1
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Lee CS, Li JYZ, Juneja R, Ullah S, van der Jeugd J, Gleadle JM. Renal transplants increase in size and function in keeping with compensatory renal hypertrophy. Nephrology (Carlton) 2024; 29:363-370. [PMID: 38332342 DOI: 10.1111/nep.14275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 12/19/2023] [Accepted: 01/20/2024] [Indexed: 02/10/2024]
Abstract
AIM To evaluate changes in allograft kidney length in renal transplant recipients and the relationship with estimated glomerular filtration rate (eGFR). METHODS This single-centre retrospective study of renal transplant recipients was conducted at Flinders Medical Centre (FMC) from January 2007 to June 2020. Donor and recipient details, renal allograft length from transplant ultrasounds at 0, 1, 3, 6 and 12 months were collected. The association between compensatory renal hypertrophy (CRH) and eGFR and its magnitude was analysed using multivariate multilevel mixed-effects linear regression models. RESULTS A total of 183 renal transplant recipients were studied. 100 of 175 recipients (62.9%) demonstrated an increase in renal length defined as any increase in maximal longitudinal diameter on serial ultrasounds. Twenty-three recipients (13.1%) had no change in transplant length and 42 recipients (24%) had a decrease in length. The mean increase in kidney length over the first 12 months was 0.57 cm. Ninety of 156 (57.7%) recipients with a renal ultrasound within a month post-transplant demonstrated a mean increase kidney length of 0.3 cm. Multivariate analysis demonstrated that eGFR increased by 2.5 mL/min/1.73 m2 (95% CI 0.72- 4.4; p = .006) with every 1 cm increase in kidney length. Absolute changes in kidney length did not demonstrate any statistically significant correlation with eGFR in both complete case and multiple imputation analysis. CONCLUSION An increase in transplant kidney length is common in renal transplant recipients and is associated with enhanced eGFR. However, further studies need to be performed to study the association of absolute change in kidney length and eGFR.
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Affiliation(s)
- Chiang Sheng Lee
- Renal Unit, Flinders Medical Centre, Bedford Park, South Australia, Australia
- College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Jordan Y Z Li
- Renal Unit, Flinders Medical Centre, Bedford Park, South Australia, Australia
- College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Rajiv Juneja
- Renal Unit, Flinders Medical Centre, Bedford Park, South Australia, Australia
- College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Shahid Ullah
- College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Jane van der Jeugd
- Renal Unit, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Jonathan M Gleadle
- Renal Unit, Flinders Medical Centre, Bedford Park, South Australia, Australia
- College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
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2
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Aly R, Darwish S, Bala N, Ebrahim A, Shoemaker LR, McCray J, Garrett TJ, Alli AA. Functional and metabolomic analysis of urinary extracellular vesicles from juvenile mice with renal compensatory hypertrophy. Biochim Biophys Acta Mol Basis Dis 2024; 1870:167096. [PMID: 38499276 DOI: 10.1016/j.bbadis.2024.167096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 02/14/2024] [Accepted: 02/20/2024] [Indexed: 03/20/2024]
Abstract
Unilateral nephrectomy, a procedure reducing kidney mass, triggers a compensatory response in the remaining kidney, increasing its size and function to maintain a normal glomerular filtration rate (GFR). Recent research has highlighted the role of extracellular vesicles (EVs) in renal physiology and disease, although their involvement in unilateral nephrectomy has been underexplored. In this study, unilateral nephrectomy was performed on young mice, and urinary extracellular vesicles (uEVs) characterization and cargo were analyzed. Kidney volume increased significantly post-nephrectomy, demonstrating compensatory hypertrophy. Serum creatinine, cystatin C, and urinary electrolytes concentrations were similar in both nephrectomized and control groups. Western blot analysis revealed upregulation of sodium-glucose cotransporter 2 (SGLT2) and sodium chloride cotransporter (NCC), and downregulation of sodium‑potassium-chloride co-transporter (NKCC2) and epithelial sodium channel (ENaC) in the nephrectomized group. Metabolomic analysis of uEVs showed an enrichment of certain metabolites, including citrate and stachydrine. Interestingly, uEVs from the nephrectomized group demonstrated a protective effect, downregulating signal transducer and activator of transcription 3 (STAT3) and reducing reactive oxygen species (ROS) in renal proximal cells, compared to uEVs from the control group. This study suggests that uEVs contain bioactive components capable of inducing protective, anti-inflammatory, anti-fibrinolytic, and antioxidative effects in renal cells. These findings contribute to our understanding of uEVs' role in renal compensatory mechanisms after unilateral nephrectomy and may hold promise for future therapeutic interventions in renal diseases.
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Affiliation(s)
- Rasha Aly
- Departement of Pediatrics, Division of Pediatric Nephrology, University of Florida, 32610, United States of America
| | - Sara Darwish
- Department of Physiology and Aging, College of Medicine, University of Florida, 32610, United States of America
| | - Niharika Bala
- Department of Physiology and Aging, College of Medicine, University of Florida, 32610, United States of America
| | - Areej Ebrahim
- Department of Physiology and Aging, College of Medicine, University of Florida, 32610, United States of America
| | - Lawrence R Shoemaker
- Departement of Pediatrics, Division of Pediatric Nephrology, University of Florida, 32610, United States of America
| | - Joel McCray
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida, College of Medicine, Gainesville, FL 32610, United States of America
| | - Timothy J Garrett
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida, College of Medicine, Gainesville, FL 32610, United States of America
| | - Abdel A Alli
- Department of Physiology and Aging, College of Medicine, University of Florida, 32610, United States of America; Department of Medicine, Division of Nephrology, Hypertension, and Renal Transplantation, College of Medicine, University of Florida, 32610, United States of America.
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3
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Yan Y, Liu Y, Li B, Xu S, Du H, Wang X, Li Y. Trends and predictors of changes in renal function after radical nephrectomy for renal tumours. BMC Nephrol 2024; 25:174. [PMID: 38773467 PMCID: PMC11106867 DOI: 10.1186/s12882-024-03601-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 05/06/2024] [Indexed: 05/23/2024] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is a common postoperative complication in patients who undergo radical nephrectomy for renal tumours. However, the factors influencing long-term renal function require further investigation. OBJECTIVE This study was designed to investigate the trends in renal function changes and risk factors for renal function deterioration in renal tumour patients after radical nephrectomy. METHODS We monitored changes in renal function before and after surgery for 3 years. The progression of renal function was determined by the progression and degradation of CKD stages. Univariate and multivariate logistic regression analyses were used to analyse the causes of renal function progression. RESULTS We analysed the data of 329 patients with renal tumours who underwent radical nephrectomies between January 2013 and December 2018. In this study, 43.7% of patients had postoperative acute kidney injury (AKI), and 48.3% had CKD at advanced stages. Further research revealed that patients' renal function stabilized 3 months after surgery. Additionally, renal function changes during these 3 months have a substantial impact on the progression of long-term renal function changes in patients. CONCLUSION AKI may be an indicator of short-term postoperative changes in renal function. Renal function tests should be performed in patients with AKI after radical nephrectomy to monitor the progression of functional impairment, particularly within the first 3 months after radical nephrectomy.
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Affiliation(s)
- Yongchao Yan
- The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yunbo Liu
- The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Bin Li
- The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Shang Xu
- The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Haotian Du
- The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xinning Wang
- The Affiliated Hospital of Qingdao University, Qingdao, China.
| | - Yanjiang Li
- The Affiliated Hospital of Qingdao University, Qingdao, China.
