Management Of Kidney Disease Research Articles

Association between periodontitis and chronic kidney disease.

Periodontitis and chronic kidney disease are chronic conditions with high community prevalence across the world. Patients with chronic kidney disease have been noted to have a high burden of periodontitis, and several shared risk factors have been associated with the prevalence and severity of both conditions. However, the precise relationship between the two conditions, and the extent to which each may contribute to the development of the other, remains a matter of debate. The goals of the present work were to: (a) provide the most current and relevant literature overview of the association between periodontitis and chronic kidney disease; (b) explore mechanisms underlying this association; and (c) determine if evidence exists for an independent association between these conditions. We also assessed whether improved oral hygiene and periodontal treatment could reduce the risk of developing chronic kidney disease and, if so, what protocols these strategies involve. Finally, we aimed to reveal gaps in our current knowledge to delineate the directions of future research. Although the exact relationship between these two conditions has not yet been defined, we highlight the importance of the interprofessional interaction between dental practitioners and the nephrology team and the importance of oral health assessment in the management of chronic kidney disease.

Clinical profile, outcome and management of kidney disease in COVID-19 patients - a narrative review.

COVID-19 disease can cause damage to various organs, especially the kidneys, so the main purpose of this study was to investigate the effect of different aspects of kidney damages caused by COVID-19 in a narrative review study. To conduct this study, all studies related to the topic under discussion during 2020-2021 were reviewed by systematic search in internationally available databases including Web of Science, Science Direct, Scopus, PubMed, and Google Scholar. Finally, 42 completely related studies were selected to extract the results. The prevalence of acute kidney injury (AKI) varies in different parts of the world and has reached almost 70%. The results showed that, in general, a high percentage of COVID-19 patients had symptoms of renal dysfunction at the time of hospitalization, and the most important of these symptoms were proteinuria, hematuria, and increased serum creatinine. Based on the results, it can be said that AKI most likely occurs early in the disease and in parallel with lung damage. So far, various drugs have been used to control or treat COVID-19 and reduce inflammation in patients. Regardless of their usefulness, some of these drugs may adversely affect kidney function and damage the kidneys. The study results show that chronic kidney disease (CKD) in COVID-19 patients plays a minor role in renal replacement therapy (RRT), and the highest impact on the need for RRT is COVID-19. This study showed that one of the major negative effects of COVID-19 on the human body is kidney damage, among which acute kidney injury (AKI) is the most important one. In addition, the prevalence of AKI due to COVID-19 varies widely around the world. Although any medication may damage the kidneys, COVID-19 or anti-inflammatory drugs are not an exception to this rule, but more research is needed to gain more information.

The dire need for improved management of chronic kidney disease: Associated hypertension in Pakistan.

