US Renal Data System 2016 Annual Data Report: Epidemiology of Kidney Disease in the United States

Deep learning for early detection of chronic kidney disease stages in diabetes patients: A TabNet approach

Chronic kidney disease (CKD) poses a significant risk for diabetes patients, often leading to severe complications. Early and accurate CKD stage detection is crucial for timely intervention. However, it remains challenging due to its asymptomatic progression, the oversight of routine CKD tests during diabetes checkups, and limited access to nephrologists. This study aimed to address these challenges by developing a multiclass CKD stage prediction model for diabetes patients using longitudinal data from the Chronic Renal Insufficiency Cohort (CRIC) study. A novel iterative backward feature selection strategy was employed to determine key predictors of the CKD stage. TabNet, an attention-based deep learning architecture, was used to build classification models in complete and simplified categories. The complete model used 31 features, including complex kidney biomarkers, while the simplified model used 15 features readily available from routine checkups. The performance of TabNet was compared against traditional tree-based ensemble methods (XGBoost, random forest, AdaBoost) and a multi-layer perceptron. Model-specific and model-agnostic explainable AI (XAI) techniques were applied to interpret model decisions, enhancing the transparency and clinical applicability of the proposed approach. The TabNet models demonstrated superior performance, achieving 94.06 % and 92.71 % accuracy in cross-validation for the complete and simplified models, respectively, and 91.00 % and 88.00 % accuracy on test sets. XAI analysis identified serum creatinine, cystatin C, sex, and age as the most influential factors in CKD stage classification. The proposed TabNet models offer a robust approach for early CKD severity detection in diabetes patients, potentially improving clinical decision-making and patient outcomes.

Early metabolomics revealed the sensitivity of sacubitril/valsartan to person with end-stage renal disease accompanied by heart failure

Heart failure (HF) is a major complication in patients with end-stage renal disease (ESRD) and is the leading cause of death in this high-risk population. Sacubitril/Valsartan is an angiotensin receptor-neprilysin inhibitor (ARNI) that has been shown to improve treatment outcomes in patients with ESRD accompanied by HF. Unfortunately, in clinical practice, some patients who received sacubitril/valsartan treatment not only did not show a good therapeutic effect, but also got worse with the passage of time. To explore potential biomarkers for predicting the clinical efficacy of sacubitril/valsartan, serum samples were prospectively collected upon admission and again collected after sacubitril/valsartan treatment was completed. Patients were divided into good response group (GR) and poor response group (PR). At the same time, samples before treatment were divided into GR group and PR group by sample tracing and matching, and metabolomics analysis was conducted. In the end, a total of 9 different metabolites were identified between patients in the early GR and PR groups. In order to find more effective biomarkers, two algorithms, random forest (RF) and support vector machine (SVM), were used for metabolite selection and performance evaluation, and three kinds of Lysophosphatidylcholine (LysoPC) metabolites showed good predictive effect, and the expression of the enzyme phospholipase A2 group IVA (PLA2G4A), associated with this metabolite was significantly elevated in the PR group. The disordered metabolism may reduce the sensitivity of patients to sacubitril/valsartan treatment, and PLA2G4A targeted inhibitors may be a promising therapeutic strategy to improve the sensitivity of patients with ESRD and HF to sacubitril/valsartan treatment.

The Alpha to Omega of Dialysis Access: Arteriovenous Fistula and Graft (Part 1)

Background: Vascular access is a critical determinant of hemodialysis efficacy in patients with end-stage kidney disease (ESKD). The choice between arteriovenous fistulas (AVFs) and arteriovenous grafts (AVGs) influences long-term dialysis outcomes, with AVFs offering superior patency but higher maturation failure rates and AVGs providing immediate usability at the expense of increased complications. Recent advancements in endovascular techniques and biomaterials have introduced novel approaches to optimizing vascular access. Purpose: This review examines the latest evidence on AVF and AVG creation, focusing on factors affecting maturation, long-term patency, and emerging minimally invasive techniques, such as percutaneous AVF creation, to enhance hemodialysis access outcomes. Research Design: A systematic review of current literature, clinical guidelines, and innovations in vascular access for dialysis patients was conducted. Emphasis was placed on comparative effectiveness studies, patency and complication rates, and new endovascular approaches. Study Sample: Data were sourced from clinical trials, registry reports, and systematic reviews evaluating AVF and AVG outcomes, as well as emerging endovascular fistula technologies. Data Collection and/or Analysis: Key parameters such as patency rates, infection rates, thrombosis incidence, and maturation success were analyzed. Particular attention was given to procedural innovations, including bioengineered grafts and percutaneous fistula creation, assessing their impact on long-term dialysis access viability. Results: AVFs maintain superior long-term patency but are hindered by primary failure rates, necessitating interventions for maturation. AVGs, while more prone to infection and thrombosis, offer a viable alternative when native vessels are unsuitable. Endovascular AVF creation has demonstrated high technical success and promising long-term outcomes, reducing the need for traditional surgical approaches. Advances in biomaterials and adjunctive pharmacologic therapies may further improve vascular access durability. Conclusions: Individualized vascular access planning remains essential to optimizing hemodialysis outcomes. The evolution of minimally invasive techniques, coupled with improved patient selection criteria and emerging biomaterials, offers new opportunities for enhancing dialysis access longevity. Future research should focus on refining endovascular approaches and integrating novel technologies to minimize complications and improve access patency.

Global, Regional, and National Prevalence of Chronic Type 2 Diabetic Kidney Disease From 1990 to 2021: A Trend and Health Inequality Analyses Based on the Global Burden of Disease Study 2021

BACKGROUND

Diabetic kidney disease (DKD) is a prevalent and severe complication of diabetes that significantly impacts global health and quality of life. Most DKD is attributable to type 2 diabetes; therefore, chronic type 2 DKD warrants further examination.

OBJECTIVE

To deliver targeted assistance in alleviating the worldwide, regional, and national burden of chronic type 2 DKD, we executed a survey assessing the prevalence of chronic type 2 DKD utilizing the Global Burden of Disease, Injury, and Risk Factors (GBD) database.

METHODS

We examined the temporal trends of chronic type 2 DKD prevalence over the past 30 years using the 2021 GBD database, analyzed the trends by population, epidemiological change, and aging, and quantified cross-country health inequalities. Additionally, we forecasted the trend during the subsequent two decades.

RESULTS

In 2021, there were over 107 million cases of chronic type 2 DKD globally, reflecting an 85.11% rise from 58 million cases in 1990. The age-standardized rate (ASR) declined with an estimated annual percentage change of 0.17% per annum. Epidemiological change and population expansion are the primary factors influencing the alterations. The contributions of epidemiological change, population, and aging vary with alterations in the sociodemographic index (SDI). Significant health inequalities were observed across 204 countries and territories, with the slope index of inequality increasing over time. The forecast for the worldwide burden of chronic type 2 DKD from 2020 to 2040 suggests a significant rise in case numbers, while the alterations in ASR remain largely stable.

CONCLUSIONS

These findings indicate the significant disease burden of chronic type 2 DKD, necessitating more targeted and effective interventions for its prevention and management.

A Mendelian randomization study on the causal association of circulating cytokines with diabetic nephropathy

BACKGROUND

Circulating cytokines were reported to be related to diabetic nephropathy (DN) in observational studies. However, the causal relationship between them remains unknown. This study aimed to investigate the causal relationship between DN and circulating cytokines with genetic data in the frame of Mendelian Randomization (MR).

METHODS

We performed a two-sample MR analysis to investigate the causal relationship in individuals of European ancestry, utilizing publicly available genome-wide association study (GWAS) statistics. We selected eligible instrumental SNPs that were significantly related to the circulating cytokines. Multiple MR analysis approaches were employed, including inverse variance weighted (IVW), Weighted Median, MR-Egger, Weighted Mode, Simple Mode, and MR pleiotropy residual sum and outlier (MR-PRESSO) methods.

RESULTS

We found evidence supporting the causal role of genetically predicted circulating levels in the increased risk of DN. Specifically, we observed associations for interferon-gamma [OR = 1.352, 95% CI: 1.089-1.678, P = 0.006], stem cell factor [OR = 1.252, 95% CI: 1.028-1.525, P = 0.025], and stromal-cell-derived factor 1 alpha [OR = 1.326, 95% CI: 1.017-1.727, P = 0.037]. Additionally, MR analysis revealed a negative causal association between macrophage inflammatory protein 1b and DN [OR = 0.921, 95% CI: 0.858-0.988, P = 0.022]. The results obtained from MR-Egger, Weighted Median, Weighted Mode, and Simple Mode methods were consistent with the Inverse Variance Weighted (IVW) estimates. Sensitivity analyses showed no evidence of horizontal pleiotropy, suggesting that the causal estimates were not biased.

CONCLUSIONS

Our findings offer promising leads for developing novel therapeutic targets for DN. By identifying the role of inflammatory cytokines in this debilitating condition through a genetic epidemiological approach, our study made contributions to a better understanding of the underlying disease mechanisms.

Reduced intensity incremental hemodialysis start does not decrease life expectancy and saves money: results of the RIDDLE study

BACKGROUND

Since 2001, twice-weekly hemodialysis has been the standard method for starting hemodialysis at the Alba Hospital (Piedmont, Italy).

METHODS

Incident patients who started in-center hemodialysis from January 2001 to December 2016, had sufficient residual kidney function (urine output > 500 ml/day), and survived on hemodialysis > 1 year were selected and followed until death or censoring on December 31, 2019. The endpoints for the whole cohort are survival, duration of twice-weekly hemodialysis, preservation of residual kidney function, and cost savings. Analysis was performed on subgroups with long-term (L: >  = 365 days) or short-term (S: < 365 days) twice-weekly hemodialysis duration, matched for age, sex, year of hemodialysis start, type of vascular access and diabetes.

RESULTS

The study included 146 patients with a total follow-up of 251,328 patient-days, of which 80,635 on twice-weekly hemodialysis. The median survival was 1793 days, median twice-weekly hemodialysis duration was 417 days, and median residual kidney function duration was 820 days. In the matched comparison, the long-term duration twice-weekly hemodialysis group had lower admissions (18.2 vs 27.7/1000 patient-days) and unscheduled hemodialysis session rates (0.26 vs 0.75/1000 patient-days) and greater median residual kidney function duration (1353 vs 445 days), but similar median survival (1809 vs 1744 days). During twice-weekly hemodialysis, 12,291 hemodialysis sessions were spared, resulting in a cost saving of 1,986,226 Euros, based on current local reimbursement fees.

CONCLUSIONS

Twice-weekly hemodialysis, under strict clinical surveillance appears to be a safe, feasible, and cost-saving method for initiating hemodialysis in patients with residual kidney function.

