The evolution of nephrology practice in Egypt: legacy, current challenges, and future directions-a narrative review

Egypt, home to over 114 million people, hosts a diverse and expanding nephrology landscape, anchored by leading academic institutions and tertiary care centers that provide services across the full spectrum of kidney disease-from acute kidney injury (AKI) and chronic kidney disease (CKD) to dialysis and transplantation. Some centers have earned international recognition for their scientific contributions and attract referrals from across the region. Notwithstanding the range of services offered, the Egyptian healthcare system-which includes insurance-based, commercial, and governmental models-faces significant obstacles, such as unequal access to care, a lack of adequate data infrastructure, and resource limitations. This narrative review, authored by a multidisciplinary team of Egyptian nephrology experts, provides a comprehensive overview of nephrology care in Egypt, highlighting current strengths, identifying key challenges, and offering future-oriented solutions to advance kidney health nationwide. It aims to serve as a roadmap for policymakers, stakeholders, clinicians, and researchers committed to improving nephrology care delivery in Egypt and shaping a more equitable, enhanced, and sustainable future.

Electroacupuncture versus sham for insomnia in patients undergoing maintenance hemodialysis: study protocol for a pilot randomized controlled trial

BACKGROUND

Insomnia causes severe health problems and poor quality of life in patients with end-stage renal disease (ESRD) undergoing maintenance hemodialysis (MHD). Conventional therapies are limited due to the poor availability and opaque evidence, and electroacupuncture (EA) is considered an alternative for improving insomnia in patients with ESRD undergoing MHD.

METHODS

This is a study protocol for a pilot randomized, sham-controlled, single-center, clinical trial. A total of 60 patients with insomnia in ESRD undergoing MHD will be randomly assigned to treatment group (EA, 3 sessions per week for 4 weeks), or sham group (sham EA, 3 sessions per week for 4 weeks) in a 1:1 ratio. Participants will complete the trial by visiting the research center at Week 8 for a follow-up assessment. The primary outcome is the response rate: the proportion of patients achieving a minimal clinically important difference, which is defined as ≥7 points on insomnia severity index (ISI) at Week 4 compared with baseline. Secondary outcomes include sleep diary, ISI, pittsburgh sleep quality index (PSQI), short form health survey-12 (SF-12), fatigue severity scale (FSS), 24-Hour ambulatory blood pressure, and plasma levels of C-reactive protein (CRP) and D-Dimer.

DISCUSSION

This is the first standardized protocol investigating the efficacy and safety of EA for patients with ESRD undergoing MHD. This trial may provide evidence for clinical application of EA for patients with ESRD undergoing MHD.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (registered number: ChiCTR2300071814).

Gut microbiota modulation via fecal microbiota transplantation mitigates hyperoxaluria and calcium oxalate crystal depositions induced by high oxalate diet

Hyperoxaluria, including primary and secondary hyperoxaluria, is a disorder characterized by increased urinary oxalate excretion and could lead to recurrent calcium oxalate kidney stones, nephrocalcinosis and eventually end stage renal disease. For secondary hyperoxaluria, high dietary oxalate (HDOx) or its precursors intake is a key reason. Recently, accumulated studies highlight the important role of gut microbiota in the regulation of oxalate homeostasis. However, the underlying mechanisms involving gut microbiota and metabolite disruptions in secondary hyperoxaluria remain poorly understood. Here, we investigated the therapeutic efficacy of fecal microbiota transplantation (FMT) sourced from healthy rats fed with standard pellet diet against urinary oxalate excretion, renal damage and calcium oxalate (CaOx) crystal depositions via using hyperoxaluria rat models. We observed dose-dependent increases in urinary oxalate excretion and CaOx crystal depositions due to hyperoxaluria, accompanied by significant reductions in gut microbiota diversity characterized by shifts in Ruminococcaceae_UCG-014 and Parasutterella composition. Metabolomic analysis validated these findings, revealing substantial decreases in key metabolites associated with these microbial groups. Transplanting microbes from healthy rats effectively reduced HDOx-induced urinary oxalate excretion and CaOx crystal depositions meanwhile restoring Ruminococcaceae_UCG-014 and Parasutterella populations and their associated metabolites. Furthermore, FMT treatment could significantly decrease the urinary oxalate excretion and CaOx crystal depositions in rat kidneys via, at least in part, upregulating the expressions of intestinal barrier proteins and oxalate transporters in the intestine. In conclusion, our study emphasizes the effectiveness of FMT in countering HDOx-induced hyperoxaluria by restoring gut microbiota and related metabolites. These findings provide insights on the complex connection between secondary hyperoxaluria caused by high dietary oxalate and disruptions in gut microbiota, offering promising avenues for targeted therapeutic strategies.

Elevated atherogenic index of plasma is associated with increased cardiorenal syndrome prevalence: a cross-sectional study

PURPOSE

Cardiorenal syndrome (CRS) is a complex clinical condition characterized by the simultaneous dysfunction of the heart and kidneys. The atherogenic index of plasma (AIP), calculated as the logarithm of the ratio of triglycerides (TG) to high-density lipoprotein cholesterol (HDL-C), has emerged as a potential biomarker for cardiovascular risk. This study investigates the association between AIP and CRS, aiming to explore the potential linkage between AIP and CRS.

METHODS

Data were sourced from the National Health and Nutrition Examination Survey spanning 2005-2018, involving 35,365 participants after applying exclusion criteria. The primary exposure variable was AIP, categorized into quartiles, while the primary outcome variable was CRS, defined by the coexistence of cardiovascular disease (CVD) and chronic kidney disease (CKD). Statistical analyses, considering sample weights, included ANOVA, Chi-square tests, logistic regression models, and restricted cubic spline (RCS) analysis to examine nonlinear relationships.

RESULTS

The weighted logistic regression analysis showed a positive correlation between AIP and CRS across all models. In the fully adjusted model, the highest AIP quartile had a significantly increased odds ratio (OR) for CRS (Q4: OR = 1.62; 95% CI: 1.21-2.15). RCS analysis confirmed a positive correlation between AIP and CRS, with TG positively and HDL-C negatively correlated with CRS. Subgroup analysis indicated a significant interaction with hypertension, showing a stronger association in non-hypertensive individuals.

CONCLUSION

Higher AIP levels are associated with an increased prevalence of CRS, with a notable hypertension-specific interaction indicating a higher effect in individuals without hypertension.

International society of sports nutrition position stand: nutrition and weight cut strategies for mixed martial arts and other combat sports

Following an extensive literature review, the International Society of Sports Nutrition (ISSN) has developed an official position on nutritional and weight cut strategies for combat sports. The type of combat sport, length of the fight camp, and time between weigh-in and competition are factors influencing nutritional and weight cut strategies. The following 16 points constitute the Position Statement of the Society; the Research Committee has approved them. 1. Combat sports have differing weight categories, official weigh-in times, and competition frequencies, influencing the nutritional and weight cut strategies for training and competition. 2. As the duration of a combat match increases, >4 min, contribution of the aerobic system can rise to >70%, yet anaerobic alactic pathways and anaerobic glycolytic pathways support high-output bursts. 3. During the off camp/general preparation phase, athletes should maintain a weight ranging 12% to 15% above the weight division requirement. 4. Supplements including creatine, beta-alanine, beta-hydroxy-beta-methylbutyrate, and caffeine have been shown to enhance performance and/or recovery during preparation phases, competition, and post-competition. 5. During fight camp, strategic decreases in calorie intake are necessary for an efficient longitudinal weight descent. Individual caloric needs can be determined using indirect calorimetry or validated equations such as Mifflin St. Jeor or Cunningham. 6. Protein should be prioritized during longitudinal weight descents to preserve lean body mass, and the timely delivery of carbohydrates supports training demands. Macronutrients should not drop below the following: carbohydrates 3.0-4.0 g/kg, protein 1.2-2.0 g/kg, and fat 0.5 to 1.0 g/kg/day. 7. Suitable losses in body mass range from 6.7% at 72 h, 5.7% at 48 h, and 4.4% at 24 h, prior to weigh-in. 8. Sodium restriction and water loading are effective for inducing polyuria and acute water loss. 9. During fight week, water-bound glycogen stores can be depleted through exercise and carbohydrate restriction, facilitating a 1% to 2% loss in body mass, with equivalent losses from a low-fiber intake of <10 g/day for 4 days. 10. During fight week, acute water loss strategies, including sauna, hot water immersion, and mummy wraps, can be used effectively with appropriate supervision (optimally ~2-4% of body mass within 24 h of weigh-in). 11. Post-weigh-in, rapid weight gain strategies are utilized to recover lost body fluid/mass before competition with the intent of gaining a competitive advantage. 12. Oral rehydration solutions (1 to 1.5 liters/h) combined with a sodium range of 50-90 mmol/dL should take precedence immediately post-weigh-in. 13. Fast-acting carbohydrates at a tolerable rate of ≤ 60 g/h should follow oral rehydration solutions. Post weigh-in intake of fiber should be limited to avoid gastrointestinal distress. 14. Post-weigh-in carbohydrate intake at 8-12 g/kg may be appropriate for combat athletes that undertook significant glycogen depletion strategies during fight week. About 4-7 g/kg may be suitable for modest carbohydrate restriction. 15. Post weigh-in, rehydration/refueling protocols should aim to regain ≥10% of body mass to mitigate declines in performance and the negative effects of rapid weight loss. 16. The long-term effects of frequent weight cuts on health and performance are unknown, necessitating further research.

Safflower injection against obesity-induced mice podocyte injury by improving insulin resistance through increasing renal INSR and eNOS expression

BACKGROUND

Podocyte injury is a common pathologic mechanism in obesity-related glomerulopathy (ORG). Safflower injection (SFI), scientifically extracted and refined from safflower, is used to treat diabetic kidney disease according to clinical guideline. Our previous study confirmed that the main active compounds of SFI ameliorated high glucose-induced podocyte injury. It is uncertain whether SFI has an effect on ORG-related podocyte injury.

