a positive response in submaximal functional capacity to intradialytic training in kidney failure patients on maintenance haemodialysis.

Inequities in kidney health and kidney care

Health inequity refers to the existence of unnecessary and unfair differences in the ability of an individual or community to achieve optimal health and access appropriate care. Kidney diseases, including acute kidney injury and chronic kidney disease, are the epitome of health inequity. Kidney disease risk and outcomes are strongly associated with inequities that occur across the entire clinical course of disease. Insufficient investment across the spectrum of kidney health and kidney care is a fundamental source of inequity. In addition, social and structural inequities, including inequities in access to primary health care, education and preventative strategies, are major risk factors for, and contribute to, poorer outcomes for individuals living with kidney diseases. Access to affordable kidney care is also highly inequitable, resulting in financial hardship and catastrophic health expenditure for the most vulnerable. Solutions to these injustices require leadership and political will. The nephrology community has an important role in advocacy and in identifying and implementing solutions to dismantle inequities that affect kidney health.

Review of prognostic factors for kidney transplant survival

Transplantation is the most effective treatment for end-stage chronic kidney disease, as this procedure prolongs and improves the patient's quality of life. One of the key problems is the risk of graft rejection. The purpose of this research was to identify and analyse prognostic factors that will prevent rejection. In particular, the prognostic factors grouped by methods of synthesis, generalisation and statistical processing with calculation and graphical representation of hazard ratio and correlation coefficient were grouped, namely: age of donor and recipient, time of cold kidney ischaemia, duration of preoperative dialysis, body mass index, presence of concomitant diseases (diabetes mellitus, hypertension), primary causes causing transplantation. Several molecular genetic and biochemical prognostic markers (transcription factors, immunocompetent cell signalling and receptors, cytostatin C, creatinine, citrate, lactate, etc.) are annotated. It has been demonstrated that creatinine reduction rate determines the risk of rejection, displaying the dynamics of cystatin C and creatinine changes in the postoperative period. Young recipients who underwent prolonged preoperative dialysis were identified as having the highest risk of rejection. Diabetes and hypertension bear a non-critical but commensurately equal risk of rejection. The survival rate of the graft is better when transplanted from a living donor than from a deceased donor. A correlation between cold ischaemia time, body mass index and the probability of graft failure has been proven, namely, the greater the donor and recipient body mass index and the longer the cold ischaemia time, the lower the chance of successful long-term organ acclimation. The data obtained can be used as prognostic factors for graft accommodation at different intervals after surgery.

Brachial plexus block using only 1% lidocaine to reduce pain during the endovascular treatment of dysfunctional arteriovenous access

BACKGROUND

Interventional endovascular treatments of dysfunctional arteriovenous (AV) access for hemodialysis can cause pain and discomfort to the patients. Ultrasound-guided brachial plexus block (BPB) is an alternative regional anesthesia method, but conventional BPB using ropivacaine or bupivacaine may cause long-lasting motor power loss, significantly reducing patient satisfaction. This study aimed to introduce BPB using only 1% lidocaine, which induces sensory loss while minimizing motor block, and evaluate the efficacy and safety of this procedure.

METHODS

This retrospective study was conducted on 277 consecutive patients with dysfunctional AV access requiring percutaneous transluminal angioplasty (PTA). Of these, 174 patients underwent the BPB procedure using 1% lidocaine. Time data were recorded, and the motor strength grade (MRC scale, grade 0-5) was evaluated. Numeric rating pain score (NRPS, grade 0-10) was asked during every PTA, and overall NRPS and satisfaction scores (scale 1-3) were asked after the procedure was completed.

RESULTS

Of the 174 patients who received BPB, the success rate was 100%, and there were no significant complications related to BPB. The MRC scale measured at the time when the complete sensory loss was achieved was 1.99 ± 0.63, and that at the point of sensory recovery when the block effect expired was 3.93 ± 0.62, indicating a good grade of motor strength. The average NRPS during PTA in the BPB group was significantly lower than that of the control group without BPB (1.04 ± 2.04vs 6.30 ± 2.71, p < 0.001). The overall satisfaction score was significantly higher in the BPB group than in the control group (2.79 ± 0.50vs 2.00 ± 0.81, p < 0.001).

CONCLUSIONS

BPB using only 1% lidocaine can induce a sensory block while minimizing the effect on motor function. It can be applied safely in an outpatient clinic setting with relatively higher satisfaction.

