Need For Dialysis Research Articles

Contemporary outcomes of open thoracoabdominal aortic repair: single centre experience.

Untreated cases of thoraco-abdominal aortic aneurysms pose significant challenges, often leading to severe morbidity and high mortality. While promising, endovascular treatment is not suitable in all cases, particularly younger patients and those with collagen disorders. This study reports on the contemporary outcomes of open thoraco-abdominal aortic aneurysm repair at our academic medical center from 2015 to 2023. All patients with thoraco-abdominal aortic aneurysm (Crawford-Safi Types I-V), including elective and non-elective cases, who underwent open surgical repair between January 2015 and December 2023 were included. Patient characteristics, intraoperative variables, and postoperative outcomes were prospectively recorded and analyzed retrospectively. The primary end-point was operative mortality; secondary end-points included rates for spinal cord injury, stroke, tracheostomy, need for dialysis and a comparison of outcomes between elective and non-elective cases. 190 patients (146 elective/44 non-elective) were included, with a mean age of 63.8 years (standard deviation 11.5), and 58% were male. Operative mortality was 7.9%, with 7.5% in elective cases and 9.1% in non-elective cases. Stroke with persisting symptoms at discharge occurred in 5.8% of patients, and tracheostomy was required in 3.7%. Spinal cord injury symptoms were observed in 7.4%, with persistent paraparesis in 2.1% and paraplegia in 1.6% at discharge. Acute kidney injury occurred in 38.4% of patients, with 6.9% requiring dialysis and 3.7% continuing dialysis at discharge. Open thoraco-abdominal aortic aneurysm surgery, supported by a multidisciplinary team approach and strict perioperative protocols, remains effective in managing this complex patient population, demonstrating low rates of mortality and severe complications.

A Second Look: Retrospective Identification of Thrombotic Microangiopathy in Pediatric Stem Cell Transplant Patients With Veno-Occlusive Disease.

Veno-occlusive disease (VOD) and transplant-associated thrombotic microangiopathy (TA-TMA) remain a diagnostic and therapeutic challenge for patients undergoing hematopoietic stem cell transplant (HSCT). Both VOD and TA-TMA share an underlying etiology of microvascular endothelial damage. Potential under-recognition of TA-TMA in the context of VOD leaves HSCT recipients vulnerable to additional endothelial damage, and risk of end-organ failure. A cohort of 44 pediatric HSCT recipients diagnosed with VOD between 2010and 2019 were retrospectively evaluated for the development of TA-TMA within 1 week before and 2 months after VOD diagnosis. Patients were classified into three categories: sole diagnosis of VOD (VOD), concurrent clinical diagnosis of TA-TMA during the VOD course (VOD+TA-TMA), and patients with VOD who on retrospective review satisfied criteria for diagnosis of TA-TMA (VOD+rTA-TMA). A total of 42 patients were evaluated and 50% of the patients were diagnosed clinically with TA-TMA (5) or where retrospectively identified to have TA-TMA (16). There was no difference in the severity of the course of VOD between the three groups based on need for intubation, dialysis, and pediatric intensive care unit (PICU) care. Patients in the VOD only group had the highest survival at 1 year (66.7%, n = 14) compared with patients in the VOD+TA-TMA group (60%, n = 3) and VOD+rTA-TMA group (62.5%, n = 10), p = 0.9582. Better understanding of the association between these two endotheliopathies is essential to improve diagnosis, treatment, and prevention of potentially fatal adverse outcomes in transplant recipients.

The Rise of Polycystic Kidney Disease (PKD): Early Detection and New Treatment Options