OBJECTIVES

This study aimed to explore the pharmacological effects and related mechanisms of SFI on podocyte injury of ORG mice.

METHODS

First, by combining ultra-high performance liquid chromatography tandem mass spectrometry analysis with online databases, the pathway enrichment, target-pathway analysis, and human protein-protein interaction network were conducted to discover the possible crucial mechanism of SFI against ORG. Then, ORG mice model was established by high-fat diet and biochemical assays, histopathology and western blot were used to explore the effects of SFI on obesity and podocyte injury. Finally, system pharmacology-based findings were evaluated in ORG mice.

RESULTS

The results of system pharmacology suggested that SFI could alleviate ORG through insulin resistance (IR)-related pathway by regulating insulin receptor (INSR) and endothelial nitric oxide synthase (eNOS) expressions. The in vivo experiment confirmed that SFI ameliorated obesity, lipid metabolism-related indicators, podocyte injury of ORG mice. The mechanism relationships among IR, INSR, and eNOS were further verified in ORG mice.

CONCLUSIONS

Our findings imply that by up-regulating the expression of renal INSR and eNOS, thereby inhibiting IR, SFI may be a promising candidate for the treatment of ORG.

Development and validation of multi-center serum creatinine-based models for noninvasive prediction of kidney fibrosis in chronic kidney disease

OBJECTIVE

Kidney fibrosis is a key pathological feature in the progression of chronic kidney disease (CKD), traditionally diagnosed through invasive kidney biopsy. This study aimed to develop and validate a noninvasive, multi-center predictive model incorporating machine learning (ML) for assessing kidney fibrosis severity using biochemical markers.

METHODS

This multi-center retrospective study included 598 patients with kidney fibrosis from four hospitals. A training cohort of 360 patients from Shanghai Tongji Hospital was used to develop a predictive nomogram and ML model, with fibrosis severity classified as mild or moderate-to-severe based on Banff scores. Logistic regression identified key predictors, which were incorporated into a nomogram and ML model. An external validation cohort of 238 patients from three additional hospitals was used for model evaluation.

RESULTS

Serum creatinine (Scr), estimated glomerular filtration rate (eGFR), parathyroid hormone (PTH), brain natriuretic peptide (BNP), and sex were identified as independent predictors of kidney fibrosis severity. The nomogram demonstrated superior discriminative ability in the training cohort (AUC: 0.89, 95% CI: 0.85-0.92) compared to eGFR (AUC: 0.83, 95% CI: 0.78-0.87) and Scr (AUC: 0.87, 95% CI: 0.83-0.91). Among ML models, the Random Forest (RF) model achieved the highest AUC (0.98). In external validation, the nomogram and RF models maintained robust performance with AUCs of 0.86 and 0.79, respectively.

CONCLUSION

This study presents a validated, noninvasive, multi-center Scr-based machine learning model for assessing kidney fibrosis severity in CKD. The integration of a clinical nomogram and ML approach offers a novel, practical alternative to biopsy for dynamic fibrosis evaluation.

U-shaped relationship between serum phosphate levels and mortality in critically ill patients with atrial fibrillation: Insights from the MIMIC-IV database

INTRODUCTION

Atrial fibrillation (AF), a common arrhythmia in critically ill patients, significantly affects prognosis. While phosphate disturbances are strongly associated with cardiovascular risks, the impact of serum phosphate on critically ill AF patients' prognosis remains uncertain.

METHODS

Utilizing data from the MIMIC-IV database, we retrospectively analyzed 11,744 critically ill AF patients. The primary outcome was 30-day all-cause mortality, with secondary outcomes at 90 days and 1 year. Cox regression models quantified the association between serum phosphate and mortality. Nonlinear associations were evaluated using restricted cubic splines (RCS), with inflection points further characterized through segmented Cox proportional hazards model.

RESULTS

Mortality rates at 30 days, 90 days, and 1 year were 12.7 %, 14.4 %, and 15.8 %, respectively. Kaplan-Meier analysis showed higher mortality in patients with high phosphate levels. Adjusted Cox regression demonstrated that hyperphosphatemia independently predicted increased mortality at 30 days (HR: 1.55, 95 % CI: 1.36-1.78, p < 0.001), 90 days (HR: 1.55, 95 % CI: 1.37-1.76, p < 0.001), and 1 year (HR: 1.57, 95 % CI: 1.39-1.77, p < 0.001). RCS and two-piece Cox regression revealed a U-shaped nonlinear relationship between serum phosphate and mortality, with risk decreasing below a threshold and increasing above it. Similar patterns were observed across all time points.

CONCLUSION

Our findings demonstrated a U-shaped relationship between serum phosphate levels and mortality in critically ill AF patients, highlighting the importance of maintaining optimal phosphate levels in managing this population.

Late-onset Complications in a Chronic Proton Pump Inhibitor User: Electrolyte Abnormalities and a Diagnostic Approach

This case presents an unusual presentation of severe hypocalcemia, hypomagnesemia, and hypokalemia that suddenly developed in a patient with a prior 15-year history of proton pump inhibitor (PPI) use with no prior complications. The patient developed acute onset of persistent tingling and numbness in her fingertips followed by acute confusion and perioral tingling. Upon hospitalization, she was found to have severe hypocalcemia, hypomagnesemia, and hypokalemia and required IV electrolyte repletion. This episode recurred, prompting the discontinuation of her PPI therapy. This unusual timing prompted an extensive workup to exclude alternative etiologies of hypocalcemia. Ultimately, PPI-induced hypomagnesemia was identified as the primary driver of the patient's electrolyte abnormalities. This case serves dual teaching points. First, it underscores the importance of recognizing that refractory hypocalcemia and hypokalemia can often be linked to untreated hypomagnesemia so that timely diagnosis, effective management, and minimization of hospitalizations can be ensured. Second, this case highlights the unusual timing of symptomatic hypomagnesemia and subsequent hypocalcemia and hypokalemia despite years of prior PPI usage without prior known complications.

The roles of bacteria on urolithiasis progression and associated compounds

As a common urological disease, the formation of urinary tract stones involves multiple factors, including genetics, the environment, dietary habits, and bacterial species (e.g., Proteus mirabilis and Escherichia coli). Previous studies have demonstrated that P. mirabilis primarily contributes to infectious urinary calculus formation by producing urease, an enzyme that breaks down urea into ammonia and carbon dioxide, thereby altering the urinary pH and promoting crystal formation and growth. In contrast, calcium oxalate (CaOx) stones are the main type of kidney stones, and the most common bacteria in CaOx stones are E. coli. Intriguingly, E. coli can also facilitate stone formation via flagellin and other virulence factors, which induce renal epithelial cell injury and increase crystal adhesion and aggregation. These bacteria play complex and multidimensional roles in the formation of urinary tract stones, necessitating further research to elucidate their underlying mechanisms. Here, we summarise the roles of common urinary tract bacteria, particularly P. mirabilis and E. coli, in forming urinary tract stones, aiming to enhance our understanding of urolithiasis exploration in the future.

Activation of toll-like receptor 2 promotes the expression of inflammatory mediators and cell proliferation of human polycystic kidney disease cells

Autosomal dominant polycystic kidney disease (ADPKD) is characterized by the progressive enlargement of fluid-filled cysts, leading to a decline in renal function. Toll-like receptors (TLR)-2 and TLR4 are pattern recognition receptors and components of the innate immune response. We found that mRNA levels for TLR2 and TLR4, an adaptor protein MyD88, and the transcription factor NF-κB were elevated in the kidneys of ADPKD patients and PKD mice. There was decreased expression of IκBα, an inhibitory protein sequestering NF-κB in the cytosol, and increased NF-κB nuclear translocation in human ADPKD kidneys compared with normal human kidneys (NHK). Pam3CSK4, a synthetic TLR2 agonist, increased the phosphorylation of IκBα, decreased its total levels, and caused NF-κB nuclear translocation and upregulation of pro-inflammatory mediators in cultured human ADPKD cells. Pam3CSK4 also increased phosphorylated ERK, a mitogen-activated protein kinase, and phosphorylated S6, a downstream target of the mTOR pathway, and accelerated ADPKD cell proliferation. By contrast, Pam3CSK4 did not affect NF-κB or ERK in NHK cells, but rather induced cytotoxicity, suggesting that TLR2 activation's effect was specific to ADPKD cells. Treatment with a TLR4 agonist did not affect NF-κB or ERK signaling in either ADPKD or NHK cells. Inhibition of TGF-β-activated kinase-1 (TAK1) effectively suppressed Pam3CSK4-induced NF-κB and ERK activation and the proliferation of ADPKD cells. These findings suggest that activation of TLR2 increases NF-κB-mediated-inflammatory mediators and ERK-dependent cell proliferation through TAK1 in ADPKD cells. We propose that the TLR2/TAK1 axis is a potential therapeutic target to reduce inflammation and cyst growth in ADPKD.

