The role of hyperuricemia in the progression of end-stage kidney disease and its molecular prospective in inflammation and cardiovascular diseases: A general review

With the ongoing development of the Chinese economy, the occurrence of chronic kidney disease (CKD) has experienced a remarkable upsurge recently, and due to uremia caused by CKD, the number of patients undergoing dialysis has shown a dramatic increase. China has been ranked first in the world for patients undergoing hemodialysis (HD) and peritoneal dialysis (PD) with approximately one million patients across the country. Due to the loss of kidney function caused by CKD, the kidneys tend to lose their ability to excrete uric acid (UA) out of the body; therefore, most patients undergoing dialysis are complicated with hyperuricemia (HUA). HUA is an abnormal disease of purine metabolism, and it's considered a chronic disease. More than 90% of patients suffering from HUA will not show any symptoms on physical examination. According to statistics, if high serum UA is left untreated, 55% of patients will develop severe problems due to the purine crystallization in the body, and the kidneys are the most affected organs by HUA causing renal insufficiency that can promote end-stage kidney disease (ESKD) by activating the renin-angiotensin system (RAS), which will lead to inflammation, arteriosclerosis, cardiovascular diseases (CVD), and other diseases. Lifestyle modifications and pharmacological interventions are the first primary choice for lowering UA, although dialysis will tend to reduce the high UA levels in the blood, drugs are also necessary. This review will summarize the mechanisms and metabolism of UA, the relationship between HUA and ESKD progression, HUA and inflammation, HUA and CVD, and pharmacological treatment of HUA.

Magnesium and Migraine

Migraine is a widespread and intricate neurological condition that involves various factors and is marked by recurring headache episodes. Migraine is among the ten neurological conditions accounting for the greatest disability in the whole population, the leading cause of disability for children and adolescents aged 5-19 years, and the second cause of disability for adults aged 20-59 years. Magnesium deficiency is also a very common condition resulting from diverse reasons, including insufficient dietary consumption or increased loss through the gastrointestinal or renal system. Accumulated evidence from case reports, case-control studies, observational studies, and randomized, placebo-controlled trials has shown the effectiveness of magnesium supplementation in alleviating migraine, both acutely and chronically. Mechanisms that may help explain these results include the potential link between magnesium deficit and spreading cortical depression, vascular changes, oxidative stress, chronic inflammation, nervous excitation, neurotransmitter release, and electrolyte imbalances. This article aims to provide a comprehensive review of the available evidence on the links between magnesium and migraine, considering the role of magnesium in the pathogenesis of migraine and the utility of magnesium in its prevention and treatment.

DEKODE-A cloud-based performance feedback model improved DKA care across multiple hospitals in the UK

AIM

A current gap in Diabetes-related ketoacidosis (DKA) research is understanding the factors contributing to variations in care and outcomes between people admitted with DKA. We aimed to create a system to facilitate gathering data on DKA management across multiple centres and identify trends in complications and outcomes associated with DKA.

RESEARCH DESIGN AND METHODS

Between January 2020 and December 2022, we set up a cloud-based Quality improvement project (QIP) that provided regular feedback to 11 hospitals in the United Kingdom (UK).

RESULTS

Of the 1977 episodes, we observed an increase in adherence in fluid prescription in hospitals C, D, E, F and G (C- 23% vs. 75% p = <0.001; D- 27% vs. 60%, p = <0.001; E- 17 vs. 79% p = <0.001; F- 16% vs. 57%, p = <0.001; G- 36% vs. 75% p = <0.001). Notable improvements in adherence to glucose monitoring were observed in hospitals B, D, and G (B- 11 vs. 38% p = <0.001; D- 36% vs. 56%, p = 0.05; G- 22% vs. 67% p = <0.001). Although we didn't observe significant changes in complications and outcomes among participating hospitals from the start to the end of the reported period, notable fluctuations were evident across quarters. These variations were relayed to the respective hospitals, underscoring how feedback and interventions could influence the care provided. This initiative also marks the initial move towards establishing and improving data collection practices in acute diabetes.

CONCLUSIONS

We demonstrate a sustainable QIP that improves adherence to national guidelines in some indicators for DKA care and serves as an early warning system to identify adverse trends.

An analysis of the burden of urolithiasis: differences between the global, China, India and the United States, with projections through 2050

This report analyzes the patterns of urolithiasis in China, India, the United States, and globally from 1990 to 2021 using data from the Global Burden of Disease Study (GBD) 2021. Various techniques such as the Joinpoint model, age-period-cohort analysis, decomposition analysis, health inequities analysis, and the Bayesian age-period-cohort model were applied. According to the Joinpoint model, the average annual percent change (AAPC) for incidence, disability-adjusted life years, and mortality related to urolithiasis globally was negative. However, Indian women showed a positive AAPC of 0.20 in age-standardized incidence rate (ASIR). Both sexes in the United States showed positive AAPCs for age-standardized mortality rate (ASMR). The age-period-cohort analysis indicates that the peak ASIR occurs around ages 50-60. According to decomposition analysis, the main factors contributing to the rising burden of urolithiasis are population aging and growth, whereas changes in the disease's epidemiology slow its growth. Health inequities analysis shows increasing disparities between regions with high and low socio-demographic index (SDI). Forecasting models predict continued rise in prevalence without intervention. Overall, among the three countries, India faces the highest health burden, particularly among younger populations and women, whereas the United States experiences higher mortality rates among the elderly. Despite significant progress made by China in controlling urinary health burdens over the past three decades, the high incidence of urolithiasis and its subsequent impacts remain a concern, particularly in light of the country's demographic structure.

Pro-Tumorigenic Effect of Continuous Cromolyn Treatment in Bladder Cancer

Globally, bladder cancer is the sixth most frequently diagnosed cancer among men. Despite the increasing availability of immunomodulatory treatments for bladder cancer, the survival rates are still low, which calls for potential new drug-repurposing targets. This study aimed to investigate the effects of cromolyn, a mast cell (MC) stabilizer in allergic reactions, on a subcutaneous tumor model with a syngeneic mouse MB49 bladder cancer cell line. A concentration of 50 mg/kg of cromolyn was daily administered intraperitoneally in a 4-day therapeutic protocol to mice with established tumors and in a continuous 11-day protocol which started one day prior to the subcutaneous injection of tumor cells. Therapeutic treatment demonstrated a marked downregulation of genes related to angiogenesis and upregulation of genes related to cytotoxic T-cell and NK cell activity. Conversely, continuous cromolyn treatment suppressed genes involved in immune cell recruitment and activation, as well as apoptotic and necroptotic pathways, leading to a greater tumor burden (+142.4 mg [95CI + 28.42, +256.4], p = 0.0158). The same pro-tumorigenic effect was found in mast cell-deficient mice (KitW-sh/W-sh + 301.7 mg [95CI + 87.99, 515.4], p = 0.0079; Cpa3Cre/+ +107.2 mg [95CI - 39.37, +253.57], p = 0.1423), indicating that continuous cromolyn treatment mostly acts through the inhibition of mast cell degranulation. In summary, our results demonstrate the distinct effects of cromolyn on tumor progression, which depend on the protocol of cromolyn administration.

Molecular insights into cell signaling pathways in kidney stone formation

Urolithiasis, or kidney stones, has emerged as a significant public health concern. Despite this, effective treatments targeting stone formation and recurrence are limited. This review delves into the molecular mechanisms underlying the condition. Investigating these molecular aspects can address existing gaps in treatment options. Future research can uncover new therapeutic strategies by targeting downstream pathways, and effector molecules. Cell signaling pathways offer potential targets, as they involve complex interactions that can be modulated to address multiple clinical symptoms. An imbalance in calcium and oxalate levels can lead to kidney stone formation which is characterized by oxidative stress, inflammation, and cell death. The interplay between key organelles like the endoplasmic reticulum and mitochondria triggers stress pathways, including oxidative stress and apoptosis. This review consolidates recent advances in understanding the pathophysiology and signaling events associated with kidney stones.

Biomarkers to predict or measure steroid resistance in idiopathic nephrotic syndrome: A systematic review

In this systematic review we have sought to summarise the current knowledge concerning biomarkers that can distinguish between steroid-resistant nephrotic syndrome and steroid-sensitive nephrotic syndrome. Additionally, we aim to select biomarkers that have the best evidence-base and should be prioritised for further research. Pub med and web of science databases were searched using "steroid resistant nephrotic syndrome AND biomarker". Papers published between 01/01/2012 and 10/05/2022 were included. Papers that did not compare steroid resistant and steroid sensitive nephrotic syndrome, did not report sensitivity/specificity or area under curve and reviews/letters were excluded. The selected papers were then assessed for bias using the QUADAS-2 tool. The source of the biomarker, cut off, sensitivity/specificity, area under curve and sample size were all extracted. Quality assessment was performed using the BIOCROSS tool. 17 studies were included, comprising 15 case-control studies and 2 cross-sectional studies. Given the rarity of nephrotic syndrome and difficulty in recruiting large cohorts, case-control studies were accepted despite their limitations. We present a range of candidate biomarkers along with scores relating to the quality of the original publications and the risk of bias to inform future investigations. None of the selected papers stated whether the authors were blinded to the patient's disease when assessing the index test in the cohort. Highlighting a key problem in the field that needs to be addressed. These candidate biomarkers must now be tested with much larger sample sizes. Using new biobanks such as the one built by the NURTuRE-INS team will be very helpful in this regard.

