Pakistan has more than 241 million people [1]. But there isn’t a complete registry to show how many have chronic kidney disease (CKD). In 2024, only 28 centers shared their data, so the actual number of cases is probably higher [2]. Some studies estimate that about 24% to 25% of Pakistanis have CKD [3,4]. Based on these estimates, around 58-61 million Pakistanis have CKD. Treating CKD is very costly. Given the fragile economy, this is a major public health problem. Most people can’t get hemodialysis or peritoneal dialysis. Kidney transplants usually help people with CKD to live longer. Sporadic live kidney transplantation does happen in Pakistan. On the contrary, organ donation after death doesn’t happen much in Pakistan. As a result, deceased kidney transplantation is negligible in the country. Pakistan puts just about 1% of its GDP into health care [5]. That means treatments like dialysis aren’t fully covered, and patients usually have to pay the costs themselves. Most big hospitals only do dialysis for emergencies. Very few centers provide long-term maintenance dialysis. In 2024–2025, the average person made around $1,824, but a year of dialysis can cost $13,510 [6,7]. Around 61% of people live in rural areas, where dialysis is even harder to access [8]. Even when people can get it, it’s rarely free. Kidney transplants help people live longer and can really improve their quality of life [8,9]. The initial cost of transplant is high, but over time, it is lower than that of regular dialysis [10]. The first kidney transplant in Pakistan happened back in 1979, and since then, transplants from living donors have continued [11]. But it’s still very rare to get a kidney from a deceased donor. Kidneys donated after brain death (DBD) or donation after cardiac death (DCD) provide better survival than dialysis [12]. DBD is common in many countries, and DCD is also used in several places [13]. Due to advancements in pharmacotherapy and perfusion techniques, donated organs from deceased donors last longer than before [14]. For example, in the United States, a kidney from a deceased donor now lasts about 12 years, compared to just 8 years in the 1990s [15].

End-stage kidney disease (ESKD) remains a growing public health concern in Brunei Darussalam, where the incidence and prevalence of kidney replacement therapy (KRT) are among the highest globally. While dialysis and kidney transplantation (KTX) extend survival, the health-related quality of life (HRQoL) and biochemical outcomes among patients across different modalities remain insufficiently explored. This study examines the interplay between sociodemographic and biochemical factors and their associations with HRQoL among patients undergoing hemodialysis (HD), peritoneal dialysis (PD), or KTX. A cross-sectional study was conducted among 574 adult patients receiving HD, PD, or KTX from government healthcare facilities across Brunei. Data on sociodemographic characteristics, biochemical profiles, and HRQoL were collected between May and September 2024. HRQoL was assessed using the SF-12 questionnaire, generating Physical Health Score (Phs) and Mental Health Score (Mhs). Linear regression analyses were employed to examine factors associated with HRQoL. Of the participants, 77

Both traditional statistics, such as the logistic regression (LR) model, and machine learning (ML) have strengths and limitations for predicting outcomes after kidney transplantation. The LR model is simple, interpretable, and reliable with small datasets. ML can capture complex, nonlinear patterns and manage many variables, but it needs larger, high-quality datasets to reach its full potential. In the recent issue of World Journal of Nephrology, Salgado et al compared six ML models with the LR model using donor, transplant, and recipient data from 523 deceased-donor kidney transplants. Surprisingly, ML models only slightly outperformed the LR model, and overall predictive performance remained modest, especially for identifying patients who developed delayed graft function. These results emphasize that dataset size, completeness, and relevant clinical variables may be more important than algorithm complexity. Future work should focus on improving data quality and developing models that are both accurate and clinically interpretable.

