Nephrology Clinic Research Articles

Impact of arteriovenous fistula formation on trajectory of kidney function decline: a target trial emulation

Abstract Background Prior nonrandomised studies have suggested nephroprotective effects of arteriovenous fistula (AVF) formation, but these are plausibly susceptible to immortal time and selection biases. Methods We studied patients attending nephrology clinics in the West of Scotland during 2010-2022 with an eGFR ≤15mL/min/1.73m2 and no prior AVF. Using target trial emulation and a sequential trial design, we simulated a hypothetical trial that would randomise patients to either undergo AVF formation immediately or not to undergo AVF formation. The primary outcome was the difference in eGFR slope for the first six months of follow-up, estimated using a mixed-effects model. The secondary outcomes were 5-year absolute risks of dialysis and death, estimated using the Aalen-Johansen and Kaplan-Meier estimators respectively. Results 1,364 unique patients (mean age 51.1, 55.7% male) contributed 3,125 person-trials, with 561 in the AVF and 2,564 in the no AVF group. Mean eGFR was 12.6mL/min/1.73m2 and the median number of eGFR measurements per person-trial was 7 (IQR 4 – 12). Slope of eGFR decline did not differ significantly between the AVF and no AVF groups (between group difference -0.67mL/min/1.73m2/year, 95%CI -1.43, 0.10). The 5-year absolute risk of dialysis was 87% (95%CI 84, 91) in the AVF group and 75% (95%CI 73, 77) in the no AVF group and the 5-year survival probability was 77% (95%CI 70, 83) in the AVF group and 67% (95%CI 64, 69) in the no AVF group. Conclusions In this study of patients with advanced CKD, there was no evidence of a nephroprotective effect of AVF formation.

Identification and Prioritization of Canadian Society of Nephrology Clinical Practice Guideline Topics

Identification and Prioritization of Canadian Society of Nephrology Clinical Practice Guideline Topics

Much ado about nothing: the impact of coronary angiography on kidney function in individuals with chronic kidney disease

Abstract Background and Objectives Chronic kidney disease (CKD) is associated with premature coronary artery disease and an increased risk of cardiovascular morbidity and mortality (1). Historically, there has been a tendency to delay or even avoid coronary angiography (CA) in those with CKD due to an increased risk of contrast-induced nephropathy or concern over precipitating the need for chronic dialysis. Such "renal nihilism" may account for the poorer outcomes observed in CKD patients who present with acute coronary syndromes (2). The role of this retrospective analysis was to evaluate the impact of CA on the temporal trend in kidney function in individuals with CKD over a 24-month period. Methods The clinical details of 120 individuals under long-term local follow-up by various Nephrology clinics (CKD clinic, low creatine clearance, polycystic kidney disease, transplant and immunosuppression clinics) was collected. All underwent CA locally. Kidney function was observed at set intervals of 12-, 9-, 6- and 3-months prior to CA, immediately post-CA, and at 3-, 6-, 9- and 12-months post-CA. Only results obtained after the desired time point but within 28 days were included. All CAs regardless of either their indication (elective or urgent) or whether percutaneous intervention (PCI) was performed, were included. Patients already on dialysis at the time of the CA were excluded. Statistical analysis was performed via one-way ANOVA. Results Patient characteristics are summarised in table 1. The average age of patients was 67, with a male preponderance (72%). 22% had CKD 3, 24% had CKD 4 and 12% had CKD 5. 9% were kidney transplant recipients. 37% underwent urgent CA whilst a total of 22% had PCI. 27% progressed to requiring renal replacement therapy (RRT). The mean length to RRT was 2.8 years. The rate of decline in kidney function in the last 12 months prior to CA was 7.7% and 6.3% in the year after CA (figure 1). There was no statistically significant difference in kidney function after CA (p = 0.395). This was replicated in analyses focussing on CKD classes 3, 4 and 5 individually, within stable kidney transplant recipients, and within analysis comparing PCI vs non-intervention CAs. Conclusion The results demonstrate CA does not accelerate the decline in kidney function in those with known CKD over a 12-month period, and suggests where appropriate, an invasive treatment strategy should be consider and utilised more often in this population.Table 1:Patient characteristicsFigure 1:Trend in eGFR relative to CA

Chronic kidney disease in Kuwait: a multicenter study of two cohorts with different levels of access to public healthcare

