Search Results (409)

The prevalence of early non-infectious peritoneal dialysis (PD) catheter complications makes performing PD challenging for patients and difficult for the healthcare team to manage. Three common patient scenarios are presented: catheter flow dysfunction, peri-catheter leaks, and catheter-related abdominal pain. Practice recommendations are integrated into each scenario and tailored to clinical presentation, patient need, and resource availability. The importance of including patients in the decision-making process is emphasized, and examples of how contextual factors modify the proposed approach to complications are given. Full article

Background/Objectives: Iron deficiency without anaemia (IDNA) is common in non-dialysis-dependent chronic kidney disease (CKD) and contributes to fatigue, reduced exercise tolerance, and impaired quality of life (QoL). While intravenous (IV) iron replacement is known to benefit anaemic patients, its role in IDNA remains uncertain. This study aimed to evaluate the impact of ferric derisomaltose (FDI) on patient-reported QoL outcomes in CKD patients with IDNA. Methods: This was a post hoc analysis of the double-blind, multicentre Iron and the Heart randomised controlled trial. Fifty-four participants with IDNA (ferritin < 100 µg/L or transferrin saturation < 20% and haemoglobin 110–150 g/L) and CKD stages G3b–G5 were randomised 1:1 to receive either 1000 mg FDI (n = 26) or placebo (n = 28). An additional 10 iron-replete CKD patients served as controls. SF-36v2 QoL surveys were collected at baseline, 1 month, and 3 months. Results: SF-36v2 scores declined across all domains, but deterioration was consistently milder in the FDI group. Role physical declined by 3% in the FDI group versus 12% with placebo and 4% in controls. Bodily pain improved by 2.8% with FDI but worsened by 1.5% in the placebo group. Mental health improved by 3.4 points with FDI and declined by 2.7 points in the placebo group, creating a 6.1-point separation. While differences did not reach statistical significance, likely due to small sample size, the consistent trends favour FDI. Conclusions: IV iron may attenuate QoL decline in non-dialysis-dependent CKD patients with IDNA. These findings support the need for larger, adequately powered trials to assess patient-centred outcomes in this population. Full article

Introduction/Objective: Peritonitis remains a serious complication in patients undergoing automated peritoneal dialysis (APD), requiring prompt and effective antibiotic administration. This study evaluated whether delivering antibiotics directly through APD bags is as effective as administering them via an additional manual daytime exchange. Methods: We conducted a randomized, single-blind, non-inferiority clinical trial involving patients diagnosed with peritonitis. Participants were randomly assigned to receive Ceftazidime and Vancomycin, either via APD bags or through a combined approach of continuous ambulatory peritoneal dialysis (CAPD) plus APD. A total of 64 patients (32 per group) were enrolled, with comparable baseline demographic and clinical profiles, including laboratory markers of infection severity and dialysis history. Results: Peritonitis resolved in 90.6% of the patients treated via APD bags and in 81.3% of those receiving antibiotics through manual exchange plus APD. Although this difference did not reach statistical significance ($p$ = 0.281), the observed absolute difference of 9.3% was well within the predefined non-inferiority margin of 30%, supporting the clinical non-inferiority of the APD-only method. The mean time to resolution was similar between groups ($p$ = 0.593). Post hoc power analyses indicated limited statistical power (18.5% for the resolution rate and 9.2% for time to resolution), suggesting that modest differences may not have been detectable given the sample size. Nevertheless, the high resolution rates observed in both groups reflect valid and encouraging clinical outcomes. Conclusion: Antibiotic administration via APD bags demonstrated comparable clinical effectiveness to the combined manual exchange plus APD method for treating peritonitis. Given its operational simplicity and favorable results, the APD-only strategy may offer a pragmatic alternative in routine care. Further studies with larger sample sizes are recommended to confirm these findings and optimize treatment protocols. Trial registration: NCT04077996. Funding source: None to declare. Full article

