Chronic kidney disease: identification and management in primary care

The health-economic impact of urine albumin-to-creatinine ratio testing for chronic kidney disease in Japanese non-diabetic patients

BACKGROUND

The objective of this analysis was to estimate the clinical and economic impact of undertaking urine albumin-to-creatinine ratio (UACR) testing alongside regular estimated glomerular filtration rate testing for chronic kidney disease in non-diabetic Japanese patients versus no testing and versus urine protein-creatinine ratio (UPCR) testing.

METHODS

An economic model, taking a Japanese healthcare perspective, estimated the health-economic impact of UACR testing over a lifetime time horizon. Outcomes reported were additional costs, clinical benefits measured, such as prevented dialyses and cardiovascular events, quality-adjusted life years gained, and incremental cost-effectiveness ratios. Health states were derived from risk levels reported in the Kidney Disease: Improving Global Outcomes heatmap. Results were derived assuming that after testing, treatment was available in the form of current standard-of-care or emerging chronic kidney disease therapies.

RESULTS

Repeated UACR testing was found to be cost-effective compared to both no urine testing and UPCR testing, with incremental cost-effectiveness ratios of ¥1,953,958 and ¥1,966,433, respectively.

CONCLUSION

Overall, this model demonstrates the health-economic value of undertaking UACR testing within the non-diabetic Japanese population.

Tackling chronic kidney disease in Nepal: from evidence to action

Chronic kidney disease (CKD) poses a significant burden in Nepal. We reviewed the epidemiology of CKD in Nepal and proposed strategies to mitigate its burden. A nationwide survey of non-communicable diseases in 2019 reported CKD prevalence of 6.2% (95% Confidence Interval [CI]: 5.7-6.6%). Further, we found that the age-standardized prevalence of chronic kidney disease in Nepal grew by 0.11% (95% uncertainty interval, [UI]: 0.10-0.11%) per annum between 1990 and 2021. Despite the high burden (10,887.7 prevalent CKD per 100,000 population), the country only has 56 nephrologists and 60 hemodialysis centers, the majority of which are located in the country's capital, serving only 15% of the population. CKD requires multi-component interventions that address the diverse causes and pathological expressions of the disease. Integrating interventions across the care continuum, such as health education and literacy, screening, lifestyle modifications, and improved access to renal replacement therapies, can enhance effective coverage and scalability of care. Additionally, it is crucial to explore and address disparities in access to CKD treatment, including gender and socioeconomic disparities.

T-Cell Subpopulations and Differentiation Bias in Diabetic and Non-Diabetic Patients with Chronic Kidney Disease

BACKGROUND

Chronic kidney disease (CKD) patients often experience dysregulated inflammation, particularly when compounded by comorbidities such as type 2 diabetes (T2D).

OBJECTIVE

The aim of this study was to determine whether T2D influences the profile of memory T lymphocytes, regulatory T cells (Tregs), and the gene expression of transcription factors such as T-bet (Tbx21), GATA3, RORyT (RORC), and FOXP3 in CKD patients.

METHODS

Twenty-two CKD patients undergoing hemodialysis were selected for the study. Flow cytometry was used to identify naïve T cells, Tregs (CD4+CD25+CD127-), central memory T lymphocytes (CCR7+CD45RA-), effector memory T lymphocytes (CCR7-CD45RA-), and TEMRA cells (CCR7-CD45RA+). The expression of helper T cell differentiation regulatory genes was assessed using real-time RT-PCR.

RESULTS

Both helper and cytotoxic effector memory T cell populations were found to be higher than naïve lymphocytes in CKD patients, regardless of T2D status. However, Tregs were significantly more frequent in diabetic CKD patients (5.1 ± 2.6%) compared to non-diabetic patients (2.8 ± 3.1%). In terms of transcription factor expression, a significant correlation was observed between T-bet and FOXP3 in diabetic patients, and between RORyT and FOXP3 in non-diabetic patients.

CONCLUSIONS

While T2D does not notably alter the distribution of memory T cells in CKD patients, it significantly impacts the frequency of Tregs and their correlation with pro-inflammatory transcription factors like T-bet (Tbx21) and RORyT.

The role of finerenone in the management of CKD in T2D -Practical considerations for primary care

The prevalence of diabetes and chronic kidney disease (CKD) is increasing worldwide. Diabetic kidney disease is a chronic condition characterized by a gradual increase in urinary albumin excretion, blood pressure, cardiovascular risk, and a decline in glomerular filtration rate (GFR) that can progress to end-stage kidney disease (ESKD). Individuals with diabetes should be screened for CKD annually. Screening should include both measurement of albuminuria and estimation of GFR (eGFR). The structural changes in diabetic kidney disease in individuals with type 1 diabetes are rather uniform, but the histological picture in those with type 2 diabetes and CKD is on the contrary a mix of changes ranging from minor abnormalities to severe glomerulosclerosis, tubulointerstitial fibrosis, and arteriolohyalinosis. Scarring of the kidneys is closely related to the kidney function. Individuals with diabetes often require multiple therapies to prevent progression of CKD and its associated comorbidities and mortality. Management of cardiorenal risk factors, including lifestyle modification, control of blood glucose, blood pressure, and lipids, use of renin-angiotensin-aldosterone system (RAAS) blockers, use of sodium-glucose co-transporter 2 (SGLT2) inhibitors, and the non-steroidal mineralocorticoid receptor antagonist finerenone in individuals with T2D are the cornerstones of therapy. Primary care physicians (PCPs) play a critical role in identifying individuals with CKD, managing early stages of CKD, and referring those with moderate to severe CKD or rapidly declining kidney function to a nephrologist. Referral to a nephrologist should be considered when certain thresholds for eGFR, albuminuria, proteinuria, hematuria, or hypertension are exceeded. This review summarizes current guidelines for the management of CKD and its complications and highlights the role of PCPs in the care of individuals with CKD.

Early Identification and Management of Chronic Kidney Disease: A Narrative Review of the Crucial Role of Primary Care Practitioners

Early-stage (stage 1-3) chronic kidney disease (CKD) has an asymptomatic presentation such that most people with CKD are unaware of their disease status and remain undiagnosed. CKD is associated with multiple long-term conditions (MLTC), or multimorbidity, the most common of these being cardiovascular disease, hypertension, and type 2 diabetes. Primary care practitioners (PCPs) are crucial in the early identification and management of patients with CKD. For individuals at high risk of CKD, measurements of estimated glomerular filtration rate, urine albumin-creatinine ratio, and blood pressure should be obtained regularly and recorded in a timely manner. The importance of lifestyle changes in the prevention and management of CKD should also be highlighted. A recent addition to the treatment of CKD in people with and without type 2 diabetes has been the recommendation by clinical practice guidelines of a sodium-glucose co-transporter 2 (SGLT2) inhibitor alongside a renin-angiotensin-aldosterone system inhibitor as foundational therapy. SGLT2 inhibitors prevent CKD progression and reduce fatal and non-fatal kidney and cardiovascular events, hospitalization for heart failure, and all-cause mortality, and they have a favorable safety and tolerability profile. However, uptake has been slow, particularly in people with CKD without type 2 diabetes. A multifaceted approach is required to ensure that people with CKD receive optimal kidney protection. Measures to raise awareness of the importance of early identification and intervention include local/national campaigns via social media and practice-based education; clinical education programs; integration of clinical decision support tools into electronic health records; detection programs built around electronic health records; and good interdisciplinary communication. PCPs at the forefront of multidisciplinary care are best placed to implement the evidence-based clinical practice CKD guidelines for lifestyle modification and guideline-directed medical therapy.

Patient and Clinician Perspectives: To Create a Better Future for Chronic Kidney Disease, We Need to Talk About Our Kidneys

Chronic kidney disease (CKD) affects more than one in ten people worldwide. However, results from the REVEAL-CKD study suggest that it is often not diagnosed. Many patients are therefore unaware that they have CKD, putting them at increased risk of disease progression and complications. Empowering patients with knowledge about CKD will allow them to become active participants in their own care, driving improvements in diagnosis rates and changing patient outcomes for the better. In this article, we provide patient and clinician perspectives on the importance of early CKD diagnosis and management. We present an overview of the tests commonly used to diagnose CKD in clinical practice, as well as actionable suggestions for patients, clinicians, and health policymakers that could help improve disease detection and treatment. Navdeep Tangri, a nephrologist and epidemiologist at the University of Manitoba, and Jane DeMeis, a patient living with chronic kidney disease, discuss how results from the REVEAL-CKD study highlight the need for change to improve management of chronic kidney disease. Video Abstract (MP4 141866 KB).

