Treatment For End-stage Renal Disease Research Articles

Transplantation of decellularized porcine kidney grafts repopulated with primary human cells demonstrates filtration function in pigs

BackgroundEnd-stage renal disease is a growing global health issue, disproportionately impacting low- and middle-income countries. While kidney transplantation remains the best treatment for end-stage renal disease, access to this treatment modality is limited by chronic donor organ shortages. To address this critical need, we are developing transplantable bioengineered kidney grafts.MethodsPodocyte differentiation was achieved in adherent monoculture through Wnt and TGF-β inhibition with IWR-1 and SB431542, respectively. Podocytes along with endothelial cells were then used to recapitulate glomeruli within decellularized porcine kidney scaffolds to generate bioengineered kidneys grafts. These bioengineered kidney grafts were functionally assessed via normothermic perfusion which compared kidney grafts recellularized with only endothelial cells as a control to bi-culture kidney grafts comprised of endothelial cells and podocytes. Heterotopic implantation further tested bi-culture kidney graft function over 3 successive implant sessions with 1–2 grafts per session.ResultsWe demonstrate the ability to source primary human podocytes at scale. Decellularized porcine kidney grafts repopulated with podocytes and endothelial cells exhibit native glomerular structure and display blood filtration capabilities during normothermic perfusion testing. Extending these findings to a clinically relevant model, bioengineered kidneys produce urine with indices of filtration when heterotopically implanted in pigs.ConclusionsOur results showcase a human-scale, transplantable bioengineered kidney capable of performing requisite filtration function. This study reinforces the possibility for the bioengineering of transplantable human kidneys, which could someday provide increased and more equitable access to kidney grafts for the treatment of end-stage renal disease.

Analysis of research trends and hotspots in the primary treatment of end-stage renal disease.

There is a lack of bibliometric analysis in research regarding primary therapy for end-stage renal disease (ESRD). This study aims to analyze the literature on ESRD therapy published over the past decade to understand current conditions and study trends for future research. Data were collected from the Web of Science Core Collection (WOSCC) database. Tools like CiteSpace 6.2.R4, 6.1.R6, VOSviewer 1.6.18, and Bibliometrix R4.1.1 were used to reveal research trends and hotspots. In addition, KEGG/GO analysis examined the probable functionalities of genes implicated in ESRD therapy to guide future research. The bibliometric analysis presented in this paper indicates that the number of publications has remained relatively stable since 2013. The level of international collaboration is notably high, with the United States serving as the dominant research hub in this field. The University of California system is the most prolific institution, and Transplantation Proceedings is the most frequently published journal in this area. Kalantar-Zadeh, Kamyar is recognized as the most published and cited author. Keywords such as "secondary hyperparathyroidism," "uremic toxins," "cyclosporine," "mycophenolate mofetil," and "biomarkers" have seen a surge in interest recently, reflecting emerging research trends. Furthermore, inflammation and stem cell research have been identified as promising new therapeutic avenues for ESRD. This study identifies major areas, frontiers, and trends in research on primary treatments for ESRD, providing significant implications for future research.

Renal transplantation in Alport syndrome.

Kidney transplantation is recognized as an effective treatment for end-stage renal disease in Alport syndrome, demonstrating outcomes comparable to or even superior to those in other causes of renal failure. When considering living related donor kidney transplantation for Alport syndrome patients, it is crucial to consider genetic factors during the donor selection process. In addition to a comprehensive health check, genetic testing is strongly recommended for potential donors at risk of carrying mutations in COL4A3-COL4A5 before undergoing kidney transplantation. Individuals carrying these mutations face an inherent risk of kidney disease and due to the possibility of further deterioration in renal function after nephrectomy for transplantation, they are not suitable as priority donors. Posttransplant anti-glomerular basement membrane nephritis is rare but can lead to graft loss, especially in males with X-linked Alport syndrome.

Molecular mechanisms of ferroptosis in renal ischemia-reperfusion injury Investigated via bioinformatics analysis and animal experiments.