Chronic Kidney Disease (CKD) refers to various kidney disorders ranging from mild to severe chronic kidney failure. Because of its escalating incidence and mortality rates, CKD is a serious public health concern in Pakistan. According to a study published in 2018, the overall prevalence of CKD among Pakistani adults was 21.2%, the highest in South Asia. (1) Although there are numerous risk factors for CKD, such as diabetes, cardiovascular disease, smoking, obesity, and genetics, hypertension poses the most serious threat, as the global prevalence of CKD-associated hypertension is between 60 – 90%. (2) In most people with CKD, proteinuria is observed in conjunction with hypertension. (3) As per the Kidney Disease Outcomes Quality Initiative (KDOQI) recommendations, ACE inhibitors and Angiotensin II Receptor Blockers (ARBs) are the preferred treatment choices for diabetic kidney disease and non-diabetic kidney disease patients with proteinuria. In 2013, a cross-sectional study conducted in Karachi, Pakistan, revealed that only 46.1% of General Practitioners opted for ACE inhibitors and ARBs as primary treatment for hypertension and proteinuria associated with CKD. (4) A randomized crossover trial conducted in March 2021 compared candesartan’s antihypertensive and antiproteinuric effects and the newest ARB, azilsartan medoxomil. The study results revealed that azilsartan (20 mg daily) treatment significantly decreased proteinuria and blood pressure without a noticeable increase in side effects than candesartan (8 mg daily) in patients with CKD who required antihypertensive drugs. (5) Considering the high prevalence of CKD in Pakistan, doctors must follow KDOQI guidelines and prescribe ARBs as the primary therapeutic agents for hypertensive patients with CKD. Azilsartan, the most recent ARB, has been proven to have the most potent antihypertensive and antiproteinuric benefits with the fewest side effects. (5) Therefore, physicians should encourage CKD patients to use azilsartan instead of candesartan and other classes of ARBs. Furthermore, improved screening techniques for CKD must be introduced and implemented so that doctors can manage the disease more effectively before it progresses into its final stages. Such screening tests would also help to improve blood pressure control among patients recognized to have CKD. Therefore, Pakistan’s public health sector should ensure the implementation of Kidney Disease Improving Global Outcomes (KDIGO) criteria to screen and manage CKD and CKD-associated hypertension and diabetes. Lastly, there is a dire need for awareness programs to educate general health practitioners regarding CKD management and the benefits of timely referral to a nephrologist.

Abstract 1: Efficacy and safety of novel non-steroidal mineralocorticoid receptor antagonist finerenone in the management of diabetic kidney disease: A meta-analysis

Background: Data are scant on use of finerenone in diabetic kidney disease (DKD). We undertook this meta-analysis to address this knowledge-gap.Methods: Electronic databases were searched for RCTs involving diabetes-patients receiving finerenone compared to controls. Primary outcome was changes in urine albumin-creatinine ratio (UACR). Secondary outcomes were time to kidney failure (decline in GFR by >40% from baseline over 4 weeks), time to end-stage kidney disease, hospitalization for any cause, death and adverse events reported.Results: From initially screened 79 articles, data from 7 RCTs involving 13,783 patients was analysed [3 in active control group (ACG) defined as having eplerenone/spironolactone as active comparator; 4 in passive control group (PCG) defined as having placebo as controls]. Patients receiving finerenone had greater percentage lowering of UACR from baseline as compared to PCG [MD -23.82% (95%CI:-24.87– -22.77);P<0.01;I2=96%] at 90 days, after 2 years [MD-37.9% (95%CI:-38.09– -37.71);P<0.01] and 4 years [MD -25.20%(95%CI:-25.63– -24.77);P<0.01] of treatment. Patients receiving finerenone has lower chance of >40% decline in GFR [OR 0.83 (95%CI:0.75 – 0.92);P<0.01; I2=0%]. Patients receiving finerenone had lower occurrence of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke or hospitalization for heart failure, as compared to placebo/eplerenone [OR0.86 (95%CI: 0.78 – 0.95);P=0.003;I2=0%]. TAEs was similar [RR 0.97 (95%CI:0.88–1.07);P=0.56;I2=0%], but SAEs significantly lower [RR 0.91 (95%CI:0.84– 0.97);P<0.01;I2=0%] in finerenone-group compared to controls.Conclusion: This meta-analysis provides reassuring data on beneficial impact of finerenone in reducing UACR and GFR decline as compared to placebo in albuminuric DKD. We still lack head-to-head comparison of renal outcomes of finerenone vs eplerenone/spironolactone in DKD.

Genetic Etiologies, Diagnosis, and Management of Neonatal Cystic Kidney Disease.

Fetal kidney development is a complex and carefully orchestrated process. The proper formation of kidney tissue involves many transcription factors and signaling pathways. Pathogenic variants in the genes that encodethese factors and proteins can result in neonatal cystic kidney disease. Advancements in genomic sequencing have allowed us to identify many of these variants and better understand the genetic underpinnings for an increasing number of presentations of childhood kidney disorders. This review discusses the genes essential in kidney development, particularly those involved in the structure and function of primary cilia, and implications of gene identification for prognostication and management of cystic kidney disorders.

