End-stage Disease Research Articles

Prognostic factors and outcomes of chronic limb threatening ischaemia in patients post kidney transplant: a systematic review

BackgroundKidney Transplantation (KT) is widely recognized as the optimal treatment for patients with End Stage Renal Disease (ESRD), improving not only life expectancy but also quality of life. Undetected peripheral arterial disease (PAD) in patients undergoing KT may lead to lower limb ischaemic ulceration and gangrene which is associated with an increased mortality rate. If undiagnosed and untreated this may lead to limb loss and graft failure. This review aims to evaluate the current evidence related to the prognosis of chronic limb-threatening ischemia (CLTI) in patients with a KT.MethodsWe conducted a systematic review of the literature in PubMed and MEDLINE, the Cochrane database of systematic reviews, Elsevier, Web of Science, and CINAHL using relevant search keywords to identify the prognosis and progression of CLTI in patients with a KT. Outcomes of interest were CLTI and progression rate in terms of haemodynamic measurement. This systematic review adhered to the guidelines set forth by the Cochrane Collaboration. The study design, population selection, and follow-up time frame were outlined in accordance with the PRISMA guidelines.ResultsStudies have shown a decline in the ankle-brachial index (ABI) post-KT, indicating vascular deterioration. Surgical interventions and amputations are more likely, particularly on the ipsilateral side of KT. The infrapopliteal artery is the most compromised in this cohort. A low ABI was found to be an independent predictor of graft failure, doubling the risk of mortality post-KT. Quality of evidence was observed to be low primarily due to confounding and selection bias.ConclusionsThe available evidence regarding the prognosis of CLTI in individuals with KT is limited to a small number of studies offering predominantly low-quality evidence and conflicting results pertaining to PAD and its progression into CLTI. Further research is required on CLTI prognosis and progression among KT recipients.

Prevalence and pattern of Mineral Bone Disorders in patients with end-stage renal disease and the impact of diabetic status and type of phosphate binders on these disorders

Prevalence and pattern of Mineral Bone Disorders in patients with end-stage renal disease and the impact of diabetic status and type of phosphate binders on these disorders

Fluid Overload Modifies Hemodynamic Impact of CRRT: Evidence of a Covert Cardiorenal Syndrome?

Fluid overload (FO) in critically ill children correlates with higher morbidity and mortality rates. Continuous renal replacement therapy (CRRT) is commonly employed to manage FO. In adults, both FO and CRRT adversely affect myocardial function. It remains unclear if children experience similar cardiovascular effects. Observational single-center study on children (<18 years) receiving CRRT at Texas Children's Hospital from 11/2019 to 3/2021. Excluded were those with end-stage renal disease, pacemakers, extracorporeal membrane oxygenation, ventricular assist devices, apheresis, or without an arterial line. Electrocardiometry (ICON® Osypka Medical GmbH (Berlin, Germany)) which is non-invasive and utilizes bioimpedance, was applied to obtain hemodynamic data over the first 48 hours of CRRT. Our aim was to identify how FO >15% affects hemodynamics in children receiving CRRT. Seventeen children, median age 43 months (IQR 12-124), were included. The median FO at CRRT initiation was 14.4% (2.4%-25.6%), with 9 (53%) patients having FO >15%. Differences were noted in systemic vascular resistance index (1277 [IQR 1088-1666] vs. 1030 [IQR 868-1181] dyne*s/m2/cm5, P < 0.01), and cardiac index (3.90 [IQR 3.23-4.75] vs. 5.68 [IQR 4.65-6.32] L/min/m2, P < 0.01), with no differences in heart rate or mean arterial pressure between children with and without FO. FO affects the hemodynamic profile of children on CRRT, with those having FO >15% showing higher SVRI and lower CI, despite HR and MAP remaining unchanged. Our study illustrates the feasibility and utility of electrocardiometry in these patients, suggesting future research employ this technology to further explore the hemodynamic effects of dialysis in children.