IntroductionKuwait has a large expatriate community who experience both restricted access to public health services and lower income than Kuwaiti citizens. Given these conditions, we examined differences in characteristics and management of chronic kidney disease (CKD) between Kuwaitis and expatriates.MethodsClinical and laboratory data for adult CKD Stages 3–5 not on dialysis (CKD 3–5 ND) patients with native kidneys attending nephrology clinics in all Ministry of Health hospitals collected from January 1, 2022, to December 31, 2022. Cohort was then divided into Kuwaiti patients and expatriates patients for comparison.ResultsWe collected data from 2,610 patients (eGFR: 30.8 ml/min/1.73m2; age: 62.6 years; males: 56.7%; Kuwaitis: 62.1%). Kuwaitis were older (63.94 vs. 60.3 years, p < 0.001), with lower mean eGFR (30.4 vs. 31.5 ml/min/1.73m2, p = 0.052) than non-Kuwaitis, however, Kuwaitis had lower mean blood pressure (137.2/76.5 vs. 139.1/78.9 mmHg, p = 0.006), lower HbA1c in diabetics (7.59 vs. 7.82%, p = 0.010), and better lipid profile despite higher body mass indexes (29.6 vs. 28.9 kg/m2, p = 0.002). Both groups had high diabetes mellitus and hypertension rates. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) were used in only 22.6% and renin-angiotensin-aldosterone system inhibitors (RAASi) in only 46.2%.ConclusionCKD 3–5 ND is caused by diabetes mellitus in 56.6% of cases, and the majority have hypertension. In our study, non-Kuwaitis had higher eGFR; however, restricted public healthcare access and lower income can lead to an unhealthy diet and suboptimal care, which may cause higher blood pressure, higher HbA1c, and a higher dyslipidemia rate. RAASi and SGLT2i utilization must increase to combat CKD, and antihypertensive selection must improve.

Ambulatory blood pressure monitoring in Egyptian children with nephrotic syndrome: single center experience

BackgroundHypertension (HTN), especially masked hypertension, is one of the cardiovascular consequences of nephrotic syndrome. Masked hypertension cannot be identified during routine follow-up visits and adversely effects the patients’ cardiac function. The purpose of this study was to use ambulatory blood pressure monitoring (ABPM) to evaluate the blood pressure status of children with nephrotic syndrome.MethodsNinety children with nephrotic syndrome (NS) participated in this cross-sectional study, which was carried out at Cairo University Children Hospital’s nephrology clinic (CUCH). A sphygmomanometer was used in the clinic to measure blood pressure, and a Meditech monitor was used for 24-hour ambulatory blood pressure monitoring (ABPM). Interventricular septum (IVS) was measured, and heart functions were evaluated, using echocardiography.ResultsTwo groups comprised the included patients: Group1 (n = 70): HTN group included masked and ambulatory hypertension, and Group 2 (n = 20): non-HTN group included normal blood pressure, white coat HTN and well controlled HTN, 35% of the studied cohort (n = 32/90) had masked HTN.The serum urea was significantly higher in HTN group than non-HTN group with p-value: 0.047, while the serum albumin was significantly lower in HTN group than non-HTN group with p-value: 0.017. The cut-off point of 9.9, the sensitivity and specificity of serum urea to predict the occurrence of hypertension in NS patients was 92.9% and 35% respectively, with p-value : 0.024 and 95% CI (0.534–0.798). The z score of IVS is significantly higher in group 1 (2.5 ± 1.2) when compared to group 2 (1.7 ± 2.1) with p-value: 0.025 and Among group 1, it was noticed that 74% (n = 52/70) of them were systolic non-dipper, also it was observed that the mean serum potassium and cholesterol were significantly higher among systolic non-dipper when compared with systolic dipper patients with p-values: 0.045 and 0.005 respectively.ConclusionChildren with nephrotic syndrome are particularly vulnerable to experience ambulatory hypertension and masked hypertension, which may adversely impact their cardiac condition because they are not detectable by standard blood pressure readings at the clinic.