Chronic inflammation plays a central role in the progression and complications of chronic kidney disease (CKD). The nod-like receptor pyrin domain-containing 3 (NLRP3) inflammasome pathway has emerged as a crucial mediator of the inflammatory response in CKD. This cross-sectional study evaluated the expression of NLRP3 in patients with CKD undergoing different treatments. Blood samples were collected from 32 non-dialysis (ND) patients [63 (11.2) years, estimated glomerular filtration rate, 43.5 (22.0) mL/min, BMI, 29.5 (10.0) kg/m²)], 50 hemodialysis (HD) patients [48.5 (16.5) years, 60.5 (50) months on HD, BMI, 24.2 (4.9) kg/m²)], and 8 peritoneal dialysis (PD) patients [56.5 (8.5) years, 40.5 (41.2) months on PD, BMI, 28.8 (2.6) kg/m²)]. The mRNA expression level of NLRP3 was measured using real-time PCR. The cytokines and the malondialdehyde (MDA) levels were also assessed. The results indicated that the mRNA level of NLRP3 was significantly elevated in patients undergoing HD (1.23, IQR = 0.95) compared with that in non-dialysis patients (0.79, IQR = 0.35) and in patients undergoing PD (0.77, IQR = 0.38) after adjusting for confounding variables, including age, sex, BMI, and dialysis duration. Furthermore, the MDA levels were significantly higher in HD patients. NLRP3 is upregulated in HD patients, and the results suggested that the inflammasome may be associated with oxidative stress in patients with CKD. Full article

p-Cresyl sulfate (PCS), a gut-derived uremic toxin with proinflammatory and cytotoxic effects, has been implicated in cardiovascular injuries among patients with chronic kidney disease (CKD). Aortic stiffness (AS), assessed by carotid–femoral pulse wave velocity (cfPWV), is a recognized predictor of cardiovascular risk. This study investigated the association between serum PCS levels and AS in patients with nondialysis-dependent CKD. In total, 165 patients with nondialysis-dependent CKD were enrolled. Clinical data and fasting blood samples were collected. Arterial stiffness (AS) was assessed bilaterally by measuring carotid–femoral pulse wave velocity (cfPWV) on both the left and right sides. A value above 10 m/s was considered indicative of increased stiffness. Serum PCS levels were quantified using high-performance liquid chromatography–mass spectrometry. Fifty patients (30.3%) had AS. The AS group was significantly older and had higher diabetes prevalence, systolic blood pressure, fasting glucose, urinary protein-creatinine ratio, and PCS levels than the control group. In the multivariate analysis, both PCS (odds ratio [OR]: 1.097; 95% confidence interval [CI]: 1.024–1.175; p = 0.008) and age (OR: 1.057; 95% CI: 1.025–1.090; p < 0.001) were independently associated with AS. In conclusion, elevated serum PCS and older age were independently associated with AS. Thus, PCS is a potential early marker of vascular damage in CKD. Full article

The evidence regarding allopurinol’s effects on renal function among people with hyperuricemia and gout has been conflicting, though clinicians are often cautious about using allopurinol in chronic kidney disease (CKD). We sought to examine the relation between allopurinol use in those with gout and CKD and the risk of worsening renal function. We conducted a time-stratified propensity score (PS)-matched cohort study on the IQVIA Medical Research Data representative of the UK general population. Among participants 18–89 years old with gout and CKD 3–4 not on urate-lowering therapy within one year prior, we identified new users of allopurinol and matched them 1:1 with a non-user. We analyzed the relation between incident allopurinol use and the changes in the eGFR at one year of follow-up using linear regression adjusted for the potential confounders included in the PS model. We PS-matched 10,716 allopurinol initiators to 10,716 non-users, among whom 42% were female, the mean age was 74 years and 7% had CKD4. The progression to dialysis or kidney transplant was similar in both groups. The mean eGFR prior to the study entry was 48.4 mL/min among allopurinol initiators and 49.5 mL/min among non-users, while the last eGFR within one year was 49.4 and 49.7 mL/min, respectively. The allopurinol initiators had an adjusted mean increase in the eGFR of 0.81 mL/min (95% CI 0.57–1.05) greater than that of non-users. Among those with gout and CKD 3–4, allopurinol did not worsen renal function and may have slightly improved it, suggesting that allopurinol is not detrimental to patients with gout who have CKD. Full article

Background/Objectives: Low-density lipoprotein cholesterol (LDL-C) is a causal factor in the development of atherosclerosis and a predictor of cardiovascular disease. However, the association between LDL-C levels and cardiovascular outcomes in patients undergoing dialysis remains controversial, with current guidelines advising against initiating statin therapy in this population. This study investigated the relationship between LDL-C levels and cardiovascular outcomes in Korean adults undergoing dialysis, using nationwide data. Methods: A total of 21,692 patients with end-stage kidney disease undergoing dialysis between 2009 and 2017 were identified from the Korean National Health Insurance Service database. Statin non-users (primary cohort) and users (secondary cohort) comprised 15,414 and 6278 patients, respectively. LDL-C levels were categorized, and cardiovascular outcomes including composites of cardiovascular death, myocardial infarction, and ischemic stroke were analyzed. Results: Among statin non-users, LDL-C levels > 100 mg/dL were significantly associated with an increased risk of the composite outcome, in a dose-dependent manner, compared with LDL-C levels < 70 mg/dL. Specifically, participants with LDL-C levels ≥ 160 mg/dL demonstrated a 43% increased risk of the composite outcome and a 2.25-fold higher risk of myocardial infarction compared to those with LDL-C levels < 70 mg/dL. Among statin users, LDL-C levels > 130 mg/dL were associated with an increased risk of the composite outcome. Conclusions: This study highlights the significant association between elevated LDL-C levels and adverse cardiovascular outcomes in patients undergoing dialysis. These findings underscore the importance of close monitoring and proactive management of LDL-C levels in this high-risk population. Future research should focus on developing tailored lipid-lowering strategies to improve cardiovascular outcomes in these patients. Full article