Emerging data on finerenone have drawn significant interest from nephrologists and cardiologists for its clinical potential in patient management. Its nonsteroidal structure, greater receptor selectivity, and reduced risk of hyperkalemia make it a distinctive choice for clinicians. Mineralocorticoid receptors (MRs) are expressed in the collecting ducts, endothelial and vascular smooth muscle cells of the interlobar arteries, as well as in podocytes, mesangial cells, and renal fibroblasts. These receptors are also present in cardiovascular and inflammatory cells. MR activation contributes to ischemia-reperfusion injury (IRI) and mediates calcineurin inhibitor (CNI) toxicity, proteinuria, and fibrosis in both the cardiovascular system and kidneys. Blocking MR activation with finerenone may exert therapeutic effects in renal allografts by mitigating IRI, preventing CNI toxicity, reducing proteinuria and renal fibrosis, and lowering the risk of renal and cardiovascular events. Preclinical and clinical studies in the general population with diabetes have demonstrated that finerenone effectively reduces proteinuria and improves renal and cardiovascular outcomes. However, clinical evidence in kidney transplant recipients remains extremely limited, and the efficacy and safety of finerenone in this population are yet to be established. To date, no clinical trials specifically investigating finerenone in kidney transplantation have been published, with only the EFFEKTOR trial currently underway. This review discusses the mechanistic rationale, extrapolates evidence from nontransplant populations, identifies key knowledge gaps, and proposes future research directions to evaluate the safety and efficacy of finerenone in kidney transplant recipients.

BACKGROUND:Brunei Darussalam currently lacks a deceased donor kidney transplant (DDKT) program, and its establishment in a small population poses challenges related to limited expertise and community misconceptions. Healthcare workers (HCWs), as the operational backbone of any transplant service, are central to translating policy into practice and guiding patient understanding. Assessing their perceptions is essential for gauging system readiness and informing strategies for future program development. AIM:To explore HCWs' views on initiating a DDKT program, with specific focus on knowledge of kidney disease and attitudes toward deceased organ donation, opt-in donor card policy and transplant commercialization. METHODS:This was a questionnaire-based knowledge, attitude and practice study conducted at the main tertiary hospital in Brunei Darussalam. Statistical analyses included bivariate tests for categorical variables and multivariable logistic regression to identify factors associated with supportive or non-supportive attitudes towards DDKT. RESULTS:A total of 370 HCWs participated in the study, with a female predominance (76%), comprising 58 doctors, 271 nurses, and 41 allied health professionals. Overall, 61% of respondents demonstrated high knowledge, while 39% had low knowledge. Regarding attitudes toward DDKT, 44% agreed, 12% disagreed, and 45% remained neutral. An opt-in donor card system was favored by 54%, while 35% were neutral and 11% disagreed. Attitudes towards transplant commercialization showed little variation, with 21% expressing acceptance, 45% neutrality, and 33% disagreement. Islamic religion, Malay ethnicity, nursing profession, lower knowledge level, female sex, and unawareness of fatwa were significantly associated with disagreement towards both DDKT and the donor card system (all P < 0.05). In multivariable logistic regression analysis, profession [adjusted odds ratio (aOR) = 4.54], religion (aOR = 7.34), education level (aOR = 4.11) and knowledge status (aOR = 1.88) remained independently associated with disapproval of DDKT. CONCLUSION:Among HCWs in Brunei Darussalam, support for a DDKT program outweighs opposition, although a sizeable proportion remain undecided. Notably, some view commercialized transplantation as a potential means to address donor shortages, signaling ethical and policy concerns. These findings underscore the need to address knowledge gaps, enhance educational exposure, and clarify contextual issues to inform the development of a national DDKT program.

BACKGROUND:End-stage kidney disease (ESKD) requires lifelong kidney replacement therapy (KRT), which significantly influences patients' quality of life (QoL). Primary KRT modalities include hemodialysis (HD), peritoneal dialysis (PD), and kidney transplant (KTX), each with varying impacts on QoL and clinical outcomes. Comparative data regarding these modalities in the local context, is limited. OBJECTIVES:This study aims to evaluate and compare the QoL and biochemical profiles of patients undergoing different KRT modalities in Brunei Darussalam. METHODS:A cross-sectional study was conducted in 2024 among 574 patients receiving HD, PD, or KTX across all government dialysis centers in Brunei. QoL was assessed using the validated SF-12 questionnaire, and biochemical parameters were collected from Brunei Darussalam Healthcare Information and Management System (BruHIMS). Sociodemographic and clinical data were used to profile and subgroups analysis. RESULTS:KTX patients reported the highest QoL scores and most favorable biochemical profiles, reinforcing transplantation as the optimal modality when available. Among dialysis patients, PD was associated with higher physical health scores than HD, suggesting better QoL. KTX patients were generally younger, with higher educational and employment levels. Significant differences in biochemical parameters such as hemoglobin, albumin, creatinine, urea, phosphate, and cholesterol were observed across modalities, indicating modality-specific clinical impacts. CONCLUSION:The findings suggest that PD may be associated with slightly better QoL outcomes compared to HD. However, these differences were not statistically significant and should be interpreted with caution, particularly given the potential for residual confounding inherent in observational study designs. Future research should focus on examining the long-term QoL trajectories among PD patients and identifying strategies to optimize its clinical benefits in the management of ESKD in Brunei.