Raman Spectral Characterization of Urine for Rapid Diagnosis of Acute Kidney Injury

Acute kidney injury (AKI) is a common syndrome characterized by various etiologies and pathophysiologic processes that deteriorate kidney function. The aim of this study is to identify potential biomarkers in the urine of non-acute kidney injury (non-AKI) and AKI patients through Raman spectroscopy (RS) to predict the advancement in complications and kidney failure. Selected spectral regions containing prominent peaks of renal biomarkers were subjected to partial least squares linear discriminant analysis (PLS-LDA). This discriminant analysis classified the AKI patients from non-AKI subjects with a sensitivity and specificity of 97% and 100%, respectively. In this study, the RS measurements of urine specimens demonstrated that AKI had significantly higher nitrogenous compounds, porphyrin, tryptophan and neopterin when compared with non-AKI. This study’s specific spectral information can be used to design an in vivo RS approach for the detection of AKI diseases.

Elevated homocysteine level as an indicator for chronic kidney disease in community-dwelling middle-aged and elderly populations in Taiwan: A community-based cross-sectional study

Background

Hyperhomocysteinemia is an important factor for endothelial cell damage and a risk factor for cardiovascular diseases. Chronic kidney disease (CKD) is recognized as a leading burden in Taiwan’s healthcare system. This study aimed to investigate the association between homocysteine levels and CKD in middle-aged and elderly adults from a community in northern Taiwan.

Methods

A total of 396 middle-aged and elderly Taiwanese adults were enrolled and completed the health survey. We divided participants according to tertiles of homocysteine levels as first group (homocysteine level ≤ 11.1 μmol/L), second group (homocysteine level 11.2∼14.3 μmol/L), and third group (homocysteine level > 14.3 μmol/L). CKD was defined as estimated glomerular filtration rate (eGFR) < 60 (mL/min/1.73 m²) or urine albumin to creatinine ratio > 30 (mg/g). Pearson correlation was calculated between eGFR and other related risk factors after adjustment for age. The risk of CKD in the second and third groups compared to that in the first group was assessed by multivariate logistic regression after adjustment for age, sex, smoking, hypertension (HTN), diabetes mellitus (DM), body mass index (BMI), dyslipidemia, and uric acid. The Youden index and receiver operating characteristic (ROC) curve were calculated for the optimized cutoff value.

Results

Elevated plasma homocysteine levels were more likely to lower the eGFR and increase the prevalence of CKD. Pearson correlation showed a positive correlation between eGFR and high-density lipoprotein cholesterol, while a negative correlation was observed between homocysteine levels, waist circumference, systolic blood pressure, uric acid levels and BMI (all p < 0.05). In the logistic regression analysis, the prevalence of CKD increased, as well as the homocysteine level. The odds ratio of CKD under 95% confidence interval was 2.655 (1.284–5.490) for the third group compared with the first group after adjusting for age, sex, smoking, DM, HTN, dyslipidemia, uric acid, and BMI (p = 0.008). The area under the ROC curve was 0.662, and a cutoff value of 15.15 μmol/L for the homocysteine level was obtained for detecting subjects with CKD.

Conclusion

Our study findings revealed that elevated homocysteine levels were significantly associated with CKD and could be used as an indicator of CKD among the middle-aged and elderly populations in Taiwan.

Quality of life and cognitive assessment in healthy older Asian people with early and moderate chronic kidney disease: The NAHSIT 2013–2016 and validation study

Background

Taiwan has the highest prevalence of chronic kidney disease (CKD). Impaired cognition and quality of life are significant phenomena in the late stages of CKD. We sought to obtain an overview and the attributable effect of impaired glomerular filtration on multiple domains in cognition and dimensions of quality of life for community-based healthy older adults in Taiwan.

Methods

The study was derived from the Nutrition and Health Survey in Taiwan (NAHSIT) 2013–2016, a nationwide cross-sectional study conducted to sample healthy, community-based older adults aged ≥65 years in Taiwan. Participants were categorized into four CKD groups: CKD stage 1, stage 2, stages 3a and 3b, and stages 4–5. The Mini-Mental State Examination (MMSE) and the QoL questionnaire derived from the 12-item Short Form Health Survey (SF-12) were measured. Generalized linear mixed models (GLMMs) and principal component regressions were employed for the analysis and validation, respectively.

Results

Participants with moderate CKD (stages 3a and 3b) showed deficits in global MMSE, domain orientation to time, calculation, complex commands, and role-physical and vitality in QoL questionnaires. In GLMMs, impaired eGFR per 30 mL/min/1.73 m² was associated with lower global MMSE scores (β = -0.807, standard error [SE] = 0.235, P = 0.0007), domain orientation to time (β = -0.155, SE = 0.047, P = 0.0011), calculation (β = -0.338, SE = 0.109, P = 0.0020), complex commands (β = -0.156, SE = 0.079, P = 0.0494), and role-physical (β = -2.219, SE = 0.779, P = 0.0046) dimensions of QoL.