Kidney transplantation is a pivotal treatment for end-stage renal disease. However, renal ischemia-reperfusion injury (IRI) during surgery significantly impacts graft function. Despite unclear molecular mechanisms, no specific therapies or preventative measures are available. Gene expression profiles from renal biopsies before and after IRI were downloaded from public databases. Differentially expressed genes were identified using the Wilcoxon rank-sum test and weighted gene co-expression network analysis. Ferroptosis-associated genes were screened using the FerrDb database. The genes with the highest connectivity were identified via the protein-protein interaction (PPI) network and upstream regulatory miRNAs were found through the gene-miRNA network. A mouse renal IRI model was constructed for transcriptome sequencing and quantitative real-time polymerase chain reaction (qRT-PCR) validation to elucidate the relationship between key ferroptosis genes and regulatory miRNAs in renal IRI. Differential analysis identified 15 ferroptosis-associated genes (TNFAIP3, IL6, KLF2, EGR1, JUN, ZFP36, GDF15, CDKN1A, HSPB1, BRD2, PDK4, DUSP1, SLC2A3, DDIT3, and CXCL2) involved in renal IRI regulation. In animal experiments, ferroptosis-related genes were also upregulated in the model group. Enrichment analysis and hematoxylin-eosin pathological staining suggested these genes are primarily involved in renal inflammatory responses. PPI network analysis revealed IL6 as the gene with the highest connectivity, and the gene-miRNA network indicated IL6 might be regulated by miR-let-7a. Animal experiments revealed decreased miR-let-7a and increased IL6 levels in the model group, identifying potential therapeutic targets. MiR-let-7a regulates ferroptosis in renal IRI by targeting IL6, highlighting IL6 as a crucial gene in the ferroptosis process of renal IRI.

Peer support groups and care burden in hemodialysis caregivers: a RCT in an Iranian healthcare setting

BackgroundChronic renal failure poses a significant global health challenge, exerting a substantial burden on both patients and their caregivers. Hemodialysis, a common treatment for end-stage renal disease, imposes extensive physical, emotional, and financial pressures on caregivers, often leading to a high care burden. This study uniquely examines the impact of peer support groups on reducing the care burden among caregivers of patients receiving hemodialysis in an Iranian healthcare setting, an aspect that has not been extensively explored before.MethodsA parallel-controlled clinical trial was conducted involving 60 caregivers, divided into intervention and control groups. The intervention group participated in an 8-session peer support program tailored to their identified needs, including coping with stress, social isolation, and financial challenges. The Zarit Care Burden Interview Scale was used to measure care burden before and after the intervention.ResultsThe study revealed statistically significant reductions in care burden, particularly in physical, social, and emotional dimensions, among caregivers in the intervention group compared to the control group. The total care burden score showed a marked decrease, indicating the effectiveness of the peer support intervention. While economic challenges remained a concern, the intervention had a limited impact in this domain.ConclusionThis study demonstrates that peer support groups significantly alleviate the care burden experienced by caregivers of patients receiving hemodialysis, improving their well-being across several dimensions. The findings highlight the importance of integrating peer support strategies into healthcare programs for chronic disease management and underscore the need for supplementary economic support measures to comprehensively address caregivers’ needs. Future research should explore the scalability and long-term sustainability of such interventions and address the unique economic challenges faced by these caregivers.Trial registrationThis study was registered in the Iranian Registry of Clinical Trials (IRCT) under the registration number IRCT20220724055540N1 on 11/08/2022.

Association between salivary microbiota and tacrolimus pharmacokinetic variability in kidney transplant

Kidney transplantation (KT) serves as a highly effective treatment for end-stage renal disease (ESRD). Nonetheless, the administration of tacrolimus, a commonly used immunosuppressant in KT, faces challenges due to the lack of dependable biomarkers for its efficacy and the considerable variability in tacrolimus pharmacokinetics (TacIPV). In this study, 183 saliva samples from 48 KT recipients under tacrolimus therapy, alongside 9 healthy control samples, were subjected to 16S rRNA sequencing. The analysis revealed significant differences in the composition of salivary microbiota among KT recipients, patients with ESRD, and healthy controls. Moreover, trough blood concentrations (C0) of tacrolimus were associated with alterations in microbiota composition. Notably, Capnocytophage consistently exhibited a negative correlation in both group-level and individual trends. Furthermore, distinct taxa were identified that effectively distinguished recipients with varying TacIPV, as demonstrated by a cross-validation random forest model (mean AUC = 0.7560), with Anaerolinea emerging as a prominent contributor to the classifier. These findings suggest that salivary microbiota is closely linked to tacrolimus C0 levels and could aid clinicians in differentiating KT recipients based on TacIPV.

