High Plasma Angiopoietin-2 Levels Predict the Need to Initiate Dialysis within Two Years in Patients with Chronic Kidney Disease.

Volume status, congestion, endothelial activation, and injury all play roles in glomerular filtration rate (GFR) decline. In this study, we aimed to determine whether the plasma endothelial and overhydration markers could serve as independent predictors for dialysis initiation in patients with chronic kidney disease (CKD) 3b-5 (GFR < 45 mL/min/1.72 m2) and preserved ejection fraction. A prospective, observational study in a single academic center was conducted from March 2019 to March 2022. Plasma levels of angiopoietin (Ang)-2, Vascular Endothelial Growth Factor-C (VEGF-C), Vascular Cell Adhesion Molecule-1 (VCAM-1), Copeptin (CPP), beta-trace protein (BTP), brain natriuretic peptide (BNP), and cardiac troponin I (cTnI) were all measured. Lung ultrasound (US) B-lines, bioimpedance, and echocardiography with global longitudinal strain (GLS) were recorded. The study outcome was the initiation of chronic dialysis (renal replacement therapy) during 24 months of follow-up. A total of 105 consecutive patients with a mean eGFR of 21.3 mL/min/1.73 m were recruited and finally analyzed. A positive correlation between Ang-2 and VCAM-1 and BTP was observed. Ang-2 correlated positively with BNP, cTnI, sCr, E/e', and the extracellular water (ECW)/intracellular water (ICW) ratio (ECW/ICW). After 24 months, a deterioration in renal function was observed in 47 patients (58%). In multivariate regression analysis, both VCAM-1 and Ang-2 showed independent influences on risk of renal replacement therapy initiation. In a Kaplan-Meier analysis, 72% of patients with Ang-2 concentrations below the median (3.15 ng/mL) survived without dialysis for two years. Such an impact was not observed for GFR, VCAM, CCP, VEGF-C, or BTP. Endothelial activation, quantified by plasma levels of Ang-2, may play a key role in GFR decline and the need for dialysis initiation in patients with CKD 3b, 4, and 5.

Overhydration: A cause or an effect of kidney damage and how to treat it.

Volume overload can be both the cause and effect of chronic kidney disease (CKD). Overhydration often accompanies renal insufficiency. In cardiovascular disease (CVD), fluid overload can also be the cause of renal function impairment. Beside salt restriction, loop diuretics are the first-line therapy. Frequently developed resistance can be overcome by switching to intravenous administration, adding albumin alone or in combination with other diuretics. Transient factors like infection or contrast media can impair diuretic response and contribute to congestion. Apart from conservative management, ultrafiltration (UF) and peritoneal dialysis (PD) are used. In huge congestion with inadequate diuretic effect, hemodialysis with UF plays an important role as a temporary or permanent remedy. An increasing amount of data indicates that sodium-glucose co-transporter-2 inhibitors (SGLT2i) have allowed for a breakthrough in controlling fluid volume in diabetic and non-diabetic patients with CKD. Sodium-glucose cotransporter 2 inhibitors show cardioand renoprotective effects and have a positive impact on hard cardiovascular and renal endpoints.

Pathophysiology of hyperuricemia and its clinical significance - a narrative review.

Hyperuricemia, i.e. increased serum uric acid (UA) concentration, is a common problem in clinical practice. While there are clear guidelines concerning management of symptomatic hyperuricemia in acute conditions such as gout, urolithiasis or acute urate nephropathy, less is known about their secondary prevention. Moreover, despite the ongoing debate on the role of UA in the pathogenesis of chronic kidney disease, hypertension, cardiovascular disease and heart failure, the management of asymptomatic hyperuricemia in patients with these chronic conditions is still mainly up to physicians' judgement. Individual considerations should always be taken into account when prescribing urate-lowering therapy. In this narrative review study, we attempt to present current trends concerning treatment of patients with either symptomatic or asymptomatic hyperuricemia in the light of the available knowledge on the role of hyperuricemia in the development of gout, renal, cardiovascular and other diseases.

Arterial Stiffness Assessed by Oscillometric Method in Kidney Transplant, Predialysis, and Dialysis Patients.

