Kidney and Dialysis

Background: Handgrip strength (HGS) is a simple, low-cost indicator of muscle function and predictor of morbidity and mortality in patients with chronic kidney disease (CKD). Objective: To establish sex- and age-specific normative values for HGS in Colombian patients undergoing hemodialysis and to examine its association with clinical and biochemical factors. Methods: A multicenter, cross-sectional study was conducted between August and September 2023 in five cities across Colombia. A total of 436 hemodialysis patients aged 15 to over 80 years were assessed. HGS was measured post-dialysis using a CAMRY EH101 digital dynamometer in both flexion and extension of each arm. The Box–Cox Power Exponential (BCPE) model within the GAMLSS framework was used to generate percentile curves by sex. Comparisons were performed by sex, diabetes status, and occupation. Spearman’s correlation was used to explore associations between HGS and biochemical variables. Results: Males exhibited significantly higher HGS than females (mean difference: 8.09 kg; p < 0.001). Lower HGS was observed among individuals with diabetes and those unemployed. HGS showed a moderate inverse correlation with alkaline phosphatase (r = −0.29, p = 0.0014) and a weak inverse correlation with KT/V (r = −0.22, p = 0.02). No other biochemical markers showed significant associations. Reference percentiles (P3 to P97) were constructed for both sexes. Conclusions: These normative values for HGS represent the first reference standards for Colombian patients on hemodialysis. HGS assessment may support early identification of functional impairment and inform clinical decisions related to rehabilitation and nutritional support. Full article

Background: Kidney transplantation activity at the University Hospital of Guadeloupe was briefly interrupted at the onset of the COVID-19 pandemic, reflecting the global impact of this health crisis on organ transplantation. This study assessed patient and graft recovery in 335 recipients transplanted between 2013 and 2023, comparing those transplanted before 2020 and after the resumption of activity. The objective was to evaluate changes in recipient profiles, surgical parameters, and post-transplant outcomes following this disruption. Methods: This retrospective cohort included all kidney transplants performed at the University Hospital of Guadeloupe over a ten-year period. Most patients (70%) received transplants before 2020, with 30% afterward. All grafts were ABO-compatible, and 98.2% were from deceased donors. Trends in transplant activity were analyzed to identify variations over time, with a peak observed in 2018, followed by a decline until 2021 and a progressive recovery from 2022. Comparative analyses were performed to examine disparities in donor and recipient characteristics, ischemia durations, and outcomes between the two periods. Results: After 2020, recipients were more likely to be elderly (≥70 years), immunized, obese, have heterozygous sickle cell disease, or have polycystic kidney disease (p < 0.05). Mean cold ischemia time decreased (p = 0.009), while warm ischemia time increased (p < 0.001), reflecting procedural and logistical adaptations. Graft survival remained stable, with 97.5% at 6 months and 89.8% at 4 years for transplants before 2020, versus 100% and 96.9%, respectively, after 2020 (p = 0.160). Patient survival did not differ significantly between periods (p = 0.199). Independent factors associated with mortality included recipient age ≥ 60 years, diabetes, graft failure, transplantation before 2020, cold ischemia time ≥ 1200 min, and graft pyelonephritis. Conclusions: Despite the temporary suspension of activity and an increased proportion of transplants with expanded criteria after 2020, graft recovery and patient survival were not adversely affected. These findings suggest that kidney transplantation in Guadeloupe demonstrated strong resilience and capacity for adaptation during and after the COVID-19 crisis, maintaining outcomes comparable to the pre-pandemic period. Full article