Prolonged Hospital Stays in Continuous Ambulatory Peritoneal Dialysis (CAPD) Patients: The Role of Comorbid Conditions

Background: Continuous ambulatory peritoneal dialysis (CAPD) is a widely used treatment for end-stage renal disease (ESRD), but it is associated with frequent hospitalizations that can significantly impact patients' quality of life and increase healthcare costs. This study aimed to investigate the influence of comorbid conditions on the length of hospital stay (LOS) in CAPD patients. Methods: A retrospective cohort study was conducted on CAPD patients admitted to Dr. Kariadi General Hospital Semarang between January 1st, 2023, and December 31st, 2023. Data on demographics, comorbidities, and LOS were extracted from medical records. The Charlson Comorbidity Index (CCI) was used to assess comorbidity burden. Multivariable linear regression analysis was performed to identify predictors of prolonged LOS, defined as exceeding the median LOS. Results: The study included 52 CAPD patients with a median LOS of 18 days (range: 1-72 days). Patients with comorbidities had a significantly longer LOS compared to those without comorbidities (20.25 ± 12.88 days vs. 12.50 ± 3.63 days, p = 0.045). The presence of comorbidities was significantly associated with prolonged LOS (odds ratio [OR] 2.87, 95% confidence interval [CI] 1.15-7.16, p = 0.023), as were older age (OR 1.05, 95% CI 1.01-1.09, p = 0.012) and peritonitis as the primary reason for hospitalization (OR 3.54, 95% CI 1.38-9.08, p = 0.008). Conclusion: Comorbid conditions are significant contributors to prolonged hospital stays in CAPD patients. These findings underscore the importance of effectively managing comorbidities in this population to optimize healthcare resource utilization and improve patient outcomes.

Defining the Etiology of Renal Allograft Dysfunction Using Banff 2019 Classification: Correlation with Post-Transplant Duration and Creatinine Levels-A Comprehensive Analysis of 200 Renal Biopsies at a Tertiary Care Medical Center Hospital.

Chronic kidney disease is a growing global health issue, contributing significantly to morbidity and mortality. The incidence of end-stage renal disease (ESRD) is approximately 100 per million population. Renal transplantation remains the cornerstone treatment for ESRD, with a projected 20-year survival rate of 60%. We aim to define the etiology of renal allograft dysfunction using the Banff 2019 classification by analyzing 200 renal allograft biopsies in correlation with creatinine levels across post-transplant time frames. 200 renal allograft biopsies are analyzed using the recent Banff 2019 classification with creatinine levels and post-transplant duration correlation. The study included 150 (75%) male patients and 50 (25%) female patients, with the majority 78 (39%) representing the age group of 16-30 years. 36 (18%) biopsies were within 3-month post-transplant, while 92 (46%) were 2-year post-transplant. According to the Banff 2019 classification, 92 (46.0%) transplant rejection biopsies were identified, with most 54 (27%) exhibiting antibody-mediated rejection (Category 2), including 40 (20%) active acute antibody-mediated rejection (ABMR) and 14 (7.0%) chronic active ABMR. T-cell-mediated rejection (TCMR; Category 4) represented 12 (6%) biopsies, including 10 (5%) acute TCMR and 2 (1%) chronic active TCMR. Category 5, the miscellaneous group, represented 100 (50%) biopsies, out of which 32 (16%) exhibited calcineurin inhibitor (CNI) toxicity, 38 (19%) acute tubular necrosis, and 8 (4%) thrombotic microangiopathy. A notable variation in the dysfunction distribution across different post-transplant time frames indicated a temporal evolution in the underlying causes of allograft dysfunction. Specific Banff categories showed a robust association with renal dysfunction, potentially contributing to the elevation of creatinine levels and renal function deterioration. Our study highlights the intricate pathophysiology of renal allograft dysfunction. Most biopsies were attributed to ABMR whereas one-third of biopsies exhibited mixed lesions (ABMR and TCMR or ABMR and calcineurin inhibitor toxicity (CNIT)). Additionally, this study suggests that renal allograft rejection remains a significant contributor to graft dysfunction. A complex interplay between histological findings, Banff classification, and renal function is noted. A significant difference in the distribution of dysfunction across post-transplant time frames is noted suggesting a temporal evolution in the etiology of allograft dysfunction. Certain Banff categories demonstrate a stronger association with renal dysfunction that may influence creatinine level increase and renal function deterioration. In correspondence to the recent Banff 2019 guidelines for diagnosing ABMR, we emphasize the role of C4d staining on immunofluorescence or immunohistochemistry in allograft biopsies as imperative for timely diagnosis and immunosuppressant therapy adjustment, ultimately enhancing graft survival. Further research is needed to elucidate the underlying mechanisms driving renal dysfunction in different Banff categories, ultimately informing personalized management strategies for patients with renal allograft dysfunction. In line with the Banff 2019 guidelines for diagnosing ABMR, this study highlights the critical role of C4d staining through immunofluorescence or immunohistochemistry in allograft biopsies for early diagnosis and timely adjustment of immunosuppressive therapy, ultimately improving graft survival.