Sex differences in mortality among patients with lupus nephritis

ObjectiveTo evaluate the prognostic importance of sex in lupus nephritis (LN).MethodsA retrospective cohort of 1048 biopsy-confirmed LN patients, diagnosed between January 1, 1996, and December 31, 2018, was analyzed. Demographics, clinical characteristics, laboratory findings, and renal pathology were assessed. The primary outcome was mortality, and the secondary outcomes included doubling of serum creatinine and end-stage renal disease (ESRD). Sex-associated risks were evaluated using Cox regression models.ResultsAmong the1048 patients, 178 (17%) were male and 870 (83%) were female. Male patients exhibited more aggressive features: higher blood pressure, earlier disease onset, and elevated levels of serum creatinine (Scr), uric acid, blood urea nitrogen. Intriguingly, male patients also displayed more severe histopathological alterations, such as more total crescents, cellular crescents formations, higher level of glomerular leukocyte infiltration and Activity Index (AI), even when overall renal pathology was comparable between sexes. During a median follow-up of 112 months, mortality was registered in 141 patients (15.3%). Mortality rates were conspicuously higher in males (24.2% males vs. 13.4% females, p = 0.0029). Secondary outcomes did not show significant sex differences. Cox regression analysis highlighted male, age of renal biopsy, eGFR, and Chronicity Index (CI) as independent risk factors for survival in LN patients. Notably, infections emerged as the leading cause of mortality among LN patients, with a significant higher rate in male patients.ConclusionIn our cohort with LN, there was a higher rate of all-cause mortality and proportion of infection-related death in male. Recognizing and further exploring these sex disparities is crucial for optimized LN patients care.Graphical

Tipping Point: Pathogenic Stress and the Biopolitics of Euthanasia.

Hopelessness and demoralization following a terminal diagnosis can affect the capacity for self-governance. Such dispositions can increase the allostatic load-the cumulative burden of stress and anxiety-resulting in a neurophysiologic decline that can impair autonomy and influence the desire to end one's life deliberately. An allostatic overload is characterized by the inability to autoregulate stress and is associated with pathological changes to the hypothalamic-pituitary-adrenal axis and hippocampus. These changes raise concerns about the reliability of concepts of autonomy in extremis, potentially undermining arguments that are used to justify voluntary euthanasia and medically assisted death. Studies have associated depression and hopelessness with suicidal ideation in the general population. However, fewer studies have examined how patients without a history of depression or suicidal ideation may suddenly contemplate the act when facing a terminal prognosis. This paper will argue that an allostatic overload can help explain how the spectrum of physical and psychological comorbidities associated with the onset of a terminal illness can influence a decision to hasten death. Data show that patients with a terminal disease wishing to hasten death typically exhibit lower rates of clinical depression, higher rates of demoralization, and a greater likelihood of rational suicide. These differences indicate that suicidal ideation in the terminal disease patient population is different. Changes in autonomous decision-making secondary to pathological alterations in the brain may offer an explanation. Such changes have been shown to dysregulate executive control functions, specifically intentionality and voluntariness. Clinical evidence also indicates that spirituality and hopefulness can help manage the allostatic load during the palliative stages of a disease so that patients can better process end-of-life decisions. Based on these data, this paper will further argue that jurisdictions offering euthanasia are morally compelled to make mental and spiritual counseling available to patients seeking this course of action.

Quality of life among patients with end-stage renal disease undergoing haemodialysis in Africa: a systematic review

ABSTRACT Chronic kidney disease affects every aspect of patients’ lives, particularly burdening those in 44low- and middle-income countries. This systematic review aims to explore the quality of life of haemodialysis patients in Africa. Following the PRISMA guidelines, inclusion and exclusion criteria were pre-established for this systematic review, leading to the selection of eight articles on life quality of haemodialysis patients in Africa. This review reveals, on the one hand, that studies carried out in Africa on the quality of life of haemodialysis patients are rare and, on the other hand, that the different domain scores of the Kidney Disease Quality of Life (KDQOL) questionnaire show a deterioration in the quality of life of haemodialysis patients in Africa. According to the results of this review, African healthcare systems need to pay more attention to haemodialysis patients, especially in countries where resources are limited.

Oral health and chronic kidney disease: Findings from a descriptive survey in Lagos, Nigeria.

