Social and humanitarian issues in nephrology and hypertension.

PURPOSE OF REVIEW: Chronic kidney disease and hypertension, two widely prevalent conditions worldwide, present an urgent and pressing need for immediate action. The review describes how social conditions and humanitarian issues can influence hypertension and kidney disease. RECENT FINDINGS: Undoubtedly, social determinants of health (SDoH) are key influencers in the development of many noncommunicable diseases, including hypertension and kidney disease. Healthcare professionals, including public health workers, play a crucial role in addressing these issues. Poverty, low education level, poor nutrition, housing, exposure to environmental hazards, and stress-related disorders are all factors that can be addressed, either directly or indirectly, through improved awareness and access to proper healthcare services. Besides personal factors, national, regional, or global factors cause serious apprehension. Disasters, whether natural or man-made, can lead to significant aftermaths on the healthy person and certainly on kidney disease and hypertensive patients. A Global Overview Report, 2023 turned out to be one of the most violent years since the end of the Cold War. In 2023, 59 state-based conflicts were recorded in 34 countries, the highest number registered since 1946. The wars in Ukraine and Gaza were the primary contributors with a significant impact on the kidney population, especially people living on dialysis and transplantation patients. They also yielded many refugees or displaced persons with ongoing suffering. SUMMARY: It is crucial to recognize that social and humanitarian conditions can quickly exacerbate the health of vulnerable populations, particularly those with noncommunicable diseases like hypertension and chronic kidney disease. These patients, who often require continuous follow-up, especially those on dialysis, are particularly vulnerable during difficult times. Their lives depend on uninterrupted access to dialysis or transplantation medications, making the need for special attention and care more pressing. Further research and advocacy are needed to address these issues and ensure the health and well being of these populations.

Advances in critical care nephrology through artificial intelligence.

PURPOSE OF REVIEW: This review explores the transformative advancement, potential application, and impact of artificial intelligence (AI), particularly machine learning (ML) and large language models (LLMs), on critical care nephrology. RECENT FINDINGS: AI algorithms have demonstrated the ability to enhance early detection, improve risk prediction, personalize treatment strategies, and support clinical decision-making processes in acute kidney injury (AKI) management. ML models can predict AKI up to 24-48 h before changes in serum creatinine levels, and AI has the potential to identify AKI sub-phenotypes with distinct clinical characteristics and outcomes for targeted interventions. LLMs and generative AI offer opportunities for automated clinical note generation and provide valuable patient education materials, empowering patients to understand their condition and treatment options better. To fully capitalize on its potential in critical care nephrology, it is essential to confront the limitations and challenges of AI implementation, including issues of data quality, ethical considerations, and the necessity for rigorous validation. SUMMARY: The integration of AI in critical care nephrology has the potential to revolutionize the management of AKI and continuous renal replacement therapy. While AI holds immense promise for improving patient outcomes, its successful implementation requires ongoing training, education, and collaboration among nephrologists, intensivists, and AI experts.

Embracing the (r)evolution of social media and digital scholarship in pediatric nephrology education.

Free Open-Access Medical Education (FOAMed) has transformed medical education in the past decade by complementing and substituting for traditional medical education when needed. The attractiveness of FOAMed resources is due to their inexpensive nature, wide availability, and user ability to access on demand across a variety of devices, making it easy to create, share, and participate. The subject of nephrology is complex, fascinating, and challenging. Traditional didactic lectures can be passive and ineffective in uncovering these difficult concepts and may need frequent revisions. Active teaching methods like flipped classrooms have shown some benefits, and these benefits can only be multifold with current social media tools. Social media will inspire the involvement of students and allow them to create and share educational content in a "trendy way," encouraging the participation of their peers and thus building an educational environment more conducive to them while promoting revision and retainment. FOAMed also promotes asynchronous learning, spaced learning, microlearning, and multimodal presentation with a meaningful variation. This article discusses the evolution of digital education, social media platforms, tools for creating and developing FOAMed resources, and digital scholarship.

How artificial intelligence is transforming nephrology.

