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Pediatric Nephrology (Berlin, Germany) Mar 2023Idiopathic nephrotic syndrome is the most frequent pediatric glomerular disease, affecting from 1.15 to 16.9 per 100,000 children per year globally. It is characterized... (Review)
Review
Idiopathic nephrotic syndrome is the most frequent pediatric glomerular disease, affecting from 1.15 to 16.9 per 100,000 children per year globally. It is characterized by massive proteinuria, hypoalbuminemia, and/or concomitant edema. Approximately 85-90% of patients attain complete remission of proteinuria within 4-6 weeks of treatment with glucocorticoids, and therefore, have steroid-sensitive nephrotic syndrome (SSNS). Among those patients who are steroid sensitive, 70-80% will have at least one relapse during follow-up, and up to 50% of these patients will experience frequent relapses or become dependent on glucocorticoids to maintain remission. The dose and duration of steroid treatment to prolong time between relapses remains a subject of much debate, and patients continue to experience a high prevalence of steroid-related morbidity. Various steroid-sparing immunosuppressive drugs have been used in clinical practice; however, there is marked practice variation in the selection of these drugs and timing of their introduction during the course of the disease. Therefore, international evidence-based clinical practice recommendations (CPRs) are needed to guide clinical practice and reduce practice variation. The International Pediatric Nephrology Association (IPNA) convened a team of experts including pediatric nephrologists, an adult nephrologist, and a patient representative to develop comprehensive CPRs on the diagnosis and management of SSNS in children. After performing a systematic literature review on 12 clinically relevant PICO (Patient or Population covered, Intervention, Comparator, Outcome) questions, recommendations were formulated and formally graded at several virtual consensus meetings. New definitions for treatment outcomes to help guide change of therapy and recommendations for important research questions are given.
Topics: Child; Humans; Nephrotic Syndrome; Glucocorticoids; Nephrology; Immunosuppressive Agents; Proteinuria; Steroids; Recurrence
PubMed: 36269406
DOI: 10.1007/s00467-022-05739-3 -
Seminars in Nephrology Sep 2018IgA nephropathy (IgAN), or Berger's disease, is the most common primary glomerular disease worldwide, but varies largely in its geographic distribution. A systematic...
IgA nephropathy (IgAN), or Berger's disease, is the most common primary glomerular disease worldwide, but varies largely in its geographic distribution. A systematic review of 1,619 publications from the five continental regions of the world was performed to assess the prevalence of IgAN in different worldwide regions and analyze factors responsible for geographic differences. All observational studies that described the prevalence and incidence data on glomerulonephritis were considered. IgAN is more frequent in Asian populations (45 cases per million population/y in Japan) than in Caucasians (31 cases per million population/y in France). These differences are owing to some relevant aspects: (1) systematic mass screening of urine in populations, as occurring in some Asian countries (Hong Kong, Japan, Korea, and Singapore), is not common in Western countries; (2) general practitioners and health care professionals in Western countries underestimate persistent microscopic hematuria and/or mild proteinuria in apparently healthy individuals causing late referral to a nephrologist; and (3) nephrologists adopt different indications for kidney biopsy in individuals with persistent urinary abnormalities. In addition, differences also are owing to the source of data, because the frequency of IgAN observed in a nephrology center with a high incidence of kidney biopsies is higher than in a regional renal biopsy registry that receives data from many centers. In conclusion, greater efforts should be made to diagnose IgAN earlier in individuals who manifest persistent microhematuria and/or mild proteinuria and to introduce less stringent indications for kidney biopsies. This preventive approach, followed by early therapy, may reduce the global burden of end-stage kidney disease caused by IgAN.
