Journal of the Nephrology Society of Thailand

Prognostic Factors of Patency Loss of Arteriovenous Fistula After Percutaneous Transluminal Angioplasty

Peeranat Srivachirawat, Kumtorn Lelamali, Thitiya Puavilai — Sat, 17 Feb 2024 00:00:00 +0700

Introduction: Arteriovenous fistula (AVF) is recommended as 1st choice of vascular access for hemodialysis (HD). Percutaneous transluminal angioplasty (PTA) helps increase the patency of AVF, which enhances HD adequacy. However, a slow decline in blood flow rate over time after PTA is common. The present study examined factors associated with patency loss at 6 months after PTA.
Method: This is a single-center prospective cohort study of 54 HD patients using AVF as dialysis access. Demographic data and characteristics of AVF were collected at baseline. The changes in blood flow rates after PTA were recorded immediately and at 3- and 6-month after the procedure. Factors associated with patency loss at 6 months after PTA were evaluated.
Results: The average age of AVF was 77.1 ± 68.4 months. Sixty-three percent of the fistula were in the upper arm. Central vein stenosis was present in 15.3%. Forty-six percent had previous interventions to the fistula. The most common type of intervention was plain balloon angioplasty (90.7%). The access blood flow rate (ABF) rate improved significantly immediately after the PTA. However, a slow but significant decline in ABF rate was observed at 3 and 6 months. The patency rates of the fistula at 3 and 6 months were 94.4% and 75.9 %, respectively. Independent predictors for patency loss at 6 months were ABF <500 ml/min immediately after the procedure, multiple stenotic lesions, and higher PTH level. Higher hemoglobin and lower ABF rate immediately after the PTA were independently correlated with >25% decline in the ABF at follow-up
Conclusion: Low ABF rate immediately after PTA, higher number of stenotic lesions, and higher PTH level predicted patency loss of AVF after PTA. These findings could help identify patients at high risk of AVF failure who might benefit from close monitoring.

Efficacy and Safety of Elobixibat on Constipation in End-Stage Kidney Disease Patients Undergoing Hemodialysis: A Randomized Controlled Trial

Sat, 17 Feb 2024 00:00:00 +0700

Background: Chronic constipation is prevalent among patients with end-stage kidney disease (ESKD). Recently, elobixibat, a novel inhibitor of the ileal bile acid transporter, has been used to treat chronic constipation by stimulating bowel function. However, its efficacy and safety in ESKD patients undergoing hemodialysis (HD) have yet to be examined.
Methods: HD patients diagnosed with chronic constipation, as per the Rome IV criteria, were randomized in a 1:1 allocation ratio to receive either elobixibat or a placebo for 12 weeks. Changes in the Bristol Stool Form Scale (BSFS), frequencies of spontaneous bowel movements (SBM) and complete spontaneous bowel movements (CSBM) per week, LDL cholesterol levels, and the gut microbiota-derived metabolite, P-cresol, from baseline were evaluated after the 12-week period.
Results: A total of 46 patients participated in the study. After 12 weeks of treatment, significant improvements were observed in the BSFS (mean difference [95% confidence interval] = 1.93 [1.37, 2.48], P<0.001), and there was an increase in the frequencies of SBM (2.46 [1.69, 3.23], P<0.001) and CSBM (2.83 [1.63, 3.39], P<0.001) per week in the elobixibat group compared with the placebo group. Additionally, LDL cholesterol levels significantly decreased in the elobixibat group relative to the placebo group (-12.41 [-24.72, -0.09], P<0.001). No significant differences were noted in other laboratory data or P-cresol levels. Furthermore, no serious adverse events were reported in either group.
Conclusion: Elobixibat exhibited an efficacy in improving constipation and reducing LDL cholesterol levels. These findings suggest that elobixibat might be an effective treatment for chronic constipation in ESKD patients undergoing HD.

Factors Associated with Hypokalemia after Furosemide Treatment in Hospitalized Patients with Acute Decompensated Heart Failure

Kittipat Aimbudlop, Donlawat Saengpanit — Sat, 17 Feb 2024 00:00:00 +0700

Background: Hypokalemia, defined as serum potassium <3.5 mmol/L, is commonly associated with the use of loop diuretics. Hypokalemia after furosemide treatment may lead to adverse outcomes in hospitalized patients with acute decompensated heart failure (ADHF). Risk factors associated with hypokalemia in this patient population are not well characterized. This retrospective case-control study aimed to identify risk factors and outcomes associated with hypokalemia after furosemide treatment in hospitalized patients with ADHF.
Methods: The data were retrieved from the medical records using ICD-10 coding. Factors associated with hypokalemia were analyzed using univariate and multivariate logistic regression analyses. Clinical outcomes associated with the hypokalemia were also examined.
Results: A total of 350 patients met the eligibility criteria, of whom 101 patients developed hypokalemia after receiving furosemide, while 249 patients did not. Furosemide dose >1.5 mg/kg, urine volume after furosemide treatment >2 ml/kg/hour, higher baseline serum albumin and body mass index, the presence of baseline hypomagnesemia and lower baseline serum potassium were independently associated with hypokalemia after furosemide treatment. Prior use of spironolactone was associated with a decreased risk of hypokalemia. Patients in the hypokalemia group had significantly higher incidence of cardiac arrhythmia and sepsis compared with the non-hypokalemia group.
Conclusion: Close monitoring of serum potassium among high risk patients may help reduce the incidence of hypokalemia and adverse clinical outcomes in hospitalized patients with ADHF who received furosemide.