Conclusions

Elderly Han Chinese adults with moderately impaired renal filtration could manifest cognitive deficits in orientation to time, calculation, and impaired quality of life in physical role functioning.

Potential nephroprotective phytochemicals: Mechanism and future prospects

ETHNOPHARMACOLOGICAL RELEVANCE

Kidney disease (KD) is one of the serious health issues, which causes worrisome morbidity and economic burden. Therapeutic strategies are available however majority of them are associated with severe adverse effects and poor patient compliance and adherence. This explorative article was undertaken to provide a holistic review of known nephroprotective (NP) phytoconstituents along with their research-based evidences on mechanism, sources, and clinical trials that may play essential role in prevention and cure of KD.

AIM OF THE STUDY

The present systematic review aimed to provide in-depth and better evidences of the global burden of KD, phytoconstituents as NP with emphasis on mechanism of action both in vitro and in vivo, their wide biological sources as well as their clinical efficacy in management of kidney disease and its related disorders.

MATERIAL AND METHODS

Comprehensive information was searched systematically from electronic databases, namely, PubMed, Sciencedirect, Wiley, Scopus, Google scholar and Springer until February 2021 to find relevant data for publication on phytoconstituents with nephroprotective potential.

RESULTS

In total, 24,327 articles were screened in first search for "phytoconstituents and medicinal plants for nephroprotection and kidney disorder". On the basis of exclusion and inclusion criteria, 24,091 were excluded. Only 236 papers were spotted to have superlative quality data, which is appropriate under titles and sub-titles of the present review. The phytoconstituents having multiple research evidence along with wide number of medicinal plants sources and mechanism reported for nephroprotection have been selected and reviewed.

CONCLUSION

This review, based on pre-clinical and clinical data of NP phytoconstituents, provides scientific-basis for the rational discovery, development and utilization of these upcoming treatment practices. Further,-more clinical studies are warranted to improve the pharmacodynamic and pharmacokinetic understanding of phytoconstituents. Also, more specific evaluation for natural sources is needed.

Smartphone and application use in self-management of chronic kidney disease: a cross-sectional feasibility study

INTRODUCTION

Smartphone and application use can improve communication and monitoring of chronic diseases, including chronic kidney disease, through self-management and increased adherence to treatment.

OBJECTIVE

To assess smartphone use in patients with chronic kidney disease on dialysis and their willingness to use mobile applications as a disease self-management strategy.

DESIGN AND SETTING

This was a cross-sectional study of chronic kidney disease patients on hemodialysis in the São Francisco Valley in the Northeast Region, Brazil.

METHODS

The questionnaire developed by the authors was administered between April and June 2021. Cronbach's alpha coefficient for the construct was 0.69. Associations between the dependent and independent variables were determined using univariate analysis. Multivariate analysis with logistic regression analysis was also performed.

RESULTS

A total of 381 patients were included, of whom 64% had a smartphone, although only 3.1% knew of a kidney disease-related application. However, 59.3% believed that using an application could help them manage their disease. Having a smartphone was associated with treatment adherence, higher educational attainment, and higher per capita income. Educational attainment remained an independent factor in multivariate analysis.

CONCLUSION

More than 64% of patients had a smartphone, although few knew of applications developed for kidney disease. More than half of the population believed that technology use could benefit chronic kidney disease treatment. Smartphone ownership was more common among the younger population, with higher educational attainment and income, and was associated with greater adherence to hemodialysis sessions.

Loneliness Level and Its Associated Factors in Patients With Hemodialysis

Verify the level of loneliness and its relationship with socioeconomic and health conditions, social support, family functionality, and depressive symptoms in patients undergoing hemodialysis. Analysis of secondary data, with a primary cross-sectional investigation, correlational with a quantitative approach, carried out in 2019, with 80 patients with CKD on hemodialysis. Applied instruments: socio-demographic, economic, and health condition characterization, UCLA Loneliness Scale, Medical Outcomes Study Social Support Scale, Patient Health Questionnaire9, and the Family APGAR. Showed female prevalence (55%), white ethnicity (65%), and mean age 59.63 years. In the perception of loneliness, the highest index was (55%), moderately high. Social support scored worst in the Positive Social Interaction domain, mean 74.31. In depression, showed prevalence of severe depression (28.7%). Family functioning showed good score (68.8%). There was a weak negative correlation between loneliness and all domains of Social Support, besides Family Functioning.