Background: Chronic kidney disease (CKD) is a global public health problem, characterized by a progressive and irreversible decline in renal functions, and affecting up to 22.3% of Nigerians. Oral diseases are increasingly recognized to have a bidirectional relationship with CKD, contributing to systemic inflammation, infections, protein-energy wasting, and atherosclerotic complications. Given this interconnectedness, we aimed to explore the relationship between CKD and oral conditions among LASUTH patients to better understand and address these co-occurring health issues. Methods: This descriptive observational study was conducted in the nephrology unit of LASUTH. Patients aged &gt;20 years with a diagnosis of CKD were enlisted and a validated questionnaire with the modified WHO oral health status proforma was utilized to record clinical data: Estimated Glomerular Filtration Rate (EGFR), End-Stage Renal Disease (ESRD), Creatinine and Urinalysis from medical records and oral examination findings, Oral Hygiene Index-Simplified (OHI-S), Gingival Index (GI), Community Periodontal Index of Treatment needs (CPITN), oral malodour, and Oral lesions. Multivariate logistic regression analysis was conducted with adjustments for covariates like age, alcohol use, and BMI to determine the association between oral diseases and CKD. The significance level (p) was set at 0.05, with a confidence interval (CI) of 95%. Results: A total of 200 patients at different stages of CKD were included. The age range was 22–83 years. The majority were aged 31-60 years (mean age 55.22 ± 14.35 years); 69% were males; 7% were current smokers while 12% currently drank alcohol; 27% had eGFR&lt; 15 mL/min/1.73m2 (ESRD); 27% had Creatinine values &gt;1.3mg/dl; prevalence of Gingivitis was 72%; periodontitis was 14% (CPI score ≥3: Pocket depth of ≥4 mm); and poor OHI was 22%. The commonest oral lesions were white lesions 2%, candidiasis 4.5%, hyperpigmentation 22%, oral ulcers 5%, hemorrhagic lesions 12.5%, and Oral malodor 74.5%. Multiple logistic regression analysis revealed significantly increased odds of ESRD among uneducated respondents (OR 1.194; CI: 0.832-1.713); those &gt;60years (OR: 1.129; CI:0.436-2.923); current alcohol drinkers (OR:1.125; CI: 0.281-4.409); and smokers (OR:2.328; CI: 0.27-20.289). The odds of low stimulated saliva flow rate (OR: 1.181; CI:0.768-4.512), oral malodor (OR:1.093; CI: 0.763-1.565), and periodontal disease (OR: 1.242; CI: 0.698-2.209) were also significantly higher among those with ESRD. Conclusion: Individuals with CKD and ESRD may have a higher prevalence of oral diseases and conditions. There were significantly increased odds of ESRD among uneducated respondents, those over 60, current alcohol consumers, and smokers. Additionally, the odds of low stimulated saliva flow rate, oral malodor, and periodontal disease was also significantly higher among those with ESRD. This relationship may also be bidirectional, highlighting the need for appropriate oral self-care and regular dental-care utilization in patients with renal disease. The findings underscore the need for integrated healthcare approaches that consider both oral and renal health, providing a foundation for further research and targeted interventions.

Nonstandardized High-Intensity Dialysis Dose Improves Survival in Patients With End-Stage Renal Disease

Nonstandardized High-Intensity Dialysis Dose Improves Survival in Patients With End-Stage Renal Disease

Clinical manifestations, diagnosis and treatment of hereditary fibrinogen Aα-chain renal amyloidosis: one case report and systematic review.