Particularities in the "Oldie but Goldie" Tc-99m DMSA Renography: A Retrospective Reference Centre Overview of 931 Children

Background/Objectives: The Tc-99m dimercaptosuccinic acid (DMSA) renal scan clearly images the renal cortex, highlighting functional tissue areas and indicating regions of renal scarring, infection, malformations, or other types of renal damage. To enhance the management of paediatric cases involving renal malformations and to reduce the incidence of chronic and progressive kidney diseases in "future adults", our study aims to identify and categorise various renal anomalies. Methods: This has been achieved by analysing the Tc-99m DMSA renal scans of a large cohort of 931 children diagnosed with different renal pathologies. After interpreting the scans, we categorised the renal malformations and cortical modifications into four groups: kidney number anomalies, positional anomalies, structural anomalies, and shape anomalies. Results: There has been a notable increase in the demand for renal scintigraphy in recent years, rising from 82 cases in 2019 to 183 cases in 2024. Structural anomalies were the most common type of malformations (73% from all patients), featuring a significant variety of cortical modifications. In total, 98 cases (93% from kidney number anomalies and 10.5% from all children) were diagnosed with renal agenesis. Additionally, 30 children (3.2% from all patients) had positional anomalies, primarily ectopic kidneys, and 54 patients (5.8% from all cases) had shape malformations, especially fused kidneys. Conclusions: Combining the Tc-99m DMSA renal scan with ultrasound provides a more reliable diagnosis of paediatric renal progressive diseases. A more accurate diagnosis allows for quicker treatment and prevention of potential complications, ultimately improving the quality of life and decreasing hospital costs of paediatric patients becoming adults.

Development and Validation of the Patient-Level Chinese Diabetes Outcome Model on Long-term Complications in Type 2 Diabetes: An Application of the Hong Kong Diabetes Register

OBJECTIVE

Patient-level simulation models, mainly developed in Western populations, capture complex interactions between risk factors and complications to predict the long-term effectiveness and cost-effectiveness of novel treatments and identify high-risk subgroups for personalized care. However, incidence of outcomes varies significantly by ethnicity and region. We used high-quality, patient-level register data to develop the Chinese Diabetes Outcomes Model (CDOM) for predicting incident and recurrent events in type 2 diabetes (T2D).

RESEARCH DESIGN AND METHODS

The CDOM was developed using the prospective Hong Kong Diabetes Register (HKDR) cohort (n = 21,453; median follow-up duration, 7.9 years; 166,433 patient-years). It was externally validated with a retrospective territory-wide cohort of Chinese patients with T2D attending Hong Kong publicly funded diabetes centers and community clinics (n = 176,120; follow-up duration, 7.2 years; 953,523 patient-years).

RESULTS

The CDOM predicted first and recurrent events with satisfactory performance during internal (C-statistic = 0.740-0.941) and external (C-statistic = 0.758-0.932) validation after calibration. The respective C-statistic values for cancer were 0.664 and 0.661. Subgroup analysis showed consistent performance during internal (C-statistic = 0.632-0.953) and external (C-statistic = 0.598-0.953) validation after calibration.

CONCLUSIONS

The CDOM, developed using comprehensive register data with long-term follow-up, is a robust tool for predicting long-term outcomes in Chinese patients with T2D. The model enables the identification of patient subgroups to augment study design and develop tailored novel treatment strategies, inform policy, and guide practice to improve cost-effectiveness of diabetes care.

Scalable ion concentration polarization dialyzer for peritoneal dialysate regeneration

A wearable artificial kidney (WAK) stands poised to offer dialysis treatment with maximal temporal and spatial flexibility for end-stage renal disease (ESRD) patients, while portability has not yet been achieved due to difficulties in portable purification. The ion concentration polarization (ICP), one of the nanoelectrokinetic phenomenon, has garnered substantial attention in the realm of portable purification applications, owing to its remarkable capacity for charge separation. In this work, scalable ICP dialyzer with 10,000-fold increase in throughput, was applied for peritoneal dialysate regeneration. First, the mechanism underpinning dialysate purification was corroborated based on micro-nanofluidics. Simultaneously, the electrochemical reactions utilized the complete decomposition of uncharged toxin (urea), achieving approximately 99% clearance, while the ICP phenomenon promoted the removal of positively charged toxin (creatinine), achieving approximately 30% clearance. Second, 3-D scalable ICP dialyzer was developed with a creation of micro-nanofluidic environment inside. Throughput scalability was demonstrated up to 1 mL/min with average approximately 30% toxins clearance. Ultimately, the 3-D ICP dialyzer was applied to assist peritoneal dialysis (PD) using a bilateral nephrectomy rat model. We demonstrated that regenerated dialysate successfully reduced in vivo toxicity, with average toxins removal ratio of approximately 30% per cycle. We believe that the integration of this scalable ICP dialyzer into the WAK holds tremendous potential for substantially enhancing the quality of life for individuals with ESRD.

Socioeconomic Differences in Navigating Access to Lung Transplant

Importance

Inequitable access to transplant in the US is well recognized, yet the nature and extent of upstream disparities in care prior to transplant are unknown.

Objective

To understand patterns of referral for lung transplant by race, ethnicity, and neighborhood-level socioeconomic status.

Design, Setting, and Participants

This retrospective cohort study included adults aged 18 to 80 years with obstructive and restrictive lung disease from a single large-volume transplant center in Cleveland, Ohio, who were diagnosed between January 1, 2006, and May 11, 2023.

Exposures

Neighborhood resources.

Main Outcomes and Measures

The main outcome was the transition to the next stage of the transplant care continuum, death, or a lapse in care. Cause-specific Cox proportional hazards regression models were used to account for death as a competing risk, adjusting for age at index encounter (respective to each cohort), diagnosis, and sex as covariates.

Results

This study included 30 050 patients with obstructive and restrictive lung disease with primary care encounters (mean [SD] age, 65 [13] years; 56.1% female), 73 817 with a pulmonary medicine encounter, 4198 undergoing lung transplant evaluation, and 1378 on the lung transplant waiting list. In a multivariable model including age, diagnosis, sex, area deprivation index, and race and ethnicity (including 3.3% Hispanic, 15.2% non-Hispanic Black, and 81.5% non-Hispanic White individuals), patients residing in the least-resourced neighborhoods were 97% more likely to die without transitioning to pulmonary medicine (hazard ratio [HR], 1.97 [95% CI, 1.78-2.17]), 90% more likely to die prior to lung transplant evaluation (HR, 1.90 [95% CI, 1.77-2.04]), 40% more likely to die prior to placement on the waiting list (HR, 1.40 [95% CI, 1.11-1.76]), and 97% more likely to die prior to transplant (HR, 1.97 [95% CI, 1.18-3.29]) compared with patients residing in the most-resourced neighborhoods. These patients were also 13% less likely to transition to pulmonary medicine (HR, 0.87 [95% CI, 0.82-0.92]) and 45% less likely to be placed on the waiting list (HR, 0.55 [95% CI, 0.44-0.68]) despite a 69% increased likelihood of transplant evaluation (HR, 1.69 [95% CI, 1.36-2.09]). While non-Hispanic Black patients had lower risks of death across all stages of care, they experienced a 39% lower likelihood of proceeding to lung transplant evaluation (HR, 0.61 [95% CI, 0.51-0.74]). Racial differences in the cumulative incidence of waiting list placement were found, but differences were not consistent across levels of neighborhood resources.

Conclusions and Relevance

In this retrospective cohort study of patients diagnosed with restrictive and obstructive pulmonary disease, increased mortality risks and decreased likelihood of care escalations for patients who were socioeconomically disadvantaged and for racial and ethnic minority patients were found. These results suggest potential interventions for advancing equitable access to lung transplant.

Incorporating area-level social drivers of health in predictive algorithms using electronic health record data

OBJECTIVES

The inclusion of social drivers of health (SDOH) into predictive algorithms of health outcomes has potential for improving algorithm interpretation, performance, generalizability, and transportability. However, there are limitations in the availability, understanding, and quality of SDOH variables, as well as a lack of guidance on how to incorporate them into algorithms when appropriate to do so. As such, few published algorithms include SDOH, and there is substantial methodological variability among those that do. We argue that practitioners should consider the use of social indices and factors-a class of area-level measurements-given their accessibility, transparency, and quality.

RESULTS

We illustrate the process of using such indices in predictive algorithms, which includes the selection of appropriate indices for the outcome, measurement time, and geographic level, in a demonstrative example with the Kidney Failure Risk Equation.

DISCUSSION

Identifying settings where incorporating SDOH may be beneficial and incorporating them rigorously can help validate algorithms and assess generalizability.

Tunneled Catheter-Related Bloodstream Infections in Chronic Hemodialysis Patients: Frequency, Risk Factors, and Outcomes-A 10-Year Analysis

The aim of this study is to investigate the rate, risk factors, causative microorganism distribution, and treatment outcomes of catheter-related bloodstream infection (CRBSI) in chronic hemodialysis patients undergoing treatment with a tunneled hemodialysis catheter. Data for all patients who underwent hemodialysis treatment with tunneled catheters at our center between January 2014 and January 2024 were retrospectively analyzed. A total of 171 patients were included in the study. Forty-five patients had 54 CRBSI episodes. The average time between catheter placement and the development of CRBSI was 127.4 days, and the risk of developing CRBSI increased as this duration extended. In the bivariate logistic regression analysis, advanced age (p = 0.03), diabetes (p = 0.005), duration of hemodialysis (p < 0.001), decompensated cirrhosis (p = 0.02), and the femoral vein being the entry site (p = 0.011) were identified as risk factors for CRBSI. In the ROC analysis, the hemoglobin A1c threshold value for the development of CRBSI in diabetic patients was determined to be 9.350 (69% sensitivity, 87% specificity, AUC = 0.755, p < 0.001). We believe that avoiding femoral vein catheterization as much as possible and expediting the transition from catheter to another method for dialysis are important measures to prevent the development of CRBSI.

