Background and hypothesis:Equations estimating glomerular filtration rate (GFR) based on creatinine and/or cystatin C incorporate demographic variables such as age and sex. However, clinical determinants may lead to substantial bias in GFR estimation. We aimed to identify clinical factors associated with biased GFR estimation with the Modification of Diet in Renal Disease, Chronic Kidney Disease-Epidemiology Collaboration, and European Kidney Function Consortium equations. Methods:In this retrospective cross-sectional study, we included patients referred for GFR measurement from March 2008 to February 2024 in the Physiology unit of Bichat Hospital, Paris, France. GFR was measured as the urinary clearance of a radio-isotopic tracer and the error of estimated GFR (eGFR), was expressed as log(eGFR/measured GFR) and analyzed with linear regression models. Results:Among 3838 patients (mean age 51 ± 15 years, mean measured GFR 59 ± 26 ml/min/1.73 m²), several clinical variables were associated with significant estimation error in the multivariable analysis. For all creatinine-based equations, underestimation occurred with HIV infection, high BMI, loop diuretics, and cotrimoxazole use, while overestimation occurred with younger age, female sex, lower BMI, history of kidney transplantation, and cirrhosis. For all cystatin C-based equations, underestimation was associated with older age, HIV infection, corticosteroid use, and history of kidney transplantation; overestimation was associated with younger age, female sex, and sub-Saharan African origin. Equations using both biomarkers performed better in conditions affecting each biomarker in opposite directions. By cumulating several conditions, bias can vary from -50% to more than +50% leading to a completely erroneous GFR estimation. Conclusion:Common clinical features are independently associated with biased GFR estimation that can be of high clinical relevance, especially when cumulated. Our results guide GFR evaluation by giving a qualitative and most importantly quantitative estimation of the expected bias depending on individual patient profile and comorbidities.
Background and aims:Acute kidney injury (AKI) is increasingly recognized as a long-term risk factor for chronic kidney disease and cardiovascular disease (CVD). However, it remains uncertain which patients with AKI are at greatest CVD risk. We performed a systematic review and meta-analysis to quantify CVD risks post-AKI and to determine whether these risks differ by AKI severity, duration, and clinical setting. Methods:PubMed and Embase were systematically searched for studies comparing individuals with and without AKI and reporting major adverse cardiovascular events (MACE) or individual outcomes such as myocardial infarction (MI), stroke, heart failure (HF), or cardiovascular mortality. Follow-up was at least 1 year. Relative risks (RRs) were pooled in meta-analyses using random-effect models. Subgroup and metaregression analyses were used to explore heterogeneity across patient and AKI characteristics, and clinical settings. Results:We included 54 studies comprising 1261 090 individuals, of whom 290 648 experienced AKI. Meta-analyses showed that AKI was associated with an RR of 1.97 [95% confidence interval (CI) 1.67-2.27] for MACE (13.9% overall incidence), 1.64 [95% CI 1.38-1.89] for MI (3.5% overall incidence), 1.36 [95% CI 1.13-1.59] for stroke (1.7% overall incidence), 1.92 [95% CI 1.67-2.16] for HF (3.5% overall incidence), and 1.86 [95% CI 1.59-2.13] for cardiovascular mortality (9.4% overall incidence), compared to patients without AKI. Elevated risks were observed across all AKI stages and durations and in patients across all studied clinical settings, including noncardiac care. The highest RRs were shown for more severe AKI stages and longer AKI durations. Older age and lower baseline estimated glomerular filtration rate were associated with even higher risk of MACE compared to patients without AKI. Conclusions:AKI is followed by an increase in CVD risk, even after AKI with low severity. These findings highlight AKI as a clinically relevant CVD risk marker and support the need for targeted post-AKI care management to prevent future cardiovascular events.