We reported a confirmed case of Fibrinogen Aa-chain (AFib) amyloidosis and conducted systematic review of the genetic and protein mutation types, clinical manifestations, diagnostic methods and treatment for patients with this disease worldwide. We reported a case of AFib amyloidosis. Meanwhile, a systematic search was performed using defined terms and updated up to November 2023 in the Wanfang, China National Knowledge Infrastructure, VIP, PubMed, and Web of Science databases to identify reported cases of AFib renal amyloidosis worldwide, according to PRISMA guidelines. A 46-year-old male patient was admitted for more than half a month because of oedematous lower limbs. Renal tissue mass spectrometry suggested an AFib type. Gene detection demonstrated that the patient carried the c.1673del (p.Lys558Argfs*10) locus heterozygous mutation of Fibrinogen Aα-chain gene (FGA). The patient was treated with haemodialysis because of uncontrollable hypertension. This systematic review comprised 46 cases. We found the onset age to be lower in women than in men (P < 0.05). All patients showed incipient symptoms including proteinuria; 10 (21.7%) patients progressed to end-stage renal disease (ESRD) or received renal replacement therapy (including dialysis and kidney transplantation) within 1year; 18 (39.1%) patients progressed to ESRD or received renal replacement therapy within 1-5years, and 4 (8.7%) patients did not progress to ESRD or received renal replacement therapy within 5years. AFib amyloidosis progresses rapidly. The diagnosis of this disease is primarily based on renal biopsy, mass spectrometry, and molecular gene detection. Reducing proteinuria is the main method of treating this disease. CRD42024516146.

Recipient selection for lung transplantation: perspective in decision-making.

To determine the conditions that prevented transplant in patients referred to our center due to end-stage lung disease. Descriptive study. Department of lung transplant clinic, Koşuyolu High Specialization Education and Research Hospital, Istanbul, Turkey, from December 2017 to January 2022. Patients with end-stage lung disease referred to our clinic were retrospectively evaluated with regard to reasons for exclusion, diagnosis, and demographic data. The Karnofsky Performance Status scoring scale was used to measure the functional status of the patients. A total of 311 patients were evaluated during the study period. The mean age was 44.2 (range 4-73) years. There were 207 (66.6%) male patients. The most common indications were idiopathic interstitial pneumonia in 104 (33.4%) patients, chronic obstructive pulmonary disease in 53 (17%) patients, bronchiectasis in 49 (15.7%) patients, and cystic fibrosis in 28 (9%) patients. Of the patients, 106 (34%) were not appropriate candidates for a lung transplant. The most common reasons for refusal were preventable situations such as activity limitation and poor performance in 53 (50%) patients, weight in 49 (46.2%) patients, and smoking in 10 (9.4%) patients. Impaired performance status was the most common cause of lung transplant exclusion. Weight and smoking were preventable causes of exclusion. Implementing pulmonary rehabilitation in very few patients was the most important handicap. It is believed that providing optimal treatment with a multidisciplinary approach and timely referral to transplant centers will significantly reduce the reasons for exclusion. Key message What is already known on this topic? Referring lung transplant candidates to clinics at the earliest stage is essential for assessing their condition and exploring treatment options. What this study adds? Factors like smoking, obesity, and muscle loss can hinder the transplantation process; thus, timely interventions are crucial. The primary reason for excluding candidates from lung transplantation is the decline in performance status. How this study might affect research, practice or policy? Programs focused on smoking cessation, weight management, and muscle strengthening can play a vital role in enhancing patients' health before transplantation. It is imperative to expand and enhance the accessibility of pulmonary rehabilitation programs.

Scaffolding patient agency: Conceptualising readers' cognitive work in the comic gutter.

A life-limiting illness can erode an individual's positive sense of self. Storytelling can help counteract this, through scaffolding patients' agency and supporting them in acting to change something which matters to them. This article explains how visual stories - comics - are used within the PATCHATT intervention to support the redevelopment of a person's agential self. Through the provision of a conceptual map, this article explores the gutter as a liminal space, arguing for the importance of the deep reader engagement which takes place there. It uses Bob's comic, a story used within PATCHATT, to explore how reflexivity and imagination work together within the liminal space of the gutter to stimulate and enhance palliative care patients' agential change leadership. It concludes by considering the implications of the argument put forward for palliative care practice.

Perioperative and Long-Term Outcomes After Combined Liver and Kidney Transplantation: A Single-Center Experience.

