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Peritoneal Dialysis-First Policy: Historical and Current Perspectives

Peritoneal dialysis (PD)-First Policy has been established in Hong Kong since 1985 and it has been successful given the collaborative effort from the government, health ministries, medical professionals, patients and caregivers. The PD-First Policy represented a significant advancement in the management of end stage kidney disease (ESKD), building upon historical achievements in PD and embracing the current evidence supporting its clinical, social and economic benefits. By adopting the PD-First Policy, the healthcare system can optimize patient outcomes, enhance resource allocation and improve overall care for ESKD patients. However, addressing the challenges associated with implementation is crucial for realizing the full potential of the PD-First Policy in transforming kidney replacement therapy practice.

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Pretransplant Kidney Function Predicts Sustained Kidney Dysfunction After Living-Donor Liver Transplantation

BACKGROUND: Impaired renal function after liver transplantation would increase the mortality rate. There are few published Taiwanese data on living-donor liver transplantation (LDLT) to evaluate the renal dysfunction after transplantation. We aimed to investigate whether pre-transplant renal function correlates with the renal dysfunction one year after LDLT. METHODS: Patients who received LDLT between January 2003 and January 2019 were enrolled. The primary outcome was sustained estimated glomerular rate (eGFR) of less than 60 mL/min/1.73 m^2 one year after LDLT. RESULTS: A total of 403 patients were enrolled in this study, including 84 with sustained kidney dysfunction (eGFR < 60 mL/min/1.73 m^2 at one year) and 319 without kidney dysfunction (eGFR > 60 mL/min/1.73 m^2). Patients with sustained kidney dysfunction were older (58.6 ± 7.1 vs. 53.5 ± 8.4 years, P < 0.001), had lower serum albumin level (2.7 ± 0.6 vs. 2.9 ± 0.7 g/dL, P = 0.037), and more were diabetic (31% vs. 14.1%, P < 0.001). Multivariable logistic regression showed that age (adjusted odds ratio [OR], 1.08; 95% confidence interval [CI], 1.04-1.13; P < 0.001), eGFR (adjusted OR per 10 mL/ min/1.73 m^2, 0.74; 95% CI, 0.68-0.82; P < 0.001), diabetes (adjusted OR, 2.60; 95% CI, 1.28-5.27; P = 0.008) and perioperative acute kidney injury (AKI) (adjusted OR, 2.54; 95% CI, 1.42-4.55; P = 0.002) were independent predictors for sustained kidney dysfunction. Furthermore, the association of pretransplant eGFR with the risk of kidney dysfunction one year after LDLT was linear (P < 0.001). CONCLUSION: We found that pretransplant kidney function as well as age, diabetes and perioperative AKI were independent risk factors for sustained kidney dysfunction one year after LDLT. With regard to recipients with pretransplant eGFR of less than 60 mL/min/1.73 m^2, nephrologists should screen to find out correctable factors for CKD and intervene early.

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The Roles of Sacubitril/Valsartan in Major Adverse Cardiovascular Events and Renal Function Decline in Hypertensive Patients With Heart Failure

BACKGROUND: Several recent studies suggest that sacubitril/valsartan use improves patients' renal function. However, the United Kingdom Heart and Renal Protection-III trial showed no effect of this treatment on kidney function compared with irbesartan; thus, more real-world studies of sacubitril/ valsartan's effects are needed. In addition, most studies in hypertensive patients only focused on reducing blood pressure. None of the studies investigated renal function in hypertensive patients. METHODS: To compare the clinical outcomes of sacubitril/valsartan use and nonuse in hypertensive patients with heart failure. Real-world cohort study in Taiwan. Patients aged ≥ 20 years who were diagnosed with heart failure and hypertension between March 1, 2017, and March 1, 2020, were included. We examined data from 1,916 propensity score-matched sacubitril/valsartan users and controls. Cox regression models and survival analysis were used to compare the outcomes of interest (all-cause mortality, major adverse cardiovascular events and renal adverse outcomes [i.e., end-stage renal disease, ESRD]). The patients were followed until death or the end of the study period. RESULTS: After propensity score matching, a Cox proportional-hazards model showed that sacubitril/valsartan use was associated with lower risks of ESRD (hazard ratio [HR], 0.73; 95% confidence interval [CI], 0.50-0.99; P = 0.040) and ischemic stroke (HR, 0.41; 95% CI, 0.26-0.65; P < 0.001). A Kaplan-Meier survival curve revealed that sacubitril/valsartan use was associated with lower risks of ESRD (P = 0.046) and ischemic stroke (P < 0.001). Ejection fraction (EF) changes on cardiograms after sacubitril/valsartan use and a survival curve showed that sacubitril/valsartan use was associated with better EF outcomes (P = 0.040). CONCLUSIONS: Sacubitril/valsartan use decreased the deterioration of renal function and was associated with lower risks of ischemic stroke. It was also associated with EF improvement on transthoracic echocardiograms.