Background:Fibrillary glomerulonephritis (FGN) is a very rare glomerular disease characterized by non-branching fibril deposition and DNAJB9 positivity. We aimed to analyze our cohort to better elucidate clinicopathologic features and outcomes of patients with FGN. Methods:Adult patients diagnosed with FGN between 2007 and 2025 and showing DNAJB9 positivity were included. Primary composite outcome was defined as doubling of serum creatinine from baseline, undergoing dialysis or transplantation, development of stage 5 chronic kidney disease or death. Results:Fifty native kidney biopsies of 44 patients were examined; 17 belonged to males (34%). Most common patterns of injury were mesangial (24, 48%) and membranoproliferative (16, 32%). Mean fibril diameter was 13.7 ± 2.5 nm. Eight biopsies (16%) showed atypical variants such as congophilia, light-chain restriction on frozen immunoflorescence and immunoglobulin G (IgG) negativity. Out of 44 patients, 25 (56.8%) had adequate follow-up data; the mean age was 48.4 ± 12.7 years. Over a median of 27 (7.5-89.5) months, 13 patients (52%) reached primary composite outcome, 10 (40%) underwent kidney replacement therapies and 3 (12%) died. Multivariate logistic regression models showed hemoglobin predicted the primary outcome whereas histopathological features or immunosuppressive use did not. Baseline serum C3 was associated with primary outcome (area under the curve 0.759, 0.525-0.916) with 134 mg/dL as cut-off value. The kidney survival rate was 30.8% in patients with serum C3 ≤134 mg/dL and 87.5% in serum C3 >134 mg/dL. However, multivariate regression models failed to show a clear association between serum C3 levels and primary outcome. Conclusions:Atypical histopathological features are not uncommon in FGN, complicating the differential diagnosis. Prognosis is still quite dismal despite immunosuppressive use. Lower baseline hemoglobin might indicate poorer outcomes.
Background:Up to 8% of renal tumors have a monogenic cause, yet hereditary renal cell carcinoma (hRCC) syndromes such as von Hippel-Lindau (VHL), Tuberous Sclerosis Complex (TSC), Birt-Hogg-Dubé (BHD), and Hereditary Leiomyomatosis and Renal Cell Cancer remain underdiagnosed. Early diagnosis is critical for patient management, genetic counseling, and family screening. We developed and prospectively validated a structured risk assessment tool (hRCC score) for identifying patients at risk of hereditary renal tumors. Methods:A prospective single-center study was conducted at the University Hospital Cologne (2020-2022) including 200 patients with histologically confirmed renal tumors. The hRCC score incorporated age at diagnosis, multifocal/bilateral disease, histology, extrarenal manifestations, and family history. Patients with a score ≥1.5 were referred for genetic testing using a multiplex MLPA (Multiplex Ligand-dependent Probe Amplification)-based panel including TSC, MET, VHL, FH, SDH-A-D, and FLCN. Results:Of 195 eligible patients, 34.4% (n = 67) had a high-risk hRCC score (≥1.5). Overall, 71 (36.4%) underwent genetic testing; a pathogenic or likely pathogenic variant was detected in 50.7% of tested patients, corresponding to 18.5% of the total cohort. The most common diagnoses were TSC (58.3%), VHL (16.7%), and BHD (11.1%). Confirmed hereditary cases had significantly higher mean hRCC scores (4.67 vs 0.48, P < .0001). Extrarenal manifestations and bilateral or multifocal disease were the strongest predictors. The cutoff of 1.5 yielded 97.2% sensitivity and 79.8% specificity. Conclusions:The hRCC score is an effective clinical screening tool for detecting patients at risk for hereditary renal tumors, demonstrating high diagnostic yield and supporting targeted referral for genetic evaluation.
Background:Anemia is a common complication in chronic kidney disease (CKD), especially in hemodialysis patients, causing fatigue and reduced quality of life. Standard treatments involve iron and erythropoietin (EPO). Ascorbic acid (vitamin C) supports iron metabolism by converting ferric to ferrous iron and enhancing absorption and mobilization. This systematic review and meta-analysis evaluated the effectiveness of ascorbic acid in improving hematologic and iron parameters in adult anemic patients undergoing maintenance hemodialysis. Methods:Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a comprehensive search was performed in PubMed, EMBASE, Cochrane, Scopus, Web of Science, CINAHL and Google Scholar through May 2025. Only randomized controlled trials and crossover studies assessing ascorbic acid in adult anemic hemodialysis patients were included. The protocol was registered in the International Prospective Register of Systematic Review (PROSPERO) (CRD420251056337). Primary outcomes were hemoglobin (Hb), ferritin, serum iron, transferrin saturation (TSAT) and total iron-binding capacity (TIBC). Meta-analyses used DerSimonian-Laird random-effects models. Results:Of 479 screened articles, 14 studies were included. Ascorbic acid supplementation was associated with a modest but significant increase in Hb [mean difference (MD) 0.94 g/dL; 95% confidence interval (CI) 0.57 to 1.31; P < .01; I² = 87.2%] and TSAT (MD 6.86%; 95% CI 1.93 to 11.78; P < .01; I² = 96.7%). Ferritin levels showed a slight but significant reduction (MD -65.00 ng/mL; 95% CI -117.20 to -12.80; P = .01; I² = 57.2%), along with a decrease in TIBC (MD -22.54 µg/dL; 95% CI -42.37 to -2.72; P = .03; I² = 76.1%). EPO requirements expressed as units/kg/week were significantly reduced (MD -21.29; 95% CI -27.73 to -14.84; P < .01; I² = 0.0%). No significant changes were observed in serum iron levels or EPO dosage expressed as IU/week. Conclusion:Ascorbic acid supplementation may confer modest hematologic benefits in hemodialysis patients with improvements in Hb, TSAT and iron utilization, and a small reduction in weight-adjusted erythropoiesis-stimulating agent dose. However, the certainty of evidence is low, and long-term safety and patient-centered outcomes remain unestablished.