Combined liver-kidney transplantation (CLKT) has evolved as a therapeutic option for patients with concurrent end-stage liver and renal diseases. This study evaluates the perioperative and long-term outcomes of CLKT at a single center in Slovenia, highlighting the challenges and successes of simultaneous organ transplantation. We retrospectively analyzed all patients undergoing simultaneous CLKT at the University Medical Centre Ljubljana from April 2014 to June 2023. Data on demographics, cause of liver and kidney disease, operative details, postoperative complications, patient and graft survival, and follow-up were collected and analyzed. Five patients aged 27 to 60 years underwent CLKT within the study period. All transplants involved deceased donors with whole-liver grafts. Indications for CLKT were polycystic liver disease (n = 3), Caroli's disease (n = 1), and alcoholic cirrhosis (n = 1). The mean follow-up duration was 45.2 months, with a 100% survival rate. The incidence of surgical and postoperative complications was low. This pioneering series of simultaneous CLKTs in Slovenia demonstrates the feasibility and effectiveness of the procedure in smaller transplant centers. Despite challenges, including T cell-mediated kidney rejection and surgical complications, the study emphasizes the importance of comprehensive postoperative care and management in optimizing outcomes for CLKT recipients.

Precise Acetabular Prosthesis Positioning Using a Novel Robot-Assisted Total Hip Arthroplasty System: A Multicenter, Randomized Controlled Trial.

Total hip arthroplasty (THA) is currently one of the most effective treatment methods for end-stage hip joint disease, and its long-term effectiveness largely depends on the accurate placement of the acetabular prosthesis. In conventional surgery, the placement of the acetabular prosthesis mainly relies on the surgeon's clinical experience and surgical techniques. To further improve the accuracy of prosthesis placement, a new robotic system for THA is designed. The purpose of this study is to verify the effectiveness and safety of THA assisted by this robotic system. A multicenter, prospective, randomized controlled, superiority study design was adopted with statistical methods of t test and Chi-squared test. Participants undergoing primary THA have been enrolled in three centers of joint surgery in China since July 17, 2023. Robotic THA was operated in the experimental group, and conventional instruments were used in the control group. The primary outcome is the proportion of anteversion and inclination angles in the safe zone. The secondary outcomes include operation time, WOMAC score, Harris score, SF-36 health questionnaire, dislocation rate of hip joint, and rates of adverse events and serious adverse events. A total of 138 patients were included in this study. The proportion of both anteversion and inclination angles in the safe zone was 92.2% in the experimental group and 50.8% in the control group, with significant difference (p < 0.01). The average operation time in the experimental group and control group was 116.4 and 80.5 min respectively, with significant difference (p < 0.01). There was no significant difference in WOMAC score, Harris score, and SF-36 between the two groups (6 ± 2) weeks after operation (p > 0.05). The dislocation rate of hip joint in the experimental group and control group were 3.0% and 1.5%, respectively, without significant difference (p > 0.05). The rate of adverse events and severe adverse events in the experimental group and control group also showed no significant difference (p > 0.05). No adverse events or serious adverse events were judged to be "definitely related" to the experimental instruments. Robotic THA could prolong the operation time within an acceptable range, but more precise acetabular prosthesis positioning could be obtained when compared with conventional surgery. Besides, no significant difference was found in function scores, dislocation rate or other adverse events, which indicates that this new robot system shows both good effectiveness and safety in THA. Clinical Trials: NCT05947734.

Structural equation modeling analysis of factors influencing decisional conflict between dialysis modality among end-stage kidney disease patients in Wuhan