Background: Delayed graft function (DGF) is a frequent early complication after deceased donor kidney transplantation (DDKT), leading to prolonged hospitalization, increased risk of acute rejection, and reduced graft survival. Reliable and easily measurable preoperative biomarkers for DGF prediction remain limited. This study aimed to evaluate the predictive value of pre-operative Absolute Eosinophil Count (AEC) and Albumin-to-Globulin Ratio (AGR) for DGF in DDKT recipients. Methods: A retrospective analysis was conducted on all DDKT procedures performed at our institution between January 2018 and December 2023. Patients were divided into two groups: Group 1 (DGF) and Group 2 (non-DGF). DGF was defined as the requirement for hemodialysis within the first seven postoperative days. Demographic, clinical, and laboratory data—including pre-operative AEC and AGR—were collected and compared between groups. Statistical analysis was performed using appropriate parametric and nonparametric tests. Receiver operating characteristic (ROC) curves were generated to assess the individual and combined predictive performance of AEC and AGR for DGF. Results: A total of 38 patients underwent DDKT, comprising 27 males (71.05%) and 11 females (28.95%), with a mean age of 43.3 ± 9.41 years. Fifteen patients (39.47%) developed DGF. The mean AEC and AGR were significantly lower in the DGF group compared to the non-DGF group (AEC: 0.20 ± 0.16 vs. 0.40 ± 0.35, p = 0.04; AGR: 1.43 ± 0.22 vs. 1.66 ± 0.39, p = 0.02). ROC analysis demonstrated that both AEC (p = 0.04) and AGR (p = 0.04) were significant predictors of DGF. Combining both parameters resulted in a higher area under the curve (AUC), improved sensitivity, and enhanced negative predictive value (NPV) compared to either marker alone. Conclusions: DGF occurred in nearly two-fifths of DDKT recipients in this cohort. Patients with lower preoperative AEC and AGR were more likely to develop DGF, suggesting that these easily available hematological and biochemical indices can serve as potential preoperative predictors of early graft dysfunction. Future multicentric prospective studies are warranted to validate these findings and explore their integration into DGF risk prediction models. Full article

Background: The peritoneal dialysis (PD) catheter is commonly placed using an open surgery approach. However, mechanical peritoneal catheter-related complications are common causes of peritoneal dialysis technical failure. In recent years, laparoscopic procedures have been recommended because of less invasiveness and high effectiveness in reducing catheter dysfunction; however, this approach is burdened by higher costs and higher risks related to general anesthesia. Methods: We have developed a new advanced video-laparoscopy (ALS) approach with a simple technique that does not require general anesthesia. By using an ultrasound-guided procedure it is possible to place a PD catheter by regional anesthesia (Transversus Abdominis Plane (TAP) block associated with bilateral quadratus lumborum (QLB) block). Results: We here report the outcomes of 20 patients who underwent ALS implantation of straight-neck, double-cuffed Tenckhoff catheters using cutaneous anesthesia with TAP and QLB block. No major complications, including bleeding, were reported. No patient needed intravenous treatment for pain control, and all procedures were well tolerated. During a median follow-up of 21 months [IQR, 15–35] no mechanical complication was reported. Conclusions: ALS without general anesthesia is a simple and well-tolerated technique that can be used in patients at high risk. It therefore allows recruiting a greater number of patients for PD and ensuring well-performing catheters with lower risk of mechanical complications. Full article

Background: Renal arteriovenous malformations (rAVMs) are rare vascular anomalies that may lead to hematuria, anemia, or acute kidney injury (AKI). Although endovascular embolization is the treatment of choice, post-procedural complications such as new-onset proteinuria may occur and require long-term management. Case Presentation: A 56-year-old man with recurrent gross hematuria and elevated serum creatinine (128 μmol/L) was diagnosed with a right rAVM and underwent successful selective embolization. Despite recovery of renal function, follow-up revealed new-onset proteinuria (2.2 g/24 h). Results: Introduction of an angiotensin-converting enzyme inhibitor (ACEi) resulted in partial improvement of proteinuria, while subsequent addition of a sodium–glucose cotransporter-2 inhibitor (SGLT2i) achieved almost complete resolution of proteinuria (0.33 g/24 h) and stable renal function (serum creatinine 93 μmol/L) after 12 months. Conclusions: This case highlights the occurrence of post-embolization proteinuria and illustrates the synergistic renoprotective effect of combined ACEi and SGLT2i therapy in a non-diabetic patient with vascular kidney disease. Full article