Outcome of Arteriovenous Fistula Following Renal Transplantation

Background: Renal transplantation is the preferred treatment for end-stage renal disease (ESRD), but the management of arteriovenous fistulas (AVFs) post-transplant remains controversial due to complications like thrombosis.Objective: To determine the outcome of AVFs following renal transplantation, focusing on the incidence and timing of AVF thrombosis.Methods: This ambi-directional cohort study included 155 patients with ESRD who underwent kidney transplantation at the Sindh Institute of Urology and Transplantation, Karachi, in 2021. All included patients had a functional AVF at the time of transplantation. Data were collected from electronic health records, including demographic information, AVF characteristics, and incidence of thrombosis. AVF outcomes were monitored through follow-up assessments until September 2024. Statistical analysis was conducted using SPSS version 25, with significance set at p<0.05.Results: Thrombosis occurred in 71 (45.8%) patients, most frequently within one week (14.8%), within four weeks (21.9%), and within one year (34.2%). Surgical ligation was required in 5 patients (3.22%). No significant associations were found between thrombosis and age, comorbidities, or AVF type (p>0.05).Conclusion: AVF thrombosis is a frequent complication post-transplant, not significantly influenced by patient demographics or AVF type, highlighting the need for continued surveillance.

Peritoneal dialysis promotes microbial-driven biosynthesis pathways of sesquiterpenes and triterpenes compounds in end-stage renal disease patients

The concept of the gut-kidney axis is gaining significant attention due to the close relationship between gut microbiota and kidney disease. Peritoneal dialysis is recognized as a crucial renal replacement therapy for end-stage renal disease (ESRD). The alterations in gut microbiota and related mechanisms after receiving this dialysis method are not fully understood. This study conducted shotgun metagenomic sequencing on fecal samples from 11 end-stage renal disease patients who did not receive dialysis (ESRD_N) and 7 patients who received peritoneal dialysis (ESRD_P). After quality control and correlation analysis of the data, our study is aimed at exploring the impact of peritoneal dialysis on the gut microbiota and health of ESRD patients. Our research findings indicate that the complexity and aggregation characteristics of gut microbiota interactions increase in ESRD_P. In addition, the gut microbiota drives the biosynthesis pathways of sesquiterpenes and triterpenes in ESRD_P patients, which may contribute to blood purification and improve circulation. Therefore, our research will lay the foundation for the prevention and treatment of ESRD.

Podocyte-Specific Expression of the Stress Response Protein REDD1 is Necessary for Diabetes-induced Podocytopenia.