Objective:Sodium-glucose cotransporter 2 inhibitors (SGLT2i) improve cardiovascular outcomes in chronic kidney disease, but their effects in peritoneal dialysis (PD) patients who are infection prone, remain unclear. Study design:The study design of this research is target-trial emulation using the global federated electronic health record database. Adults (18-90 years) with type 2 diabetes on PD for ≥3 months between February 2015 and June 2025 were included. Propensity score matching balanced SGLT2i and nonuser. Primary outcomes were all-cause mortality, severe sepsis, sepsis, and pneumonia; secondary outcomes included major adverse cardiovascular events (MACE) and PD-associated peritonitis. Results:Among 29 529 eligible patients, 2815 (9.5%) received SGLT2i. After matching, 2749 patients were retained in each group with well-balanced baseline characteristics. Over a median follow-up of 0.79 years, SGLT2i users were associated with lower risks of all-cause mortality [adjusted hazard ratio (aHR) 0.818], severe sepsis (aHR 0.802), sepsis (aHR 0.661), pneumonia (aHR 0.664), and PD-associated peritonitis (aHR 0.340). MACE was not significantly different (aHR 0.798). SGLT2i was not associated with increased diabetic ketoacidosis, hypoglycemia, genital infection, volume depletion, or amputation. Conclusions:In this large real-world PD cohort with type 2 diabetes, SGLT2i use was associated with lower risks of death and major infections without safety concerns, supporting potential benefit pending randomized trial confirmation.
Background:B-cell depletion with anti-CD20 agents has been evaluated as part of induction immunosuppression (IS) in lupus nephritis (LN). Data on its long-term efficacy for maintenance of remission remains limited. Methods:Retrospective case series evaluating outcomes in patients with relapsing, refractory and severe LN at diagnosis who received rituximab (RTX)-induced continuous B-cell depletion for both induction and maintenance at Massachusetts General Hospital from 2008 to 2023. Results:A total of 26 patients with active LN were included. Eighty-eight percent (23/26) had class III/IV ± V on kidney biopsy; 12% (3/26) had pure class V LN. Median follow-up (from first to last RTX) was 32 months [interquartile range (IQR) 14-68]; median cumulative dose of RTX was 10 g (IQR 6-17). At RTX initiation, all patients received prednisone and oral IS with an intention to taper off oral agents in 12 months. Eighty-one percent (21/26) achieved at least partial remission. Median prednisone dose decreased from 30 to 5 mg/day at 6 months (P < .01). Fifty-eight percent (15/26) of patients at 12 months and 79% (11/14) at 24 months were on RTX monotherapy. Six renal relapses occurred in five patients with median time-to-first relapse of 43 months (range 24-142); all episodes but one were preceded by B-cell repopulation. Five patients developed end-stage kidney disease; all had creatinine >2 mg/dL at RTX initiation. Thirty-one percent (8/26) experienced severe infections requiring hospitalization. No deaths occurred. Conclusion:Long-term continuous B-cell depletion may be an effective treatment strategy in patients with LN who have failed prior IS or with severe disease at diagnosis. Future controlled studies are needed to further evaluate this approach as the backbone therapy in LN.