Topics: Biopsy; General Practice; Glomerulonephritis, IGA; Hematuria; Humans; Incidence; Kidney; Mass Screening; Nephrology; Prevalence; Proteinuria; Referral and Consultation
PubMed: 30177015
DOI: 10.1016/j.semnephrol.2018.05.013 -
Nefrologia 2020Physical exercise may offer multiple benefits to patients with chronic kidney disease (CKD). However, it was not traditionally recommended because of the possibility of... (Meta-Analysis)
Meta-Analysis
Physical exercise may offer multiple benefits to patients with chronic kidney disease (CKD). However, it was not traditionally recommended because of the possibility of impairing renal function and increasing proteinuria. The objective of this study is to review the clinical trials on physical exercise in patients with CKD and describe its effect on the progression of kidney disease and other factors associated. Randomized clinical trials (RCT) comparing an intervention that included an exercise component with a control group without physical exercise in non-dialysis patients with CKD from 2007 to 2018 in English and Spanish were included. PubMed, Scopus, Embase, Ovid (Medline) and PEDro databases were used for the search. Effects of physical exercise were summarized by the standardized mean difference (SMD). No differences were found in glomerular filtration rate or proteinuria between the intervention group and the control group: SMD -0.3 (P=.81); SMD 26.6 (P=.82). Positive effects were obtained on peak oxygen consumption: SMD 2.5 (P<.001), functional capacity: SMD 56.6 (P<.001), upper limb strength: SMD 6.8 (P<.001) and hemoglobin: SMD 0.3 (P=.003). An improvement on the quality of life was also evident using the KDQOL-36 survey: SMD 3.56 (P=.02) and the SF-36 survey: SMD 6.66 (P=.02). In conclusion, the practice of low-intensity physical exercise routinely has no negative impact on renal function. On the contrary, it improves aerobic and functional capacity, impacting positively on the quality of life.
Topics: Cardiovascular System; Combined Modality Therapy; Exercise; Exercise Therapy; Female; Glomerular Filtration Rate; Humans; Kidney; Male; Oxygen Consumption; Proteinuria; Quality of Life; Randomized Controlled Trials as Topic; Renal Insufficiency, Chronic; Renal Replacement Therapy; Treatment Outcome
PubMed: 32305232
DOI: 10.1016/j.nefro.2020.01.002 -
American Journal of Obstetrics and... May 2022Limited evidence exists on the role that the cause of chronic kidney disease plays in determining pregnancy outcomes. The aim of this systematic review and meta-analysis... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
Limited evidence exists on the role that the cause of chronic kidney disease plays in determining pregnancy outcomes. The aim of this systematic review and meta-analysis was to examine the association between chronic kidney disease and adverse pregnancy outcomes by the cause and severity of chronic kidney disease where reported. The protocol was registered under the International Prospective Register of Systematic Reviews (CRD42020211925).
DATA SOURCES
PubMed, Embase, and Web of Science were searched until May 24, 2021, supplemented with reference list checking.
STUDY ELIGIBILITY CRITERIA
Studies that compared the pregnancy outcomes in women with or without chronic kidney disease were included. Two reviewers independently screened titles, abstracts, and full-text articles according to a priori defined inclusion criteria.
METHODS
Data extraction and quality appraisal were performed independently by 3 reviewers. The grading of recommendations, assessment, development, and evaluation approach was used to assess the overall certainty of the evidence. Random-effects meta-analyses were used to calculate the pooled estimates using the generic inverse variance method. The primary outcomes included preeclampsia, cesarean delivery, preterm birth (<37 weeks' gestation), and small for gestational age babies.
RESULTS
Of 4076 citations, 31 studies were included. Prepregnancy chronic kidney disease was significantly associated with a higher odds of preeclampsia (pooled crude odds ratio, 8.13; [95% confidence interval, 4.41-15], and adjusted odds ratio, 2.58; [1.33-5.01]), cesarean delivery (adjusted odds ratio, 1.65; [1.21-2.25]), preterm birth (adjusted odds ratio, 1.73; [1.31-2.27]), and small for gestational age babies (adjusted odds ratio, 1.93; [1.06-3.52]). The association with stillbirth was not statistically significant (adjusted odds ratio, 1.67; [0.96-2.92]). Subgroup analyses indicated that different causes of chronic kidney disease might confer different risks and that the severity of chronic kidney disease is associated with a risk of adverse pregnancy outcomes, as pregnancies with later stages of chronic kidney disease had higher odds of preeclampsia, preterm birth, and small for gestational age babies than those at earlier stages. The grading of recommendations, assessment, development, and evaluation certainty of the evidence overall was "very low".