Advancements in Breathomics: Special Focus on Electrochemical Sensing and AI for Chronic Disease Diagnosis and Monitoring

This Review examines the potential of breathomics in enhancing disease monitoring and diagnostic precision when integrated with artificial intelligence (AI) and electrochemical sensing techniques. It discusses breathomics' potential for early and noninvasive disease diagnosis with a focus on chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), and lung cancer, which have been well studied in the context of VOC association with diseases. The noninvasive nature of exhaled breath analysis can be advantageous compared to traditional diagnostic methods for CKD, which often rely on blood and urine testing. VOC analysis can enhance spirometry and imaging methods used in COPD diagnosis, providing a more comprehensive picture of the disease's progression. Breathomics could also provide a less intrusive and potentially earlier diagnostic approach for lung cancer, which is now dependent on imaging and biopsy. The combination of breathomics, electrochemical sensing, and AI could lead to more personalized and successful treatment plans for chronic illnesses using AI algorithms to decipher complicated VOC patterns. This Review assesses the viability and effectiveness of combining breathomics with electrochemical sensors and artificial intelligence by synthesizing recent research findings and technological developments.

Effectiveness of ertugliflozin during Ramadan fasting in patients with type 2 diabetes mellitus: a real-world study (ErtuRamadan study)

Background

Management of type 2 diabetes mellitus (T2DM) during Ramadan fasting presents unique challenges due to prolonged fasting periods, irregular meal schedules, and altered medication timing, potentially impacting glycemic control. Ertugliflozin, a sodium-glucose co-transporter 2 (SGLT2) inhibitor, has been shown to improve glycemic control in T2DM effectively. However, the effectiveness of ertugliflozin during Ramadan fasting, a period with unique glycemic challenges, has not been studied extensively.

Methods

This study was a multicenter, real-life experience study involving 1373 adult patients with known T2DM for at least one year, an HbA1c level of less than 10%, and who intended to fast during Ramadan. Participants were divided into two groups: the Ertu group (n=703), consisting of patients who had been on a stable dose of ertugliflozin for at least three months before Ramadan, and the non-Ertu group (n=670), which included patients receiving other oral antihyperglycemic drugs (OADs) except ertugliflozin. Patients attended a baseline visit one month before the first day of Ramadan and a follow-up visit within one month after the last day of Ramadan. Both visits included history taking, physical examinations, and laboratory tests. The primary endpoints were changes in HbA1c levels, body weight, body mass index (BMI), and the incidence of hypoglycemia during Ramadan fasting.

Results

The mean age of the study participants was 50.37 ± 11.14 (SD) years, with 40.6% male and 58.7% female. Patients receiving ertugliflozin showed significant reduction in HbA1C (-0.65 ± 0.67% vs. -0.22 ± 0.64%, p<0.001), body weight (-1.24 ± 2.58 kg vs. -0.36 ± 3.41 kg, p<0.001), and BMI (-0.48 ± 1.03 kg/m² vs. -0.11 ± 1.33 kg/m², p<0.001) compared to the non-Ertu group. Hypoglycemia was reported in 0.3% of the ertugliflozin group and 0.7% of the other group, with comparable adverse events (p=.23; ≥0.05), indicating a favorable safety profile for ertugliflozin during fasting.

Conclusion

This study demonstrates that ertugliflozin is effective and safe for patients with T2DM during Ramadan fasting.

A unique case report of wilkie syndrome in a middle-aged female with posterior nutcracker syndrome

Nutcracker syndrome and Wilkie syndrome are rare and often diagnosed incidentally during imaging investigations for other conditions and, on occasion, together. In this paper, we present the case of a 36-year-old patient with quasi-permanent symptoms including epigastralgia, loss of appetite, early satiety, left lumbar colic pain, normal stool and dysuria. The clinical examination revealed a non-distended abdomen, sensitivity to palpation in the epigastrium and hypogastrium regions, frequent urination in small amounts, and a body mass index (BMI) of 15 kg/m2, indicating severe protein calorie malnutrition. Laboratory tests indicated persistent microscopic hematuria without proteinuria with repeated urinary infections. Abdominal-pelvic ultrasound with Doppler revealed a left renal vein dilated up to 10 mm in the left paraaortic region (Nutcracker syndrome) and distal duodenal obstruction with distension in the same region, which was also confirmed by gastroduodenoscopy (Wilkie syndrome). Abdominal‒pelvic computed tomography angiography revealed a malformed and dilated left renal vein that was compressed as a result of aorto-mesenteric obstruction and communicating with an aberrant left paravertebral and paraspinal network extending to L1 and L5 and thrombosis of the left ovarian vein. The patient benefitted from conservative treatment, which intended to correct the malabsorption syndrome with the help of a nutritionist, who suggested a personalized diet to help gain weight. As a result, the patient was able to avoid surgical treatment. The case is peculiar in that the patient presented with a very rare form of Nutcracker syndrome (posterior type) associated with another rare syndrome, Wilkie syndrome.

Development of minimum data set and electronic registry for hemodialysis patients management

BACKGROUND

This study aimed to develop a minimum dataset and an electronic registry system for hemodialysis patients to evaluate hemodialysis patients' treatment procedures and outcomes, conduct related research, and design therapeutic interventions.

METHODS

This developmental research was performed in multiple phases, including content determination using the Delphi technique; database designing using MySQL; building a user interface using PHP; usability evaluation using the think-aloud method by 10 evaluators through a scenario consisting of 7 tasks; and finally, the system was piloted by entering the 160 patients' paper records into the system.

RESULTS

Following the CVR and CVI content validity assessment, 108 of the 118 extracted data elements (DEs) were validated. Then, using the Delphi technique, nephrologists chose 57 DEs and divided them into 4 information categories, including the patient's clinical history, hemodialysis episodes, laboratory findings, and the outcomes of hemodialysis. The three tabs that made up the user interface were the homepage, information recording, reports, and definitions. The problems with appearance and performance were discovered using the think-aloud method, and they were then resolved. Finally, users had the opportunity to identify issues, improve the system's capabilities, and express their satisfaction throughout the system's three-month test period.

CONCLUSIONS

The E-hemodialysis registry was created based on knowledge gained from industrialized nations, opinions and suggestions from medical specialists, and the facilities that were accessible. Information from this system can be utilized as a starting point for evaluating the hemodialysis patients' status, identifying problems, and making sensible decisions for the best possible planning and management of end-stage renal disease.

Nephrostomy (PCN) versus nephroureteral stent (Double JJ); An ongoing battle

In the realm of medical procedures for urinary obstructions, a distinct division of roles is evident: the vast majority of percutaneous nephrostomies (PCNs) are the domain of Interventional Radiology (IR), while the placement of double J stents (JJ stents) falls squarely under Urology. This division, however, is not without its complexities. When confronted with a patient suffering from a urinary obstruction, the decision-making process can become intricate. The underlying cause often fuels the debate: should IR intervene with a PCN, or should Urology place a JJ stent? Such decisions have profound implications for the individual patient.In this comprehensive review, we aim to compare the utilization of PCN to that of JJS in a variety of clinical settings and evaluate their indications, relative efficacies, and potential complications to ascertain whether one procedure outperforms the other.

Research progress of hypoxia-inducible factor-1α and zinc in the mechanism of diabetic kidney disease

Diabetic kidney disease is one of the common complications in diabetic patients and has gradually become an important pathogenic factor in chronic kidney disease. Therefore, studying the mechanisms of its occurrence and development is of great significance for the prevention and treatment of diabetic kidney disease. Some researchers have pointed out that there is a phenomenon of hypoxia in diabetic kidney tissue and believe that hypoxia-inducible factor-1α is closely related to the occurrence and progression of diabetic kidney disease. Additionally, the homeostasis of zinc plays a key role in the body's adaptation to hypoxic environments. However, the specific relationship among these three factors remains unclear. This article provides a detailed review of the multiple roles of hypoxia-inducible factor-1α in the pathogenesis of diabetic kidney disease, including: regulating angiogenesis, increasing the expression of erythropoietin, modulating oxidative stress through the PI3K/AKT and HIF-1α/HO-1 pathways, promoting inflammatory cell infiltration and the release of inflammatory factors to induce inflammatory responses, facilitating epithelial-mesenchymal transition, pathological angiogenesis, and promoting the release of fibrotic factors, ultimately leading to renal fibrosis. Furthermore, HIF-1α also participates in the occurrence and development of diabetic kidney disease through mechanisms such as regulating apoptosis, inducing mitochondrial autophagy, and vascular calcification. At the same time, this article clarifies the regulatory role of the trace element zinc on hypoxia-inducible factor-1α in diabetic kidney disease. This article provides references and insights for further research on the pathogenesis and progression of diabetic kidney disease.