ObjectivesTo explore the influencing factors and relationships associated with decisional conflict of dialysis modality in End-stage kidney disease (ESKD) patients.MethodsThis study was a survey-based cross-sectional investigation conducted on 150 ESKD patients in a third-class hospital in Wuhan. The general information questionnaire, decisional conflict scale, Montreal cognitive assessment, frail scale, perceived social support scale, and brief health literacy screen were used for investigation. SPSS 25.0 was used to compare the differences between the decisional and non-decisional conflict groups, and AMOS 23.0 was used to construct a structural equation model to explore the influencing factors.ResultsThe incidence of decisional conflict in 150 ESKD patients was 33.3% (50/150). Binary logistic regression analysis showed that the independent risk factors for decisional conflict of dialysis modality in ESKD patients included monthly household income (OR = 0.184), cognitive function (OR = 7.0), social support (OR = 0.891), health literacy (OR = 0.608), the level of eGFR (OR = 1.488), and the level of cTnI (OR = 9.558). The constructed path analysis model had a good fit (x2/df = 1.499, GFI = 0.957, AGFI = 0.911, NFI = 0.906, CFI = 0.967, RMSEA = 0.055). The path analysis showed that health literacy (0.577) had the greatest impact on the decisional conflict, with a direct effect of 0.480 and an indirect effect of 0.097 through cognitive function and monthly household income. Next was social support, with an effect value of 0.434.ConclusionsIn clinical practice, it is important to enhance the health literacy of patients and their families and to provide advanced education on dialysis plans. Additionally, in managing and planning chronic kidney disease progression and dialysis, it is recommended to regularly and systematically assess cognitive function, particularly before the patient’s cognitive impairment worsens or the severity of the disease progresses. Advanced care planning can be established through collaboration between healthcare professionals and patients to ensure appropriate decision-making and management.Implications for the profession and patient careThis paper finds that the factors that influence and relate to dialysis methods in end-stage renal disease patients help nurses exercise autonomy better, assist patients in reducing their decisional conflict, and improve clinical outcomes.Patient or public contributionPatients received a relevant questionnaire survey, and caregivers assisted in conducting the study.

Exploring innovative approaches to fundraising for palliative care

Palliative care is a holistic approach aimed at improving the quality of life for those facing life-limiting illnesses and their families. Palliative care services often face financial constraints that restrict their ability to reach all those in need. There are difficulties accessing traditional funding mechanisms; therefore, innovative fundraising strategies are required to sustain and expand palliative care initiatives. In this paper, diverse fundraising approaches for palliative care are described, based on group discussions and collective brainstorming sessions by clinicians undergoing a Fellowship in Palliative Care. Fundraising approaches that were deemed innovative, yet feasible to apply in each locality, were shortlisted and described, with their strengths and challenges outlined in detail. These approaches include art and photography exhibitions, &amp;ldquo;piggy-bank&amp;rdquo; projects, community-based fundraising, charity shops, lottery and lucky draws, shuttle bus services, grants from international organizations and collaborative networks, the use of tap-on technology, festive events, and restaurant partnerships. It is hoped that through these innovative approaches, collaborative efforts, strategic planning, and resource mobilization, it would be possible to generate funds to develop and provide palliative care services for those in need to fulfill a fundamental human right.

Early intervention in viper bites: A potential strategy to mitigate acute kidney injury and its long-term consequences.

Dear Editor, By this letter we intend to highlight the close association between snake bites and acute kidney injury, as the causative snakes are common natives of Tropical regions and a common cause of death because of being poorly managed. Snake bites are a significant cause of acute kidney injury in tropical regions, particularly in Eastern Pakistan, where Russell's viper, a common cause, is prevalent. The farmlands of Sindh and Balochistan are predisposed to snake bites due to their favorable weather and vast fields. A 2020 study found 454 snakebite cases in Southern Sindh, with 6 deaths. The most common mechanisms are venom-mediated consumption coagulopathy (VMCC) and endothelial damage, leading to systemic bleeding diathesis and decreased perfusion of end organs. Long-term effects of snake bites include worsening renal conditions and progression towards end-stage renal disease. Eastern Pakistan commonly harbors Russell’s viper- a frequent cause of snakebite-associated mortality, which belongs to the Viperidae family and is famously known to produce vasculotoxic venom. (1) The farmlands of Sindh and Balochistan are predisposed to snake bites as the weather of these regions and the vast fields allow the vipers to flourish and thrive well. A study conducted in 2020, representing the population of Southern Sindh, demonstrated a total of 454 cases of snakebite in a span of 1 year, out of which 6 victims died. (2) Since the prevalence of vipers is common in the district of Sindh, the deaths could be attributable to the hemorrhagic manifestations of vipers' bites. The most significant mechanisms underlying viper bite presentations are venom-mediated consumption coagulopathy (VMCC) and endothelial damage resulting in systemic bleeding diathesis, which together contribute to decreased perfusion of end organs like the heart, kidneys, brain, or gastrointestinal system. (3) VMCC is a major contributor to acute kidney injury (AKI), a common outcome of vasculotoxic snake bites, along with enzymatic dissolution of the glomerular basement membrane (BM) by the venom metalloproteinases. (4) The hemorrhagic deterioration of the vessels leads to ischemic nephropathy, and the impaired BM allows proteinuria, hemoglobinuria, and increased creatinine, often predisposing the victim to timely dialysis. A study concluded that individuals with co-morbidities are more susceptible to developing long-term effects of snake bites like worsening renal conditions such as new-onset hypertension, dialysis dependence, and end-stage renal disease. (5) ---Continue