Diabetic nephropathy (DN) is the leading cause of end-stage renal disease and effective treatment modalities that fully address its molecular etiology are lacking. Prior studies support that the stress response protein REDD1 (Regulated in Development and DNA Damage 1) contributes to the development of diabetic complications. This study investigated a potential role for REDD1 expression in podocytes in diabetes-induced podocyte loss and compromised glomerular filtration. Podocyte-specific REDD1 deletion protected against renal injury, as evidenced by reduced albuminuria, glomerular hypertrophy, and mesangial matrix deposition in streptozotocin (STZ)-induced diabetic mice. Podocyte-specific REDD1 expression was required for diabetes-induced reduction in slit diaphragm (SD) proteins podocin and nephrin. Notably, podocyte-specific REDD1 deletion protected against podocytopenia and preserved glomerular basement membrane and foot process architecture in diabetic mice. In the kidneys of diabetic mice and in human podocyte cultures exposed to hyperglycemic conditions, REDD1 was necessary for increased expression of the transient receptor potential canonical 6 (TRPC6) channel. More specifically, REDD1 promoted NF-κB-dependent transcription of TRPC6, intracellular calcium entry, and cytoskeletal remodeling under hyperglycemic conditions. Overall, the findings provide new insight into the role of podocyte-specific REDD1 expression in renal pathology and support the possibility that therapeutics targeting REDD1 in podocytes could be beneficial for DN.

Knowledge and willingness to donate kidney for transplantation among general population in Saudi Arabia

IntroductionKidney transplantation is the preferred treatment for end-stage renal disease (ESRD), offering a superior quality of life and extended survival compared to other renal replacement therapies. As the number of ESRD patients grows, so does the demand for organ transplants. The prevalence of ESRD is anticipated to escalate further due to the rising rates of diabetes mellitus (DM), hypertension (HTN), and obesity. Organ donation, particularly from living donors, remains the main source of transplants in the region, despite the notable underutilization of potential deceased donors’ organs. The objective of this research is to assess the level of knowledge, attitudes, and willingness to donate kidneys among the general population, a pivotal step in addressing the organ shortage crisis.MethodsThis cross-sectional study was conducted in the Aseer region of Saudi Arabia using a previously validated questionnaire. The questionnaire collected demographic data and insights into general attitudes, knowledge, and beliefs about organ donation. Logistic regression was used to identify predictors of knowledge and willingness to donate.ResultsThe study involved 705 participants, predominantly young adults with a high level of education. Awareness of kidney donation was high, and knowledge about donation was broad, especially regarding religious permissibility and awareness of the donor registry. However, only 25% expressed willingness to donate their kidneys, and a 4% were already registered as donors. Furthermore, higher educational level was not associated with higher odds of knowledge or willingness to donate.ConclusionDespite the considerable awareness, actual donor registration rates were low, highlighting the necessity for targeted educational interventions and a deeper understanding of the cultural and socioeconomic barriers that exist.

Modified yoga program for Chronic Kidney Disease (CKD) patients undergoing hemodialysis: Study protocol for a randomized controlled trial

Background and objectivesHemodialysis is a life-saving treatment for end-stage renal disease (ESRD). Dialysis patients have a variety of physical and psychological side effects that significantly lower their quality of life. Yoga demonstrated to significantly improve Chronic Kidney Disease (CKD) patients' physical and psychological symptoms. The current study evaluates the impact of Yoga on the renal, cardiac, and psychological health of hemodialysis-dependent individuals with CKD. Methods and analysisEighty ESRD patients with CKD stage-5 undergoing dialysis will be recruited for the study. 40 people in each group will be randomly assigned to the yoga and wait-list control groups. A modified sixty-minute yoga program will be given to the yoga group as an intervention in addition to the standard treatments (medication and hemodialysis). The wait-list control group's standard treatments will continue. Data will be collected at baseline, the end of the first month, the third month, and six months. The estimated Glomerular Filtration Rate (eGFR) is the primary variable. Secondary variables include renal function tests, hemoglobin, C-reactive protein, and subjective variables obtained through questionnaires (pain, depression, anxiety, fatigue, symptom score, sleep quality, and Quality of Life). Data will be analyzed with appropriate statistical tests after normality checks. The current study results could underscore the need for a patient-centered, holistic approach in hospital care that takes into account individual health dimensions. Ethics and disseminationThe study is approved by the Institutional Ethics Committee of S-VYASA Deemed to be University. Voluntary participation and a written consent form will be obtained prior to the inclusion of participants. The findings of the study will be disseminated through research articles and conferences. Trial registration numberCTRI/2021/11/038244 at Clinical Trial Registry of India.