Association between magnesium depletion score and prostate cancer

The Magnesium Depletion Score (MDS) is a practical tool used to assess magnesium deficiency. Studies have indicated that MDS is associated with various urological conditions, such as kidney stones and the prognosis of chronic kidney disease. However, the relationship between MDS and prostate cancer (PCa) remains unclear. Therefore, this study aims to investigate the association between MDS and PCa. This study conducted a cross-sectional analysis of 16,043 participants from the 2005-2018 NHANES database. Subgroup analysis, restricted cubic splines (RCS), and multivariable logistic regression were employed to examine the association between MDS and the prevalence of PCa. A total of 16,043 participants were included in this study, of whom 511 had PCa. After adjusting for all variables using multivariable logistic regression, each 1-unit increase in MDS was associated with a 26% higher prevalence of PCa (OR = 1.26, 95% CI: 1.05, 1.50). Additionally, compared to an MDS of 0, an MDS of 3 or higher was associated with a 3.04-fold increase in PCa prevalence (OR = 3.04, 95% CI: 1.53, 6.01). RCS analysis demonstrated a significant linear positive correlation between MDS and PCa prevalence. Subgroup analysis indicated that the positive association between MDS and PCa was generally consistent across different population groups. This study indicates a significant association between MDS and the risk of PCa, with higher MDS linked to an increased prevalence of PCa. These findings highlight the potential role of MDS in PCa. Further research is needed to determine whether a causal relationship exists between MDS and PCa, which would help assess the appropriateness of potential interventions.

Integrated proteomics reveals enrichment of oxidative stress and inflammatory proteins in the urine and stone matrix of calcium oxalate stone formers

Nephrolithiasis is a multifactorial disease associated with urinary and matrix proteins that become a focal point of research for diagnostic and preventative strategies. The functional relevance of these proteins in lithogenesis, along with their origins and impacts, remains a major subject of ongoing lithogenic research. Here, an integrated analysis was done on multiple proteome datasets compiled from various studies of normal urine (NU), urine from calcium oxalate stone formers (SFU), and calcium oxalate stone matrix (SM). Functional annotation and network analysis revealed the profound enrichment of proteins associated with oxidative stress and inflammation only in the stone-related samples (both "SFU but not NU" and "SM but not NU" cohorts). The oxidative stress and inflammation-related proteins were most abundant in the "SM but not NU" cohort and had higher proportions in the "SFU but not NU" cohort than the "NU only" cohort. KEGG pathway analysis corroborated such observation and highlighted the inclusion of proteins in the complement and coagulation pathways, particularly in SM. The findings of this study inform some mechanistic insights into the roles of calcium oxalate stone-related proteins and may help develop effective prevention and treatment strategies for nephrolithiasis.

Clinical advances in kidney autotransplantation: a review

Kidney autotransplantation is a surgical procedure with multiple indications and advancing technological approaches. Kidney autotransplantation is used to address complex kidney-related diseases including renal vascular lesions, ureteral diseases, tumors, loin pain-hematuria syndrome, and conditions affecting a solitary kidney or both kidneys. Renal artery lesions, including aneurysms and stenoses, often necessitate kidney autotransplantation in cases involving renal artery bifurcation or distant failure of endovascular repair. Complex ureteral lesions such as ureteral avulsions are commonly treated with kidney autotransplantation. Renal tumors, especially centrally located tumors or those involving the renal hilum, are treated using this technique while preserving renal function. It is worth emphasizing that this would be a rarely used last-resort technique in the modern era of minimally invasive nephron-sparing surgery. Kidney autotransplantation may be indicated for the rare condition of loin pain-hematuria syndrome when conservative measures fail. Additionally, individuals with solitary or bilateral kidney disease benefit from kidney autotransplantation to preserve their renal function. Traditional open-kidney autotransplantation involves renal extraction, workbench repair, and renal reimplantation. Technological advancements have introduced minimally invasive techniques including laparoscopic- and robot-assisted kidney autotransplantation, which reduce surgical trauma and recovery times. These techniques have shown promising outcomes, and robotic platforms have the potential to further reduce complications. In this study, we reviewed diverse indications and recent technological innovations in the field of kidney autotransplantation.

Relationship Between Obstructive Sleep Apnea and Enuresis in Children: Current Perspectives and Beyond

Background

Nocturnal enuresis (NE) and obstructive sleep apnea (OSA) are common diseases in children, which often cause various social and psychological problems. The coexistence of both seriously affects the physical and mental health of children. However, whether OSA can directly lead to NE and the specific pathogenesis is still unclear. Moreover, the benefits of surgical and non-surgical treatments for OSA on NE symptoms remain controversial. This review summarizes the relationship between NE and OSA and how to treat them, aiming to provide a reference for the clinical treatment of OSA and NE in children.

Methods

All pertinent original publications to this point from PubMed database have been collected, including investigations on the connection between OSA and NE as well as studies on the mechanism and therapeutic strategy of NE in children with OSA.

Results

There is a bidirectional relationship between OSA and NE in children. NE increases with the incidence of OSA, and children with NE often have sleep-disordered respiratory disease. Children with OSA may be susceptible to NE due to aberrant humoral factors secretion, sleep-wake disorder, bladder dysfunction, obesity, and psychosomatic factors. It has been suggested that adenotonsillectomy (AT) may be the best treatment option for children suffering from OSA with NE. The benefits of positive airway pressure (PAP) therapy in children with NE remain to be further studied.

Conclusion

NE and OSA comorbidity seriously affect the physical and mental health of children. AT can benefit children with OSA and NE. A comprehensive multidisciplinary evaluation of children with NE and OSA is needed, and the mechanism and treatment of NE in children with OSA need to be further explored.

Genotype-Based Molecular Mechanisms in Alport Syndrome

Alport syndrome is an inherited disorder characterized by kidney disease, sensorineural hearing loss, and ocular abnormalities. Alport syndrome is caused by pathogenic variants in COL4A3 , COL4A4 , or COL4A5 , which encode the α 3, α 4, and α 5 chains of type 4 collagen that forms a heterotrimer expressed in the glomerular basement membrane. Knowledge of its genetic basis has informed the development of different models in dogs, mice, and rats that reflect its autosomal and X-linked inheritance patterns as well as different mutation types, including protein-truncating and missense variants. A key difference between these two types is the synthesis of α 3 α 4 α 5(IV), which is not made in autosomal Alport syndrome (two pathogenic variants in trans or biallelic) or male patients with X-linked Alport syndrome due to protein-truncating variants. By contrast, α 3 α 4 α 5(IV) is synthesized in Alport syndrome because of missense variants. For missense variants, in vitro studies suggest that these cause impaired type 4 collagen trafficking and endoplasmic reticulum stress. For protein-truncating variants, knockout models suggest that persistence of an immature α 1 α 1 α 2(IV) network is associated with biomechanical strain, which activates endothelin-A receptors leading to mesangial filopodia formation. Moreover, studies suggest that activation of collagen receptors, integrins and discoidin domain receptor 1, play a role in disease propagation. In this review, we provide an overview of how these genotype-phenotype mechanisms are key for a precision medicine-based approach in the future.

Implementation of a National Antimicrobial Stewardship Training Programme for General Practice: A Case Study

BACKGROUND

Approximately 71% of antibiotics in England are prescribed in general practice settings. Whilst there are various impactful training resources available to support clinicians in antimicrobial stewardship (AMS) activities, implementation, reach, and uptake affect how successful they are nationally. This case study explores the feasibility, acceptability, and usefulness of embedding the TARGET (Treat Antibiotics Responsibly, Guidance, Education and Tools) AMS training into a local incentive scheme.

METHOD

Black Country Integrated Care Board (ICB) invited a representative from all associated general practises to a TARGET AMS training event; attendance was linked to a local incentive scheme. Data were collected via a pre- and post-workshop survey capturing TARGET toolkit knowledge, AMS attitudes and behaviours, training feedback, and intention to implement AMS behaviours. Descriptive analyses were conducted.

RESULTS

157 and 101 attendees completed the pre- and post-session surveys, respectively. In total, 89% agreed that attending the session was a good use of their time. The proportions of attendees stating an intention to use the TARGET toolkit and implement a range of AMS strategies following the session were high (TARGET Toolkit: >82%, AMS strategies: >90%). Most attendees planned to implement these actions within 3 months (47%) or within 3-6 months (30%).

CONCLUSION

Results suggest that embedding the training into a local incentive scheme is a viable implementation approach in extending training reach. Although the impact on prescribing rates is not yet available, the high engagement and intention to implement AMS strategies observed should inspire confidence in this approach to training implementation.