Factors Influencing Self-Management among Non-Dialysis Chronic Kidney Disease Patients.

Aim: The new trend in the management of chronic kidney disease (CKD) is based on the adoption of self-management approaches. However, there is a paucity of research assessing the level of self-management behavior among non-dialysis patients. The aim of the study is to assess the association between self-management behaviors and the level of disease-specific knowledge among non-dialysis CKD patients. In addition, this study aimed to assess the predictors of self-management among non-CKD patients. Methods: A convenience sample of 203 non-dialysis patients with stage 3–5 CKD was surveyed from the nephrology clinics in Saudi Arabia. Descriptive statistics and linear regression were used to analyze the data. Results: The mean level of knowledge and self-management was 17.9 ± 3.2 and 76.9 ± 13.3, respectively. The results of the multiple regression of self-management showed that knowledge was independently associated with self-management (r = 0.51, **, p < 0.001). Conclusions: This study demonstrated that knowledge and self-management were associated with each other in non-dialysis patients. More efforts are needed to track and enhance the knowledge levels in patients with CKD. Future research should focus on the effectiveness of educational programs of self-management behavior.

Long-term effectiveness of a primary care practice facilitation program for chronic kidney disease management: an extended follow-up of a cluster-randomized FROM-J study.

Practice facilitation program by multidisciplinary care for primary care physicians (PCPs) is expected to improve chronic kidney disease (CKD) outcomes, but there is no clear evidence of its long-term effectiveness. We have previously performed a cluster-randomized controlled trial for 3.5 years (the Frontier of Renal Outcome Modifications in Japan (FROM-J) study) with two arms-group A without the program and group B with the program. We aimed to assess the long-term effectiveness of the practice facilitation program on CKD outcomes via an extended 10-year follow-up of the FROM-J study. We enrolled patients who were in the FROM-J study. The primary composite endpoint comprised cardiovascular disease (CVD), renal replacement therapy initiation and a 50% decrease in the estimated glomerular filtration rate (eGFR). The secondary endpoints were survival rate, eGFR decline rate and collaboration rate between PCPs and nephrologists. The occurrence of the primary composite endpoint tended to be lower in group B (group A: 27.1%versus group B: 22.1%, P=0.051). Furthermore, CVD incidence was remarkably lower in group B (group A: 10.5%versus group B: 6.4%, P=0.001). Although both mortality and the rate of eGFR decline were identical between both groups, the eGFR decline rate was significantly better in group B than in group A only in patients with stage G3a at enrollment (group A: 2.35±3.87mL/min/1.73m2/year versus group B: 1.68±2.98mL/min/1.73m2/year, P=0.02). The collaboration rate was higher in group B. The CKD practice facilitation program for PCPs reliably decreases CVD events and may reduce the progression of cases to end-stage kidney disease.

Role of artificial intelligence in the diagnosis and management of kidney disease: applications to chronic kidney disease and acute kidney injury.

Chronic kidney disease (CKD) and acute kidney injury (AKI) are global public health problems associated with a significant burden of morbidity, healthcare resource use, and all-cause mortality. This review explores recently published studies that take a machine learning approach to the diagnosis, management, and prognostication in patients with AKI or CKD. The release of novel therapeutics for CKD has highlighted the importance of accurately identifying patients at the highest risk of progression. Many models have been constructed with reasonable predictive accuracy but have not been extensively externally validated and peer reviewed. Similarly, machine learning models have been developed for prediction of AKI and have found sufficient accuracy. There are issues to implementing these models, however, with conflicting results with respect to the relationship between prediction of an AKI outcome and improvements in the occurrence of other adverse events, and in some circumstances potential harm. Artificial intelligence models can help guide management of CKD and AKI, but it is important to ensure that they are broadly applicable and generalizable to various settings and associated with improved clinical decision-making and outcomes.