Background and Objectives: The worldwide prevalence of chronic kidney disease (CKD) continues to increase, representing a major concern for public health systems. CKD is associated with gut microbiota dysbiosis, which may exacerbate disease progression by increasing the levels of uremic toxins, systemic inflammation, and oxidative stress. Modulation of the gut microbiota through biotic supplementation has been proposed as a potential therapeutic strategy to slow CKD progression and mitigate its complications. This study aimed to evaluate the effect of 10-month synbiotic supplementation on estimated glomerular filtration rate (eGFR), circulating concentrations of indoxyl sulfate (IS), p-cresyl sulfate (p-CS), interleukin-6 (IL-6), and malondialdehyde (MDA) in patients with stage IV–V CKD not receiving dialysis, in comparison to placebo. Materials and Methods: Fifty non-dialysis CKD IV–V patients were assigned (n = 25 each) via matched, non-randomized allocation (age, sex, and primary disease) to synbiotic or placebo. This single-blind, placebo-controlled trial blinded participants and laboratory personnel. The synbiotic group received daily capsules containing Lactobacillus acidophilus La-14 (2 × 10¹¹ CFU/g) + fructooligosaccharides; controls received identical placebo. Adherence was monitored monthly (pill counts, diaries), with < 80% over two visits resulting in withdrawal. The eGFR, IS, p-CS, IL-6, and MDA were measured at baseline and month 10. Results: Forty-two patients (21/arm) completed the study; eight withdrew (4 per arm). At 10 months, the change in eGFR was −1.2 ± 2.5 mL/min/1.73 m² (synbiotic) vs. −3.5 ± 3.0 mL/min/1.73 m² (placebo); between-group difference in change was 2.3 mL/min/1.73 m² (95% CI: 0.5–4.1; p = 0.014; adjusted p = 0.07). IS decreased by −15.4 ± 8.2 ng/L vs. −3.1 ± 6.5 ng/L; between-group difference in change was −12.3 ng/L (95% CI: −17.8 to −6.8; p < 0.001; adjusted p = 0.005). No significant differences were observed for p-CS, IL-6, or MDA after correction. Conclusions: Synbiotic supplementation over a 10-month period resulted in a trend toward decreased serum IS levels in patients with advanced CKD, suggesting potential benefits of microbiota-targeted therapies. However, no significant effects were observed on renal function, inflammatory, or oxidative stress markers. Further large-scale studies are warranted to confirm these findings and explore the long-term impact of synbiotics in CKD management. Full article

Background: Vascular access (VA) is one of the most critical procedures during dialysis for patients with end-stage renal disease (ESRD), as it influences morbidity, mortality, and quality of life. Methods: This cross-sectional study analyzed the vascular access epidemiology of patients undergoing chronic HD in 15 nephrology centers across Greece from 2013 to 2019. Data on VA type, demographic characteristics, fatigue severity, and quality of life were gathered from a sample of 373 patients. Results: The prevailing result of this study is that arteriovenous fistula (AVF) was the commonly practiced VA, and its associated survival outcomes were better when compared to arteriovenous grafts (AVGs) and central venous catheters (CVCs). Patients with AVFs had significantly longer survival times (median 165 months) compared to non-fistula access. Furthermore, the degree of fatigue and quality of life were also dependent on the type of VA used, with patients on AVF having lower fatigue levels and better quality of life. Age, gender, and an early nephrologist referral were noted to affect the selection and the rate of maturation of VA. Despite AVF being the preferred VA, late referrals and high initial reliance on CVCs remain challenges. Conclusions: This study underscores the need for early nephrological intervention, surveillance programs, and patient education to optimize vascular access outcomes. Future research should focus on national strategies to reduce CVC-related complications and improve long-term HD care in Greece. Full article