Polycystic Kidney Disease (PKD) is a hereditary disorder that results in the formation of fluid-filled cysts in the kidneys. Cysts can cause damage or worse renal failure over time. Although PKD has no cure, recent developments have helped in early detection and provided additional therapies that can control the condition and improve the quality of life of the affected. Early detection is essential to slow its progression and maintain renal function. It is inherited in an autosomal dominant pattern so the children of the afflicted parents have a 50% chance of developing this condition. The symptoms include kidney infections, flank pain, high blood pressure, and frequent urination, they don’t show up until later in life. Cyst formation may start sooner in childhood, and the condition may advance more quickly in certain instances. PKD can be confirmed by performing genetic testing in families with a history of the condition. Imaging methods such as MRI and ultrasound are essential in early diagnosis. Ultrasonography can be used to visualize the cyst. If this condition is diagnosed early medical professionals can treat the patient and control the symptoms while delaying kidney impairment. Some medications can delay its progression, but currently, no cure is there. There is a drug called Tolvaptan which inhibits the growth of kidney cysts and aids in maintaining renal function, is considered one of the noteworthy achievements. It has shown promising results in delaying the need for dialysis or kidney transplants by inhibiting the hormone vasopressin, a hormone responsible for the formation of cysts. Hypertension can worsen renal damage so drugs such as ACE inhibitors and angiotensin receptor blockers (ARBs) are prescribed to maintain blood pressure levels. Stem cell researchers are working on the repairing and renewal of damaged kidney tissue. Research on this subject has just started but the potential of this research can be foreseen in producing novel medicines that could revolutionize PKD care shortly. Life style plays an important role in controlling PKD, kidney strain can be reduced by maintaining a healthy life style, eating a diet that is low in proteins, and avoiding smoking. Frequent exercise can improve health and blood pressure. PKD is a health concern that affects people significantly but early detection and new treatments like tolyaptan and ongoing research are the hope for patients. Although no cure is available advancements in managing the disease can improve the quality of life and delay renal failure. With early intervention and the right treatment approach, PKD patients can lead healthier and more fulfilling lives.

P-821. Invasive Streptococcus pyogenes Infections: Is Anti-toxin Therapy Necessary?

Abstract Background Invasive Streptococcus pyogenes or group A Streptococcus (GAS) carries a high morbidity and mortality rate. In addition to penicillin, adjunct anti-toxin therapy (AT) with linezolid or clindamycin is the standard of care. Although the use of AT is supported by in vitro data and observational studies, there are limited conclusive data supporting its efficacy in reducing GAS mortality. Our study aimed to compare clinical outcomes of patients receiving AT versus those who did not. Methods This was a retrospective cohort study of hospitalized patients with positive blood cultures for GAS at our five-hospital system from June 2013 to August 2023. Patients were identified through Microsoft SQL Server. Patients who received AT therapy for > 48 hours were defined as the AT group; the control group did not receive AT therapy. Patients who received AT for < 48 hours were excluded. Collected variables included demographics, infection & microbiological characteristics, and clinical outcomes. Data was analyzed using SPSS. Results 265 patients were included in the study of whom 179 (68%) received AT (Table 1). About half were female, and the median age was 58 years. Comorbidities were overall similar between the two groups. Persons who inject drugs or with chronic hepatitis C were more common in the control group. Abscess/cellulitis was the most common clinical syndrome in both groups. Shock requiring vasopressors, need for dialysis and mechanical ventilation, and toxic shock syndrome were prevalent in the AT group. There was no difference in the duration of bacteremia, clindamycin resistance, and management between the two groups except for receipt of intravenous immunoglobulin (IVIG), which was more common in the AT group (Table 2). Outcomes, including length of stay, readmission for infection-related complications, and 30-day mortality, were similar between the two groups. Conclusion Utilization of AT for invasive GAS infections correlated with severity of illness, but clinical outcomes did not significantly differ between patients receiving AT and those who did not, suggesting a potential opportunity for antimicrobial stewardship. Further research is needed to determine whether AT should be reserved for patients with select infectious syndromes Disclosures Rachel M. Kenney, PharmD, BCIDP, Medtronic Inc: Spouse is an employee, stockholder

Hypertensive load predicts recovery of renal function for patients undergoing revascularisation for renal artery stenosis