BACKGROUND:End-stage kidney failure (ESKF) requires kidney replacement therapy (KRT), which has a significant effect on the quality of life (QoL) of patients. Globally, well-established treatment options for ESKF include HD, PD, and kidney transplantation. Each has a unique effect on a patient's QoL in terms of their physical, mental, and social health. The objective of this study was to evaluate and compare the QoL of patients undergoing PD and HD by utilizing the 36-item Short Form Health Survey (SF-36), EuroQoL-5-dimension (EQ-5D), and WHOQOL-BREF questionnaires. METHODS:We performed a comprehensive review and meta-analysis by identifying relevant research through the use of ScienceDirect, CINAHL, MEDLINE, and Google Scholar. These studies examined patients with ESKF who were undergoing either HD or PD and reported changes in QoL and biochemical characteristics. If heterogeneity was present, we calculated and pooled the standardized mean differences (SMDs) in QoL among modalities via a random effects model. RESULTS:This analysis included twenty-five (25) studies that examined the QoL and biochemical characteristics of a total of 5,440 participants. Among these participants, 3465 (63.75%) were receiving HD, and 1975 (36.25%) were receiving PD. The QoL instruments assess a variety of effects. However, these studies demonstrate that PD consistently performs better than HD in multiple assessment components, including for burdens of kidney disease, general health, mental health, and emotional. Nevertheless, there was no significant difference in the QoL scores regarding cognitive ability, energy levels, physical health, patient satisfaction, psychology, social interaction, emotional well-being, sexual functioning, or sleeping patterns between these modalities. CONCLUSION:The study's findings show that patients with PD have a higher QoL in comparison to those with HD. Despite reports of enhanced QoL among PD patients, their global prevalence remains relatively low. Therefore, healthcare professionals should prioritize the development and implementation of strategies for ESKF patients, considering PD as the primary treatment. The results suggest a trend favoring PD over HD in various aspects of QOL. However, the significant heterogeneity and the lower number of PD patients require careful interpretation of these findings.

Brunei Darussalam, a small Southeast Asian nation, faces a unique healthcare challenge with one of the world's highest incidence and prevalence of kidney replacement therapy. This report highlights the remarkable success of Brunei in increasing the utilization of peritoneal dialysis (PD) to address this challenge. As of August 2023, Brunei's PD penetrance rate stands at 16%, a significant leap from 9.7% just three years ago. This is comparable to many other high-income countries. The key to this success lies in a series of governmental support strategies that fostered rapid PD growth. These strategies include the establishment of a dedicated task force, securing dedicated operating theater slots, collaboration with surgery and anesthesia departments, nephrologist training, a dedicated surgeon for complex cases, outsourcing to private hospitals, prioritizing nursing staff, structured patient training programs, patient advocacy and established clinical protocols. These collaborative efforts, along with a patient-centric approach, have not only reduced PD catheter insertion waiting times but also empowered patients to voice their preferences in shared decisions. Brunei's journey serves as an inspiring example for other nations seeking to proliferate their PD services.