THE ANALYSIS STUDY OF RENAL TRANSPLANTATION BENEFITS PATIENTS WITH END-STAGE RENAL DISEASE BY IMPROVING ERECTILE FUNCTION: A COMPREHENSIVE SYSTEMATIC REVIEW

Background: Renal transplantation is a highly effective treatment for end-stage renal disease (ESRD), addressing the impact of erectile dysfunction on quality of life. Erectile dysfunction, characterized by the inability to achieve and sustain an erection for good sexual activity, affects the physical and psychological well-being of individuals and their partners. However, research on the impact of renal transplantation on erectile dysfunction has yielded conflicting results. Understanding the beneficial impacts of renal transplantation on erectile dysfunction could potentially lead to more successful outcomes. Methods: Adhering to the PRISMA 2020 standards, this systematic investigation sought to examine complete English literature texts published from 2004 until 2024. Only editorials and review articles that had a Digital Object Identifier (DOI) and were published in the same magazine as the submission were considered for acceptance. We utilized many sources, such as ScienceDirect, PubMed, and SagePub, to acquire the literature. Result: The study examined over 40 papers sourced from reliable venues like Science Direct, SagePub, and PubMed. After selecting eight papers for further scrutiny, a comprehensive analysis of the complete corpus of literature was conducted. Conclusion: Renal transplantation has shown significant improvement in erectile function in patients with end-stage renal disease (ESRD), with a lower prevalence of erectile dysfunction and higher function scores. Factors such as pretransplantation IIEF-5 score, age, and anastomosis to the common iliac artery have significant associations with improved erectile function. However, the exact mechanism behind this effect remains unclear.

Recent advances in fecal microbiota transplantation for Clostridium difficile infection-associated diarrhea after kidney transplantation

Kidney transplantation is considered to be the best treatment for end-stage renal disease. To reduce the incidence of rejection and improve the survival of recipients and kidney grafts, kidney transplant recipients must take immunosuppressive agents, and some patients require them for the rest of their lifetime. These treatment regimens can result in susceptibility to opportunistic infections and disrupt the intestinal microbiota, thereby leading to diarrhea, which causes water and electrolyte metabolism disorder, nutrient malabsorption, and instability in the blood concentrations of the immunosuppressive agents. Fluctuating blood concentration levels of these agents necessitate frequent laboratory monitoring and dose adjustments to avoid poor adherence and increase the risk of graft rejection. Furthermore, severe diarrhea can cause kidney transplant failure or death. Clostridium difficile infection (CDI) is the leading cause of diarrhea after renal transplantation. Traditional antibiotics can kill C. difficile; however, spores can remain in the gut. Disruption of the intestinal flora caused by antibiotherapy increases the risk of developing recurrent CDI (rCDI). Fecal microbiota transplantation (FMT) has been proven to be a safe and effective treatment for CDI and is recommended for rCDI owing to its convenient material acquisition method, high efficacy, and low incidence of adverse reactions. This review summarizes the recent progress in FMT for CDI-associated diarrhea after renal transplantation.

Protective effect of Cyclo(His-Pro) on peritoneal fibrosis through regulation of HDAC3 expression.

Peritoneal dialysis is a common treatment for end-stage renal disease, but complications often force its discontinuation. Preventive treatments for peritoneal inflammation and fibrosis are currently lacking. Cyclo(His-Pro) (CHP), a naturally occurring cyclic dipeptide, has demonstrated protective effects in various fibrotic diseases, yet its potential role in peritoneal fibrosis (PF) remains uncertain. In a mouse model of induced PF, CHP was administered, and quantitative proteomic analysis using liquid chromatography-tandem mass spectrometry was employed to identify PF-related protein signaling pathways. The results were further validated using human primary cultured mesothelial cells. This analysis revealed the involvement of histone deacetylase 3 (HDAC3) in the PF signaling pathway. CHP administration effectively mitigated PF in both peritoneal tissue and human primary cultured mesothelial cells, concurrently regulating fibrosis-related markers and HDAC3 expression. Moreover, CHP enhanced the expression of nuclear factor erythroid 2-related factor 2 (Nrf2) while suppressing forkhead box protein M1 (FOXM1), known to inhibit Nrf2 transcription through its interaction with HDAC3. CHP also displayed an impact on spleen myeloid-derived suppressor cells, suggesting an immunomodulatory effect. Notably, CHP improved mitochondrial function in peritoneal tissue, resulting in increased mitochondrial membrane potential and adenosine triphosphate production. This study suggests that CHP can significantly prevent PF in peritoneal dialysis patients by modulating HDAC3 expression and associated signaling pathways, reducing fibrosis and inflammation markers, and improving mitochondrial function.