Current research in nephrology is increasingly focused on elucidating the complexity inherent in tightly interwoven molecular systems and their correlation with pathology and related therapeutics, including dialysis and renal transplantation. Rapid advances in the omics sciences, medical device sensorization, and networked digital medical devices have made such research increasingly data centered. Data-centric science requires the support of computationally powerful and sophisticated tools able to handle the overflow of novel biomarkers and therapeutic targets. This is a context in which artificial intelligence (AI) and, more specifically, machine learning (ML) can provide a clear analytical advantage, given the rapid advances in their ability to harness multimodal data, from genomic information to signal, image and even heterogeneous electronic health records (EHR). However, paradoxically, only a small fraction of ML-based medical decision support systems undergo validation and demonstrate clinical usefulness. To effectively translate all this new knowledge into clinical practice, the development of clinically compliant support systems based on interpretable and explainable ML-based methods and clear analytical strategies for personalized medicine are imperative. Intelligent nephrology, that is, the design and development of AI-based strategies for a data-centric approach to nephrology, is just taking its first steps and is by no means yet close to its coming of age. These first steps are not even homogeneously taken, as a digital divide in access to technology has become evident between developed and developing countries, also affecting underrepresented minorities. With all this in mind, this editorial aim to provide a selective overview of the current use of AI technologies in nephrology and heralds the "Artificial Intelligence in Nephrology" special issue launched by BMC Nephrology.

Analysis of Performance Trends from 2010-2019 on the American Board of Internal Medicine Nephrology Certifying Exam.

BACKGROUND: The pass rate on the American Board of Internal Medicine (ABIM) nephrology certifying exam has declined and is among the lowest of all internal medicine (IM) subspecialties. In recent years, there have also been fewer applicants for the nephrology fellowship match. METHODS: This retrospective observational study assessed how changes between 2010 and 2019 in characteristics of 4094 graduates of US ACGME-accredited nephrology fellowship programs taking the ABIM nephrology certifying exam for the first time, and how characteristics of their fellowship programs were associated with exam performance. The primary outcome measure was performance on the nephrology certifying exam. Fellowship program pass rates over the decade were also studied. RESULTS: Lower IM certifying exam score, older age, female sex, international medical graduate (IMG) status, and having trained at a smaller nephrology fellowship program were associated with poorer nephrology certifying exam performance. The mean IM certifying exam percentile score among those who subsequently took the nephrology certifying exam decreased from 56.7 (SD, 27.9) to 46.1 (SD, 28.7) from 2010 to 2019. When examining individuals with comparable IM certifying exam performance, IMGs performed less well than United States medical graduates (USMGs) on the nephrology certifying exam. In 2019, only 57% of nephrology fellowship programs had aggregate 3-year certifying exam pass rates ≥80% among their graduates. CONCLUSIONS: Changes in IM certifying exam performance, certain trainee demographics, and poorer performance among those from smaller fellowship programs explain much of the decline in nephrology certifying exam performance. IM certifying exam performance was the dominant determinant.

Telehealth for Home Dialysis in COVID-19 and Beyond: A Perspective From the American Society of Nephrology COVID-19 Home Dialysis Subcommittee.

The coronavirus disease 2019 (COVID-19) pandemic, technological advancements, regulatory waivers, and user acceptance have converged to boost telehealth activities. Due to the state of emergency, regulatory waivers in the United States have made it possible for providers to deliver and bill for services across state lines for new and established patients through Health Insurance Portability and Accountability Act (HIPAA)- and non-HIPAA-compliant platforms with home as the originating site and without geographic restrictions. Platforms have been developed or purchased to perform videoconferencing, and interdisciplinary dialysis teams have adapted to perform virtual visits. Telehealth experiences and challenges encountered by dialysis providers, clinicians, nurses, and patients have exposed health care disparities in areas such as access to care, bandwidth connectivity, availability of devices to perform telehealth, and socioeconomic and language barriers. Future directions in telehealth use, quality measures, and research in telehealth use need to be explored. Telehealth during the public health emergency has changed the practice of health care, with the post-COVID-19 world unlikely to resemble the prior era. The future impact of telehealth in patient care in the United States remains to be seen, especially in the context of the Advancing American Kidney Health Initiative.

Novel genetic testing model: A collaboration between genetic counselors and nephrology.