The impact of high altitude (hypobaric hypoxia) on insulin resistance in humans

Exposure to hypobaric hypoxia (high altitude) diminishes systemic tissue oxygenation. Tissue hypoxia induces insulin resistance and a metabolic switch that reduces oxidative phosphorylation and glucose storage while enhancing glycolysis. Similarly to hypobaric hypoxia, insulin resistance develops in normal humans undergoing normobaric hypoxia and in patients with obstructive sleep apnea. Following acute exposure to high altitude, insulin resistance returns to baseline values upon returning to sea level or when compensatory mechanisms restore tissue oxygenation. However, insulin resistance persists in subjects unable to achieve sufficient oxygen delivery to tissues. Likewise, long-term residents at high altitude develop persistent insulin resistance when compensatory mechanisms do not attain adequate tissue oxygenation. Among these subjects, insulin resistance may cause clinical complications, such as hypertriglyceridemia, reduced HDL-c, visceral obesity, metabolic dysfunction-associated steatotic liver disease, essential hypertension, type 2 diabetes, subclinical vascular injury, cardiovascular disease, and kidney disease. Impaired tissue oxygenation allows the stabilization of hypoxia-inducible factor-1 (HIF-1), a transcription factor that modulates the transcriptional activity of a number of genes to coordinate the physiological responses to tissue hypoxia. Among them, HIF-1 downregulates PPARG, that codes peroxisome proliferator-activated receptor-gamma (PPAR-γ) and PPARGCA, that codes PPAR-γ coactivator-1α, in order to enable insulin resistance and the metabolic switch from oxidative phosphorylation toward glycolysis.

Folate Receptor Targeting Mn(II) Complex Encapsulated Porous Silica Nanoparticle as an MRI Contrast Agent for Early-State Detection of Cancer

Cancer is recognized as one of the major causes of mortality, however, early-stage detection can increase the survival chance greatly. It is recognized that folate receptors are gradually overexpressed in the cellular membrane with the progress of cancer from stage 1 to stage 4. Utilizing the fact, herein, developed a porous silica nanoparticle system C1@SiO2-FA-NP; A) impregnated with thermodynamically stable Mn(II) complex (1) molecules within the core of the nanoparticle, and B) surface functionalized with folate units. It exhibited a high longitudinal relaxivity value r1 = 21.45 mM-1s-1 that substantially increased to r1 = 40.97 mM-1s-1 in the presence of 0.67 mM concentration of BSA under the physiological condition. The in vitro fluorescent images after surface conjugation of C1@SiO2-FA-NP with FITC (fluorescein isothiocyanate) buttressed the inclusion of the nanoparticle exclusively within the cancerous HeLa cells than that of healthy HEK293 cells. The importance of the surface-bound folate unit in the nanoparticle is further established by comparing the fluorescent images of HeLa cells in the absence of the group. Finally, the applicability of C1@SiO2-FA-NP as the T1-weighted MRI contrast agent for early-stage cancer diagnosis is established within C57BL/6 mice after infecting the mice with HeLa cells.

β-Caryophyllene attenuates oxidative stress and inflammatory response in LPS induced acute lung injury by targeting ACE2/MasR and Nrf2/HO-1/NF-κB axis

Acute lung injury (ALI) and its severe form, acute respiratory distress syndrome (ARDS), is a clinical syndrome that can cause pulmonary edema, inflammation, oxidative stress, and immunological dysregulations. β-Caryophyllene (BCP), a natural bicyclic sesquiterpene, possesses a variety of pharmacological properties and has the potential to be a therapeutic agent. This study aimed to comprehend the effect of BCP on Nrf2/HO-1/NF-κB and ACE2/MasR axis in a rat model of ALI by lipopolysaccharide (LPS) and the underlying mechanisms during this process. The study also examined pulmonary edema, BALF, and cytokine production to investigate inflammation and oxidative stress. In the LPS group, Western blot analysis showed decreased Nrf2/HO-1 and ACE2/MasR, including increased lung edema, elevated vascular permeability, neutrophil infiltration in BALF, increased cytokine levels, and histological changes. In comparison to the LPS group, BCP dramatically reduced lung edema, vascular permeability, and histological changes. Additionally, by lowering malondialdehyde and myeloperoxidase activity in lung tissues, it also reduced oxidative stress. BCP boosted IL-10 production and decreased the levels of pro-inflammatory cytokines and neutrophil infiltration. BCP administration decreased VEGF-A and SP-D expression, subsequently lowering NF-κB activation and cytokine production. Further, BCP altered ACE2 expression, indicating its involvement by activating the ACE2/Angiotensin (1-7)/MasR axis. In addition, BCP could stimulate the Nrf2/HO-1 anti-oxidant axis to suppress NF-κB and reduce inflammation. BCP modulation of the ACE2/MasR and Nrf2/HO-1/NF-κB axis impedes the course of ALI by influencing immunological response including but not limited to oxidative stress, the influx of neutrophils, and cytokine production. Hence, BCP may act as a potential candidate for management of ALI.

Pharmacokinetic Boosting of Calcineurin Inhibitors in Transplantation: Pros, Cons, and Perspectives

ABSTRACT

The concept of pharmacokinetic (PK) boosting of calcineurin inhibitors (CNI) emerged after the FDA approval of cyclosporine-A. Several studies followed, and the proof of concept was well established by the late 1990s. This also continued for the next blockbuster immunosuppressant, tacrolimus. The driver for such research was an endeavor to save costs, as both drugs were expensive due to patent protection. Two CYP inhibitors, ketoconazole and diltiazem, have been extensively studied in this context and continue to be prescribed off-label along with the CNI. It has been observed that using ketoconazole reduces the dose requirement of tacrolimus by about 50% and 30% with diltiazem, which is in conformity with their pharmacological actions. Off-label co-prescription of these drugs with CNI is often encountered in low and middle-income countries. The foremost reason cited is economic. This article collates the evidence from the clinical studies that evaluate the PK-boosting effects of CNI and also reviews the gaps in the current evidence base. The current knowledge prevents the transplant community from making meaningful inferences about the risks and benefits of such strategies. Although the PK-boosting strategy can lead to serious adverse events, emerging evidence suggests that it may be advantageous for individuals with high CNI dose requirements. Hence, PK boosting may be an unmet need in the therapeutics of CNI. Nevertheless, there are several unanswered questions surrounding such use, and therefore, this merits testing in well-designed clinical studies. Moreover, drugs with better safer profiles and a history of successful PK boosting may be considered for evaluation with CNI.

Study of plasma essential element concentrations to explore markers of acute myocardial infarction

Essential element concentrations in biological samples may be related to the pathogenesis of various diseases. Previous studies have reported that serum iron (Fe), zinc (Zn), and copper (Cu) were related to acute myocardial infarction (AMI). However, the differences in element concentrations between AMI and other cardiac disease has not been investigated. In this study, differences in plasma Fe, magnesium (Mg), Zn, Cu, calcium (Ca), inorganic phosphorus (P), and cardiac troponin T (TnT) levels in heart disease patients (AMI, angina, heart failure, and chest pain) were investigated to explore potential markers of AMI. Fe, Mg, Zn, and Cu concentrations were assayed by using a Metallo Assay kit; Ca and inorganic P were determined by using an automatic biochemical analyzer; and cardiac TnT levels were assayed by using enzyme-linked immunosorbent assay. Plasma TnT levels were higher in AMI than in other heart diseases and were negatively correlated with Cu and Ca. Fe, Cu, and inorganic P levels were within the normal range, while Mg and Ca levels were lower, and Zn levels were higher than the normal range in heart disease patients. Except Mg, no significant differences in element levels were observed among heart diseases: Mg levels were significantly higher in AMI than in heart failure. These results suggest that lower Cu and Ca levels and a higher Mg level compared with other heart diseases may be a marker of AMI.

Erectile Dysfunction in Chronic Kidney Disease and Hemodialysis Patients: A State-of-the-Art Review

Erectile dysfunction (ED) is a prevalent condition that significantly impacts the quality of life and overall well-being of affected individuals. This state-of-the-art (SotA) review covers literature published between 2020 and 2024, focusing on adult patients with chronic kidney disease (CKD) at various stages, including those receiving hemodialysis and individuals who have undergone renal transplantation. The pathophysiology of ED in CKD patients is multifaceted, involving vascular, neurogenic, hormonal, and psychological components that are further exacerbated by the metabolic and hemodynamic alterations associated with kidney disease. The review provides a comprehensive analysis of current diagnostic approaches, including clinical assessment tools, laboratory evaluations, and imaging modalities that aid in identifying the underlying causes of ED in CKD patients. Pharmacological treatments, particularly phosphodiesterase type 5 (PDE5) inhibitors, remain the cornerstone of therapy; however, their efficacy and safety in patients with renal impairment require careful consideration. Non-pharmacological interventions, such as lifestyle modifications, exercise regimens, and psychological support, are explored as integral components of a holistic management approach. Additionally, advanced therapeutic options, including intracavernosal injections, vacuum erection devices, penile prostheses, and emerging therapies such as low-intensity shockwave therapy, stem cell treatment, and gene therapy, are critically reviewed in the context of CKD. This review also examines the bidirectional relationship between ED and comorbidities commonly associated with CKD, including cardiovascular disease, diabetes mellitus, and metabolic syndrome. Special emphasis is placed on the impact of dialysis modalities and renal transplantation on erectile function, highlighting the challenges in managing ED in these specific patient populations. Moreover, the psychological burden of ED, coupled with the stigma associated with CKD and sexual health, underscores the necessity of a multidisciplinary approach that integrates nephrologists, urologists, psychologists, and primary care providers. Despite advancements in treatment modalities, challenges such as limited patient adherence, stigma, and disparities in healthcare access persist. Addressing these issues requires targeted educational initiatives and policy changes to enhance patient awareness and access to comprehensive care.