Background:Kidney transplant recipients remain at high cardiovascular risk despite improved graft and patient survival. Physical inactivity, weight gain, and suboptimal dietary habits are common after transplantation and may contribute to this burden. Methods:The KT-LIFESTYLE trial is a pragmatic, multicentre, prospective, open-label randomized controlled study designed to evaluate whether a structured lifestyle intervention can reduce cardiovascular risk in kidney transplant recipients. Participants will be randomized 1:1 to individualized exercise prescription plus tailored dietary counselling or standard lifestyle advice. The intervention combines multidisciplinary assessment, individualized exercise programming, motivational interviewing, and nutritional counselling integrated into routine transplant follow-up. The primary endpoint is the change in 10-year cardiovascular risk, assessed by the Framingham score over 36 months. Secondary outcomes include renal function estimated by Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) 2021 equation estimated glomerular filtration rate, body composition, inflammatory markers, gut microbiota composition, health-related quality of life, adherence to physical activity and dietary counselling, hospital admissions, major adverse cardiovascular events, and all-cause mortality. Conclusions:KT-LIFESTYLE aims to provide evidence on the effectiveness and feasibility of a long-term lifestyle intervention after kidney transplantation. The study may also clarify the mechanisms through which lifestyle modification influences cardiovascular risk, inflammation, body composition, and gut microbiota in this population.Clinical trials registration number: NCT06806670.
Background To address the changing demographic and increasing frailty and comorbidity of people referred to renal services, we initiated novel, routine, embedded, consultant-led, focused geriatric assessment of a selected group of patients in our Renal Low Clearance Clinic, seeking effects on treatment decision-making, patient outcomes and undertaking a health economic analysis.Methods A total of 133 patients fulfilling study-developed referral criteria received focused geriatric assessment. Short-term results (treatment decisions) of all 133 patients, plus long-term (survival) data for the first 77 patients for whom we have 3 years' follow-up are presented. Health economic analysis compared the cost of employing the Geriatrician versus avoiding unnecessary/futile dialysis access (arteriovenous fistula) creation based on historic rates in our own unit.Results Starting in 2018, 77 patients were reviewed before suspension enforced by the COVID-19 pandemic in March 2020, and a further 56 since resumption between July 2021 and January 2023 [mean age 78 (range 62-92) years; 70% male]. Following focused geriatric assessment, the number of patients undecided about treatment changed from 43 to 3; those choosing dialysis reduced from 80 to 44 and those choosing conservative management (CM) increased from 10 to 74. The number of advance care plans made increased from 0 to 77, and recorded resuscitation decisions from 6 to 42. Thirty-six months after focused geriatric assessment, the survival rate in the group choosing dialysis was 50% and in the CM group was 33%; most deaths were unrelated to renal failure and there was a trend towards clinical frailty scores impacting outcome more than treatment choice. Health economic analysis demonstrated that the costs of providing this review were more than offset by reductions in unnecessary/futile fistula formation.Conclusions Routine, protocol-supported focused geriatric assessment in a tertiary referral renal service appears cost-effective and is associated with improved dialysis decision-making, advance care-planning and resuscitation decision-making.
Background:Patients with chronic kidney disease (CKD) exhibit an extremely high prevalence of coronary artery disease. Clonal hematopoiesis of indeterminate potential (CHIP) and CKD share pathological features such as aging, chronic inflammation, and accelerated atherosclerosis. Their coexistence can synergistically exacerbate vascular damage and increase coronary risk. However, the association between CHIP and specific coronary lesions in CKD populations has not been reported, and its relationship with cardiovascular events remains controversial. Methods:A total of 151 patients with CKD who underwent coronary angiography were prospectively included. To evaluate the status of CHIP, we utilized high-depth targeted sequencing, and measured serum inflammatory factor levels. Furthermore, we systematically followed up these patients to document the occurrence of adverse clinical events. Results:CHIP was identified in 65 (43.0%) CKD patients, with the carrier rate steadily rising with age. The CHIP subjects had higher rates of left circumflex stenosis, three-vessel disease, and Gensini scores than non-CHIP patients (all P < .05). After adjusting for relevant clinical risk factors, the presence of CHIP continued to show an independent association with three-vessel disease [odds ratio 2.26, 95% confidence interval (CI) 1.07-4.75; P = .032]. The survival analysis indicated that CHIP, along with non-DNMT3A mutations and a larger clone size (variant allele frequency ≥0.10), correlated with the primary composite endpoint (P < .01). Even after controlling for various clinical variables, the CHIP status still demonstrated an independent association with the primary composite endpoint (hazard ratio 2.02, 95% CI 1.11-3.67; P = .022). Conclusions:CHIP was associated with the severity of coronary lesions and unfavorable clinical outcomes in patients with CKD.