Eternal dilemma between percutaneous nephrostomy and double J stenting in the management of patients with ureteral obstruction: A single center study

Ureteral obstruction is one of the most common urological emergencies, the etiology of which can be benign (in case of ureteral stones or strictures secondary to surgery) or malign (when a urothelial cancer affects the ureteral lumen or when an abdominal advanced neoplastic disease compresses the ureter 'ab estrinseco'). To date, the most commonly used existing surgical methods for ureteral obstruction include percutaneous nephrostomy (PCN) and Double J stenting (DJS). The choose of the drainage method is multifactorial and, currently, no existing guidelines suggest to the urologist the ideal treatment for ureteral obstruction. Therefore, it was assessed which of the two main methods is superior in patients with ureteral obstruction according to normalization of renal function indices, post-operative complication and the perception of the quality of life (QoL) by the patient's point of view. In a period between 2019 and 2023, a total of 317 consecutive patients (198 males and 119 females) presenting to the emergency room of our hospital with a ureteral obstruction, which was resolved surgically by DJS or nephrostomy tube, were enrolled in the present study. All the patients signed written informed consent. Patients underwent surgical drainage when definitive treatment was not possible immediately or when a two-stage procedure was considered a safer approach. Inclusion criteria were: ureteral obstruction with fever (>38˚C), acute renal failure (indicated by an increase in creatinine and urea nitrogen blood values), risk of sepsis [suspected based on an increase in white blood cell (WBC) count] or intractable pain. Diagnosis of the ureteral obstruction was made by either a non-contrast CT and/or renal ultrasound. Specifically, 155 patients of the study sample were treated with nephrostomy, whereas 217 individuals underwent to stenting procedure. For each participant, data concerning the creatinine (mg/dl), azotemia (mg/dl), potassium (mEq/l), WBC count (103/mm3), core temperature (˚C), pain in the side (yes or not), anti-inflammatory therapy (yes or not) and ASA score were evaluated. A Chi-square test was used to evaluate the difference in the incidence of complications according to sex and to the type of intervention. Moreover, 2-way ANOVA, considering the time (that is, pre-intervention, 2, 3, and 4 days after the intervention) as within factor and the groups as between factor, was implemented separately for the creatinine, azotemia, WBC, and body temperature values to assess differences between the PCN and DJS groups. Multiple comparisons were performed through t-tests comparing the values pre-operation and the values at two, three and four days after the intervention for each group. Moreover, independent samples t-tests were computed to identify differences between the two groups. Importantly, the multiple comparisons results were Bonferroni corrected. Finally, in order to assess a possible effect of the age on the variations of the creatinine, azotemia, WBC and body temperature for the two groups considered, a MANCOVA was performed, considering the age as a covariate. Finally, an independent sample t-test was performed between the hospitalization time of the two groups. According to our results, PCN is an improved method compared with DJS for management of ureteral obstruction in terms of renal function preservation, also ensuring an improved QoL. Moreover, PCN patients have a higher rate of post-operative complications. Then, concerning the prediction of the hospitalization time (according to the two-class classification: hospitalization time lower or higher than 3 days), the accuracy of the prediction was 61.9% for DJS and 60.2 for PCN. These results demonstrate the feasibility of predicting the hospitalization time for the patients based on their pre-drained condition. Although the results are preliminary and the accuracies are not high, this approach could help the surgeon choose the right kind of intervention for each patient.

Outcomes and prognostic factors in childhood-onset steroid-resistant nephrotic syndrome: a retrospective single-center study

BACKGROUND

Steroid-resistant nephrotic syndrome (SRNS) is the second leading cause of chronic kidney disease (CKD) in childhood. It represents a heterogeneous group of diseases with variable kidney outcomes that are still challenging to predict. In this study, our main objective is to describe predictive factors of remission states and kidney survival comparing genetic and non-genetic SRNS.

METHODS

We conducted a retrospective analysis of 65 pediatric patients with SRNS treated at the pediatric outpatient clinic in Berlin between 2000 and 2023. Clinical characteristics, laboratory findings, and treatment strategies were systematically collected at multiple time points. Outcomes were defined by remission status, kidney survival (CKD stage I-IV), or progression to CKD stage V. Statistical analyses included univariate and multivariate logistic and Cox regression models adjusted for monogenic SRNS to identify predictors of remission and kidney survival.

RESULTS

The median age of onset was 4.0 years, with a male predominance of 57%. Patients were followed for a median of 5.9 years. At the last follow-up, 26 patients achieved complete remission, 12 achieved partial remission, and 27 showed no remission. Kidney survival rates at 5 and 10 years were 71% and 56%, respectively. High initial nephrotic-range proteinuria, confirmed genetic diagnoses, reduced eGFR, and hypoalbuminemia at 3-month and 1-year follow-ups were identified as negative predictive factors for complete or partial remission. These factors also correlated strongly with an elevated risk of progression to CKD stage V.

CONCLUSION

Our findings highlight additional prognostic factors influencing remission status and long-term kidney survival in pediatric SRNS, emphasizing the value of detailed early time-point analyses.

Chronic kidney disease in geriatric patients: Estimating glomerular filtration rate in older patients with comorbidities

Aging is an inevitable process that is usually measured by chronological age, with people aged 65 and over being defined as "older individuals". There is disagreement in the current scientific literature regarding the best methods to estimate glomerular filtration rate (eGFR) in older adults. Several studies suggest the use of an age-adjusted definition to improve accuracy and avoid overdiagnosis. In contrast, some researchers argue that such changes could complicate the classification of chronic kidney disease (CKD). Several formulas, including the Modification of Diet in Renal Disease, CKD-Epidemiology Collaboration, and Cockcroft-Gault equations, are used to estimate eGFR. However, each of these formulas has significant limitations when applied to older adults, primarily due to sarcopenia and malnutrition, which greatly affect both muscle mass and creatinine levels. Alternative formulas, such as the Berlin Initiative Study and the Full Age Spectrum equations, provide more accurate estimates of values for older adults by accounting for age-related physiological changes. In frail older adults, the use of cystatin C leads to better eGFR calculations to assess renal function. Accurate eGFR measurements improve the health of older patients by enabling better medication dosing. A thorough approach that includes multiple calibrated diagnostic methods and a detailed geriatric assessment is necessary for the effective management of kidney disease and other age-related conditions in older adults.

Advances in the pathophysiology and treatment of focal segmental glomerulosclerosis: The importance of a timely and tailored approach

Focal segmental glomerulosclerosis (FSGS) is a histological pattern of glomerular damage that significantly contributes to chronic kidney disease and end-stage renal disease. Its incidence is rising globally, necessitating timely and personalized management strategies. This paper aims to provide an updated overview of the pathophysiology, diagnosis, and therapeutic strategies for FSGS, emphasizing the importance of early interventions and tailored treatments. This editorial synthesizes key findings from recent literature to highlight advancements in understanding and managing FSGS. Emerging evidence supports the role of targeted therapies and personalized approaches in improving outcomes for FSGS patients. Advances include novel biomarkers, genetic testing, and innovative therapeutics such as transient receptor potential ion channel blockers and antisense oligonucleotides for apolipoprotein 1-related FSGS. Effective management of FSGS requires a combination of timely diagnosis, evidence-based therapeutic strategies, and ongoing research to optimize patient outcomes and address gaps in the current understanding of the disease.

Essential role of kidney biopsy in diagnosing glomerular diseases amidst evolving biomarkers

The discussion on renal biopsies and biomarkers highlights the essential aspects of nephrology. Although novel diagnostic biomarkers are emerging, renal biopsy remains critical for accurate diagnosis and treatment owing to the lack of sufficiently validated biomarkers with high sensitivity and specificity. Puspitasari et al highlighted the significant changes in renal biopsy indications and histological outcomes before and after the coronavirus disease 2019 (COVID-19) pandemic, reflecting the complex interactions between clinical workflows, public health issues, and patient demographics. Although biomarkers are increasingly utilized in nephrology, their importance remains balanced with traditional practices. Advancements in precision medicine are exemplified by tests like plasma anti-phospholipase A2 receptor levels. However, the COVID-19 pandemic revealed significant vulnerabilities in nephrology services, emphasizing the necessity for adaptable and robust healthcare strategies to manage chronic conditions during global crises. In conclusion, while biomarkers are poised to assume a more prominent role in nephrology, the significance of renal biopsies and thorough histopathological analysis remains paramount in understanding complex disease processes and guiding personalized patient management. The ongoing integration of traditional diagnostic approaches with innovative biomarker strategies promises to improve patient care and long-term health outcomes.

The secreted protease ADAMTS18 is a novel activator of latent TGF-β to exacerbate renal fibrosis

Renal fibrosis (RF) is an inevitable consequence of almost all forms of progressive chronic kidney disease (CKD). TGFβ is a powerful cytokine capable of dominating the fibrotic process. Targeting factors capable of activating latent TGF-β is a more effective and safe strategy to reduce TGF-β-induced fibrosis, but appropriate targets need to be identified. Here, we show that ADAMTS18/Adamts18 is significantly upregulated in the fibrotic kidneys of human CKD patients and mice. ADAMTS18 is primarily produced by renal tubular epithelial cells and fibroblasts during RF. Functionally, Adamts18 deletion inhibits epithelial-mesenchymal transition, inflammation, and collagen synthesis. Conversely, Adamts18 overexpression exacerbates progressive renal fibrosis. Mechanistically, the KPFR sequence in ADAMTS18 disrupts the latency-associated peptide (LAP) interaction with TGF-β and increases the release of mature TGF-β1. Blockage of ADAMTS18-mediated latent TGF-β activation by a tetrapeptide (LSKL) effectively reverses RF. Collectively, ADAMTS18 is a novel LAP-TGF-β1 activator with the potential to optimize CKD treatment strategies.

Mortality in Tuberous Sclerosis Complex in the United Kingdom, 2016-2022

BACKGROUND

Tuberous sclerosis complex (TSC) is a genetic condition caused by mutations in either TSC1 or TSC2 genes, affecting around two million people globally. This study aims to examine causes of death in TSC and explore factors contributing to mortality in people with TSC in the United Kingdom in recent years following updated management and surveillance guidelines for the condition.

METHODS

Comprehensive analysis of the available medical records of the people seen at the largest lifespan TSC clinic in the United Kingdom who passed away between 2016 and 2022 was conducted. Disease-related factors were identified, and the cause of death was determined. Where mortality cause was unobtainable, information was sought from the person's general practitioner, or their death certificate was obtained from the General Registry Office. Subsequently, the cohort was divided into subgroups to investigate potential risk factors for premature mortality. Our results were compared to that of previous TSC mortality studies.

RESULTS

The study consisted of 19 deaths. Nine deaths were unequivocally attributed to TSC. These fatalities were due to epilepsy (n = 3/19), aspiration pneumonia (n = 3/19), SEGA (n = 1/19), hepatic AML (n = 1/19) and pNET (n = 1/19). Other causes included malignant cancer (n = 6/19), sepsis (n = 2/19), COVID-19 (n = 1/19) and stroke (n = 1/19). Renal failure was a secondary cause in two deaths.