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Estimated Glomerular Filtration Rate < 60 mL/min/1.73 m^2 is Associated With Abnormal Ankle- and Toe-Brachial Index in Type 2 Diabetes Mellitus

BACKGROUND: Diabetes mellitus (DM) is associated with many complications including cardiovascular disease, nephropathy, neuropathy, retinopathy and peripheral arterial occlusive disease (PAOD). Ankle-brachial index (ABI) and toe-brachial index (TBI) are used to detect PAOD, which were cost-effective and non-invasive. The patients with chronic kidney disease have higher prevalence of developing PAOD. The aim of our study is to understand the correlation between estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m^2 with ABI < 0.9, and TBI < 0.65 and further survey the risk factors for ABI < 0.9 and TBI < 0.65 in different subgroup (eGFR ≥ 60 and < 60 mL/min/1.73 m^2) in type 2 DM patients. METHODS: Patients with type 2 DM who visited the Endocrinology and Metabolism outpatient department of the Southern Taiwan medical center between February 2022 and May 2022 were included in the study. The ABI and TBI measurements were done once for each patient. PAOD was defined as ABI < 0.9 or TBI below 0.65 in either leg. RESULTS: The mean age of 374 type 2 DM patients was 67.3 ± 11.0 years. The prevalence of ABI < 0.9 and TBI < 0.65 were 10.2% and 28.3%, respectively. After multivariable adjustment, eGFR < 60 mL/min/1.73 m^2 (odds ratio [OR] = 2.560; 95% confidence interval [CI] = 1.028-6.375; P = 0.043) was significantly associated with ABI < 0.9 in all study patients. Besides, eGFR < 60 mL/min/1.73 m^2 (OR = 2.158; 95% CI = 1.263-3.688; P = 0.005) was significantly associated with TBI < 0.65 in all study patients. Furthermore, microalbuminuria (OR = 2.910; 95% CI = 1.226-6.907; P = 0.015) was significantly associated with TBI < 0.65 in inpatients with eGFR ≥ 60 mL/min/1.73 m^2. CONCLUSIONS: Our study disclosed that eGFR < 60 mL/min/1.73 m^2 was associated with ABI < 0.9 and TBI < 0.65 in type 2 DM patients. Further, in the group of eGFR ≥ 60 mL/min/1.73 m^2, microalbuminuria is associated with TBI < 0.65. The results may help to shed light on the importance of eGFR and albuminuria on PAOD in this population.

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Machine Learning to Predict Complications After Percutaneous Native Kidney Needle Biopsy

BACKGROUND: Risk prediction models for post-biopsy complication have not been developed. The study aimed to develop and validate a model to predict post-biopsy complication. METHODS: Participants who underwent percutaneous native kidney biopsy in Taoyuan General Hospital from 2014 to 2023 were enrolled. Demographic data, comorbidities, laboratory data and procedure-related characteristics were assessed. We defined post-biopsy minor complications according to macrohematuria, perirenal hematoma and hemoglobin drop. Major complications were defined as those who need intervention. The 16 factors machine learning models, such as random forest (RF), logistic regression (LR), K-nearest neighbor (KNN), multilayer perceptron (MLP) and sector vector machine (SVM) were used and the 6 most critical risk factors were extracted by feature selection. Model performance was evaluated by area under receiver operating characteristic (AUROC) curve. To avoid overfitting and distorted effect of imbalanced data, we also compared accuracy, F1 score, and positive predictive value. RESULTS: From a total of 694 subjects, 561 vs. 133 participants were classified as development vs. validation dataset. The complication rates were 5.7% vs. 9.7%, respectively. After feature selection, bleeding time, creatinine, hemoglobin, proteinuria, parenchymal thickness, and liver function were essential to predict complications. Despite low sensitivity, RF is the best prediction model according to AUROC (0.943 [0.901-0.985] vs. 0.910 [0.837-0.982]), accuracy (0.973 vs. 0.960) and F1 score (0.727 vs. 0.758). The prediction performance of 6-factors RF model was non-inferior to 16-factors model (AUROC: 0.943 vs. 0.900 and 0.910 vs. 0.869, P > 0.05). CONCLUSION: The study demonstrated the feasibility of 6-factors RF model to predict post-biopsy complications.

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Focal Segmental Glomerulosclerosis Following Nuvavxovid COVID-19 Vaccine: A Case Report and Literature Review

Nephrotic syndrome after COVID-19 vaccination is an uncommon complication. It was only reported in patients receiving viral vector or mRNA COVID-19 vaccines from current literature. We report a case of a 30-year-old male developing nephrotic syndrome after COVID-19 vaccination (Nuvavxovid®, recombinant protein vaccine) with biopsy-proven pathologic diagnosis of focal segmental glomerulosclerosis. We assumed that the nephrotic syndrome in this patient was most likely attributed to COVID-19 vaccination from the timeline and the serologic workup. After diagnosis, this patient started to receive a standard dose of oral prednisolone (1 mg/kg/day). Diuresis with urine bubble disappearance was noted 8 days after steroid therapy was initiated. Complete remission of his nephrotic syndrome was achieved thereafter. He remained in remission after 1 year since steroid initiation.