Journal of the Nephrology Society of Thailand

Mind the Gap in Kidney Care: Translating What We Know into What We Do

Tue, 28 May 2024 00:00:00 +0700

Historically, it takes an average of 17 years to move new treatments from clinical evidence to daily practice. Given the highly effective treatments now available to prevent or delay kidney disease onset and progression, this is far too long. The time is now to narrow the gap between what we know and what we do. Clear guidelines exist for the prevention and management of common risk factors for kidney disease, such as hypertension and diabetes, but only a fraction of people with these conditions worldwide are diagnosed, and even fewer are treated to target. Similarly, the vast majority of people living with kidney disease are unaware of their condition, because in the early stages it is often silent. Even among patients who have been diagnosed, many do not receive appropriate treatment for kidney disease. Considering the serious consequences of kidney disease progression, kidney failure, or death, it is imperative that treatments are initiated early and appropriately. Opportunities to diagnose and treat kidney disease early must be maximized beginning at the primary care level. Many systematic barriers exist, ranging from patient to clinician to health systems to societal factors. To preserve and improve kidney health for everyone everywhere, each of these barriers must be acknowledged so that sustainable solutions are developed and implemented without further delay.

Pathophysiology and Health Effects of Aging Kidneys

Chokchai Chaovarin — Tue, 28 May 2024 00:00:00 +0700

The prevalence of an aging population poses a significant challenge globally. As individuals grow older, there is a notable decrease in their glomerular filtration rate (GFR), declining at a rate of approximately 1 ml/minute/1.73 m² each year. By the age of 70, the average GFR typically falls to around 60 ml/minute/1.73 m². This decline in kidney function has profound implications for the health of older adults and can significantly impact family dynamics. Aging kidneys are characterized by shrinkage in the size of the kidneys and the development of glomerulosclerosis, tubular atrophy, and interstitial fibrosis. The reduction in kidney function leads to electrolyte imbalances, fluid retention, and an increased susceptibility to acute kidney injury. The aging process of the kidneys is intricately linked to cellular senescence, which involves cell cycle arrest, resistance to apoptosis, and the secretion of pro-inflammatory factors such as the senescence-associated secretory phenotype. Additionally, aging kidneys exhibit heightened fibrosis and altered vascular responses. There is currently no specific treatment proven to halt the decline in kidney function associated with aging. Therefore, the cornerstone of caring for elderly individuals with aging kidneys lies in close monitoring and management of co-existing conditions and complications. By prioritizing proactive healthcare measures, healthcare professionals can optimize the well-being of aging populations facing kidney-related challenges.

Complement-Mediated Atypical Hemolytic Uremic Syndrome

Saranchana Jiampochaman, Wonngarm Kittanamongkolchai — Tue, 28 May 2024 00:00:00 +0700

Atypical hemolytic uremic syndrome (aHUS) is a kidney disease caused by dysregulation of the alternative complement pathway. Uncontrolled complement activation resulted in endothelial injury, platelet activation and consumption, and thrombus formation, leading to kidney injury. Clinical features of aHUS include microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. Atypical HUS occurs in genetically susceptible individuals who have an acquired precipitating event that unmasks a complement regulatory deficiency. The incidence of aHUS is 0.5 per million per year. Histopathological features include endothelial swelling, fibrin thrombi, and fragmented red blood cells. Current treatment options are complement-inhibiting therapy, plasma exchange, immunosuppressive medication, and kidney and/or liver transplantation. The choice of treatment is based on the underlying complement regulation defect.

An Update on Novel Targeted Treatments for IgA Nephropathy

Hansa Kidkaem, Eakalak Lukkanalikitkul — Tue, 28 May 2024 00:00:00 +0700

Immunoglobulin A nephropathy (IgAN) stands as the most prevalent primary glomerular disease globally. Its pathogenesis is multifaceted, primarily characterized by elevated circulating levels of Gd-IgA1, which is targeted by autoantibodies. This interaction leads to the formation of circulating immune complexes that subsequently deposit in the glomeruli, triggering intrarenal inflammation. Current therapeutic approaches primarily focus on conservative measures, such as optimized control of blood pressure and proteinuria, aimed at enhancing renal function. Additionally, immunosuppressive therapy, including corticosteroids, may be considered for patients exhibiting persistent proteinuria (>1 g/day) after a minimum of 90 days of conservative management. Recent advancements have led to the development of novel drugs targeting the underlying pathogenic mechanisms of IgAN, particularly those involving immune response and mucosal immunity, with the goal of reducing Gd-IgA1 levels and immune complex deposition in the glomeruli. Furthermore, other treatments, including drugs affecting the complement pathway, endothelin-1 receptor inhibitors, and SGLT2 inhibitors, have demonstrated potential in reducing proteinuria and kidney inflammation. These emerging strategies are promising improving outcomes in IgAN.