Gender-associated features in diabetic kidney disease

Diabetic kidney disease (DKD) is the leading cause of end-stage renal failure. Evidence indicates gender differences in the progression of this disease. This study aimed to determine gender differences in prevalence and identify gender-associated risk factors contributing to the development of diabetic kidney disease in individuals with type 2 diabetes mellitus (T2DM). The cross-sectional study included 132 patients with T2DM ranging in age from 50 to 65 years. Subjects were stratified by sex (80 women and 52 men). Gender differences have been studied in relation to the incidence and prevalence of DKD, their phenotypes and clinical manifestations, and several risk factors that have different effects on both sexes. The outcome of clinical kidney function assessment showed that 70% subjects were diagnosed with DKD (71% of women and 67% of men). The study indicated an association between the duration of T2DM and urinary albumin levels, as well as between arterial hypertension and triglyceride levels, which are independent risk factors for DKD development. Notably, older women with T2DM have a higher prevalence of DKD than older men. The albuminuric component of DKD was more frequently observed in men. Additionally, men were more likely to have adverse risk factors, including dyslipidemia, lower high-density lipoprotein cholesterol, and glomerular filtration rate, which are factors involved in the mechanisms of DKD. In summary, the results indicate that: 1) women with type 2 diabetes mellitus are at a higher risk of developing a normoalbuminuric phenotype of diabetic kidney disease, while men are at a higher risk of developing an albuminuric phenotype of diabetic kidney disease leading to renal failure and end-stage renal disease; 2) gender differences are most noticeable among older adults and may have significant implications for the development of more effective diagnostic and treatment methods for diabetic kidney disease, tailored to individual needs.

Exploring the role of ketogenic diet in ADPKD treatment: A promising avenue.

Dear Editor, This letter intends to highlight the importance of the keto diet in the treatment and slowing the progression of Autosomal Dominant Polycystic Kidney Disease (ADPKD). We aim to increase awareness about this newly advertised nutrition plan for ADPKD patients. Autosomal Dominant Polycystic Kidney Disease (ADPKD) is a disease that continuously expands multiple cysts in both kidneys. Clinical symptoms (Flanks pain, haematuria, hypertension) mostly develop in the fourth decade of life and around 50% of almost 12 million worldwide affected people will go into end-stage renal disease (ESRD) in their sixth decade of life.1 In 2015, EMA approved the use of Vasopressin receptor antagonists, i.e., tolvaptan, for the treatment of ADPKD in adults with CKD stages 1-3 and with rapidly progressive disease.2 However, these drugs are associated with side effects such as transient extracellular volume reduction and continuous symptoms of increased aquaresis, liver toxicity, avoiding pregnancy and breastfeeding and drug interactions.2 Moreover, strict criteria for patient selection such as GFR values, changes in GFR, patient age and cost-effectiveness needed to be fulfilled before commencing this particular therapy.2 The ongoing advancements in medical sciences have recently provided evidence that introducing the keto diet in patients with ADPKD can lead to a decline in the reduction rate of GFR and to a reduced rate of increasing kidney volume.3,4 A small study published in November 2023 compared the effects of the keto diet (KD) with control and water fasting groups.5 KD group surprisingly showed a decrease in height-adjusted total kidney volume by 0.55% and height-adjusted total liver volume by 4.7%.5 The most important observed effect was an increase in eGFR by 5.5% compared to the other groups, which showed a decrease in eGFR.5 Serum levels of Beta Hydroxy Butyrate were used to evaluate the ketosis state.5 The most commonly reported side effect was transiently occurring keto flu. However, one patient developed appendicitis and one patient also had nephrolithiasis.5 This three-month duration study overall shows good outcomes in ADPKD patients. We encourage physicians and the broader community of nephrologists to prioritise and carry out larger-scale randomised controlled trials based on the previously mentioned study using the keto diet in the management of ADPKD patients. This will require not only the aggressive participation of physicians in carrying out the research study but also the active education of the general public about this newly introduced nutrition plan. ---Continue