Characteristics of Vascular Access Cannulation Complications in End Stage Kidney Disease Patients in West Java from 2018 to 2022: A Retrospective Observational Study

Background

End-stage kidney disease (ESKD) is associated with a tremendous financial burden. Data in Indonesia shows an increasing number of patients with ESKD taking hemodialysis as a routine procedure every year. Establishment and maintenance of vascular access are important in the management of ESKD. Vascular complications that often arise due to hemodialysis are common and one of the main reasons for hospitalization. Cannulation complications ranged from minor hematomas to acute bleeding from pseudoaneurysms that required emergency surgical procedures. This study aims to assess the different clinicopathological characteristics of ESKD patients with vascular access cannulation complications and the surgical management related to the complications.

Materials and Methods

This research is a retrospective observational study. The research subjects in this study were ESKD patients in the vascular and endovascular surgery division of the tertiary hospital in West Java, Indonesia. There were 121 study subjects. Clinicopathological characteristics of vascular cannulation complications and surgical management are extracted from the medical record.

Results

Three major vascular complications were ruptured pseudoaneurysms 64/121 (52.9%), impending rupture pseudoaneurysms 28/121 (23.1%), and pseudoaneurysms 21/121 (17.4%). Common surgical procedures were ligation of the draining vein 47/121 (38.8%), arterial primary repair 28/121 (23.1%), and arterial patch repair 18/121 (14.9%). There was a significant relationship between symptoms of bleeding in ruptured pseudoaneurysms and bulging masses in pseudoaneurysms (p = 0.001). There was a significant relationship between the diameter of the vascular mass, vascular defect size, and hematoma and the type of surgical procedure taken (p < 0.010).

Conclusion

Ruptured, impending rupture, and pseudoaneurysms are major complications of vascular access in ESKD patients, and there was a significant relationship between the carried-out surgical procedure and the size of the vascular mass, defect, and hematoma.

Leading Causes of Chronic Kidney Disease Among Dialysis Patients in Al-Baha Region, Saudi Arabia

Introduction Chronic kidney disease (CKD) and its progression to end-stage renal disease (ESRD) represent a growing health concern globally, with hypertension and diabetes commonly identified as primary etiological factors. This study evaluates the demographic and health profiles of individuals undergoing dialysis treatment in the Al-Baha region of Saudi Arabia, aiming to identify the predominant causes of ESRD and the associated socioeconomic and healthcare-related factors. Methodology This cross-sectional study analyzed data from patients receiving dialysis in Al-Baha. We assessed variables including etiology of ESRD, demographic data, presence of comorbid conditions, initial symptoms, and pre-dialysis health care engagement. Statistical analysis focused on the prevalence and correlations between the different variables and ESRD. The study also examined patients' educational background and employment status to ascertain ESRD's socioeconomic impact. Results The study found hypertension and diabetes as the leading causes of ESRD. Unknown etiologies accounted for 10.1% of cases, highlighting an area for further research. Notably, coronavirus disease 2019 (COVID-19) and cardiogenic shock emerged as potential new contributors, each representing 1.7% of cases. Most patients resided in urban areas, with the largest age group being 46 to 55 years. Men had a higher prevalence of ESRD than women. Low educational attainment was significant among patients, and unemployment due to ESRD was prevalent, pointing towards the need for vocational support. Clinical findings revealed late referrals to nephrologists, with a substantial proportion of diagnoses occurring in emergency settings. Family history suggested a higher-than-expected genetic component of CKD in the region. Conclusion The study confirms hypertension and diabetes as principal contributors to ESRD in Al-Baha while also pointing to the emergence of COVID-19 as a potential risk factor. Socioeconomic factors, including educational and employment status, are critical to patient management and outcomes. The high percentage of unknown etiologies and familial CKD prevalence warrants additional research. Improving early detection, enhancing patient education, and fostering timely nephrology consultations could mitigate the progression to ESRD and enhance patient quality of life.

The drivers of non-adherence to albuminuria testing guidelines and the clinical and economic impact of not identifying chronic kidney disease

BACKGROUND

Regular monitoring is required to ensure that patients who have, or are at risk of, chronic kidney disease (CKD) receive appropriate management. Guidelines recommend regular testing of estimated glomerular filtration rate (GFR) and albuminuria. However, evidence suggests that albuminuria testing rates, specifically urine albumin-to-creatinine ratio (UACR), are suboptimal.

AIM

To assess published evidence relating to the drivers of non-adherence to albuminuria testing guidelines and the impact of not identifying CKD across the course of progression.

MATERIALS AND METHODS

A systematic review of five bibliographic databases was conducted, supplemented by hand searches of relevant conference abstracts.

RESULTS

One study was identified that reported drivers of non-adherence to albuminuria testing guidelines. The largest barrier was the perception that testing does not impact patient management. Thirteen studies were identified that evaluated the impact of not identifying CKD patients. All included studies analyzed the effect of not identifying worsening CKD severity leading to late referral (LR). 12/13 studies reported only on clinical impact, and 1/13 reported on clinical and economic impact. LR led to higher costs and worse outcomes than early referral, including higher rates of mortality and worsened kidney replacement therapy preparation.

CONCLUSION

This systematic review demonstrates a gap in evidence exploring the drivers of non-adherence to albuminuria testing guidelines and the impact of not identifying patients in the early stages of CKD. Guideline-recommended testing allows timely identification, referral, and treatment for patients with, or at risk of, CKD, providing the best chance of avoiding the worsened outcomes identified in this review.

Cape York Kidney Care: service description and baseline characteristics of a client-centred multidisciplinary specialist kidney health service in remote Australia

BACKGROUND

Chronic Kidney disease (CKD) is over-represented amongst First Nation people with more than triple the rate of CKD in those aged 15 years and over. The impact of colonisation, including harmful experiences of health practices and research, has contributed to these health inequities. Cape York Kidney Care (CYKC) has been created as an unique service which provides specialist care that aims to centre the client within a multidisciplinary team that is integrated within the primary care setting of the remote health clinics in six communities in western Cape York, Australia. This research aims to describe the Cape York Kidney Care service delivery model, and baseline service data, including aggregated client health measures.

METHODS

The model of care is described in detail. Review of the first 12 months of service provision has been undertaken with client demographic and clinical profile baseline data collected including kidney health measures. Participants are adults (> 18 years if age) with CKD grades 1-5. This data has been de-identified and aggregated.

RESULTS

CYKC reviewed 204 individuals, with 182 not previously been reviewed by specialist kidney health services. Three quarters of clients identified as Aboriginal. The average age was 55 with a high level of comorbidity, with majority having a history of hypertension and Type 2 diabetes (average Hba1c 8.2%). Just under one third had cardiovascular disease. A large proportion of people had either Grade 2 CKD (32%) or Grade 3 CKD (~ 30%), and over half had severely increased albuminuria (A3), with Type 2 diabetes being the predominant presumed cause of CKD. Most clients did not meet evidence-based targets for diabetes, blood pressure or lipids and half were self-reported smokers. The proportion of clients reviewed represents 6.2% of the adult population in the participating First Nation communities.

CONCLUSION

The CYKC model was able to target those clients at high risk of progression and increase the number of people with chronic kidney disease reviewed by specialist kidney services within community. Baseline data demonstrated a high burden of chronic disease that subsequently will increase risk of CKD progression and cardiovascular disease. People were seen to have more severe disease at younger ages, with a substantial number demonstrating risk factors for rapid progression of kidney disease including poorly controlled Type 2 diabetes and severely increased albuminuria. Further evaluation concerning implementation challenges, consumer and community satisfaction, and health outcomes is required.

Feasibility of Wave Intensity Analysis from 4D Cardiovascular Magnetic Resonance Imaging Data

Congenital heart defects (CHD) introduce haemodynamic changes; e.g., bicuspid aortic valve (BAV) presents a turbulent helical flow, which activates aortic pathological processes. Flow quantification is crucial for diagnostics and to plan corrective strategies. Multiple imaging modalities exist, with phase contrast magnetic resonance imaging (PC-MRI) being the current gold standard; however, multiple predetermined site measurements may be required, while 4D MRI allows for measurements of area (A) and velocity (U) in all spatial dimensions, acquiring a single volume and enabling a retrospective analysis at multiple locations. We assessed the feasibility of gathering hemodynamic insight into aortic hemodynamics by means of wave intensity analysis (WIA) derived from 4D MRI. Data were collected in n = 12 BAV patients and n = 7 healthy controls. Following data acquisition, WIA was successfully derived at three planes (ascending, thoracic and descending aorta) in all cases. The values of wave speed were physiological and, while the small sample limited any clinical interpretation of the results, the study shows the possibility of studying wave travel and wave reflection based on 4D MRI. Below, we demonstrate for the first time the feasibility of deriving wave intensity analysis from 4D flow data and open the door to research applications in different cardiovascular scenarios.