CONCLUSION
This meta-analysis quantified the associations between prepregnancy chronic kidney disease and adverse pregnancy outcomes, both overall and according to the cause and severity of the disease. These findings might support the clinicians aiming to counsel women having chronic kidney disease by allowing them to tailor their advice according to cause and severity of the chronic kidney disease. We identified the gaps in the literature, and further studies examining the effect of specific kidney diseases and other clinical characteristics (eg, proteinuria, hypertension) on adverse pregnancy outcomes are warranted.
Topics: Female; Humans; Infant, Newborn; Infant, Small for Gestational Age; Male; Pre-Eclampsia; Pregnancy; Pregnancy Outcome; Premature Birth; Renal Insufficiency, Chronic
PubMed: 34736915
DOI: 10.1016/j.ajog.2021.10.037 -
International Urology and Nephrology Apr 2022Emphysematous pyelonephritis (EPN) is an acute, severe necrotising infection of the kidney. There has been a shift from early nephrectomy to conservative methods. We... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
Emphysematous pyelonephritis (EPN) is an acute, severe necrotising infection of the kidney. There has been a shift from early nephrectomy to conservative methods. We conducted a meta-analysis to assess the impact of risk factors and treatment choices on outcomes in EPN.
METHODS
We conducted a database search of all studies in English, reporting more than 12 patients of EPN from 1980 to 2020. We compiled the demographics, clinical presentations, risk factors, critical diagnostic results, treatment modalities and outcomes, including mortality.
RESULTS
We identified 37 observational studies, 32 retrospective and 5 prospective. The studies reported on 1146 patients, of which 790(68.9%) were female, and 946 (82.5%) were diabetic. In addition, 184 (16.1%) patients had stones, and 235 (20.5%) had obstructive uropathy. Fever and flank pain were the most frequent symptoms. The most common clinical features were pyuria, fever, flank tenderness, and tachycardia. E. coli, Klebsiella pneumoniae and Proteus were the most frequent organisms isolated. X-ray KUB and ultrasound were used as initial diagnostic modalities, but CT scan was the usual diagnostic and confirmatory investigation. Confusion, shock, thrombocytopenia, sepsis, emergency nephrectomy and hyponatremia were significantly associated with mortality. In particular, confusion and hyponatremia were associated with a sevenfold increase in mortality risk. There was no evidence that diabetes, stones, obstructive uropathy, AKI or proteinuria was associated with higher mortality. Nevertheless, 143 of the total 1146 patients died (12.5%). While 26% of the patients who had upfront emergency nephrectomy died, only 9.7% and 10% of patients with medical management and medical management plus minimally invasive treatments died. However, patients that failed medical and minimally invasive treatments and needed salvage emergency nephrectomy had a mortality of upwards of 27%.
CONCLUSION
The risk factors for mortality in emphysematous pyelonephritis are shock, thrombocytopenia, confusion, hyponatremia and emergency nephrectomy. Conservative and minimally invasive treatment should be the initial management strategy for emphysematous pyelonephritis as they carry lesser mortality risks. The presence of risk factors may help predict the subset of patients who need aggressive treatment and minimally invasive treatment modalities or early nephrectomy.
Topics: Emphysema; Escherichia coli; Female; Humans; Prospective Studies; Pyelonephritis; Retrospective Studies; Risk Factors; Treatment Outcome
PubMed: 35103928
DOI: 10.1007/s11255-022-03131-6 -
JAMA Jul 2020Many patients with systemic amyloidosis are underdiagnosed. Overall, 25% of patients with immunoglobulin light chain (AL) amyloidosis die within 6 months of diagnosis...
IMPORTANCE
Many patients with systemic amyloidosis are underdiagnosed. Overall, 25% of patients with immunoglobulin light chain (AL) amyloidosis die within 6 months of diagnosis and 25% of patients with amyloid transthyretin (ATTR) amyloidosis die within 24 months of diagnosis. Effective therapy exists but is ineffective if end-organ damage is severe.