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4
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Vauhkonen P, Oura P, Kriikku P, Lindroos K, Mäyränpää MI. Prediction model for anabolic androgenic steroid positivity in forensic autopsy cases - a new tool to the autopsy room. Int J Legal Med 2024:10.1007/s00414-024-03227-x. [PMID: 38589641 DOI: 10.1007/s00414-024-03227-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 03/20/2024] [Indexed: 04/10/2024]
Abstract
Non-prescription use of anabolic androgenic steroids (AAS) is associated with an increased risk of premature death. However, these substances are seldom screened in connection with forensic cause-of-death investigation, unless the forensic pathologist specifically suspects use, often based on a positive AAS use history. Since AAS use is often concealed from others, this practice may lead to mistargeting of these analyses and significant underestimation of the true number of AAS positive cases undergoing forensic autopsy. Thus, more accurate diagnostic tools are needed to identify these cases. The main objective of this study was to determine, whether a multivariable model could predict AAS urine assay positivity in forensic autopsies. We analyzed retrospectively the autopsy reports of all cases that had been screened for AAS during forensic cause-of-death investigation between 2016-2019 at the Finnish Institute for Health and Welfare forensic units (n = 46). Binary logistic regression with penalized maximum likelihood estimation was used to generate a nine-variable model combining circumferential and macroscopic autopsy-derived variables. The multivariable model predicted AAS assay positivity significantly better than a "conventional" model with anamnestic information about AAS use only (area under the receiver operating characteristic curve [AUC] = 0.968 vs. 0.802, p = 0.005). Temporal validation was conducted in an independent sample of AAS screened cases between 2020-2022 (n = 31), where the superiority of the multivariable model was replicated (AUC = 0.856 vs. 0.644, p = 0.004). Based on the model, a calculator predicting AAS assay positivity is released as a decision-aiding tool for forensic pathologists working in the autopsy room.
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Affiliation(s)
- Paula Vauhkonen
- Forensic Medicine Unit, Finnish Institute for Health and Welfare, Mannerheimintie 166, P.O. Box 30, FI-00271, Helsinki, Finland.
- Faculty of Medicine, University of Helsinki, Haartmaninkatu 3, P.O. Box 63, FI-00014, Helsinki, Finland.
| | - Petteri Oura
- Forensic Medicine Unit, Finnish Institute for Health and Welfare, Mannerheimintie 166, P.O. Box 30, FI-00271, Helsinki, Finland
- Department of Forensic Medicine, Faculty of Medicine, University of Helsinki, Haartmaninkatu 3, P.O. Box 21, FI-00014, Helsinki, Finland
| | - Pirkko Kriikku
- Department of Forensic Medicine, Faculty of Medicine, University of Helsinki, Haartmaninkatu 3, P.O. Box 21, FI-00014, Helsinki, Finland
- Forensic Toxicology Unit, Finnish Institute for Health and Welfare, P.O. Box 30, 00271, Helsinki, Finland
| | - Katarina Lindroos
- Forensic Medicine Unit, Finnish Institute for Health and Welfare, Mannerheimintie 166, P.O. Box 30, FI-00271, Helsinki, Finland
| | - Mikko Ilari Mäyränpää
- Department of Pathology, University of Helsinki, Haartmaninkatu 3, P.O. Box 21, FI-00014, Helsinki, Finland
- Helsinki University Hospital, P.O. Box 340, FI-00029, Helsinki, Finland
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5
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Nassau D, Deebel NA, Kresch E, Temple D, Kulandavelu S, Arora H, Ramasamy R. Age-dependent effect on contralateral testicular compensation after testicular loss. F&S SCIENCE 2023; 4:311-316. [PMID: 37751815 DOI: 10.1016/j.xfss.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 09/28/2023]
Abstract
OBJECTIVE To study compensatory changes in testicular growth and the hormonal axis after unilateral orchiectomy in a neonatal, prepubertal, and pubertal/adult murine model. This is the first study to use a neonatal mouse survival surgery model. DESIGN A laboratory-based study examining a control, neonatal, prepubertal, and pubertal/adult mouse model. SETTING University-based basic science research laboratory. ANIMALS Control, neonatal (2-4 days of life), prepubertal (12-21 days of life), and pubertal/adult (42-44 days of life) C57BL/6 mouse models. INTERVENTION Unilateral orchiectomy in the neonatal, prepubertal, and pubertal/adult mouse models at their respective ages. MAIN OUTCOME MEASURES Body and testis weight and testicular length in the long axis were measured in a blinded fashion. In a similar way, testosterone, luteinizing hormone (LH), and follicle-stimulating hormone were assessed. RESULTS Testes from neonatal and prepubertal mice weighed more (110.5, 12.2 and 103.0, 7.2 mg, respectively) than the control mice (91, 11.9 mg). There was no difference between the postpubertal group and the control group. The degree of compensatory hypertrophy was greater in the neonatal group but not in the prepubertal group when compared with the postpubertal group. Differences in follicle-stimulating hormone and testosterone were not statistically significant between the experimental and control arms. LH was significantly elevated in all experimental groups compared with the control. CONCLUSIONS This is the first study to assess testicular compensatory hypertrophy using a neonatal mouse survival surgery model. Testicular hypertrophy occurs when unilateral loss occurs before puberty, but not in adulthood in mice. Earlier testis loss may contribute to a greater degree of growth. Functionally, the unilateral testis can maintain eugonadal testosterone levels, but higher levels of LH are required after hemicastration to sustain eugonadal testosterone levels.
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Affiliation(s)
- Daniel Nassau
- Nicklaus Children's Hospital, University of Miami, Miami, Florida
| | - Nicholas A Deebel
- Department of Urology, Wake Forest University School of Medicine, Winston-Salem, North Carolina.
| | - Eliyahu Kresch
- Department of Urology, University of Florida College of Medicine Jacksonville, Florida
| | - Davis Temple
- Department of Urology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Shathiyah Kulandavelu
- Department of Pediatrics and Interdisciplinary Stem Cell Institute, University of Miami, Florida
| | - Himanshu Arora
- Desai Sethi Urology Institute, University of Miami, Florida
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Sun L, Ding M, Chen F, Zhu D, Xie X. Long non‑coding RNA L13Rik promotes high glucose-induced mesangial cell hypertrophy and matrix protein expression by regulating miR-2861/CDKN1B axis. PeerJ 2023; 11:e16170. [PMID: 37868060 PMCID: PMC10586299 DOI: 10.7717/peerj.16170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 09/03/2023] [Indexed: 10/24/2023] Open
Abstract
Background Diabetic nephropathy (DN) is a frequent microvascular complication of diabetes. Glomerular mesangial cell (MC) hypertrophy occurs at the initial phase of DN and plays a critical role in the pathogenesis of DN. Given the role of long non coding RNA (lncRNA) in regulating MC hypertrophy and extracellular matrix (ECM) accumulation, our aim was to identify functional lncRNAs during MC hypertrophy. Methods Here, an lncRNA, C920021L13Rik (L13Rik for short), was identified to be up-regulated in DN progression. The expression of L13Rik in DN patients and diabetic mice was assessed using quantitative real-time PCR (qRT-PCR), and the function of L13Rik in regulating HG-induced MC hypertrophy and ECM accumulation was assessed through flow cytometry and western blotting analysis. Results The L13Rik levels were significantly increased while the miR-2861 levels were decreased in the peripheral blood of DN patients, the renal tissues of diabetic mice, and HG-treated MCs. Functionally, both L13Rik depletion and miR-2861 overexpression effectively reduced HG-induced cell hypertrophy and ECM accumulation. Mechanistically, L13Rik functioned as a competing endogenous RNA (ceRNA) to sponge miR-2861, resulting in the de-repression of cyclin-dependent kinase inhibitor 1B (CDKN1B), a gene known to regulate cell cycle and MC hypertrophy. Conclusions Collectively, the current results demonstrate that up-regulated L13Rik is correlated with DN and may be a hopeful therapeutic target for DN.