Potassium Binders for Hyperkalemia in Patients with Chronic Kidney Disease

Kattareeya Jandaboot, Kittrawee Kritmetapak — Tue, 28 May 2024 00:00:00 +0700

Hyperkalemia is a life-threatening complication of chronic kidney disease (CKD), particularly in patients with an estimated glomerular filtration rate of less than 45 mL/min/1.73 m2. The colon is responsible for approximately 10% of total potassium excretion, whereas the kidneys account for the remaining 90%. Nevertheless, the colon can become an important site of potassium excretion in patients with CKD. Renin-angiotensin-aldosterone system (RAAS) blockers, which can delay the progression of CKD and improve cardiovascular outcomes, usually require dose reduction or discontinuation when hyperkalemia occurs. Patiromer and sodium zirconium cyclosilicate (SZC) are potassium binders that provide alternatives to sodium polystyrene sulfonate and cause fewer gastrointestinal adverse effects. In randomized controlled studies of patients with hyperkalemia, patiromer and SZC have shown their clinical efficacy in reducing serum potassium levels with a good safety profile. These potassium binders may allow patients with CKD at risk for hyperkalemia to optimize RAAS blocker therapy. Further long-term studies are required to confirm the survival benefits of patiromer and SZC among patients with CKD.

The Outcome of Hemoperfusion as an Adjuvant Therapy in Patients with Severe COVID-19 Pneumonia

Rujirada Teeraboonchaikul, Wanniya Meenune — Tue, 28 May 2024 00:00:00 +0700

Background: Coronavirus disease-2019 (COVID-19) pneumonia can result in cytokine release syndrome and a high mortality rate. In addition to anti-viral medications, immunomodulators, and systemic corticosteroids, cytokine removal therapy, also known as hemoperfusion, might have a role in improving patient outcomes.
Methods: This is a retrospective observational study of patients with severe COVID-19 pneumonia who received hemoperfusion using HA 330® in addition to conventional treatment compared to conventional treatment alone during May 2021 – June 2022. The primary outcome was the 28-day survival rate.
Results: 155 patients were included; 98 patients in the hemoperfusion group; and 57 patients in the conventional treatment group. Patients who received hemoperfusion had a higher Sequential Organ Failure Assessment score (10±3.3 vs. 7±2.9; p<0.001). There was no significant difference in the 28-day survival rate between the two groups (54.1% vs. 42.1%; p=0.198). Hemoperfusion for 24-48 hours significantly improved PaO2/FiO2 ratio (P=0.001) and reduced high-sensitivity C-reactive protein (p<0.001) and ferritin levels (P=0.003). Acute kidney injury was associated with an increased risk of 28-day mortality (Hazard ratio (95% confidence interval): 4.72 (2.87 to 7.77); p<0.001). The most common cause of death was bacterial pneumonia.
Conclusions: Hemoperfusion using HA330® was not associated with an improvement in 28-day survival in patients with severe COVID-19 pneumonia during the delta variant outbreak.

Predictors and Outcomes of Erythrocytosis After Sodium-Glucose Cotransporter-2 Inhibitors in Type 2 Diabetes Mellitus

Panita Prasathinphimai, Laddaporn Wongluechai — Tue, 28 May 2024 00:00:00 +0700

Background: Current evidence suggests that treatment with sodium-glucose cotransporter-2 inhibitors (SGLT2i) may increase hemoglobin levels. An increase in hemoglobin may be beneficial in improving cardiovascular and renal outcomes. This study examined changes in hemoglobin, the prevalence, and predictors of erythrocytosis in patients with type 2 diabetes mellitus (T2DM) who received SGLT2i. The associations between erythrocytosis with cardiovascular events and renal outcomes were also investigated.
Methods: This retrospective study was conducted in patients with T2DM who received SGLT2i for at least 3 consecutive months between January 2020 and December 2022. Hemoglobin and hematocrit were collected at baseline and after 3-12 months of SGLT2i treatment until the end of the study. Erythrocytosis was defined as an increase in hemoglobin level ≥2 gm/dL from baseline during the study period.
Results: Three hundred thirty-six patients were included in the study. The prevalence of erythrocytosis was 125 patients (37.2 %). The hemoglobin levels increased over time with median differences from baseline of 0.7, 1, 1.3, and 1.5 gm/dL at 3, 6, 12, and >24 months, respectively. The predictors of erythrocytosis were age >60 years, chronic kidney disease, using thiazide and beta-blockers, lower hemoglobin, and estimated glomerular filtration rate at baseline. Cardiovascular and renal outcomes were not different between the erythrocytosis and non-erythrocytosis groups.
Conclusion: A gradual increase in hemoglobin levels was observed in patients with T2DM after SGLT2i treatment. Erythrocytosis was common but was not associated with adverse cardiovascular events or renal outcomes.