OBJECTIVE
To provide evidence-based recommendations that could allow clinicians to diagnose this rare set of diseases earlier and enable accurate staging and counseling about prognosis.
EVIDENCE REVIEW
A comprehensive literature search was conducted by a reference librarian with publication dates from January 1, 2000, to December 31, 2019. Key search terms included amyloid, amyloidosis, nephrotic syndrome, heart failure preserved ejection fraction, and peripheral neuropathy. Exclusion criteria included case reports, non-English-language text, and case series of fewer than 10 patients. The authors independently selected and appraised relevant literature.
FINDINGS
There was a total of 1769 studies in the final data set. Eighty-one articles were included in this review, of which 12 were randomized clinical trials of therapy that included 3074 patients, 9 were case series, and 3 were cohort studies. The incidence of AL amyloidosis is approximately 12 cases per million persons per year and there is an estimated prevalence of 30 000 to 45 000 cases in the US and European Union. The incidence of variant ATTR amyloidosis is estimated to be 0.3 cases per year per million persons with a prevalence estimate of 5.2 cases per million persons. Wild-type ATTR is estimated to have a prevalence of 155 to 191 cases per million persons. Amyloidosis should be considered in the differential diagnosis of adult nondiabetic nephrotic syndrome; heart failure with preserved ejection fraction, particularly if restrictive features are present; unexplained hepatomegaly without imaging abnormalities; peripheral neuropathy with distal sensory symptoms, such as numbness, paresthesia, and dysesthesias (although the autonomic manifestations occasionally may be the presenting feature); and monoclonal gammopathy of undetermined significance with atypical clinical features. Staging can be performed using blood testing only. Therapeutic decision-making for AL amyloidosis involves choosing between high-dose chemotherapy and stem cell transplant or bortezomib-based chemotherapy. There are 3 therapies approved by the US Food and Drug Administration for managing ATTR amyloidosis, depending on clinical phenotype.
CONCLUSIONS AND RELEVANCE
All forms of amyloidosis are underdiagnosed. All forms now have approved therapies that have been demonstrated to improve either survival or disability and quality of life. The diagnosis should be considered in patients that have a multisystem disorder involving the heart, kidney, liver, or nervous system.
Topics: Algorithms; Benzoxazoles; Dexamethasone; Diagnosis, Differential; Gene Silencing; Heart Failure; Humans; Immunoglobulin Light-chain Amyloidosis; Liver Transplantation; Melphalan; Prognosis; Proteinuria; Stem Cell Transplantation
PubMed: 32633805
DOI: 10.1001/jama.2020.5493 -
BMJ Global Health Jan 2022The burden of chronic kidney disease (CKD) is growing rapidly around the world. However, there is limited information on the overall regional prevalence of CKD, as well... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
The burden of chronic kidney disease (CKD) is growing rapidly around the world. However, there is limited information on the overall regional prevalence of CKD, as well as the variations in national prevalence within Asia. We aimed to consolidate available data and quantify estimates of the CKD burden in this region.
METHODS
We systematically searched MEDLINE, Embase and Google Scholar for observational studies and contacted national experts to estimate CKD prevalence in countries of Asia (Eastern, Southern and South Eastern Asia). CKD was defined as estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m or the presence of proteinuria. For countries without reported data, we estimated CKD prevalence using agglomerative average-linkage hierarchical clustering, based on country-level risk factors and random effects meta-analysis within clusters. Published CKD prevalence data were obtained for 16 countries (of the 26 countries in the region) and estimates were made for 10 countries.
RESULTS
There was substantial variation in overall and advanced (eGFR <30 mL/min/1.73 m) CKD prevalence (range: 7.0%-34.3% and 0.1%-17.0%, respectively). Up to an estimated 434.3 million (95% CI 350.2 to 519.7) adults have CKD in Asia, including up to 65.6 million (95% CI 42.2 to 94.9) who have advanced CKD. The greatest number of adults living with CKD were in China (up to 159.8 million, 95% CI 146.6 to 174.1) and India (up to 140.2 million, 95% CI 110.7 to 169.7), collectively having 69.1% of the total number of adults with CKD in the region.