Predictors of Treatment Adherence in Kidney Transplant Patients: A Systematic Review of the Literature

Background: Kidney transplantation (KTx) is a safe procedure that improves the life expectancy and quality of life of patients requiring it. However, despite the known benefits for patients who receive a kidney transplant, non-adherence to immunosuppressive medication is an unsolved problem, reflected mainly by graft rejection. Objective: The aim of this study is to systematically review the existing literature on adherence factors to medication after renal transplantation. Methods: A systematic literature review of studies published since 2010 was conducted in three databases. Records for the search were limited to publications from 2010 to 2024, available in full-text. The search was carried out in July 2024. In total, 2632 abstracts were downloaded from the different databases. Inclusion criteria were papers of any type (quantitative or qualitative) whose objective was the identification of predictors of adherence for patients who were prescribed immunosuppressive medication after kidney transplantation. Results: The predictors of adherence to treatment found in the systematic review were grouped into the following categories of the World Health Organization classification: socio-economic factors, factors related to the treatment/therapy, patient-related factors, disease-related factors, and health care system factors. Most of the studies were excluded, and in the end, 30 were included in the final analysis. According to these studies, a set of strong predictors was identified, but discrepancies among the variables of gender in young patients, pre-emptive transplantation, and the time of the transplantation were detected. Conclusions: In this study, we identified specific predictors and directions for the association of those predictors with adherence to immunosuppressive medication for patients after KTx. Further research should consider conducting reviews for different patient sub-groups on medication adherence and the development and validation of a screening instrument for adherence/non-adherence factors that clinicians could use as a detection tool for subjects at risk of low adherence.

Epidemiological risk factors for acute kidney injury outcomes in hospitalized adult patients: a multicenter cohort study

Background

Multiple studies have identified risk factors for acute kidney injury (AKI) in hospitalized patients, but less is known about factors associated with AKI severity, including non-recovery of AKI.

Methods

Retrospective cohort study of adults (≥18 years) hospitalized between 2014 and 2017 at three US academic medical centers. Study outcomes included incidence of AKI and non-recovery from AKI at hospital discharge in those who survived hospitalization. AKI was defined by KDIGO serum creatinine criteria. Non-AKI recovery was defined as persistent AKI stage ≥1 at time of discharge. Multivariable models assessed the association of risk factors for each outcome, focusing on race, diabetes, and obesity (BMI ≥ 30 versus <30 kg/m2), and adjusting for potential confounders.

Results

Among 56 056 patients included in the study (mean age 57, 25% Black, 48% women), 12 954 (23%) developed AKI. In adjusted models, Black race [odds ratio (OR) 1.26, 95% confidence interval (CI): 1.20, 1.32], diabetes (OR 1.14, 95% CI: 1.08, 1.19) and obesity (OR 1.14, 95% CI: 1.10, 1.20) were all associated with incident AKI. A total of 3591 of the 11 672 (30.8%) patients with AKI who survived until discharge had AKI non-recovery. In adjusted models, obesity (OR 1.27, 95% CI: 1.17, 1.39) was independently associated with higher risk of AKI non-recovery at hospital discharge.

Conclusions

Black race, diabetes, and obesity were associated with the development of AKI in hospitalized patients, but only obesity was associated with non-recovery from AKI at hospital discharge. These findings emphasize the growing relevance of obesity as an epidemiological risk factor of AKI.

Association of cardiac troponin I level with in-hospital and late mortality in dialysis patients

Background

Cardiovascular diseases (CVDs) are highly prevalent among the end-stage renal disease (ESRD) patients. Prognostic value of cardiac troponin I (cTnI) in patients with asymptomatic ESRD is less conclusive. This study was an observational study to evaluate correlation of first admitted cTnI level with early and late (during 6 months) hospitalization and mortality of ESRD patient admitted due to non-acute coronary and non-heart failure causes in ESRD patients.

Materials and Methods

In this prospective observational study, 460 dialysis patients without overt CVD who were admitted at two university hospital were included and followed during 6 months. Patients' demographic information and laboratory investigations including cTnI level and cause of admission were recorded. The association between cTnI level with in-hospital and late mortality was evaluated.

Results

cTnI level was higher in female (35.9%), hemodialysis patients (28.1%), and patients with permanent catheter vascular access (29.4%). There were significant differences in level of triglyceride (TG), low-density lipoprotein (LDL) cholesterol, and high-density lipoprotein (HDL) cholesterol between patients with normal and abnormal cTnI levels (P < 0.05). Patients with abnormal cTnI levels had higher level of TG and LDL cholesterol and lower level of HDL cholesterol. cTnI levels were associated with higher in-hospital and 6-month follow-up mortality rate. In logistic regression analysis, only female gender (odds ratio [OR] =1.89, confidence interval [CI] =1.22-3.076) and TG (OR = 1.007, CI = 1.003-1.01) were positively and HDL cholesterol level (OR = 0.994, CI = 0.98-0.99) was negatively associated with increased cTnI level. cTnI level was associated with early (OR = 4.81, CI = 1.64-14.89) and late (OR = 4.31, CI = 1.61-10.96) mortality.

Conclusion

Although in this study, cTnI level is not directly associated with cardiovascular disorders and admission and readmission causes, it is a strong predictor of early and late mortality.

Validation of the role of apolipoproteins in coronary artery disease patients with impaired kidney function for prognosis: a prospective cohort study in China

OBJECTIVE

This study aims to evaluate the relationship between apolipoproteins (ApoA1, ApoB, and the ApoB/A1 ratio) and the incidence of major adverse cardiovascular events (MACE) in patients with coronary artery disease (CAD) and impaired kidney function, assessing their potential role in secondary prevention.

METHOD

A prospective cohort of 1,640 patients with impaired kidney function who underwent percutaneous coronary intervention in China was analyzed. Patients were categorized based on the measurements of ApoA1, ApoB, and ApoB/A1 ratio. MACE, defined as a composite of all-cause mortality, cardiovascular death, nonfatal myocardial infarctions, strokes, and unplanned revascularizations, was tracked post-procedure, with statistical analyses including Kaplan-Meier survival curves and Cox regression models to identify associations with apolipoproteins. Subgroup analyses according to kidney function were conducted.

RESULT

During a median follow-up of 3.1 years, 324 MACE events were observed. Multivariable Cox regression analyses illustrated higher levels of ApoB and the ApoB/A1 ratio were significantly associated with increased MACE incidence (adjusted HR [95%CI] 1.668[1.044-2.666]; adjusted HR [95%CI] 2.231[1.409-3.533], respectively), while lower ApoA1 levels correlated with a higher risk (adjusted HR [95%CI] 0.505[0.326-0.782]). ROC curve analyses indicated comparable predictive performances to traditional risk factors like LDL cholesterol. Subgroup analysis revealed that the above association was not statistically significant in the moderate-to-severe renal impairment CAD patients (eGFR < 45 mL/min/1.73 m2).

CONCLUSION

Our findings illustrate that apolipoproteins, specifically ApoA1 and ApoB, along with their ratio, are significant predictors of major adverse cardiovascular events in CAD patients with impaired kidney function. These results emphasize the need for incorporating apolipoprotein measurements in secondary prevention strategies for this high-risk population.

Leadless Pacemaker vs. Transvenous Pacemaker in End Stage Kidney Disease: Insights from the Nationwide Readmission Database

Background: Leadless pacemakers offer a safe and effective alternative pacing strategy. However, limited data are available for patients with end stage renal disease (ESRD), a population of significant relevance. Methods: Using the Nationwide Readmission Database, we extracted data from all adult patients with ESRD who underwent traditional transvenous or leadless pacemaker implantation between 2016 and 2021. We compared in-hospital mortality, 30-day readmission rates, complication rates, and healthcare resource utilization between the two cohorts. Results: A total of 6384 (81.2%) patients were included in the transvenous pacemaker cohort, and 1481(18.8%) patients were included in the leadless pacemaker cohort. In patients with ESRD, leadless pacemaker implantation was linked to higher in-hospital complications when compared to transvenous pacemakers. These included the need for blood transfusion (aOR 1.85, 95% CI 1.32-2.60, p < 0.01), vascular complications (aOR 3.6, CI 1.40-9.26, p = 0.01), and cardiac complications (aOR 4.12, CI 1.70-9.98, p < 0.01). However, there were no differences between the two groups in terms of in-hospital mortality and 30-day readmission rates. The median length of stay was longer for leadless pacemaker implantation than transvenous pacemaker implantation (5 days vs. 4 days, p < 0.01). The total hospitalization charges were also higher ($139,826 vs. $93,919, p < 0.01). Conclusions: Although previous studies have demonstrated lower long-term complication rates with leadless pacemakers than transvenous pacemakers, our analysis shows a higher risk of short-term in-hospital complications in ESRD patients, though no differences in in-hospital mortality and 30-day readmissions.

Explaining International Trends in Mortality on Hemodialysis Through Changes in Hemodialysis Practices in the Dialysis Outcomes and Practice Patterns Study (DOPPS)

RATIONALE & OBJECTIVE

Case-mix adjusted hemodialysis mortality has decreased since 1998. Many factors that influence mortality may have contributed to this trend, and these associations may differ by continental region. We studied changes in hemodialysis facility practices over time and their potential role in mediating changes in patient survival.

STUDY DESIGN

Observational prospective cohort study.

SETTING & PARTICIPANTS

Adult hemodialysis patients treated in 500 hemodialysis facilities participating in the Dialysis Outcomes and Practice Patterns Study (DOPPS) between 1999 and 2015 in the United States, Japan, and 4 European countries: Germany, Italy, Spain, and the United Kingdom.

PREDICTORS

Four practice measures at each facility: the percentages of patients with Kt/V≥1.2, interdialytic weight gain [IDWG]<5.7%, phosphorus<6mg/dL, and using arteriovenous fistulas (AVFs).

OUTCOME

Patient survival.

ANALYTICAL APPROACH

Mediation analyses, adjusted for case mix, were conducted using 3-year study phase as the exposure and facility practice measures as potential mediators.

RESULTS

In Europe, we observed a 13% improvement in overall case-mix adjusted survival per decade. Trends in facility practice measures, especially Kt/V and phosphorus, explained 10% improvement in case-mix survival per decade, representing 77% (10% explained of 13% improvement) of the observed improvement. In Japan, 73% of the observed 12%/decade improvement in case-mix adjusted survival could be attributed to facility practices, especially Kt/V and IDWG. In the United States, 56% of the observed 47%/decade improvement in case-mix adjusted survival could be attributed to facility practices, especially AVF use and phosphorus control.

LIMITATIONS

Unmeasured changes in the characteristics of the patient population over this period may confound the observed associations.

CONCLUSIONS

The improvements in adjusted hemodialysis patient survival in Europe, Japan, and the United States from 1999 to 2015 can be largely explained by improvements in specific facility practices. Future changes in patient survival may be responsive to further evolution in the implementation of common clinical practices.

PLAIN-LANGUAGE SUMMARY

Case-mix adjusted survival of patients treated with hemodialysis has improved over the last 2 decades in the United States, Japan, and Europe. Some of this improvement can be explained by region-specific changes in 4 dialysis practices, namely increases in the proportions of patients achieving (1) Kt/V≥1.2, (2) serum phosphorus levels<6mg/dL, (3) interdialytic weight gain<5.7% of body weight, and/or (4) use of arteriovenous fistulas as vascular access, with the magnitude varying according to region-specific trends in these practices. These findings suggest that further improvement in these practice measures may be attended by further reductions in mortality among patients treated with maintenance hemodialysis.