Renal ischaemia due to renal artery stenosis produces two differing responses - a juxtaglomerular hypertensive response and cortical renal dysfunction. The reversibility of renal impairment is not predictable, and thus renal revascularisation is controversial. This study aims to test the hypothesis that the hypertensive response to renal ischaemia reflects viable renal parenchyma, and thus could be used to predict the recovery in renal function. A retrospective analysis was performed of all patients who had renal revascularisation for renal impairment in a defined geographical area (West of Scotland, population 2.4 million) between 2008 and 2024. Clinical records were used to determine the pre-intervention blood pressure, anti-hypertensive medication load and renal function, and post-intervention outcomes. The Hypertensive Index (HTi), a combined measure of systolic blood pressure and antihypertensive drug load, was used as a measure of pre-intervention hypertensive response. 75 patients had intervention for renal impairment over 15 years (68 endovascular, 7 open). Mean pre-intervention serum creatinine of 323 µmol/L was reduced to 191 umol/L at discharge and 182 µmol/L at 6-month follow-up. Refractory hypertension (HTi > 120) was associated with a significant benefit from revascularisation with improved renal function (p = 0.003) and reduced risk of future dialysis (p = 0.001). Renal impairment with no hypertensive response was highly predictive of the need for future dialysis. The hypertensive index is a good predictor of the impact of renal revascularisation on improving renal function with good outcomes in selected patients, and the absence of this is an indicator of chronic non-reversible renal dysfunction.

Many strategies enabling us to optimize kidney care may also be planet-friendly.

Kidney replacement therapy (KRT) is one of the most energy-consuming and waste-producing medical treatments. Reducing the need of dialysis is therefore an environmentally friendly choice. However, preferring prevention, lifestyle-related interventions and patient education to drugs is time consuming and most physicians are already overburdened by the many demands of routine clinical practice. In this mini review, we discuss the role that could be played by prevention, diet and non-pharmacological interventions in reducing the impact of care of chronic kidney disease and KRT. Although evaluating the environmental impact of CKD and KRT is extremely complicated, the need for rethinking all the steps in current nephrology practice to preserve our planet's health is urgent, and shifting from a "drug prescription" model to a "time prescription" one would benefit both our patients and the environment.

Predictive Value of Age, Creatinine, and Ejection Fraction I and II Scores for Postoperative Atrial Fibrillation in Isolated On-Pump Coronary Artery Bypass Grafting Surgery: A Multicenter Retrospective Study

Objectives: This study evaluated the predictive performance of age, creatinine, and ejection fraction (ACEF) I and II scores for the development of postoperative atrial fibrillation (PoAF) after isolated on-pump coronary artery bypass grafting (CABG) surgery and compared them with a novel nomogram model developed for PoAF prediction. Subjects and Methods: This retrospective multicenter study involved 511 patients who underwent isolated on-pump CABG. Their ACEF scores were calculated, and multivariate logistic regression analysis was performed to develop a nomogram model. The discriminative performance of the ACEF scores and the novel nomogram model was assessed using the area under the receiver operating characteristic curve (AUC). Results: Of the 511 patients, 169 (33.1%) developed PoAF. The ACEF I and II scores showed moderate discriminative ability (AUC = 0.642 and 0.647, respectively), with no significant difference between them (p = 0.787). Logistic regression analyses identified age, preoperative hemoglobin levels, emergency procedure, chronic kidney disease or need for dialysis, preoperative β-blocker use, preoperative angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use, inotrope requirement, postoperative stroke, and postoperative potassium levels as independent predictors of PoAF. The novel nomogram model demonstrated greater predictive ability than the ACEF scores (AUC = 0.742, p < 0.001). Conclusion: ACEF scores could be helpful risk stratification tools for PoAF after on-pump CABG procedures. Additional validation studies are required to confirm their clinical utility in diverse surgical procedures and patient populations.

Predicting rapid decline in kidney function among type 2 diabetes patients: a machine learning approach

Diabetic kidney disease (DKD) is one of the typical complications of type 2 diabetes (T2D), with approximately 10% of DKD patients experiencing a Rapid decline (RD) in kidney function. RD leads to an increased risk of poor outcomes such as the need for dialysis. Albuminuria is a known kidney damage biomarker for DKD, yet RD cases do not always show changes in albuminuria, and the exact mechanism of RD remains unclear. Previous studies focused on a limited number of laboratory tests, no comprehensive study targeting a wide range of laboratory tests has been done. We target to develop a model that predicts RD among T2D and points to key laboratory tests of interest in understanding RD from various laboratory tests. Our machine learning model predicts whether RD, as represented via eGFR, will happen within 1 year. Additionally, the model uses Recursive feature elimination with cross-validation (RFECV) to eliminate the features that do not contribute to the prediction. We trained and assessed the model using 1202 types of laboratory tests from 3438 diabetes patients at the University of Tokyo Hospital. The means (95% confidence interval) of the receiver operating characteristic area under the curve (ROC-AUC), precision-recall area under the curve, accuracy rate, and F1-score of an 8-feature-model were 0.820 (0.811, 0.829), 0.430 (0.410, 0.451), 0.754 (0.747, 0.761), and 0.500 (0.485, 0.515), respectively. The RFECV revealed that 7 test types (MCH, γ-GTP, Cre, HbA1c, HDL-C, eGFR, and Hct) contributed to RD prediction. The model's ROC-AUC of 0.820 improves on the ROC-AUC of 0.775 seen in previous studies. The proposed model accurately predicts RD among diabetes patients and helps physicians focus on inhibiting progression of kidney damage. The contributing laboratory tests may serve as alternative biomarkers for DKD.