Fabry disease in female monozygotic twins with complex intronic haplotype variants: a case report

BackgroundFabry disease is an X-linked lysosomal storage disease caused by the impairment of α-galactosidase A. The complex intronic haplotype (CIH) variants, located in promoter and intronic regulatory lesions, has been found in patients with classical forms of Fabry disease. We present a case of Fabry disease in female monozygotic twins exhibiting the CIH mutation and classical manifestations.Case presentationA 61-year-old woman with a history of stroke, carotid artery occlusion, hypertrophic cardiomyopathy, and chronic kidney disease was referred to the nephrology clinic for management of her chronic kidney disease. Her monozygotic twin sister also presented with hypertrophic cardiomyopathy, atrial flutter, carotid stenosis, and proteinuria. Clinical symptoms and a comprehensive family history strongly suggested the presence of Fabry disease. Genetic analysis revealed the presence of 5 variants within a complex intronic haplotype (CIH): c.−10 C > T, c.369 + 990 C > A, c.370 − 81_370–77delCAGCC, c.640–16 A > G, and c.1000–22 C > T. We conducted a review of the patient’s previous kidney biopsy findings, which demonstrated the presence of lamellated inclusion bodies in electron microscopy. Remarkably, both the monozygotic twin sister and her son exhibited the same genetic mutation. Enzyme replacement therapy was initiated for the patient. Her kidney function decreased throughout a thorough 2-year follow-up period, while there was a slight decrease in the left ventricular mass index.ConclusionsThis is the first reported case of female monozygotic twins with the CIH variants representing cardiac, cerebrovascular, and renal manifestations suggestive of Fabry disease.

Effectiveness of a health literacy intervention targeting both chronic kidney disease patients and health care professionals in primary and secondary care: a quasi-experimental study.

Chronic kidney disease (CKD) patients with limited health literacy are at risk for faster disease progression. To counteractthis problem, we developed 'Grip on your Kidneys' (GoYK), an intervention targeting patients and health care professionals. We assessed the effect on self-management, patient activation, clinical parameters, consultation quality, and the professionals' use of health literacy strategies. We further evaluated the process. A quasi-experimental study included 147 patients with CKD and 48 professionals from Dutch general practices and nephrology clinics. Patients and professionals in the intervention group (IG) received GoYK. Control patients received care-as-usual from the participating professionals. Data were collected with questionnaires and from patient records at baseline (T0), 4months (T1) and 9months (T2). No effects on self-management and patient activation were found. Conversely, at T2, the proportion of patients with hypertension decreased in the intervention group (odds ratio = 0.45, 95% confidence interval (95%CI) [0.20, 0.99]). In the intervention group, more lifestyle topics were discussed, at T1 (difference = 0.80, 95%CI [0.28, 1.31]) and T2 (difference = 0.69, 95%CI [0.14, 1.25]). Furthermore, several outcomes related to consultation quality improved. Professionals in the intervention group improved the use of health literacy strategies more, at T1 (difference = 0.64, 95%CI [0.33, 0.95]) and T2 (difference = 0.56, 95%CI [0.19, 0.93]). In general, patients and professionals considered GoYK to be useful. GoYK is promising, and offers a blueprint to optimize care for patients with limited health literacy. Researchers should develop and test interventions like GoYK, focusing on patients at risk for CKD, and with very low health literacy.

Real-World Utilization of a Patient-Reported Outcome (PRO) Assessment Tool in Nephrology Clinic: Patient and Provider Perspectives

Real-World Utilization of a Patient-Reported Outcome (PRO) Assessment Tool in Nephrology Clinic: Patient and Provider Perspectives

Genetic Testing in Nephrology and Kidney Transplant Clinics in an Academic Center with a Predominant Minority Population

Genetic Testing in Nephrology and Kidney Transplant Clinics in an Academic Center with a Predominant Minority Population

Frequency of CKD Patient Referrals to Nephrology Clinics Using the Kidney Failure Risk Equation at Kaiser Permanente Northern California

Frequency of CKD Patient Referrals to Nephrology Clinics Using the Kidney Failure Risk Equation at Kaiser Permanente Northern California

Composite Primary Outcome Variables in Nephrology Clinical Trials

Composite Primary Outcome Variables in Nephrology Clinical Trials

Criteria-based outpatient scheduling at a nephrology clinic: prospective evaluation of patient pre-assessment and its corresponding adaptive scheduling strategy