Postnatal enteral plasma supplementation following birth asphyxia increases fluid retention and kidney health in newborn pigs

Birth asphyxia can result in kidney dysfunction, disturbances in systemic electrolytes and fluid balance in newborns. Currently, there is no proven dietary approach to support asphyxiated newborns. This study investigates whether oral plasma supplementation improves kidney function and overall health in asphyxiated newborns. Cesarean-delivered near-term pigs with or without an 8 min intrauterine clamping of the umbilical cord were fed a milk replacer dissolved in water for 24 h in Experiment 1. Pigs were fed 72 h with milk replacers dissolved in either maternal plasma or water in Experiment 2. Blood, urine, and kidney tissue were collected for further analyses. Asphyxia disrupted blood electrolyte balance. And plasma feeding led to higher fluid retention for both asphyxiated and control pigs. Additionally, plasma feeding may also affect kidney development and protect kidneys from asphyxia induced impairments. Birth asphyxia in pigs led to immediate disturbance of electrolyte balance, impaired fluid retention, and kidney impairments. Plasma feeding may improve postnatal newborn hydration and may also improve the condition of kidneys following asphyxia.

Loss of YTHDC1 m6A reading function promotes invasiveness in urothelial carcinoma of the bladder

Bladder cancer poses significant clinical challenges due to its high metastatic potential and poor prognosis, especially when it progresses to muscle-invasive stages. Here, we show that the m6A reader YTHDC1 is downregulated in muscle-invasive bladder cancer and is negatively correlated with the expression of epithelial‒mesenchymal transition genes. The functional inhibition or depletion of YTHDC1 increased the migration and invasion of urothelial cells. Integrative analysis of multimodal sequencing datasets provided detailed insights into the molecular mechanisms mediating YTHDC1-dependent phenotypes and identified SMAD6 as a key transcript involved in the invasiveness of urothelial carcinoma of the bladder. Notably, SMAD6 mRNA colocalized less with YTHDC1 in tumoral tissues than in paratumoral tissues, indicating disrupted binding during cancer progression. Our findings establish YTHDC1-dependent m6A reading as a critical epitranscriptomic mechanism regulating bladder cancer invasiveness and provide a paradigm for the epitranscriptomic deregulation of cancer-associated networks.

Transcriptomic Profiles for Elucidating Response of Bladder Intracavitary Hyperthermic Perfusion Chemotherapy in High-Risk Nonmuscular Invasive Bladder Cancer

BACKGROUND

Bladder intracavitary hyperthermic perfusion chemotherapy (HIPEC) is a promising treatment for non-muscular invasive bladder cancer (NMIBC). However, the molecular mechanisms underlying the response to HIPEC remain poorly understood. This study aimed to elucidate the transcriptomic profiles associated with the response to HIPEC in NMIBC patients.

METHODS

RNA sequencing was performed on bladder tumor samples from NMIBC patients who underwent HIPEC treatment. Differentially expressed genes (DEGs) between responders and non-responders to HIPEC were identified. Gene ontology and pathway analysis were conducted to explore the biological functions and pathways enriched in the DEGs. Additionally, the expression of specific immune-related genes was evaluated for their association with HIPEC response. The diagnostic efficiency of selected genes in predicting relapse before and after HIPEC treatment was assessed in a validation cohort.

RESULTS

We assessed the expression status of differentially expressed genes (DEGs) between responders and non-responders to HIPEC. Gene ontology and pathway analysis revealed that DEGs were enriched in immune-related pathways, including cytokine-cytokine receptor interaction, chemokine signaling pathway, and antigen processing and presentation. Furthermore, the expression of several immune-related genes, including ZMAP4, UPP2, and GALR1, was significantly associated with the response to HIPEC. Therefore, the immune system's reaction plays a crucial role in the response to HIPEC in patients with NMIBC. At last, a considerable diagnostic efficiency that tissue TMEFF2, KRT222, and GTSF1 in predicting relapse in NMIBC patients after HIPEC treatment, and ZMAP4, UPP2, and GALR1 in predicting relapse in NMIBC patients before HIPEC treatment in the validation cohort.

CONCLUSION

Transcriptomic profiling revealed that immune-related pathways and genes play a crucial role in the response to HIPEC in NMIBC patients. These findings suggest that transcriptomic profiling could provide a valuable tool for predicting treatment outcomes and identifying therapeutic targets for NMIBC.

Uric Acid to Albumin Ratio: A Predictive Marker for Acute Kidney Injury in Isolated Tricuspid Valve Surgery

Background

The plasma uric acid/albumin ratio (UAR) has emerged as a novel inflammatory biomarker for predicting the development of acute kidney injury (AKI) following percutaneous coronary intervention. However, the potential of the UAR to serve as a predictive marker for AKI in patients undergoing isolated tricuspid valve (TV) surgery remains unknown. This study aimed to explore the association between the UAR and AKI and to assess whether the UAR can predict AKI in these patients.

Methods

We conducted a retrospective analysis of patients who underwent isolated TV surgery between January 2018 and June 2019. The patients were divided into three groups based on the tertiles of the UAR. We utilized multivariate logistic regression and restricted cubic spline analysis to examine the association between the UAR and AKI. Additionally, we used the receiver operating characteristic (ROC) curve analysis to assess the predictive accuracy of the UAR for AKI.

Results

A total of 224 patients were enrolled in this study, of whom 41 developed AKI. The incidence of AKI across the three UAR tertiles was 3.8%, 22.2%, and 29.7%, with a significant difference between the group (p < 0.001). In the multivariate analysis, UAR ≥8.5 was associated with a 7-fold increased risk of AKI (odds ratio (OR): 7.73, 95% confidence interval (CI): 1.61-37.14), while a UAR ≥10.8 was a linked to a 9-fold increased risk (OR: 9.34, 95% CI: 1.96-44.60). The restricted cubic spline model showed a linear association between the UAR and AKI development. The area under the curve (AUC) value for the UAR was 0.713 (95% CI: 0.633-0.793; p < 0.001) with a cutoff value of 8.89.

Conclusions

An increased UAR was significantly associated with a higher risk of AKI in patients undergoing isolated TV surgery; however, while the UAR could serve as a marker to predict AKI, it was not superior to uric acid alone.

Temporary bilateral clamping of renal arteries induces ischemia-reperfusion: A new pig model of acute kidney injury using total intravenous anesthesia

Ischemia-reperfusion (IR) is a leading cause of acute kidney injury (AKI), and pigs are commonly used in preclinical AKI models. However, existing models often vary in the methods used to induce ischemia, and the resulting AKI tends to be mild-to-moderate. Moreover, follow-up is often performed under volatile anesthesia, which, in contrast to total intravenous anesthesia (TIVA), can induce malignant hyperthermia and cause hemodynamic instability. Here we present a novel surgical model of IR-induced AKI using bilateral renal artery clamping under TIVA. Anesthesia was induced via TIVA with diazepam, ketamine, and morphine. After retroperitoneal exposure, the renal arteries were isolated and clamped with a plastic tube for 90 min, followed by 8 h of reperfusion. The IR group (n = 6) was compared with a Sham group (n = 5) that underwent the same procedure without IR. The IR group developed moderate-to-severe AKI as evidenced by reduced glomerular filtration, a 158% increase in plasma creatinine versus 21% in the Sham group, and elevated neutrophil gelatinase-associated lipocalin levels (+280% in IR vs. 0% in Sham), indicating tubular injury. Histopathology confirmed these findings. Thus, this preclinical model successfully induced moderate-to-severe AKI in pigs. The TIVA anesthetic protocol offered several advantages compared to halogenated gas anesthesia.