Significance of intrarenal vascular lesions in Ig A nephropathy prognosis

BackgroundImmunoglobulin A nephropathy (IgAN) is the predominant primary glomerulonephritis globally and remains a subject of active research with a focus on understanding its course and prognosis. Although vascular lesions are associated with IgAN, the current histopathological grading systems do not consider intrarenal vascular lesions when predicting patient prognosis. Therefore, this retrospective study conducted at Kyungpook National University Hospital between October 2016 and December 2021, aimed to elucidate the significance of intrarenal vascular lesions in IgAN by comparing the clinical data of patients with and without such lesions.MethodsData of patients with biopsy-confirmed primary IgAN between October 2016 and June 2021 at Kyungpook National University Hospital (Daegu, South Korea) were collected, and their medical records were reviewed. All slides from these 138 cases were independently pathologically reviewed by two nephropathologists (Y. J. K. and M. S. K.) using light microscope. The vascular lesions included in this study were fibrous intimal thickening, arteriolar wall thickening, and arteriolar hyalinosis. All cases were reviewed according to the Oxford Classification of IgA Nephropathy (2016) and Haas classification.ResultsOf the 138 patients, 88 exhibited at least one intrarenal vascular lesion. Patients with arteriolar wall thickening demonstrated a reduced estimated glomerular filtration rate (eGFR), elevated serum creatinine level and urine protein-to-creatinine ratio, an increased proportion of global glomerulosclerosis, and a higher histologic grade of interstitial fibrosis and tubular atrophy at the time of biopsy.ConclusionArteriolar wall thickening in IgAN are associated with reduced eGFR and global glomerulosclerosis. Moreover, reduced eGFR and global glomerulosclerosis are correlated with the progression to end-stage renal disease. Although the direct correlation between vascular lesions and end-stage renal disease is not entirely clear, a marginally significant association (log-rank test, p = 0.06) was observed with arterial wall thickening. This study suggests the potential importance of vascular lesions in the prognosis of IgAN, encouraging further investigation using larger cohort studies to establish a clearer association.

Insights into the Novel Biomarkers Expressed in Diabetic Nephropathy: Potential Clinical Applications.

Diabetic nephropathy (DN) is increasing worldwide in parallel with type 2 diabetes mellitus. Identifying diagnostic biomarkers for DN at an early stage is crucial due to the considerable societal and economic burden associated with diabetes mellitus (DM) and its risk factors. In the past, early indicators of microvascular problems, such as microalbuminuria (MA), have been used to predict the possibility of developing advanced chronic kidney disease (CKD). However, because of the incapacity of MA to appropriately estimate DN, particularly, non-albuminuric DN, additional markers have been suggested for recognizing the early renal abnormalities and structural lesions, even before MA. This study aims to assess the existing and future biomarkers used to diagnose or predict early DN. This review provides comprehensive insight into diagnostic approaches for early detection of CKD, addressing the following areas: (i) markers of glomerular damage, (ii) markers of tubular damage, (iii) oxidative stress biomarkers, (iv) inflammatory biomarkers and (v) futuristic biomarkers such as micro-ribonucleic acids (miRNAs), proteomics, metabolomics and genomics and gut microbiota. Early detection of DN may lead to improvement in clinical management and quality of life, emphasizing the importance of identifying a specific and reliable predictive biomarker. Emerging serum and urinary biomarkers offer promise for early DN diagnosis, potentially reducing prevalence and preventing progression to end-stage renal disease (ESRD). Further advancements in miRNAs, proteomics, metabolomics genomics and gut microbiota offer prospects for even earlier and more precise DN diagnosis.