Outcomes Following Arteriovenous Fistula Creation in Medicare Beneficiaries With End-Stage Kidney Disease

The objective of this study was to measure the contemporary patency rates and frequency of interventions required for arteriovenous fistula (AVF) care in a representative US population of patients with end-stage kidney disease, including by age, race, and gender. All Medicare beneficiaries aged >20 years who underwent AVF graft creation for end-stage kidney disease between 2017 and 2019 were included for analysis. The primary end points included primary patency, primary assisted patency, postintervention patency, and fistula functionality up to 1 year after AVF placement. The secondary end point included admission for an associated adverse event after AVF creation. Multivariate analysis of patency rates was also assessed. Of 43,457 patients included in the analysis, the cumulative primary patency at 90 days was 68.4% and at 1 year, 31.5%. At 1 year, the primary assisted patency rate, postintervention patency, and fistula use were 70.4%, 30.2%, and 59.1%, respectively. There was no difference in primary patency rates when comparing age groups (age 40 to 59 years: hazard ratio [HR] 1.01, 95% confidence interval [CI] 0.95 to 1.06, p = 0.84 or age ≥60 years: HR 0.99, 95% CI 0.93 to 1.04, p = 0.61) with the reference of age group 20 to 39 years. Women were at greater risk of experiencing primary patency failure than were men (HR 1.16, 95% CI 1.14 to 1.20, p <0.001), and Black patients were at greater risk of experiencing primary patency failure than were White patients (HR 1.34, 95% CI 1.31 to 1.38, p <0.001). The cumulative incidence of admissions for adverse events was 32.6% at 1 year. In conclusion, our findings suggest that the real-world AVF patency rates remain low, with disproportionately low rates in women and Black patients.

Chronic Kidney Disease and Infection Risk: A Lower Incidence of Peritonsillar Abscesses in Specific CKD Subgroups in a 16-Year Korean Nationwide Cohort Study

Peritonsillar abscesses and deep neck infection are potentially serious infections among patients with chronic kidney disease (CKD), posing risks for severe complications and drawing significant public health concern. This nationwide, population-based longitudinal study (2002-2019) assessed the extended relationship between chronic kidney disease (CKD) and the likelihood of peritonsillar abscess and deep neck infection in a Korean cohort. Using a 1:4 propensity score overlap-weighted matching, we included 16,879 individuals with CKD and 67,516 comparable controls, accounting for demographic variables and comorbidities to ensure balanced group comparisons. Hazard ratios (HRs) and 95% confidence intervals (CIs) for deep neck infection and peritonsillar abscesses in relation to CKD history were calculated with a propensity score overlap-weighted Cox proportional hazards model. Our results revealed no significant increase in the overall incidence of deep neck infections or peritonsillar abscesses in CKD patients compared to controls. Interestingly, CKD patients demonstrated a 50% reduced likelihood of developing peritonsillar abscesses (HR 0.50; 95% CI = 0.30-0.83; p = 0.007), particularly among subgroups aged 70 years or older, females, non-smokers, rural residents, overweight individuals, and those with lower comorbidity burdens (e.g., absence of hypertension, hyperlipidemia, or hyperglycemia). In summary, the results suggest that lifestyle modifications and the effective management of comorbidities could reduce the risk of peritonsillar abscess in certain CKD subgroups. Our findings may help to alleviate public health concerns regarding peritonsillar abscesses and deep neck infections as CKD-related comorbidities.

An updated systematic review of the risk factors for unplanned dialysis initiation

Background

Previously, a comprehensive review of the risk factors for unplanned dialysis initiation (UDI) was conducted by Hassan et al. (2019), based on studies published up to the end of 2017. They demonstrated that high-quality data and well-designed studies on the subject are lacking. Thus we updated their review to establish the modifiable factors associated with UDI.

Methods

MEDLINE and Embase were searched from January 2018 to August 2023. Following several rounds of screening, we identified 17 international studies (the majority of which were based in Europe) that met the eligibility criteria.

Results

Many of the included studies were well designed, utilised large datasets and adopted properly adjusted analyses to examine associations between patient characteristics and UDI. Definitions of UDI varied across studies, i.e. timeliness of presentation, vascular access type, initiating dialysis as an inpatient/outpatient or for life-threatening indications. The most common risk factors reported were cardiovascular disease, older age, lower body mass index, cause of kidney disease, cancer, diabetes, lower serum albumin, faster decline in kidney function and fewer number of nephrology visits prior to dialysis start. These were in line with those reported by Hassan et al., however, our updated review revealed several other important predictors of UDI, e.g. worse coding of chronic kidney disease in the general practitioner health record, lower health literacy and having acute kidney injury.

Conclusions

Our review provides new insights into reasons why people start dialysis in an unplanned manner, many of which are modifiable, thus contributing to efforts in reducing the rate of UDI.

Optimized fast non-singular integral terminal sliding mode control of immune response and HCMV infection of renal transplant recipient

Kidneys are the most commonly transplanted organs, and renal transplant is the best treatment for patients with advanced stages of renal disease. Immunosuppressive drugs are used after renal transplant to prevent the body from rejecting the transplanted kidney and ensure its proper kidney functioning. However, suppression of the immune system increases the risk of viral infections and other complications. Therefore, careful monitoring and management of immunosuppressive and antiviral drugs are essential for the success of the transplants. This article presents a hybrid fast non-singular integral terminal sliding mode control technique to adjust the efficacies of these drugs in renal transplant recipients, ensuring successful transplants and preventing viral infections. The proposed strategy tracks system trajectories to reference values and adjusts the treatment plan accordingly. The Lyapunov stability theorem is used to prove the asymptotic stability of the closed-loop system. Several simulation studies are conducted in MATLAB/Simulink environment to evaluate the performance of the proposed control technique in maintaining a balance between over-suppression and under-suppression. Genetic Algorithm is used to optimize the gain values to further improve the performance of the proposed control technique. Its performance is compared with two other variants of terminal sliding mode controllers to demonstrate its effectiveness against them.

A prospective study of factors associated with successful maturation of arteriovenous fistulas for hemodialysis

Aim

Our objective was to determine the factors associated with the successful maturation of arteriovenous fistulas during hemodialysis.

Material and methods

This prospective study included patients treated with hemodialysis and predialysis patients. Clinical, biochemical, sociodemographic, vascular ultrasound mapping, flow-mediated dilatation, and surgical factors were analyzed. Success in the maturation process was defined by ultrasonographic criteria at six weeks.

Results

Thirty-seven patients were included. With a mean ± standard deviation age of 40 ± 14 years, 73% were male, 65% had type-2 diabetes mellitus, and 95% had hypertension. Arteriovenous fistulas were brachycephalic in 18 patients (49%), brachymedian in nine patients (24%), brachycommunicating posterior in five patients (14%), brachibasal in three patients (8%), radiocephalic in two patients (8%), and radiocephalic in two patients (5%). Fourteen percent of patients had unsuccessful maturation. The vein diameter was 4.3 ± 1.0 mm (maturation group) vs 3.2 ± 0.9 mm (non-maturation group), p = 0.04. The artery diameter was similar: 4.5 ± 0.6 vs 4.5 ± 0.4, p = 0.88. Logistic regression analysis revealed that the diameter of the vein for which the surgery was performed was the factor associated with successful maturation in our population, odds ratio = 4.77 (1.14-19.97), p-value = 0.032.

Conclusions

It is highly important to plan vascular access in patients to perform vascular mapping and measure veins and arteries in patients. Vein measurement is a significant factor in successful maturation of the arteriovenous fistulas.

Relationship of serum total cholesterol and triglyceride with risk of mortality in maintenance hemodialysis patients: a multicenter prospective cohort study

OBJECTIVE

The relationship between serum total cholesterol (TC) and triglyceride (TG) levels and mortality in maintenance hemodialysis (MHD) patients remains inconsistent. We aimed to explore the individual and combined association of TC and TG levels with the risk of mortality in Chinese MHD patients.

METHODS

1036 MHD patients were enrolled in this multicenter, prospective cohort study. The serum levels of total cholesterol and triglycerides were measured at baseline. The primary outcome was all-cause mortality and secondary outcome was cardiovascular disease (CVD) mortality.

RESULTS

During a median follow-up duration of 4.4 years (IQR= 2.0-7.9 years), 549 (53.0%) patients died, and 297 (28.7%) deaths were attributed to CVD. Compared with patients with TC levels in the first three quartiles (<182.5 mg/dL), a significantly higher risk of all-cause mortality was found in participants with TC in the fourth quartile (hazard ratio [HR], 1.43; 95% confidence interval [CI], 1.17-1.76). However, a significantly lower risk of all-cause mortality was observed in participants with TG in the fourth quartile (≥193.9 mg/dL) (HR, 0.78; 95%CI: 0.63-0.98), compared with participants with TG in the first three quartiles. Similar trends were observed in CVD mortality. When analyzed jointly, patients with lower TC (<182.5 mg/dL) and higher TG (≥193.9 mg/dL) levels had the lowest risk of all-cause mortality and CVD mortality.Conclusions: In MHD patients in southern China, higher TC levels were associated with higher risk of mortality, while higher TG levels were related to lower risk of mortality. Patients with lower TC and higher TG levels had the best survival prognosis.

Development and validation of a prediction model for all-cause mortality in maintenance dialysis patients: a multicenter retrospective cohort study

BACKGROUND

The mortality risk varies considerably among individual dialysis patients. This study aimed to develop a user-friendly predictive model for predicting all-cause mortality among dialysis patients.

METHODS

Retrospective data regarding dialysis patients were obtained from two hospitals. Patients in training cohort (N = 1421) were recruited from the Fifth Affiliated Hospital of Sun Yat-sen University, and patients in external validation cohort (N = 429) were recruited from the First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine. The follow-up endpoint event was all-cause death. Variables were selected by LASSO-Cox regression, and the model was constructed by Cox regression, which was presented in the form of nomogram and web-based tool. The discrimination and accuracy of the prediction model were assessed using C-indexes and calibration curves, while the clinical value was assessed by decision curve analysis (DCA).

RESULTS

The best predictors of 1-, 3-, and 5-year all-cause mortality contained nine independent factors, including age, body mass index (BMI), diabetes mellitus (DM), cardiovascular disease (CVD), cancer, urine volume, hemoglobin (HGB), albumin (ALB), and pleural effusion (PE). The 1-, 3-, and 5-year C-indexes in the training set (0.840, 0.866, and 0.846, respectively) and validation set (0.746, 0.783, and 0.741, respectively) were consistent with comparable performance. According to the calibration curve, the nomogram predicted survival accurately matched the actual survival rate. The DCA showed the nomogram got more clinical net benefit in both the training and validation sets.