Non-coding RNAs in urinary bladder cancer microenvironment: Diagnostic, therapeutic, and prognostic perspective

Urinary bladder cancer (UBC) is the ninth most common cancer worldwide. Despite the reliance of UBC therapy on definite pathological grading and classifications, the clinical response among patients varies widely. The molecular basis of this type of cancer appeals to considerable research; hence, new diagnostic and therapeutic options are introduced. Convenient keywords were searched in Google Scholar, PubMed, the Egyptian Knowledge Bank (EKB), and Web of Science. The recent era of UBC research is concerned with non-coding RNAs (ncRNAs), predominantly, microRNAs (miRNAs) and long non-coding RNA (lncRNAs). In addition, snoRNAs, PIWI-interacting RNAs, mitochondrial RNAs, circular, and Schistosoma haematobium-related ncRNAs appeared to contribute to the pathogenesis of the UBC. This review underscored the recently studied ncRNAs and their importance in the pathogenesis of UBC. Besides, we introduced the prospectives regarding their diagnostic, therapeutic, and prognostic significance in UBC clinical settings. Conclusion. Oncogenic and oncosuppressor ncRNAs' definite balances and interaction within the TME of UBC are key players in the fate of the tumor. Thus, profiling ncRNA in-depth inspects the TME of the UBC for better clinical insights.

The spatiotemporal and paradoxical roles of NRF2 in renal toxicity and kidney diseases

Over 10% of the global population is at risk to kidney disorders. Nuclear factor erythroid-derived 2-related factor 2 (NRF2), a pivotal regulator of redox homeostasis, orchestrates antioxidant response that effectively counters oxidative stress and inflammatory response in a variety of acute pathophysiological conditions, including acute kidney injury (AKI) and early stage of renal toxicity. However, if persistently activated, NRF2-induced transcriptional cascade may disrupt normal cell signaling and contribute to numerous chronic pathogenic processes such as fibrosis. In this concise review, we assembled experimental evidence to reveal the cell- and pathophysiological condition-specific roles of NRF2 in renal chemical toxicity, AKI, and chronic kidney disease (CKD), all of which are closely associated with oxidative stress and inflammation. By incorporating pertinent research findings on NRF2 activators, we dissected the spatiotemporal roles of NRF2 in distinct nephrotoxic settings and kidney diseases. Herein, NRF2 exhibits diverse expression patterns and downstream gene profiles across distinct kidney regions and cell types, and during specific phases of nephropathic progression. These changes are directly or indirectly connected to altered antioxidant defense, damage repair, inflammatory response, regulated cell death and fibrogenesis, culminating ultimately in either protective or deleterious outcomes. The spatiotemporal and paradoxical characteristics of NRF2 in mitigating nephrotoxicity suggest that translational application of NRF2 activation strategy for prevention and interventions of kidney injury are unlikely to be straightforward - right timing and spatial precision must be taken into consideration.

O-linked β-N-acetylglucosamine (O-GlcNAc) modification: Emerging pathogenesis and a therapeutic target of diabetic nephropathy

AIMS

O-Linked β-N-acetylglucosamine (O-GlcNAc) modification, a unique post-translational modification of proteins, is elevated in diabetic nephropathy. This review aims to summarize the current knowledge on the mechanisms by which O-GlcNAcylation of proteins contributes to the pathogenesis and progression of diabetic nephropathy, as well as the therapeutic potential of targeting O-GlcNAc modification for its treatment.

METHODS

Current evidence in the literature was reviewed and synthesized in a narrative review.

RESULTS

Hyperglycemia increases glucose flux into the hexosamine biosynthesis pathway, which activates glucosamino-fructose aminotransferase expression and activity, leading to the production of O-GlcNAcylation substrate UDP-GlcNAc and an increase in protein O-GlcNAcylation in kidney cells. Protein O-GlcNAcylation regulates the function of kidney cells including mesangial cells, podocytes, and proximal tubular cells, and promotes renal interstitial fibrosis, resulting in kidney damage. Current treatments for diabetic nephropathy, such as sodium-glucose cotransporter 2 (SGLT-2) inhibitors and renin-angiotensin-aldosterone system (RAAS) inhibitors, delay disease progression, and suppress protein O-GlcNAcylation.

CONCLUSIONS

Increased protein O-GlcNAcylation mediates renal cell damage and promotes renal interstitial fibrosis, leading to diabetic nephropathy. Although the full significance of inhibition of O-GlcNAcylation is not yet understood, it may represent a novel target for treating diabetic nephropathy.

PCSK9 in metabolism and diseases

PCSK9 is a serine protease that regulates plasma levels of low-density lipoprotein (LDL) and cholesterol by mediating the endolysosomal degradation of LDL receptor (LDLR) in the liver. When PCSK9 functions unchecked, it leads to increased degradation of LDLR, resulting in elevated circulatory levels of LDL and cholesterol. This dysregulation contributes to lipid and cholesterol metabolism abnormalities, foam cell formation, and the development of various diseases, including cardiovascular disease (CVD), viral infections, cancer, and sepsis. Emerging clinical and experimental evidence highlights an imperative role for PCSK9 in metabolic anomalies such as hypercholesterolemia and hyperlipidemia, as well as inflammation, and disturbances in mitochondrial homeostasis. Moreover, metabolic hormones - including insulin, glucagon, adipokines, natriuretic peptides, and sex steroids - regulate the expression and circulatory levels of PCSK9, thus influencing cardiovascular and metabolic functions. In this comprehensive review, we aim to elucidate the regulatory role of PCSK9 in lipid and cholesterol metabolism, pathophysiology of diseases such as CVD, infections, cancer, and sepsis, as well as its pharmaceutical and non-pharmaceutical targeting for therapeutic management of these conditions.

Correlation between coronary calcification and cardiac structure in non-dialysis patients with chronic kidney disease

AIMS

We aim to explore the correlation between coronary artery calcification (CAC) score (CACS) and cardiac structure and function in chronic kidney disease (CKD) patients, create a clinical prediction model for severe CAC associated with cardiac ultrasound indexes.

METHODS AND RESULTS

The study included 178 non-dialysis CKD patients who underwent CACS testing and collected general information, serological indices, cardiac ultrasound findings and follow-up on renal function, heart failure (HF) manifestations and re-hospitalization. The mean age of participants in the study cohort was 67.4 years; 59% were male, and 66.9% of patients had varying degrees of comorbid CAC. CKD patients with CACS > 100 were older, predominantly male and had a higher proportion of smoking, diabetes and hypertension (P < 0.05) compared with those with CACS = 0 and 0 < CACS ≤ 100, and had higher brain natriuretic peptide, serum magnesium and fibrinogen levels were also higher (P < 0.05). CACS was positively correlated with left atrial inner diameter (LAD), left ventricular end-diastolic inner diameter (LVDd), left ventricular volume at diastole (LVVd), output per beat (SV) and mitral orifice early diastolic blood flow velocity/early mitral annular diastolic myocardial motion velocity (E/e) (P < 0.05). We tested the associations between varying degrees of CAC and HF and heart valve calcification using multivariable-adjusted regression models. The risk of HF in patients with severe CAC was about 1.95 times higher than that in patients without coronary calcification, and the risk of heart valve calcification was 2.46 times higher than that in patients without coronary calcification. Heart valve calcification and HF diagnosis, LAD and LVDd are essential in predicting severe CAC. During a mean follow-up time of 18.26 ± 10.17 months, 65 (36.52%) patients had a composite renal endpoint event, of which 36 (20.22%) were admitted to renal replacement therapy. Patients with severe CAC had a higher risk of progression of renal function, re-admission due to cardiovascular and renal events and more pronounced symptoms of HF (P < 0.05).

CONCLUSIONS

There is a correlation between CACS and cardiac structure and function in non-dialysis CKD patients, which may mainly involve abnormalities in left ventricular structure and cardiac diastolic function. CAC may affect renal prognosis and quality of survival in CKD patients. Based on clinical information, HF, valvular calcification status and indicators related to left ventricular hypertrophy can identify people at risk for severe CAC.

The Effect of Massage, Acupressure and Reflexology on Restless Legs Syndrome Severity and Sleep Quality in Patients Receiving Haemodialysis Treatment: A Systematic Review and Meta-Analysis

AIM

This study aimed to review massage, acupressure and reflexology interventions applied to haemodialysis patients with restless legs syndrome and to examine the effects of these interventions on sleep quality.

DESIGN

A systematic review and meta-analysis.

DATA SOURCES

A systematic literature search was conducted on databases ScienceDirect, Web of Science, Cochrane Central Register of Controlled Trials, EBSCO and PubMed.

METHODS

The Modified Jadad scale was used. The statistical analysis was conducted using the Stata 15.0 software, with the aim of evaluating heterogeneity between studies using both chi-square and I2 statistics. The risk of bias in the included studies was assessed using both the Cochrane risk of bias assessment tool and statistical tests. A funnel plot was used to detect potential publication bias, which is indicated by an asymmetry in the plot. The Egger regression test was also performed to evaluate publication bias.

RESULTS

Twelve studies were selected for the meta-analysis. All studies included in this meta-analysis were of good quality. In the subgroup analysis, it was determined that massage and acupressure reduced the severity of restless legs syndrome as a result of the intervention, while reflexology had no effect. Interventions did not affect the sleep quality of patients. Restless legs syndrome severity was significantly reduced in studies using oil and in studies that intervened for more than 15 min per session.