Optimizing Multidisciplinary Care of Patients with Chronic Kidney Disease and Type 2 Diabetes Mellitus

Diabetes is the leading cause of chronic kidney disease (CKD), a condition associated with significant morbidity and mortality. As these patients have a high risk of developing cardiovascular disease and end-stage kidney disease, there is a need for early detection and early initiation of appropriate therapeutic interventions that slow disease progression and prevent adverse outcomes. Due to the complex nature of diabetes and CKD management, a holistic, patient-centered, collaborative care approach delivered by a coordinated multidisciplinary team (ideally including a clinical pharmacist as part of a comprehensive medication management program) is needed. In this review, we discuss the barriers to effective care, the current multidisciplinary approach used for CKD prevention and treatment, and the potential ways that the multidisciplinary management of CKD associated with type 2 diabetes mellitus can be refined to improve patient outcomes.

Predict, diagnose, and treat chronic kidney disease with machine learning: a systematic literature review

OBJECTIVES

In this systematic review we aimed at assessing how artificial intelligence (AI), including machine learning (ML) techniques have been deployed to predict, diagnose, and treat chronic kidney disease (CKD). We systematically reviewed the available evidence on these innovative techniques to improve CKD diagnosis and patient management.

METHODS

We included English language studies retrieved from PubMed. The review is therefore to be classified as a "rapid review", since it includes one database only, and has language restrictions; the novelty and importance of the issue make missing relevant papers unlikely. We extracted 16 variables, including: main aim, studied population, data source, sample size, problem type (regression, classification), predictors used, and performance metrics. We followed the Preferred Reporting Items for Systematic Reviews (PRISMA) approach; all main steps were done in duplicate.

RESULTS

From a total of 648 studies initially retrieved, 68 articles met the inclusion criteria. Models, as reported by authors, performed well, but the reported metrics were not homogeneous across articles and therefore direct comparison was not feasible. The most common aim was prediction of prognosis, followed by diagnosis of CKD. Algorithm generalizability, and testing on diverse populations was rarely taken into account. Furthermore, the clinical evaluation and validation of the models/algorithms was perused; only a fraction of the included studies, 6 out of 68, were performed in a clinical context.

CONCLUSIONS

Machine learning is a promising tool for the prediction of risk, diagnosis, and therapy management for CKD patients. Nonetheless, future work is needed to address the interpretability, generalizability, and fairness of the models to ensure the safe application of such technologies in routine clinical practice.

Living with Chronic Kidney Disease and Type 2 Diabetes Mellitus: The Patient and Clinician Perspective

Comorbid type 2 diabetes mellitus (T2D) and chronic kidney disease (CKD) is associated with poor health outcomes and a high economic burden. Management of these conditions remains a significant challenge for current healthcare systems. The objective of this article is to describe the experiences of patients living with T2D and CKD and their thoughts on how communication between patients and their clinicians could be improved despite the multiple comorbidities that need to be addressed. We present the individual perspectives of three patient authors, followed by relevant discussion around the management of CKD in patients with T2D by clinician authors.Audio abstract available for this article. Audio Abstract. In this audio introduction, the authors Patrick Gee (a patient author) and Eugene Wright (a clinician author) provide a brief overview and discuss the key findings of their article titled "Living with Chronic Kidney Disease and Type 2 Diabetes Mellitus: The Patient and Clinician Perspective".

The protection afforded by Berberine against chemotherapy-mediated nephropathy in rats involves regulation of the antioxidant axis

Doxorubicin (DOX) treatment in cancer patients leads to nephrotoxicity. The nephroprotective effect of Berberine (BBR), a herbal ingredient, is well documented as antioxidant and activation of the Nrf2 signalling. This study aimed to investigate if Nrf2 is a major protective mechanism of BBR in DOX animal models. Rats were divided as (n = 6 each): Control, BBR (100 mg/kg, orally), DOX (15 mg/kg, orally), BBR + DOX, and BBR + DOX + brusatol (0.2 mg/kg, i.p./twice per week) (an Nrf2 inhibitor). DOX was given as a single dose (day 10), whereas BBR was administered for 3 weeks on a daily basis. BBR reduced tubular degeneration and improved renal markers in DOX-treated rats. It also reduced renal nuclear levels of NF-κB p65, total reactive oxygen species (ROS), lipid peroxides, interleukin-6 (IL-6), and tumour necrosis factor-α (TNF-α), as well as mRNA levels of Bax and cleaved caspase-3. However, BBR stimulated glutathione (GSH) and superoxide dismutase (SOD) levels, the transcription of Bcl2, and the mRNA, total cytoplasmic, and nuclear levels of Nrf2 with no effect on the cytoplasmic keap1 levels. All these effects disappeared by brusatol. In conclusion, BBR prevents DOX-induced renal damage by activating Nrf2.

Findings and Implications of the REVEAL-CKD Study Investigating the Global Prevalence of Undiagnosed Stage G3 Chronic Kidney Disease

Chronic kidney disease (CKD) is a progressive condition that can lead to kidney failure and the requirement for renal dialysis or transplantation. Early-stage CKD is often missed because the disorder is initially asymptomatic; hence, many patients with CKD already have symptomatic advanced disease (Stages G4–G5) at the time of diagnosis. This is an important issue because the drugs available for the treatment of CKD are most effective when given during the early stages of the disease (Stages G1–G3). EMJ conducted interviews in July 2022 with two key opinion leaders, Navdeep Tangri from the University of Manitoba, Winnipeg, Canada, and Luca De Nicola from the University of Campania Luigi Vanvitell, Naples, Italy, both of whom have a wealth of experience in the management of patients with CKD. The experts provided important insights into the ongoing REVEAL-CKD study, which was designed to explore the global prevalence of undiagnosed Stage G3 CKD. This article describes the main findings of the REVEAL-CKD study published to date and their implications. Possible approaches to improving the diagnosis of CKD are also discussed.

Effect of a Pay-for-Performance Program on Renal Outcomes Among Patients With Early-Stage Chronic Kidney Disease in Taiwan

BACKGROUND

With the promising outcomes of the pre-ESRD (end-stage renal disease) pay-for-performance (P4P) program, the National Health Insurance Administration (NHIA) of Taiwan launched a P4P program for patients with early chronic kidney disease (CKD) in 2011, targeting CKD patients at stages 1, 2, and 3a. This study aimed to examine the long-term effect of the early-CKD P4P program on CKD progression.

METHODS

We conducted a matched cohort study using electronic medical records from a large healthcare delivery system in Taiwan. The outcome of interest was CKD progression to estimated glomerular filtration rate (eGFR) <45 mL/min/1.73 m2 between P4P program enrolees and non-enrolees. The difference in the cumulative incidence of CKD progression between the P4P and non-P4P groups was tested using Gray's test. We adopted a cause-specific (CS) hazard model to estimate the hazard in the P4P group as compared to non-P4P group, adjusting for age, sex, baseline renal function, and comorbidities. A subgroup analysis was further performed in CKD patients with diabetes to evaluate the interactive effects between the early-CKD P4P and diabetes P4P programs.

RESULTS

The incidence per 100 person-months of disease progression was significantly lower in the P4P group than in the non-P4P group (0.44 vs. 0.69, P<.0001), and the CS hazard ratio (CS-HR) for P4P program enrolees compared with non-enrolees was 0.61 (95% CI: 0.58-0.64, P<.0001). The results of the subgroup analysis further revealed an additive effect of the diabetes P4P program on CKD progression; compared to none of both P4P enrolees, the CS-HR for CKD disease progression was 0.60 (95% CI: 0.54-0.67, P<.0001) for patients who were enrolled in both early-CKD P4P and diabetes P4P programs.

CONCLUSION

The present study results suggest that the early-CKD P4P program is superior to usual care to decelerate CKD progression in patients with early-stage CKD.

The Impact of Human Microbiotas in Hematopoietic Stem Cell and Organ Transplantation

The human microbiota heavily influences most vital aspects of human physiology including organ transplantation outcomes and transplant rejection risk. A variety of organ transplantation scenarios such as lung and heart transplantation as well as hematopoietic stem cell transplantation is heavily influenced by the human microbiotas. The human microbiota refers to a rich, diverse, and complex ecosystem of bacteria, fungi, archaea, helminths, protozoans, parasites, and viruses. Research accumulating over the past decade has established the existence of complex cross-species, cross-kingdom interactions between the residents of the various human microbiotas and the human body. Since the gut microbiota is the densest, most popular, and most studied human microbiota, the impact of other human microbiotas such as the oral, lung, urinary, and genital microbiotas is often overshadowed. However, these microbiotas also provide critical and unique insights pertaining to transplantation success, rejection risk, and overall host health, across multiple different transplantation scenarios. Organ transplantation as well as the pre-, peri-, and post-transplant pharmacological regimens patients undergo is known to adversely impact the microbiotas, thereby increasing the risk of adverse patient outcomes. Over the past decade, holistic approaches to post-transplant patient care such as the administration of clinical and dietary interventions aiming at restoring deranged microbiota community structures have been gaining momentum. Examples of these include prebiotic and probiotic administration, fecal microbial transplantation, and bacteriophage-mediated multidrug-resistant bacterial decolonization. This review will discuss these perspectives and explore the role of different human microbiotas in the context of various transplantation scenarios.