CONCLUSIONS

The effective and convenient nomogram may help clinicians quantify the risk of mortality in maintenance dialysis patients.

Integrin subunit beta 6 is a potential diagnostic marker for acute kidney injury in patients with diabetic kidney disease: a single cell sequencing data analysis

BACKGROUND

Diabetic kidney disease (DKD), a prevalent complication of diabetes mellitus, is often associated with acute kidney injury (AKI). Thus, the development of preventive and therapeutic strategies is crucial for delaying the progression of AKI and DKD.

METHODS

The GSE183276 dataset, comprising the data of 20 healthy controls and 12 patients with AKI, was downloaded from the Gene Expression Omnibus (GEO) database to analyze the AKI group. For analyzing the DKD group, the GSE131822 dataset, comprising the data of 3 healthy controls and 3 patients with DKD, was downloaded from the GEO database. The common differentially expressed genes (DEGs) in renal tubular epithelial cells (TECs) were subjected to enrichment analyses. Next, a protein-protein interaction (PPI) network was constructed using the Search Tool for the Retrieval of Interacting Genes database to analyze gene-related regulatory networks. Finally, the AKI animal models and the DKD and AKI cell models were established, and the reliability of the identified genes was validated using quantitative real-time polymerase chain reaction analysis.

RESULTS

Functional analysis was performed with 40 common DEGs in TECs. Eight hub genes were identified using the PPI and gene-related networks. Finally, validation experiments with the in vivo animal model and the in vitro cellular model revealed the four common DEGs. Four DEGs that share molecular mechanisms in the pathogenesis of DKD and AKI were identified. In particular, the expression of Integrin Subunit Beta 6(ITGB6), a hub and commonly upregulated gene, was upregulated in the in vitro models.

CONCLUSION

ITGB6 may serve as a biomarker for early AKI diagnosis in patients with DKD and as a target for early intervention therapies.

The effect of early conversion from central venous catheter to arteriovenous fistula on hospitalization and mortality in incident haemodialysis patients

BACKGROUND

Controversy remains as to whether initiating haemodialysis (HD) with a central venous catheter (CVC) and vascular access conversion are associated with the risk of morbidity and mortality in incident HD patients.

METHODS

At our dialysis centre, the vascular access strategy is to create an arteriovenous fistula (AVF) early and use the AVF to initiate HD. In emergency situations, HD is initiated with a CVC and subsequent conversion from a CVC to an AVF as soon as possible. The effects of early AVF conversion on hospitalization and mortality were analysed.

RESULTS

At HD initiation, 35.42% used AVF, 15.63% used CVC with immature AVF and 48.96% used CVC, and all patients were able to convert from CVC to AVF within approximately 3 months. Compared to starting HD using an AVF, using a CVC was associated with access-related hospitalizations at 2 years, regardless of whether an AVF was created before (incidence rate ratio (IRR) = 3.02, 95% CI 0.89-10.24, p = 0.03) or after (IRR = 4.10, 95% CI 1.55-10.85, p < 0.01) HD initiation. The Kaplan-Meier method showed that the 2-year survival probability was not statistically significant between the three groups (log-rank χ2 = 0.165, p = 0.921). Multivariate Cox proportional hazards regression showed that starting HD with a CVC was not associated with mortality at 2 years (p > 0.05).

CONCLUSION

In this cohort, initiating HD with a CVC was associated with more access-related hospitalizations. Under the impact of an early AVF conversion strategy, despite initiating HD with a CVC, subsequent conversion from a CVC to an AVF within approximately 3 months had no impact on all-cause mortality in incident HD patients.

Association of dietary antioxidant indices with kidney function indicators in patients with type 2 diabetes: a cross-sectional study

This cross-sectional study investigated the relationship between dietary antioxidant indices and kidney function indicators in 240 outpatient adults with type 2 diabetes. Dietary intake was assessed using three 24-h dietary recalls. Dietary total antioxidant capacity (DTAC), dietary antioxidant index (DAI), and dietary antioxidant quality score (DAQS) were obtained. Indicators of kidney function, including serum creatinine, urea, blood urea nitrogen (BUN), and glomerular filtration rate (GFR), were extracted from medical records. After adjustment, the highest DAI tertile had lower serum creatinine (0.98 ± 0.27 vs 1.03 ± 0.32 mg/dL, P < 0.001), reduced urea (30.97 ± 8.75 vs 34.07 ± 14.45 mg/dL, P = 0.005), and higher GFR (85.16 ± 29.43 vs 74.16 ± 22.18 ml/min per 1·73 m2, P < 0.001) compared to the lowest tertile. The results of logistic regression analysis indicated a borderline significant inverse association of serum urea > 20 mg/dl with DTAC (odds ratio (OR):0.28; 95% CI: 0.07-1.09; Ptrend = 0.06). Multivariable linear regression analysis revealed a significant aligned correlation between DAQs and GFR (β: 0.20; P-value: 0.005) and a marginally significant direct relationship between DAI and GFR (β: 0.14; P-value: 0.06). However, no significant association was observed for DTAC with GFR (β:-0.02; P-value: 0.80). Diets with higher antioxidant capacity may be linked to improved kidney function in type 2 diabetes but our results did not support this strongly.

Dapagliflozin attenuates AKI to CKD transition in diabetes by activating SIRT3/PGC1-α signaling and alleviating aberrant metabolic reprogramming

BACKGROUND

Patients with diabetes are prone to acute kidney injury (AKI) with a high mortality rate, poor prognosis, and a higher risk of progression to chronic kidney disease than non-diabetic patients.

METHODS

Streptozotocin (STZ)-treated type 1 and db/db type 2 diabetes model were established, AKI model was induced in mice by ischemia-reperfusion injury(IRI). Mouse proximal tubular cell cells were subjected to high glucose and hypoxia-reoxygenation in vitro. Transcriptional RNA sequencing was performed for clustering analysis and target gene screening. Renal structural damage was determined by histological staining, whereas creatinine and urea nitrogen levels were used to measure renal function.

RESULTS

Deteriorated renal function and renal tissue damage were observed in AKI mice with diabetic background. RNA sequencing showed a decrease in fatty acid oxidation (FAO) pathway and an increase in abnormal glycolysis. Treatment with Dapa, Sitagliptin(a DPP-4 inhibitor)and insulin reduced blood glucose levels in mice, and improved renal function. However, Dapa had a superior therapeutic effect and alleviated aberrant FAO and glycosis. Dapa reduced cellular death in cultured cells under high glucose hypoxia-reoxygenation conditions, alleviated FAO dysfunction, and reduced abnormal glycolysis. RNA sequencing showed that SIRT3 expression was reduced in diabetic IRI, which was largely restored by Dapa intervention. 3-TYP, a SIRT3 inhibitor, reversed the renal protective effects of Dapa and mediated abnormal FAO and glycolysis in mice and tubular cells.

CONCLUSION

Our study provides experimental evidence for the use of Dapa as a means to reduce diabetic AKI by ameliorating metabolic reprogramming in renal tubular cells.

Effect of GLP-1 Receptor Agonists on Renal Functions and Diabetic Nephropathy in Type 2 Diabetes Mellitus (T2DM) Patients: A Systematic Review and Meta-Analysis

Diabetes mellitus (DM) causes multiple kidney problems ultimately leading to renal failure, with a marked rise in the number of patients worldwide requiring renal replacement therapy (RRT). Diabetic kidney disease (DKD) remains a leading cause of morbidity and death despite advancements in treatment; however, recent cardiovascular outcome trials have highlighted the potential benefits of glucagon-like peptide-1 (GLP-1) receptor agonists and sodium-glucose cotransporter 2 (SGLT2) inhibitors in managing chronic kidney disease (CKD) and cardiovascular risks in type 2 diabetes (T2DM) patients, leading to recommendations for their use following metformin in clinical guidelines. The meta-analysis was run on RevMan 5.4 (The Cochrane Collaboration, 2020). Risk of bias was done using the Cochrane Risk of Bias (RoB) 2 tool for the quality assessment of studies. Eleven studies were selected for this systematic review, all of which provided sufficient data for the outcomes. The effect size calculated for urinary albumin excretion rate (UAER) was calculated to be d = -0.48, CI = 95% (-1.72, 0.75) and for estimated glomerular filtration rate (eGFR) % and eGFR mL/min, it was found to be d = -0.71, CI = 95% (-2.00, 0.58) and d = -0.71, CI = 95% (-2.00, 0.58), respectively. Overall, this meta-analysis supports the use of GLP-1 receptor agonists as an effective therapeutic option to protect renal function in T2DM patients, particularly those at high risk of or with existing DKD.

DeSUMOylation of RBMX regulates exosomal sorting of cargo to promote renal tubulointerstitial fibrosis in diabetic kidney disease

INTRODUCTION

Diabetic kidney disease (DKD) has become the primary cause of chronic renal failure in China, and renal tubulointerstitial fibrosis plays a central role in DKD progression. Urinary exosomes, which reflect kidney changes, are largely influenced by RNA-binding proteins (RBPs) in their miRNA content.

OBJECTIVES

Our research aimed to determine the effect of the RNA-binding protein RBMX on exosomal miRNA in DKD.

METHODS

We introduced a higher level of Rbmx into diabetic mice using an adenoassociated virus and isolated exosomes from their kidney tissue through advanced centrifugation techniques and specialized kits. We then conducted a series of tests, including qRT-PCR, Western blot, MitoSOX, ATP luminescence, coimmunoprecipitation, SUMOylation assays, RNA immunoprecipitation, and confocal microscopy.

RESULTS

RBMX is found in higher levels in DKD and contributes to worsening kidney fibrosis, mitochondrial damage, and miRNA mismanagement in exosomes. It specifically binds with miR-26a, miR-23c, and miR-874 within the exosomes. This dysfunction may be linked to changes in RBMX SUMOylation. These miRNAs seem to protect against mitochondrial damage in kidney cells by targeting CERS6.

CONCLUSION

DeSUMOylation of RBMX plays a crucial role in determining the makeup of miRNAs in kidney cell exosomes, impacting the protective miRNAs which regulate mitochondrial damage through their interaction with CERS6 mRNA, ultimately affecting mitochondrial health in DKD.