INTRODUCTION: Chronic kidney disease (CKD) is strongly associated with a higher risk of cardiovascular disease (CV). An important nontraditional risk factor of cardiovascular disease in renal patients is vascular stiffness, which currently can be evaluated by oscillometric measuring of pulse wave velocity (PWV) and heart rate-corrected augmentation index (AIx@75). AIM: The aim of our study was to compare vascular stiffness between kidney transplant (KTx) recipients, patients on dialysis maintenance, and those in the predialysis period. MATERIALS AND METHODS: A cross-sectional study of 140 patients (52 in CKD stage 3-4; 37 in CKD stage 5 on hemodialysis maintenance [HD]; and 51 KTx recipients) had their PWV and AIx@75 measured with Mobil-O-Graph (IEM Gmbh, Stolberg, Germany) blood and pulse pressure monitor. RESULTS: KTx, HD, and CKD G3-4 were comparable in term of age, sex, body mass index, and diagnoses of diabetes mellitus and hypertension. The PWV was higher in the HD group than in the KTx and CKD G3-4 (9.4 m/s vs 8.4 m/s vs 7.9 m/s respectively; P < .05 for HD vs other groups), while the difference between the KTx and CKD G3-4 was not significant. AIx@75 values were similar in the HD and KTx groups (27.1 and 25.6; P > .05) and significantly lower in CDK G3-4 (17.8; P < .05). CONCLUSIONS: According to our results, the highest CV risk expressed by PWV (vascular stiffness) was found in hemodialysis patients. Although patients with CKD 3-4 and after KTx showed comparable large artery stiffness, transplant recipients additionally showed higher stiffness in smaller arteries as measured by heart rate-corrected AIx.

Dialysis Catheter Insertion with Extended Ultrasound Monitoring.

INTRODUCTION: Dialysis catheter insertion is a routine procedure performed when there is necessity of urgent renal replacement therapy initiation. Due to limited access, higher costs, and long waiting times for fluoroscopy, alternative visualization methods are introduced into clinical practice. One of the most promising is transthoracic echocardiographic monitoring of guide-wire introduction. OBJECTIVE: The feasibility of the technique was verified by nephrologists inserting dialysis catheters. METHODS: A single center prospective trial was performed (NCT03727581). Introduction of guide-wire was monitored with ultrasound to confirm correct position of the wire in the inferior vena cava (IVC) or right atrium (RA). The study group included 30 patients, 19 males and 11 females, 25-83 years old. RESULTS: It was possible to obtain a good picture of IVC in the majority of patients. In 20 (66.7%) cases, IVC view was excellent; in 9 (30%) cases, was fair; and in 1 (3.3%) patient, we failed to visualize IVC. The guide-wire was identified in IVC in 12 (42.8%) patients, in another 9 (32.1%) patients guide-wire was visible in IVC after withdrawing and advancing it, and in RA in 6 (21.4%) patients. Catheters were successfully placed in 29 (96.7%) patients. CONCLUSIONS: Detection of the guide-wire confirms correct course of the procedure and increases the safety of catheter insertion without fluoroscopy.

Prevalence and genotyping of Pneumocystis jirovecii in renal transplant recipients-preliminary report.

Pneumocystis jirovecii is an opportunistic fungus occurring in human lungs. The group at highest risk consists of HIV-infected and non-HIV-infected immunosuppressed individuals. In these patients, P. jirovecii infection may lead to Pneumocystis pneumonia; it may, however, persist also in an asymptomatic form. This study aimed to determine the prevalence of P. jirovecii and potential risk factors for infection in a group of renal transplant recipients and to characterize the genetic diversity of this fungus in the studied population. Sputum specimens from 72 patients were tested for presence of P. jirovecii using immunofluorescence microscopy, as well as nested PCR targeting the mtLSU rRNA gene. Genotyping involving analysis of four loci-mtLSU rRNA, CYB, DHPS, and SOD-was used to characterize the diversity of the detected organisms. Pneumocystis DNA was detected in eight (11.11%) patients. It has been shown that low eosinophil count and dual immunosuppressive treatment combining prednisone and calcineurin inhibitors are potential risk factors for colonization. Analysis of genotype distribution showed an association of the wild-type genotype of mtLSU rRNA with lower average age of patients and shorter time after kidney transplantation. Furthermore, CYB 2 genotype was detected only in patients with the ongoing prophylaxis regimen. In conclusion, renal transplant recipients are at risk of Pneumocystis colonization even a long time after transplantation. The present preliminary study identifies specific polymorphisms that appear to be correlated with certain patient characteristics and highlights the need for deeper investigation of these associations in renal transplant recipients.