Challenges in Management of Kidney Failure in a Free Clinic Setting: A Case Report

Chronic kidney disease (CKD) is a condition that involves the deterioration of renal function over the course of months to years. Various clinical manifestations occur at the initial insult to the kidney, ranging from subtle changes in metabolic and volume control to asymptomatic hematuria, hypertension, and diabetes. The kidneys can adapt to damage or injury, but if left untreated, then there is a possibility of a gradual decline in renal function that progresses to kidney failure that requires dialysis. The rate of progression between stages of CKD is based upon the underlying disease, presence of comorbidity conditions, treatments, socioeconomic status, genetics, and ethnicity. If an individual’s renal function progresses to kidney failure, then patients may experience a constellation of signs and symptoms that include hyperkalemia, volume overload, hypertension, anemia, and bone disorders. Classification or staging of CKD provides a guide to management and stratification of risk for progression to kidney failure.

In this report, we describe a 47-year-old African American male who reported a 25-year history of intermittent homelessness, cocaine, and heroin use but remained free from drug use for 10 years before presenting to our clinic. The patient was diagnosed with hypertension and stage 3 kidney disease in his 30s but was unable to have regular follow-up appointments with a physician due to a lack of access to care. The patient presented asymptomatic with an estimated glomerular filtration rate of 14 mL/min and creatinine of 5.42 mg/dL. We stabilized his hypertension and consulted nephrology to assess the need and timing for dialysis. Once approved for Medicare, the patient was able to be seen within 72 hours and started on dialysis shortly after. He is currently awaiting a kidney transplant.

In this case, we describe and highlight the gaps in care for the medically uninsured, specifically patients with CKD. Our patient was diagnosed with stage 3 kidney disease 17 years before presenting to the Gary Burnstein Clinic. The gaps in accessible healthcare prevented him from accessing treatments he desperately needed. We also highlight the achievements and barriers free health clinics face on a day-to-day basis when trying to manage complex medical needs. We were able to provide high-quality healthcare to bridge the gap in access to care and ultimately get the patient the proper treatment.

Intestinal Microbiota-Derived Short Chain Fatty Acids in Host Health and Disease

Intestinal microbiota has its role as an important component of human physiology. It produces metabolites that module key functions to establish a symbiotic crosstalk with their host. Among them, short chain fatty acids (SCFAs), produced by intestinal bacteria during the fermentation of partially and non-digestible polysaccharides, play key roles in regulating colon physiology and changing intestinal environment. Recent research has found that SCFAs not only influence the signal transduction pathway in the gut, but they also reach tissues and organs outside of the gut, through their circulation in the blood. Growing evidence highlights the importance of SCFAs level in influencing health maintenance and disease development. SCFAs are probably involved in the management of host health in a complicated (positive or negative) way. Here, we review the current understanding of SCFAs effects on host physiology and discuss the potential prevention and therapeutics of SCFAs in a variety of disorders. It provides a systematic theoretical basis for the study of mechanisms and precise intake level of SCFAs to promote human health.

Frailty, Health Literacy, and Self-Care in Patients with Chronic Kidney Disease in Taiwan

Chronic kidney disease (CKD) is a chronic and often irreversible disease that requires active self-care to mitigate adverse outcomes. This study aimed to analyze the associations of demographic and disease data, frailty, health literacy (HL), and CKD self-care (CKDSC) in patients with CKD. We conducted a cross-sectional study at two hospitals in Taiwan. A total of 144 CKD patients with a mean age of 66.8 ± 9.1 years were included in the study. Among them, 79.2% were in CKD G3, and the mean time since diagnosis of CKD was 86 ± 48 months. Approximately 62.5% were identified as non-frail. The mean of HL and CKDSC were 11.76 ± 4.10 and 62.12 ± 9.31. In multivariate linear regression analysis, age ≥ 65 years (odds ratio (OR) = 5.67, 95% confidence interval (CI) 1.59–9.75), non-frailty (OR = 2.19, 95% CI 0.02–5.40), and high critical HL (OR = 1.43, 95% CI 0.13–2.90) showed significant positive correlation with CKDSC. Therefore, management of patients with CKD should focus on the young population, reinforcing health education strategies that improve critical HL and preventing frailty that may interfere with self-care. In addition, the patient’s social support resources should be expanded to achieve the goal of CKDSC.

Critical shear stress of red blood cells as a novel integrated biomarker for screening chronic kidney diseases in cases of type 2 diabetes

BACKGROUND:

The glomerular filtration rate (GFR) and albumin-to-creatinine ratio (ACR) have been widely used to identify and manage diabetic kidney disease (DKD). However, classifications based on these two indices do not always concur in terms of DKD diagnosis; for example, cases of high ACR with normal GFR or normal ACR with low GFR may occur. A recent study suggested that critical shear stress (CSS), a hemorheological parameter to represent aggregating force of red blood cells (RBCs), is a potential screening index for DKD. In the present study, we investigated the diagnostic potential of CSS for DKD according to the KDIGO 2012 Guideline.

METHODS:

A total of 378 patients with type 2 diabetes who visited Yeungnam University Hospital between 2014 and 2017 were included. CSS was measured using a transient microfluidic hemorheometer, Rheoscan-D300® (Rheomeditech, Seoul, Republic of Korea) with whole blood. Patients who were DKD negative (green zone) were compared with patients who were DKD positive (red zone) as Model 1 and patients at risk for (orange zone) and red zones as Model 2, respectively.

RESULTS:

After exclusion criteria such as eGFR < 30 mL/min/1.73 m², alcoholism, and macrovascular complications were applied, the sensitivity and specificity were 100% and 77.8% for Model 1 and 75.0% and 72.0% for Model 2, respectively. The diagnostic accuracy measures of the CSS for Model 1 were found to be highly accurate or have the potential to alter clinical decisions. Similarly, the diagnostic accuracy measures of CSS for Model 2 were found to provide useful information, despite them expanding to the orange and red zones.

CONCLUSION:

DKD was successfully identified using a novel integrated hemorheological index of CSS that satisfied both ACR and GFR criteria. Therefore, CSS may be useful for the additive diagnosis of DKD with GFR and uACR.

A practical approach to chronic kidney disease in primary care

Chronic kidney disease (CKD), a common clinical problem in primary care, can be defined as any abnormality of the kidney structure and/or function that has been present for at least 3 months. Over the past 20 years, the incidence and prevalence of CKD have been increasing in Malaysia in line with the rising number of non-communicable diseases. At present, CKD has no cure. The treatment of CKD is very much dependent on early diagnosis and prevention of CKD progression. In this article, we aim to illustrate a practical approach to CKD in primary care, including diagnosis, evaluation, and management of CKD.

Sepsis and the Risks of Long-Term Renal Adverse Outcomes in Patients With Chronic Kidney Disease

Background

Sepsis is known to cause renal function fluctuations during hospitalization, but whether these patients discharged from sepsis were still at greater risks of long-term renal adverse outcomes remains unknown.

Methods

From 2011 to 2018, we included 1,12,628 patients with chronic kidney disease (CKD) aged ≥ 20 years. The patients with CKD were further divided into 11,661 sepsis group and 1,00,967 non-sepsis group. The following outcome of interest was included: all-cause mortality, readmission for acute kidney injury, estimated glomerular filtration rate decline ≥50% or doubling of serum creatinine, and end-stage renal disease.

Results

After propensity score matching, the sepsis group was at higher risks of all-cause mortality [hazard ratio (HR) 1.39, 95% CI, 1.31–1.47], readmission for acute kidney injury (HR 1.67, 95% CI 1.58–1.76), eGFR decline ≥ 50% or doubling of serum creatinine (HR 3.34, 95% CI 2.78–4.01), and end-stage renal disease (HR 1.43, 95% CI 1.34–1.53) than non-sepsis group.

Conclusions

Our study found that patients with CKD discharged from hospitalization for sepsis have higher risks of subsequent renal adverse events.

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.