Urine Biomarkers of Tubular Injury Predict Outcomes in Diabetic Nephropathy: A Prospective Cohort Study

Atit Suwannathot, Bancha Satirapoj, Ouppatham Supasyndh, Naowanit Nata — Sat, 17 Feb 2024 00:00:00 +0700

Background: Currently available biomarkers, such as serum creatinine and albuminuria, exhibit low sensitivity in predicting renal progression. Novel biomarkers of tubular injury may aid in identifying patients with type 2 diabetes mellitus (T2DM) at high risk for renal progression. This study evaluates the potential of urine biomarkers of tubular damage in predicting renal progression and the composite outcome of renal progression and death in T2DM.
Methods: This prospective cohort study involved 257 patients with T2DM. Urine biomarkers of tubular injury were assessed at baseline. The outcomes examined were the composite renal outcome of end-stage kidney disease (ESKD), a 40% decline in eGFR, and death.
Results: Most patients were in chronic kidney disease (CKD) stages 3 and 4, with a median urine albumin/creatinine ratio of 60.8 mg/g. The median follow-up duration was 7 years. Baseline urine concentrations of cystatin-C, angiotensinogen, kidney injury molecule-1 (KIM-1), and neutrophil-gelatinase associated lipocalin (NGAL) were significantly higher among patients who reached the composite renal outcome. All tubular biomarkers demonstrated intermediate predictive performance for the composite renal outcome, with area under the curve (AUC) values ranging between 0.65 and 0.72, comparable to urine albumin/creatinine. Using the optimal cut-off value for each urine biomarker, higher levels were significantly associated with the composite renal outcome. However, when employing an adjusted Cox proportional hazards model for the composite renal endpoint across the quartiles of urine tubular biomarker levels, only the upper quartiles of urine cystatin-C and KIM-1 significantly predicted the composite renal endpoint.
Conclusion: Urine biomarkers of tubular injury effectively identified diabetic patients at elevated risk for CKD progression and death in T2DM patients

Renal adverse events of immune checkpoint inhibitors

Supawattana Phapun, Eakalak Lukkanalikitkul — Sat, 17 Feb 2024 00:00:00 +0700

Immune checkpoint inhibitors are new cancer immunotherapies based on the principle of stimulating the immune system to eliminate cancer cells. There are three types of immune checkpoint inhibitors including anti-CTLA4 antibody, anti-PD-1 antibody, and anti-PD-1L antibody. The mechanism of action involves the inhibition of the immune checkpoint, thereby activating T-cells to destroy cancer cells. However, enhancing T-cell activity also leads to immune-related adverse events that can affect virtually any organ. The reported adverse events in the kidneys include electrolyte imbalance, glomerular disease, acute kidney injury and acute rejection in kidney transplants. Acute kidney injury occurs in 2-5% and is presumed to be immune-related resulting in acute tubulointerstitial nephritis. Withholding the drug and administration of corticosteroid are the mainstays of treatment. The medication may be rechallenged after the improvement of renal function. Glomerular disease, although uncommon, can be manifested as nephrotic or nephritic syndrome with variable pathology. The heightened T-cell activation is likely the cause of acute rejection in kidney transplants. There are currently no recommended treatments, therefore, it is advisable to monitor the patient closely for any possible side effects.

Sodium-Glucose Cotransporter 2 Inhibitors in Acute Kidney Injury

Anyarin Wannakittirat, Nattachai Srisawat — Sat, 17 Feb 2024 00:00:00 +0700

Acute kidney injury (AKI) is a common complication in hospitalized patients and is associated with an increase in morbidity and mortality. Moreover, patients with a history of AKI have an increased risk for congestive heart failure, rehospitalization, recurrence of AKI, progression to chronic kidney disease, and end-stage kidney disease. Currently, there is no specific treatment for post-AKI survivors. Sodium-Glucose Cotransporter 2 (SGLT2) inhibitors, a new and promising drug class, have now been widely used to control blood sugar, delay chronic kidney disease progression, and improve cardiovascular outcomes. By blocking the SGLT2 cotransporter at the proximal tubules, SGLT2 inhibitors result in glucosuria and natriuresis. In addition to lowering blood glucose levels, the drugs enhance the diuretic effect, minimize intravascular and interstitial volume overload, and reduce sympathetic activity. In the heart, SGLT2 inhibitors reduce oxidative stress and inflammation, which are protective against cardiac injury. The inhibition of Na+/H+ exchanger in cardiomyocytes can also reduce congestive heart failure. In the kidneys, SGLT2 inhibitors can reduce oxygen consumption in the renal cortex. There is currently no direct evidence regarding the protective effect of SGLT2 inhibitors in AKI. However, these promising mechanisms and other indirect evidence suggest that SGLT2 inhibitors may help improve long-term outcomes in patients with AKI.

The Role of Nephrologists in Management of Toxic Alcohol Poisoning

Ployrawee Thanaprirax, Adisorn Pathumarak — Sat, 17 Feb 2024 00:00:00 +0700

Toxic alcohol poisoning has been reported as one of the most common causes of poisoning. It affects cellular metabolism, resulting in multi-organ dysfunction, acid-base disturbances, electrolyte abnormalities, and acute kidney injury. If left undiagnosed and untreated, alcohol overdose can lead to the death of the patient. Since the symptoms and laboratory abnormalities develop quite rapidly, early recognition of clinical signs and symptoms, as well as an understanding of the pathophysiology for each type of alcohol overdose, is essential for prompt diagnosis and proper treatment. The management of toxic alcohol poisoning comprises supportive treatment, specific antidotes, and dialysis.