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Discover the most talked about and latest scientific content & concepts.

Journal: Nephrology (Carlton, Vic.)

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The options for long-term maintenance therapy in lupus nephritis (LN) remain controversial. This meta-analysis of randomized controlled trials (RCTs) assessed the prognosis and safety of mycophenolate mofetil (MMF) versus azathioprine (AZA) used as maintenance therapy for lupus nephritis.

Concepts: Mycophenolic acid

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AIM: Treatment of chronic kidney disease (CKD) includes parenteral iron therapy, and these infusions can lead to iron overload. Secondary iron overload is typically treated with iron chelators, of which deferasirox is one of the most promising. However, it has not been studied in patients with CKD and iron overload. METHODS: A pilot study was conducted to evaluate the pharmacokinetics and safety of deferasirox in 8 haemodialysis-dependent patients, who were receiving intravenous iron for treatment of anaemia of CKD. Deferasirox was administered at two doses (10 mg/kg and 15 mg/kg), either acute (once daily for two days) or steady-state (once daily for two weeks). RESULTS: A dose of 10 mg/kg in either protocol was not sufficient to achieve a plasma concentration in the therapeutic range (acute peak 14.1 and steady-state 22.8 μmol/l), while 15 mg/kg in either protocol maintained plasma concentration well above this range (acute peak 216 and steady-state 171 μmol/l). Plasma concentration observed at 15 mg/kg was well above that expected for this dose (40-50 μmol/l), although no adverse clinical events were observed. CONCLUSION: This study highlights the need to profile drugs such as deferasirox in specific patient groups, such as those with CKD and iron overload.

Concepts: Pharmacology, Chronic kidney disease, Erythropoietin, Medicine, Medical terms, Dose, Artificial kidney, Routes of administration

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To derive a simple risk score to predict the individual risk of major complications for patients undergoing a percutaneous renal biopsy procedure of native kidneys.

Concepts: Nephritic syndrome

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Patients with diabetic nephropathy develop nephrotic syndrome, and may show limited response to conventional therapy. They often require earlier initiation of renal replacement therapy because they become refractory to diuretics, and experience excessive fluid retention. We aimed to investigate the efficacy of tolvaptan, an oral arginine vasopressin type 2 receptor antagonist, in a case series of 14 severe diabetic renal failure patients who were severely refractory to maximal doses of furosemide and had excessive fluid retention despite preserved cardiac function and residual renal function. All 14 patients experienced immediate and sustained water diuretic effects, resulting in alleviation of congestive heart failure. None required initiation of renal replacement therapy. Tolvaptan promptly increased urine volume and free water clearance, reversed progressive fluid retention, and alleviated congestive heart failure. Thus, tolvaptan could serve as a potential adjunct therapy for severe diabetic renal failure patients with excessive fluid retention and congestive heart failure.

Concepts: Renal failure, Kidney, Nephrology, Hypertension, Urine, Renal physiology, Diabetes insipidus, Hypokalemia

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Chronic kidney disease (CKD) is strongly associated with cardiovascular disease and muscle wasting, arising from numerous factors associated with declining renal function and lifestyle factors. Exercise has the ability to impact beneficially on the comorbidities associated with CKD and is accepted as an important intervention in the treatment, prevention and rehabilitation of other chronic diseases, however, the role of exercise in CKD is overlooked, with the provision of rehabilitation programmes well behind those of cardiology and respiratory services. Whilst there is now a large evidence base demonstrating the efficacy and safety of exercise training interventions in patients receiving dialysis, and this is now becoming incorporated into clinical guidelines for treatment of dialysis patients, there is a paucity of research evaluating the effectiveness of exercise in patients with CKD who are not on dialysis. Despite this, existing studies indicate that exercise can improve physical functioning and impact positively on the mediators of co-morbid diseases and upstream factors associated with progression of renal disease. Although preliminary evidence appears positive, more research is required to identify the best modes, frequency and intensities of exercise in order to optimise exercise prescription in pre-dialysis CKD patients. This review summarises what is known about the main effects of exercise in pre-dialysis CKD patients, discusses the potential of exercise in the rehabilitation and treatment of disease and highlights the need for further research.