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Affiliation(s)
- Linlin Sun
- Nephrology, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Miao Ding
- Nephrology, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fuhua Chen
- Nephrology, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dingyu Zhu
- Nephrology, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xinmiao Xie
- Nephrology, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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7
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Hosseini-Dastgerdi H, Pourshanazari AA, Nematbakhsh M. The role of Mas receptor on renal hemodynamic responses to angiotensin II administration in chronic renal sympathectomized male and female rats. Res Pharm Sci 2023; 18:489-504. [PMID: 37842515 PMCID: PMC10568965 DOI: 10.4103/1735-5362.383705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/14/2023] [Accepted: 05/09/2023] [Indexed: 10/17/2023] Open
Abstract
Background and purpose Renal hemodynamics is influenced by renal sympathetic nerves and the renin-angiotensin system. On the other hand, renal sympathetic denervation impacts kidney weight by affecting renal hemodynamics. The current study evaluated the role of the Mas receptor on renal hemodynamic responses under basal conditions and in response to angiotensin II (Ang II) in chronic renal sympathectomy in female and male rats. Experimental approach Forty-eight nephrectomized female and male rats were anesthetized and cannulated. Afterward, the effect of chronic renal sympathectomy was investigated on hemodynamic parameters such as renal vascular resistance (RVR), mean arterial pressure (MAP), and renal blood flow (RBF). In addition, the effect of chronic sympathectomy on kidney weight was examined. Findings/Results Chronic renal sympathectomy increased RVR and subsequently decreased RBF in both sexes. Renal perfusion pressure also increased after sympathectomy in male and female rats, while MAP did not change, significantly. In response to the Ang II injection, renal sympathectomy caused a greater decrease in RBF in all experimental groups, while it did not affect the MAP response. In addition, chronic sympathectomy increased left kidney weight in right nephrectomized rats. Conclusion and implications Chronic renal sympathectomy changed systemic/renal hemodynamics in baseline conditions and only renal hemodynamics in response to Ang II administration. Moreover, chronic sympathectomy increased compensatory hypertrophy in nephrectomized rats. These changes are unaffected by gender difference and Mas receptor blocker.
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Affiliation(s)
- Hajaralsadat Hosseini-Dastgerdi
- Water and Electrolytes Research Center, Isfahan University of Medical Sciences, Isfahan, I.R. Iran
- Department of Physiology, Medical School, Isfahan University of Medical Sciences, Isfahan, I.R. Iran
| | - Ali-Asghar Pourshanazari
- Department of Physiology, Medical School, Isfahan University of Medical Sciences, Isfahan, I.R. Iran
| | - Mehdi Nematbakhsh
- Water and Electrolytes Research Center, Isfahan University of Medical Sciences, Isfahan, I.R. Iran
- Department of Physiology, Medical School, Isfahan University of Medical Sciences, Isfahan, I.R. Iran
- Isfahan MN Institute of Basic and Applied Sciences Research, Isfahan, I.R. Iran
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8
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Kikuchi H, Chou CL, Yang CR, Chen L, Jung HJ, Park E, Limbutara K, Carter B, Yang ZH, Kun JF, Remaley AT, Knepper MA. Signaling mechanisms in renal compensatory hypertrophy revealed by multi-omics. Nat Commun 2023; 14:3481. [PMID: 37328470 PMCID: PMC10276015 DOI: 10.1038/s41467-023-38958-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 05/24/2023] [Indexed: 06/18/2023] Open
Abstract
Loss of a kidney results in compensatory growth of the remaining kidney, a phenomenon of considerable clinical importance. However, the mechanisms involved are largely unknown. Here, we use a multi-omic approach in a unilateral nephrectomy model in male mice to identify signaling processes associated with renal compensatory hypertrophy, demonstrating that the lipid-activated transcription factor peroxisome proliferator-activated receptor alpha (PPARα) is an important determinant of proximal tubule cell size and is a likely mediator of compensatory proximal tubule hypertrophy.
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Affiliation(s)
- Hiroaki Kikuchi
- Epithelial Systems Biology Laboratory, Systems Biology Center, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA.
| | - Chung-Lin Chou
- Epithelial Systems Biology Laboratory, Systems Biology Center, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Chin-Rang Yang
- Epithelial Systems Biology Laboratory, Systems Biology Center, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Lihe Chen
- Epithelial Systems Biology Laboratory, Systems Biology Center, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Hyun Jun Jung
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Euijung Park
- Epithelial Systems Biology Laboratory, Systems Biology Center, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Kavee Limbutara
- The Center of Excellence in Systems Biology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Benjamin Carter
- Laboratory of Epigenome Biology, Systems Biology Center, National Heart, Lung and Blood Institute, NIH, Bethesda, MD, USA
| | - Zhi-Hong Yang
- Lipoprotein Metabolism Section, Translational Vascular Medicine Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Julia F Kun
- Lipoprotein Metabolism Section, Translational Vascular Medicine Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Alan T Remaley
- Lipoprotein Metabolism Section, Translational Vascular Medicine Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Mark A Knepper
- Epithelial Systems Biology Laboratory, Systems Biology Center, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA.
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9
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Mohammed EH, Kaddourah A, Al Khori N, Djekidel M. The diagnostic value of DMSA scan in differentiating functional pseudo-tumors from malignancies in scarred kidneys: case series and literature review. BMC Nephrol 2023; 24:148. [PMID: 37237327 DOI: 10.1186/s12882-023-03113-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 02/17/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND The terms "renal regenerating nodule" and "nodular compensatory hypertrophy" are used in the literature to describe functioning pseudo-tumors (FPT) in the setting of an extensively scarred kidney. FPTs are usually discovered incidentally during routine renal imaging. Differentiating these FPTs from renal neoplasms is critical but can be challenging in the setting of chronic kidney disease (CKD) given the limitations related to using contrast-based imaging. CASE SUMMARIES We report a pediatric case series of 5 CKD patients, with history of urinary tract infections, in which tumor-like lesions evolved in scarred kidneys and were incidentally discovered on routine renal imaging. These were diagnosed as FPT by utilizing dimercaptosuccinic acid (DMSA) imaging and showed stable size and appearance upon follow-up with ultrasound and MRI. CONCLUSION FPTs can be picked up on routine imaging of pediatric patients with CKD. Although larger cohort studies are needed to confirm these conclusions, our case series supports the evidence that DMSA scan showing uptake at the site of the mass can be a useful tool to suggest the diagnosis of FPTs in children with kidney scarring, and that SPECT DMSA scan adds more precision in picking up and accurately localizing FPTs compared to planar DMSA.
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Affiliation(s)
- Enas Hussein Mohammed
- Department of Pediatrics, Division of Nephrology and Hypertension, Sidra Medicine, Doha, Qatar.
| | - Ahmad Kaddourah
- Department of Pediatrics, Division of Nephrology and Hypertension, Sidra Medicine, Doha, Qatar
- Department of Pediatrics, Weill Cornel Medicine University, Doha, Qatar
| | - Noor Al Khori
- Department of Radiology, Division of Body Imaging, Sidra Medicine, Doha, Qatar
| | - Mehdi Djekidel
- Department of Radiology, Division of Nuclear Medicine, Northwell, New York, USA
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10
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Stem Cells in Kidney Ischemia: From Inflammation and Fibrosis to Renal Tissue Regeneration. Int J Mol Sci 2023; 24:ijms24054631. [PMID: 36902062 PMCID: PMC10002584 DOI: 10.3390/ijms24054631] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 02/19/2023] [Accepted: 02/23/2023] [Indexed: 03/04/2023] Open
Abstract
Ischemic nephropathy consists of progressive renal function loss due to renal hypoxia, inflammation, microvascular rarefaction, and fibrosis. We provide a literature review focused on kidney hypoperfusion-dependent inflammation and its influence on renal tissue's ability to self-regenerate. Moreover, an overview of the advances in regenerative therapy with mesenchymal stem cell (MSC) infusion is provided. Based on our search, we can point out the following conclusions: 1. endovascular reperfusion is the gold-standard therapy for RAS, but its success mostly depends on treatment timeliness and a preserved downstream vascular bed; 2. anti-RAAS drugs, SGLT2 inhibitors, and/or anti-endothelin agents are especially recommended for patients with renal ischemia who are not eligible for endovascular reperfusion for slowing renal damage progression; 3. TGF-β, MCP-1, VEGF, and NGAL assays, along with BOLD MRI, should be extended in clinical practice and applied to a pre- and post-revascularization protocols; 4. MSC infusion appears effective in renal regeneration and could represent a revolutionary treatment for patients with fibrotic evolution of renal ischemia.