Renal replacement or conservative treatment in end-stage renal disease in elder patients?

When elder individuals develop chronic kidney failure, doctors, patients, and family members are faced with the decision: Should dialysis (still) be initiated, or should a conservative-palliative therapy strategy be chosen? A prerequisite for shared decision-making is structured education about the various options, ensuring all necessary information and consequences are communicated. This article outlines the advantages and disadvantages of haemodialysis and peritoneal dialysis, as well as conservative-palliative therapy. Additionally, it discusses the option of a trial dialysis and the choice to discontinue ongoing dialysis.

Pay-for-Performance Incentives for Home Dialysis Use and Kidney Transplant

The Centers for Medicare & Medicaid Services' mandatory End-Stage Renal Disease Treatment Choices (ETC) model, launched on January 1, 2021, randomly assigned approximately 30% of US dialysis facilities and managing clinicians to financial incentives to increase the use of home dialysis and kidney transplant. To assess the ETC's association with use of home dialysis and kidney transplant during the model's first 2 years and examine changes in these outcomes by race, ethnicity, and socioeconomic status. This retrospective cross-sectional study used claims and enrollment data for traditional Medicare beneficiaries with kidney failure from 2017 to 2022 linked to same-period transplant data from the United Network for Organ Sharing. The study data span 4 years (2017-2020) before the implementation of the ETC model on January 1, 2021, and 2 years (2021-2022) following the model's implementation. Receiving dialysis treatment in a region randomly assigned to the ETC model. Primary outcomes were use of home dialysis and kidney transplant. A difference-in-differences (DiD) approach was used to estimate changes in outcomes among patients treated in regions randomly selected for ETC participation compared with concurrent changes among patients treated in control regions. The study population included 724 406 persons with kidney failure (mean [IQR] age, 62.2 [53-72] years; 42.5% female). The proportion of patients receiving home dialysis increased from 12.1% to 14.3% in ETC regions and from 12.9% to 15.1% in control regions, yielding an adjusted DiD estimate of -0.2 percentage points (pp; 95% CI, -0.7 to 0.3 pp). Similar analysis for transplant yielded an adjusted DiD estimate of 0.02 pp (95% CI, -0.01 to 0.04 pp). When further stratified by sociodemographic measures, including age, sex, race and ethnicity, dual Medicare and Medicaid enrollment, and poverty quartile, there was not a statistically significant difference in home dialysis use across joint strata of characteristics and ETC participation. In this cross-sectional study, the first 2 years of the ETC model were not associated with increased use of home dialysis or kidney transplant, nor changes in racial, ethnic, and socioeconomic disparities in these outcomes.

Impact of Norepinephrine and Dopamine Infusion on Renal Arterial Resistive Index during Pre-Emptive Living Donor Kidney Transplantation: Propensity Score Matching Analysis.