Background:Chronic kidney disease (CKD) imposes physical, psychological, and social burdens. While self-management is essential in CKD, many existing interventions lack theoretical grounding and patient co-design. The Kidney Health 4 Life (KH4L) program was developed to address these gaps via a modular, online, peer-supported self-management intervention. Methods:This open-label, single-blind, parallel group randomized controlled trial recruited Australian adults with CKD. Participants were randomized 1:1 to receive the KH4L intervention or standard care. The intervention consisted of six self-paced online modules, health coaching, and peer support. The primary outcome was self-management capability. Secondary outcomes included self-efficacy, knowledge, and psychological wellbeing. Outcomes were assessed at baseline, 6 weeks, and 18 weeks post baseline. Linear mixed models were utilized for quantitative outcomes and qualitative feedback was analysed using simple thematic analysis. Results:Of 394 enrolled, 383 were included in the analysis. There was no significant change in the primary outcome of total self-management scores. However, the intervention group showed significant improvements in problem solving (P = .009), self-efficacy (P = .048), and CKD-related knowledge (P = .017). Mixed results were seen with the psychological outcomes with depression scores improving more in the control group (P = .043) and no improvement in anxiety. Subgroup analyses indicated greater benefits for those accessing CKD-specific modules compared to dialysis-specific content, possibly due to smaller sample size. Conclusions:KH4L improved some self-management outcomes in people with CKD. The findings highlight the value of tailored, stage-specific digital interventions and suggest theory-informed programs can improve self-efficacy and knowledge. Further research is needed to optimize engagement and ascertain long-term impacts.
Background Autosomal dominant polycystic kidney disease (ADPKD) is the most common inherited kidney disorder and a major contributor to kidney failure worldwide. However, the impact of ADPKD on health-related quality of life (HRQoL) across chronic kidney disease (CKD) stages and kidney replacement therapies (KRT) is poorly understood. This study aimed to synthesize existing evidence on HRQoL as measured by patient-reported outcome measures (PROMs) in people with ADPKD, stratified by disease stage and KRT modality.Methods A systematic review was conducted using five databases (Medline, Embase, PsycINFO, CINAHL, Web of Science) and Google Scholar to identify studies published between January 2014 and October 2024. Eligible studies reported HRQoL in individuals with ADPKD using generic, kidney-specific, or ADPKD-specific PROMs Study populations were stratified by CKD stage and KRT modality. Scores were adjusted using country-specific population norms matched for age and sex, with population multipliers calculated to express patient-reported outcomes (PROs) as a proportion of the reference population.Results Six studies assessed PROs using the Short-Form-36/12 survey. Physical health worsened with CKD progression, corresponding to lower values relative to matched population norms. Mental health showed smaller deviations from population norms. Dialysis patients had the lowest physical health multipliers, while transplant recipients had better physical health it did not improve to early-stage CKD levels. Two studies using the EuroQual 5-Dimension tool had fewer notable differences between CKD stages. Kidney disease and ADPKD-specific scores showed more pronounced declines across CKD stages than generic PROMs, suggesting greater sensitivity to stage-related changes.Conclusions This review demonstrates that PROs for individuals with ADPKD are lower in later CKD stages compared with earlier stages, with the largest effect on physical health. Mental health scores were less affected suggesting adaptation over time. Our findings suggest generic PROMs may underestimate the impact of ADPKD compared to disease-specific tools.