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11
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Yano K, Choijookhuu N, Ikenoue M, Fidya, Fukaya T, Sato K, Lee D, Taniguchi N, Chosa E, Nanashima A, Hishikawa Y. Spatiotemporal expression of HMGB2 regulates cell proliferation and hepatocyte size during liver regeneration. Sci Rep 2022; 12:11962. [PMID: 35831365 PMCID: PMC9279446 DOI: 10.1038/s41598-022-16258-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 07/07/2022] [Indexed: 11/09/2022] Open
Abstract
Liver regeneration is an extraordinarily complex process involving a variety of factors; however, the role of chromatin protein in hepatocyte proliferation is largely unknown. In this study, we investigated the functional role of high-mobility group box 2 (HMGB2), a chromatin protein in liver regeneration using wild-type and HMGB2-knockout (KO) mice. Liver tissues were sampled after 70% partial hepatectomy (PHx), and analyzed by immunohistochemistry, western blotting and flow cytometry using various markers of cell proliferation. In WT mice, hepatocyte proliferation was strongly correlated with the spatiotemporal expression of HMGB2; however, cell proliferation was significantly delayed in hepatocytes of HMGB2-KO mice. Quantitative PCR demonstrated that cyclin D1 and cyclin B1 mRNAs were significantly decreased in HMGB2-KO mice livers. Interestingly, hepatocyte size was significantly larger in HMGB2-KO mice at 36-72 h after PHx, and these results suggest that hepatocyte hypertrophy appeared in parallel with delayed cell proliferation. In vitro experiments demonstrated that cell proliferation was significantly decreased in HMGB2-KO cells. A significant delay in cell proliferation was also found in HMGB2-siRNA transfected cells. In summary, spatiotemporal expression of HMGB2 is important for regulation of hepatocyte proliferation and cell size during liver regeneration.
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Affiliation(s)
- Koichi Yano
- Department of Anatomy, Histochemistry and Cell Biology, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan.,Department of Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, 889-1692, Japan
| | - Narantsog Choijookhuu
- Department of Anatomy, Histochemistry and Cell Biology, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Makoto Ikenoue
- Department of Anatomy, Histochemistry and Cell Biology, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan.,Department of Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, 889-1692, Japan
| | - Fidya
- Department of Anatomy, Histochemistry and Cell Biology, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Tomohiro Fukaya
- Division of Immunology, Department of Infectious Diseases, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Katsuaki Sato
- Division of Immunology, Department of Infectious Diseases, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Deokcheol Lee
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889‑1692, Japan
| | - Noboru Taniguchi
- Department of Orthopaedic Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8‑35‑1 Sakuragaoka, Kagoshima, 890‑8520, Japan
| | - Etsuo Chosa
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889‑1692, Japan
| | - Atsushi Nanashima
- Department of Surgery, Faculty of Medicine, University of Miyazaki, Miyazaki, 889-1692, Japan
| | - Yoshitaka Hishikawa
- Department of Anatomy, Histochemistry and Cell Biology, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan.
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12
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Almutlaq RN, Evans LC. Angiotensin in the acute and chronic responses to unilateral nephrectomy. Am J Physiol Renal Physiol 2022; 322:F575-F576. [PMID: 35343851 DOI: 10.1152/ajprenal.00063.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Rawan N Almutlaq
- Department of Integrative Biology and Physiology, University of Minnesota, Minneapolis, Minnesota
| | - Louise C Evans
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota
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13
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Shimada S, Yang C, Kurth T, Cowley AW. Divergent roles of angiotensin II upon the immediate and sustained increases of renal blood flow following unilateral nephrectomy. Am J Physiol Renal Physiol 2022; 322:F473-F485. [PMID: 35224992 PMCID: PMC8977133 DOI: 10.1152/ajprenal.00376.2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 01/31/2022] [Accepted: 02/18/2022] [Indexed: 12/18/2022] Open
Abstract
Although the molecular and functional responses related to renal compensatory hypertrophy after unilateral nephrectomy (UNX) has been well described, many aspects of these events remain unclear. One question is how the remaining kidney senses the absence of the contralateral organ, and another is what the role of the renin-angiotensin system is in these responses. Both acute anesthetized and chronic unanesthetized experiments were performed using the angiotensin II type 1 receptor blocker losartan and the renin inhibitor aliskiren to determine the contribution of the renin-angiotensin system to immediate changes and losartan for chronic changes of renal blood flow (RBF) and the associated hypertrophic events in male Sprague-Dawley rats. Chronic experiments used implanted RBF probes and arterial catheters for continuous data collection, and the glomerular filtration rate was determined by noninvasive transcutaneous FITC-sinistrin measurements. The results of the acute experiments found that RBF increased nearly 25% (4.6 ± 0.5 to 5.6 ± 0.6 mL/min/g kidney wt) during the first 15 min following UNX and that this response was abolished by losartan (6.7 ± 0.7 to 7.0 ± 0.7 mL/min/g kidney wt) or aliskiren (5.8 ± 0.4 to 6.0 ± 0.4 mL/min/g kidney wt) treatment. Thereafter, RBF increased progressively over 7 days, and kidney weight increased by 19% of pre-UNX values. When normalized to kidney weight determined at day 7 after UNX, RBF was not significantly different from pre-UNX levels. Semiquantification of CD31-positive capillaries revealed increases of the glomeruli and peritubular capillaries that paralleled the kidney hypertrophy. None of these chronic changes was inhibited by losartan treatment, indicating that neither the compensatory structural nor the RBF changes were angiotensin II type 1 receptor dependent.NEW & NOTEWORTHY This study found that the immediate increases of renal blood flow (RBF) following unilateral nephrectomy (UNX) are a consequence of reduced angiotensin II type 1 (AT1) receptor stimulation. The continuous monitoring of RBF and intermittent measurement of glomerular filtration rate (GFR) in conscious rats during the 1-wk period of rapid hypertrophy following UNX provided unique insights into the regulation of RBF and GFR when faced with increased metabolic loads. It was found that neither kidney hypertrophy nor the associated increase of capillaries was an AT1-dependent phenomenon.
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Affiliation(s)
- Satoshi Shimada
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Chun Yang
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Theresa Kurth
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Allen W Cowley
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin
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14
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Gadelkareem RA, Mohammed N. Unilateral hypoplastic kidney in adults: An experience of a tertiary-level urology center. World J Nephrol 2022; 11:30-38. [PMID: 35117977 PMCID: PMC8790306 DOI: 10.5527/wjn.v11.i1.30] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 08/07/2021] [Accepted: 12/23/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Unilateral small-sized kidney is a radiological term referring to both the congenital and acquired causes of reduced kidney volume. However, the hypoplastic kidney may have peculiar clinical and radiological characterizations.