DISCUSSION

Compared to limited previous mortality studies, this cohort appears to be less affected by SUDEP. This group is also more greatly affected by cancer and presents a potential link between early mortality and renal AML size. Moreover, a clearer role of intellectual disability in mortality of people with TSC may have been identified. Most causes of mortality in this TSC cohort are potentially prevented with suitable interventions earlier.

Fungal peritonitis in a patient on peritoneal dialysis caused by Hyphopichia burtonii: A rare pathogen in human infection

Fungal peritonitis in peritoneal dialysis (PD) patients is rare but is associated with high morbidity and mortality. Candida species are the most common causative agents, but infections caused by unusual, often "nonpathogenic," fungi are being increasingly reported. Hyphopichia burtonii is typically associated with food spoilage and has rarely been reported in human infections. We describe the case of a 44-year-old female with end-stage renal disease on continuous ambulatory peritoneal dialysis (CAPD) who developed peritonitis caused by Hyphopichia burtonii. Following the identification of the fungus, the patient was put on hemodialysis, the peritoneal dialysis catheter was removed, and he was given fluconazole for two weeks having favorable clinical development. 2012 Elsevier Ltd. All rights reserved.

Liver Transplantation in Primary Hyperoxaluria: A Single-Center 10-Year Experience

BACKGROUND

Primary hyperoxalurias (PHs) are rare inborn errors of metabolism caused by a deficiency of hepatic enzymes, leading to excessive urinary oxalate excretion and the overproduction of oxalate, which accumulates in various organs. If left untreated, PHs can cause serious morbidity, end-stage kidney disease (ESKD), and mortality. Liver transplantation (LT) is a recognized treatment option for children with these diseases. This study aimed to analyze the outcome of PHs disease post-LT from a single center in Iran.

METHODS

This retrospective, single-center study was conducted at the Shiraz Transplant Center from 2012 to 2023, focusing on liver transplant recipients with PH. We evaluated long-term outcomes and post-transplantation results for both deceased donor liver transplantation (DDLT) and living donor liver transplantation (LDLT). Biochemical lab results (pre- and post-transplantation), perioperative data, surgical procedures, transplantation outcomes, and recipient and donor characteristics were reported. Kaplan-Meier survival analysis was used to assess graft and patient survival.

RESULTS

33 recipients with LT (LDLT, n = 6; DDLT, n = 27) were included. The median age at the time of transplantation was 8 years (range: 3-18 years). Following liver transplantation, all of the patients had normalization of liver enzymes. Urine oxalate levels gradually decreased from 198 to 51 (< 45 mg/1.73 m2/day). Among the 33 patients, eight experienced episodes of acute rejection, and five developed chronic rejection. Eight patients underwent kidney transplantation before liver transplantation, while 21 patients initially received liver transplantation. 26 patients survived and remained in good health during a median follow-up period of 7 years (range: 1.5-11 years). For patients with PHs, the survival rates at 6 months, 1 year, 3 years, and 5 years were 100%, 97%, 94%, and 85%, respectively. The graft survival for patients was 100%, 100%, 97%, and 97% at 6 months, 1 year, 3 years, and 5 years, respectively.

CONCLUSIONS

PHs is a rare metabolic disorder, and LT significantly improves both survival and quality of life for affected patients. In our cohort, the majority of patients exhibited favorable long-term outcomes, along with a notable reduction in urine oxalate levels post-transplantation. However, challenges persist, including graft shortages and the risk of renal graft loss due to oxalosis, which continue to affect overall treatment outcomes. These findings highlight the importance of close monitoring and multidisciplinary care in managing PH patients' post-transplant.

Elucidating the Molecular Landscape of Cystic Kidney Disease: Old Friends, New Friends and Some Surprises

Cystic kidney diseases (CyKD) are a diverse group of disorders affecting more than 1 in 1000 individuals. Over 120 genes are implicated, primarily encoding components of the primary cilium, transcription factors, and morphogens. Prognosis varies greatly by molecular diagnosis. Causal variants are not identified in 10%-60% of individuals due to our limited understanding of CyKD. To elucidate the molecular landscape of CyKD, we queried the CAG Biobank using the ICD10 codes N28.1, Q61.1, Q61.11, Q61.19, Q61.2, Q61.3, and Q61.8 to identify individuals with CyKD. One hundred eight individuals met clinical criteria for CyKD and underwent proband-only exome sequencing. Causal variants were identified in 86/108 (80%) individuals. The most common molecular diagnoses were PKD1-related autosomal dominant polycystic kidney disease (32/108; 30%) and autosomal recessive polycystic kidney disease (21/108; 19%). Other common molecular diagnoses were ciliopathy syndromes (7/108; 6.5%) and Tuberous Sclerosis (6/108; 5.6%). Seven individuals had variants in genes not previously associated with CyKD (7/108; 6.5%). Candidate genes were identified in five individuals (5/108; 4.5%). Discordance between molecular and clinical diagnosis was present in two individuals. We demonstrate a high molecular diagnosis rate in individuals with CyKD that can result in diagnostic reclassification, supporting a role for genetic testing in CyKD.

Efficacy and safety of teriparatide in kidney transplant recipients with osteoporosis and low bone turnover: a real-world experience

INTRODUCTION

Kidney transplantation is the preferred treatment for end-stage kidney disease (ESKD), enhancing survival and quality of life. However, kidney transplant recipients (KTRs) are at high risk for bone disorders, particularly low bone turnover disease, which increases fracture risk. Teriparatide, an anabolic agent, may provide a beneficial treatment option for these patients.

MATERIALS AND METHODS

This single-center, retrospective observational study involved 18 KTRs with osteoporosis, low bone turnover, and a history of vertebral or non-vertebral fractures. Patients received teriparatide (20 μg/day) for up to 2 years. Areal bone mineral density (aBMD) at the lumbar spine (LS), total hip (TH), femoral neck (FN), and trabecular bone score (TBS) were measured at baseline, 1 year, and 2 years. In addition, bone turnover markers (BTMs), serum calcium, phosphorus, parathyroid hormone (PTH), and kidney function were monitored.

RESULTS

Significant increases in LS aBMD were observed after 1 year (0.941 ± 0.152 vs 1.043 ± 0.165, p = 0.04) and maintained after 2 years compared to baseline (0.941 ± 0.152 vs 1.074 ± 0.154, p = 0.03). TH aBMD significantly increased after 2 years (0.753 ± 0.145 vs 0.864 ± 0.141, p = 0.04), while FN and TBS showed non-significant improvement. Teriparatide was well-tolerated, with mild and transient hypercalcemia and hypophosphatemia.

CONCLUSION

Teriparatide significantly improved BMD at the LS and TH in KTRs with osteoporosis and low bone turnover, showing a favorable safety profile.

Advances in kidney biopsy lesion assessment through dense instance segmentation

Renal biopsies are the gold standard for the diagnosis of kidney diseases. Lesion scores made by renal pathologists are semi-quantitative and exhibit high inter-observer variability. Automating lesion classification within segmented anatomical structures can provide decision support in quantification analysis, thereby reducing inter-observer variability. Nevertheless, classifying lesions in regions-of-interest (ROIs) is clinically challenging due to (a) a large amount of densely packed anatomical objects, (b) class imbalance across different compartments (at least 3), (c) significant variation in size and shape of anatomical objects and (d) the presence of multi-label lesions per anatomical structure. Existing models cannot address these complexities in an efficient and generic manner. This paper presents an analysis for a generalized solution to datasets from various sources (pathology departments) with different types of lesions. Our approach utilizes two sub-networks: dense instance segmentation and lesion classification. We introduce DiffRegFormer, an end-to-end dense instance segmentation sub-network designed for multi-class, multi-scale objects within ROIs. Combining diffusion models, transformers, and RCNNs, DiffRegFormer is a computational-friendly framework that can efficiently recognize over 500 objects across three anatomical classes, i.e., glomeruli, tubuli, and arteries, within ROIs. In a dataset of 303 ROIs from 148 Jones' silver-stained renal Whole Slide Images (WSIs), our approach outperforms previous methods, achieving an Average Precision of 52.1% (detection) and 46.8% (segmentation). Moreover, our lesion classification sub-network achieves 89.2% precision and 64.6% recall on 21889 object patches out of the 303 ROIs. Lastly, our model demonstrates direct domain transfer to PAS-stained renal WSIs without fine-tuning.

Podocyte-related biomarkers' role in evaluating renal toxic effects of silver nanoparticles with the possible ameliorative role of resveratrol in adult male albino rats

Extensive uses of silver nanoparticles (Ag NPs) in different industries result in exposure to these nanoparticle imperatives in our daily lives. Resveratrol is found in many plants as a natural compound. The present study aimed to estimate the renal toxic effects of Ag NPs in adult male albino rats and the underlying relevant mechanisms while studying the possible role of resveratrol in ameliorating these effects. Thirty adult albino rats were split into 5 groups; control, vehicle, resveratrol (30 mg/kg), Ag NPs (300 mg/kg), and resveratrol + Ag NPs groups. The treatments were given orally for 4 weeks. Ag NPs group displayed a reduction in kidney weight ( absolute and relative), excess in urinary levels of kidney injury molecule, neutrophil gelatinase-associated lipocalin, cystatin, and blood kidney biomarkers (creatinine, urea, and potassium), increases in oxidative stress markers with the reduction in antioxidant markers, and decreases in serum sirtuin 1(SIRT1) level. Upregulation of interleukin 1 beta, tumor necrosis factor-alpha, and monocyte chemoattractant protein-1 gene expressions with downregulation of nephrin and podocin gene expressions in renal tissues were also observed. These changes were associated with histological alterations of the glomeruli and tubules, and increased area percentage of collagen fiber. A significant increase in the optical density of transforming growth factor-beta 1 and claudin-1 immunostaining was detected in the Ag NPs group when compared to other groups. All these changes were alleviated by the usage of resveratrol through its anti-oxidant, anti-inflammatory, and activation of SIRT1 recommending its use as a renoprotective agent.