Chronic kidney disease-associated pruritus (CKD-aP) is a distressing symptom that affects both dialysis and non-dialysis patients, significantly impairing their quality of life. Despite its multifactorial pathophysiology, no gold-standard treatment has been established. This review explores various therapeutic options and evaluates their effectiveness based on recent clinical studies and meta-analyses. Therapies targeting novel mechanisms have evolved in recent years. Difelikefalin, a κ-opioid receptor agonist, represents a breakthrough in systemic treatment, demonstrating efficacy with a favorable safety profile. Another opioid-based therapy, nalfurafine, has shown notable symptom relief in multiple clinical studies, with a low risk of abuse. Sertraline, an antidepressant, offers another alternative, although its delayed onset remains a limitation. Nonpharmacologic approaches are also evolving. Phototherapy, particularly UV-B therapy, modulates the immune response, reduces inflammation, and effectively alleviates itching in hemodialysis patients. Personalized treatment strategies are crucial, as responses vary among patients. Further research, including comparative and long-term studies, is essential to refine treatment algorithms and improve patient outcomes. By integrating new pharmacologic and nonpharmacologic options, CKD-aP management is shifting toward a more tailored and effective approach that addresses the individual needs of each patient. Full article

Dietary management is a pillar of chronic kidney disease (CKD) treatment. While some rules are the same as dietary prescriptions for the general population and those suffering from other chronic diseases (energy intake, salt intake, avoidance of ultra-processed food and limited intake of animal fats), in non-dialysis-dependent patients living with CKD, the specific focus is on protein intake. Low-protein diets (LPDs) and supplemented very low protein diets (sVLPDs) have been successfully employed to decrease the symptoms of people living with non-dialysis-dependent CKD, delay the progression of the disease and retard the need for dialysis. Randomized clinical trials have yielded conflicting results on efficacy, resulting in conflicting guidelines. Concerns about the risk of malnutrition (specifically when the main source of proteins is plant-derived), electrolyte imbalances, and energy intake, and the idea that adherence is difficult, jeopardize the use and wide application of LPDs and sVLPDs. That dietary management focuses mainly on nutrients while dietary quality occupies second place is also an erroneous concept that requires discussion. In September 2023, a group of experts composed of nephrologists and dieticians gathered in Frankfurt, Germany, to try to reconcile the different guideline indications and address most of the common doubts of final dispatchers to increase the prescription of “renal diets” and improve people living with CKD’s adherence to them. Full article

Background: Acute phosphate nephropathy (APN) is an underrecognized cause of acute kidney injury (AKI), typically associated with the use of oral sodium phosphate (OSP)-based bowel preparations. It is characterized by calcium phosphate crystal deposition within the renal tubules and may result in permanent renal impairment. Despite known risks, phosphate-containing solutions are still widely used without sufficient risk stratification. Methods: We retrospectively evaluated 517 native kidney biopsies performed in our nephrology clinic between 2017 and 2022. Among these, 12 patients with unexplained AKI and recent colonoscopy history were identified. In nine cases, non-specific tubular deposits on routine staining prompted further histochemical analysis. All had a history of recent OSP-based bowel cleansing. The use of von Kossa staining confirmed calcium phosphate deposition, consistent with APN. Results: Out of 517 kidney biopsies performed during the study period, 9 patients were diagnosed with APN based on histopathological findings following recent colonoscopy and OSP-based bowel cleansing. The mean age was 58.7 years, and three were female. Hypertension was present in seven patients, diabetes mellitus in three, and epilepsy in two; one patient had no comorbidities. Baseline renal function was normal (mean serum creatinine 0.86 mg/dL) and increased to 1.76 mg/dL at three months post-exposure. All biopsies revealed tubulointerstitial calcium phosphate deposits and interstitial inflammation; mesangial hypercellularity was observed in five cases, tubular atrophy in three, and acute tubular necrosis in one. All samples stained positive with von Kossa staining. Over time, all patients developed chronic kidney disease, and one progressed to end-stage renal disease requiring dialysis. Conclusions: In patients presenting with unexplained AKI and recent OSP-based bowel preparation, APN should be considered in the differential diagnosis. When routine histology is inconclusive, definitive diagnosis may require special histochemical staining. Risk-based restrictions on phosphate-containing agents are warranted to reduce preventable kidney injury. Full article