Do SGLT2 Inhibitors Protect the Kidneys? An Alternative Explanation.

SGLT2 inhibitors are a family of drugs that were developed to treat diabetes mellitus. In randomized controlled trials, SGLT2 inhibitors seem to prevent kidney deterioration in patients with nephropathies, both diabetic and non-diabetic. However, in contrast to biochemical/physiological results (proteinuria and serum creatinine levels) that improve in all studies, the clinical results (all-cause mortality, cardiovascular death, need for dialysis, or renal transplant) do not consistently improve. In this article, the author would like to suggest that SGLT2 inhibitors do not, in fact, prevent the progression of renal diseases but rather alter laboratory results. This study will present a theory that gives an alternative explanation for the findings in the studies that would explain the above discrepancy between biochemical/physiological and clinical results. In general, the author claims that SGLT2 inhibitors change the kinetics of renal creatinine and microalbumin excretion but do not prevent parenchymal adverse changes in kidneys. This causes a dissociation between renal function markers (such as serum creatinine level and urinary protein) and the real kidney function. Thus, the clinical renal prognosis does not improve despite seemingly better laboratory results.

Contemporary contrast media dosing during percutaneous coronary intervention in patients with pre-existing renal impairment.

Contrast volume minimization can mitigate acute kidney injury (AKI) risk following percutaneous coronary intervention (PCI), but national data regarding contemporary contrast volume dosing patterns are lacking. The authors analyzed data from the National Cardiovascular Data Registry (NCDR) CathPCI registry to assess the prevalence and outcomes of renal function-based contrast dosing during PCI in patients with pre-existing renal impairment. The authors analyzed data from 463 753 patients with an eGFR ≤ 60 mL/min/1.73 m2, and categorized patients based on contrast volume/eGFR: high (> 3), low (1-3), and ultra-low (less than 1). eGFR was calculated using the Chronic Kidney Disease Epidemiology Collaboration creatinine equation. The primary outcome was occurrence of AKI. Outcomes were adjusted based on covariates derived from a validated AKI prediction model. The majority (51.4%) of patients received high contrast volume. Compared with patients who received low contrast volume, patients with high contrast volume use had a significantly higher incidence of AKI (adjusted OR 1.36 [1.28 to 1.45]) and a higher stage of AKI (adjusted OR 1.90 [1.80 to 2.00]). The incidence of AKI was similar between low and ultra-low contrast volume use. The development of new need for dialysis was higher in patients who received high contrast volume (2.8%) compared with those who received low contrast volume (0.8%) and ultra-low contrast volume (0.8%) (P less than .001). High contrast volume during PCI is associated with worse outcomes including AKI and new need for dialysis. Our study provides further support for the use of contrast volume less than 3 times the eGFR as a target to guide contrast dosing during PCI.

Acute kidney injury: a post-COVID-19 complication in children and adolescents.

To describe cases of acute kidney injury (AKI) in children diagnosed with COVID-19, associated risk factors, clinical aspects and outcome of cases. Retrospective study, carried out in a pediatric hospital between March 2020 and September 2021, with patients with COVID-19 who were diagnosed with AKI, studying information present in medical records such as comorbidities, age, gender and use of nephrotoxic medications. We studied 40 cases, and male individuals were significantly more affected (62.5%; p=0.025). AKI was a severe complication of COVID-19 infection, with 100% of the sample requiring admission to the Intensive Care Unit and 22.5% dying. The most prevalent comorbidities analyzed in this study were epilepsy, cerebral palsy and heart disease. Most patients were classified according to Kidney Disease: Improving Global Outcomes (KDIGO) criteria as KDIGO 1 (42.5%), and required orotracheal intubation (67.5%). The frequency of use of nephrotoxic medications and need for dialysis was low, with percentages of 35 and 17.5%, respectively. Among the children who died, 70.4% had some comorbidity and 88.8% received invasive ventilation. AKI in children with COVID-19 infection is associated with severe conditions. Despite the severity, most patients were discharged alive from the hospital.