Effects of a Hemodialysis Diet Education Program on Hemodialysis Patients

The burden of chronic disease on health care services worldwide is growing and the increased development of educational interventions which help patients to better manage their conditions is evident internationally. It has been recognized that poor adherence to treatments and guidelines can be a serious risk to the health and wellbeing of patients. Adherence to fluid restrictions, dietary and medication guidelines as well as attendance at prescribed hemodialysis sessions are essential for adequate management of chronic kidney disease. The aim of this study was to identify the effects of a repeated hemodialysis diet education program on the diet of hemodialysis patients. This eight-week quasi-experimental design study involved adult patients who were undergoing chronic hemodialysis treatment for at least three months at the Nephrology Unit of Permata Bekasi Hospital. Adolescent participants were registered in each group, so that a total of 20 participants were registered. The experimental group received diet education four times. Data were analyzed by t-test. There was a statistically significant difference between the groups in dietary knowledge at the time of assessment, and there was also a difference in the mean intradialysis weight gain in the intervention and control groups. Repeated health education had an effect on the fluid diet of hemodialysis patients with a p-value &lt; 0.05. Due to the resulting improvement in dietary knowledge and self-care adherence, the repeated education program implemented in this study could be used to prevent complications in patients undergoing hemodialysis.&#x0D; Keywords: hemodialysis, diet, knowledge, compliance

Commentary on the 2020 update of the KDOQI clinical practice guideline for nutrition in chronic kidney disease.

Commentary on the 2020 update of the KDOQI clinical practice guideline for nutrition in chronic kidney disease.

Nuclear receptors in renal health and disease.

SummaryAs a major social and economic burden for the healthcare system, kidney diseases contribute to the constant increase of worldwide deaths. A deeper understanding of the underlying mechanisms governing the etiology, development and progression of kidney diseases may help to identify potential therapeutic targets. As a superfamily of ligand-dependent transcription factors, nuclear receptors (NRs) are critical for the maintenance of normal renal function and their dysfunction is associated with a variety of kidney diseases. Increasing evidence suggests that ligands for NRs protect patients from renal ischemia/reperfusion (I/R) injury, drug-induced acute kidney injury (AKI), diabetic nephropathy (DN), renal fibrosis and kidney cancers. In the past decade, some breakthroughs have been made for the translation of NR ligands into clinical use. This review summarizes the current understanding of several important NRs in renal physiology and pathophysiology and discusses recent findings and applications of NR ligands in the management of kidney diseases.

POS-414 AUTOMATED PREDICTIVE ANALYSIS OF MITOCHONDRIAL MEAN INTENSITY USING ARTIFICIAL INTELLIGENCE ALGORITHM AND INTRAVITAL TWO-PHOTON MICROSCOPY IN A RENAL DISEASE MODEL

Many areas in health care, such as disease diagnostics, forecasting patient outcomes, and automating image interpretation, have shown considerable potential in the use of machine learning algorithmic systems. Even though there are few studies on artificial intelligence (AI) applications in renal illness, the promise of AI in kidney disease management has been recognized.

POS-306 OUTPATIENT TREATMENT PATTERNS IN HYPERKALEMIA: AN OBSERVATIONAL STUDY IN THE US

Hyperkalemia (HK), a serum potassium concentration above 5.0 mEq/L, is a potentially severe condition that may result in arrhythmias and sudden death. Renin-angiotensin-aldosterone system inhibitor (RAASi) treatment is a cornerstone in the management of chronic kidney disease (CKD) and heart failure (HF), but can also induce HK. Potassium binders are a key pillar in the treatment of HK, but routine use of conventional binders such as sodium polystyrene sulfonate (SPS) is hampered by questionable effectiveness and safety concerns.