Background: Living donor kidney transplantation (LDKT) is a crucial treatment for end-stage renal disease, with pre-emptive LDKT (transplantation before dialysis initiation) offering significant benefits in graft function and patient survival. The selection of a vasopressor during LDKT, particularly between norepinephrine and dopamine, and its impact on renal arterial hemodynamics measured using the renal arterial resistive index (RARI) is poorly understood. Methods: This retrospective observational cohort study enrolled 347 eligible pre-emptive LDKT recipients from the Seoul St. Mary's Hospital between January 2019 and June 2023. Utilizing propensity score matching (PSM), the patients were categorized into dopamine and norepinephrine groups to compare the effects of these vasopressors on the intraoperative RARI, postoperative estimated glomerular filtration rate (eGFR), and hourly urine output. The RARI was measured via the Doppler ultrasonography of the renal hilum and parenchyma post-graft vascular and ureteral anastomoses. Results: The preoperative differences in the recipients' and donors' characteristics were mitigated following PSM. The dopamine group exhibited higher intraoperative RARI values at the renal hilum (0.77 ± 0.11 vs. 0.66 ± 0.13, p < 0.001) and parenchyma (0.71 ± 0.1 vs. 0.6 ± 0.1, p < 0.001) compared to those of the norepinephrine group. However, these differences were not statistically significant on postoperative day 7. The norepinephrine infusion adjusted for the propensity scores was associated with significantly lower odds of an RARI > 0.8 (hilum: OR = 0.214, 95% CI = 0.12-0.382, p < 0.001; parenchyma: OR = 0.1, 95% CI = 0.029-0.348, p < 0.001). The early postoperative outcomes showed a higher eGFR (day 1: 30.0 ± 13.3 vs. 25.1 ± 17.4 mL/min/1.73 m2, p = 0.004) and hourly urine output (day 1: 41.8 ± 16.9 vs. 36.5 ± 14.4 mL/kg/h, p = 0.002) in the norepinephrine group. Furthermore, the long-term outcomes were comparable between the groups. Conclusions: Norepinephrine infusion during pre-emptive LDKT is associated with more favorable intraoperative renal arterial hemodynamics, as evidenced by a lower RARI and improved early postoperative renal function compared to those of dopamine. These findings suggest a potential preferential role for norepinephrine in optimizing perioperative management and early graft functions in LDKT recipients. Given the retrospective nature of this study, further prospective studies are needed to confirm these observations. Additionally, the study limitations include the potential for unmeasured confounding factors and the inability to determine causality due to its observational design.

Mediating role of inner strength in the relationship between medication literacy and medication adherence among kidney transplant patients.

Compared with long-term renal replacement therapy, kidney transplantation is the ideal treatment for end-stage renal disease (ESRD), significantly extending patient life and improving quality of life. Kidney transplant patients need to adhere to lifelong immunosuppressive medication regimens, but their medication adherence is generally poor compared with other organ transplant recipients. Medication adherence is closely related to medication literacy and psychological status, yet related studies are limited. This study aims to investigate the current status of medication adherence, inner strength, and medication literacy in kidney transplant patients, analyze the relationships among these 3 factors, and explore the mediating role of inner strength in the relationship between medication literacy and medication adherence. A cross-sectional survey was conducted from March to October 2023 involving 421 patients aged≥18 years who visited kidney transplantation outpatient clinics at 4 tertiary hospitals in Hunan Province. The inner strength, medication literacy, and medication adherence of kidney transplant patients were investigated using the Inner Strength Scale (ISS), the Chinese version of the Medication Literacy Assessment in Spanish and English (MedLitRxSE), and the Chinese version of the Morisky Medication Adherence Scale-8 (C-MMAS-8), respectively. Univariate analysis was performed to examine the effects of demographic and clinical data on medication adherence. Correlation analysis was conducted to explore the relationships among medication literacy, medication adherence, and inner strength. Significant variables from univariate and correlation analyses were further analyzed using multiple linear regression, and the mediating effect of inner strength was explored. Among the 421 questionnaires collected, 408 were valid, with an effective rate of 96.91%. The scores of C-MMAS-8, MedLitRxSE, and ISS were 6.64±1.16, 100.63±14.67, and 8.47±4.03, respectively. Among the 408 patients, only 86 (21.08%) patients had a high level of medication adherence, whereas 230 (56.37%) patients had a medium level of medication adherence, and 92 (22.55%) patients had poor medication adherence. Univariate analysis indicated that the kidney transplant patients' age, marital status, education levels, years since their kidney transplant operation, number of hospitalizations after the kidney transplant, and adverse drug reactions showed significant differences in medication adherence (all P<0.05). Correlation analysis showed that inner strength positively correlated with both medication literacy (r=0.183, P<0.001) and medication adherence (r=0.201, P<0.001). Additionally, there was a positive correlation between medication adherence and medication literacy (r=0.236, P<0.001). Inner strength accounted for 13.22% of the total effect in the mediating role between medication literacy and medication adherence. The level of medication adherence among kidney transplant patients needs improvement, and targeted intervention measures are essential. Inner strength mediates the relationship between medication literacy and medication adherence in these patients. Healthcare professionals should focus on enhancing medication literacy and supporting patients' inner strength to improve medication adherence.