Retroperitoneal Soft Tissue Sarcoma and Kidney Autotransplantation: A Case Report

ABSTRACTSoft tissue sarcomas (STSs) are rare malignancies, with retroperitoneal soft tissue sarcoma (RPS) constituting 10%–15% of all STSs. RPS often presents late due to minimal early symptoms, typically requiring complete en‐bloc resection for optimal survival outcomes. Achieving radical resection can be challenging due to the tumor's proximity to vital organs. In cases where the kidney is involved, a nephrectomy can lead to significant morbidity, especially in patients with pre‐existing renal impairment. Kidney autotransplantation offers a unique solution by preserving renal function in these cases, avoiding the need for dialysis and immunosuppressive therapy. This case report presents a 61‐year‐old female with a large RPS encasing her only functioning kidney. After unsuccessful neoadjuvant chemotherapy, she underwent an en‐bloc resection and subsequent autotransplantation. Postoperatively, she experienced complications such as pneumonia and bowel obstruction due to poor clinical status, but after recovery, she has remained disease‐free at 1‐year follow‐up. This case illustrates the potential of kidney autotransplantation in selected cases to prevent treatment‐induced renal failure. Although the risk of recurrence is relevant, autotransplantation provides an option for preserving renal function while allowing for curative resection, with careful consideration of the balance between recurrence risk and morbidity.

Syndecan-1 in the Serum of Deceased Kidney Donors as a Potential Biomarker of Kidney Function.

The process of kidney transplantation remains the optimal treatment for end-stage renal disease, offering improved quality of life and increased survival rates compared to long-term dialysis. However, despite advances in surgical techniques, immunosuppression regimens, and post-operative care, there are still significant challenges in predicting the organ's status and long-term outcomes of transplantation. Among the many factors that influence graft survival, the quality of the donated organ plays a fundamental role. There is an ongoing need for accurate and reliable biomarkers. Syndecan-1 is found in the endothelial glycocalyx and shed at a higher rate into the blood during systemic pathological conditions. The aim of this study is to evaluate the potential of serum syndecan-1 levels as a biomarker for assessing donor kidney quality and to investigate its correlation with donor characteristics and short-term outcomes in kidney recipients. We investigated serum syndecan-1 levels in 80 deceased donors and correlated them with donor characteristics and short-term outcomes (defined as delayed graft function - defined as the need for dialysis within the first week post-transplantation and renal function at 3 months post-transplantation - assessed using serum creatinine levels) in 104 corresponding kidney recipients. This single-center retrospective observational cohort study was conducted from April to December 2021. The donor pool consisted of 65% males with a median age of 53 years. Of these, 45 donors (56%) were classified as extended criteria donors. Higher syndecan-1 levels correlated with the last creatinine levels before organ procurement (R = 0.32, p = 0.01) and were marginally higher in donors with acute kidney injury (p = 0.07). However, syndecan-1 levels were not associated with short-term outcomes in kidney recipients (renal function at 3 months). The data suggests syndecan-1 could be a potential biomarker for assessing donor kidney quality, although its implications on recipient outcomes require further study. This pilot investigation underscores the importance of syndecan-1 in evaluating organ quality but highlights the necessity for more extensive research to validate these findings and explore their implications in transplant success.