Many barriers to genetic testing currently exist which delay or prevent diagnosis. These barriers include wait times, staffing, education, and cost. Specialists are able to identify patients with disease that may need genetic testing, but lack the genetics support to facilitate that testing in the most cost, time, and medically effective manner. The Nephrology Division and the Genetic Testing Stewardship Program at Nemours A.I. duPont Hospital for Children created a novel service delivery model in which nephrologists and genetic counselors collaborate in order to highlight their complementary strengths (clinical expertise of nephrologists and genetics and counseling skills of genetic counselors). This collaboration has reduced many barriers to care for our patients. This workflow facilitated the offering of genetic testing to 76 patients, with 86 tests completed over a 20-month period. Thirty-two tests were deferred. Twenty-seven patients received a diagnosis, which lead to a change in their medical management, three of whom were diagnosed by cascade family testing. Forty-two patients had a negative result and 16 patients had one or more variants of uncertain significance on testing. The inclusion of genetic counselors in the workflow is integral toward choosing the most cost and time effective genetic testing strategy, as well as providing psychosocial support to families. The genetic counselors obtain informed consent, and review genetic test results and recommendations with the patient and their family. The availability of this program to our patients increased access to genetic testing and helps to provide diagnoses and supportive care.

Peritoneal dialysis: Status report in South and South East Asia.

BACKGROUND: Peritoneal dialysis (PD) as a modality of kidney replacement therapy (KRT) is largely underutilized globally. We analyzed PD utilization, impact of economic status, projected growth and impact of state policy(s) on PD growth in South Asia and Southeast Asia (SA&SEA) region. METHODS: The National Nephrology Societies of the region responded to a questionnaire on KRT practices. The responses were based on the latest registry data, acceptable community-based studies and societal perceptions. The representative countries were divided into high income and higher-middle income (HI & HMI) and low income and lower-middle income (LI & LMI) groups. RESULTS: Data provided by 15 countries showed almost similar percentage of GDP as health expenditure (4%-7%). But there was a significant difference in per capita income (HI & HMI -US$ 28 129 vs. LI & LMI - US$ 1710.2) between the groups. Even after having no significant difference in monthly cost of haemodialysis (HD) and PD in LI & LMI countries, they have poorer PD utilization as compared to HI & HMI countries (3.4% vs. 10.1%); the reason being lack of formal training/incentives and time constraints for the nephrologist while lack of reimbursement and poor general awareness of modalities has been a snag for the patients. The region expects ≥10% PD growth in the near future. Hong Kong and Thailand with 'PD first' policy have the highest PD utilization. CONCLUSION: Important deterrents to PD underutilization were lack of PD centric policies, lackadaisical patient/physician's attitude, lack of structured patient awareness programs, formal training programs and affordability.

The changing landscape of PAs and NPs in nephrology.

BACKGROUND: Physician assistants (PAs) and NPs have expanded roles in nephrology as both the patient load and acuity of care needed for this population have increased. PURPOSE: To evaluate the workforce patterns of PAs and NPs working in nephrology over the past decade. METHODS: Using the biannual survey from the National Kidney Foundation Council of Advanced Practitioners, data were collected and analyzed over the past decade. RESULTS: Surveys of nephrology practitioners show the evolution of the dialysis-focused practitioner to one encompassing all aspects of nephrology: hospital, ICU, research, office, and all types of dialysis. Salaries and benefits have increased to compensate for the expansion of responsibilities. CONCLUSIONS: PAs and NPs in nephrology have the opportunity to use their skills and training in caring for this high-risk population.

[Nephrology†: what's new in 2020†?] / Néphrologie.

Impact of gliflozines in the treatment of non-diabetic nephropathies and cardiac failure has lately been demonstrated. Tolvaptan has now been recognized in Switzerland as a treatment of hyponatremia. In hemodialysis, some progress has been made in the management of dysfunctional arterio-venous fistulas. A glimmer of hope in the treatment of uremic pruritus? Conservative management of a stable coronary heart disease is also advocated in patients with end-stage kidney disease. Therapy with immune cells may either minimize or remove the need for immunosuppression in renal transplant patients. A new predictive score combining several markers can predict long-term graft failure.

