Clinical Scenarios in Chronic Kidney Disease: Chronic Tubulointerstitial Diseases

Shenkang injection combined with alprostadil for chronic renal failure: A systematic review and meta-analysis

Objective

To systematically evaluate the clinical efficacy and safety of Shenkang injection (SKI) combined with alprostadil in the treatment of chronic renal failure (CRF).

Method

Randomized controlled trials (RCTs) of Shenkang injection combined with alprostadil in CRF treatment were investigated by retrieving a total of 7 databases including CNKI, Wanfang database, VIP, CBM, PubMed, Embase and Cochrane Library, with the search time ranging from 2012 to now. Revman 5.2 software was used for data analysis, and Cochrane bias risk tool was used to evaluate the quality of the included literature. The final results were represented by relative risk (RR), mean difference (MD) and 95% confidence interval (95% CI).

Results

A total of 20 RCTs and 1,573 patients were included in this study. Meta-analysis showed that the overall response rate (ORR) of the treatment group was superior to the control group [RR = 0.20, 95% CI (0.16, 0.25), P < 0.00001]. Compared with the control group, the treatment group achieved favorable improvement in terms of the creatinine clearance rate (Ccr) [MD = 9.48, 95% CI (8.73, 10.24), P < 0.00001], serum creatinine (Scr) [MD = −55.12, 95% CI (−63.42, −46.82), P < 0.00001], quantitative urine protein (Upro) [MD = −0.48, 95% CI (−0.53, −0.43), P < 0.00001], and blood urea nitrogen (BUN) [MD=-3.73, 95% CI (−4.08, −3.3) 7, P < 0.00001]. There was no statistical difference in the incidence of adverse reactions in each group.

Conclusion

Currently, Shenkang injection combined with alprostadil has been widely used in clinical treatment of CRF due to the certain effect superior to other methods. However, its specific efficacy and safety need to be further verified through numerous large-scale clinical trials.

Exosomes and ultrasound: The future of theranostic applications

Biomaterials and pertaining formulations have been very successful in various diagnostic and therapeutic applications because of its ability to overcome pharmacological limitations. Some of them have gained significant focus in the recent decade for their theranostic properties. Exosomes can be grouped as biomaterials, since they consist of various biological micro/macromolecules and possess all the properties of a stable biomaterial with size in nano range. Significant research has gone into isolation and exploitation of exosomes as potential theranostic agent. However, the limitations in terms of yield, efficacy, and target specificity are continuously being addressed. On the other hand, several nano/microformulations are responsive to physical or chemical alterations and were successfully stimulated by tweaking the physical characteristics of the surrounding environment they are in. Some of them are termed as photodynamic, sonodynamic or thermodynamic therapeutic systems. In this regard, ultrasound and acoustic systems were extensively studied for its ability towards altering the properties of the systems to which they were applied on. In this review, we have detailed about the diagnostic and therapeutic applications of exosomes and ultrasound separately, consisting of their conventional applications, drawbacks, and developments for addressing the challenges. The information were categorized into various sections that provide complete overview of the isolation strategies and theranostic applications of exosomes in various diseases. Then the ultrasound-based disease diagnosis and therapy were elaborated, with special interest towards the use of ultrasound in enhancing the efficacy of nanomedicines and nanodrug delivery systems, Finally, we discussed about the ability of ultrasound in enhancing the diagnostic and therapeutic properties of exosomes, which could be the future of theranostics.

Assessment of renal microcirculation in biopsy-proven tubulointerstitial nephritis in patients with and without glomerular disease: the role of resistive index

BACKGROUND

Renal resistive index (RRI) measured by Doppler sonography is a marker of microvascular status and it is associated with changes in renal function. Aim of the study was to assess RRI in biopsy-proven tubulointerstitial nephritis (TIN) in patients with and without glomerular disease.

METHODS

132 consecutive patients underwent to native renal biopsy with diagnosis of isolated TIN or in association with glomerulonephritis. Estimated glomerular filtration rate (eGFR), 24-hour urinary protein excretion and renal ecocolorDoppler ultrasonography with RRI assessment were performed at time of enrollment.

RESULTS

Patients with isolated-TIN had significantly higher RRI than both patients with non-immunoglobulin A glomerulonephritis (non-IgA-TIN) [0.73 (0.68-0.77) vs 0.64 (0.60-0.67), p < 0.001] and patients with IgA nephropathy (IgAN) [0.73 (0.68-0.77) vs 0.66 (0.60-0.71), p < 0.01]. Patients with isolated-TIN had mainly RRI ≥ 0.70 (n = 15, 65.2%) with the respect to patients with non-IgA-TIN (n = 7, 12.3%) and patients with IgAN (n = 17, 32.7%). A negative linear correlation was found between RRI and hemoglobin (r = 0.233, p < 0.01) and between RRI and eGFR (r = 0.537, p < 0.001).

CONCLUSION

Tubulointerstitial damage is the most accurate histological lesion that correlates with eGFR and renal impairment. RRI can be a useful parameter to detect tubulointerstitial lesions.