AIM To evaluate the clinical presentations, complications, and management approaches of the radiologically diagnosed unilateral hypoplastic kidney.
METHODS A retrospective review of the records of patients with a radiological diagnosis of unilateral hypoplastic kidney between July 2015 and June 2020 was done at Assiut Urology and Nephrology Hospital, Assiut University, Egypt.
RESULTS A total of 33 cases were diagnosed to have unilateral hypoplastic kidney with a mean (range) age of 39.5 ± 11.2 (19-73) years. The main clinical presentation was loin pain (51.5%), stone passer (9.1%), anuria (12.1%), accidental discovery (15.2%), or manifestations of urinary tract infections (12.1%). Computed tomography was the most useful tool for radiological diagnosis. However, radioisotope scanning could be requested for verification of surgical interventions and nephrectomy decisions. Urolithiasis occurred in 23 (69.7%) cases and pyuria was detected in 22 (66.7%) cases where the infection was documented by culture and sensitivity test in 19 cases. While the non-complicated cases were managed by assurance only (12.1%), nephrectomy (15.2%) was performed for persistent complications. However, symptomatic (27.3%) and endoscopic (45.6%) approaches were used for the management of correctable complications.
CONCLUSION Unilateral hypoplastic kidney in adults has various complications that range from urinary tract infections to death from septicemia. Diagnosis is mainly radiological and management is usually conservative or minimally invasive.
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Affiliation(s)
- Rabea Ahmed Gadelkareem
- Department of Urology, Assiut Urology and Nephrology Hospital, Faculty of Medicine, Assiut University, Assiut 71515, Egypt
| | - Nasreldin Mohammed
- Department of Urology, Assiut Urology and Nephrology Hospital, Faculty of Medicine, Assiut University, Assiut 71515, Egypt
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15
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Compensatory Hypertrophy in Paediatric Patients with a Unilateral Ureteropelvic Junction Obstruction. EUR UROL SUPPL 2021; 34:10-16. [PMID: 34934962 PMCID: PMC8655380 DOI: 10.1016/j.euros.2021.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2021] [Indexed: 11/23/2022] Open
Abstract
Background Compensatory hypertrophy is common in children with solitary functioning kidney, but it is unknown whether it also develops in children with unilateral partial reduction of kidney function. Objective The aim of this study was to assess whether children with a unilateral ureteropelvic junction obstruction (UPJO) show compensatory growth of the unaffected kidney. Furthermore, we investigated whether the length of the unaffected kidney was related to the degree of split kidney function lost and other possible risk factors. Lastly, we studied a possible relationship with signs of kidney injury. Design, setting, and participants We retrospectively analysed clinical information from 194 children with a unilateral UPJO who participated in the Aetiologic research into Genetic and Occupational/environmental Risk factors for Anomalies in children (AGORA) data- and biobank. Data on kidney length, split kidney function, and other factors possibly associated with kidney length were extracted from electronic patient records. Outcome measurements and statistical analysis Pearson’s correlation coefficients between the split kidney function and unaffected kidney length were calculated. Multivariable logistic regression analyses were performed to identify factors associated with kidney length and signs of kidney injury. Results and limitations Most children with a UPJO had an unaffected kidney length above the reference for age at the end of follow-up (median age 6.5 yr). A correlation with split kidney function was present only in children with a split kidney function of ≥60% in the unaffected kidney (r = 0.41). Aside from split kidney function, UPJO side was the only determinant of kidney length, while no associations between kidney length and kidney injury were identified. Conclusions Compensatory growth was visible in most children with a UPJO after sufficient follow-up time and was correlated with split kidney function in children with a severe UPJO. Contralateral kidney length provided no clear prognostic value for developing kidney injury. Studies with more patients and additional biomarkers of kidney injury are needed to further personalise care. Patient summary Children with obstruction of urine outflow in one kidney often had a larger contralateral kidney. However, the size of this kidney could not be used to predict which children would develop kidney injury.
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16
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Preoperative versus Postoperative Compensation of the Contralateral Normal Kidney in Patients Treated with Radical Nephrectomy for Renal Cell Carcinoma. J Clin Med 2021; 10:jcm10214918. [PMID: 34768437 PMCID: PMC8584614 DOI: 10.3390/jcm10214918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 10/05/2021] [Accepted: 10/21/2021] [Indexed: 12/12/2022] Open
Abstract
Background: We sought to identify the factors affecting renal compensatory processes that occur preoperatively as well as postoperatively in patients treated with radical nephrectomy (RNx) for renal cell carcinoma (RCC). Methods: We retrospectively reviewed the records of 906 patients treated with RNx for RCC. We defined the early compensatory process (process 1) as compensatory adaptation of the contralateral normal kidney (CNK) before RNx. We defined the late compensatory process (process 2) as compensatory adaptation of the CNK after RNx. Total compensation was defined as the combination of these two processes. Multivariable logistic regression analyses were used to identify significant factors associated with processes 1, 2 and total compensation. Results: Mean preoperative, 1-week, and 5-year postoperative estimated glomerular filtration rates (eGFR) were 84.5, 57.6 and 63.7 mL/min/1.73 m2, respectively. Female sex (p < 0.001), lower body mass index (BMI) (p < 0.001), absence of hypertension (p = 0.019), lower preoperative eGFR (p < 0.001), larger tumor volume (p < 0.001), and larger CNK volume (p < 0.001) were significantly associated with process 1. Younger age (p = 0.019), higher BMI (p < 0.001), and absence of diabetes mellitus (DM) (p = 0.033) were significantly associated with process 2. Female sex (p < 0.001), younger age (p < 0.001), absence of DM (p = 0.002), lower preoperative eGFR (p < 0.001), and larger tumor (p = 0.001) and CNK volumes (p < 0.001) were significantly associated with total compensation. Conclusions: Different factors affected each compensatory process. Process 1 made a greater contribution to the entire renal compensatory process than process 2.
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17
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Lee Y, Ryu J, Kang MW, Seo KH, Kim J, Suh J, Kim YC, Kim DK, Oh KH, Joo KW, Kim YS, Jeong CW, Lee SC, Kwak C, Kim S, Han SS. Machine learning-based prediction of acute kidney injury after nephrectomy in patients with renal cell carcinoma. Sci Rep 2021; 11:15704. [PMID: 34344909 PMCID: PMC8333365 DOI: 10.1038/s41598-021-95019-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 07/20/2021] [Indexed: 12/17/2022] Open
Abstract
The precise prediction of acute kidney injury (AKI) after nephrectomy for renal cell carcinoma (RCC) is an important issue because of its relationship with subsequent kidney dysfunction and high mortality. Herein we addressed whether machine learning (ML) algorithms could predict postoperative AKI risk better than conventional logistic regression (LR) models. A total of 4104 RCC patients who had undergone unilateral nephrectomy from January 2003 to December 2017 were reviewed. ML models such as support vector machine, random forest, extreme gradient boosting, and light gradient boosting machine (LightGBM) were developed, and their performance based on the area under the receiver operating characteristic curve, accuracy, and F1 score was compared with that of the LR-based scoring model. Postoperative AKI developed in 1167 patients (28.4%). All the ML models had higher performance index values than the LR-based scoring model. Among them, the LightGBM model had the highest value of 0.810 (0.783-0.837). The decision curve analysis demonstrated a greater net benefit of the ML models than the LR-based scoring model over all the ranges of threshold probabilities. The application of ML algorithms improves the predictability of AKI after nephrectomy for RCC, and these models perform better than conventional LR-based models.