Explainable machine learning model incorporating social determinants of health to predict chronic kidney disease in type 2 diabetes patients

Background and objectives

Social determinants of health (SDOH) play a critical role in the onset and progression of chronic kidney disease (CKD). Despite the well-established role of SDOH, previous studies have not fully incorporated these factors in predicting CKD in Type 2 diabetes patients. To bridge this gap, this study aimed to develop and evaluate the machine learning (ML) models that incorporate SDOH to enhance CKD risk prediction in Type 2 diabetes patients.

Methods

Data were obtained from the 2023 Behavioral Risk Factor Surveillance System (BRFSS), a national survey that collects comprehensive health-related data from adults across the United States. Missing data were addressed using the K-nearest neighbor imputation method, and the Synthetic Minority Oversampling Technique (SMOTE) was applied to balance class distributions. Potential predictive features were selected using correlation coefficient analysis. The dataset was partitioned into training (80%) and testing (20%) subsets, with a 3-fold cross-validation strategy applied to the training data. Seven ML models were developed for CKD risk prediction, including logistic regression (LR), decision tree (DT), K-nearest neighbor (KNN), random forest (RF), eXtreme Gradient Boosting (XGBoost), and an artificial neural network (ANN). Model performance was evaluated using multiple metrics, including the area under the receiver operating characteristic curve (AUROC), precision, recall, F1 score, accuracy, and false positive rate.

Results

The study included 19,912 Type 2 diabetes patients (weighted sample size: 818,878), among whom 2,924 (weighted 13.92%) had CKD, and 16,988 (weighted 86.08%) did not. Over half of the CKD group (50.4%) were aged 65 or older. The proportion of female patients was higher in both groups, comprising 53.8% of the CKD group and 50.5% of the non-CKD group. Among the ML models evaluated, the RF model demonstrated the highest predictive performance for CKD, with an AUROC of 0.89 (95% CI: 0.88 - 0.90), followed by the DT model (0.84, 95% CI: 0.83 - 0.85) and XGBoost (0.83, 95% CI: 0.82 - 0.84). The RF model achieved an accuracy of 0.81 (95%CI: 0.81 - 0.81), a precision of 0.79 (95%CI: 0.79 - 0.79), a recall of 0.85 (95%CI: 0.85 - 0.85), and an F1 score of 0.82 (95%CI: 0.82 - 0.82). Additionally, the RF model exhibited strong calibration, reinforcing its reliability as a predictive tool for CKD risk in individuals with Type 2 diabetes.

Conclusion

The study findings underscore the potential of ML models, particularly the RF model, in accurately predicting CKD among individuals with Type 2 diabetes. This approach not only enhances the precision of CKD prediction but also highlights the importance of addressing social and environmental disparities in disease prevention and management. Leveraging ML models with SDOH can lead to earlier interventions, more personalized treatment plans, and improved health outcomes for vulnerable populations.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-025-01621-9.

Dynamic changes in metabolic syndrome components and chronic kidney disease risk: a population-based prospective cohort study

OBJECTIVE

To investigate the relationships between dynamic changes in metabolic syndrome (MetS) components and chronic kidney disease (CKD) risk.

METHODS

Data from the UK Biobank, including baseline assessments from 2006 to 2010, repeat assessments in 2012-2013, and linked national health records, were analyzed. MetS components consisted of abdominal obesity, elevated blood pressure (BP), fasting blood glucose (FBG), serum uric acid (SUA), and lipid abnormalities. The Kaplan-Meier method and log-rank test were used to analyze CKD incidence and group differences. Cox regression models assessed the association between dynamic changes in MetS components and CKD risk.

RESULTS

The study enrolled 455,060 participants (45.7% male, 18.4% aged 65 years or older) with a median follow-up of 12.68 years. Those with MetS had a significantly higher 10-year CKD cumulative incidence probability of CKD than those without MetS (4.14% VS 1.14%). Multivariate analysis showed all baseline metabolic abnormalities were linked to CKD risk with HRs from 1.40(1.35-1.45) to 1.85 (1.78-1.92), and MetS strongly associated with CKD (HR: 2.31). CKD risk rose with more MetS components and progression stages. Notably, with FBG being the exception, the four MetS components that shifted from normal at baseline to abnormal at follow - up were associated with elevated CKD risk, with HRs (95% CI) ranging from 1.21 (1.00-1.48) to 1.73 (1.34-2.24). Participants with high baseline SUA, even if it normalized at follow - up, still faced a 1.30 - fold higher CKD risk (95% CI: 1.25-1.35), distinct from other components. For those developing one and ≥ 2 new MetS components at follow - up, the CKD risk HRs (95% CI) were 1.49 (1.00-2.35) and 2.26 (1.21-4.24) respectively.

CONCLUSION

MetS and its component changes are significantly associated with CKD risk, in a dose - response pattern. Incorporating SUA into MetS assessments enhances risk identification, especially noting females' higher susceptibility to elevated SUA. Dynamic monitoring of MetS components is crucial for assessing and predicting CKD risk.

CLINICAL TRIAL NUMBER

Not applicable.

Increased incidence of anemia in individuals with impaired fasting glucose: a cohort study

AIMS

Anemia is common in diabetes patients, but its prevalence in pre-diabetes remains under-researched. Therefore, we aimed to investigate the incidence of anemia and potential risk factors in individuals with impaired fasting glucose using health examination data.

METHODS

A cohort of 7075 participants, all aged over 18 years and free of anemia at baseline, were included in this study to monitor the incidence of anemia through annual routine health check-ups. Cox regression models were used to estimate the age- and sex-adjusted hazard ratios of each risk factor.

RESULTS

The incidence of anemia among patients with impaired fasting glucose was 7.04 (95%CI: 6.08-8.00) per 1000 person-years overall, with a gender-specific incidence of 4.24 (95%CI: 3.37-5.10) and 15.21 (95%CI: 12.45-18.02) per 1000 person-years in men and women. COX regression analysis identified that female, lower levels of TC, LDL-C, ALT, AST, ALB, and alcohol drinking were associated with higher risk of anemia in individuals with impaired fasting glucose.

CONCLUSIONS

In individuals with impaired fasting glucose, anemia incidence differed by gender and age, being higher in women than men and surpassing that of the general Chinese population. Furthermore, lower levels of TC, LDL-C, ALT, AST, ALB, and alcohol drinking were associated with higher risk of anemia in individuals with impaired fasting glucose.

Transcutaneous ultrasonography for visualization of the kidneys in captive Asian elephants (Elephas maximus): a quantitative assessment of echogenicity and echotexture in comparison with the liver and spleen

BACKGROUND

Kidney transcutaneous ultrasonography can be used to assess renal condition and is less invasive than transrectal ultrasonography, which typically requires intensive restraint, sedation, or general anesthesia. To date, this less invasive technique has not been evaluated in Asian elephants (Elephas maximus). The gray level histogram technique associated with transcutaneous ultrasonography is a quantitative approach to objectively measure echogenicity and echotexture. This study utilized gray-level histograms (GLH) to assess echogenicity and echotexture of the kidneys, spleen, and liver of 49 captive Asian elephants via transcutaneous ultrasonography, to obtain a baseline for healthy animals and to compare various internal organs as a reference for quantitative analyses.

RESULTS

Retroperitoneal fat was the most hyperechoic region identified, followed by the spleen. The renal medullas and the left cortex were the three most homogenous tissues. No significant differences were found between the sexes or age groups.

CONCLUSIONS

This study found that transcutaneous ultrasonography could be used to quantitatively measure echogenicity and echotexture in captive Asian elephants using the GLH technique. Baseline GLH references were developed for healthy captive Asian elephants for renal, hepatic and splenic transcutaneous ultrasonography.

Flavokawain A Attenuated Chronic Kidney Disease: Evidence From Network Pharmacology and Experimental Verification

Chronic kidney disease (CKD) is a silent global epidemic affecting ~700 million people worldwide, contributing to rising mortality rates. Despite the variety of underlying causes, renal fibrosis is the key pathological feature of CKD. Flavokawain A (FKA), a natural chalcone, is thought to offer protective effects against CKD through its anti-inflammatory, antioxidant, and anti-fibrotic properties. This study aims to investigate the therapeutic potential of FKA against CKD, using network pharmacology (NP), molecular docking analysis, and In Vivo validation. GeneCards, SwissTargetPrediction, and SuperPred databases were utilized to identify therapeutic targets related to CKD and FKA. Protein-protein interactions (PPIs) were performed using the STRING database. Gene ontology and pathway enrichment analyses were performed with DAVID databases, followed by network construction in Cytoscape. For validation, molecular docking studies were performed using PyRx and tested at doses of 50 mg/kg and 100 mg/kg (p.o.) for 21 days using a unilateral ureteral obstruction (UUO) rat model. The study identified 109 therapeutic targets for FKA in relation to CKD, highlighting 11 hub targets and 78 potential pathways. Molecular docking showed strong binding efficacy with nuclear factor κB subunit 1 (NF-κB1) and matrix metallopeptidase 9 (MMP9). In vivo validation supported these findings, as FKA administration showed protective effects on kidney function and histology with the downregulation of extracellular matrix (ECM) markers, such as fibronectin (FN) and transforming growth factor β1 (TGF-β1), along with reduced expression of NF-κB1 and MMP9. These findings indicate that FKA could be a valuable therapeutic candidate for managing CKD by targeting NF-κB1 and MMP9.