Role of serial urine sediment examination in progression and outcome of sepsis-associated acute kidney injury

ABSTRACT Introduction Sepsis-associated acute kidney injury (SA-AKI) is common in hospitalized patients. There is a rising interest in validating new tools for predicting its prognosis and outcome. We aimed to assess the role of serial urine sediment examination in the progression and outcome of SA-AKI. Material and Methods This research is a prospective study which included 80 patients with SA-AKI stage 1 or 2. Urine sediment examination was done with calculations of Perazella score (PS) and Chawla score (CS) at days 1, 3, and 7 and correlated with AKI progression and outcomes. Results Fifty-eight females and 22 males were enrolled in the study with a mean age of 61.10 ± 11.26 years, and initial serum creatinine at presentation was 2.06 ± 0.51 mg/dl.47.5% of patients progressed to stage 3 AKI, while 52.5% did not progress. Patients who progressed to stage 3 AKI had a significantly lower urine output at presentation, higher need for dialysis, higher mortality, higher serum creatinine, and lower eGFR at discharge and after 3 months. Both PS and CS at the time of diagnosis (day 1) showed no statistical difference between those with and without AKI progression. However, examination at day 3 and 7 revealed that AKI progressors had significantly higher PS and CS (p < 0.001 and < 0.001), respectively. P2 and P3 in Perazella score showed an AUC of 0.902 and 0.932, while C2 and C3 in Chawla score showed an AUC of 0.914 and 0.945 for prediction of AKI progression. Regarding prediction for mortality, the AUC for P1, P2, and P3 of Perazella score was 0.625, 0.767, and 0.791, respectively. While that of C1, C2, and C3 was 0.568, 0.794, and 0.788, respectively. Conclusions Serial urine sediment examination can be helpful in predicting SA-AKI outcomes. Larger randomized clinical trials are needed to support its use.

Characteristics and outcomes of in-hospital patients with Covid-19 and history of tuberculosis: a matched case-control from the Brazilian Covid-19 Registry

BackgroundThe Covid-19 pandemic caused a negative impact on other infectious diseases control, prevention, and treatment. Consequently, low and middle-income countries suffer from other endemic diseases, such as tuberculosis. This study was designed to compare Covid-19 manifestations and outcomes between patients with previously treated tuberculosis and controls without this condition.MethodsWe performed a matched case-control study drawn from the Brazilian Covid-19 Registry data, including in-hospital patients aged 18 and over with laboratory-confirmed Covid-19 from March 1, 2020, to March 31, 2022. Cases were patients with a past history of tuberculosis. Controls were Covid-19 patients without a tuberculosis history. Patients were matched by hospital, sex, presence of HIV, and number of comorbidities, with a 1:4 ratio.ResultsOf 13,636 patients with laboratory-confirmed diagnoses of Covid-19 enrolled in this study, 80 had a history of tuberculosis. Statistical differences in history of chronic pulmonary obstructive disease (15% vs. 3.2%), psychiatric disease (10% vs. 3.5%,), chronic kidney disease (11.2% vs. 2.8%), and solid-organ transplantation; (5% vs. 0.9%, p < 0.05 for all) were higher in patients with a past history of tuberculosis. Prior use of inhalatory medications (5% vs. 0.6%,), oral corticoids (8.8% vs. 1.9%), immunosuppressants (8.8% vs. 1.9%,) and the use of illicit drugs were more common in the case group (6.2% vs. 0.3% p < 0.05for all). There were no significant differences in in-hospital mortality, mechanical ventilation, need for dialysis, and ICU admission.ConclusionsPatients with a history of tuberculosis infection presented a higher frequency of use of illicit drugs, chronic pulmonary obstructive disease, psychiatric disease, chronic kidney disease, solid-organ transplantation, prior use of inhalatory medications, oral corticoids, and immunosuppressants. The outcomes were similar between cases and controls.

Pharmacological Nephroprotection in Chronic Kidney Disease Patients with Type 2 Diabetes Mellitus-Clinical Practice Position Statement of the Polish Society of Nephrology.

Both chronic kidney disease (CKD) and type 2 diabetes (T2D) are modern epidemics worldwide and have become a severe public health problem. Chronic kidney disease progression in T2D patients is linked to the need for dialysis or kidney transplantation and represents the risk factor predisposing to serious cardiovascular complications. In recent years, important progress has occurred in nephroprotective pharmacotherapy in CKD patients with T2D. In the current position paper, we described a nephroprotective approach in CKD patients with T2D based on the five following pillars: effective antihyperglycemic treatment, SGLT2 inhibitor or semaglutide, antihypertensive therapy, use of RASi (ARB or ACEi), and in selected patients, finerenone, as well as sodium bicarbonate in patients with metabolic acidosis. We thought that the current statement is comprehensive and up-to-date and addresses multiple pathways of nephroprotection in patients with CKD and T2D.