L'efficacité des gliflozines est également reconnue dans le traitement de l'insuffisance cardiaque et des néphropathies non diabétiques. Le tolvaptan est maintenant reconnu en Suisse pour le traitement de l'hyponatrémie. Une stratégie de mise en dialyse plus attentiste dans l'insuffisance rénale aiguë est définitivement confirmée. En hémodialyse, quelques progrès sont obtenus dans la prise en charge des dysfonctions d'accès vasculaires et du prurit urémique. Un traitement conservateur d'emblée est préconisé pour une coronaropathie stable également chez les patients en insuffisance rénale terminale. En transplantation rénale, l'emploi d'une immunothérapie cellulaire permettrait de diminuer ou même d'arrêter l'immunosuppression. La perte du greffon peut être évaluée avec un nouveau score prédictif combinant plusieurs marqueurs.

Telenephrology: An Emerging Platform for Delivering Renal Health Care.

Electronic-based health care delivery systems are gaining popularity among patients and clinicians because of convenience. Importantly, telemedicine, the delivery of health care and/or health information using electronic systems, can deliver primary and specialized health care to geographically isolated patients, who account for nearly 20% of the US population. In nephrology, where a growing discrepancy exists between the geographic location of nephrologists and patients with kidney disease, telenephrology can bridge distance and deliver renal care and education to the isolated. Large nationalized health care systems, for which incentives are aligned to innovate and implement new platforms to deliver cost-effective care, have been at the forefront of telenephrology. These systems include synchronous direct physician-patient care through clinical videoconferencing, and asynchronous modalities such as electronic consultation and video telehealth to educate internists about specialized clinical topics. Large health care organizations are adopting these platforms as standalone services; however, expansion into the private health care system has been limited by reimbursement, regulations, and other issues. Though telenephrology is patient centered, studies are needed to rigorously test its clinical efficacy and cost-effectiveness. Nonetheless, growing patient demand for patient-centric health care will continue to expand the telenephrology space.

Assessment of Hydration Status in Peritoneal Dialysis Patients: Validity, Prognostic Value, Strengths, and Limitations of Available Techniques.

BACKGROUND: The majority of patients undergoing peritoneal dialysis (PD) suffer from volume overload and this overhydration is associated with increased mortality. Thus, optimal assessment of volume status in PD is an issue of paramount importance. Patient symptoms and physical signs are often unreliable indexes of true hydration status. SUMMARY: Over the past decades, a quest for a valid, reproducible, and easily applicable technique to assess hydration status is taking place. Among existing techniques, inferior vena cava diameter measurements with echocardiography and natriuretic peptides such as brain natriuretic peptide and N-terminal pro-B-type natriuretic peptide were not extensively examined in PD populations; while having certain advantages, their interpretation are complicated by the underlying cardiac status and are not widely available. Bioelectrical impedance analysis (BIA) techniques are the most studied tool assessing volume overload in PD. Volume overload assessed with BIA has been associated with technique failure and increased mortality in observational studies, but the results of randomized trials on the value of BIA-based strategies to improve volume-related outcomes are contradictory. Lung ultrasound (US) is a recent technique with the ability to identify volume excess in the critical lung area. Preliminary evidence in PD showed that B-lines from lung US correlate with echocardiographic parameters but not with BIA measurements. This review presents the methods currently used to assess fluid status in PD patients and discusses existing data on their validity, applicability, limitations, and associations with intermediate and hard outcomes in this population. Key Message: No method has proved its value as an intervening tool affecting cardiovascular events, technique, and overall survival in PD patients. As BIA and lung US estimate fluid overload in different compartments of the body, they can be complementary tools for volume status assessment.

Consensus-based technical recommendations for clinical translation of renal T1 and T2 mapping MRI.