Potential value of three-dimensional ultrasonography in diagnosis of diabetic nephropathy in Chinese diabetic population with kidney injury

Background

To explore the potential value of three-dimensional ultrasonography (3DUS) and contrast-enhanced ultrasound (CEUS) in the diagnosis of diabetic nephropathy (DN) in Chinese diabetic patients with kidney injury.

Methods

Patients with type 2 diabetes mellitus and kidney injury in our hospital were enrolled, and the clinical characteristics as well as the laboratory data of patients were collected; 3DUS and CEUS were used to evaluate the morphological structure and blood perfusion of kidneys. Eligible patients were categorized into two groups based on renal biopsy results: DN group and non-diabetic renal diseases (NDRD) group. Correlation analysis and logistic regression analysis were applied to identify the risk factors of DN development.

Results

A total of 115 patients aged from 24 to 78 years old were recruited in the experiment, of which 64 patients (55.65%) and 51 patients (44.35%) were in the DN group and NDRD group, respectively. After correction to CKD stage, BMI and right kidney volume index were retained to identify patients with DN. The ROC of the logistic regression model had an AUC of 0.703 (95% CI: 0.591–0.815) and it was higher than both indicators.

Conclusion

3DUS has potential value in the diagnosis of diabetic nephropathy in Chinese diabetic population with kidney injury and may act as an auxiliary diagnosis for DN. More prospective and well-designed studies with larger samples are needed to verify the result.

Role of remodeling of small diameter kidney arteries in the prognosis of progression of tubulointerstitial fibrosis in patients with chronic glomerulonephritis

Aim. To assess the role of remodeling of small diameter kidney arteries in the prognosis of progression of tubulointerstitial fibrosis in patients with chronic glomerulonephritis.

Material and methods. The study involved 97 patients with primary glomerulonephritis. The average age of patients was 37,27±1,2 years. The inclusion criterion was the presence of indications for renal biopsy. Renal biopsy was used to analyze renal tissue, in particular, for determining of tubulointerstitial fibrosis (TIF). Based on TIF sign, the patients were divided in 2 groups. The first group includes patients with TIF, the second — without TIF. Vasometry, a measurement of the renal arteries structures, was performed as part of renal biopsy. Parameters of internal and external diameters, wall thickness, intima, media, intima-media complex, vascular mass were analyzed.

Results. The influence of the size of the inner and outer diameters of the interlobular artery (MA) on the studied risk was established. Probability of TIF developing increases with decreasing of MA inner diameter (χ2-criterion =5,34, p=0,02) and increasing of MA outer diameter (χ2-criterion =7,77, p=0,005). Intimal thickness does not have a statistically significant effect on the risk of TIF developing (p=0,29), whereas media thickness has a high statistical significance in renal tissue remodeling (χ2-criterion =13,71, p=0,0002). A statistically significant effect of an increase in the vascular mass on the risk of TIF was determined (χ2-criterion =6,55, p=0,01).

Conclusion. We established that changes in the structure of small diameter kidney arteries in chronic glomerulonephritis occurs according to a hypertrophic type. Remodeling of small diameter kidney arteries plays significant role on the risk of TIF.

Ultrasound and color Doppler applications in chronic kidney disease

Chronic kidney disease (CKD) includes all clinical features and complications during the progression of various kidney conditions towards end-stage renal disease (ESRD). These conditions include immune and inflammatory disease such as: primary and hepatitis C virus (HCV)-related glomerulonephritis; infectious disease such as pyelonephritis with or without reflux and tuberculosis; vascular disease such as chronic ischemic nephropathy; hereditary and congenital disease such as polycystic disease and congenital cystic dysplasia; metabolic disease including diabetes and hyperuricemia; and systemic disease (collagen disease, vasculitis, myeloma). During the progression of CKD, ultrasound imaging and color Doppler imaging (US-CDI) can differentiate the etiology of the renal damage in only 50-70% of cases. Indeed, the end-stage kidney appears shrunken, reduced in volume (Ø < 9 cm), unstructured, amorphous, and with acquired cystic degeneration (small and multiple cysts involving the cortex and medulla) or nephrocalcinosis, but there are rare exceptions, such as polycystic kidney disease, diabetic nephropathy, and secondary inflammatory nephropathies. The main difficulties in the differential diagnosis are encountered in multifactorial CKD, which is commonly presented to the nephrologist at stage 4-5, when the kidney is shrunken, unstructured and amorphous. As in acute renal injury and despite the lack of sensitivity, US-CDI is essential for assessing the progression of renal damage and related complications, and for evaluating all conditions that increase the risk of CKD, such as lithiasis, recurrent urinary tract infections, vesicoureteral reflux, polycystic kidney disease and obstructive nephropathy. The timing and frequency of ultrasound scans in CKD patients should be evaluated case by case. In this review, we will consider the morpho-functional features of the kidney in all nephropathies that may lead to progressive CKD.