BackgroundOutpatient Clinics (OCs) are under pressure because of increasing patient volumes and provider shortages. At the same time, many patients with chronic diseases receive routine follow-up consultations that are not always necessary. These patients block access to care for patients that are in actual need for care. Pre-assessing patient charts has shown to reduce unnecessary outpatient visits. However, the resulting late cancellations due to the pre-assessment, challenge efficient alignment of capacity with actual patient demand, leading to either empty slots or overtime. This study aims to develop a method to analyse the effect of pre-assessing patients before inviting them to the OC. This involves 1) to select who should come and 2) to optimize the impact of pre-assessment on the schedule and efficient use of OC staff.MethodsThis prospective mixed-methods evaluation study consists of 1) an expert meeting to determine a pre-assessment strategy; 2) a retrospective cohort study to review the impact of this strategy (12 months of a Dutch nephrology OC); 3) mathematical optimization to develop an optimal criteria-based scheduling strategy; and 4) a computer simulation to evaluate the developed strategy. Primary outcomes are the staff idle time and staff overtime. Secondary outcomes evaluate the number of weekly offered appointments.ResultsThe expert group reached consensus about the pre-assessment criteria. 875 (18%) of the realized appointments in 2022 did not meet the OC visit pre-assessment criteria. In the best performing scheduling strategy, 94 slots (87% of the available capacity) should be scheduled on a weekly basis. For this schedule, 26.8% of the OC weeks will experience idle time (μ\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\mu$$\\end{document}=2.51, σ\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\sigma$$\\end{document}=1.44 appointment slots), and 21% of the OC weeks will experience overtime (μ\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\mu$$\\end{document}=2.26, σ\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\sigma$$\\end{document}=1.65 appointment slots) due to the variation in patient appointment requests. Using the pre-assessment strategy combined with the best performing scheduling strategy under full capacity (108 slots), up to 20% increase in patient demand can be handled with equal operational performance.ConclusionsThis evaluation study allows OC managers to virtually test operational impact of pre-assessment strategies on the capacity of their OC, and shows the potential of increasing efficient use of scarce healthcare capacity.Trial registrationNot applicable.

Impact of a health literacy sensitive model of care in outpatient nephrology dietetic clinics.

Inadequate health literacy in people with chronic kidney disease is associated with poorer disease management and greater complications. Adherence to the renal diet is known to be suboptimal and patient feedback about the renal diet suggests that patients leave nephrology clinics feeling confused. The present study aimed to evaluate the impact of a health literacy sensitive model of care (MOC) in outpatient nephrology dietetic clinics. This quasi-experimental non-randomised pre-post study recruited adults attending three renal dietitian clinics. The revised MOC consisted of a renal diet question prompt sheet, teachback, and plain language materials and instructions. Outcomes assessed included clinical, dietary, patient-reported satisfaction and quality of life. Differences between and within groups were analysed using paired t-tests, independent sample t-tests (or non-parametric equivalent), chi-squared and McNemar's tests. Linear mixed models evaluated change in total diet quality score, fruit, vegetable, protein and dairy intake with time as a fixed effect and a random subject specific effect. Fail to attend rates at the initial appointments were lower in the revised MOC (21.5% vs. 9.1%). The revised MOC was associated with significantly improved fruit (p = 0.03) and vegetable (p = 0.003) intake and an improved proportion with adequate diet quality (p = 0.03). These impacts were of moderate effect size (d = 0.5, 95% confidence interval = 0.0-1.0). The revised MOC was also associated with greater satisfaction at baseline (p = 0.04) and higher acceptability scores for all questions at the review appointments. Quality of life improved clinically but not significantly in the revised MOC (p = 0.92). This low-cost health literacy sensitive intervention is a promising strategy to improve fruit and vegetable intake in adults attending renal dietitian clinics. Further research to determine fidelity of teachback use and cost utility analysis would be beneficial. Larger scale trials powered to detect changes in quality of life would also be informative.

Real-Time Dialysis Dose: Ionic Dialysis Versus Classical Urea Kinetic Modeling Indices.