POS-262 LOW-PROTEIN DIETS IN CHRONIC KIDNEY DISEASE – SAFE OR NOT? A SINGLE LARGE CENTER EXPERIENCE

Recent studies emphasized the role of low-protein diets (LPDs) in the management of chronic kidney disease (CKD) in order to postpone renal replacement therapy. However, the risk of malnutrition in CKD patients on LPDs has often been debated. We present the results of a large single-center, focusing on the safety of LPDs in both diabetic and non-diabetic patients with CKD. A prospective, randomized, controlled study with 207 non-diabetic patients with CKD stage 4+ were grouped by the type of nutritional intervention - vegetarian very low protein diet with 0.3g/kg-day supplemented with ketoanalogues of essential aminoacids (sVLPD) versus LPD with 0.6g/kg-day for 15 months. We present the safety parameters at the end of study (EOS), but also after 10 years of follow-up. Safety data from a second interventional study, including 97 diabetic patients with stage 4+ CKD who received LPD supplemented with ketoanalogues of essential aminoacids (sLPD) for 12 months are also presented. Subjective Global Assessment (SGA), clinical data (Body Mass Index, BMI), and biochemical parameters (serum albumin, C-reactive protein) were analyzed. Patients’ adherence to the type of nutritional intervention was assessed by the estimated protein intake using urinary urea excretion. Both protein and energy intake were also evaluated through food diary. Nutritional status of non-diabetic patients was preserved for both sVLPD and LPD at 15 months after inclusion (SGA A 84 versus 85%, p=0.83). Moreover, the subjects continued the nutritional intervention after the EOS. After 10 years of nutritional intervention, the kidney’s survival (86 versus 46%, p<0.0001) and patients’ survival (89 versus 60%, p<0.0001) were much better in the sVLPD group. The levels of serum albumin were constantly around 4 g/dL, without any significant differences between groups at all study moments. The C-reactive protein levels were lower in patients on sVLPD at 15 months after inclusion (4 versus 5 mg/L, p<0.0001), respectively at 10 years after inclusion (5 versus 10 mg/L, p<0.0001). Patients’ adherence was confirmed at all study moments. For diabetic patients, during the study, there were improvements in body weight (BMI 27.1 versus 26.0 kg/m², p<0.0001), serum albumin (3.9 to 4.1 g/dL, p<0.0001), and in C-reactive protein levels (14 to 9 mg/L, p<0.0001). All patients had SGA A throughout the study. Nutritional intervention with different low-protein regimens seem to be safe for patients with CKD, both in diabetics and in non-diabetics.

ROLE OF ENDOVASCULAR INTERVENTIONAL RADIOLOGY IN CHRONIC KIDNEY DISEASE PATIENTS: SINGLE CENTRE EXPERIENCE

BACKGROUND AND AIMS: To study different vascular interventional procedures done in patients with chronic kidney disease (CKD) and End Stage Renal Disease (ESRD) patients and management of vascular pathologies using interventional procedures wherever applicable. METHOD: A retrospective study of CKD/ESRD patients referred to the department of Interventional Radiodiagnosis for undergoing hemodialysis related or renal diagnostic/therapeutic interventions during 12 months period. In our study of 60 patie RESULTS: nts following procedures were performed,16 patients underwent central venous angioplasty for central venous stenosis,10 patients underwent permcath insertion for hemodialysis,9 patients underwent stulography/stuloplasty,15 patients underwent renal artery angiography/angioplasty of the native and transplant kidney respectively,8 underwent embolization for post biopsy vascular complication and 2 patients underwent Trans jugular kidney biopsy. The individual most common procedure in our hospital was central venousplasty (16 patients), however combined most common procedure was for establishing dialysis access (19 patients, stulography/stuloplasty and permcath insertion) Interventional CONCLUSIONS: Radiology has a major role in management of CKD/ESRD patients as described in this study done in a tertiary care centre.