The potential for reducing greenhouse gas emissions through disease prevention: a secondary analysis of data from the CREDENCE trial.

The health-care sector is responsible for 5·2% of global emissions, however, little data exist regarding the environmental impact of disease management strategies. SGLT2 inhibitors are now widely used to reduce the risk of hospital admission and kidney failure in people with type 2 diabetes and chronic kidney disease. This study aimed to estimate the impact of SGLT2 inhibitors on greenhouse gas emissions using data from the CREDENCE trial. For this modelling analysis, we used data from the randomised, double-blind, placebo-controlled, CREDENCE trial, which compared the effect of canagliflozin versus placebo on kidney and cardiovascular outcomes in patients with type 2 diabetes and albuminuric chronic kidney disease. For this secondary analysis, we included all participants randomly assigned to canagliflozin or placebo at baseline in the CREDENCE trial. Data on greenhouse gas emissions resulting from hospital inpatient days, maintenance dialysis therapy, and SGLT2 inhibitor tablet production were derived from published reports and used to model greenhouse gas emissions from total number of hospital inpatient days, total number of days of maintenance dialysis therapy, and from SGLT2 inhibitor treatment over the course of the CREDENCE trial. We compared greenhouse gas emission estimates for participants in the canagliflozin group and placebo group of the CREDENCE trial. We used bootstrapping analyses to calculate uncertainty estimates and permutation tests to generate p values for the difference in number of days on dialysis and inpatient bed days between treatment groups. 4401 participants who were randomly assigned to the canagliflozin (n=2202) or placebo group (n=2199) were included in the secondary analyses. During a median follow-up of 2·62 years (IQR 0·02 to 4·53), SGLT2 inhibitor production for 2202 participants resulted in greenhouse gas emissions of 63 tonnes of CO2 equivalent (CO2e; 95% CI 62 to 64). The total number of inpatient bed days was 17 002 days in the placebo group versus 13 672 days in the canagliflozin group; the 3330 fewer inpatient days (95% CI 1037 to 5686; p=0·042) with SGLT2 inhibitor treatment equated to a reduction of approximately 126 tonnes of CO2e (95% CI 39 to 216). Participants in the placebo group required 24 877 days of maintenance dialysis compared with 16 605 days in the treatment group; 8272 fewer days of dialysis ( -168 to 16 755; p=0·16), equated to a reduction of 161 tonnes of CO2e (-3 to 327). Overall, mean greenhouse gas emissions per-participant-year were reduced from 196 kg of CO2e per-participant-year to 157 kg of CO2e per-participant-year. The addition of an SGLT2 inhibitor to routine therapy for people with type 2 diabetes and chronic kidney disease has the potential to reduce greenhouse gas emissions through the prevention of hospital admissions and need for dialysis. None.

The Safety and Late Hemodynamics of Donor Cardiac Undersizing in Heart Transplantation.

Predicted heart mass ratio (PHMr) has become the standard donor-recipient size matching method in heart transplantation. While utilization of small PHMr hearts is associated with increased one-year mortality, the underlying mechanisms and time horizon of mortality remain uncertain. A single institution analysis of isolated heart transplant recipients (01/2019-7/2022) was performed (N=334). Patients were stratified by PHMr: undersized (<0.86) (n=106), matched (0.86-1.15) (n=175), and oversized (>1.15) (n=53). Survival within PHMr groups was further stratified: complex transplant group (preoperative LVAD, adult congenital, or preoperative ECMO) and non-complex transplant group (all others). Donor and recipient variables were similar. However, undersized patients were more likely to have a durable LVAD (P=0.022). While postoperative PGD and inotrope score were similar between groups, there was a trend toward increased postoperative dialysis need with undersized hearts (P=0.056). Overall, thirty-day (P=0.012) and one-year survival (P=0.002) was significantly worse in the undersized group compared to matched or oversized groups. However, on subset analysis, these differences only remained among the complex transplant recipients (P=0.013), but not the non-complex transplant recipients (P=0.428). Median mixed venous oxygen saturations at serial time-points were maintained between 65-70% in all heart size groups, with cardiac indices between 2.4-2.8 LPM/m2. Small PHMr hearts are associated with increased one-year mortality, driven by complex transplant operations. Recipients who received undersized PHMr hearts from non-complex transplant operations had a similar hemodynamic profile and survival as those who received matched and oversized hearts. Small PHMr hearts may be selectively safe for transplantation.