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Affiliation(s)
- Yeonhee Lee
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehakro, Jongno-gu, Seoul, 03080, South Korea.,Department of Internal Medicine, Uijeongbu Eulji Medical Center, Eulji University, Uijeongbu-si, Gyeonggi-do, South Korea
| | - Jiwon Ryu
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea
| | - Min Woo Kang
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehakro, Jongno-gu, Seoul, 03080, South Korea
| | - Kyung Ha Seo
- Medical Research Collaborating Center, Seoul National University Hospital, Seoul, South Korea
| | - Jayoun Kim
- Medical Research Collaborating Center, Seoul National University Hospital, Seoul, South Korea
| | - Jungyo Suh
- Department of Urology, Seoul National University College of Medicine, Seoul, South Korea
| | - Yong Chul Kim
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehakro, Jongno-gu, Seoul, 03080, South Korea
| | - Dong Ki Kim
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehakro, Jongno-gu, Seoul, 03080, South Korea
| | - Kook-Hwan Oh
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehakro, Jongno-gu, Seoul, 03080, South Korea
| | - Kwon Wook Joo
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehakro, Jongno-gu, Seoul, 03080, South Korea
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehakro, Jongno-gu, Seoul, 03080, South Korea
| | - Chang Wook Jeong
- Department of Urology, Seoul National University College of Medicine, Seoul, South Korea
| | - Sang Chul Lee
- Department of Urology, Seoul National University College of Medicine, Seoul, South Korea
| | - Cheol Kwak
- Department of Urology, Seoul National University College of Medicine, Seoul, South Korea.
| | - Sejoong Kim
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehakro, Jongno-gu, Seoul, 03080, South Korea. .,Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea. .,Center for Artificial Intelligence in Healthcare, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea.
| | - Seung Seok Han
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehakro, Jongno-gu, Seoul, 03080, South Korea.
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18
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Capibaribe DM, Coelho MOS, Reis LO. How to draw the line between partial and radical nephrectomy. Int Braz J Urol 2021; 47:784-786. [PMID: 33848069 PMCID: PMC8321473 DOI: 10.1590/s1677-5538.ibju.2020.0149.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Diego Moreira Capibaribe
- Divisão de Oncologia Urológica, Pontifícia Universidade Católica de Campinas - PUC-Campinas, Campinas, SP, Brasil.,Laboratório de UroSciências, Pontifícia Universidade Católica de Campinas - PUC-Campinas, Campinas, SP, Brasil.,Departamento de Urologia, Universidade Estadual de Campinas - Unicamp, Campinas, SP, Brasil
| | - Marcos Oliveira Siebra Coelho
- Divisão de Oncologia Urológica, Pontifícia Universidade Católica de Campinas - PUC-Campinas, Campinas, SP, Brasil.,Laboratório de UroSciências, Pontifícia Universidade Católica de Campinas - PUC-Campinas, Campinas, SP, Brasil.,Departamento de Urologia, Universidade Estadual de Campinas - Unicamp, Campinas, SP, Brasil
| | - Leonardo O Reis
- Divisão de Oncologia Urológica, Pontifícia Universidade Católica de Campinas - PUC-Campinas, Campinas, SP, Brasil.,Laboratório de UroSciências, Pontifícia Universidade Católica de Campinas - PUC-Campinas, Campinas, SP, Brasil.,Departamento de Urologia, Universidade Estadual de Campinas - Unicamp, Campinas, SP, Brasil
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19
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Kajiwara K, Yamano S, Aoki K, Okuzaki D, Matsumoto K, Okada M. CDCP1 promotes compensatory renal growth by integrating Src and Met signaling. Life Sci Alliance 2021; 4:4/4/e202000832. [PMID: 33574034 PMCID: PMC7893822 DOI: 10.26508/lsa.202000832] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 01/07/2021] [Accepted: 01/19/2021] [Indexed: 12/15/2022] Open
Abstract
CDCP1 promotes HGF-induced compensatory renal growth by focally and temporally integrating Src and Met-STAT3 signaling in lipid rafts. Compensatory growth of organs after loss of their mass and/or function is controlled by hepatocyte growth factor (HGF), but the underlying regulatory mechanisms remain elusive. Here, we show that CUB domain-containing protein 1 (CDCP1) promotes HGF-induced compensatory renal growth. Using canine kidney cells as a model of renal tubules, we found that HGF-induced temporal up-regulation of Src activity and its scaffold protein, CDCP1, and that the ablation of CDCP1 robustly abrogated HGF-induced phenotypic changes, such as morphological changes and cell growth/proliferation. Mechanistic analyses revealed that up-regulated CDCP1 recruits Src into lipid rafts to activate STAT3 associated with the HGF receptor Met, and activated STAT3 induces the expression of matrix metalloproteinases and mitogenic factors. After unilateral nephrectomy in mice, the Met-STAT3 signaling is transiently up-regulated in the renal tubules of the remaining kidney, whereas CDCP1 ablation attenuates regenerative signaling and significantly suppresses compensatory growth. These findings demonstrate that CDCP1 plays a crucial role in controlling compensatory renal growth by focally and temporally integrating Src and Met signaling.
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Affiliation(s)
- Kentaro Kajiwara
- Department of Oncogene Research, Research Institute for Microbial Diseases, Osaka University, Osaka, Japan
| | - Shotaro Yamano
- Japan Bioassay Research Center, Japan Organization of Occupational Health and Safety, Kanagawa, Japan
| | - Kazuhiro Aoki
- Division of Quantitative Biology, Okazaki Institute for Integrative Bioscience, National Institute for Basic Biology, National Institutes of Natural Sciences, Aichi, Japan
| | - Daisuke Okuzaki
- Genome Information Research Center, Research Institute for Microbial Diseases, Osaka University, Osaka, Japan
| | - Kunio Matsumoto
- Division of Tumor Dynamics and Regulation, Cancer Research Institute, Kanazawa University, Kanazawa, Japan
| | - Masato Okada
- Department of Oncogene Research, Research Institute for Microbial Diseases, Osaka University, Osaka, Japan
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20
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Tsujita M, Goto N, Futamura K, Okada M, Hiramitsu T, Narumi S, Uchida K, Morozumi K, Watarai Y. The importance of kidney volume as a marker in the assessment of living-donor kidney transplantation in Japan. Clin Exp Nephrol 2021; 25:537-544. [PMID: 33411116 DOI: 10.1007/s10157-020-02014-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 12/24/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND In living kidney transplantation, predicting the risk of end-stage kidney disease in the organ donors though crucial remains to be resolved. Thus, any useful biomarker to predict kidney outcome would be highly desirable to safeguard donors. METHODS This retrospective study was conducted at Nagoya Daini Red Cross Hospital to confirm whether an increase in preserved kidney volume (PKV) was a predict marker of proteinuria. A change of PKV before and 1 year after kidney donation was measured, and its association with proteinuria 3 years after the donation was analyzed. RESULTS A total of 119 kidney donors who met the Japanese donor guideline were enrolled. The mean age was 57.4 years, 46.2% were male. The mean values of the variables before kidney donation (baseline) were: BMI levels: 23.4 kg/m2, BSA-adjusted PKV: 132.9 cm3/1.73 m2, and estimated glomerular filtration rate (eGFRave): 82.9 mL/min/1.73 m2. A positive correlation was noted between BSA-adjusted PKV and eGFRave (r = 0.61, p < 0.001). BSA-adjusted PKV increased by 19.5% 1 year after donation, and the median urine protein was 0.04 g/gCre. Linear regression analyses showed that change of PKV and BSA-adjusted PKV before the donation were significantly associated with proteinuria 3 years after donation. CONCLUSION Change of PKV and BSA-adjusted PKV before donation is important factors for proteinuria after donation under the Japanese donor guidelines. Further studies are needed to confirm whether these factors are associated with renal survival after donation.