Background: Oral frailty is a state between normal oral function and oral hypofunction. Oral frailty progresses to oral hypofunction and dysphagia, which leads to malnutrition, and then to physical frailty and sarcopenia. Oral frailty is reported to be associated with physical frailty and malnutrition in hemodialysis patients, but there have been no reports on peritoneal dialysis (PD) patients. Methods: This prospective cohort study investigated the associations of oral frailty with physical frailty, sarcopenia, and malnutrition in patients on PD. Patients were divided into an oral frailty group and a non-oral frailty group according to the Oral Frailty Index-8. Patients were assessed for physical frailty, sarcopenia, and malnutrition at baseline and 1 year later, and changes in each measure were compared between the two groups. Physical frailty was assessed using the Revised Japanese version of the Cardiovascular Health Study Criteria (Revised J-CHS) and the FRAIL scale. Sarcopenia was assessed using the diagnostic criteria reported by the Asian Working Group for Sarcopenia in 2019 (AWGS2019 criteria) and the Screening Tool for Sarcopenia Combined with Calf Circumference (SARC-CalF), skeletal muscle index (SMI), calf circumference (CC), grip strength, and gait speed. Nutritional status was assessed with the Short-Form Mini-Nutritional Assessment (MNA-SF), the Malnutrition Universal Screening Tool (MUST), the Global Leadership Initiative on Malnutrition (GLIM) criteria, weight, and body mass index (BMI). Results: Of the 58 eligible patients, 51 completed the study. The oral frailty group was significantly older and had slower gait speed, fewer teeth, higher intact parathyroid hormone, higher C-reactive protein, higher frequency of cardiovascular disease, and lower employment at baseline. The oral frailty group had significantly worse physical frailty (Revised J-CHS, p = 0.047; FRAIL scale, p = 0.012), sarcopenia (SMI, p = 0.018; CC, p = 0.002), and nutritional status (MNA-SF, p = 0.029; MUST, p = 0.005; GLIM criteria, p = 0.022; weight, p < 0.001; BMI, p < 0.001). However, there were no significant differences in the worsening of sarcopenia (AWGS2019 criteria, SARC-CalF, grip strength, and gait speed). Conclusions: Oral frailty in patients on PD was associated with the development and progression of physical frailty and malnutrition, and may be associated with the development and progression of sarcopenia. Full article

Indoxyl sulfate (IS), which is a protein-bound uremic toxin, is involved in vascular dysfunction and cardiovascular risk in subjects with chronic kidney disease (CKD). However, its role in peripheral arterial stiffness (PAS) remains unclear. This cross-sectional study evaluated the relationship between IS and PAS in patients diagnosed with CKD stages 3 through 5 who are not undergoing dialysis. Patients with CKD from a single center were enrolled. High-performance liquid chromatography analyzed the serum IS levels. PAS was evaluated using brachial–ankle pulse wave velocity (baPWV). IS was independently associated with PAS (odds ratio [OR]: 1.389 for 1 μg/mL increase in IS, 95% confidence interval [CI]: 1.086–1.775, p = 0.009) in a multivariable analysis after adjustment for age, hypertension, diabetes mellitus, blood pressure, lipid profiles, renal function, albumin, and proteinuria. Moreover, the mean baPWV (p = 0.010), left baPWV (p = 0.009), and right baPWV (p = 0.015) levels significantly correlated with the log-transformed IS (log-IS) levels. The area under the receiver operating characteristic curve for serum IS as a predictor of PAS was determined to be 0.667 (95% CI: 0.580−0.754; p = 0.0002). IS was associated with PAS in non-dialysis CKD stages 3–5, suggesting that IS may be a possible vascular risk marker. Future studies should address the nature of the relationship between IS and vascular dysfunction and assess therapeutic strategies to reduce IS. Full article

Kidney disease causes the retention of uremic metabolites in blood, which is associated with many comorbidities. Hemodialysis does not properly clear many metabolites, including large, middle-sized, and small protein-bound uremic toxins (PBUTs). Adsorption strategies for metabolite removal require the development of engineered adsorbents with tailored surfaces to increase the binding of desired metabolites. Albumin is uniquely positioned for modifying blood-contacting surfaces to absorb uremic metabolites, as it (i) minimizes non-specific protein adsorption and (ii) binds a range of molecules at Sudlow Sites I and II with different affinities. It is unknown if albumin-modified surfaces retain the adsorption qualities of solution-free albumin, namely, adsorption stability or specificity. Herein, albumin was covalently attached to iron oxide nanoparticles and characterized using multiple methods. Metabolite adsorption was conducted by incubating particles in a model solution of thirty-three uremic metabolites associated with kidney failure. Adsorption efficiency, selectivity, and stability were affected by albumin concentration and incubation time. Metabolite adsorption was found to change with time, and it was more effective on albumin-modified particles than unmodified controls. The findings outlined in this paper are crucial for the design of next-generation advanced blood-contacting materials to enhance dialysis and blood purification for patients with kidney disease. Full article