Hypertension (HTN) and chronic kidney disease (CKD) are significant global health burdens, with microalbuminuria (MA) serving as a key early marker of renal damage and cardiovascular risk. While nutritional interventions are pivotal for management, the evidence for specific nutrients is often complex and inconsistent, creating challenges for clinical guidance. This review critically evaluates current evidence on the interaction among macronutrients, micronutrients, and established dietary approaches and their influence on the development and course of HTN and MA. Strong consensus is present regarding sodium restriction, increased intakes of potassium, and the implementation of dietary patterns like Dietary Approaches to Stop Hypertension (DASH) and the Mediterranean diet to improve blood pressure and renal outcomes. Evidence favors protein moderation (approximately 0.8 g/kg/day), especially from plant sources, and emphasizes carbohydrate quality (e.g., high fiber, low glycemic index) over absolute quantity. The role of micronutrients is more nuanced; maintaining vitamin D sufficiency is protective, but intervention trials for many supplements, including B vitamins and antioxidant vitamins (C and E), have yielded inconsistent results. Several minerals, such as iron and selenium, exhibit a U-shaped risk curve where both deficiency and excess are detrimental, highlighting the risks of unselective supplementation. Ideal nutrition care prioritizes holistic dietary patterns over a focus on single nutrients. Clinical guidance should be founded on sodium reduction and potassium-rich foods, with personalized recommendations for protein and micronutrient supplementation based on an individual’s specific cardiovascular and renal profile. Future research must target nutrients with conflicting evidence to establish clear, evidence-based intake guidelines. Full article

Hemodialysis (HD) technology, pivotal in managing end-stage kidney disease, has witnessed significant advancements. Yet, the high cost of novel equipment often restricts its usage in resource-limited settings. This study introduces a two-filter adaptation to conventional HD machines, aimed at enhancing toxin removal while maintaining cost-effectiveness. Using a benchtop experimental setup, the performance of the adapted system was compared with that of standard HD. The results demonstrated that the two-filter system improved urea clearance rates by 54% compared with standard HD, without increasing albumin loss or causing additional hemolysis. In a pilot study of four HD patients, the modified setup achieved a higher single-pool Kt/V (1.82) and urea-reduction ratio (80%). These findings underscore the potential of this adaptation to enhance HD machine efficiency without additional patient risks, thereby offering a feasible solution for improving access to advanced renal therapies in under-resourced areas. Further clinical trials with larger populations are warranted to validate these benefits and evaluate middle-molecule clearance for comparison with hemodiafiltration (HDF). Full article

Background: Oral frailty is a new concept, introduced in Japan in 2013. In our preliminary study, oral hypofunction was observed in more than half of patients undergoing maintenance hemodialysis (MHD). This allowed us to determine the exact prevalence of oral frailty in MHD patients and investigate the association between oral cavity function, findings obtained via comprehensive geriatric assessment, and motor features. Methods: We initiated a two-week hospitalization program for MHD patients to evaluate frailty including oral cavity functions. Along with a comprehensive geriatric assessment and evaluation of motor functions, seven items pertaining to oral cavity functions were assessed by a professional dentist to determine oral frailty. After the incidence of each item had been determined, the association between these factors was retrospectively analyzed to explore the factors that affect oral frailty. Results: Oral frailty was observed in 33 out of 50 patients (66%). In particular, tongue lip motor functions were frequently impaired in this population. Oral cavity function scores, which increased as oral function deteriorated, negatively correlated with cognitive function (r = −0.349; p = 0.0129; 1−β = 0.71) and grip strength (r = −0.364; p = 0.00933; 1−β = 0.75). Conclusions: Oral frailty was commonly observed in MHD patients. We are currently considering implementing exercise programs to improve tongue lip motor function, enhance cognitive function through interprofessional cooperation, and strengthen grip. Full article

Background: Diabetic ketoacidosis (DKA) in patients with kidney failure receiving dialysis presents a formidable clinical challenge. Standard DKA protocols, designed for patients with preserved renal function, often fail in this cohort and can be unsafe when applied without modification. Patients are at risk of iatrogenic fluid overload, dyskalaemia, and hypoglycaemia due to altered insulin kinetics, impaired gluconeogenesis, and the absence of osmotic diuresis. Purpose: This narrative review aims to synthesise current understanding of DKA pathophysiology in dialysis patients, delineate distinct clinical phenotypes, and propose individualised management strategies grounded in physiology-based reasoning, comparative guideline insights, and consensus-supported literature. Methods: We searched PubMed/MEDLINE, Embase, and Google Scholar (January 2004–June 2024) for adult dialysis populations, using terms spanning DKA, kidney failure, insulin kinetics, fluid balance, and cerebral oedema. Reviews, observational cohorts, guidelines, consensus statements, and physiology papers were prioritised; case reports were used selectively for illustration. Evidence was weighted by physiological plausibility and practice relevance. Nephrology-led authors aimed for a pragmatic, safety-first synthesis, seeking and integrating contradictory recommendations. Conclusions: Our findings highlight the critical need for a nuanced approach to fluid management, a tailored insulin strategy that accounts for glucose-insulin decoupling and prolonged insulin half-life, and careful consideration of potassium and acidosis correction. We emphasise the importance of recognising specific volume phenotypes (hypovolaemic, euvolaemic, hypervolaemic) to guide fluid therapy, and advocating the judicious use of variable-rate insulin infusions (‘dry insulin’) to mitigate fluid overload. We also show that service-level factors are critical. Dialysis-specific pathways, interdisciplinary training, and quality improvement metrics can reduce iatrogenic harm. By linking physiology with workflow adaptations, this review provides a physiologically sound, bedside-oriented map for navigating this complex emergency safely and effectively. In doing so, it advances an individualised model of DKA care for dialysis-dependent patients. Full article