Prevalence and risk factors associated with chronic kidney disease in Moroccan rural communes: Fez-Meknes region

Background and aimsChronic kidney disease is a worldwide public health issue. It can be a serious problem, especially in developing countries including Morocco. However, few studies have explored the factors influencing chronic kidney disease in this country. Hence, using the definitions proposed by Kidney Disease Improving Global Outcomes in 2012, we have conducted this study to establish the prevalence and risk factors of chronic kidney disease particularly in rural communities in the Fez-Meknes region. MethodsWeight, height, blood pressure, proteinuria, hematuria, plasma creatinine, estimated glomerular filtration rate (using the Modification of Diet in Renal Disease formula), and fasting glycemia were measured. Abnormal results were controlled within two weeks; estimated Glomerular filtration rate was retested at 3 months. Furthermore, to determine the factors associated with chronic kidney disease, multivariate logistic regression was used. ResultsA total of 431 patients participated in the study; the prevalence of confirmed proteinuria, hematuria, and reduced estimated Glomerular filtration rate was 5.3%, 1.8%, and 3%, respectively. Overall, chronic kidney disease was found to be present in 6.5% of the population. Chronic kidney disease 1 and 2 accounted for 32.1% and 21.4% of the overall chronic kidney disease population, respectively, while chronic kidney disease 3 accounted for 46.4% (3A: 38.2%; 3B: 7.14%). Chronic kidney disease 4 and 5 were not present in the total chronic kidney disease population. Chronic kidney disease was strongly linked with advanced age (OR 2.65; 95%CI: 1.05-6.65), hypertension (OR 2.41; 95%CI: 1.03-5.63), agricultural occupation (OR 1.02; 95%CI: 1.00-1.04) and contact with Agrochemicals (OR 1.40; 95%CI: 0.81-2.71). ConclusionsIt is important to note that screening for kidney damage and being aware of the risks linked to it, is key for the early detection and management of chronic kidney disease; they are also crucial to provide in a database for the development of a national prevention policy.

The utility of a genetic kidney disease clinic employing a broad range of genomic testing platforms: experience of the Irish Kidney Gene Project

Background and aimsGenetic testing presents a unique opportunity for diagnosis and management of genetic kidney diseases (GKD). Here, we describe the clinical utility and valuable impact of a specialized GKD clinic, which uses a variety of genomic sequencing strategies.MethodsIn this prospective cohort study, we undertook genetic testing in adults with suspected GKD according to prespecified criteria. Over 7 years, patients were referred from tertiary centres across Ireland to an academic medical centre as part of the Irish Kidney Gene Project.ResultsAmong 677 patients, the mean age was of 37.2 ± 13 years, and 73.9% of the patients had family history of chronic kidney disease (CKD). We achieved a molecular diagnostic rate of 50.9%. Four genes accounted for more than 70% of identified pathogenic variants: PKD1 and PKD2 (n = 186, 53.4%), MUC1 (8.9%), and COL4A5 (8.3%). In 162 patients with a genetic diagnosis, excluding PKD1/PKD2, the a priori diagnosis was confirmed in 58% and in 13% the diagnosis was reclassified. A genetic diagnosis was established in 22 (29.7%) patients with CKD of uncertain aetiology. Based on genetic testing, a diagnostic kidney biopsy was unnecessary in 13 (8%) patients. Presence of family history of CKD and the underlying a priori diagnosis were independent predictors (P < 0.001) of a positive genetic diagnosis.ConclusionsA dedicated GKD clinic is a valuable resource, and its implementation of various genomic strategies has resulted in a direct, demonstrable clinical and therapeutic benefits to affected patients.Graphical abstract

Nephroprotective potential of Sharbat-e-Bazoori Motadil (sugar-free) in HEK-293 cells and Wistar rats against cisplatin induced nephrotoxicity