TNF-α, IL-1β, MMP-8 Crevicular Profile in Patients with Chronic Kidney Disease and Periodontitis

Increasing evidence sustains the potential of periodontitis as a risk factor for chronic kidney disease (CKD). Our study aimed to analyze several periodontal specific inflammatory biomarkers within the gingival crevicular fluid (GCF) of patients with CKD, compared to patients with normal kidney function, providing an inflammatory profile of the dialysis patient. The study comprised 79 patients divided into: group 1 (59 subjects with periodontitis and CKD) and group 2 (20 patients with periodontitis, without other systemic conditions). Clinical diagnosis was performed via dental and periodontal examination. GCF samples were collected from each patient, and the levels of TNF-α, IL-1β and MMP-8 were determined by using ELISA assay. In group 1, the average values were: 22.85 ± 5.87 pg/mL for TNF-α, 33.00 ± 39.68 pg/mL for IL-1β and 18.80 ± 27.75 ng/mL for MMP-8. In group 2, the mean values were: 2.10 ± 1.34 pg/mL for TNF-α, 0.71 ± 2.42 pg/mL for IL-1β and 5.35 ± 0.37 ng/mL for MMP-8. Statistical analysis revealed significant differences between groups as referring to all three biomarkers and, TNF-α and MMP-8, in certain stages of periodontitis. The level of TNF-α, IL-1β and MMP-8 points out the increased inflammatory status of the dialysis patient with PD, supporting the mutual connection of the two pathologies.

Assessment of Renal Function in Egyptian HCV Patients Treated with Combination Therapy of Sofosbuvir and Daclatasvir

BACKGROUND: According to the most recent Egyptian demographic health census, the estimated Hepatitis C virus (HCV) prevalence in the 15–59 age range was 14.7%. Globally, the incidence of renal impairment in HCV-positive individuals is 40% higher than in HCV-negative patients. HCV-induced renal impairment can range from mild-to-severe, and it frequently complicates the treatment outcome of HCV infection. AIM: This study aimed to explore the changes in renal function in Egyptian HCV patients treated with a combination of Sofosbuvir (SOF) and Daclatasvir (DCV). METHODOLOGY: Six hundred and eleven chronic HCV patients treated with SOF-DCV were enrolled. Patients were classified into three groups according to their baseline renal function: unimpaired group (estimated glomerular filtration rate [eGFR] ≥ 90 ml/min/1.73 m2), mildly impaired group (eGFR of ≥60–89 ml/min/1.73 m2), and moderately impaired group (eGFR of ≥30–59 ml/min/1.73 m2). Every month during treatment and at 24 weeks after treatment (sustained virological response 24), the eGFR level was evaluated. RESULTS: Our findings indicated that the eGFR level was significantly increased (p < 0.001) in all groups during the treatment but subsequent decline (p < 0.001) in all groups was documented after 6 months of treatment. Multivariate analysis identified baseline renal impairment (<90 ml/min/1.73 m2, p < 0.001) and baseline anemia (p < 0.001) as independent risk factors for renal function deterioration at the end of treatment. CONCLUSION: Clinical physicians should closely monitor renal function in patients treated with SOF-DCV. Furthermore, anemia therapy prior to SOF-DCV treatment should be recommended.

Investigating the global prevalence and consequences of undiagnosed stage 3 chronic kidney disease: methods and rationale for the REVEAL-CKD study

Background

Timely diagnosis and treatment of stage 3 chronic kidney disease (CKD) can prevent further loss of kidney function and progression to kidney failure. However, contemporary data on the global prevalence of undiagnosed stage 3 CKD are scarce. REVEAL-CKD is a multinational, multifocal and observational study aiming to provide insights into undiagnosed stage 3 CKD in a large population.

Methods

Patients (aged ≥18 years) with data in selected secondary databases from 11 countries will be included if they have at least two estimated glomerular filtration rate (eGFR) measurements from 2015 onwards that are ≥30 and <60 mL/min/1.73 m², recorded >90 and ≤730 days apart. Undiagnosed cases are those without an International Classification of Diseases 9/10 diagnosis code for CKD (any stage) any time before and up to 6 months after the second qualifying eGFR measurement. Time to diagnosis will be assessed using a Kaplan–Meier approach; patient characteristics associated with undiagnosed CKD will be assessed using adjusted logistical regression analyses.

Results

REVEAL-CKD will assess the point prevalence of undiagnosed stage 3 CKD and time to CKD diagnosis in initially undiagnosed cases overall and in individual countries. Trends in undiagnosed CKD prevalence by calendar year will be assessed. Patient characteristics, healthcare resource utilization, adverse clinical outcomes, and CKD management and monitoring practices in patients with versus without a CKD diagnosis will be compared.

Conclusions

REVEAL-CKD will increase awareness of the global clinical and economic burden of undiagnosed stage 3 CKD and provide valuable insights to inform clinical practice and policy changes.

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, todefinethenursingdiagnoses, results, andinterventions.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 thestatisticalanalyses.

Results

Theriskforbleedingdiagnosisshowed 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.

Associations of serum soluble klotho and fibroblast growth factor 23 with carotid artery calcification in patients undergoing continuous ambulatory peritoneal dialysis: A retrospective study

ABSTRACT

This study aimed to assess the associations of serum soluble klotho and fibroblast growth factor 23 (FGF-23) with the occurrence of carotid artery calcification. Peritoneal dialysis patients treated from June 2018 to June 2019 were retrospectively analyzed. They were divided into the carotid artery calcification and non-carotid artery calcification groups according to color Doppler ultrasound findings. Basic indicators in both groups were compared, and the influencing factors of carotid artery calcification were analyzed by logistic regression. Among the 73 continuous ambulatory peritoneal dialysis (CAPD) patients enrolled, 40 (54.8%) had carotid artery calcification. Significant differences were found in age (68.85 ± 7.45 vs 46.62 ± 5.51 years), dialysis time (8.15 ± 1.42 vs 6.02 ± 1.14 months), klotho amounts (325.56 ± 41.15 vs 436.65 ± 45.58 pg/mL) and FGF-23 levels (114.45 ± 15.56 vs 70.15 ± 12.23 pg/mL) between the carotid artery calcification and non-carotid artery calcification groups (all P < .001). The above factors were associated with carotid artery calcification occurrence in univariate analysis. Multivariate analysis showed that elevated age (odds ratio [OR] = 1.55, 95% confidence interval [CI] 1.13-1.74; P = .025) and FGF-23 (OR = 2.16, 95% CI 2.01-2.44; P = .042), and lower klotho (OR = 0.66, 95% CI 0.47-0.85; P = .036) were independent risk factors for carotid artery calcification in CAPD. Serum FGF-23 and age are risk factors for carotid artery calcification in patients with CAPD, whereas klotho is a protective factor.

Non-adherence to hemodialysis regimens among patients on maintenance hemodialysis in sub-Saharan Africa: an example from Cameroon

Background

Non-adherence (NA) to hemodialysis regimens is one of the contributors to the high morbidity and mortality observed in patients with end-stage kidney disease (ESKD). We aimed to determine the prevalence and predictors of NA to hemodialysis (HD) regimens among patients on maintenance HD in Cameroon.

Methods

A cross-sectional study in two HD centers in Cameroon was conducted from January to February 2016. Consenting patients on HD for ≥3 months were included. NA to fluid restriction was defined as a mean interdialytic weight gain (IDWG) in the past month >5.7% of the dry weight, NA to dietary restriction as a pre dialysis serum phosphorus >5.5 mg/dl in a patient on phosphate binders and who is well-nourished, and NA to HD sessions as skipping at least one session in the past month. The study was approved by the institutional ethics board.

Results

A total of 170 (112 males) participants with a median age of 49 years (range 14–79) were included. The median dialysis vintage was 35 months (range 3–180 months). The prevalence of NA was 15.3% to fluid restriction, 26.9% to dietary restriction, and 21.2% to dialysis sessions. Age ≤49 years (p = .006, OR: 5.07, 95% CI: 1.59–16.20) and unmarried status (p = .041, OR: 2.63, 95% CI: 1.04–6.66) were independently associated with NA to fluid restrictions. No factor was associated with NA to dietary restrictions and HD sessions.

Conclusions

NA to HD regimens is common amongst patients in Cameroon. Younger age and being unmarried were the predictors of NA to fluid restriction.

Screening and early detection of chronic kidney disease at primary healthcare

Chronic kidney disease (CKD) represents a global public health concern and results in poor health outcomes. While the burden of CKD is accurately well defined in developed countries, increasing evidence indicates that the CKD burden may be even greater in developing countries. Primary care has an essential role in the early identification of CKD and the prompt integrated management between primary and secondary CKD care, with participation of the patient, should be done in high quality. Systematic screening for CKD in at-risk individuals is strongly indicated for timely intervention when needed and to perceive the impact of such policies on CKD incidence. Furthermore, failure to recognize a patient in stages 1-3 of CKD may result in high incidence of CKD complications and kidney failure, often leaving the patient unsuitable for different renal replacement therapies, such as dialysis and transplantation. Therefore, primary care early referral and consultation with a nephrologist can give a better chance for different dialysis procedures and minimize the rate of hospitalization and mortality.