Background The Kidney Failure Risk Equation (KFRE) is a widely used tool to estimate the 2- and 5-year risk of progression to kidney failure in patients with chronic kidney disease (CKD). The choice of estimated glomerular filtration rate (eGFR) equation and biomarker may influence its prognostic performance. We aimed at comparing the predictive performance of the KFRE when used with different eGFR equations [CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) vs. EKFC (European Kidney Function Consortium)] and biomarkers (creatinine, cystatin C, or both) in a large French CKD cohort. Methods We analyzed 2168 patients with CKD stages G3-G5 from the prospective Chronic Kidney Disease Renal Epidemiology and Information Network cohort. Eight eGFR equations were evaluated in combination with both the four- and eight-variable KFRE models. Prognostic performance was assessed at 2 and 5 years using the time-dependent area under the receiver operating characteristic curve (AUROC), Brier scores, calibration plots, and decision curve analysis. Subgroup analyses were performed by age and sex. Results Discrimination was uniformly high (AUROC > 0.89), but calibration patterns and decision curve analyses differed between equations. The creatinine-based CKD-EPI 2009 equation demonstrated robust and consistent performance across models and time horizons. EKFC equations-especially when using creatinine alone-showed slightly improved clinical utility at the 40% decision threshold. Cystatin C-based equations did not improve KFRE predictions compared to creatinine-based ones. Conclusions In this French CKD cohort, both CKD-EPI 2009 and EKFC creatinine-based equations supported accurate risk prediction using the KFRE. These findings support the use of EKFC in European clinical practice and reinforce the importance of aligning eGFR equations with the population context when applying prognostic models. [GRAPHICS]
Background:Skeletal muscle wasting due to aging, acute illness, and chronic disease is associated with adverse outcomes including mortality, frailty, and multi-morbidity. We investigated the relationship of creatinine muscle index (CMI), a serum biological signature of muscle mass, in UK Biobank participants with gold standard muscle measurement and adverse outcomes. Method:We compared CMI with Magnetic Resonance Imaging (MRI) measured muscle mass in 33 799 participants using linear regression. We then assessed CMI's ability to discriminate low muscle mass (≤2.5 SD below the mean). In the full UK Biobank cohort (n = 450 812), we utilized Cox-proportional hazards models to investigate associations between CMI with mortality, frailty and comorbidity. Results:CMI demonstrated moderate to good linear correlation with gold-standard MRI muscle mass measurements [R males: 0.68 (0.60-0.76); females: 0.65 (0.56-0.73)], after accounting for data imbalance. CMI discriminated muscle mass ≤2.5 standard deviations from the mean, with an area under the curve of 0.80 (95% CI:0.75-0.86) in males and 0.84 (95% CI:0.78-0.89) in females. CMI consistently decreased with increasing age, frailty and comorbidity. Over an 8-year follow-up, lower CMI was associated with higher morality: adjusted hazard ratio for the 25th vs 75th CMI centiles were 0.61 (95% CI: 0.58-0.66) in males and 0.72 (95% CI: 0.66-0.78) in females. Conclusions:In over 450 000 UK Biobank participants, low CMI was significantly associated with baseline comorbidity, frailty and survival on follow-up (independent of age, sex, and comorbidity). This study supports CMI as a potential biological signature for skeletal muscle wasting in clinical and research settings.
Introduction:Sickle cell disease (SCD) carries a high risk of chronic kidney disease, necessitating accurate glomerular filtration rate (GFR) monitoring. This study evaluated the performance of creatinine-based (eGFRcrea), cystatin C-based (eGFRcys), and combined (eGFRcrea+cys) equations against directly measured GFR (mGFR). Methods:Clinically stable Congolese adults with SCD were recruited in 13 medical centers from Kinshasa. GFR was measured using iohexol plasma clearance. We compared the bias, precision, and accuracy of Chronic Kidney Disease Epidemiology (CKD-EPI) and European Kidney Function Consortium (EKFC) equations. Results:Among 207 patients included (24 [20;31] years and 58% of women), mean mGFR was 129 ± 38 ml/min/1.73 m2 with 41% of patients hyperfiltrating (mGFR >135 ml/min/1.73 m2). Among eGFRcrea equations, CKD-EPI was superior in hyperfiltrating patients, while EKFC performed better in normofiltrating patients. However, all eGFRcrea equations were suboptimal with only around 80% of estimated GFR (eGFR) results within 30% of mGFR. eGFRcys equations showed severe underestimation and poor accuracy. eGFRcrea+cys equations offered no clear added value. Conclusion:All eGFR equations were suboptimal in this young SCD population, with cystatin C performing particularly poorly. Given the limitations of current biomarkers, measuring GFR by a reference method remains the recommended standard. However, given the cost and logistical challenges of mGFR in low-income settings, relying on creatinine-based EKFC equation for normofiltrating patients and on creatinine based Chronic Kidney Disease Epidemiology Equation (CKD-EPIcrea) for hyperfiltrants appears to be a more feasible and pragmatic approach.