HLA-C, HLA-DP and HLA-DQ are thought to be benign due to low expression and few initial negative studies. Historically, most allocation programs used HLA-A, HLA-B and HLA-DR antigens for matching. With the advent and use of single-bead antigen assays, more was learned about donor-specific antibodies (DSAs) against these antigens. Interest in these antigens and antibodies grew when cases of acute antibody-mediated rejection (AMR), mixed rejections, chronic AMR, and reduced graft survival were reported with DSAs against these antigens. Although the deleterious effects of these DSAs are more pronounced in retransplants, harmful effects have also been observed in first-time recipients. DSAs against each of these antigens can trigger rejection alone. Their combination with DSAs against HLA-A, HLA-B and HLA-DR can cause more damage. It has been shown that strategies that reduce mismatches for these antigen lead to fewer rejections and better graft survival. There is a need for greater consensus on the universal typing of these antigens prior to transplantation for better patient and graft outcomes. This review focuses on the interaction of these antigens with lymphocytes and killer immunoglobulin receptors, arguments for not typing them, detailed analyses of the literature about their harmful effects, potential strategies moving forward, and recommendations for the future.

Renal allograft rejection and its detection are challenging problems for transplant clinicians. Transplant physicians rely on serum creatinine, estimated glomerular filtration rate, proteinuria, donor-specific antibodies, and graft biopsy to detect rejection. The sensitivity and specificity in these blood and urine tests are low, and the invasiveness of graft biopsy has led transplant clinicians to seek alternative diagnostic tools. Cell-free DNA (cfDNA) is a fragment of DNA released from cell death due to necrosis and apoptosis. Donor-derived cfDNA (dd-cfDNA) has been proposed as a potential non-invasive biomarker for detecting rejection. However, one must interpret it cautiously in conditions such as ischemia-reperfusion injury, delayed graft function, BK virus nephropathy, post-kidney biopsy, and dual kidney transplantation, which may cause dd-cfDNA elevation. There is a lack of standardized cutoff values for diagnosing various types of rejections. Low specificity, higher cost, and lack of universal availability are the multiple obstacles to using this tool. There is a need to establish clinical guidelines for its future utility in early rejection detection, graft surveillance, and tailoring of immunosuppression.

Continuous glucose monitoring (CGM) is used more frequently among patients with chronic kidney disease (CKD), including those undergoing haemodialysis and peritoneal dialysis. However, there is a lack of information and evidence regarding CGM use in kidney transplantation (KT). Dysglycaemia is commonly observed in the transplant setting; often complicated by impaired kidney function with fluctuating glomerular filtration rates and competing influences of diabetogenic immunosuppressants, perioperative surgical stress and transplant-related complications. This narrative review, the first of its kind, examines the utility, accuracy, efficacy and clinical outcomes of CGM in KT patients. It also addresses specific transplant-related issues that may necessitate future CGM usage and highlights knowledge gaps to inform future research directions.

BACKGROUND:Brugada syndrome (BS) is a rare disorder affecting approximately 5 in every 10000 people. Reports of kidney donation in individuals with BS are exceptionally uncommon. CASE SUMMARY:The decision to permit live kidney donation places significant responsibility on clinicians. Donors must adapt to life with a single kidney. While the risk of developing chronic kidney disease post-donation is minimal, it remains higher than in matched healthy individuals. Additionally, the theoretical risk of electrolyte imbalances in kidney donors with BS may have important clinical implications. We present a case of successful kidney donation by a donor with an incidental diagnosis of a sporadic case of BS type 1. An extensive electrophysiological evaluation was conducted to assess the risk of arrhythmia to approval for donation. Anesthetic management was meticulously planned, and the donor was monitored postoperatively in a coronary care unit for 48 hours. This case underscores the ethical considerations and the multidisciplinary approach necessary to ensure donor safety. CONCLUSION:Kidney donation in individuals with BS requires careful evaluation to mitigate the risk of fatal arrhythmias during surgical and anesthetic stress. With comprehensive preoperative assessment and vigilant perioperative management, kidney donation can be performed safely.

Deceased donor kidney transplantation (DDKT) is common in high income Western countries with high transplantation rates. However, the utilization of deceased organs is suboptimal in Asia, due to a multitude of factors. Coherent policies are integral to the development of DDKT programs and deterrence of commercialization, but most are still at an infancy and formative stage in Asia. This review article identifies the glass ceiling effects of social, cultural, religious, political, and technical factors hampering the progress of DDKT in Asia. Additionally, it reviews the history of policy development in different countries and describes their idiosyncratic barriers and challenges. Lastly, it discusses innovative policy measures that can be undertaken to proliferate DDKT practice and curtail commercialization. The long-term ideal is to achieve regional equity and self-sufficiency, through a shared ethos of social and ethical responsibility that transcends and resonates with the different segments of the Asian community.