Introduction Worldwide, over 850 million people need renal replacement therapy, and over 80% of them are on hemodialysis. The term "dialysis adequacy" is most often associated with the achievement of minimally acceptable indices - single pool Kt/V (spKt/V) and urea reduction ratio (URR%) and largely does not take into account other clinical indicators in patients. In addition, it should be taken into account that in the conditions of clinical practice, their measurement is carried out according to standards controlled by the regulatory structures and is carried out with a frequency between one and three months, and not during each dialysis procedure. Accordingly, based on the obtained value, we assume that it refers to the urea clearance of the entire dialysis prescription. A new methodology for measuring dialysis adequacy through ionic dialysis allows dose estimation in real time without the need for additional blood testsby recording the difference in sodium ion conductivity at the dialyzer inlet and outlet. The latter corresponds to the dialysis dose delivered and can be measured at each dialysis session, enabling timely therapeutic intervention at minimal cost to the community. The aim of this original article is to present ion dialysis to the community as a reliable and inexpensive alternative to classical urea kinetic modeling (UKM), evaluating the comparability of the two methods and the possible sources of error in the result. Material and methods This was a retrospective study of 32 patients undergoing hemodialysis at the Clinic of Nephrology and Dialysis at the University Hospital St. Marina (Varna, Bulgaria) for the period between January and December 2020.For each of the patients, four measurements (every three months) of the delivered dialysis dose were performed by ion dialysis and classical urea kinetic modeling in order to assess the comparability and reliability of the two methods. Results The analysis of the results proved a high correlation between the validated indicators of dialysis adequacy (spKt/V; URR) and those registered with online monitoring (online clearance monitor) by ionic dialysis - online Kt/V (onKt/V)while at the same time reporting a significant difference in the two methods - primarily based on the anthropometric formulas used to estimate the volume. The established regression models confirmed the high predictive value of ionic dialysis in relation to the actually delivered dose. Discussion Despite the high bond strength, our recorded values ​​for onKt/V are 8% lower compared to results using UKM. Therefore, onKt/V as an assessment metric has the ability to underestimate the dialysis dose received. Various factors as a possible source of error and its cause have been reported by some authors. Several studies have reported differences of 2-5% in instantaneous conductance measurements, which they associate mainly with differences in the diffusion coefficients of urea and sodium, as well as different effects of dialysis membrane charge or inadequate ultrafiltration correction. Conclusions Our study confirms that online clearance monitoring (OCM) is a practical non-invasive tool for daily use that complements the classic performance of OCM by helping to deliver an adequate dialysis dose with increased patient benefit and minimal cost of financial resources.

Zarażenia pasożytami jelitowymi u dzieci ukraińskich − uchodźców wojennych mieszkających w Warszawie

Introduction and objectiveThe war and the humanitarian crisis in Ukraine have resulted in a mass migration of millions of Ukrainians into the EU countries. According to the data obtained from Statistics Poland, a governmental agency collecting and publishing the country’s statistical data, the number of Ukrainian children currently living in Poland is approximately 500,000. The massive influx of immigrants into Poland poses a considerable challenge to the national health care sector. The aim of this study was to assess the prevalence of intestinal parasitic infections among Ukrainian child war refugees living in Warsaw.Material and methodsThe study involved a total of 25 Ukrainian children, patients of the Clinic of Paediatrics, Nephrology and Paediatric Allergology at the Military Institute of Medicine – National Research Institute in Warsaw. Parasitological diagnostic work-up was carried out in October 2023 at the Department of Epidemiology and Tropical Medicine, the Military Institute of Medicine – National Research Institute in Gdynia. Stool tests for the presence of intestinal parasites were conducted by light microscopy using three different methods (direct smear in Lugol’s solution, decantation with distilled water, Fülleborn’s flotation).ResultsA total of 20% of the children studied (5/25) were found to be infected with potentially pathogenic stramenopile &lt;i&gt;Blastocystis&lt;/i&gt; spp. In addition, two of the children were also infected with non-pathogenic &lt;i&gt;Endolimax&lt;/i&gt; nana and &lt;i&gt;Entamoeba&lt;/i&gt; coli protozoa. There were no infections with nematodes, cestodes or trematodes among the study participants.ConclusionsThe confirmation of potentially pathogenic &lt;i&gt;Blastocystis&lt;/i&gt; spp. in stool samples collected from Ukrainian children, war refugees living in Warsaw, justifies the necessity to re-introduce a large-scale routine screening for intestinal parasites in the paediatric population in Poland.

