Kidney Dial., Volume 2, Issue 3 (September 2022) – 12 articles

Background. Secondary hyperparathyroidism (SHPT) is a major risk factor for cardiovascular events and all-cause mortality in hemodialysis (HD) patients. The purpose of our study was to evaluate the effects and tolerability of etelcalcetide in HD patients with SHPT. Methods. An observational study was conducted on 16 hemodialysis patients with SHPT treated with etelcalcetide. All patients were followed up for a duration of 6 months. The primary endpoints were the reduction in mean PTH ≥ 30% and ≥40% from baseline after 6 months of etelcalcetide. All patients were divided into two groups (group A versus group B) based on baseline serum PTH level prior to etelcalcetide: above and below the median serum PTH (1300 pg/mL), respectively. Results. After 6 months, a significant decrease in PTH levels was achieved by all patients receiving etelcalcetide (p = 0.015). Both primary endpoint of reduction in PTH ≥ 40% at 6 months (p = 0.01), and the secondary endpoint of reduction in median PTH values (p = 0.0001) and median percentage reduction in PTH values (p = 0.009) were significantly achieved in group A. In contrast, a greater decline of calcium (p = 0.028) and phosphorus was reached in group B than group A. Dialysis vintage ≥ 36 months, arteriovenous fistula (AVF)-based hemodialysis, post-diluition hemodiafiltration (HDF) method, and baseline values of PTH < 1300 pg/mL can positively influence the achievement of the endpoints. Furthermore, the baseline PTH < 1300 pg/mL, among these variables, was the only one showing statistically significant relevance (OR 2.28, 95% CI 1.32–3.96, p = 0.015). The history of cinacalcet use negatively correlated with the possibility to reach therapeutic targets with etelcalcetide (OR 0.47, 95% CI 0.26–0.85, p = 0.031). Treatment with etelcalcetide was well tolerated and no adverse effects were observed. Conclusions. In our study, patients with low baseline PTH levels showed a better response to etelcalcetide than patients with higher PTH levels. Consequently, the possibility to reach desirable therapeutic targets could depend on SHPT severity at the time of initiation of therapy. Full article

A discrepancy between serum concentrations of cystatin C (CysC) and creatinine (sCr) has been reported in patients with acute obstructive nephropathy. However, the usefulness of CysC for predicting the recovery of kidney function in patients with severe obstructive nephropathy remains unclear. We examined the predictability of the estimated glomerular filtration rate calculated with CysC or sCr (eGFRcys or eGFRcreat) for the post-treatment recovery of kidney function. We retrospectively collected patients with severe obstructive nephropathy (eGFRcreat < 30 mL/min/1.73 m²) whose baseline sCr and CysC were measured between 48 h before and 24 h after the release of urinary tract obstruction (UTO). The primary outcome was recovery from severe eGFRcreat depression (i.e., eGFRcreat ≥ 30 mL/min/1.73 m²) 7 days after the release of UTO. We calculated the area under the curve (AUC) of the receiver operating characteristic (ROC) curve for the relationship between eGFRcys or eGFRcreat and recovery. Thirty-four patients (20 males) with a median age of 76 years were eligible. We identified 20 recovery cases. The AUCs of the ROC curves (95% confidence interval) for eGFRcys and eGFRcreat were 0.81 (0.66–0.96) and 0.53 (0.32–0.73), respectively. These results imply cystatin C-based eGFR may help predict kidney prognosis in patients with severe obstructive nephropathy. Full article

Patients with type 2 diabetes (T2D) and end-stage kidney disease (ESKD) on renal replacement therapy represent a specific population with high morbidity and mortality, an increased risk of hypoglycemic episodes and large intra- and interdialysis glycemic variability. Antidiabetic treatment adjustment is therefore challenging, especially in insulin-treated patients. Continuous glucose monitoring (CGM) is increasingly proposed to T2D patients on hemodialysis (HD), although data regarding flash monitoring systems (FMSs) and real-time CGM (rtCGM) in HD patients are limited. Small CGM pilot studies of a short duration demonstrated improvements in glycemic control and decreased hypoglycemic events, despite a lower accuracy of CGM as compared to capillary blood glucose. Moreover, CGM–drug interactions with vitamin C, mannitol and paracetamol can occur in HD diabetic patients and need further study. Despite these shortcomings, professional CGM has the potential to become an integral part of glucose monitoring of HD patients treated with insulin. Personal CGM prescriptions can especially be useful in highly selected, motivated T2D HD patients on multiple daily insulin injections or experiencing frequent hypoglycemia with preserved diabetes self-management abilities or in whom diabetes is fully managed by medical providers. A close collaboration between the clinical staff working on HD units and diabetology teams, and ongoing patient education, are mandatory for optimal use of CGM. Full article

Anemia in chronic kidney disease (CKD) has become an important clinical issue with the increased prevalence of elderly patients living with CKD progressing to kidney failure. The causes of anemia in elderly individuals tend to be multifactorial, exacerbated by the physiological effects of aging, frailty and declining kidney function. Erythropoiesis-stimulating agents (ESAs) are the conventional therapeutic option for anemia in CKD. However, ESA hyporesponsiveness is a commonly observed issue in clinical practice and an issue that is more challenging to resolve in elderly patients living with frailty, kidney disease, and multi-morbidities. Following the emergence of oral hypoxia-induced factor prolyl-hydroxylase inhibitors (HIF-PHI) in recent years, there is discussion on whether it is a solution to the conundrum of ESA hyporesponsiveness, as HIF-PHI treats anemia via an alternative physiological pathway. There remains uncertainty on the suitability of HIF-PHI use in elderly patients, given a lack of data on its safety over long-term follow-up for the elderly population. Further study is needed to provide answers, considering the clinical significance of this issue within a public-health scale. Full article