CONCLUSION
The large number of people with CKD, and the substantial number with advanced CKD, show the need for urgent collaborative action in Asia to prevent and manage CKD and its complications.
Topics: Adult; Asia; Asia, Southeastern; Humans; Prevalence; Renal Insufficiency, Chronic; Risk Factors
PubMed: 35078812
DOI: 10.1136/bmjgh-2021-007525 -
Pharmacological Research Nov 2022Coptis Chinensis Franch is widely used in the treatment of diabetes, and berberine is the primary bioactive component in it. Evidence from previous studies has shown... (Meta-Analysis)
Meta-Analysis Review
Coptis Chinensis Franch is widely used in the treatment of diabetes, and berberine is the primary bioactive component in it. Evidence from previous studies has shown that berberine supplementation is effective for treating diabetic nephropathy (DN) in animal models. In this systematic review and meta-analysis, we evaluated the effects and potential mechanisms of action of berberine in animal models of DN. Relevant studies were searched from the English language databases PubMed, Web of Science, and Embase starting from the establishment of the database till June 2022. Twenty-five studies were included, and the risk of bias tool from SYRCLE was used to assess the methodological quality. Statistical analysis was conducted using STATA 15.1. Fasting blood glucose (FBG), blood urea nitrogen (BUN), serum creatinine (SCR), and the kidney index (KI) were the primary outcomes to be analyzed. The overall results showed that berberine improves the indicators of renal function, such as BUN, SCR, proteinuria, and KI. Meanwhile, berberine also improved inflammatory indicators, such as IL-6 and TNF-α, and oxidative stress indicators, such as the superoxide dismutase activity and malondialdehyde content. Additionally, berberine lowered the levels of known risk factors, including triglyceride (TG), total cholesterol (TC), and low-density lipoprotein cholesterol (LDL). These beneficial effects of berberine in DN may be related to its anti-fibrotic, anti-inflammatory, and anti-oxidative stress properties. However, to assess the anti-diabetic nephropathy effects and safety of berberine in a more accurate manner, additional large-scale, long-term, and high-quality preclinical trials are needed to confirm these findings before clinical application.
Topics: Animals; Berberine; Diabetic Nephropathies; Creatinine; Triglycerides; Cholesterol, LDL; Diabetes Mellitus
PubMed: 36195307
DOI: 10.1016/j.phrs.2022.106481 -
Lancet (London, England) Jan 2016Recent hypertension guidelines have reversed previous recommendations for lower blood pressure targets in high-risk patients, such as those with cardiovascular disease,... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Recent hypertension guidelines have reversed previous recommendations for lower blood pressure targets in high-risk patients, such as those with cardiovascular disease, renal disease, or diabetes. This change represents uncertainty about whether more intensive blood pressure-lowering strategies are associated with greater reductions in risk of major cardiovascular and renal events. We aimed to assess the efficacy and safety of intensive blood pressure-lowering strategies.
METHODS
For this updated systematic review and meta-analysis, we systematically searched MEDLINE, Embase, and the Cochrane Library for trials published between Jan 1, 1950, and Nov 3, 2015. We included randomised controlled trials with at least 6 months' follow-up that randomly assigned participants to more intensive versus less intensive blood pressure-lowering treatment, with different blood pressure targets or different blood pressure changes from baseline. We did not use any age or language restrictions. We did a meta-analysis of blood pressure reductions on relative risk (RR) of major cardiovascular events (myocardial infarction, stroke, heart failure, or cardiovascular death, separately and combined), and non-vascular and all-cause mortality, end-stage kidney disease, and adverse events, as well as albuminuria and progression of retinopathy in trials done in patients with diabetes.