To develop technical recommendations on the acquisition and post-processing of renal longitudinal (T1) and transverse (T2) relaxation time mapping. A multidisciplinary panel consisting of 18 experts in the field of renal T1 and T2 mapping participated in a consensus project, which was initiated by the European Cooperation in Science and Technology Action PARENCHIMA CA16103. Consensus recommendations were formulated using a two-step modified Delphi method. The first survey consisted of 56 items on T1 mapping, of which 4 reached the pre-defined consensus threshold of 75% or higher. The second survey was expanded to include both T1 and T2 mapping, and consisted of 54 items of which 32 reached consensus. Recommendations based were formulated on hardware, patient preparation, acquisition, analysis and reporting. Consensus-based technical recommendations for renal T1 and T2 mapping were formulated. However, there was considerable lack of consensus for renal T1 and particularly renal T2 mapping, to some extent surprising considering the long history of relaxometry in MRI, highlighting key knowledge gaps that require further work. This paper should be regarded as a first step in a long-term evidence-based iterative process towards ever increasing harmonization of scan protocols across sites, to ultimately facilitate clinical implementation.

Technical recommendations for clinical translation of renal MRI: a consensus project of the Cooperation in Science and Technology Action PARENCHIMA.

PURPOSE: The potential of renal MRI biomarkers has been increasingly recognised, but clinical translation requires more standardisation. The PARENCHIMA consensus project aims to develop and apply a process for generating technical recommendations on renal MRI. METHODS: A task force was formed in July 2018 focused on five methods. A draft process for attaining consensus was distributed publicly for consultation and finalised at an open meeting (Prague, October 2018). Four expert panels completed surveys between October 2018 and March 2019, discussed results and refined the surveys at a face-to-face meeting (Aarhus, March 2019) and completed a second round (May 2019). RESULTS: A seven-stage process was defined: (1) formation of expert panels; (2) definition of the context of use; (3) literature review; (4) collection and comparison of MRI protocols; (5) consensus generation by an approximate Delphi method; (6) reporting of results in vendor-neutral and vendor-specific terms; (7) ongoing review and updating. Application of the process resulted in 166 consensus statements. CONCLUSION: The process generated meaningful technical recommendations across very different MRI methods, while allowing for improvement and refinement as open issues are resolved. The results are likely to be widely supported by the renal MRI community and thereby promote more harmonisation.

Going to war on COVID-19: Mobilizing an academic nephrology group practice.

AIM: The COVID-19 pandemic poses unprecedented operational challenges to nephrology divisions in every country as they cope with COVID-19-related kidney disease in addition to regular patient care. Although general approaches have been proposed, there is a lack of practical guidance for nephrology division response in a hospital facing a surge of cases. Here, we describe the specific measures that our division has taken in the hope that our experience in Singapore may be helpful to others. METHODS: Descriptive narrative. RESULTS: A compilation of operational responses to the COVID-19 pandemic taken by a nephrology division at a Singapore university hospital. CONCLUSION: Nephrology operational readiness for COVID-19 requires a clinical mindset shift from usual standard of care to a crisis exigency model that targets best outcomes for available resources. Rapid multi-disciplinary efforts that evolve flexibly with the local dynamics of the outbreak are required.

The Global Kidney Health Atlas: Burden and Opportunities to Improve Kidney Health Worldwide.

CKD is a growing public health problem. The Global Kidney Health Atlas (GKHA) is an important initiative of the International Society of Nephrology. The GKHA aims to improve the understanding of inter- and intranational variability across the globe, focusing on capacity for kidney care delivery. The GKHA survey was launched in 2017 and then again in 2019, using the same core data, supplemented by information about dialysis access and conservative care. Based on a WHO framework of the 6 building blocks essential for health care, the GKHA assesses capacity in 6 domains: information systems, services delivery, workforce, financing, access to essential medicines, and leadership/governance. In addition, the GKHA assesses the capacity for research in all regions of the world, across all domains (basic, translational, clinical, and health system research). The results of the GKHA have informed policy and been used to enhance advocacy strategies in different regions. In addition, through documentation of the disparities within and between countries and regions, initiatives have been launched to foster change. Since the first survey, there has been an increase in the number of countries which have registries to document the burden of CKD or dialysis. For many, information about the burden of disease is the first step toward addressing care delivery issues, including prevention, delay of progression, and access to services. Worldwide collaboration in the documentation of kidney health and disease is an important step toward the goal of ensuring equitable access to kidney health worldwide.

[Therapeutic innovation in nephrology : 10 years of progress]. / Nouveautés thérapeutiques en néphrologie : 10 ans d'avancées.