Background: Despite efforts to rely on arteriovenous fistulas/grafts for maintenance hemodialysis, a significant number of patients still depend on tunnel hemodialysis catheters for treatment. This poses a risk factor for central line-associated bloodstream infection (CLABSI) and, subsequently, vascular access compromise. Method: We conducted a retrospective study in five dialysis centers to determine the potential factors resulting in vascular access loss, CLABSI incidence, and microbe distribution patterns in Saudi Arabia at centers under the Ministry of National Guard Health Affairs. Adults who regularly received hemodialysis and had positive blood cultures between January 2019 and December 2023 were the subjects of the study. Results: Our study identified the presence of tunnel infection (p < 0.001), the presence of a Gram-negative pathogen (p = 0.036), and a high body mass index (BMI > 30) (p = 0.04) as potential risk factors leading to the loss of tunnel central venous catheters. In contrast, there was a lower probability of central venous catheter loss due to Gram-positive pathogens (p = 0.01). The CLABSI rate was 1.55 per 100 patients per month over a five-year period. Patients with CVC required more hospital treatment and had a significantly higher rate of vascular access loss (p < 0.001). Both central and peripheral blood cultures had nearly identical microbe spectra. Methicillin-sensitive Staphylococcus aureus (MSSA), Methicillin-resistant Staphylococcus aureus (MRSA), and Staphylococcus epidermidis had the highest prevalence rates among Gram-positive organisms. Among the Gram-negative bacteria, Enterobacter cloacae was the most common, followed by Klebsiella pneumonia and Pseudomonas aeruginosa. Conclusions: Our findings indicate the need for rigorous measures and interventions to prevent Gram-negative infections and decrease the reliance on central venous catheters, to decrease infections in hemodialysis patients, and decrease morbidity and cost. Strict hand hygiene, patient education, and surveillance programs are recommended to monitor these patients. Full article

Introduction: Allogeneic hematopoietic cell transplantation (allo-HSCT)-associated thrombotic microangiopathy (TA-TMA) and pre-transplant renal dysfunction are recognized risk factors for mortality after allo-HSCT. Utilizing the data from the Center for International Blood and Marrow Transplant Research (CIBMTR), we investigated the association between onset of TA-TMA and pre-HSCT renal dysfunction on renal failure requiring dialysis (RFD). Methods: We evaluated TA-TMA as a time-dependent covariate in a multivariate Cox regression model for RFD in Allo-HSCT recipients aged ≥ 40 years between 2008 and 2016. Pre-HSCT patients were divided into two groups, estimated GFR (eGFR) < 60 mL/min/1.73 m² group and eGFR ≥ 60 mL/min/1.73 m². Cumulative hazards of RFD in patients with and without onset of TA-TMA were estimated. Results: TA-TMA was significantly associated with increased risk (6.6-fold compared to No TA-TMA) for RFD, the highest of all the significant risk factors. The estimated cumulative hazard for patients with TA-TMA in the two pre-HSCT renal function groups was significantly elevated when compared to similar patients with no TA-TMA (80% vs. 12% for eGFR < 60 mL/min and 50% vs. 5% for eGFR ≥ 60 mL/min group, respectively) at 12 months post-HSCT. Conclusions: Our results demonstrate that the adjusted HR of renal failure requiring dialysis and cumulative hazard was much higher in patients with onset of TA-TMA, especially among patients with pre-existing renal dysfunction, underscoring the importance of early recognition and risk-adapted management. Full article