Religious Service Attendance and Mortality among Adults in the United States with Chronic Kidney Disease

Religion and related institutions have resources to help individuals cope with chronic conditions, such as chronic kidney disease (CKD). The purpose of this investigation is to examine the association between religious service attendance and mortality for adults with CKD. Data were drawn from NHANES III linked to the 2015 public use Mortality File to analyze a sample of adults (n = 3558) who had CKD as defined by a single value of estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m² using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation and/or albumin-to-creatinine ratio ≥17 mg/g for males or ≥25 for females. All-cause mortality was the primary outcome and religious service attendance was the primary independent variable. Cox proportional hazards models were estimated to determine the association between religious service attendance and mortality. The mortality risks for participants who attended a service at least once per week were 21% lower than their peers with CKD who did not attend a religious service at all (HR 0.79; CI 0.64–0.98). The association between religious service attendance and mortality in adults with CKD suggest that prospective studies are needed to examine the influence of faith-related behaviors on clinical outcomes in patients with CKD.

Fatores associados à ativação de pacientes em hemodiálise

Objetivo: mensurar a ativação de pacientes em hemodiálise e determinar os fatores associados à ativação dessa população. Materiais e método: estudo exploratório, de caráter descritivo e corte transversal com 162 pacientes em tratamento hemodialítico no interior de Minas Gerais, Brasil. Os dados foram coletados de janeiro a abril de 2019, com instrumentos para avaliação sociodemográfica, socioeconômica e clínica e da escala Patient Activation Measure de 13 itens. A análise de dados foi realizada por estatística descritiva e regressão de Poisson com variância robusta. Resultados: a medida de ativação dos pacientes em hemodiálise variou de 39,4 a 90,7 pontos, em que a média é 60,85 + 15,57 pontos e a mediana 53,2 (IC: 58,4-63,3) pontos. Dos participantes, 52,5 % (n = 85) apresentavam baixa ativação, sendo que o menor quantitativo de pessoas (18,5 %, n = 30) se encontrava no nível 3. Foi associado à maior prevalência de alta ativação o fato de apresentar o nível superior de ensino e não necessitar de cuidador. Conclusões: embora as variáveis associadas à alta ativação não sejam modificadas pelos profissionais de saúde, conhecê-las permite inferir qual o perfil de pacientes em hemodiálise que necessitam de intervenções direcionadas ao aumento dos níveis de ativação.

Spectrum of Complications of Patients with Chronic Kidney Disease on Maintenance Continuous Ambulatory Peritoneal Dialysis: An Experience of Tertiary Nephrology Center in Najaf City-Iraq

BACKGROUND: Chronic kidney disease (CKD), also called chronic kidney failure, is described as gradual loss of kidney function. CKD can progress to end-stage kidney failure, which is fatal without artificial filtering (dialysis) or kidney transplant. Peritoneal dialysis (PD) has a widespread renal replacement therapy with great acceptance because of simplicity, flexibility, and independence. AIM: The aim of this study was to evaluate the complications of continuous ambulatory PD (CAPD) in patients with CKD. METHODS: A cross-sectional study, involved 140 patients, aged between 18 and 80 years old and suffered from CKD under maintenance CAPD in the dialysis unit of the renal center. All data regarding the sociodemographic profile of the patient, vitals, etiological diagnosis, frequency and duration of dialysis, and dialysis-related complications were taken. RESULTS: In the current study, there is a significant difference in the distribution of complications among gender where the female patients had a higher incidence of both infectious and non-infectious complications. The study also reported that there is much lower rate of complications among patients on laparoscope operation in compared with the open operation. In addition, patients with open abdomen PD developed the complications earlier than those with laparoscope maintenance CAPD. CONCLUSION: Peritoneal infection is the most prevalent complication among the other complications in the current study. There is much lower rate of complications among patients on PD in compared with hemodialysis and on laparoscope in compared with the open operation.

Nutritional Parameters in Early and Late Kidney Transplantation

BACKGROUND

Kidney transplantation (KT) has the advantage of providing a better quality of life and freedom for the patient. However, nutritional changes can occur, with clinical repercussions. The aim of the study was to compare the nutritional status in the initial and late post-KT period.

METHODS

A cross-sectional study was conducted involving 169 outpatients post-KT. Clinical, demographic, biochemical, food intake, handgrip strength (HGS), and anthropometric data were collected from medical records for the first nutritional care after KT. Statistical tests were performed to compare the groups according to the time of KT: early (≤1 year) and late (>1 year). The level of significance adopted was 5%.