Background Citrate is frequently applied in kidney stone formers (KSFs), yet long-term safety data are lacking. We evaluated the effects of prolonged citrate therapy on metabolic health, urinary risk factors and stone recurrence in high-risk KSFs in Switzerland.Methods The Swiss Kidney Stone Cohort (SKSC) is a multicenter study including KSFs and controls. Blood and urine analyses were performed at baseline and longitudinally over 2 years in KSFs, with subsequent telephone follow-up for stone events. A total of 654 KSFs (110 with citrate, 544 without) and 207 controls were included. Outcomes comprised anthropometric indices (body mass index, body roundness index, waist-to-hip ratio), metabolic parameters, urinary relative supersaturation ratios (RSR), stone recurrence and stone composition.Results No evidence for between-group differences in 1- to 2-year changes in anthropometric, glucose or lipid outcomes was identified. Anthropometric indices remained stable in both groups. HbA1c rose in non-citrate (NC) but not in citrate (C) group patients. High-density lipoprotein (HDL) cholesterol increased in both groups, while low-density lipoprotein (LDL) decreased only in C patients. Propensity score-matched analyses showed no between-group differences in 1- to 2-year changes in anthropometric, glucose or lipid outcomes, with only modest within-group changes in the C group (hemoglobin A1c, HDL- and LDL-cholesterol). Urine analyses showed a greater reduction in RSR for brushite among NC patients, whereas C patients had a stronger decline in uric acid (UA) RSR. Calcium oxalate RSR decreased similarly across groups. Stone recurrence was more frequent in C patients, with 43% versus 30% of NC patients changing stone type during follow-up. No shift toward calcium phosphate stones was observed in citrate users.Conclusions Long-term citrate therapy appeared metabolically safe, and selectively reduced UA supersaturation, while non-treated patients showed a more pronounced decrease for brushite. Higher recurrence among treated patients may reflect different baseline risk. A prospective trial is warranted to clarify additive benefits of citrate beyond dietary-guided counseling.
Background:Rapidly progressive glomerulonephritis (RPGN) is a prototypical nephrology emergency requiring rapid recognition and treatment. Despite the promise of immersive virtual reality (VR), nephrology lacks VR-based emergency training. Building on our initial VR simulation, we evaluated the feasibility, acceptance and effectiveness of large-scale curricular implementation. Methods:On the STEP-VR platform, we embedded a custom three-dimensional RPGN case as a mandatory internal medicine module for fifth-year students. Knowledge was measured pre- and post-training. Instructional design effects were tested by comparing tutor-guided versus tutorless sessions and by examining a pretesting effect. Acceptance and simulation sickness were surveyed. Results:A total of 408 students participated (mean age 25.4 years, 59.6% female). In the pretest-posttest cohort, knowledge increased after training (overall relative gain +101%; P < .001, Cohen's d = 1.30). After adjustment, tutor-guided sessions yielded higher posttest scores than tutorless sessions (+5.5 points on a 0-49 scale). Between-cohort posttest comparisons suggested an exploratory forward-testing effect (P ≤ .01). Improvements spanned RPGN recognition, urine sediment examination, laboratory and histology interpretation and hyperkalaemia management. Acceptance was high and simulation sickness was infrequent. Conclusions:This study demonstrates the successful large-scale curricular integration of VR-based training for nephrology emergencies, confirming its feasibility and educational effectiveness. By sustainably embedding immersive VR into medical education, this approach bridges a long-standing training gap in nephrology, enhances clinical competencies, increases student engagement with the specialty and may contribute to long-term efforts to address the nephrology workforce shortage.
Background:Despite the heavy symptom burden and progressive nature of non-malignant kidney diseases, access to palliative care services may be limited. We evaluated access to specialist palliative care (SPC), and its effect on health care utilization among patients with non-malignant and malignant kidney disease during their final year of life. Methods:This retrospective cohort study examined causes of death among ≥18-year-old individuals in Finland in 2019 using the National Causes of Death Register. Data on access to SPC, emergency department contacts, and hospitalizations were collected from the National Care Register for the final year of life. Results:Five hundred eighty-five patients had non-malignant kidney disease (54.8% females, mean age 84 years at the time of death) and 706 patients had malignant kidney disease (35.3%, 77.2 years, respectively). Of the patients with non-malignant kidney disease, only 54 (9.1%) had access to SPC services compared to 195 (27.6%) with malignant kidney disease (P < .001). Within patients with malignant kidney disease, those who had access to SPC died at home more often (10.6% vs. 5.9%; P = .049), had fewer emergency department contacts (19.7% vs. 32.9%), and had a lower proportion of hospitalizations (16.4% vs. 37.2%; P < .001) and readmissions to secondary care (4.6% vs. 10.6%; P = .025) when compared to those without SPC access. No difference with regard to SPC access was seen among patients with non-malignant kidney disease. Conclusion:While SPC demonstrated benefits in malignant kidney disease patients' health care utilization, access was markedly limited for patients with non-malignant conditions, underscoring the need for improvements in service provision.