The Role of the Gut Microbiota in Complications among Hemodialysis Patients

The composition of the gut microbiota varies among end-stage renal disease (ESRD) patients on the basis of their mode of renal replacement therapy (RRT), with notably more pronounced dysbiosis occurring in those undergoing hemodialysis (HD). Interventions such as dialysis catheters, unstable hemodynamics, strict dietary restrictions, and pharmacotherapy significantly alter the intestinal microenvironment, thus disrupting the gut microbiota composition in HD patients. The gut microbiota may influence HD-related complications, including cardiovascular disease (CVD), infections, anemia, and malnutrition, through mechanisms such as bacterial translocation, immune regulation, and the production of gut microbial metabolites, thereby affecting both the quality of life and the prognosis of patients. This review focuses on alterations in the gut microbiota and its metabolites in HD patients. Additionally, understanding the impact of the gut microbiota on the complications of HD could provide insights into the development of novel treatment strategies to prevent or alleviate complications in HD patients.

A non-linear association between low-density lipoprotein cholesterol and the risk of diabetic kidney disease in patients with type 2 diabetes in China

Objective

To explore the intrinsic relationship between low-density lipoprotein cholesterol (LDL-C) and diabetic kidney disease (DKD) in patients with type 2 diabetes (T2D) in China.

Methods

This cross-sectional study included 1,313 patients with type 2 diabetes treated at the Affiliated Jinhua Hospital of Zhejiang University School of Medicine, located in Jinhua, China. The data were combined from two periods, 2017 and 2020-2021. Participants were categorized into groups with and without DKD. The relationship between LDL-C levels and DKD was evaluated employing logistics regression analysis and restricted cubic spline (RCS) curves.

Results

Generally, there was no statistical difference in LDL-C levels between DKD and non-DKD groups, however, a significantly non-linear relationship (Pnon-linear = 0.011) was observed between LDL-C levels and DKD prevalence after adjusting for confounding factors according to the RCS analysis. Two optimal cut-points of 2.97 and 3.61 mmol/L were selected out using random forest algorithm. With the middle LDL-C concentration (2.97-3.61 mmol/L) as the reference, the odds ratios for low (<2.97 mmol/L) and high (>3.61 mmol/L) concentrations were 1.45 (1.08-1.96) and 1.47 (1.01-2.15) respectively, after adjusting for confounding factors in the multivariate analyses. Notably, this association was more pronounced among female participants in the subgroup analyses.

Conclusion

A non-linear association was observed between LDL-C levels and the risk of DKD in patients with T2D in China. LDL-C levels below 2.97 mmol/L may elevate the risk of DKD, particularly in female patients with T2D.

High-sensitive troponin T, suPAR and Beta-2-microglobulin changes in concentration during hemodialysis

Hemodialysis (HD) patients are at high risk of cardiovascular disease and death. Reliable biomarkers for risk stratification and detection of acute myocardial infarction (AMI) are therefore pivotal. Cardiac troponins (cTn) are the preferred biomarkers for AMI. It remains unclear, if cTn concentrations changes as a consequence of HD treatment itself during dialysis. In this study, cTn was compared with soluble urokinase plasminogen activator receptor (suPAR) and Beta-2-microglobulin (B2M). We performed a prospective study including 17 HD patients measuring high-sensitive cardiac troponin t (hs-cTnT), suPAR and B2M before and after a dialysis session and verified the results in a random subgroup of eight patients from the group by repeating their measurements before and after a dialysis session 15 weeks later. Biomarker concentrations after dialysis were adjusted according to hemodilution or concentration according to the hemoglobin concentration. The average hs-cTnT concentration decreased significantly by -9.9% after dialysis (95% CI: -13.6% to -6.2%). The average (paired) difference were - 6.7 ng/L (p = 0.0104) after dialysis comparing 25 HD treatment occasions. SuPAR was not significantly influenced by dialysis. B2M decreased by -58% after HD as an expected result from the molecular size of the biomarker. The hs-cTnT in average decreased by -9.9% after dialysis. This is a diagnostic challenge since the current guidelines suggest a 20% change in hs-cTnT in patients with acute myocardial infarction. Larger prospective studies investigating the different factors influencing hs-cTnT after HD are warranted. Adjusting biomarker concentrations according to hemodilution or concentration using the hemoglobin concentration, should be considered in future studies to determine more exact changes in concentrations of cTnT and other relevant biomarkers.

Descriptive analysis of long-term survival after aortic valve replacement for dialysis patients: importance of renal pathologies and age

OBJECTIVES

This study analyzed the long-term survival of dialysis patients undergoing AVR using the Japanese National Clinical Database with additional survival data.

METHODS

De-novo AVR for dialysis-dependent patients between 2010 and 2012 who were registered in the Japan Cardiovascular Surgery Database were included. Concomitant aortic surgery and transcatheter aortic valve replacement were excluded. An additional questionnaire was sent to each hospital regarding the underlying kidney disease, the duration of dialysis initiation to the surgery, and clinical outcomes. The Kaplan-Meier survival curve was descriptively shown for all cohorts and each renal pathology. Furthermore, we compared the incidence of bioprosthetic valve failure in patients who were < 65 years old (group Y) and ≧65 years old (group O).

RESULTS

Of these 1529 patients, diabetic nephropathy was 517, chronic glomerulonephritis was 437, and renal sclerosis was 210, regarding renal pathology. 1, 3, and 5-year survival in each pathology was 78.4%, 58.6%, 45.9% in diabetic nephritis, 78.8%, 68.4%, 58.2% in chronic glomerulonephritis, 79.0%, 67.8%, 52.1% in renal sclerosis, and 74.4%, 62.6%, 49.2% in others. Active infectious endocarditis was more prevalent in group Y (O 2.7% vs. Y 9.6%). The incidence of bioprosthetic valve failure requiring re-hospitalization was too small to analyze. 1, 3, and 5-year survival was 76.0%, 63.4%, 49.2% in group O and 74.3%, 64.2%, and 47.7% in group Y.

CONCLUSIONS

Long-term survival of AVR for dialysis-dependent was higher in patients with chronic glomerulonephritis and lower in patients with diabetic nephritis than in other pathologies.

Thunbergia's Flowers Secondary Metabolites a Natural Armor Against Kidney Damage by Diclofenac

Nephrotoxicity is a common side effect arising from exposure to drugs or toxins. The study investigates the therapeutic effects of Thunbergia alata and Thunbergia erecta flowers on diclofenac-induced renal injury. Secondary metabolite characterization by positive mode high-resolution-ESI (LC-HR-ESI-MS) was followed by assessing their renal protection against diclofenac-induced damage and molecular docking studies. Using positive LC-HR-ESI-MS, 18 compounds from T. erecta and T. alata were identified. Diclofenac administration induced significant deterioration of all parameters in the kidney in addition to renal tissue contents of several inflammatory markers. The flower extracts of T. alata and T. erecta showed a clear improvement in the treated groups compared to the diclofenac-control group. The results were confirmed by histopathological examinations followed by immunohistochemical determination of vascular endothelial growth factor (VEGF), nuclear factor erythroid 2-related factor 2 (Nrf2), and transforming growth factor beta 1 (TGF-β1) expression. Furthermore, a protein-protein network to understand the complex interplay between the target proteins and their counterparts was done in addition to a molecular docking study of the de-replicated compounds in the active sites of NF-κB, TGF-β1, and VEGFR.

A clinical comparative study on carbamylated haemoglobin as a surrogate marker to differentiate acute kidney injury from chronic kidney disease

Introduction

Carbamylated haemoglobin is the result of reaction of isocyanate with N-terminal valine residues of the α and β chains of haemoglobin. Carbamylated haemoglobin concentration is dependent on the degree and duration of uraemia and thus may potentially serve as a marker to differentiate acute kidney injury (AKI) and chronic kidney disease (CKD).

Methods

A hospital-based prospective clinical comparative study was conducted in an urban tertiary medical care centre. Carbamylated haemoglobin was estimated in a total of 60 patients, 30 each of chronic kidney disease and acute kidney injury. The comparison of the carbamylated haemoglobin levels among the CKD and AKI groups was done using Mann-Whitney test. The mean value of carbamylated haemoglobin among the CKD group was 240.71 ± 75.64 μgVH/g, whereas among the AKI group, it was 67.15 ± 17.05 μgVH/g. These values are statistically significant with P < 0.001.

Results

Carbamylated haemoglobin values were elevated in relation to renal dysfunction, and it significantly correlated with chronicity of kidney disease. Mean CarHb among the CKD group was significantly high in comparison to the AKI group with statistical significance, with a P value of <0.001.

Conclusion

It was significantly attributed in this study that carbamylated haemoglobin >100 μgVH/g is diagnostic of CKD and a value <100 μgVH/g is diagnostic of AKI. Thus, in this study, it can be concluded that carbamylated haemoglobin is a useful marker to differentiate AKI from CKD.

The Relationship between Circulating Kidney Injury Molecule-1 and Cardiovascular Morbidity and Mortality in Hemodialysis Patients

BACKGROUND

The importance of identifying mortality biomarkers in chronic kidney disease (CKD), and especially in patients treated with hemodialysis (HD), has become evident. In addition to being a marker of tubulointerstitial injury, plasma kidney injury molecule-1 (KIM-1) has been mentioned in regard to HD patients as a risk marker for cardiovascular (CV) mortality and coronary artery calcification. The aim of this study was to assess the level of plasma KIM-1 as a marker of cardiovascular disease (CVD) and mortality in CKD5-HD patients (patients with CKD stage G5D treated with hemodialysis).

METHODS

We conducted a prospective case-control study that included 63 CKD5-HD patients (HD for 1-5 years) followed up for 48 months and a control group consisting of 52 non-dialysis patients diagnosed with CKD stages G1-G5 (ND-CKD). All patients had a CVD baseline assessment including medical history, echocardiography, and electrocardiography (ECG). Circulating plasma KIM-1 levels were determined with single-molecule counting immunoassay technology using an enzyme-linked immunosorbent assay. We obtained the following parameters: serum creatinine and urea; the inflammation markers CRP (C-reactive protein) and IL-6 (interleukin-6); and the anemia markers complete blood count, serum ferritin, and transferrin saturation (TSAT).

RESULTS

The mean plasma KIM-1 level was 403.8 ± 546.8 pg/mL, showing a statistically significant correlation with inflammation (CRP, R = 0.28, p = 0.02; IL-6, R = 0.36, p = 0.005) and with anemia (hematocrit, R = -0.5, p = -0.0316; hemoglobin (Hb), R = -0.5, p = 0.02). We found that patients with left ventricular hypertrophy (LVH) on echocardiography (59.7%) had significantly lower mean levels of plasma KIM-1 than patients from the control group (155.51 vs. 432.12 pg/mL; p = 0.026). Regarding the patients' follow-up, we assessed all-cause mortality as an endpoint. After 24 months of follow-up, we found a mortality rate of 22.23%, while after 48 months, the mortality rate was 50.73%. A plasma KIM-1 level < 82.98 pg/mL was significantly associated with decreased survival in hemodialysis patients (p < 0.001).