Concepts: Renal failure, Chronic kidney disease, Kidney, Nephrology, Erythropoietin, Dialysis, Medicine

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Metformin is a biguanide derivative widely used for the treatment of type 2 diabetes mellitus. Recent evidence implicates that this anti-hyperglycemic drug exerts renal protective effects, yet the mechanisms remain poorly understood. MCP-1 has been recognized as a key mediator of renal fibrosis in chronic kidney diseases including diabetic nephropathy. This study aimed to investigate the effects of metformin on TGF-β1-induced MCP-1 expression and the underlying mechanisms in rat renal tubular epithelial cells.

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To compare the health-related quality of life (HRQOL) and health utility of Chinese patients with end-stage renal disease (ESRD) undergoing nocturnal home haemodialysis against those patients undergoing other modes of dialysis.

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In contrast to peritoneal dialysis, residual kidney function is commonly disregarded for haemodialysis patients, and not regularly monitored or taken into account in routine clinical care. This is despite evidence that higher levels of residual kidney function in haemodialysis patients associate with better outcomes including survival, total solute clearance, nutrition, inflammation, and fluid balance. This review aims to summarise the clinical effects of residual kidney function specifically in haemodialysis patients. Some level of residual kidney function is present in over 80% of patients at the time of dialysis initiation, and while this declines over time, up to 30% of patients on haemodialysis for 5 years still have a measurable level of native kidney function. There is little evidence on how best to preserve residual kidney function in haemodialysis patients, although it has been observed that intensive haemodialysis regimens in incident haemodialysis patients appear to accelerate residual kidney function decline. Residual kidney function is not commonly factored in to haemodialysis prescription and measures of adequacy, despite the fact that some guidelines such as KDOQI and European Best Practice Guidelines suggest that it is reasonable to do. This likely relates, at least in part, to perceived concerns regarding the inconvenience of timed urine collections, and to the complexity and lack of consensus regarding the methods for integrating the intermittent clearance of haemodialysis with the continuous clearance of native renal function. Further research is required into how best to maintain and maximise the benefits of residual kidney function in haemodialysis patients. This article is protected by copyright. All rights reserved.

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Severe urea cycle defects (UCDs), organic acidemias (OAs), and maple syrup urine disease (MSUD) are life-threatening disorders presenting in the first days of life. Renal replacement therapy (RRT) is an emergency option in affected newborns, mostly performed as ultima ratio. We report our 10-year experience using emergency RRT in newborns with UCDs, OAs, and MSUD. Twelve newborns (8 with UCDs, 2 with methylmalonic acidemia, and 2 with MSUD) underwent emergency RRT. The overall survival rate to RRT was 58.3%. Hyperammonemic newborns required earlier RRT with respect to MSUD patients (75 [65-102] vs 301 [192-410] hours of life, p<0.01). Hyperammonemic neonates surviving (n=5) and nonsurving (n=5) the acute neonatal decompensation showed similar birth weight (p=0.690), duration of intubation (p=0.917), ammonia at onset (p=0.916) and at the start of RRT (p=0.426), age at RRT (p=0.999), and duration of coma before RRT (p=0.691). Remarkably, all survivors quickly responded to RRT, with ammonia concentration <300 μmol/l after 8 hours of treatment. One patient with UCD successfully treated by neonatal RRT died at 4 months of life because of sepsis. All patients with MSUD normalized leucine levels after 12 hours of RRT, surviving the acute neonatal decompenstation. All long-term survivors (5 liver transplanted, 1 waiting for liver transplantation) currently show normal or near-normal neurologic development (48±39 months of age). Early response to RRT was associated to survival irrespective of pre-treatment picture. RRT can be considered even in huge neonatal metabolic decompensations. Early liver transplantation may be an option for selected patients. This article is protected by copyright. All rights reserved.

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ABO-incompatible (ABOi) kidney transplantation (KT) has become a routine procedure with graft survival rates comparable to those of ABO-compatible KT. However, the clinical significance of the isoagglutinin titer in ABOi KT remains uncertain. Therefore, in this study, we analyzed the clinical outcomes of ABOi KT according to the baseline and postoperative isoagglutinin titer.