Background:Global inequities in dialysis and kidney transplantation among immigrant populations remain poorly characterized. At the crossroads of European migration, Brussels' Brugmann University Hospital provides an opportunity to examine outcomes in one of the most ethnically diverse dialysis cohorts in Western Europe, including a substantial proportion of undocumented immigrants. Methods:We conducted a retrospective 15-year analysis of 497 incident dialysis patients (2010-2024), categorized as Western European (WE, 32%), Eastern European (EE, 21%), North African (NA, 26%), or Sub-Saharan African (SSA, 21%). Kaplan-Meier and Cox models assessed survival, while Fine-Gray competing-risk analyses evaluated transplant access. Results:Despite language barriers, housing instability, and the frequent lack of legal residency, equitable dialysis delivery was achieved, with peritoneal dialysis implemented in 25%-30% of patients, including asylum seekers and undocumented immigrants. Median pre-dialysis nephrology follow-up was longer in WE (8 months) than in other groups (<1 month). Age (HR = 1.73) and comorbidity (HR = 1.62) independently predicted mortality, whereas ethnicity (HR = 0.77) reflected demographic rather than systemic disparities. Competing-risk analysis showed the highest transplant access among SSA patients (35%-40% at 10 years; sub-distribution hazard ratios) = 2.13, P = .004), confirming that allocation was driven by clinical suitability rather than origin. Conclusion:In this uniquely multicultural setting, equitable access to dialysis and transplantation can be achieved across all immigrant groups, even among undocumented patients, but only when a dedicated hospital, social, and administrative structure is deliberately built to make it possible. The success of peritoneal dialysis among asylum seekers and the high transplant rates in SSA patients reflect an integrated system where equity is actively implemented, not assumed. These findings demonstrate that outcomes depend on clinical and organizational excellence rather than geography or migration status, offering a model for inclusive nephrology care in increasingly diverse European societies.
Background:Percutaneous kidney allograft biopsy is essential for evaluating graft dysfunction, but post-procedural bleeding remains the most frequent complication, particularly among recipients with impaired renal function. Desmopressin (DDAVP) is often used prophylactically to reduce bleeding risk, yet its efficacy in the transplant setting remains uncertain. Methods:We conducted a single-center, double-blind, randomized, placebo-controlled trial at a quaternary transplant center in Brazil. Adult kidney transplant recipients with estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m² undergoing allograft biopsy were randomized (1:1) to receive intravenous desmopressin (0.3 μg/kg) or placebo before biopsy. All procedures were ultrasound-guided and performed by experienced nephrologists. The primary endpoint was any biopsy-related bleeding complication. Secondary outcomes included major bleeding (transfusion, embolization, nephrectomy, or death), minor bleeding (macroscopic hematuria, hematoma, hemoglobin drop >20%), and hyponatremia. Results:A total of 96 biopsies were randomized (48 per group). Baseline demographics, clinical, and procedural characteristics were well balanced. Any biopsy-related bleeding complication occurred in 29.1% of procedures overall, without a significant difference between the desmopressin and placebo groups (35.4% vs. 22.9%, P = .262). One major bleeding event occurred in the desmopressin group (2.1%) and none in the placebo group (P = 1.00). Minor bleeding was more frequent with desmopressin-treated patients (35.4% vs. 22.9%, P = .262) than in placebo, but without statistical significance. In adjusted analyses using penalized logistic regression, desmopressin was not associated with reduced bleeding risk [OR 1.61 (95%CI 0.63-4.20)]. By contrast, surveillance biopsies were independently associated with a markedly higher risk of minor bleeding compared with indication biopsies (adjusted OR 10.2; 95%CI 1.8-68.7). No cases of hyponatremia were documented, and adverse events were rare and balanced across groups. Conclusions:In this trial of high-risk kidney transplant recipients, prophylactic desmopressin did not reduce biopsy-related bleeding complications compared with placebo. Routine pre-biopsy administration is not supported when biopsies are performed under optimal technical conditions and patient preparation.