Metalloproteinases (MMPs) in hypertensive disorders: role, function, pharmacology, and potential strategies to mitigate pathophysiological changes

Matrix metalloproteinases (MMPs) are a family of enzymes that play an important role in the pathophysiology of hypertensive disorders, particularly through their involvement in extracellular matrix (ECM) remodeling and vascular dysfunction. Their activity is closely linked to hypertension-mediated organ damage, which affects the vascular and cardio-renal systems. MMPs are responsible for degrading various components of the ECM, which is crucial for maintaining vascular structure and function. In hypertensive patients, several MMPs, including MMP-1, MMP-3, and MMP-9, are often found at elevated levels. This is associated with vascular remodeling and dysfunction due to chronic high blood pressure. The activation of MMPs in hypertension can be triggered by several factors, such as oxidative stress, inflammatory cytokines, and vasoactive agents like angiotensin II. In addition to increasing MMP activity, these variables cause an imbalance between MMPs and tissue inhibitors of metalloproteinases (TIMPs), which are the MMPs' natural inhibitors. This imbalance contributes to excessive degradation of the ECM and promotes pathological changes in vascular smooth muscle cells (VSMCs), leading to their transition from a contractile to a synthetic phenotype. This shift facilitates cell growth and migration, exacerbating vascular remodeling. Given their critical roles in hypertension-related organ damage, MMPs are being explored as potential pharmacological targets. Inhibitors of MMPs may help mitigate the adverse effects of hypertension by restoring balance in ECM remodeling processes. Understanding their mechanisms opens avenues for targeted therapies that could significantly improve outcomes for individuals suffering from hypertension-related complications.

Predicting catheter removal in peritoneal dialysis peritonitis patients visiting the emergency department: a multivariable logistic regression and decision tree analysis

Peritonitis is a debilitating complication of peritoneal dialysis (PD). Identifying high-risk patients requiring PD catheter removal based on early information in the emergency room (ER) is critical. This cross-sectional study included 518 PD patients who visited the ER in the Chang Gung Memorial Hospital, Chia-Yi branch between 2002 and 2018. Among the 518 PD patients, 31 (6%) required PD catheter removed during the visit. Decision tree analysis, incorporating five key factors (neutrophil count, CRP, age, sodium, and albumin), identified 16 terminal nodes (TNs), with four higher risk groups (> 20%): lower neutrophils with lower CRP and younger age (TN1), lower neutrophils with higher CRP (TN4), higher neutrophils with moderate age and lower albumin (TN14), and high neutrophils with older age (TN16). Decision tree analysis effectively predicts the optimal timing for catheter removal in PD peritonitis patients. Clinically, this approach helps reduce mortality resulting from delayed catheter removal.

Establishment of adult reference interval of oxalate in spot urine using real-world data

BACKGROUND

Hyperoxaluria, characterized by excessive oxalate production, can be attributed to high dietary oxalate intake, genetic disorders affecting oxalate metabolism, or certain intestinal diseases. Despite its clinical significance, there is a paucity of comprehensive discussions regarding the reference interval (RI) for oxalate levels in spot urine samples. This study aims to establish an appropriate adult RI for oxalate in spot urine to enhance the interpretation of clinical data.

METHODS

Between January 2021 and July 2021, a cohort of 608 adults aged 19 to 85 years undergoing routine physical examinations was recruited to establish the RI. Additionally, 381 adults with complete datasets were analyzed to examine variables influencing the urinary oxalate/urinary creatinine (UOA/UCr) ratio. Urinary oxalate levels were quantified using a high-performance liquid chromatography assay assured by a proficiency testing from the College of American Pathologists.

RESULTS

The study established sex- and age-specific Ris for the UOA/UCr ratio. For males, three age-specific partitions were identified: 19-29 years (8.499-54.39 mmol/mol), 30-39 years (10.25-61.29 mmol/mol), and ≥ 40 years (12.13-68.69 mmol/mol). In contrast, for females, two age-specific partitions were required: 19-39 years (11.03-64.93 mmol/mol) and ≥ 40 years (11.00-93.84 mmol/mol). UALB/UCr and UREA were recognized as key confounding factors in linear regression that could account for the differences in the UOA/UCr ratio in people.

CONCLUSION

Determining adult RI of oxalate in spot urine is crucial for diagnosing hyperoxaluria. Our sex and age-specific reference intervals will be beneficial for hyperoxaluria screening. The findings regarding the relationship between variables support explaining the variation of UOA/UCr ratio in individuals.

Urinary proteins from stone formers promote calcium oxalate crystallization, growth and aggregation via oxidative modifications

INTRODUCTION

Various urinary parameters are used for determining kidney stone risk. However, almost all of the widely used lithogenic indices rely on urinary concentrations of small molecules/ions and pH.

OBJECTIVE

To address whether urinary macromolecules (especially oxidatively modified proteins) also play a critical role in determining the stone risk.

METHODS

Complexed urinary proteins (proteome) were purified from healthy individuals and calcium oxalate (CaOx) stone formers and performed various crystal assays and quantitative proteomics to compare them. Bioinformatic analyses were performed to gain additional insights, and the obtained data were verified by ELISA.

RESULTS

While the normal urinary proteome inhibited CaOx stone-forming mechanisms (i.e., crystallization, growth and aggregation), the stone formers' urinary proteome promoted all these CaOx crystal parameters. Descriptive proteomics by nanoLC-ESI-LTQ-Orbitrap-MS/MS analysis identified 203 and 381 proteins in the urine of healthy individuals and stone formers, respectively. Analyses of physicochemical properties revealed only molecular mass and isoelectric point that slightly increased in the stone formers' urine, whereas instability index, grand average of hydrophathicity (GRAVY) and amino acid composition were comparable. Interestingly, proportion of oxidatively modified proteins (particularly those with methionine oxidation, methionine dioxidation and cysteine trioxidation) markedly increased (∼2.5-fold) in the stone formers' urine. Quantitative proteomics revealed 89 increased and 56 decreased proteins in the stone formers' urine. The oxidized proteins had a greater proportion (>3-fold) in the increased proteins (77 %) compared with the decreased ones (23 %), whereas the non-oxidized proteins showed comparable proportions (54 % and 46 %, respectively). Functional enrichment analyses revealed a correlation between the increased proteins and oxidative stress biological processes and molecular functions. Finally, ELISA confirmed the significantly increased levels of oxidized proteins in the stone formers' urine compared with that of healthy individuals.

CONCLUSION

These data implicate that oxidatively modified proteome serves as a key pathogenic factor or risk for CaOx kidney stone formation.

The prognostic value of serum hepcidin-25 in predicting cardiovascular events among maintenance hemodialysis patients: insights from the INFINITY cohort

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of mortality among maintenance hemodialysis patients, with iron metabolism disorders, particularly involving hepcidin, contributing to this heightened risk. This study aimed to evaluate whether serum hepcidin-25 levels are associated with the incidence of new CVD events in maintenance hemodialysis patients, using a novel, clinically applicable assay.

METHODS

In this prospective, multicenter observational study, 567 maintenance hemodialysis patients from the INFINITY Cohort in Japan were followed for one year. Serum hepcidin-25 levels were measured using a latex turbidimetric immunoassay. The primary outcome was the incidence of new CVD events, including myocardial infarction, angina, and stroke. Logistic regression and Cox proportional hazards models were used to identify factors associated with new CVD events.

RESULTS

During the one-year follow-up, 42 patients (7.4%) experienced new CVD events. Patients with new CVD events had significantly lower serum hepcidin-25 levels compared to those without events (19.0 vs. 37.8 ng/mL, P < 0.05). Multivariate logistic regression analysis revealed that lower hepcidin-25 levels (odds ratio 0.82, 95% confidence interval 0.72-0.94, P = 0.0036), higher glycoalbumin levels, and lower high-density lipoprotein cholesterol levels were independently associated with increased CVD risk.

CONCLUSIONS

Lower serum hepcidin-25 levels were independently associated with an increased risk of new CVD events in maintenance hemodialysis patients. Serum hepcidin-25 may serve as a potential biomarker for predicting cardiovascular risk, and addressing iron deficiency could help mitigate this risk.

FOTELP-VOX-OA: Enhancing radiotherapy planning precision with particle transport simulations and Optimization Algorithms

BACKGROUND AND OBJECTIVE

Accurate tumor targeting with minimal exposure to healthy tissue remains a significant challenge in radiotherapy. Modern techniques like Intensity-Modulated Radiation Therapy and stereotactic radiotherapy increasingly rely on detailed simulations and planning to achieve maximum treatment efficiency. Particle transport simulations play a crucial role in accurately modeling interactions between radiation and biological structures, providing a foundation for advancements in treatment planning. Building on this, FOTELP-VOX-OA is introduced as a novel framework designed to determine the optimal external-beam radiotherapy treatment plan. The primary aim of this study is to integrate the existing FOTELP-VOX framework with various Optimization Algorithms, focusing on estimating the parameters of interest that lead to the optimal radiation dose. While the framework itself is not pathology-specific, ocular melanoma is chosen as a test case due to its requirement for exceptionally precise dose delivery, given the small tumor volume and proximity of critical ocular structures.

METHODS

Particle transport simulations were conducted with FOTELP-VOX software, enabling detailed dose distribution analysis in tissues. Simulated conditions included a detailed biological model of eye melanoma to closely mimic clinical scenarios. The study integrates advanced optimization algorithms, such as Random Search, Tree-structured Parzen Estimator, and Genetic Algorithm, into the FOTELP-VOX framework, creating FOTELP-VOX-OA, to achieve the optimal treatment plan. Additionally, a specialized metric named Total Error was developed to determine the efficiency of the proposed treatment plan, focusing on both the desired tumor dose and minimizing exposure to surrounding tissues.

RESULTS

In the presented case-study, FOTELP-VOX-OA, utilizing the Genetic Algorithm, achieved a Total Error of 1701.52, significantly improving treatment planning compared to a human expert. However, this approach required the longest computation time among all methods. In contrast, the Tree-structured Parzen Estimator within the FOTELP-VOX-OA framework provided a balanced trade-off between speed and accuracy, while the Random Search-based solution was the fastest but also the least accurate.

CONCLUSION

The FOTELP-VOX-OA framework improves radiotherapy precision, reduces risks to surrounding healthy tissues, and achieves better treatment outcomes. This approach demonstrates how particle transport simulations, coupled with optimization techniques, can address critical challenges in radiotherapy planning, paving the way for future applications in other tumor sites and clinical contexts.