TCC placement is a skilled procedure; one must be aware of possible complications, particularly those related to the positioning of catheters, which are vital for the proper functioning of catheters and hemodialysis procedure. It is also equally important to be familiar with the appropriate management if such complications are encountered. Full article

Globally, the incidence and prevalence of diabetes mellitus has risen dramatically, owing mainly to the increase in type 2 diabetes mellitus (T2DM). In 2021, 537 million people worldwide (11% of the global population) had diabetes, and this number is expected to increase to 783 million (12%) by 2045. The growing burden of T2DM is secondary to the pandemic of obesity, which in turn has been attributed to increased intake of processed food, reduced physical activity, and increased sedentary behaviour. This so-called western lifestyle is related with the global increase in urbanization and technological development. One of the most frequent and severe long-term complications of diabetes is diabetic kidney disease (DKD), defined as chronic kidney disease in a person with diabetes. Approximately 20–50% of patients with T2DM will ultimately develop DKD. Worldwide, DKD is the leading cause of chronic kidney disease and end-stage kidney disease, accounting for 50% of cases. In addition, DKD results in high cardiovascular morbidity and mortality, and decreases patients’ health-related quality of life. In this review we provide an update of the diagnosis, epidemiology, and causes of DKD. Full article

Previous findings assessing the relationship between high-density lipoprotein cholesterol (HDL-c) and kidney function have demonstrated contradictory results including positive, negative, and U-shaped relationships. Many prior studies in this area have been conducted in healthy populations, but few have considered the influence of metabolic health status. In the present study, a cross-sectional analysis was conducted using complex survey sample weighting in the assessment of 6455 subjects from the 2013–2018 National Health and Nutrition Examination Surveys (NHANES), representative of 94,993,502 United States citizens. Subjects were classified as metabolically healthy or unhealthy and linear regression analyses were performed to evaluate the influence of HDL-c on estimated glomerular filtration rate (eGFR). HDL-c was found to be negatively associated with eGFR in the metabolically healthy, unhealthy, and combined groups (B = −0.16, p < 0.0001, B = −0.21, p < 0.0001, and B = −0.05, p = 0.0211, respectively). This relationship persisted after adjustment for confounding variables (B = −0.24, p < 0.0001, B = −0.17, p < 0.001, and B = −0.18, p < 0.0001, respectively). The relationship between HDL-c and eGFR was found to be a negative linear association, rather than a U-shaped association, and it persisted in all models tested, despite statistical adjustment for confounding variables. After controlling the samples for outliers, the negative relationship between HDL-c and eGFR was attenuated in the healthy and total groups but remained significant in the MetS group, indicating a stronger relationship between HDL-c and eGFR in those with poorer health. Full article

Diabetic kidney disease (DKD) is a major public health problem and its incidence is rising. The disease course is unpredictable with classic biomarkers, and the search for new tools to predict adverse renal outcomes is ongoing. Renal magnetic resonance imaging (MRI) now enables the quantification of metabolic and microscopic properties of the kidneys such as single-kidney, cortical and medullary blood flow, and renal tissue oxygenation and fibrosis, without the use of contrast media. A rapidly increasing number of studies show that these techniques can identify early kidney damage in patients with DKD, and possibly predict renal outcome. This review provides an overview of the currently most frequently used techniques, a summary of the results of some recent studies, and our view on their potential applications, as well as the hurdles to be overcome for the integration of these techniques into the clinical care of patients with DKD. Full article

For over thirty-five years, available data suggested that therapeutic plasma exchange (TPE) was a useful treatment for patients with Rapidly Progressive Glomerulonephritis (RPGN) associated with ANCA Associated Vasculitis (AAV) and elevated creatinine levels. The publication of the PEXIVAS study has challenged this conclusion. This perspective will outline the history of this issue and present our assessment of the current status. Full article

Diabetic kidney disease (DKD) represents an important diabetes (DM) complication associated with significant impacts on morbidity, mortality, and quality of life. Recent evidence from cardiovascular and kidney outcome trials has dramatically impacted the standard of care for patients with DKD. While agents from the glucagon-like peptide-1 (GLP-1) receptor agonist class are known for their atherosclerotic cardiovascular disease (ASCVD) benefits, growing mechanistic and clinical evidence supports the benefit of GLP-1 receptor agonist therapy on progression of DKD. GLP-1 receptor activation is associated with anti-inflammatory and antifibrotic effects in the kidney, providing a plausible mechanism for kidney protection. Based on currently available clinical trial evidence, guidelines recommend the use of GLP-1 receptor agonists to mitigate ASCVD risk in patients with type 2 diabetes (T2D). Furthermore, based on secondary outcome data for kidney disease, GLP-1 receptor agonists are recommended as an option to mitigate kidney and ASCVD risk in patients with T2D and DKD who require intensification of glycemic control or for those who cannot take a sodium-glucose cotransporter-2 (SGLT2) inhibitor due to side effects or advanced stage DKD. Ongoing dedicated kidney disease outcome trials will further inform the role of GLP-1 receptor agonists in DKD management. This review discusses current considerations for GLP-1 receptor agonist use in patients with T2D and DKD. Full article

Worsening renal function is associated with poor outcomes in heart failure and often accompanies the initiation and up-titration of guidelines-directed heart failure therapy. This narrative review summarizes current evidence on immediate and long-term effects of pharmacological or device-based treatment in heart failure patients with reduced or preserved left ventricular ejection fraction. Full article