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Affiliation(s)
- Makoto Tsujita
- Department of Kidney Transplantation, Masuko Memorial Hospital, 35-28 Takebashi-cho, Nakamura-ku, Nagoya, 453-8566, Japan. .,Department of Kidney Disease Center, Transplant Nephrology and Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan.
| | - Norihiko Goto
- Department of Kidney Disease Center, Transplant Nephrology and Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Kenta Futamura
- Department of Kidney Disease Center, Transplant Nephrology and Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Manabu Okada
- Department of Kidney Disease Center, Transplant Nephrology and Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Takahisa Hiramitsu
- Department of Kidney Disease Center, Transplant Nephrology and Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Shunji Narumi
- Department of Kidney Disease Center, Transplant Nephrology and Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Kazuharu Uchida
- Department of Kidney Transplantation, Masuko Memorial Hospital, 35-28 Takebashi-cho, Nakamura-ku, Nagoya, 453-8566, Japan
| | - Kunio Morozumi
- Department of Kidney Transplantation, Masuko Memorial Hospital, 35-28 Takebashi-cho, Nakamura-ku, Nagoya, 453-8566, Japan
| | - Yoshihiko Watarai
- Department of Kidney Disease Center, Transplant Nephrology and Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan
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21
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Kubik MJ, Wyczanska M, Gasparitsch M, Keller U, Weber S, Schaefer F, Lange-Sperandio B. Renal developmental genes are differentially regulated after unilateral ureteral obstruction in neonatal and adult mice. Sci Rep 2020; 10:19302. [PMID: 33168884 PMCID: PMC7653944 DOI: 10.1038/s41598-020-76328-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 10/26/2020] [Indexed: 12/12/2022] Open
Abstract
Congenital obstructive nephropathy hinders normal kidney development. The severity and the duration of obstruction determine the compensatory growth of the contralateral, intact opposite kidney. We investigated the regulation of renal developmental genes, that are relevant in congenital anomalies of the kidney and urinary tract (CAKUT) in obstructed and contralateral (intact opposite) kidneys after unilateral ureteral obstruction (UUO) in neonatal and adult mice. Newborn and adult mice were subjected to complete UUO or sham-operation, and were sacrificed 1, 5, 12 and 19 days later. Quantitative RT-PCR was performed in obstructed, intact opposite kidneys and sham controls for Gdnf, Pax2, Six4, Six2, Dach1, Eya1, Bmp4, and Hnf-1β. Neonatal UUO induced an early and strong upregulation of all genes. In contrast, adult UUO kidneys showed a delayed and less pronounced upregulation. Intact opposite kidneys of neonatal mice revealed a strong upregulation of all developmental genes, whereas intact opposite kidneys of adult mice demonstrated only a weak response. Only neonatal mice exhibited an increase in BMP4 protein expression whereas adult kidneys strongly upregulated phosphatidylinositol 3 kinase class III, essential for compensatory hypertrophy. In conclusion, gene regulation differs in neonatal and adult mice with UUO. Repair and compensatory hypertrophy involve different genetic programs in developing and adult obstructed kidneys.
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Affiliation(s)
- Melanie J Kubik
- Department of Pediatrics, Ruprecht-Karls-University, Heidelberg, Germany
| | - Maja Wyczanska
- Division of Pediatric Nephrology, Department of Pediatrics, Dr. v. Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-University (LMU) Munich, Lindwurmstr.4, 80337, Munich, Germany
| | - Mojca Gasparitsch
- Division of Pediatric Nephrology, Department of Pediatrics, Dr. v. Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-University (LMU) Munich, Lindwurmstr.4, 80337, Munich, Germany
| | - Ursula Keller
- Division of Pediatric Nephrology, Department of Pediatrics, Dr. v. Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-University (LMU) Munich, Lindwurmstr.4, 80337, Munich, Germany
| | - Stefanie Weber
- University Children's Hospital, Philipps-University, Marburg, Germany
| | - Franz Schaefer
- Department of Pediatrics, Ruprecht-Karls-University, Heidelberg, Germany
| | - Bärbel Lange-Sperandio
- Division of Pediatric Nephrology, Department of Pediatrics, Dr. v. Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-University (LMU) Munich, Lindwurmstr.4, 80337, Munich, Germany.
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22
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Jufar AH, Lankadeva YR, May CN, Cochrane AD, Bellomo R, Evans RG. Renal functional reserve: from physiological phenomenon to clinical biomarker and beyond. Am J Physiol Regul Integr Comp Physiol 2020; 319:R690-R702. [PMID: 33074016 DOI: 10.1152/ajpregu.00237.2020] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Glomerular filtration rate (GFR) is acutely increased following a high-protein meal or systemic infusion of amino acids. The mechanisms underlying this renal functional response remain to be fully elucidated. Nevertheless, they appear to culminate in preglomerular vasodilation. Inhibition of the tubuloglomerular feedback signal appears critical. However, nitric oxide, vasodilator prostaglandins, and glucagon also appear important. The increase in GFR during amino acid infusion reveals a "renal reserve," which can be utilized when the physiological demand for single nephron GFR increases. This has led to the concept that in subclinical renal disease, before basal GFR begins to reduce, renal functional reserve can be recruited in a manner that preserves renal function. The extension of this concept is that once a decline in basal GFR can be detected, renal disease is already well progressed. This concept likely applies both in the contexts of chronic kidney disease and acute kidney injury. Critically, its corollary is that deficits in renal functional reserve have the potential to provide early detection of renal dysfunction before basal GFR is reduced. There is growing evidence that the renal response to infusion of amino acids can be used to identify patients at risk of developing either chronic kidney disease or acute kidney injury and as a treatment target for acute kidney injury. However, large multicenter clinical trials are required to test these propositions. A renewed effort to understand the renal physiology underlying the response to amino acid infusion is also warranted.
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Affiliation(s)
- Alemayehu H Jufar
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia.,Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Yugeesh R Lankadeva
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Clive N May
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew D Cochrane
- Department of Cardiothoracic Surgery, Monash Health and Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia
| | - Roger G Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia
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23
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Mehrvar S, Foomani FH, Shimada S, Yang C, Zheleznova NN, Mostaghimi S, Cowley AW, Ranji M. The early effects of uninephrectomy on rat kidney metabolic state using optical imaging. JOURNAL OF BIOPHOTONICS 2020; 13:e202000089. [PMID: 32436651 DOI: 10.1002/jbio.202000089] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 05/13/2020] [Accepted: 05/14/2020] [Indexed: 05/09/2023]
Abstract
Uninephrectomy (UNX) is known to result in structural and metabolic changes to the remaining kidney, although it is uncertain if this alters the mitochondrial redox state and how soon such changes may occur. A custom-designed fluorescence cryo-imaging technique was used to quantitatively assess the effect of UNX by measuring the levels of nicotinamide adenine dinucleotide (NADH) and flavin adenine dinucleotide (FAD) in the remaining kidney. Kidneys were snap-frozen 3 days following UNX, and the intrinsic fluorescence of NADH and FAD were optically acquired. The 3D images were created to characterize the NADH/FAD redox ratios (RR) of the right kidneys, which underwent UNX and the remaining kidneys 3 days following UNX. Both the NADPH-oxidases (Nox2 and Nox4) and the mitochondria are the main sources of reactive oxygen species (ROS) production in tubular epithelial cells. Responses to the UNX were obtained in kidneys of normal Sprague Dawley (SD) rats, Dahl salt-sensitive (SS) rats and SS rats in which NADPH-oxidase isoform 4 (Nox4) was knocked out (SSNox4-/- ). The results found that each of the strains exhibited similar increase in kidney weights averaging 17% after 3 days of UNX. SD and SSNox4-/- rats both exhibited global reductions of the RR (P < .05) with a similar tendency observed in SS rats (P < .08), indicating increased ROS production. The unexpected reduction of the RR in the remnant kidneys of SSNox4-/- rats indicates that mechanisms independent of H2 O2 produced from Nox4 may be responsible for this global increase of ROS. We propose that the reduced RR was largely a consequence of enhanced mitochondrial bioenergetics due to increased tubular workload of the remaining kidney. The data indicate that mitochondria become the dominant source of increased ROS following UNX and could represent an important hypertrophic signaling mechanism.