CONCLUSION

Interventions applied to haemodialysis patients with restless legs syndrome can reduce the severity of restless legs syndrome. It is recommended to conduct randomised controlled trials that determine the effects of methods on restless legs syndrome severity and sleep quality in haemodialysis patients.

Finerenone Efficacy in Patients with Chronic Kidney Disease, Type 2 Diabetes, and Anemia in FIDELITY

BACKGROUND

Anemia is common in patients with chronic kidney disease and type 2 diabetes. Finerenone improved heart and kidney outcomes in patients with chronic kidney disease and type 2 diabetes in FIDELITY.

OBJECTIVES

This post hoc analysis investigated the efficacy and safety of finerenone vs placebo by baseline anemia status.

METHODS

Anemia was defined as serum hemoglobin levels <13 g/dL (male) or <12 g/dL (female) or treatment with an erythropoiesis-stimulating agent at baseline. Outcomes included cardiovascular (CV) and kidney composites, hospitalization for heart failure, and all-cause mortality. Safety was assessed through treatment-emergent adverse events.

RESULTS

Of 12,971 patients, 33% had anemia at baseline. Finerenone reduced the risk of the CV composite outcome to a greater extent in patients with vs without anemia (HR: 0.75 [95% CI: 0.65-0.88] vs HR: 0.93 [95% CI: 0.82-1.05]; P for interaction = 0.03). Finerenone reduced the risk of the kidney composite outcome vs placebo, with no heterogeneity between patients with vs without anemia (HR: 0.79 [95% CI: 0.65-0.95] and HR: 0.74 [95% CI: 0.60-0.91]; P for interaction = 0.77). The risk of hospitalization for heart failure and all-cause mortality was lower with finerenone vs placebo, irrespective of anemia status. Patients with anemia experienced higher incidence of treatment-emergent hyperkalemia vs those without.

CONCLUSIONS

Finerenone demonstrated CV and kidney benefit in patients with and without anemia. The benefit of finerenone on CV outcomes was greater in patients with vs without anemia at baseline. Anemia is likely a marker for higher-risk patients who are more susceptible to the benefits of finerenone. (Efficacy and Safety of Finerenone in Subjects With Type 2 Diabetes Mellitus and Diabetic Kidney Disease [FIDELIO-DKD], NCT02540993; Efficacy and Safety of Finerenone in Subjects With Type 2 Diabetes Mellitus and the Clinical Diagnosis of Diabetic Kidney Disease [FIGARO-DKD], NCT02545049).

Molecular profiling of bladder cancer xenografts defines relevant molecular subtypes and provides a resource for biomarker discovery

Bladder cancer (BLCA) genomic profiling has identified molecular subtypes with distinct clinical characteristics and variable sensitivities to frontline therapy. BLCAs can be categorized into luminal or basal subtypes based on their gene expression. We comprehensively characterized nine human BLCA cell lines (UC3, UC6, UC9, UC13, UC14, T24, SCaBER, RT4V6 and RT112) into molecular subtypes using orthotopic xenograft models. Patient-derived, luciferase-tagged BLCA cell lines were cultured in vitro and engrafted into bladders of NSG mice. Tumor growth was monitored using bioluminescence imaging and mRNA-based molecular classification was used to characterize xenografts into molecular subtypes. RNAseq analysis and basal, luminal, and epithelial-mesenchymal transition (EMT) marker expression revealed distinct patterns; certain cell lines expressed predominantly basal or luminal markers while others demonstrated mixed expression. SCaBER expressed high basal and EMT markers and low luminal markers, consistent with a true basal cell. RT4V6 was a true luminal cell line, displaying only high luminal makers. UC13, T24 and UC3 only showed increased expression of EMT markers. RT112, UC6, UC9 and UC14 expressed basal, luminal, and EMT markers. Immunohistochemical analysis validated our findings. Ki67 was assessed as a continuous percentage of positively stained cells. Morphological assessment of xenografts included H&E and α-SMA staining. These findings will allow for the rational use of appropriate models to develop targeted therapies to overcome or manipulate mechanisms of treatment resistance in BLCA.

Dose-related effects of eugenol: Exploring renal functionality and morphology in healthy Wistar rats

Eugenol has pharmacological properties, but its impact on renal function is limitedly studied. Thus, this study evaluated the effects of eugenol at 10, 20, and 40 mg kg-1, administered via gavage for 60 days, on histological, biochemical, oxidative, and proteomic parameters in rat kidneys. Adult Wistar rats treated with 10 mg kg-1 of eugenol had kidneys with low total antioxidant capacity, high nitric oxide content, and high percentual of blood vessels, with no damage to renal function or morphology. The kidney proteome revealed an upregulation of proteins associated with energy metabolism, oxidative stress, and mitochondrial function. Eugenol at 20 mg kg-1 did not alter kidney histology but inhibited Na+/K+ ATPase activity. This dose elicited an upregulation of proteins associated with mitochondrial function and cellular defense. Finally, 40 mg kg-1 eugenol had more pronounced effects on the kidney, increasing serum sodium, potassium, and chloride levels, inhibiting Na+/K+ ATPase activity, triggering an adaptive response to oxidative stress, and showing apical brush border thinness in proximal tubules. We concluded that eugenol exerted dose-dependent effects on kidney function and morphology. These findings highlight the importance of careful consideration of eugenol's dosage in therapeutic applications.

Addition of a Loop Diuretic to Norepinephrine During Treatment of Hepatorenal Syndrome Type 1

Introduction

Diuretics are commonly discontinued in patients with cirrhosis with acute kidney injury (AKI) because they are presumed to trigger hepatorenal syndrome type 1 (HRS-1). We hypothesized that if HRS-1 is adequately treated with a vasoconstrictor (mean arterial pressure [MAP] effectively increased), diuretics are safe and effective.

Methods

Records of hospitalized patients with cirrhosis who received i.v. furosemide while receiving i.v. norepinephrine as a vasoconstrictor to treat HRS-1 were examined. We assessed change in urine output (UOP), trajectory of serum creatinine (sCr), and impact of portopulmonary hypertension (PoPHTN) on the therapeutic response.

Results

Twenty-six patients with HRS-1 received i.v. furosemide (median: 2 days, 160 mg boluses every 6-24 hours) added to i.v. norepinephrine. Median age was 51 years; 91% were of White race, 36% were women, and median model for end-stage liver disease score was 32. The median initial sCr was 4.0 mg/dl. Before treatment, median UOP was 358 ml/d. Norepinephrine alone led to a median increase in UOP to 850 ml/d. Addition of furosemide to norepinephrine induced a subsequent increase in median UOP to 2072 ml/d (P < 0.0001), which was not observed in a control group (n = 22) who did not receive furosemide. Nineteen patients (73%) treated with norepinephrine plus furosemide (median MAP increase, 16 mm Hg) either maintained or improved their sCr trajectory. The magnitude of norepinephrine-induced increase in MAP correlated with the norepinephrine plus furosemide-induced UOP (r = 0.67, P = 0.0002), and the correlation coefficient was numerically stronger among those with PoPHTN.

Conclusion

In patients with HRS-1 who are adequately treated with norepinephrine and achieved an optimal MAP increment, addition of i.v. furosemide enhances diuresis without negatively affecting renal recovery.

Cyclosporine: Immunosuppressive effects, entwined toxicity, and clinical modulations of an organ transplant drug

The discovery and use of cyclosporine since its inception into the clinics in the '70s and up have played a crucial role in advancing transplant therapy, and containment of the immune-based rejections. The drug has improved the high rates of acute rejections and has supported early graft survival. However, the long-term survival of renal allografts is still less prevalent, and an in-depth analysis, as well as reported findings led us to believe that there is a chronic irreversible component to the drug, that is tackled through its metabolites, and that causes toxicity, which has led to new therapies, including monoclonal antibody-based medications. A recap of the immunosuppressive effects, and entwined toxicity of the drug, now relegated primarily to bone marrow early transplants, is being overviewed for the past protocols that were used to minimize, and avoid, or use this calcineurin inhibitor class of drug, cyclosporine, in combination with other drugs. The current review circumvents the cyclosporine's mechanism of action, pathophysiology, cytochrome roles, and other factors associated with acute and chronic toxicity developments. The review also attempts to find conclusive strategies reported in the recent studies to avoid its toxic side effects, and develop a safe-use strategy for the drug. Gastrointestinal decontamination, supporting the airway, monitoring for signs of respiratory insufficiency, monitoring for severe reactions, such as seizures, need for administration of oxygen, and avoiding the administration of drugs, that increase the blood levels of the cyclosporine, are beneficial interventions, when encountering cyclosporine toxicity cases. The constrained therapeutic outcomes have also led to redesign, and making use of combined formulations to reassess the pharmacokinetics of the drug.