RESULTS

The median age of the patients was 46 years (range, 38-57), 50.3% were men, and it was observed that 66.9% underwent KT with a deceased donor. There was a higher prevalence of diabetes mellitus (42.6% vs 23.5%; P = .011), and higher body mass index (28.80 ± 7.26 vs 26.51 ± 6.62 kg/m²; P = .046), arm muscle circumference (25.84 ± 4.63 vs 24.09 ± 3.36 cm; P = .019), and HGS (26.97 ± 10.70 vs 20.21 ± 10.83 kg; P = .010) in patients with late KT. Linear regression analysis showed that at each log of time, there was an increase of 1.90 kg in HGS (P = .045) and 0.48 cm (P = .036) in mid-arm muscle circumference.

CONCLUSION

The present study demonstrated that late kidney transplantation was associated with higher values of body mass index, mid-arm muscle circumference, and HGS.

Correlation between urinary KIM-1 and kidney protein expression of p-ERK following damage in rats exposed to gentamicin or lead acetate

Kidney injury molecule-1 (KIM-1) is a membrane receptor upregulated in the proximal tubule cells following various types of kidney injuries. Notably, studies have suggested a correlation between KIM-1 expression and extracellular signal-regulated kinase (ERK) activation. In this study, we aimed to investigate the association between the kidney overexpression pattern of cytoplasmic phosphorylated-ERK (p-ERK) protein and increased urinary KIM-1 levels in rats exposed to gentamicin or lead acetate, both at the end of toxic exposure and after a 4-week recovery period. Although other proteins were evaluated, only kidney overexpression of cytoplasmic p-ERK protein correlated with increased urinary KIM-1 levels. For both toxic substances, the increased urinary KIM-1 levels corresponded with kidney inflammation. Our results suggest that KIM-1 and p-ERK share a common mechanism in kidney injury mediated by both toxic substances that induce proximal tubule damage.

Overcoming Barriers to Implementing New Therapies for Diabetic Kidney Disease: Lessons Learned

As a result of the growing number of patients with type 2 diabetes mellitus, the prevalence of diabetic kidney disease (DKD) has proven to be one of the fastest growing health care challenges globally. Early detection and initiation of appropriate interventions to slow the progression of DKD are impeded by low awareness of the health consequences of DKD, high complexity of care that includes the need for lifestyle modifications, difficulties with adhering to increasingly complicated medication regimens, and low acceptance and application of guideline-directed management. After 2 decades of status quo in the care of patients with DKD, recently approved glucose-lowering agents are promising to transform care by demonstrating slowed DKD disease progression and improved survival. As has been learned over the last 2 decades, multiple barriers exist to the optimal integration and utilization of new therapies to improve kidney outcomes. The health care community, professional societies, and regulatory agencies must join efforts to develop implementation strategies for increasing DKD awareness, detection, and treatment.

The diagnostic yield of whole exome sequencing as a first approach in consanguineous Omani renal ciliopathy syndrome patients

Background: Whole exome sequencing (WES) is becoming part of routine clinical and diagnostic practice. In the investigation of inherited cystic kidney disease and renal ciliopathy syndromes, WES has been extensively applied in research studies as well as for diagnostic utility to detect various novel genes and variants. The yield of WES critically depends on the characteristics of the patient population. Methods: In this study, we selected 8 unrelated Omani children, presenting with renal ciliopathy syndromes with a positive family history and originating from consanguineous families. We performed WES in affected children to determine the genetic cause of disease and to test the yield of this approach, coupled with homozygosity mapping, in this highly selected population. DNA library construction and WES was carried out using SureSelect Human All Exon V6 Enrichment Kit and Illumina HiSeq platform. For variants filtering and annotation Qiagen Variant Ingenuity tool was used. Nexus copy number software from BioDiscovery was used for evaluation of copy number variants and whole gene deletions. Patient and parental DNA was used to confirm mutations and the segregation of alleles using Sanger sequencing. Results: Genetic analysis identified 4 potential causative homozygous variants each confirmed by Sanger sequencing in 4 clinically relevant ciliopathy syndrome genes, ( TMEM231, TMEM138, WDR19 and BBS9), leading to an overall diagnostic yield of 50%. Conclusions: WES coupled with homozygosity mapping provided a diagnostic yield of 50% in this selected population. This genetic approach needs to be embedded into clinical practise to allow confirmation of clinical diagnosis, to inform genetic screening as well as family planning decisions. Half of the patients remain without diagnosis highlighting the technical and interpretational hurdles that need to be overcome in the future.

