Changing Paradigms in the Management of Rejection in Kidney Transplantation: Evolving From Protocol-Based Care to the Era of P4 Medicine

Defining participatory health informatics - a scoping review

Healthcare has been shifting toward individuals participating in decision-making and empowered to be active in their treatment, and health monitoring. The term "participatory health informatics" (PHI) started to appear in literature. A clear definition of PHI is missing, and facets of PHI still have to be shaped. The objective of this paper is to offer a definition of PHI considering themes and technologies that make healthcare participatory. We searched Pubmed, ACM Digital Library, IEEE Xplore, EMBASE, and conference proceedings for articles that reported about use of information technology or informatics in the context of PHI. We performed qualitative synthesis and reported summary statistics. 39 studies were eligible after screening 382 titles and abstracts and reviewing 82 full texts. The top 5 person-centered key themes related to PHI included empowerment, decision-making, informed patient, collaboration, and disease management. Finally, we propose to define PHI as multidisciplinary field that uses information technology as provided through the web, smartphones, or wearables to increase participation of individuals in their care process and to enable them in self-care and shared decision-making. Goals to be achieved through PHI include maintaining health and well-being; improving the healthcare system and health outcomes; sharing experiences; achieving life goals; and self-education.

Sex-Associated Differences in Cytomegalovirus Prevention: Prophylactic Strategy is Potentially Associated With a Strong Kidney Function Impairment in Female Renal Transplant Patients

Post-transplantation cytomegalovirus (CMV) syndrome can be prevented using the antiviral drug (val)ganciclovir. (Val)ganciclovir is typically administered following a prophylactic or a pre-emptive strategy. The prophylactic strategy entails early universal administration, the pre-emptive strategy, early treatment in case of infection. However, it is not clear which strategy is superior with respect to transplantation outcome; sex-specific effects of these prevention strategies are not known. We have retrospectively analyzed 540 patients from the multi-centre Harmony study along eight pre-defined visits: 308 were treated according to a prophylactic, 232 according to a pre-emptive strategy. As expected, we observed an association of prophylactic strategy with lower incidence of CMV syndrome, delayed onset and lower viral loads compared to the pre-emptive strategy. However, in female patients, the prophylactic strategy was associated with a strong impairment of glomerular filtration rate one year post-transplant (difference: -11.8 ± 4.3 ml min-1·1.73 m-2, p = 0.006). Additionally, we observed a tendency of higher incidence of acute rejection and severe BK virus reactivation in the prophylactic strategy group. While the prophylactic strategy was more effective for preventing CMV syndrome, our results suggest for the first time that the prophylactic strategy might lead to inferior transplantation outcomes in female patients, providing evidence for a strong association with sex. Further randomized controlled studies are necessary to confirm this potential negative effect.

Predictive, Personalized, Preventive and Participatory (4P) Medicine Applied to Telemedicine and eHealth in the Literature

The main objective of this work is to provide a review of existing research work into predictive, personalized, preventive and participatory medicine in telemedicine and ehealth. The academic databases used for searches are IEEE Xplore, PubMed, Science Direct, Web of Science and ResearchGate, taking into account publication dates from 2010 up to the present day. These databases cover the greatest amount of information on scientific texts in multidisciplinary fields, from engineering to medicine. Various search criteria were established, such as ("Predictive" OR "Personalized" OR "Preventive" OR "Participatory") AND "Medicine" AND ("eHealth" OR "Telemedicine") selecting the articles of most interest. A total of 184 publications about predictive, personalized, preventive and participatory (4P) medicine in telemedicine and ehealth were found, of which 48 were identified as relevant. Many of the publications found show how the P4 medicine is being developed in the world and the benefits it provides for patients with different illnesses. After the revision that was undertaken, it can be said that P4 medicine is a vital factor for the improvement of medical services. It is hoped that one of the main contributions of this study is to provide an insight into how P4 medicine in telemedicine and ehealth is being applied, as well as proposing outlines for the future that contribute to the improvement of prevention and prediction of illnesses.

Association Between Newborn Metabolic Profiles and Pediatric Kidney Disease

INTRODUCTION

Metabolomics offers considerable promise in early disease detection. We set out to test the hypothesis that routine newborn metabolic profiles at birth, obtained through screening for inborn errors of metabolism, would be associated with kidney disease and add incremental information to known clinical risk factors.

METHODS

We conducted a population-level cohort study in Ontario, Canada, using metabolic profiles from 1,288,905 newborns from 2006 to 2015. The primary outcome was chronic kidney disease (CKD) or dialysis. Individual metabolites and their ratio combinations were examined by logistic regression after adjustment for established risk factors for kidney disease and incremental risk prediction measured.

RESULTS

CKD occurred in 2086 (0.16%, median time 612 days) and dialysis in 641 (0.05%, median time 99 days) infants and children. Individual metabolites consisted of amino acids, acylcarnitines, markers of fatty acid oxidation, and others. Base models incorporating clinical risk factors only provided c-statistics of 0.61 for CKD and 0.70 for dialysis. The addition of identified metabolites to risk prediciton models resulted in significant incremental improvement in the performance of both models (CKD model: c-statistic 0.66 NRI 0.36 IDI 0.04, dialysis model: c-statistic 0.77 NRI 0.57 IDI 0.09). This was consistent after internal validation using bootstrapping and a sensitivity analysis excluding outcomes within the first 30 days.

CONCLUSION

Routinely collected screening metabolites at birth are associated with CKD and the need for dialytic therapies in infants and children, and add incremental information to traditional clinical risk factors.

The Role of Trio, a Rho Guanine Nucleotide Exchange Factor, in Glomerular Podocytes

Nephrotic syndrome is a kidney disease featured by heavy proteinuria. It is caused by injury to the specialized epithelial cells called “podocytes” within the filtration unit of the kidney, glomerulus. Previous studies showed that hyperactivation of the RhoGTPase, Rac1, in podocytes causes podocyte injury and glomerulosclerosis (accumulation of extracellular matrix in the glomerulus). However, the mechanism by which Rac1 is activated during podocyte injury is unknown. Trio is a guanine nucleotide exchange factor (GEF) known to activate Rac1. By RNA-sequencing, we found that Trio mRNA is abundantly expressed in cultured human podocytes. Trio mRNA was also significantly upregulated in humans with minimal change disease and focal segmental glomerulosclerosis, two representative causes of nephrotic syndrome. Reduced expression of Trio in cultured human podocytes decreased basal Rac1 activity, cell size, attachment to laminin, and motility. Furthermore, while the pro-fibrotic cytokine, transforming growth factor β1 increased Rac1 activity in control cells, it decreases Rac1 activity in cells with reduced Trio expression. This was likely due to simultaneous activation of the Rac1-GTPase activation protein, CdGAP. Thus, Trio is important in the basal functions of podocytes and may also contribute to glomerular pathology, such as sclerosis, via Rac1 activation.