The incidence of kidney diseases has been increasing in the last decade due to extended lifespan, which is often related to polymorbidity. Chronic kidney disease (CKD) and acute kidney injury (AKI) are associated with high morbidity and mortality, elevated costs for renal replacement therapy, and heavy psychosomatic burden. At the same time, therapeutic options are limited to prophylactic and renoprotective medications and measurements, and they often cannot restore the impaired kidney function. With the development of cellular therapies, new perspectives arise on the horizon with promising potential, including mesenchymal stem cells (MSCs) and induced pluripotent cells (iPSCs). Here we review the current possibility of both cell types in the field of nephrology and assess their cost implication. Full article

We report the case of a 44-year-old man with end-stage kidney disease (ESKD) who has been on chronic hemodialysis via a radio-cephalic arteriovenous fistula (RC-AVF) for one year. The patient arrived at the emergency department due to an inability to continue dialysis through the AVF. Clinical and ultrasound exams reveal an aneurysm in the cephalic vein, measuring 2.3 cm (cm) in diameter and 5 cm long, located in the middle third of the forearm, with intraluminal thrombosis. A surgical procedure is planned to exclude the aneurysmal segment and reconnect the vein, using a graft made from a bovine pericardium patch. Immediately after surgery, a thrill is detectable, and ultrasound shows a flow rate of 651 mL/min. On the second day, dialysis is performed through the distal cephalic vein segment under ultrasound guidance, avoiding the median forearm zone. At one month, the fistula remains functional, with no signs of thrombosis or stenosis. The bovine pericardium tubular graft has shown complete integration. This case supports the feasibility, safety, and potential advantages of using a tubularized bovine pericardial graft as an alternative conduit for RC-AVF reconstruction in select patients. However, further studies on larger cohorts and with extended follow-up are necessary to validate its reproducibility and long-term patency. Full article

Hypomagnesaemia, a common complication ranging from 20% to over 90%, depending on the diagnostic criteria and population studied, significantly contributes to adverse outcomes, including new-onset diabetes after transplantation, cardiovascular complications, neurological dysfunction and increased infection risk. A total serum magnesium below 0.70 mmol/L is commonly used to define deficiency. In kidney transplant recipients, calcineurin inhibitors downregulate TRPM6 in the distal nephron, leading to early and persistent hypomagnesaemia with links to adverse metabolic and cardiovascular outcomes. Arrhythmia risk rises steeply at total magnesium of <0.50 mmol/L, while neuromuscular irritability and neuropsychiatric symptoms may appear at levels below 0.70 mmol/L. Severe manifestations, such as seizures or tetany, usually occur at ≤0.50 mmol/L and coma at <0.30 mmol/L. Normal ionised magnesium is typically ~0.48–0.65 mmol/L; transplant-specific intervention thresholds remain unvalidated. This narrative review addresses critical diagnostic gaps and explores emerging therapeutic strategies. It highlights three areas: the diagnostic accuracy of ionised magnesium over total magnesium, the critical role of pharmacogenomics in individualising immunosuppression to mitigate tacrolimus-induced hypomagnesaemia and the promising link between gut microbiome modulation and magnesium homeostasis. The implications of these insights are profound: enabling more precise diagnosis and personalised management, reducing the incidence and severity of hypomagnesaemia-related complications, and ultimately supporting more precise diagnosis and personalised management; prospective validation in transplant cohorts is required before outcome claims can be made. This review exposes current diagnostic and therapeutic limitations, advocating for more precise and personalised strategies to address this critical electrolyte imbalance. Identifying hypomagnesaemia as a mechanistically complex and clinically undertreated complication, this review proposes a thematic roadmap that serves as a scientific and clinical framework for advancing personalised electrolyte care in renal transplantation. It is emphasised that while these approaches appear promising, most remain under-evaluated or hypothesis-generating. Addressing hypomagnesaemia through validated thresholds, new research is required to test novel diagnostics and personalised strategies to improve patient and graft outcomes. Full article