The diagnostic yield of whole exome sequencing as a first approach in consanguineous Omani renal ciliopathy syndrome patients

Background: Whole exome sequencing (WES) is becoming part of routine clinical and diagnostic practice. In the investigation of inherited cystic kidney disease and renal ciliopathy syndromes, WES has been extensively applied in research studies as well as for diagnostic utility to detect various novel genes and variants. The yield of WES critically depends on the characteristics of the patient population. Methods: In this study, we selected 8 unrelated Omani children, presenting with renal ciliopathy syndromes with a positive family history and originating from consanguineous families. We performed WES in affected children to determine the genetic cause of disease and to test the yield of this approach, coupled with homozygosity mapping, in this highly selected population. DNA library construction and WES was carried out using SureSelect Human All Exon V6 Enrichment Kit and Illumina HiSeq platform. For variants filtering and annotation Qiagen Variant Ingenuity tool was used. Nexus copy number software from BioDiscovery was used for evaluation of copy number variants and whole gene deletions. Patient and parental DNA was used to confirm mutations and the segregation of alleles using Sanger sequencing. Results: Genetic analysis identified 4 potential causative homozygous variants each confirmed by Sanger sequencing in 4 clinically relevant ciliopathy syndrome genes, ( TMEM231, TMEM138, WDR19 and BBS9), leading to an overall diagnostic yield of 50%. Conclusions: WES coupled with homozygosity mapping provided a diagnostic yield of 50% in this selected population. This genetic approach needs to be embedded into clinical practise to allow confirmation of clinical diagnosis, to inform genetic screening as well as family planning decisions. Half of the patients remain without diagnosis highlighting the technical and interpretational hurdles that need to be overcome in the future.

Depression and psychosocial burden among caregivers of children with chronic kidney disease

Background

More attention has recently targeted families of children with chronic kidney diseases displaying depressive symptoms and major psychosocial burden due to the long-standing nature of the illness and its alarming complications. A cross sectional comparative study was conducted to assess the rate of occurrence of both depression severity and psychological burden, personal and role strain in a sample of Egyptian caregivers of children with chronic kidney disease.

Results

Thirty caregivers of children with CKD were enrolled compared to 30 matched controls during a 6-month period. A short pre-designed sheet including socio-demographic data, and general medical, psychiatric and family history was used, and Beck Depression Inventory, Zarit Burden Interview, Holmes and Rahe Socioeconomic Stress Scale, and Occupational Stress Questionnaire were answered.

More than half of the caregivers of children with chronic kidney disease reported moderate depression (53.3%), while 30% and 16.7% reported mild and severe depression respectively. The majority of cases 80% had moderate psychological burden. And 70% of cases reported minimal socioeconomic stress compared to 40% in the control. Logistic regression analysis showed that ZBI and SRRS scores were significantly linked to depression and burden found in caregivers of children with CKD (P = 0.001 and 0.031) respectively.

Conclusion

The rate of occurrence of depression and psychological burden is significantly high in caregivers of children with chronic kidney disease; therefore, this population must be assessed and provided with liaison psychological rehabilitation.

Renal medullary oxygenation decreases with lower body negative pressure in healthy young adults

One in three Americans suffer from kidney diseases such as chronic kidney disease, and one of the etiologies is suggested to be long-term renal hypoxia. Interestingly, sympathetic nervous system activation evokes a renal vasoconstrictor effect that may limit oxygen delivery to the kidney. In this report, we sought to determine if sympathetic activation evoked by lower body negative pressure (LBNP) would decrease cortical and medullary oxygenation in humans. LBNP was activated in a graded fashion (LBNP; -10, -20, and -30 mmHg), as renal oxygenation was measured (T2*, blood oxygen level dependent, BOLD MRI; n = 8). At a separate time, renal blood flow velocity (RBV) to the kidney was measured (n = 13) as LBNP was instituted. LBNP significantly reduced RBV (P = 0.041) at -30 mmHg of LBNP (Δ-8.17 ± 3.75 cm/s). Moreover, both renal medullary and cortical T2* were reduced with the graded LBNP application (main effect for the level of LBNP P = 0.0008). During recovery, RBV rapidly returned to baseline, whereas medullary T2* remained depressed into the first minute of recovery. In conclusion, sympathetic activation reduces renal blood flow and leads to a significant decrease in oxygenation in the renal cortex and medulla.NEW & NOTEWORTHY In healthy young adults, increased sympathetic activation induced by lower body negative pressure, led to a decrease in renal cortical and medullary oxygenation measured by T2*, a noninvasive magnetic resonance derived index of deoxyhemoglobin levels. In this study, we observed a significant decrease in renal cortical and medullary oxygenation with LBNP as well as an increase in renal vasoconstriction. We speculate that sympathetic renal vasoconstriction led to a significant reduction in tissue oxygenation by limiting oxygen delivery to the renal medulla.