Fibronectin glomerulopathy in an elderly patient with FN1 gene mutation: a case report and literature review

BackgroundFibronectin glomerulopathy (FNG) is a rare autosomal dominant glomerulopathy that can lead to nephrotic syndrome. Here we report the case of an elderly patient diagnosed with FNG, exhibiting nephrotic-range proteinuria, with a 2-year follow-up.Case presentationA 75-year-old Korean female visited the nephrology clinic after experiencing generalized edema for 2 months. Her serum creatinine was 1.36 mg/dL, and urine protein-to-creatinine ratio was 3.99 g/g. Kidney biopsy revealed mesangial and subendothelial dense deposits, and immunohistochemistry for fibronectin showed strong positivity in the glomerulus. The patient’s family history included non-specific renal disease in her mother and two siblings. Genetic testing of the fibronectin 1 (FN1) gene showed Y973C mutation. She received conservative treatment, including angiotensin II receptor blockers (ARB). Two years after biopsy, the patient has preserved renal function and reduced proteinuria.ConclusionWe report the case of a 75-year-old patient with nephrotic-range proteinuria, who was diagnosed with FNG, and found to harbor a FN1 gene mutation. In this case, conservative treatment including ARB yielded reduction of proteinuria and preservation of renal function.

The Relationship Between Weight Indices and Blood Levels of Immunosuppressive Drugs in Renal Transplant Recipients

Background: Calcineurin inhibitors and mammalian target of rapamycin (mTOR) inhibitors are essential for maintaining transplanted organs. However, determining the appropriate dosage and predicting blood concentrations of these drugs based solely on net body weight may be inadequate. Previous studies have presented contradictory results regarding the impact of obesity on drug concentrations and transplant success. Objectives: This study aims to evaluate various weight indices to identify the most reliable indicator of weight that correlates with the blood levels of drugs used in organ transplantation. Methods: This retrospective descriptive study included patients from nephrology clinics affiliated with Isfahan University of Medical Sciences who were taking calcineurin and/or mTOR inhibitor drugs. Data extracted from medical records included demographic and clinical information, such as height, weight, and various weight indices (total/ideal/adjusted body weight, lean body mass (LBM), Body Mass Index, and predicted normal weight), as well as blood levels of immunosuppressive drugs at each patient's visit. The dosages of each drug (mg/kg) were analyzed to determine which weight indices best correlated with the obtained blood concentrations, using the Generalized Estimating Equation (GEE) model with logistic regression, an independent correlation matrix, and a binary distribution for data analysis. Results: The study analyzed the medical records of 71 patients. Trough (C0) concentrations of drugs were evaluated in relation to each weight index, and odds ratios (OR) were calculated for statistical comparison. All weight indices increased the likelihood of achieving appropriate concentrations for cyclosporine, tacrolimus, and sirolimus. Drug dosing based on LBM (OR: 1.028), ideal body weight (OR: 1.075), and total body weight (OR: 1.041) showed the strongest correlations with achieving proper blood levels for cyclosporine, tacrolimus, and sirolimus, respectively. Conclusions: Integrating various weight indices for calculating individualized doses (mg/kg) of each immunosuppressive drug increases the likelihood of achieving appropriate blood concentrations. However, the optimal weight index varies for each drug. Further studies, particularly those incorporating therapeutic drug monitoring (TDM) plans in transplant centers, are warranted to validate and generalize these findings, providing a potential avenue for improving immunosuppressive therapy and enhancing transplant outcomes.

Health-Related Quality of Life with Six Domains: A Comparison of Healthcare Providers without Chronic Diseases and Participants with Chronic Diseases.

Background/Objectives: This study aims to compare the health-related quality of life (HRQOL) between healthcare providers without chronic diseases and participants with chronic diseases presenting with one of the four different primary diagnoses on the health-related quality of life with six domains (HRQ-6D) scale. Methods: This is a cross-sectional study to compare the HRQOL between healthcare providers without chronic diseases and participants with chronic diseases. Data collection was performed from May 2022 to May 2023. Data for the comparison group were taken from healthcare providers without chronic diseases, and for the participant group with chronic diseases, the data were collected from actual patients with one of four types of primary diagnoses who were recruited from specialist cardiology, oncology, psychiatry, and nephrology clinics. All the participants of this study filled in the HRQ-6D. Results: There were 238 (58.6%) healthcare providers without chronic diseases who participated in this study, as well as 41 (10.1%) patients with end-stage renal disease (ESRD), 48 (11.8%) patients with cancer, and 40 (9.9%) patients who were depressed, and the remaining patients had heart disease. The means (SD) of HRQ-6D scores among healthcare providers without chronic diseases for pain, physical strength, emotion, mobility, self-care, perception of future health, and overall HRQ-6D score were 75.3% (19.8), 74.5% (21.1), 85.6% (18.4%), 93.0% (12.3), 91.6% (13.9), 74.2% (23.3), and 82.4% (13.6), respectively. In comparisons between healthcare providers without chronic diseases and participants with chronic diseases, all mean differences of the overall HRQ-6D score and its domains and dimensions were statistically significant (p < 0.001). Conclusions: The overall score of the HRQ-6D, as well as its domains and dimensions are sensitive in detecting the study participants with chronic diseases from among those without chronic diseases. Therefore, the HRQ-6D is a reliable and valid scale to measure HRQOL. Future studies may use this scale for interventional, observational, and cost-effectiveness studies.