Multidisciplinary treatment for patients with chronic kidney disease in pre-dialysis minimizes costs: a four-year retrospective cohort analysis

INTRODUCTION

Chronic kidney disease (CKD) can progress to end-stage renal disease (ESRD), and clinical studies show that this progression can be slowed. The objective of this study was to estimate the costs to Brazil's public health system (SUS) throughout the course of CKD in the pre-dialysis stage compared to the costs to the SUS of dialysis treatment (DT).

METHODS

A retrospective cohort study was conducted to analyze clinical and laboratory variables; the outcome analyzed was need for DT. To assess cost, a microcosting survey was conducted according to the Methodological Guidelines for Economic Evaluations in Healthcare and the National Program for Cost Management, both recommended by the Brazilian Ministry of Health for economic studies.

RESULTS

A total of 5,689 patients were followed between 2011 and 2014, and 537 met the inclusion criteria. Average costs increased substantially as the disease progressed. The average cost incurred in stage G1 in Brazilian reals was R$ 7,110.78, (US$1,832.06) and in stage G5, it was R$ 26,814.08 (US$6,908.53), accumulated over the four years.

CONCLUSION

A pre-dialysis care program may reduce by R$ 33,023.12 ± 1,676.80 (US$ 8,508.26 ± 432.02) the average cost for each year of DT avoided, which is sufficient to cover the program's operation, minimizing cost. These results signal to public health policy makers the real possibility of achieving significant cost reduction in the medium term for CKD care (4 years), to a program that disbursed R$ 24 billion (US$ 6.8 billion) for DT in Brazil between 2009 and 2018.

Development and validation of resource-driven risk prediction models for incident chronic kidney disease in type 2 diabetes

Prediction models for population-based screening need, for global usage, to be resource-driven, involving predictors that are affordably resourced. Here, we report the development and validation of three resource-driven risk models to identify people with type 2 diabetes (T2DM) at risk of stage 3 CKD defined by a decline in estimated glomerular filtration rate (eGFR) to below 60 mL/min/1.73m2. The observational study cohort used for model development consisted of data from a primary care dataset of 20,510 multi-ethnic individuals with T2DM from London, UK (2007-2018). Discrimination and calibration of the resulting prediction models developed using cox regression were assessed using the c-statistic and calibration slope, respectively. Models were internally validated using tenfold cross-validation and externally validated on 13,346 primary care individuals from Wales, UK. The simplest model was simplified into a risk score to enable implementation in community-based medicine. The derived full model included demographic, laboratory parameters, medication-use, cardiovascular disease history (CVD) and sight threatening retinopathy status (STDR). Two less resource-intense models were developed by excluding CVD and STDR in the second model and HbA1c and HDL in the third model. All three 5-year risk models had good internal discrimination and calibration (optimism adjusted C-statistics were each 0.85 and calibration slopes 0.999-1.002). In Wales, models achieved excellent discrimination(c-statistics ranged 0.82-0.83). Calibration slopes at 5-years suggested models over-predicted risks, however were successfully updated to accommodate reduced incidence of stage 3 CKD in Wales, which improved their alignment with the observed rates in Wales (E/O ratios near to 1). The risk score demonstrated similar model performance compared to direct evaluation of the cox model. These resource-driven risk prediction models may enable universal screening for Stage 3 CKD to enable targeted early optimisation of risk factors for CKD.

Possible benefits of exogenous melatonin for individuals on dialysis: a narrative review on potential mechanisms and clinical implications

Prevention of oxidative stress and inflammation in chronic kidney disease patients (CKD) on dialysis may reduce dialysis-associated complications. Administration of powerful antioxidants may improve the consequences of peritoneal dialysis (PD) and hemodialysis (HD). This narrative review aimed to show the potential therapeutic effects of melatonin (MLT) on the consequences of CKD patients receiving HD or PD. The results of preclinical and clinical studies have proven that CKD and dialysis are accompanied by reduced endogenous MLT levels and related complications such as sleep disorders. Enhanced oxidative stress, inflammation, cellular damages, and renal fibrosis, along with dysregulation of the renin-angiotensin system (RAS), have been observed in CKD and patients on dialysis. Results of studies have revealed that the restoration of MLT via the exogenous source may regulate oxidative stress, inflammation, and RAS functions, inhibit fibrosis, and improve complications in patients with long-term dialysis patients. In summary, treatment of patients with CKD and dialysis with exogenous MLT is suggested as a practical approach in reducing the outcomes and improving the quality of life in patients via antioxidant, anti-inflammatory, and anti-fibrotic signaling pathways. Therefore, this hormone can be considered in clinical practice to manage dialysis-related complications.

Kidney doses in 177Lu-based radioligand therapy in prostate cancer: Is dose estimation based on reduced dosimetry measurements feasible?

The radiation dose to the kidneys should be monitored in prostate cancer patients treated with radioligand therapy (RLT) targeting the prostate-specific membrane antigen (PSMA). We analyzed whether pretherapeutic kidney function is predictive of subsequent kidney dose and to what extend the cumulative kidney dose after multiple therapy cycles at the end of treatment can be predicted from a dosimetry based on the first cycle. Methods: Data of 59 patients treated with at least 2 cycles of ¹⁷⁷Lu-PSMA-617 (PSMA-RLT) were analyzed. Treatment (median: 6 GBq/cycle) was performed at 6-8 week intervals, accompanied by voxel-based 3D-dosimetry (measured kidney dose) with SPECT/CT on each of days 0-3 and once during days 6-9. Pretherapeutic kidney function (eGFR, MAG3-clearance) was correlated to the kidney doses. Cumulative kidney doses at the end of treatment were compared to a dose estimation based on the population-based mean kidney dose, individual first cycle kidney dose and mean kidney doses of cycles 1, 3 and 5 per administered activity. Results: A total of 176 PSMA-RLT cycles were performed with a median of 3 cycles per patient. The average kidney dose per administered activity of all 176 cycles was 0.67 ± 0.24 Gy/GBq (range 0.21 - 1.60). MAG3-clearance and eGFR were no reliable predictors of subsequent absorbed kidney dose and showed only small effect sizes (R² = 0.080 and 0.014, P = 0.039 and 0.375). All simplified estimations of cumulative kidney dose correlated significantly (P < 0.001) with measured kidney doses: Estimations based on the individual first-cycle dose were more accurate than the use of the population-based average kidney dose (R² = 0.853 vs. R² = 0.560). Dose estimation was best when the doses of cycles 3 and 5 were included as well (R² = 0.960). Conclusion: Pretherapeutic renal function was not predictive for subsequent kidney dose during therapy. Extrapolation of individual data from dosimetry of the first cycle was highly predictive for the cumulative kidney dose at the end of treatment. This is further improved by the integration of dose information from every other cycle. In any case, because of a high interindividual variance, an individual dosimetry is advisable.

HCV Infection and Chronic Renal Disease

Chronic Hepatitis C virus (HCV) infection is defined as persistence of HCV RNA in the blood for more than six months. HCV is a major cause of chronic liver disease and cirrhosis. It’s serious public health problem, affects about 71 million people worldwide. HCV doesn’t destroy hepatocytes directly. It activates the host's innate and acquired immune system and causes liver injury indirectly. Behind hepatic, HCV can cause extra-hepatic manifestations. One of them is renal disease which can lead to end-stage renal disease, ESRD. The prevalence of HCV infection in patients on hemodialysis is high, ranging from 5% to 60%. HCV infection is a significant cause of morbidity and mortality in patients with ESRD on hemodialysis. In this review, we discuss HCV infection and chronic renal disease as comorbidities, their severity and outcome.

Association between MANBA Gene Variants and Chronic Kidney Disease in a Korean Population

Chronic kidney disease (CKD), a damaged condition of the kidneys, is a global public health problem that can be caused by diabetes, hypertension, and other disorders. Recently, the MANBA gene was identified in CKD by integrating CKD-related variants and kidney expression quantitative trait loci (eQTL) data. This study evaluated the effects of MANBA gene variants on CKD and kidney function-related traits using a Korean cohort. We also analyzed the association of MANBA gene variants with kidney-related traits such as the estimated glomerular filtration rate (eGFR), and blood urea nitrogen (BUN), creatinine, and uric acid levels using linear regression analysis. As a result, 14 single nucleotide polymorphisms (SNPs) were replicated in CKD (p < 0.05), consistent with previous studies. Among them, rs4496586, which was the most significant for CKD and kidney function-related traits, was associated with a decreased CKD risk in participants with the homozygous minor allele (CC), increased eGFR, and decreased creatinine and uric acid concentrations. Furthermore, the association analysis between the rs4496586 genotype and MANBA gene expression in human tubules and glomeruli showed high MANBA gene expression in the minor allele carriers. In conclusion, this study demonstrated that MANBA gene variants were associated with CKD and kidney function-related traits in a Korean cohort.