CONCLUSIONS

In patients treated with hemodialysis, low levels of plasma KIM-1 were associated with cardiovascular changes and an increased risk of mortality. Plasma KIM-1 levels were significantly higher in HD patients compared to ND-CKD patients.

Postoperative complications among dialysis-requiring patients undergoing splenectomy

BACKGROUND

Dialysis patients are at high risk for surgery, but their outcomes after splenectomy are unclear. We compared postoperative complications between dialysis and non-dialysis patients.

METHODS

Data were retrieved from the National Surgical Quality Improvement Program for this retrospective cohort. Adult patients undergoing elective splenectomy between 2005 and 2020 were included.

RESULTS

Among 10,339 included patients, 143(1.4%) were on chronic dialysis. Postoperative mortality was higher in dialysis vs. non-dialysis patients (9.1% vs. 1.8%). Dialysis patients were more likely to have 30-day major morbidity, infectious and non-infectious complications, reoperation, and prolonged hospital stay. On multivariable regression, dialysis dependence significantly increased odds of mortality, major morbidity, blood transfusion, prolonged length of stay, reoperation, and failure-to-rescue (FTR).

CONCLUSION

Dialysis patients were at higher risk of postoperative morbidity following splenectomy. Additionally, the risk of FTR in this patient population is also significantly more compared to non-dialysis patients.

Retrospective analysis of the effect of SGLT-2 inhibitors on renal function in patients with type 2 diabetes in the real world

Introduction

The protective effect of sodium-glucose cotransporter-2 (SGLT-2) inhibitors on the kidneys has been widely recognized. However, limited research has reported the changes in estimated glomerular filtration rate (eGFR) of real-world patients with type 2 diabetes mellitus (T2DM) over time after administration of SGLT-2 inhibitors. This study aimed to reflect the trend of eGFR changes over time in T2DM patients having different baseline eGFR after SGLT-2 inhibitors administration in the real world.

Methods

A single-center retrospective study was performed in a tertiary public hospital in Beijing, China. In total, 998 outpatients with T2DM who initiated SGLT-2 inhibitors treatment were included in the study. The changes in eGFR, urinary albumin/creatinine ratio (UACR), and glycolipid metabolism indicators were analyzed during the 18-month follow-up period.

Results

The eGFR levels significantly decreased to their lowest point (-3.04 mL/min/1.73 m2) in the first 3 months after initiation of SGLT-2 inhibitors treatment, however, gradually returned to the baseline level after 1 year. Compared to the subgroup with eGFR >90 mL/min/1.73 m2, improvements in renal function were more significant in patients with T2DM from the 60 < eGFR ≤90 mL/min/1.73 m2 and eGFR ≤60 mL/min/1.73 m2 subgroups after treatment with SGLT-2 inhibitors. Similarly, SGLT-2 inhibitors reduced the UACR in patients with diabetic nephropathy.

Conclusion

This study further confirmed the real-world long-term protective effect of SGLT-2 inhibitors on the kidneys of patients with T2DM, which is not related to baseline renal function and blood glucose.

An Implantable Magnetic Drive Mechanism for Non-Invasive Arteriovenous Conduit Blood Flow Control

OBJECTIVE

Hemodialysis patients usually receive an arteriovenous fistula (AVF) in the arm as vascular access conduit to allow dialysis 2-3 times a week. This AVF introduces the high flow necessary for dialysis, but over time the ever-present supraphysiological flow is the leading cause of complications. This study aims to develop an implantable device able to non-invasively remove the high flow outside dialysis sessions.

METHODS

The developed prototype features a magnetic ring allowing external coupling and torque transmission to non-invasively control an AVF valve. Mock-up devices were implanted into arm and sheep cadavers to test sizes and locations. The transmission torque, output force, and valve closure are measured for different representative skin thicknesses.

RESULTS

The prototype was placed successfully into arm and sheep cadavers. In the prototype, a maximum output force of 78.9 ± 4.2 N, 46.7 ± 1.9 N, 25.6 ± 0.7 N, 13.5 ± 0.6 N and 6.3 ± 0.4 N could be achieved non-invasively through skin thicknesses of 1-5 mm respectively. The fistula was fully collapsible in every measurement through skin thickness up to the required 4 mm.

CONCLUSION

The prototype satisfies the design requirements. It is fully implantable and allows closure and control of an AVF through non-invasive torque transmission. In vivo studies are pivotal in assessing functionality and understanding systemic effects.

SIGNIFICANCE

A method is introduced to transfer large amounts of energy to a medical implant for actuation of a mechanical valve trough a closed surface. This system allows non-invasive control of an AVF to reduce complications related to the permanent high flow in conventional AVFs.

A descriptive study of the single-nucleotide polymorphisms known to affect the Tacrolimus trough concentration per dose, among a population of kidney failure patients in a tertiary hospital in Ghana

BACKGROUND

The burden of chronic kidney disease (CKD) and kidney failure in Ghana is on the ascendency, with the prevalence of CKD estimated at 13.3%. Patients with CKD who progress to kidney failure require life sustaining kidney replacement therapy (KRT) which is almost exclusively available in Ghana as haemodialysis. Kidney transplantation is considered the best KRT option for patients with irreversible kidney failure due to its relative cost efficiency as well as its superiority in terms of survival and quality of life. However, because transplants may trigger an immune response with potential organ rejection, immunosuppressants such as tacrolimus dosing are required.

OBJECTIVE

This study sought to determine single nucleotide polymorphisms in CYP3A5, CYP3A4 and MDR1 genes that affect the pharmacokinetics of Tacrolimus in a population of Ghanaian patients with kidney failure.

METHOD

This cross-sectional study comprised of 82 kidney failure patients undergoing maintenance haemodialysis at the Renal and Dialysis unit of Korle-Bu Teaching Hospital (KBTH). Clinical and demographic data were collected and genomic DNA isolated. Samples were genotyped for specific SNPs using Polymerase Chain Reaction-Restriction Fragment Length Polymorphism (PCR-RFLP).

RESULTS

Participants, 58/82 (70.73%) harbored the wildtype CYP3A5*1/*1 AA genotype, 20/82 (24.39%) carried the heterozygous CYP3A5*1/*3 AG genotype, and 4/82 (4.88%) had the homozygous mutant CYP3A5*3/*3 GG genotype. Also, 6/82 (7.32%) carried the wildtype AA genotype, 11/82 (13.41%) had the heterozygous AG genotype, and 65/82 (79.27%) harbored the homozygous mutant GG genotype of CYP3A4*1B (-290 A>G). For MDR1_Ex21 (2677 G>T), 81/82 (98.78%) carried the wildtype GG genotype, while 1/82 (1.22%) had the heterozygous GT genotype. For MDR1_Ex26 (3435 C>T), 63/82 (76.83%) had the wildtype CC genotype, while 18/82 (21.95%) carried the heterozygous CT genotype, and 1/82 (1.22%) harbored the mutant TT genotype.

CONCLUSION

SNPs in CYP3A4, CYP3A5, and MDR1 genes in a population of Ghanaian kidney failure patients were described. The varying SNPs of the featured genes suggest the need to consider the genetic status of Ghanaians kidney failure patients prior to transplantation and tacrolimus therapy.

Effect of puncture position on catheter patency rate during tunnelled dialysis catheter insertion from the right internal jugular vein

Background

No recommendations have been made regarding the puncture position during tunnelled dialysis catheter (TDC) insertion from right internal jugular vein (RIJV). We investigated the effect of puncture positioning along with other characteristics and clinical factors associated with TDCs to determine their correlation with catheter patency rate.

Methods

We retrospectively reviewed TDC insertion procedures performed between January 2018 and December 2020 at a single institution. Patients were monitored for at least 1 year or until TDC removal or replacement. The distance on the post-operative chest radiography were measured to determine the height of puncture position. End points were freedom from catheter dysfunction.

Results

Total 949 catheters met the eligibility criteria. Catheter dysfunction occurred in 233 patients and catheter infection in 127 patients. By multivariate analysis, female sex [hazard ratio (HR) =1.497, 95% confidence interval (CI): 1.119-2.002; P=0.007] and split-tip catheter (HR =1.453, 95% CI: 1.087-1.944; P=0.012) were associated with an increased rate of catheter dysfunction. Every 10-year increment in age (HR =1.243, 95% CI: 1.123-1.376; P<0.001) and every 1-cm increase in the height of the catheter insertion site (HR =1.270, 95% CI: 1.096-1.473; P=0.001) were also associated with an increased rate of catheter dysfunction. After classifying the height of puncture position into 3 groups, significant worse patency was observed in the catheter with puncture height more than 4 cm (P=0.025). No immediate complications were observed.

Conclusions

TDC insertion at a high puncture site correlates with an increased risk of catheter dysfunction. Puncturing the RIJV close to the clavicle is safe and enhances catheter patency.

Impact of physical activity on surrogate markers of cardiovascular disease in the haemodialysis population

Background

The haemodialysis (HD) population is sedentary, with substantial cardiovascular disease risk. In the general population, small increases in daily step count associate with significant reductions in cardiovascular mortality. This study explores the relationship between daily step count and surrogate markers of cardiovascular disease, including left ventricular ejection fraction (LVEF) and native T1 (a marker of diffuse myocardial fibrosis), within the HD population.

Methods

This was a post hoc analysis of the association between daily step count and metabolic equivalent of task (MET) and prognostically important cardiac magnetic resonance imaging parameters from the CYCLE-HD study (ISRCTN11299707). Unadjusted linear regression and multiple linear regression adjusted for age, body mass index, dialysis vintage, haemoglobin, hypertension and ultrafiltration volume were performed. Significant relationships were explored with natural cubic spline models with four degrees of freedom (five knots).

Results

A total of 107 participants were included [age 56.3 ± 14.1 years, 79 (73.8%) males]. The median daily step count was 2558 (interquartile range 1054-4352). There were significant associations between steps and LVEF (β = 0.292; P = .009) and steps and native T1 (β = -0.245; P = .035). Further modelling demonstrated most of the increase in LVEF occurred at up to 2000 steps/day and there was an inverse dose-response relationship between steps and native T1, with the most pronounced reduction in native T1 between ≈2500 and 6000 steps/day.

Conclusions

The results suggest an association between daily step count and parameters of cardiovascular health in the HD population. These findings support the recommendations for encouraging physical activity but are not the justification. Further research should evaluate whether a simple physical activity intervention improves cardiovascular outcomes in individuals receiving maintenance HD.