Efficacy and safety of oral cyclophosphamide versus mycophenolate mofetil in childhood nephrotic syndrome: an open-label comparative study

IntroductionThere is a scarcity of research comparing the efficacy of cyclophosphamide and mycophenolate mofetil in childhood nephrotic syndrome. The aim was to evaluate the efficacy and safety of oral cyclophosphamide (CYC) and mycophenolate mofetil (MMF) in children with steroid-sensitive nephrotic syndrome in terms of the proportion of children who have been off steroids for at least 6 months without proteinuria (responders).MethodsThis open-label retrospective-prospective comparative study was conducted in a pediatric nephrology clinic of a referral center for children between 1 and 18 years of age with FR/SD nephrotic syndrome. Group A consisted of patients who received oral cyclophosphamide (100, 25% female) at a dose of 2–2.5 mg/kg once daily for a period of 8–12 weeks. Group B consisted of patients who received oral mycophenolate mofetil (n = 61, 18% female) (dose: 800–1200 mg/m2) for at least 12 months. Responders were defined as children who were off steroids for at least 6 months along with absence of proteinuria.ResultsIn the CYC group, 50% of the patients were responders, whereas 54% of the patients in the MMF group were responders (p = 0.614). The time to first relapse with CYC was 7 months (IQR 5.25–11) compared to 7 months (IQR 3.5–12) with MMF (p = 0.092). The relapse rate in the CYC group was 1.77 relapses per patient-year compared to 1.295 relapses per patient-year in the MMF group. The difference in relapse rate was significant (-0.474; 95% CI, 0.09 to 0.86 relapses/person-year) (p value = 0.009). Multivariate analysis revealed that an age of less than 5 years at the start of treatment was a significant factor for a better response to MMF (p value = 0.039, OR = 2.988, CI -1.055-8.468).ConclusionsThe efficacy of MMF was similar to that of CYC in terms of response (6 months without steroids) in children with FR/SD nephrotic syndrome. MMF showed a favorable response in terms of the frequency of relapse and treatment failure.Registration of the study with Clinical Trials Registry of India(http://ctri.nic.in;CTRI/2021/06/034421) (Dt: 28/06/2021).

Correlation between salivary and serum biomarkers of kidney function in chronic kidney disease patients attending the nephrology clinics at Teaching Hospital Karapitiya, Sri Lanka

The present study was designed to determine the correlation between salivary and serum levels of creatinine and urea in patients with chronic kidney disease (CKD) and to propose the use of saliva as an alternative medium for the analysis of biochemical parameters of kidney function. Accordingly, an analytical cross-sectional study was carried out using 100 CKD patients attending the Nephrology Clinics at Teaching Hospital Karapitiya, Sri Lanka. Saliva and serum samples were collected from the patients for the estimation of creatinine and urea using spectrophotometric assay kits. Of the total, the majority of the patients were found within CKD stage 3 (82%). The salivary and serum concentrations of creatinine varied within the range of 0.20 - 2.10 mg/dL and 1.54 – 11.6 mg/dL, whereas the salivary and serum concentrations of urea varied within the range of 68.04 – 127.59 mg/dL and 60.14 – 168.25 mg/dL respectively within the study population. Significant positive correlations were observed between the salivary and serum concentrations of creatinine (r= 0.985, p=0.01), and urea (r= 0.942, p=0.01), and between salivary concentrations of creatinine and urea (r=0.887, p=0.01). A significant difference was observed in the salivary biomarkers between mild to moderate stages of CKD patients and severe to end-stage CKD patients. No significant association was observed in the salivary markers with the age and sex of the patients. The area under curve values in the receiver operating characteristic analysis was&gt;0.9 (95% CI). These findings revealed high levels of diagnostic accuracy in salivary biomarkers suggesting the potential use of saliva for the assessment of kidney function in CKD patients.