The Immune Microenvironment: New Therapeutic Implications in Organ Fibrosis

Fibrosis, characterized by abnormal deposition of structural proteins, is a major cause of tissue dysfunction in chronic diseases. The disease burden associated with progressive fibrosis is substantial, and currently approved drugs are unable to effectively reverse it. Immune cells are increasingly recognized as crucial regulators in the pathological process of fibrosis by releasing effector molecules, such as cytokines, chemokines, extracellular vesicles, metabolites, proteases, or intercellular contact. Therefore, targeting the immune microenvironment can be a potential strategy for fibrosis reduction and reversion. This review summarizes the recent advances in the understanding of the immune microenvironment in fibrosis including phenotypic and functional transformations of immune cells and the interaction of immune cells with other cells. The novel opportunities for the discovery and development of drugs for immune microenvironment remodeling and their associated challenges are also discussed.

Anemia risk and mitigation strategies in type 2 diabetic patients: The role of novel antidiabetic agents

Anemia is a common yet often overlooked complication in patients with type 2 diabetes mellitus (T2DM), particularly those with chronic kidney disease. It significantly impacts patients' quality of life, cardiovascular health, and treatment outcomes. Despite its high prevalence, current clinical guidelines lack specific recommendations for anemia prevention and management in T2DM, especially in the context of newer antidiabetic therapies. This review explores the potential of emerging antidiabetic medications, such as sodium-glucose cotransporter-2 inhibitors, glucagon-like peptide-1 receptor agonists (GLP-1 RAs), and combined GLP-1-RA/GIP to mitigate anemia risk. Early detection and management of anemia in T2DM patients are crucial for improving glycemic control, reducing cardiovascular morbidity, and enhancing overall treatment outcomes. This review underscores the need for further research to better understand the mechanisms by which these novel therapies influence anemia risk and to integrate these findings into clinical practice.

Plasma proteome signatures of ASK1 inhibition by selonsertib associate with efficacy in the MOSAIC randomized trial for diabetic kidney disease

Oxidative stress is a driver of acute and chronic kidney injury. Selonsertib is a clinical stage antagonist of ASK1 (MAP3K5), a serine/threonine kinase that is a mediator of oxidative stress signaling pathways. Selonsertib has demonstrated promising effects on preserving kidney function in the Phase2b Diabetic Kidney Disease (DKD) MOSAIC trial. However, little is known about the biological effects of ASK1 inhibition by selonsertib and its potential mechanism of action in DKD. We identified a plasma proteome signature of selonsertib activity that implicates numerous signaling pathways that regulate fibrosis, inflammation and oxidative stress response demonstrating translation of non-clinical models to the clinic. We further demonstrate that the effects of selonsertib on the plasma proteome are most pronounced in a subset of patients with poor baseline kidney function but who respond well to selonsertib treatment. This observation has implications for the future development of ASK1 inhibitors in a distinct patient population with DKD.

Safety and Efficacy of Fluoroscopy-Free Technique During Retrograde Intrarenal Surgery for Renal Stones: A Prospective, Randomized, Controlled, Noninferiority Trial

Purpose: Fluoroscopy-free (FF) retrograde intrarenal surgery (RIRS) presents a promising alternative to fluoroscopy-guided (FG) RIRS to reduce radiation exposure in endourology. This study aimed to assess the noninferiority of FF-RIRS compared with FG-RIRS regarding safety and efficacy. Patients and Methods: A prospective, randomized trial was conducted at a tertiary care center from November 2021 to June 2024. Adult patients with renal stones (10-30 mm) eligible for RIRS were randomized to either the FF-RIRS group (direct endoscopic visualization) or the FG-RIRS group. The primary endpoint was the stone-free rate (SFR), with secondary outcomes including stone size reduction, fluoroscopy use in FF-RIRS, operative time, hospital stay, reintervention, and complication rates. Results: The final analysis included 253 patients in the FF-RIRS group and 249 in the FG-RIRS group. The mean age was 41.3 ± 12.3 years, and the mean stone size was 16.5 ± 3.2 mm. In the FF-RIRS group, 214 procedures (84.6%) were performed without fluoroscopy, whereas 39 (15.4%) required fluoroscopy because of intraoperative challenges. Regression analysis identified multiple stones and congenital renal anomalies as predictors for fluoroscopy use. SFRs were comparable between groups (zero residual fragments [RF]: 54.9% vs. 51.0%, no RF >2 mm: 70.4% vs. 69.1%, no RF >4 mm: 79.4% vs. 82.3%) (p > 0.05). For SFR defined as no RF >4 mm, FF-RIRS demonstrated noninferiority with a -10% margin (p = 0.021). Furthermore, per-protocol analysis confirmed noninferiority (p = 0.002), with nearly equal SFRs (82.7% vs. 82.3%, p = 0.914). Stone size reduction, operative time, hospital stay, reintervention, and complication rates were similar between groups, with no serious adverse events. Conclusions: FF-RIRS is a safe and effective alternative to FG-RIRS for selected patients. Its safety and efficacy are noninferior to FG-RIRS in direct comparison. However, fluoroscopy should remain available as a backup, especially in complex cases, to ensure optimal outcomes and patient safety.

Predictors and associations of complications in ureteroscopy for stone disease using AI: outcomes from the FLEXOR registry

We aimed to develop machine learning(ML) algorithms to evaluate complications of flexible ureteroscopy and laser lithotripsy(fURSL), providing a valid predictive model. 15 ML algorithms were trained on a large number fURSL data from > 6500 patients from the international FLEXOR database. fURSL complications included pelvicalyceal system(PCS) bleeding, ureteric/PCS injury, fever and sepsis. Pre-treatment characteristics served as input for ML training and testing. Correlation and logistic regression analysis were carried out by a multi-task neural network, while explainable AI was used for the predictive model. ML algorithms performed excellently. For intraoperative PCS bleeding, Extra Tree Classifier achieved the best accuracy at 95.03% (precision 80.99%), and greatest correlation with stone diameter(0.21) and residual fragments(0.26). PCS injury was best predicted by RandomForest (accuracy 97.72%, precision 63.50%). XGBoost performed best for ureteric injury (accuracy 96.88%, precision 60.67%). Both demonstrated moderate correlation with preoperative characteristics. Postoperative fever was predicted by Extra Tree Classifier with 91.34% accuracy (precision 58.20%). Cat Boost Classifier predicted postoperative sepsis with 99.15% accuracy (precision 66.38%), and the best overall performance. At logistic regression, postoperative fever/sepsis positively correlated with preoperative urine culture(p = 0.001). ML represents a powerful tool for automatic prediction of outcomes. Our study showed promises in algorithms training and validation on a very large database of patients treated for urolithiasis, with excellent accuracy for prediction of complications. With further research, reliable predictive nomograms could be created based on ML analysis, to serve as aid to urologists and patients in the decision making and treatment planning process.

On-treatment serum albumin levels can predict 28-day mortality and guide albumin infusion in sepsis patients

Background

As the most abundant protein in plasma, albumin (ALB) presents close association with prognosis of septic patients. Whereas, the benefit and the target level of ALB infusion remain controversial.

Methods

We conducted a retrospective investigation to assess whether on-treatment ALB levels could predict 28-day mortality and try to identify the optimal level for ALB infusion. All patients diagnosed as sepsis from January 2016 to December 2020 were recruited and re-evaluated using Sepsis-3 criteria.

Results

A total of 199 eligible patients were enrolled in this study. Compared with the survival group, the non-survival group had more males (73.97 vs. 56.35%), older patients (62.78 ± 15.93 vs. 56.43 ± 18.46), and a higher proportion of Gram-positive bacterial infection (27.40 vs. 23.02%), higher Sequential Organ Failure Assessment (SOFA) score (7.00-13.00 vs. 6.00-12.00), higher APACHE II score (18.25-29.00 vs. 15.00-26.00), higher PCT (2.84-49.18 vs. 2.43-19.14), more patients with septic shock (65.75%vs. 43.65%), shorter ICU-stay days (11.04 ± 6.28 vs. 14.83 ± 8.58), longer mechanical ventilation days (7.23 ± 7.07 vs. 5.04 ± 8.52), with statistically significant differences (p < 0.050). Furthermore, we identified that the ALB level on day 7 (HR, 0.920; 95% CI, 0.847 to 0.999; p = 0.046) and the maximum ALB level within the first 14 days (HR, 0.900; 95% CI, 0.838 to 0.967; p = 0.004) were independent protective factor for the 28-day prognosis in septic patients. Moreover, ROC curve analysis indicated that optimal target level for first 14-day maximum and on day 7 were 33.45 g/L and 27.85 g/L, respectively. Correspondingly, a negative correlation between ALB level and mortality was defined with Kaplan-Meier survival curve analysis. Further subgroup analysis showed that the group with ALB above the cut-off value was associated with favorable outcomes in female patients under 60 years, with SOFA score less than 7, and APACHE II score less than 19.

Conclusion

ALB levels on day 7 and the maximum ALB level within first 14 days after ICU admission were closely associated with 28-day mortality. 27.85 g/L would work as the target level of ALB infusion on 7 day to improve the prognosis of sepsis patients.

Predictive role of cystatin C and increased proteinuria in early assessment of acute renal toxicity in patient poisoned by nephrotoxic drugs and poisons

BACKGROUND

Acute kidney injury (AKI) is prevalent in critical care, often due to nephrotoxic drug exposure, which accounts for significant morbidity and mortality. Current biomarkers, like serum creatinine, lack sensitivity for early detection of nephrotoxicity.

AIM

This study evaluates proteinuria and serum cystatin C as early indicators of nephrotoxicity in acutely poisoned patients at Sohag University Hospitals.