Use of prenatal ultrasound findings to predict postnatal outcome in fetuses with lower urinary tract obstruction.

Lower urinary tract obstruction (LUTO) is a chronic condition with a spectrum of outcomes. It is usually suspected prenatally based on ultrasound features (USFs). Given the unknown postnatal trajectory and the potential for significant morbidity and mortality, many families choose termination of pregnancy (TOP), often based on USFs alone. Herein, we sought to develop a tool that can be used to predict postnatal outcome based on combinations of USFs, which can aid prenatal counseling and parental decision-making. This was a retrospective study of cases with suspected fetal LUTO that were seen at a high-risk fetal center and a tertiary pediatric center in Canada. Data were collected on USFs, prenatal/postnatal death and postnatal need for transplantation and/or dialysis. USFs from pregnancies with a gestational age of 13-26 weeks on initial ultrasound at the high-risk fetal center that underwent TOP were collected and matched to fetuses with comparable prenatal USFs that were not terminated, which had a known postnatal outcome, to build a random forest model. The random forest model was fitted for each outcome (death, dialysis or transplantation) and tested for accuracy using leave-one-out cross-validation. Each predictor was assessed independently with combined importance when accounting for other predictors. The model was used to predict the most likely postnatal outcomes for cases of TOP had the pregnancy been continued. USF data from 85 cases of TOP and 125 cases of expectantly managed pregnancy with prenatally suspected LUTO were retrieved. For expectantly managed cases, there was a median follow-up duration of 5.7 (interquartile range, 0.2-14.5) years among the liveborn infants. There were 14 prenatal and 22 postnatal deaths in the expectantly managed cohort. The random forest model demonstrated the highest predictive accuracy for transplantation (77% accuracy, 50% sensitivity, 80% specificity), followed by death (72% accuracy, 83% sensitivity, 67% specificity) and dialysis (71% accuracy, 70% sensitivity, 71% specificity). For the TOP cohort, had the pregnancies been continued, the model predicted transplantation and dialysis in 21/85 (25%) and 37/85 (44%) cases, respectively; pre- or postnatal death was predicted in 69/85 (81%) cases. Our data suggest that it is possible to predict death and postnatal transplantation and/or dialysis from USFs in fetuses with suspected LUTO with acceptable accuracy. Predictive accuracy will improve with continued follow-up of more patients, enabling more personalized prenatal counseling and more informed decision-making for families. © 2024 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Exploring the metaverse: opportunities for nephrology in patient care and education.

The metaverse, a digital ecosystem characterized by the convergence of physical and virtual realities through technologies like virtual reality (VR), augmented reality (AR), and mixed reality (MR), is reshaping societal and economic landscapes. In healthcare, the metaverse promises to revolutionize service delivery and medical education by overcoming geographical barriers and democratizing access to information. However, challenges such as the digital divide and privacy concerns persist. Economically, the metaverse is projected to significantly boost global GDP, with healthcare sectors poised for substantial growth through innovations like virtual clinics and telemedicine. In nephrology, the metaverse offers new avenues for patient education, treatment planning, and collaborative research. The integration of VR and AR technologies can enhance patient engagement by providing interactive platforms for understanding their condition, treatment options, and lifestyle modifications. This approach empowers patients to take an active role in managing their health, potentially improving adherence to treatment regimens and overall outcomes. Furthermore, virtual reality applications in hemodialysis have shown promise in reducing treatment-related symptoms and improving psychological well-being. The development of virtual clinics for CKD patients could facilitate remote monitoring and management, reducing the need for emergency dialysis and improving long-term patient outcomes. Despite the burgeoning interest and research in this field, the integration of VR and AR into routine clinical practice remains in its nascent stages. The potential of these technologies to enhance patient care, improve surgical precision, and provide immersive educational experiences is immense, paving the way for a future where technology and medicine are intricately linked.