Brunei Darussalam, a small nation in Southeast Asia with a population of just under half a million people, grapples with one of the world's highest incidences and prevalences of end-stage kidney disease (ESKD) and need for kidney replacement therapy (KRT). The profound challenges posed by the COVID-19 pandemic in 2021 continued to impact the local healthcare system in 2022. In response, Project One was initiated under the leadership of Brunei's Ministry of Health, with the goal of elevating ESKD care and promoting home-based KRT.

There is shortage of organs, including kidneys, worldwide. Along with deceased kidney transplantation, there is a significant rise in live kidney donation. The prevalence of prediabetes (PD), including impaired fasting glucose and impaired glucose tolerance, is on the rise across the globe. Transplant teams frequently come across prediabetic kidney donors for evaluation. Prediabetics are at risk of diabetes, chronic kidney disease, cardiovascular events, stroke, neuropathy, retinopathy, dementia, depression and nonalcoholic liver disease along with increased risk of all-cause mortality. Unfortunately, most of the studies done in prediabetic kidney donors are retrospective in nature and have a short follow up period. There is lack of prospective long-term studies to know about the real risk of complications after donation. Furthermore, there are variations in recommendations from various guidelines across the globe for donations in prediabetics, leading to more confusion among clinicians. This increases the responsibility of transplant teams to take appropriate decisions in the best interest of both donors and recipients. This review focuses on pathophysiological changes of PD in kidneys, potential complications of PD, other risk factors for development of type 2 diabetes, a review of guidelines for kidney donation, the potential role of diabetes risk score and calculator in kidney donors and the way forward for the evaluation and selection of prediabetic kidney donors.

Objective: Coronavirus disease (COVID-19) vaccinations have been shown to prevent infection with efficacies ranging from 50% to 95%. This study assesses the impact of vaccination on the clinical severity of COVID-19 during the second wave in Brunei Darussalam in 2021, which was due to the Delta variant. Methods: Patients included in this study were randomly selected from those who were admitted with COVID-19 to the National Isolation Centre between 7 August and 6 October 2021. Cases were categorized as asymptomatic, mild (symptomatic without pneumonia), moderate (pneumonia), severe (needing supplemental oxygen therapy) or critical (needing mechanical ventilation) but for statistical analysis purposes were dichotomized into asymptomatic/mild or moderate/severe/critical cases. Univariate and multivariable analyses were conducted to identify risk factors associated with moderate/severe/critical disease. Propensity score-matched analysis was also performed to evaluate the impact of vaccination on disease severity. Results: The study cohort of 788 cases (mean age: 42.1 + 14.6 years; 400 males) comprised 471 (59.8%) asymptomatic/mild and 317 (40.2%) moderate/severe/critical cases. Multivariable logistic regression analysis showed older age group (>45 years), diabetes mellitus, overweight/obesity and vaccination status to be associated with increased severity of disease. In propensity score-matched analysis, the relative risk of developing moderate/severe/critical COVID-19 for fully vaccinated (two doses) and partially vaccinated (one dose) cases was 0.33 (95% confidence interval [CI]: 0.16–0.69) and 0.62 (95% CI: 0.46–0.82), respectively, compared with a control group of non-vaccinated cases. The corresponding relative risk reduction (RRR) values were 66.5% and 38.4%, respectively. Vaccination was also protective against moderate/severe/critical disease in a subgroup of overweight/obese patients (RRR: 37.2%, P = 0.007). Discussion: Among those who contracted COVID-19, older age, having diabetes, being overweight/obese and being unvaccinated were significant risk factors for moderate/severe/critical disease. Vaccination, even partial, was protective against moderate/severe/critical disease.