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Affiliation(s)
- Shima Mehrvar
- Biophotonics Lab, Department of Electrical Engineering, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA
| | - Farnaz H Foomani
- Biophotonics Lab, Department of Electrical Engineering, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA
| | - Satoshi Shimada
- Department of Physiology, Medical College of Wisconsin, Wauwatosa, Wisconsin, USA
| | - Chun Yang
- Department of Physiology, Medical College of Wisconsin, Wauwatosa, Wisconsin, USA
| | | | - Soudeh Mostaghimi
- Biophotonics Lab, Department of Electrical Engineering, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA
| | - Allen W Cowley
- Department of Physiology, Medical College of Wisconsin, Wauwatosa, Wisconsin, USA
| | - Mahsa Ranji
- Biophotonics Lab, Department of Electrical Engineering, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA
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24
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Abstract
Although kidney oxygen tensions are heterogenous, and mostly below renal vein level, the nephron is highly dependent on aerobic metabolism for active tubular transport. This renders the kidney particularly susceptible to hypoxia, which is considered a main characteristic and driver of acute and chronic kidney injury, albeit the evidence supporting this assumption is not entirely conclusive. Kidney transplants are exposed to several conditions that may interfere with the balance between oxygen supply and consumption, and enhance hypoxia and hypoxic injury. These include conditions leading to and resulting from brain death of kidney donors, ischemia and reperfusion during organ donation, storage and transplantation, postoperative vascular complications, vasoconstriction induced by immunosuppression, and impaired perfusion resulting from interstitial edema, inflammation, and fibrosis. Acute graft injury, the immediate consequence of hypoxia and reperfusion, results in delayed graft function and increased risk of chronic graft failure. Although current strategies to alleviate hypoxic/ischemic graft injury focus on limiting injury (eg, by reducing cold and warm ischemia times), experimental evidence suggests that preconditioning through local or remote ischemia, or activation of the hypoxia-inducible factor pathway, can decrease hypoxic injury. In combination with ex vivo machine perfusion such approaches hold significant promise for improving transplantation outcomes.
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Affiliation(s)
- Christian Rosenberger
- Department of Nephrology and Medical Intensive Care, Charité Universitaetsmedizin Berlin, Berlin, Germany.
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité Universitaetsmedizin Berlin, Berlin, Germany
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25
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McArdle Z, Schreuder MF, Moritz KM, Denton KM, Singh RR. Physiology and Pathophysiology of Compensatory Adaptations of a Solitary Functioning Kidney. Front Physiol 2020; 11:725. [PMID: 32670095 PMCID: PMC7332829 DOI: 10.3389/fphys.2020.00725] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 06/03/2020] [Indexed: 12/15/2022] Open
Abstract
Children born with a solitary functioning kidney (SFK) have an increased risk of hypertension and kidney disease from early in adulthood. In response to a reduction in kidney mass, the remaining kidney undergoes compensatory kidney growth. This is associated with both an increase in size of the kidney tubules and the glomeruli and an increase in single nephron glomerular filtration rate (SNGFR). The compensatory hypertrophy and increase in filtration at the level of the individual nephron results in normalization of total glomerular filtration rate (GFR). However, over time these same compensatory mechanisms may contribute to kidney injury and hypertension. Indeed, approximately 50% of children born with a SFK develop hypertension by the age of 18 and 20–40% require dialysis by the age of 30. The mechanisms that result in kidney injury are only partly understood, and early biomarkers that distinguish those at an elevated risk of kidney injury are needed. This review will outline the compensatory adaptations to a SFK, and outline how these adaptations may contribute to kidney injury and hypertension later in life. These will be based largely on the mechanisms we have identified from our studies in an ovine model of SFK, that implicate the renal nitric oxide system, the renin angiotensin system and the renal nerves to kidney disease and hypertension associated with SFK. This discussion will also evaluate current, and speculate on next generation, prognostic factors that may predict those children at a higher risk of future kidney disease and hypertension.
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Affiliation(s)
- Zoe McArdle
- Cardiovascular Program, Monash Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, VIC, Australia
| | - Michiel F Schreuder
- Department of Pediatric Nephrology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Karen M Moritz
- Child Health Research Centre and School of Biomedical Sciences, University of Queensland, Brisbane, QLD, Australia
| | - Kate M Denton
- Cardiovascular Program, Monash Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, VIC, Australia
| | - Reetu R Singh
- Cardiovascular Program, Monash Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, VIC, Australia
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26
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Wang MK, Gaither T, Phelps A, Cohen R, Baskin L. The Incidence and Durability of Compensatory Hypertrophy in Pediatric Patients with Solitary Kidneys. Urology 2019; 129:188-193. [PMID: 30986483 DOI: 10.1016/j.urology.2019.04.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 03/04/2019] [Accepted: 04/01/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To evaluate the incidence and durability of compensatory hypertrophy with solitary kidneys in the setting of those with multicystic dysplastic kidney (MCDK) or Wilms tumor (WT) status postnephrectomy. PATIENTS AND METHODS We conducted a retrospective cohort study of patients with MCDK and WT. MCDK patients were verified by sonographic findings prenatally. WT patients entered our study at time of nephrectomy. We compared the natural history of hypertrophy between the 2 cohorts via renal length measurement. We performed linear regression to predict creatinine clearance from renal length after adjusting for age and cohort status (MCDK versus WT). RESULTS Fifty-two patients (56%) were diagnosed with WT, and 71 patients (44%) with MCDK patients met study criteria with a median age of postnatal ultrasound at 1.6 months (interquartile range 0.5-3.6). The median (IQR) follow-up time was 7.5 years. At the time of nephrectomy, 25/52 (48%) of Wilms patients had contralateral hypertrophy, while at diagnosis 22/71 (31%) of MCDK patients had contralateral hypertrophy, P = .03. Contralateral hypertrophy was a consistent finding throughout follow-up. As renal length increases by 1 cm, glomerular filtration rate increased by 7.8 mL/min/m2 (95% confidence interval 1.8-13.8, P = .01). CONCLUSION Contralateral hypertrophy appears to be a compensatory mechanism for unilateral kidney pathology as demonstrated by MCDK and WT patients. Hypertrophy often occurs at the time of diagnosis and appears to be a permanent finding as children reach their teenage years. Additionally, in nonhydronephrotic kidneys, increases in renal length correlate with improvement in glomerular filtration rate. Overall, the majority of children with solitary kidneys demonstrate compensatory hypertrophy.
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Affiliation(s)
- Mary Katie Wang
- UCSF Benioff Children's Hospital, Department of Urology, Division of Pediatric Urology, San Francisco, CA
| | - Thomas Gaither
- UCSF Benioff Children's Hospital, Department of Urology, Division of Pediatric Urology, San Francisco, CA
| | - Andrew Phelps
- UCSF Benioff Children's Hospital, Department of Radiology and Biomedical Imaging, San Francisco, CA
| | - Ronald Cohen
- UCSF Benioff Children's Hospital Oakland, Department of Radiology, Oakland, CA
| | - Laurence Baskin
- UCSF Benioff Children's Hospital, Department of Urology, Division of Pediatric Urology, San Francisco, CA.
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