Blood Glucose and Renal Function Evaluation in Patients with Viral Hepatitis

PURPOSE

To evaluate the blood glucose and renal function, determine the prevalence of hyperglycemia/diabetes mellitus (DM) and renal disease (nephropathy), and investigate the association between hyperglycemia/DM and renal disease in patients with viral hepatitis (VH).

PATIENTS AND METHODS

A total of 491 subjects were included in the study. Patients with VH were further divided into the hepatitis B virus (HBV) infection, hepatitis C virus (HCV) infection, and HBV-HCV co-infection subgroups. Fasting blood glucose, glycated hemoglobin (HbA1c), glycated albumin (GA), glutamic oxaloacetic transaminase (GOT), creatinine (Cr), and cystatin C (Cys C) levels were measured. Urine microalbumin levels were also assessed. Formulas for estimated average glucose calculated using glycated albumin(eAG(GA)), estimated average glucose calculated using HbA1c (eAG(HbA1c)), and estimated glomerular filtration rate calculated using cystatin C (eGFRcys) were used to evaluate the average glucose and renal function.

RESULTS

The prevalence of hyperglycemia/DM and renal disease was significantly higher in the VH group, especially in the HCV subgroup. The prevalence of renal disease was significantly higher in patients with VH with eAG(GA) ≥200 mg/dL.

CONCLUSION

Our study used multiple parameters to evaluate blood glucose and renal function in patients with VH and found that hyperglycemia/DM and renal disease are closely associated with VH, especially in subjects with HCV infection. Patients with VH, especially those with HCV infection and hyperglycemia/DM, were particularly vulnerable to renal disease.

Factors associated with nursing diagnoses in chronic kidney patients: a cross-sectional study

Introduction: To the care plan, the nurses must use the nursing process and adopt their perspectives, cognitive and documentary, considering the human responses of each chronic kidney disease patient, to define the nursing diagnoses, results, and interventions. This study is aimed to analyze the nursing diagnoses of NANDA-I in chronic renal patients and its association with clinical and sociodemographic variables. Materials and Methods: Analytical cross-sectional study, performed with chronic renal patients undergoing hemodialysis. The study population consisted of 177 medical records of chronic kidney disease patients. They were selected in the pre-established period of six months: July to December 2018. It was used the Google Forms® platform to import the data directly to Microsoft Excel® Program by generating an electronic spreadsheet that allowed organizing the data, this was then transcribed to the Stata 14.0 software to perform the statistical analyses. Results: The risk for bleeding diagnosis showed a significant difference with the variable access route (p = 0.02); risk for falls was associated with the variables age, occupation, education (p <0.01) and excessive fluid volume with the variable duration of treatment (p = 0.01). Discussion: In the case of nursing diagnoses, these must be planned and documented based on a standardized nursing language, with NANDA-I. Conclusion: The findings of this study showed the main nursing diagnoses and its association with clinical and sociodemographic variables in chronic renal patients in a Brazilian context. Future research may lead to implement care plans for the most prevalent nursing diagnoses in this type of population.

Performance Evaluation and Fouling Propensity of Forward Osmosis (FO) Membrane for Reuse of Spent Dialysate

The number of chronic renal disease patients has shown a significant increase in recent decades over the globe. Hemodialysis is the most commonly used treatment for renal replacement therapy (RRT) and dominates the global dialysis market. As one of the most water-consuming treatments in medical procedures, hemodialysis has room for improvement in reducing wastewater effluent. In this study, we investigated the technological feasibility of introducing the forward osmosis (FO) process for spent dialysate reuse. A 30 LMH of average water flux has been achieved using a commercial TFC membrane with high water permeability and salt removal. The water flux increased up to 23% with increasing flowrate from 100 mL/min to 500 mL/min. During 1 h spent dialysate treatment, the active layer facing feed solution (AL-FS) mode showed relatively higher flux stability with a 4–6 LMH of water flux reduction while the water flux decreased significantly at the active layer facing draw solution (AL-DS) mode with a 10–12 LMH reduction. In the pressure-assisted forward osmosis (PAFO) condition, high reverse salt flux was observed due to membrane deformation. During the membrane filtration process, scaling occurred due to the influence of polyvalent ions remaining on the membrane surface. Membrane fouling exacerbated the flux and was mainly caused by organic substances such as urea and creatinine. The results of this experiment provide an important basis for future research as a preliminary experiment for the introduction of the FO technique to hemodialysis.