The renal microcirculation in chronic kidney disease: novel diagnostic methods and therapeutic perspectives

Chronic kidney disease (CKD) affects 8–16% of the population worldwide and is characterized by fibrotic processes. Understanding the cellular and molecular mechanisms underpinning renal fibrosis is critical to the development of new therapeutics. Microvascular injury is considered an important contributor to renal progressive diseases. Vascular endothelium plays a significant role in responding to physical and chemical signals by generating factors that help maintain normal vascular tone, inhibit leukocyte adhesion and platelet aggregation, and suppress smooth muscle cell proliferation. Loss of the rich capillary network results in endothelial dysfunction, hypoxia, and inflammatory and oxidative effects and further leads to the imbalance of pro- and antiangiogenic factors, endothelial cell apoptosis and endothelial-mesenchymal transition. New techniques, including both invasive and noninvasive techniques, offer multiple methods to observe and monitor renal microcirculation and guide targeted therapeutic strategies. A better understanding of the role of endothelium in CKD will help in the development of effective interventions for renal microcirculation improvement. This review focuses on the role of microvascular injury in CKD, the methods to detect microvessels and the novel treatments to ameliorate renal fibrosis.

Acute Kidney Injury After CT in Emergency Patients with Chronic Kidney Disease: A Propensity Score-matched Analysis

INTRODUCTION

Acute kidney injury (AKI) after intravenous contrast administration for computed tomography (CT) occurs infrequently, but certain patients may be susceptible. This study evaluated AKI incidence among emergency department (ED) patients with pre-existing chronic kidney disease (CKD) undergoing CT exams.

METHODS

This retrospective cohort study in an integrated healthcare system included ED patients previously diagnosed with CKD stages 3-5 (estimated glomerular filtration rate <60 milliliters per minute per 1.73 meters squared over at least three months), undergoing CT exams with or without intravenous contrast, from January 1, 2013-December 31, 2017. We excluded patients with CT prior to (30 days) or following (14 days) index CT and missing serum creatinine (sCr) measurements. We applied propensity score matching, and then multivariable regression adjustment for post-CT ED disposition and ED diagnosis, to calculate adjusted risk of AKI. Secondary patient-centered outcomes included 30-day mortality, end-stage renal disease (ESRD) diagnosis, and dialysis initiation.

RESULTS

Among 103,573 eligible ED patients undergoing CT, propensity score matching yielded 5,589 pairs. Adjusted risk ratio (ARR) for AKI was higher overall for contrast-enhanced CT (1.60; 95% confidence interval [CI], 1.43-1.79). However, secondary outcomes were infrequent: 19/5,589 non-contrast vs 40/5,589 contrast patients with new dialysis initiation at 30 days (adjusted risk 0.3% vs 0.7%; adjusted risk reduction 0.4%; 95% CI, 0.1%-0.7%).

CONCLUSION

In ED patients with chronic kidney disease undergoing CT, intravenous contrast was associated with higher overall adjusted risk of AKI, but patient-centered secondary outcomes were rare. The clinical significance of transient kidney injury after CT is unclear, although patients with advanced chronic kidney disease appear to have elevated risk.

Herbal antioxidants in dialysis patients: a review of potential mechanisms and medical implications

The consumption of exogenous antioxidants isolated from herbal extracts has shown beneficial effects on ameliorating dialysis-related complications through debilitating oxidative stress and inflammatory process. Many clinical studies available in public databases have reported the improved consequences of dialysis in patients supplemented with herbal antioxidants. Exploration of such data offers great possibilities for gaining insights into the potential mechanisms and medical implications of herbal antioxidants. In this work, the mechanisms and implications of some famous bioactive substances including silymarin, curcumin, resveratrol, emodin, and quercetin on the consequences of dialysis in chronic kidney disease (CKD) patients were explored. The protective features of silymarin are due to the flavonoid complex silybin. Curcumin is an active element from the root of curcuma longa with extensive beneficial properties, including antioxidant, anti-inflammatory activity, and inhibitory effects on cell apoptosis. Resveratrol can reduce the oxidative stress by neutralization of free radicals. Emodin is known as a natural anthraquinone derivative isolated from Chinese herbs. Finally, quercetin has been reported to exhibit several properties including antioxidant, anti-diabetic, analgesic, antihistaminic, antiviral, cholesterol reducer, and renal hemodynamic modulator. However, potential mechanisms and medical implications of the aforementioned herbal antioxidants seem to be more complicated, that is, more studies are required in this field.

An Energy-Resolved Optical Non-invasive Device Detects Essential Electrolyte Balance in Humans at Point-of-Care

Regular monitoring of electrolyte balance is essential for patients suffering from chronic kidney disease (CKD), particularly those undergoing dialysis. In the context of the recent COVID-19 pandemic, more severe forms of infection are observed in elderly individuals and patients having co-morbidities like CKD. The repeated blood tests for the monitoring of electrolyte balance predispose them not only to COVID-19 but also other to hospital-acquired infections (HAI). Therefore, a non-invasive method for easy detection of essential electrolyte (K+ and Na+) levels is urgently needed. In this study, we developed an optical emission spectroscopy-based non-invasive device for simultaneous monitoring of salivary Na+ and K+ levels in a fast and reliable way. The device consisted of a closed spark chamber, micro-spectrometer, high voltage spark generator, electronic circuits, optical fiber, and an indigenously developed software based on the LabVIEW platform. The optical emission originating from the biological sample (i.e., saliva) due to recombination of ions energized by impingement of electrons returning from high voltage spark provides necessary information about the concentration of electrolytes. A small-scale clinical trial on 30 healthy human subjects shows the potential of the indigenously developed device in determining salivary Na + and K+ concentration. The low-cost, portable, point-of-care device requires only 2 mL of sample, and can simultaneously measure 1.0-190.0 mM Na+, and 1.0-270.9 mM K+ . To our understanding, the present work will find its relevance in combating COVID-19 morbidities, along with regular CKD patient-care.

EHR2CCAS: A framework for mapping EHR to disease knowledge presenting causal chain of disorders - chronic kidney disease example

OBJECTIVE

The goal of this work was to capture diseases in patients by comprehending the fine-grained medical conditions and disease progression manifested by transitions in medical conditions. We realize this by introducing our earlier work on a state-of-the-art knowledge presentation, which defines a disease as a causal chain of abnormal states (CCAS). Here, we propose a framework, EHR2CCAS, for constructing a system to map electronic health record (EHR) data to CCAS.

MATERIALS AND METHODS

EHR2CCAS is a framework consisting of modules that access heterogeneous EHR to estimate the presence of abnormal states in a CCAS for a patient in a given time window. EHR2CCAS applies expert-driven (rule-based) and data-driven (machine learning) methods to identify abnormal states from structured and unstructured EHR data. It features data-driven approaches for unlocking clinical texts and imputations based on the EHR temporal properties and the causal CCAS structure. This study presents the CCAS of chronic kidney disease as an example. A mapping system between the EHR from the University of Tokyo Hospital and CCAS of chronic kidney disease was constructed and evaluated against expert annotation.

RESULTS

The system achieved high prediction performance in identifying abnormal states that had strong agreement among annotators. Our handling of narrative varieties in texts and our imputation of the presence of an abnormal state markedly improved the prediction performance. EHR2CCAS presents patient data describing the temporal presence of abnormal states in CCAS, which is useful in individual disease progression management. Further analysis of the differentiation of transition among abnormal states outputted by EHR2CCAS can contribute to detecting disease subtypes.

CONCLUSION

This work represents the first step toward combining disease knowledge and EHR to extract abnormality related to a disease defined as fine-grained abnormal states and transitions among them. This can aid in disease progression management and deep phenotyping.

Diabetes, Hypertension, Obesity, and Smoking as Risk Factors for Chronic Kidney Disease in Productive Age

Background: Based on the Indonesia basic health research report in 2018, the prevalence of chronic kidney disease (CKD) in the productive age group in Indonesia had increased from the previous year, to 1.97%. This condition can cause various complications that contribute to the high morbidity, which affects quality of life and productivity, so risk factors for CKD need to be understood to prevent the occurrence of the disease. Purpose: This study aimed to analyze the risk factors associated with CKD in the Indonesian productive-age population. Method: This study used data sourced from Indonesian Family Life Survey 5 (IFLS-5) with a cross-sectional research design. The study population was composed of all Indonesian residents who were respondents of IFLS-5. The research sample was made up of respondents aged 15–64 for whom complete information was available. The sample size was 29,120 respondents. The variables analyzed in this study were diabetes, hypertension, obesity, smoking, and CKD. The analysis method used was the chi-square test. Results: Bivariate analysis showed a significant relationship between CKD and diabetes (p = 0.01; prevalence ratio [PR] = 2.71; 95% CI = 1.74–4.22), hypertension (p = 0.01; PR = 2.62; 95% CI = 2.08–3.30), obesity (p = 0.01; PR = 1.67; 95% CI = 1.25–2.23), and smoking (p = 0.01; PR = 1.43; 95% CI = 1.17–1.75) in the productive age group in Indonesia. Conclusion: Diabetes, hypertension, obesity, and smoking have a significant relationship with CKD in the productive age group in Indonesia.