Sharbat-e-Bazoori Motadil (SBM) is a traditional Unani syrupy formulation, widely used for the management of kidney diseases. Due to lack of scientific evidence, the present work prospective is aimed to evaluate the protective effect of sugar-free SBM against cisplatin (CP)-induced nephrotoxicity using in vitro and in vivo followed by phytochemical studies. The sugar-free SBM formulation was chromatographically characterized for chemical analysis through HPTLC and evaluated for its metabolic contents. Thereafter, in vitro phytochemicals and free radical scavenging assays were performed to evaluate the total phenols and flavonoid content and antioxidant potential of sugar-free SBM. Human embryonic kidney-293 (HEK-293) cell was used to assess nephroprotective and antioxidant studies of sugar-free SBM. Further, in vivo nephroprotective studies were performed in female Wistar albino rats at different dose (32.1, 64.2, 128.4 mg/kg/day, p.o.) of SBM by assessment of biochemical markers, antioxidants status, inflammatory cytokines, and histopathological analysis. Qualitative and quantitative HPTLC analysis of SBM revealed eleven and eight metabolites at 254 and 366 nm, respectively, while the content of caffeic acid and trans ferulic acid was found as 5.63 ± 0.29 and 12.64 ± 0.71 µg/mg, respectively. In vitro free radical scavenging assays showed the significant antioxidant potential of sugar-free SBM. The in vitro assay for nephroprotective and cellular antioxidant analysis of SBM showed significant (p < 0.001) nephroprotective and antioxidant potential. Additionally, in vivo studies of different doses of SBM showed significant (p < 0.001) amelioration in kidney and liver biomarkers. Besides, it also manifests antioxidant, anti-inflammatory and anti-apoptosis activity confirmed by regulation of CAT, GPx, GSH, SOD, TNF-α, IL-1β, NO and caspase-3 levels. Additionally, normalization in histopathological changes of kidney tissue against cisplatin toxicity was also observed in SBM. The sugar-free SBM significantly ameliorated cisplatin induced nephrotoxicity by exerting normalcy in biochemical markers, antioxidant, and anti-inflammatory activity. These findings indicated an opportunity to develop a sugar-free formulation from SBM composition, as well as scientific validation of its traditional claim in the Unani system of medicine.

Role of Nanotechnology and Their Perspectives in the Treatment of Kidney Diseases.

Nanoparticles (NPs) are differing in particle size, charge, shape, and compatibility of targeting ligands, which are linked to improved pharmacologic characteristics, targetability, and bioavailability. Researchers are now tasked with developing a solution for enhanced renal treatment that is free of side effects and delivers the medicine to the active spot. A growing number of nano-based medication delivery devices are being used to treat renal disorders. Kidney disease management and treatment are currently causing a substantial global burden. Renal problems are multistep processes involving the accumulation of a wide range of molecular and genetic alterations that have been related to a variety of kidney diseases. Renal filtration is a key channel for drug elimination in the kidney, as well as a burgeoning topic of nanomedicine. Although the use of nanotechnology in the treatment of renal illnesses is still in its early phases, it offers a lot of potentials. In this review, we summarized the properties of the kidney and characteristics of drug delivery systems, which affect a drug’s ability should focus on the kidney and highlight the possibilities, problems, and opportunities.

Supportive Care Program in CKD: from dream to reality

The number of older and frail patients has greatly increased in nephrology departments. Traditional treatment options have become inappropriate because they seem unable to achieve goals such as quality of life. Principles from palliative care have been brought to chronic kidney disease management with good results; thus a new way to approach these patients has been reported. In Portugal, in 2011, Direcção Geral de Saúde published a guideline to substantiate supportive care as an option, for certain patients, in certain circumstances. The best evidence known at the time was stated and the conditions that should be met were regulated, but limited information was given about practical implementation of what. In this article we describe our experience with a supportive care program from planning to the implementation steps, since 2015. We reflect on the flowchart, the barriers, the conquests, and the data up to the end of 2020.