AIM:This cross-sectional survey aimed to determine the prevalence of Interventional Nephrology (IN) practice amongst nephrologists in the Asia-Pacific Region (APR), specifically related to dialysis access (DA).METHODS:The Association of VA and intervenTionAl Renal physicians (AVATAR) Foundation from India conducted a multinational online survey amongst nephrologists from the Asia-Pacific to determine the practice of IN in the planning, creation, and management of dialysis access. The treatment modalities, manpower and equipment availability, monthly cost of treatment, specifics of dialysis access interventions, and challenges in the training and practice of IN by nephrologists were included in the survey.RESULTS:Twenty-one countries from the APR participated in the survey. Nephrologists from 18 (85.7%) countries reported performing at least one of the basic dialysis access-related IN procedures, primarily the placement of non-tunnelled central catheters (n-TCC; 71.5%). Only 10 countries (47.6%) reported having an average of <4% of nephrologists performing any of the advanced IN access procedures, the most common being the placement of a peritoneal dialysis (PD) catheter (20%). Lack of formal training (57.14%), time (42.8%), incentive (38%), institutional support (38%), medico-legal protection (28.6%), and prohibitive cost (23.8%) were the main challenges to practice IN. The primary obstacles to implementing the IN training were a lack of funding and skilled personnel.CONCLUSION:The practice of dialysis access-related IN in APR is inadequate, mostly due to a lack of training, backup support, and economic constraints, whereas training in access-related IN is constrained by a lack of a skilled workforce and finances.

Key Points Peritoneoscopic and laparoscopic peritoneal dialysis catheter insertions are complementary to each other, and each has its niche in a successful peritoneal dialysis program. Future studies need to use standardized definitions to enable comparisons across jurisdictions, and this study is the first to do so. Background Brunei Darussalam introduced peritoneoscopic insertion of peritoneal dialysis catheter (PDC) as a new method in 2014. The aim of this study was to compare outcomes of PDC insertion technique in the country, using proposed standardized definitions of outcomes. Methods This study used retrospective analysis of all PDCs inserted from January 1, 2015, to December 31, 2020, in the country. Outcomes of both peritoneoscopic and laparoscopic insertion methods were analyzed. Four main categories of outcomes were assessed—( 1 ) operative-related outcomes, ( 2 ) infective outcomes, ( 3 ) mechanical outcomes, and ( 4 ) time on peritoneal dialysis (PD) therapy. Results During the study period, 145 PDCs were inserted: 49 (33.8%) were by peritoneoscopy and 96 (66.2%) by laparoscopy. The median time on PD therapy was 54.2 months. Those with a higher body mass index and history of previous abdominal or pelvic surgery were more likely to undergo laparoscopic method. There was no significant difference in overall infective and mechanical outcomes between the two methods. There was however significantly more postoperative pain observed in the peritoneoscopic group than in the laparoscopic group (8.2% versus 1.0%, P = 0.045). During the study period, there were 49 dropouts to hemodialysis, about half were due to infection. However, there was no statistically significant difference observed in time on PD therapy between the two groups (hazard ratio 0.87 in laparoscopic group compared with peritoneoscopic group, 95% confidence interval, 0.49 to 1.54; P =0.636). Conclusions Peritoneoscopic and laparoscopic PD catheter insertions are both complementary to each other in our local setting. This study has enabled us to scrutinize our PD program, regarding our PDC insertion experience, with the aim to sustain PD growth in the country.

We read with interest the article by Kim et al.1 on the long-term control of diabetes mellitus (DM) after visiting a tertiary university hospital. In this study, patients were categorized into 4 groups based on HbA1c changes at three months; Best (≥ 1.6% decrease), Better (0.5-1.5% reduction), Neutral (≤ 0.4% decrease or ≤ 0.4% increase), and Worst (≥ 0.5% increase). The Best group had the best control up to 7 years, regardless of the baseline Hba1c. The groups with improvement (Best and Better) had lower risk for complications (cardiac and cerebrovascular), albeit not significant. This study provided important guides for target HbA1c reductions within 3, if not 12 months (no data on 3-month HbA1c reported). The accompanying editorial stressed on this and highlighted the benefits of the ‘legacy effects’, and alluded to factors that contribute to poor control that included beta cell dysfunctions, inconsistencies with guidelines and practices, and clinical inertia especially in the primary care settings.2 Treatment at primary and even secondary care levels are usually a bottom-up approach (stepwise increase in medications) and there also may be clinical inertia on part of doctors to introduce or escalate, including use of insulin, mainly for fear of inducing hypoglycemia and patient’s reluctance to accept treatment modifications.