Chronic kidney disease (CKD) impairs the quality of life and increases the risk for cardiovascular morbimortality. Intensive research is conducted in order to slow down CKD development and progression. During the past decade, a better understanding of the pathophysiological mechanisms of glomerular diseases has highlighted the benefits of rituximab. Progresses have also been made in the understanding of the mechanisms of autosomal polycystic kidney disease, the most frequent inherited kidney disease. These observations led to the discovery and validation of tolvaptan, a blocker of the V2 receptor of the antidiuretic hormone as an innovative treatment. Type 2 diabetic disease is the leading cause worldwide of endstage kidney disease and dialysis. The development of new drugs, such as the gliflozins (inhibiting the sodium glucose reabsorption in the proximal tubule), has contributed to an improvement in the management of the cardiovascular and renal risks especially reducing congestive heart failure rate. Another important progress in nephrology since the beginning of the new century concerns a more precise estimation of the kidney function, which allows to better evaluate the slope of CKD progression and test the influence of different therapeutic approaches aiming at correcting anemia, hyperkalemia, metabolic acidosis and disturbances of calcium and phosphate. The present review summarizes all of these major advances in the field of CKD diagnosis and treatment, and envisions the future of nephrology for the next decade.

L'insuffisance rénale chronique (IRC) altère la qualité de vie, expose à une morbi-mortalité cardiovasculaire majorée, et peut conduire à la dialyse chronique et/ ou la transplantation rénale. Tout progrès qui freinerait le développement et la progression de cette IRC est le bienvenu. Au cours de ces dernières années, une meilleure compréhension des mécanismes physiopathologiques de certaines maladies glomérulaires a permis l'utilisation d'un traitement plus ciblé, le rituximab, qui apporte une nouvelle option dans des situations difficiles. Des progrès ont également été faits dans la compréhension des mécanismes expliquant la perte de fonction rénale chez le patient atteint de polykystose rénale autosomique dominante, la maladie rénale génétique la plus fréquente. Les études cliniques ont permis de démontrer la néphro-protection du tolvaptan, un antagoniste des récepteurs V2 de l'hormone antidiurétique. Dans le domaine du diabète de type 2, première cause mondiale de prise en charge en dialyse, l'avènement des gliflozines (inhibiteurs de la réabsorption tubulaire rénale de glucose et de sodium) a été une réelle révolution thérapeutique pour freiner l'évolution de l'insuffisance rénale chronique et limiter le risque cardiovasculaire (surtout la décompensation cardiaque) de ces patients. Enfin, une meilleure estimation de la fonction rénale a permis de mieux situer le patient dans sa vitesse de progression à travers les différents stades de l'IRC. Ce faisant, la gestion des anomalies métaboliques rencontrées au cours de celle-ci, telles qu'anémie, hyperkaliémie, acidose, troubles du métabolisme phosphocalcique, s'est améliorée. Cette revue fait état des avancées majeures dans le domaine du diagnostic de l'IRC et de ses traitements et envisage le futur de la néphrologie dans les 10 prochaines années.

[Nephrology†: what's new in 2019†?] / Néphrologie.

Impact of gliflozines and rituximab in the treatments of diabetic and membranous nephropathies respectively has been confirmed. Roxadustat may be the new promising treatment of renal anemia. Long-acting erythropoietins may be associated with a higher death rate than short-acting ones in hemodialysis patients. Kidneys of HCV-seropositive donors can be proposed to any wait-listed patient for renal transplantation. Immunosupression minimizing the use of calcineurin inhibitors may be achieved with an everolimus-based protocol.

L'intérêt des gliflozines dans le traitement de la néphropathie diabétique et du rituximab dans celui de la néphropathie membraneuse est confirmé. Le roxadustat pourrait devenir un nouveau traitement prometteur de l'anémie rénale. En hémodialyse, les érythropoïétines à longue durée d'action seraient associées à une plus forte mortalité que celles à courte durée d'action. En transplantation rénale, les reins de donneurs VHC-séropositifs (virus de l'hépatite C-séropositifs) peuvent être proposés à tous les receveurs potentiels. L'emploi de l'évérolimus permettrait une immunosupression avec épargne des inhibiteurs de la calcineurine.