Objective: This scoping review synthesized and mapped the breadth of the existing literature on technological resources used to support individuals undergoing hemodialysis treatment. Methods: Following the methodological guidelines of the Joanna Briggs Institute (JBI) for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist, comprehensive searches were conducted across the following databases: MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Scopus, Scientific Electronic Library Online (SciELO), MedicLatina, and the Cochrane Central Register of Controlled Trials, with no time restrictions. Results: Thirty-nine studies conducted between 2003 and 2023 met the inclusion criteria. These studies covered a range of technological innovations developed specifically for hemodialysis treatment, including virtual reality, exergames, websites, and mobile applications. These technologies were designed with diverse objectives: to facilitate physical exercise, optimize dietary and medication management, improve disease adherence and management, and promote self-efficacy and self-care in patients. Conclusions: The review revealed a wide range of technological resources available to hemodialysis patients. These digital solutions show great potential to transform care by promoting more engaged and personalized health practices. Although this study did not directly assess the impact of these technologies, it provides a solid foundation for future investigations that can explore in-depth how such innovations contribute to effective disease management and improvement in clinical outcomes. Full article

Residual kidney function (RKF) plays a crucial role in improving outcomes for dialysis patients. Enhanced middle molecular clearance has been proposed as one of the several benefits of preserved RKF. Most patients who start dialysis retain some residual kidney function, providing a rationale for using incremental dialysis. RKF has been associated with mortality benefit in both peritoneal dialysis (PD) and hemodialysis (HD). It also influences technique longevity and lowers peritonitis rates in patients on PD. In both dialysis modalities, RKF improves volume management and blood pressure control. Additional potential benefits include reduced dietary restrictions, improved nutritional status, better quality of life (QOL), reduced erythropoiesis-stimulating agent (ESA) requirements, lower inflammatory marker levels, and improved bone health. RKF is less frequently measured in HD patients primarily due to the lack of standardized methods and logistical challenges. Several equations for estimating RKF have been proposed, but none are widely adopted in clinical use. Historically, HD was believed to cause a rapid loss of RKF; however, more recent data have challenged this view. Future research should focus on identifying factors that affect RKF, standardizing measurement methods, and developing strategies for preservation. Efforts to preserve RKF should be made for all dialysis patients, regardless of modality. Full article

Several studies have shown an association of fibroblast growth factor-23 (FGF-23), 25-hydroxyvitamin D (25(OH)D), and asymmetric dimethylarginine (ADMA) with the pathogenesis of albuminuria. However, the direct relationship of these biomarkers with albuminuria independent of other risk factors for chronic kidney disease (CKD) remains controversial. FGF-23 and ADMA levels were associated with the progression of CKD, with a cutoff value of ≥100 RU/mL for FGF-23 and 0.69 μmol/L for ADMA. Background/Objectives: To analyze the correlation between FGF-23, 25(OH)D, and ADMA levels and albuminuria. Methods: This was an observational analytic study with a cross-sectional design conducted in patients with CKD with various disease stages (non-dialysis). The output is albuminuria. Statistical analysis was performed using multivariate logistic regression analysis. Results: This study included 107 patients with CKD stages 2–5 with an average age of 57.32 years. Their average FGF-23, vitamin D, ADMA, and uACR levels were 197.75 RU/mL, 23.44 ng/mL, 0.719 µmol/L, and 940 mg/g, respectively. FGF-23 was weakly correlated with uACR (r = 0.252; p = 0.009). Vitamin D was weakly correlated with uACR (r = −0.375; p = 0.000). ADMA was strongly correlated with uACR (r = 0.687; p = 0.00). Multivariate analysis showed an association of ADMA ≥ 0.69 µmol/L (p = 0.000) with albuminuria ≥ 300 mg/g (p = 0.003). Conclusions: ADMA was correlated with the presence of macroalbuminuria, strongly indicating its role in the progression of CKD. Full article

End-stage chronic kidney disease remains a global challenge, with dialysis and transplantation offering only partial or limited solutions. Recent advances in bioengineering have introduced modular strategies that aim to restore kidney function not by replicating the entire organ, but by rebuilding it one segment at a time. Platforms such as kidney organoids, implantable bioartificial kidneys, 3D-bioprinted tissues, and decellularized scaffolds each target specific nephron functions, from filtration to endocrine signaling. This Perspective examines how these technologies can be integrated into interoperable systems that reflect the nephron’s native structure and functional complexity. We assess translational readiness across key benchmarks, including vascular integration, hormonal responsiveness, immune compatibility, and implantability, and discuss the ethical, regulatory, and design considerations that will shape their clinical future. Collectively, these modular strategies offer a pathway toward more personalized, scalable, and physiologically relevant approaches to kidney replacement. Full article