Survival and analysis of predictors of mortality in patients undergoing replacement renal therapy: a 20-year cohort

Background

optimal management of end-stage renal disease (ESRD) in hemodialysis (HD) patients should be more studied because it is a serious risk factor for mortality, being considered an unquestionable global priority.

Methods

we performed a retrospective cohort study from the Nephrology Service in Brazil evaluating the survival of patients with ESRD in HD during 20 years. Kaplan-Meier method with the Log-Rank and Cox’s proportional hazards model explored the association between survival time and demographic factors, quality of treatment and laboratory values.

Results

Data from 422 patients were included. The mean survival time was 6.79 ± 0.37. The overall survival rates at first year was 82,3%. The survival time correlated significantly with clinical prognostic factors. Prognostic analyses with the Cox proportional hazards regression model and Kaplan-Meier survival curves further identified that leukocyte count (HR = 2.665, 95% CI: 1.39–5.12), serum iron (HR = 8.396, 95% CI: 2.02–34.96), serum calcium (HR = 4.102, 95% CI: 1.35–12.46) and serum protein (HR = 4.630, 95% CI: 2.07–10.34) as an independent risk factor for the prognosis of survival time, while patients with chronic obstructive pyelonephritis (HR = 0.085, 95% CI: 0.01–0.74), high ferritin values (HR = 0.392, 95% CI: 0.19–0.80), serum phosphorus (HR = 0.290, 95% CI: 0.19–0.61) and serum albumin (HR = 0.230, 95% CI: 0.10–0.54) were less risk to die.

Conclusion

survival remains low in the early years of ESRD treatment. The present study identified that elevated values of ferritin, serum calcium, phosphorus, albumin, leukocyte, serum protein and serum iron values as a useful prognostic factor for the survival time.

The usefulness and feasibility of placing a clinch knot with a guidewire to achieve temporary hemostasis in arteriovenous dialysis access interventions

PURPOSE

To evaluate the usefulness and feasibility of using a reversible clinch knot with a guidewire in place rather than eliminating the access route during an arteriovenous hemodialysis access (AV access) intervention using the facing sheath technique.

MATERIAL AND METHODS

From July 2016 to June 2019, we retrospectively studied 78 sessions performed as interventional treatment for arteriovenous (AV) hemodialysis (HD) access using the "facing-sheath technique." In all sessions, all antegrade sheaths were removed while a 0.035-inch guidewire remained in place with purse-string suture and the clinch knot. Seventy-two sessions were performed in patients with thrombosed AV accesses (69 arteriovenous grafts [AVGs] and three arteriovenous fistulas [AVFs]), and six sessions were carried out to treat non-thrombosed AV accesses (four AVGs and two AVFs). We evaluated whether proper hemostasis and successful reinsertion of the sheath over the wire into the clinch knot was achieved. Clinical success was defined as achieving prompt restoration of blood flow for AV access, and the postintervention primary and secondary patency were also evaluated.

RESULT

In all 87 clinch knots created in 78 total sessions, proper hemostasis was achieved. All clinch knots that required reversal for additional procedures were successfully reopened (55 clinch knots in 50 sessions). The postintervention primary patency rates at 1, 3, and 6 months, and at 1 year were 77.8%, 68.9%, 55.6%, and 33.3%, respectively. The postintervention secondary patency rates at 1, 3, and 6 months, and also at 1 year were 93.3%, 91.1%, 86.7%, and 86.7%, respectively.

CONCLUSION

Our AV access intervention which used a clinch knot with purse-string suture while the guidewire remained in place was both useful and feasible for maintaining temporary hemostasis.

Senses and Meanings of Conservative Treatment in People with Chronic Kidney Disease

Objective: To unveil the senses and meanings of conservative treatment in people with chronic kidney disease (CKD). Materials and Methods: A descriptive and exploratory study with a qualitative approach. It was developed in 2017, with a sample of individuals with CKD undergoing conservative treatment. A semi-structured interview was used and the data were analyzed using simple descriptive statistics and content analysis. Results: 25 individuals participated in the study, of which 56 % were female; 52 % belonged to the 60-79-year-old age group; 48 % were white-skinned; 48 % did not complete elementary school; and only 12 % worked. Content analysis revealed two categories: food restriction: anguishes and impacts that affect the daily lives of patients with CKD and the social imaginary and fear related to renal replacement therapy. Conclusions: The results revealed that diet and fear about dialysis therapy produce uncertainty, anxiety, and insecurity, in addition to a wide and impacting change in people’s lives.