FINDINGS
We identified 19 trials including 44,989 participants, in whom 2496 major cardiovascular events were recorded during a mean 3·8 years of follow-up (range 1·0-8·4 years). Our meta-analysis showed that after randomisation, patients in the more intensive blood pressure-lowering treatment group had mean blood pressure levels of 133/76 mm Hg, compared with 140/81 mm Hg in the less intensive treatment group. Intensive blood pressure-lowering treatment achieved RR reductions for major cardiovascular events (14% [95% CI 4-22]), myocardial infarction (13% [0-24]), stroke (22% [10-32]), albuminuria (10% [3-16]), and retinopathy progression (19% [0-34]). However, more intensive treatment had no clear effects on heart failure (15% [95% CI -11 to 34]), cardiovascular death (9% [-11 to 26]), total mortality (9% [-3 to 19]), or end-stage kidney disease (10% [-6 to 23]). The reduction in major cardiovascular events was consistent across patient groups, and additional blood pressure lowering had a clear benefit even in patients with systolic blood pressure lower than 140 mm Hg. The absolute benefits were greatest in trials in which all enrolled patients had vascular disease, renal disease, or diabetes. Serious adverse events associated with blood pressure lowering were only reported by six trials and had an event rate of 1·2% per year in intensive blood pressure-lowering group participants, compared with 0·9% in the less intensive treatment group (RR 1·35 [95% CI 0·93-1·97]). Severe hypotension was more frequent in the more intensive treatment regimen (RR 2·68 [1·21-5·89], p=0·015), but the absolute excess was small (0·3% vs 0·1% per person-year for the duration of follow-up).
INTERPRETATION
Intensive blood pressure lowering provided greater vascular protection than standard regimens. In high-risk patients, there are additional benefits from more intensive blood pressure lowering, including for those with systolic blood pressure below 140 mmHg. The net absolute benefits of intensive blood pressure lowering in high-risk individuals are large.
FUNDING
National Health and Medical Research Council of Australia.
Topics: Albuminuria; Antihypertensive Agents; Australia; Blood Pressure; Blood Pressure Determination; Critical Care; Humans; Hypertension; Hypertensive Retinopathy; Kidney Failure, Chronic; Myocardial Infarction; Practice Guidelines as Topic; Randomized Controlled Trials as Topic; Stroke; Treatment Outcome
PubMed: 26559744
DOI: 10.1016/S0140-6736(15)00805-3 -
JAMA Feb 2015Because early-stage kidney disease is asymptomatic and is associated with both morbidity and mortality, laboratory measurements are required for its detection. (Review)
Review
IMPORTANCE
Because early-stage kidney disease is asymptomatic and is associated with both morbidity and mortality, laboratory measurements are required for its detection.
OBJECTIVE
To summarize evidence supporting the use of laboratory tests for glomerular filtration rate (GFR) and albuminuria to detect and stage acute kidney injury, acute kidney diseases and disorders, and chronic kidney disease in adults.
EVIDENCE REVIEW
We reviewed recent guidelines from various professional groups identified via the National Guideline Clearing House and author knowledge, and systematically searched MEDLINE for other sources of evidence for selected topics.
FINDINGS
The KDIGO (Kidney Disease Improving Global Outcomes) guidelines define and stage acute and chronic kidney diseases by GFR and albuminuria. For initial assessment of GFR, measuring serum creatinine and reporting estimated GFR based on serum creatinine (eGFRcr) using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) 2009 equation is recommended. If confirmation of GFR is required because of conditions that affect serum creatinine independent of GFR (eg, extremes of muscle mass or diet), or interference with the assay, cystatin C should be measured and estimated GFR should be calculated and reported using cystatin C (eGFRcys) and serum creatinine (eGFRcr-cys) or GFR should be measured directly using a clearance procedure. Initial assessment of albuminuria includes measuring urine albumin and creatinine in an untimed spot urine collection and reporting albumin-to-creatinine ratio. If confirmation of albuminuria is required because of diurnal variation or conditions affecting creatinine excretion, such as extremes of muscle mass or diet, the albumin excretion rate should be measured from a timed urine collection.
CONCLUSIONS AND RELEVANCE
Detection and staging of acute and chronic kidney diseases can be relatively simple. Because of the morbidity and mortality associated with kidney disease, early diagnosis is important and should be pursued in at-risk populations.
Topics: Adult; Albuminuria; Creatinine; Cystatin C; Glomerular Filtration Rate; Humans; Kidney Diseases; Kidney Function Tests; Practice Guidelines as Topic
PubMed: 25710660
DOI: 10.1001/jama.2015.0602