METHODS

This prospective study involved 100 acutely poisoned patients with nephrotoxic effects admitted to Sohag University Hospitals from April to August 2021. Inclusion criteria required symptomatic patients who provided at least four blood or urine samples, including one within 24 h post-ingestion. AKI was classified using the Acute Kidney Injury Network (AKIN) criteria, with baseline serum creatinine estimated from the lowest value during hospitalization. Biomarkers, including serum creatinine and cystatin C, were measured using standard assays for analysis.

RESULTS

The study included 100 patients aged 2 to 58 years, predominantly male (72%). Most participants were from rural areas (82%). Serum creatinine levels significantly increased from day 1 (mean ± SD: 1.67 ± 0.6 mg/dL) to day 2 (mean ± SD: 2.98 ± 1.35 mg/dL). Significant predictors of acute renal toxicity included serum creatinine on both days (P < 0.001), proteinuria ACR (P = 0.023), and cystatin C (P < 0.001). Cystatin C had the highest predictive value (AUC = 0.993), while proteinuria ACR and day 2 serum creatinine showed significant predictive capabilities (AUCs of 0.805 and 0.873, respectively).

CONCLUSION

In conclusion, proteinuria and cystatin C are reliable predictors for early nephrotoxicity detection in acutely poisoned patients at Sohag University Hospitals. These biomarkers effectively indicate and assess the severity of kidney injury caused by toxicity.

A higher preoperative total protein to albumin ratio independently predicted more severe postoperative acute kidney injury in patients with acute type A aortic dissection: a retrospective cohort study of 224 cases

Objectives

In this retrospective study, we investigated the incidence of postoperative acute kidney injury (AKI) and determined the predictors associated with AKI in patients underwent surgeries for acute type A aortic dissection (ATAAD).

Methods

We enrolled patients diagnosed with ATAAD and received operation. AKI was defined based on the Kidney Disease: Improving Global Outcomes criteria. Potential perioperative predictors were evaluated for postoperative AKI. Univariate and multivariate regression analyses were conducted to identify predictors associated with AKI following surgery. The primary end point was the incidence of postoperative AKI, while the secondary end points included in-hospital mortality and other major surgical complications.

Results

This study enrolled 224 patients in all. There were 155 (69.2%) patients with postoperative AKI, including 55 (24.6%) with KDIGO stage 1, 45 (20.1%) with stage 2 and 55 (24.6%) with stage 3. Twenty-eight patients (12.5%) needed renal replacement therapy after surgery. The total in-hospital mortality was 2.7% (AKI vs. non-AKI: 3.2% vs. 1.4%, p = 0.669). Multivariate regression analysis found total protein concentrations [odds ratio (OR) 1.136, 95% confidence interval (CI): 1.032-1.250, p = 0.009], intraoperative blood loss (OR 1.002, 95% CI: 1.000-1.004, p = 0.042) and ventilation time (OR 1.011, 95% CI: 1.001-1.021, p = 0.026) were independently associated with AKI. The area under the receiver operating characteristic curve was 0.688 (95% CI: 0.617-0.759). Our predictive model demonstrated a sensitivity of 72.5% and a specificity of 57.4%. The ordinal logistic regression analysis found that age (OR 1.055, 95% CI: 1.027-1.084, p < 0.001), body mass index (OR 1.194, 95% CI: 1.104-1.291, p < 0.001), a high total protein to albumin ratio (OR 2.615, 95% CI: 1.234-5.540, p = 0.012) and ventilation time (OR 1.005, 95% CI: 1.001-1.008, p = 0.005) were independently associated with the severity of AKI.

Conclusion

A higher preoperative total protein to albumin ratio independently predicted more severe postoperative AKI in patients undergoing surgical treatment for ATAAD. Monitoring preoperative total protein concentrations and the total protein to albumin ratio may assist in identifying patients at higher risk of progressing to severe AKI, though further multicenter validation is required.

Sialosis (Sialadenosis): A Sialographic Study with Clinical Correlates

OBJECTIVE

Characterize radiographic findings and co-existing pathologic processes in the parotid glands of patients with swelling or pain identified on radiographic review to be consistent with sialosis (sialadenosis) employing dynamic infusion digital sialography correlated with computed tomography (CT).

METHODS

Retrospective chart review of a consecutive series of 578 sialograms performed by the senior investigator over a 16-year period identified 39 patients with 1 or both parotid gland sialograms recorded as "sialosis" by radiologists' interpretation. After inclusion and exclusion criteria were applied, 20 patients remained for evaluation. A review of sialograms was conducted by a senior radiologist to identify co-existing pathologies (ex: stricture, sialectasis, sialolith) as well as characterize an overall aggregate impression and specific findings of ductal curvature, splaying, and truncation on a numerical scale from 1 (absent finding) to 10 (severely abnormal). Two normal sialograms served as controls. The density of each gland was assessed through CT measurement of Hounsfield units (HU). Variables collected included sex, age, symptoms, BMI, alcohol use, and comorbidities.

RESULTS

Twenty patients with a total of 27 glands classified as "sialosis" on sialography and 2 patients with normal sialography findings were evaluated. Indications for sialography included pain (90%), fluctuation in swelling of the parotid gland(s) (65%), or xerostomia (35%). Sialographic analysis identified 7 glands (26%) with sialosis to have an additional co-existing pathology (2 with strictures, 5 with sialectasis). Consistent features in glands with sialosis included ductal curvature, splaying, and truncation. CT analysis of glands with sialosis identified a median HU measurement of -36 compared to +30 for glands identified as normal (P = .03).

CONCLUSION

Sialography is useful in selected patients to evaluate for co-existing pathologies contributing to salivary symptoms. Sialography additionally demonstrates consistent findings (ductal curvature, splaying, and truncation) associated with sialosis that correlate with fat infiltration identified on CT imaging.

A novel predictive method for URS and laser lithotripsy using machine learning and explainable AI: results from the FLEXOR international database

PURPOSE

We developed Machine learning (ML) algorithms to predict ureteroscopy (URS) outcomes, offering insights into diagnosis and treatment planning, personalised care and improved clinical decision-making.

METHODS

FLEXOR is a large international multicentric database including 6669 patients treated with URS for urolithiasis from 2015 to 2023. Preoperative and postoperative(PO) correlations were investigated through 15 ML-trained algorithms. Outcomes included stone free status (SFS, at 3-month imaging follow up), intraoperative (PCS bleeding, ureteric/PCS injury, need for postoperative drainage) and PO complications (fever, sepsis, need for reintervention). ML was applied for the prediction, correlation and logistic regression analysis. Explainable AI emphasizes key features and their contributions to the output.

RESULTS

Extra Tree Classifier achieved the best accuracy (81%) in predicting SFS. PCS bleed was negatively linked with 'positive urine culture'(-0.08), 'tamsulosin'(-0.08), 'stone location'(-0.10), 'fibre optic scope'(-0.19), 'Moses Fibre'(-0.09), and 'TFL'(-0.09), and positively with 'elevated creatine'(0.25), 'fever'(0.11), and 'stone diameter'(0.21). 'PCS injury' and 'ureteric injury' both showed moderate correlation with 'elevated creatinine'(0.11), 'fever'(0.10), and 'lower pole stone'(0.09). 'Tamsulosin'(0.23) use, presence of 'multiple'(0.25) or 'lower pole'(0.25) stones, 'reusable scope'(0.17) and 'Moses Fibre'(0.2546) increased the risk for PO stent, while 'digital scope'(-0.13) or 'TFL'(-0.29) reduced it. 'Preoperative fever'(0.10), 'positive urine culture'(0.16), and 'stone diameter'(0.10) may play a role in 'PO fever' and 'sepsis'. SFS was mainly influenced by 'age'(0.12), 'preoperative fever'(0.09), 'multiple stones'(0.15), 'stone diameter'(0.17), 'Moses Fibre"(0.15) and 'TFL'(-0.28).

CONCLUSION

ML is valuable tool for accurately predicting outcomes by analysing pre-existing datasets. Our model demonstrated strong performance in outcomes and risks prediction, laying the groundwork for development of accessible predictive models.

Crescentic Glomerulonephritis Possibly Caused by COVID-19 Infection

Background: The COVID-19 (coronavirus disease 2019) pandemic has presented a serious challenge to nephrologists, since it can lead to severe kidney injury in the form of acute tubular necrosis, with many patients requiring renal replacement therapy. This is predominantly seen in people who develop severe respiratory manifestations like ARDS (acute respiratory distress syndrome) from the viral infection, a cytokine storm or septic shock with unstable hemodynamics. It also presents with various glomerular injuries, mainly collapsing glomerulopathy in high-risk APOL1 (Apolipoprotein L1) genotype patients, thrombotic microangiopathy-related renal failure due to hyper coagulopathy and occasionally pauci-immune glomerulonephritis due to immune dysregulation. All the glomerular disorders that are caused by COVID-19 infection have been described under the designation COVAN (COVID-19-associated nephropathy). Proteinuria is a predominant presentation in glomerular disorders. Gross hematuria and AKI without any respiratory symptoms from COVID-19 infection have not been described so far in the literature. We are presenting one such rare case here. Methods: We have encountered a rare case of gross hematuria and severe acute renal failure. His serological work up was negative for all autoimmune etiologies that can cause Glomerulonephritis. He was found to have infection-related crescentic glomerulonephritis due to active COVID-19 infections discovered via kidney biopsy. He tested positive for SARS-CoV-2 but didn't have any clinical respiratory symptoms. He has responded well to treatment with a steroid taper and antiviral medication (Remdesivir). This is a very rare renal manifestation of COVID-19 infection. Results: COVID-19 infection can result in crescentic glomerulonephritis. This can be diagnosed by kidney biopsy which shows extensive c3 deposits, tubuloreticular inclusion bodies along with crescentic lesions. This responds to treatment with steroids and Antiviral agents. Conclusions: Crescentic Glomerulonephritis should be considered as a possible etiology for severe acute kidney injury with hematuria in patients with active covid-19 infection without any respiratory symptoms. Kidney biopsy helps in diagnosing it and responds to treatment with steroids and antivirals.