Enhanced renoprotective effect of GDNF-modified adipose-derived mesenchymal stem cells on renal interstitial fibrosis

BACKGROUND

The therapeutic effect of mesenchymal stem cells (MSCs) from human adipose tissue on renal interstitial fibrosis has been demonstrated by several groups. However, the way to enhance the renoprotective effect of adipose-derived mesenchymal stem cells (AMSCs) and the possible mechanisms are still unclear. The present study aimed to determine whether glial cell line-derived neurotrophic factor (GDNF)-modified AMSCs hold an enhanced protective effect on renal fibrosis.

METHODS

AMSCs were isolated and purified for culture. The gene GDNF has been constructed to transfect into AMSCs. The ability of GFP-AMSCs and GDNF-AMSCs supernatants to promote tube formation of endothelial cells, repair damaged endothelial cell junctions, and improve endothelial cell function was compared by using tube formation assay, immunofluorescence techniques, and vascular ring assay, respectively. Furthermore, HE and Masson staining were used to observe the histological morphology of the kidney in vivo. Peritubular capillary changes were detected and analyzed by fluorescence microangiography (FMA). Meanwhile, the hypoxia, oxidative stress, fibrotic markers, and PI3K/Akt pathway proteins were measured by western blot or qRT-PCR technics.

RESULTS

Compared with GFP-AMSCs only, GDNF-AMSCs could enhance the repair of injured endothelial cells and promote angiogenesis through secreting more growth factors in the supernatant of GDNF-AMSC culture media demonstrated in vitro studies. Studies in vivo, unilateral ureteral obstruction (UUO)-induced mice were injected with transfected AMSCs through their tail veins. We showed that enhanced homing of AMSCs was observed in the GDNF-AMSC group compared with the GFP-AMSC group. The animals treated with GDNF-AMSCs exhibited an improvement of capillary rarefaction and fibrosis induced by obstructed kidney compared with the GFP-AMSC group. Furthermore, we reported that GDNF-AMSCs protect renal tissues against microvascular injuries via activation of the PI3K/Akt signaling pathway. Therefore, GDNF-AMSCs further ameliorated the tissue hypoxia, suppressed oxidative stress, and finally inhibited endothelial to mesenchymal transition noting by decreased coexpression of endothelial cell (CD31) and myofibroblast (a-SMA) markers.

CONCLUSION

Collectively, our data indicated that the GDNF gene enhances the ability of AMSCs in improving renal microcirculation through PI3K/Akt/eNOS signaling pathway and afterward inhibit the EndMT process and kidney fibrogenesis, which should have a vast of implications in designing future remedies for chronic kidney disease (CKD) treatment.

Expression Analysis of GDNF/RET Signaling Pathway in Human AD-MSCs Grown in HEK 293 Conditioned Medium (HEK293-CM)

Mesenchymal stem cells have been considered as the suitable source for the repair of kidney lesions. The study and identification of novel approaches could improve the efficiency of these cells in the recovery of kidney. In the present study, the effect of HEK 293 conditioned medium (HEK293-CM) was evaluated on the expression of GDNF/RET signaling pathway and their downstream genes in the human adipose-derived mesenchymal stem cells (AD-MSCs). For this purpose, the human AD-MSCs were cultured in the medium containing HEK293-CM. After the RNA extraction and cDNA synthesis, the expression level of GFRA1, GDNF, SPRY1, ETV4, ETV5, and CRLF1 genes were determined by SYBR Green Real time PCR. The obtained results indicated that the GDNF and GFRA1 expression enhanced in the AD-MSCs following treatment with 10% HEK293-CM-5%FBS as compared to the untreated AD-MSCs. These results were consistent with the decreased expression of SPRY1. The significant increased expression of ETV4, ETV5, and CRLF1 genes also showed that HEK293-CM activated the GDNF/RET signaling pathway in the AD-MSCs (P < 0.05). The obtained data suggested that the treatment with HEK293-CM activated the GDNF/RET signaling pathway in the human AD-MSCs.

Clinically-suspected cast nephropathy: A retrospective, national, real-world study

Presentation with severe acute kidney injury due to cast nephropathy (CN) is a medical emergency in multiple myeloma (MM), with high risk of dialysis-dependent renal failure and death. Accrual of patients with CN into interventional studies is difficult, while phase III trials exclude patients with severe renal insufficiency. Real-world data are warranted. We assessed 2252 patients from the population-based Danish Multiple Myeloma Registry (DMMR) who were diagnosed between 2013 and 2017. We identified 204 patients with clinically-suspected CN, defined as serum creatinine concentration >177 μmol/L and serum free light chain (sFLC) concentration >1000 mg/L at the time of diagnosis. The median age was 72 years. Thirty-one percent of patients presented with dialysis-dependent renal failure. Kidney biopsies were performed in 19% of patients and showed CN in 74% of cases. Despite prompt initiation of bortezomib-based therapy in 94% of patients, 33% of patients died in the first year after diagnosis. Compared with the rest of the patients in the DMMR with symptomatic MM, patients with clinically-suspected CN had worse overall survival (OS) irrespective of transplant eligibility. Achievement of renal recovery was associated with deep reductions of involved sFLC. Achievement of very good partial response or better in the first line of therapy and/or deep reduction of involved sFLC at 3 months after initiation of therapy were associated with superior OS. In conclusion, MM patients presenting with clinically-suspected CN have an alarmingly high one-year mortality when treated with current standards of care. Early and deep hematologic response is crucial for survival.

Serum metabolomics approach to monitor the changes in metabolite profiles following renal transplantation

Systemic metabolic changes after renal transplantation reflect the key processes that are related to graft accommodation. In order to describe and better understand these changes, the ¹HNMR based metabolomics approach was used. The changes of 47 metabolites in the serum samples of 19 individuals were interpreted over time with respect to their levels prior to transplantation. Considering the specific repeated measures design of the experiments, data analysis was mainly focused on the multiple analyses of variance (ANOVA) methods such as ANOVA simultaneous component analysis and ANOVA-target projection. We also propose here the combined use of ANOVA and classification and regression trees (ANOVA-CART) under the assumption that a small set of metabolites the binary splits on which may better describe the graft accommodation processes over time. This assumption is very important for developing a medical protocol for evaluating a patient's health state. The results showed that besides creatinine, which is routinely used to monitor renal activity, the changes in levels of hippurate, mannitol and alanine may be associated with the changes in renal function during the post-transplantation recovery period. Specifically, the level of hippurate (or histidine) is more sensitive to any short-term changes in renal activity than creatinine.

Health related quality of life utility weights for economic evaluation through different stages of chronic kidney disease: a systematic literature review

BACKGROUND

A Task Force from the International Society of Pharmacoeconomics and Outcomes Research (ISPOR) provides recommendations on how to systematically identify and appraise health state utility (HSU) weights for cost-effectiveness analyses. We applied these recommendations to conduct a systematic review (SR) to identify HSU weights for different stages of chronic kidney disease (CKD), renal replacement therapy (RRT) and complications.

METHODS

MEDLINE® and Embase were searched for interventional and non-interventional studies reporting HSU weights for patients with CKD stages 1-5 or RRT. As per ISPOR Task Force Guidance, study quality criteria, applicability for Health Technology Assessment (HTA) and generalisability to a broad CKD population were used to grade studies as either 1 (recommended), 2 (to be considered if there are no data from grade 1 studies) or 3 (not recommended).

RESULTS

A total of 17 grade 1 studies were included in this SR with 51 to 1767 participants, conducted in the UK, USA, Canada, China, Spain, and multiple-countries. Health related quality of life (HRQL) instruments used in the studies included were EQ-5D-3L (10 studies), SF-6D (4 studies), HUI2/HUI3 (1 study), and combinations (2 studies). Although absolute values for HSU weights varied among instruments, HSU weights decreased with CKD severity in a consistent manner across all instruments.

CONCLUSIONS

This SR identified HSU weights for a range of CKD states and showed that HRQL decreases with CKD progression. Data were available to inform cost-effectiveness analysis in CKD in a number of geographies using instruments acceptable by HTA agencies.