Monitoring of microvascular calcification by time-resolved photoacoustic microscopy

Monitoring of microvascular calcification (MC) is essential for the understanding of pathophysiological processes and the characterization of certain physiological states such as drug abuse, metabolic abnormality, and chronic nephrosis. In this work, we develop a novel and effective time-resolved photoacoustic microscopy (TR-PAM) technology, which can observe the obvious microvascular bio-elastic change in the development process of the MC owing to the calcium deposition along vascular walls.The feasibility of the TR-PAM imaging was validated using a group of agar phantoms and ex vivo tissues. Furthermore, MC pathological animal models were constructed and imaged in situ and in vivo by the TR-PAM to demonstrate its capability for the bio-mechanical monitoring and characterization of MC, and experimental results were consistent with the pathological knowledge. The feasibility study of monitoring MC by the TR-PAM proves that this technique has potential to be developed as a superficial microvascular bio-mechanical assessment method to supplement current clinical strategy for prediction and monitoring of some diseases.

The efficacy of novel biomarkers for the early detection and management of acute kidney injury: A systematic review

Acute kidney injury (AKI) is a frequent clinical complication lacking early diagnostic tests and effective treatments. Novel biomarkers have shown promise for enabling earlier detection, risk stratification, and guiding management of AKI. We conducted a systematic review to synthesize evidence on the efficacy of novel biomarkers for AKI detection and management. Database searches yielded 17 relevant studies which were critically appraised. Key themes were biomarker efficacy in predicting AKI risk and severity before functional changes; potential to improve clinical management through earlier diagnosis, prognostic enrichment, and guiding interventions; emerging roles as therapeutic targets and prognostic tools; and ongoing challenges requiring further validation. Overall, novel biomarkers like neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), and cell cycle arrest markers ([TIMP-2] •[IGFBP7]) demonstrate capability for very early AKI prediction and accurate risk stratification. Their incorporation has potential to facilitate timely targeted interventions and personalized management. However, factors influencing biomarker performance, optimal cutoffs, cost-effectiveness, and impact on patient outcomes require robust validation across diverse settings before widespread implementation. Addressing these limitations through ongoing research can help translate novel biomarkers into improved detection, prognosis, and management of AKI in clinical practice.

Altered brain functional network connectivity and topology in type 2 diabetes mellitus

Introduction

Type 2 diabetes mellitus (T2DM) accelerates brain aging and disrupts brain functional network connectivity, though the specific mechanisms remain unclear. This study aimed to investigate T2DM-driven alterations in brain functional network connectivity and topology.

Methods

Eighty-five T2DM patients and 67 healthy controls (HCs) were included. All participants underwent clinical, neuropsychological, and laboratory tests, followed by MRI examinations, including resting-state functional magnetic resonance imaging (rs-fMRI) and three-dimensional high-resolution T1-weighted imaging (3D-T1WI) on a 3.0 T MRI scanner. Post-image preprocessing, brain functional networks were constructed using the Dosenbach atlas and analyzed with the DPABI-NET toolkit through graph theory.

Results

In T2DM patients, functional connectivity within and between the default mode network (DMN), frontal parietal network (FPN), subcortical network (SCN), ventral attention network (VAN), somatosensory network (SMN), and visual network (VN) was significantly reduced compared to HCs. Conversely, two functional connections within the VN and between the DMN and SMN were significantly increased. Global network topology analysis showed an increased shortest path length and decreased clustering coefficient, global efficiency, and local efficiency in the T2DM group. MoCA scores were negatively correlated with the shortest path length and positively correlated with global and local efficiency in the T2DM group. Node network topology analysis indicated reduced clustering coefficient, degree centrality, eigenvector centrality, and nodal efficiency in multiple nodes in the T2DM group. MoCA scores positively correlated with clustering coefficient and nodal efficiency in the bilateral precentral gyrus in the T2DM group.

Discussion

This study demonstrated significant abnormalities in connectivity and topology of large-scale brain functional networks in T2DM patients. These findings suggest that brain functional network connectivity and topology could serve as imaging biomarkers, providing insights into the underlying neuropathological processes associated with T2DM-related cognitive impairment.

Enhancing patient safety and risk management through clinical pathways in oncology

The increasing emphasis on risk management and quality assessment in hospital management necessitates strict adherence to government and international standards. Those standards are particularly important, and certification requirements further underscore this need. The objective of this paper is to outline the application of the INTegrated Audit Model in a Comprehensive Cancer Center. This model represents a revised version of Tracer Methodology, for audit surveys, aimed at aligning audit activities with UNI EN ISO 9001:2015 and Joint Commission Standards for quality, patient safety and clinical risk management.Using the INTegrated Audit Model, a total of 7 tracers were conducted, and 31 units underwent auditing during the period spanning from 2022 to 2023. Each audit inquiry was documented, categorised and cross-referenced with International Organization for Standardization (ISO) and Joint Commission International (JCI) standards. Areas exhibiting the highest incidence of non-conformities and observations were systematically linked to relevant standards. Subsequently, a comprehensive analysis was conducted on the ensuing findings.The INTegrated Audit Model allowed for systematic data collection across clinical pathways, revealing prevalent issues and areas for improvement in patient care. By aligning identified topics with ISO and JCI standards, compliance with international guidelines was assessed, offering units insight into their current status and areas for enhancement.Overall, both auditees and auditors expressed satisfaction with the methodology and continuous training, highlighting its effectiveness in fostering collaboration, improving time management and promoting adherence to accreditation standards.The study highlights the effectiveness of the methodology in monitoring unit activities and adherence to clinical pathways and international standards applied to an oncological setting. Audits conducted with this approach provided a thorough assessment of critical areas impacting patient care and clinical governance, contributing to a comprehensive understanding of service delivery.

Machine learning models for predicting interaction affinity energy between human serum proteins and hemodialysis membrane materials

Membrane incompatibility poses significant health risks, including severe complications and potential fatality. Surface modification of membranes has emerged as a pivotal technology in the membrane industry, aiming to improve the hemocompatibility and performance of dialysis membranes by mitigating undesired membrane-protein interactions, which can lead to fouling and subsequent protein adsorption. Affinity energy, defined as the strength of interaction between membranes and human serum proteins, plays a crucial role in assessing membrane-protein interactions. These interactions may trigger adverse reactions, potentially harmful to patients. Researchers often rely on trial-and-error approaches to enhance membrane hemocompatibility by reducing these interactions. This study focuses on developing machine learning algorithms that accurately and rapidly predict affinity energy between novel chemical structures of membrane materials and human serum proteins, based on a molecular docking dataset. Various membrane materials with distinct characteristics, chemistry, and orientation are considered in conjunction with different proteins. A comparative analysis of linear regression, K-nearest neighbors regression, decision tree regression, random forest regression, XGBoost regression, lasso regression, and support vector regression is conducted to predict affinity energy. The dataset, comprising 916 records for both training and test segments, incorporates 12 parameters extracted from data points and involves six different proteins. Results indicate that random forest (R² = 0.8987, MSE = 0.36, MAE = 0.45) and XGBoost (R² = 0.83, MSE = 0.49, MAE = 0.49) exhibit comparable predictive performance on the training dataset. However, random forest outperforms XGBoost on the testing dataset. Seven machine learning algorithms for predicting affinity energy are analyzed and compared, with random forest demonstrating superior predictive accuracy. The application of machine learning in predicting affinity energy holds significant promise for researchers and professionals in hemodialysis. These models, by enabling early interventions in hemodialysis membranes, could enhance patient safety and optimize the care of hemodialysis patients.

Point-of-Care Ultrasound in Nephrology: Beyond Kidney Ultrasound

Point-of-care ultrasound (POCUS) has increasingly become an integral part of clinical practice, particularly in nephrology, where its use extends beyond renal assessment to include multi-organ evaluations. Despite challenges such as limited ultrasound training and equipment access, especially in low- and middle-income countries, the adoption of POCUS is steadily rising. This narrative review explores the growing role of multi-organ POCUS in nephrology, with applications ranging from the assessment of congestion phenotypes, cardiorenal syndrome, and hemodynamic acute kidney injury (AKI) to the evaluation of arteriovenous fistulas and electrolyte disorders. In nephrology, POCUS enhances clinical decision making by enabling rapid, bedside evaluations of fluid status, cardiac function, and arteriovenous access. Studies have demonstrated its utility in diagnosing and managing complications such as heart failure, cirrhosis, and volume overload in end-stage renal disease. Additionally, POCUS has proven valuable in assessing hemodynamic alterations that contribute to AKI, particularly in patients with heart failure, cirrhosis, and systemic congestion. This review highlights how integrating ultrasound techniques, including lung ultrasound, venous Doppler, and focused cardiac ultrasound, can guide fluid management and improve patient outcomes. With advancements in ultrasound technology, particularly affordable handheld devices, and the expansion of targeted training programs, the potential for POCUS to become a global standard tool in nephrology continues to grow, enabling improved care in diverse clinical settings.