Prospective multicenter study of a novel endovascular venous anastomotic procedure and device for implantation of an arteriovenous graft for hemodialysis

INTRODUCTION

The traditional sutured venous anastomosis used during arteriovenous graft implantation is associated with a high incidence of subsequent stenosis that is attributed to neointimal hyperplasia. Hyperplasia results from multiple factors, including hemodynamic abnormalities and vessel trauma during implantation. A novel anastomotic connector device was designed to provide an alternative, less traumatic, endovascular venous anastomosis that may ameliorate the clinical challenges associated with a sutured anastomosis. A prospective single-arm multicenter study was performed to evaluate safety and effectiveness of graft implantation using the study device.

METHODS

Patients requiring graft creation and who met the study criteria were enrolled between February 2018 and July 2021 and observed for 6 months. Collected data included baseline characteristics, graft patency and use for hemodialysis, graft interventions, and adverse events. The primary study endpoint was cumulative graft patency, compared to a pre-specified Performance Goal of 75%. Secondary endpoints included primary unassisted patency and serious adverse events, defined as the occurrence of death, graft infection, emergent surgery, significant bleeding, and pseudoaneurysm.

RESULTS

A total of 158 patients were enrolled from 10 study sites, among which 144 subjects were evaluable at 6 months and 14 were censored with partial follow-up observation. Three patients died and the graft was abandoned in 12. The primary endpoint was met (p-value < 0.001). By Kaplan Meier survival analysis, cumulative patency was 92.08% with a lower 95% Confidence Bound of 86.98%. Primary unassisted patency was 60.21% with a lower 95% Confidence Bound of 50.84%. Graft infections occurred in six patients, all unrelated to the study device. There were no reports of emergent surgery, significant bleeding or pseudoaneurysm.

CONCLUSION

These results demonstrate that the study device can be used for successful endovascular anastomosis of a vein to a graft for hemodialysis, with acceptable cumulative patency and safety profile at 6 months.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02532621.

Rejoining Veins for Forced Maturation of Small-Caliber Arteriovenous Fistula

BACKGROUND

To evaluate the efficacy of rejoining mainstream and accessory veins for forced maturation of autogenous arteriovenous fistula (AVF).

METHODS

Twenty-three patients who underwent forced maturation through vein rejoining between January 2018 and September 2022 were included. In cases where AVF maturation failure due to the presence of accessory veins, rejoining was primarily considered when distinguishing the main branch becomes challenging. This difficulty typically occurs when the sizes of the 2 vessels are nearly equal and the combined diameters of these veins exceed 6 mm.

RESULTS

The mean age and follow-up duration were 57.39 ± 16.22 years and 965.65 ± 573.42 days, respectively. Rejoining of both arterial and venous cannulation sites was performed in 11 patients (47.8%), and rejoining of only the venous cannulation site or only the arterial cannulation site was performed in 11 patients (47.8%) and 1 patient (4.3%), respectively. The mean vein size was 0.35 ± 0.06 cm before rejoining and 0.69 ± 0.07 cm after surgery, indicating a significant increase in size (P < 0.01), whereas the flow did not change significantly following rejoining surgery. Maturation and cannulation success was 100%. The 1-year primary patency rate after surgery was 82.0%. During the follow-up period, 34.8% of the patients required additional percutaneous transluminal angioplasty to maintain patency, and 2 patients (11.8%) had stenosis in the rejoined section.

CONCLUSIONS

Rejoining surgery is an effective method for achieving AVF maturation in patients with accessory veins when identification of the mainstream vein is difficult, and this method may be considered when achieving maturation by sacrificing 1 vein is expected to be challenging.

Outcomes of prosthetic upper arm arteriovenous graft vs brachiobasilic fistula for hemodialysis access

OBJECTIVE

Primary arteriovenous access such as radiocephalic and brachiocephalic fistulas are initial choices for creating vascular access in dialysis patients. When neither of these choices is an option, upper arm arteriovenous graft or brachiobasilic transposition is recommended. Although primary fistula is better than prosthetic graft for suitable patients, there is little data to guide the best treatment strategy in the absence of suitable vein for primary access creation. This study identifies factors that influence patency rates and compares outcomes of patients treated with brachiobasilic fistula vs upper arm graft in patients who have failed forearm access or are not candidates for primary access.

METHODS

A prospectively maintained database of patients with dialysis-dependent renal failure from 2010 to 2022 was analyzed. Primary, primary assisted, and secondary patency rates were calculated. Incidence rates of complications and reinterventions were compared.

RESULTS

There were 148 patients with brachiobasilic fistulas and 157 patients with upper arm grafts. The graft group was older (70.1 ± 14.7 vs 62.5 ± 14.6 years; P = .003) and had a higher incidence of pacemakers (11.9% vs 4.1%; P = .005). Brachiobasilic fistulas had higher 6-month (77.0% vs 64.3%; P = .02) and 1-year (68.2% vs 55.4%; P = .03) primary-assisted patency. Secondary patency rates were better for upper arm grafts at 1-year (82.2% vs 72.3%; P = .05). Access complications of non-maturation and aneurysm were higher in basilic vein transposition (21.6% vs 1.3%; P < .0001; 15.5% vs 6.4%; P = .017). Grafts had higher rates of occlusion (58.0% vs 25.7%; P < .0001). In terms of interventions, upper arm grafts had higher rates of thrombectomy (50.3% vs 18.9%; P < .0001), but there was no difference seen in angioplasty, stent, surgical revision, or steal procedures. Basilic vein transpositions had longer time to cannulation (104.6 ± 81.1 vs 32.5 ± 22.4 days; P < .0001), longer total catheter days (251.1 ± 181.7 vs 72.9 ± 56.3 days; P < .0001), and higher number of procedures to aid maturity (0.7 ± 0.7 vs 0.1 ± 0.3; P < .0001).

CONCLUSIONS

In this retrospective analysis, when forearm access or primary arteriovenous access is not an option, basilic vein transposition and upper arm grafts have fairly equivalent primary patency. Primary assisted patency is slightly better in basilic vein fistulas, but secondary patency is better in upper arm grafts at 1 year. Basilic fistulas also had longer time to cannulation, longer total catheter days, and more procedures to aid maturity.

Endothelial dysfunction in retinal vessels of hemodialysis patients compared to healthy controls

Endothelial dysfunction is a key factor promoting atherosclerosis and cardiovascular complications. Hemodialysis patients typically show various cardiovascular complications and impaired retinal venular dilation has been described as a risk factor for mortality. Non-invasive retinal vessel analysis provides insight into the microvasculature and endothelial function. Static retinal vessel analysis determines arteriolar and venular vessel diameters and dynamic retinal vessel analysis measures microvascular function by flicker-light induced stimulation, which results in physiological dilation of retinal vessels. We measured 220 healthy individuals and compared them to our preexisting cohort of hemodialysis patients (275 for static and 214 for dynamic analysis). Regarding static vessel diameters, hemodialysis patients and healthy individuals did not significantly differ between vessel diameters. Dynamic retinal vessel analysis showed attenuated dilation of the arteriole of hemodialysis patients with 1.6% vs 2.3% in healthy individuals (p = 0.009). Case-control matching for age (mean 65.4 years) did not relevantly diminish the difference. Hemodialysis patients also exhibited reduced venular dilation after matching for age (3.2% vs 3.8%, p = 0.019). Hemodialysis patients showed microvascular dysfunction compared to healthy individuals when using dynamic retinal vessel analysis. Further studies should focus on dynamic retinal vessel analysis which can add insights into the microvascular function and risk factors in multimorbid patients.

Rapid intervention team strategy improves intervention quality for patients undergoing hemodialysis with arteriovenous shunt dysfunction or failure

BACKGROUND

Vascular access dysfunction is a great burden for hemodialysis patients. Early intervention of a dysfunctional arteriovenous shunt is associated with higher technical success and may improve midterm patency. This trial aimed to estimate the feasibility of a new system, the "rapid intervention team" (RIT) strategy.

METHODS

We recruited hemodialysis patients who visited our hospital because of arteriovenous shunt dysfunction or failure to undergo an RIT strategy from September 1, 2019 to December 31, 2022. In addition, we included a control group comprising patients who underwent percutaneous intervention for arteriovenous shunt dysfunction or failure before this strategy was implemented from February 1, 2017 to December 31, 2022. Case number, time to intervention, all-cause mortality, cumulative survival rate, and number of patients who required temporary dialysis catheter insertion and recreation were compared between the two groups. The primary endpoints were double-lumen insertion, a composite outcome involving permanent catheter insertion, and the need for recreation. The secondary endpoint was all-cause mortality.

RESULTS

We enrolled 1054 patients, including 544 (51.6%) and 510 (48.4%) in the RIT and control groups, respectively. Even with the coronavirus disease of 2019 (COVID-19) pandemic, the number of cases significantly increased after the implementation of the RIT strategy (from 216 in 2019 to 828 in 2022, p for trend <0.001). The RIT group had a shortened time to intervention ( p for trend <0.001). The implementation of the RIT strategy was significantly associated with a reduced risk of insertion of a temporary double-lumen catheter and recreation of vascular access (1% vs 6% and 1% vs 28%, respectively; both p < 0.01). The cumulative survival rate was not significantly different between the RIT and control groups ( p = 0.16).

CONCLUSION

The implementation of the RIT strategy improves the quantity and quality of percutaneous transluminal intervention for arteriovenous shunt dysfunction or failure in patients undergoing hemodialysis.

Unexplained Residual Risk In Type 2 Diabetes: How Big Is The Problem?

PURPOSE OF REVIEW

What is new? Cardiovascular disease (CVD) is the leading cause of mortality in type 2 diabetes (T2D) individuals. Of the major risk factors for CVD, less than 10% of T2D people meet the American Diabetes Association/American Heart Association recommended goals of therapy. The present review examines how much of the absolute cardiovascular (CV) risk in type 2 diabetes patients can be explained by major CV intervention trials.

RECENT FINDINGS

Multiple long-term cardiovascular (CV) intervention trials have examined the effect of specific target-directed therapies on the MACE endpoint. Only one prospective study, STENO-2, has employed a multifactorial intervention comparing intensified versus conventional treatment of modifiable risk factors in T2D patients, and demonstrated a 20% absolute CV risk reduction. If the absolute CV risk reduction in these trials is added to that in the only prospective multifactorial intervention trial (STENO-2), the unexplained CV risk is 44.1%. What are the clinical implications? Potential explanations for the unaccounted-for reduction in absolute CV risk in type 2 diabetes (T2D) patients are discussed.

HYPOTHESIS

failure to take into account synergistic interactions between major cardiovascular risk factors is responsible for the unexplained CV risk in T2D patients. Simultaneous treatment of all major CV risk factors to recommended AHA/ADA guideline goals is required to achieve the maximum reduction in CV risk.