Prevalence, Risk Factors, and Awareness of Chronic Kidney Disease among Diabetes Mellitus and Hypertensive Individuals at the Buea Regional Hospital, Cameroon

Background: Kidney failure, cardiovascular disease, and early mortality are just a few of the major negative effects of chronic renal disease, a serious global health issue. The considerable financial and public health burden associated with chronic kidney disease can be lessened by raising awareness and adopting better practices for its impact, prevention, and early identification. Objective: In this study, individuals with hypertension and diabetes were evaluated for their knowledge of chronic kidney disease, its prevalence, and its risk factors. Method: It was a hospital-based cross-sectional study conducted on adult (>18 years) patients with diabetes mellitus and hypertension. Each participant provided written informed consent before having their data collected through interviews, medical information, and blood samples for CKD screening. The CKD epidemiology collaboration (CKD-EPI) equation was used to calculate the glomerular filtration rate (GFR) from serum creatinine, and CKD was determined using the estimated GFR (e-GFR). To find independent CKD factors, multivariate logistic regression was employed, with a p-value of 0.05 being regarded as statistically significant. This was accomplished using SPSS (Statistical Program for Social Sciences) version 22.0, IBM Corp., Armonk, NY. Result: A total of 156 participants took part in the study among which 95 (60.9%) were male, most of the participants 82 (52.6%) were aged between 51 - 70 years (mean 59.42 ± 11.007), 76 (48.7%) were unemployed and 97 (62.2%) were single. Overall, the knowledge score of participants on CKD was 65.4% for good knowledge and 34.6% for poor or inadequate knowledge of CKD. More than half of the participants (60%) had chronic kidney disease. Among these, the greatest proportion of CKD patients were those who were hypertensive (88.2%) followed by those who were both hypertensive and diabetic (70.7%). Conclusion: There is poor management of CKD in the South West Region of Cameroon which has contributed greatly to the progression of CKD and increases in the mortality rate.

Utilising continuous glucose monitoring for glycemic control in diabetic kidney disease

In this editorial,we comment on the article by Zhang et al.Chronic kidney disease(CKD)presents a significant challenge in managing glycemic control,especially in diabetic patients with diabetic kidney disease undergoing dialysis or kidney transplantation.Conventional markers like glycated haemoglobin(HbA1c)may not accurately reflect glycemic fluctuations in these populations due to factors such as anaemia and kidney dysfunction.This comprehensive review discusses the limitations of HbA1c and explores alternative methods,such as continuous glucose monitoring(CGM)in CKD patients.CGM emerges as a promising technology offering real-time or retrospective glucose concentration measure-ments and overcoming the limitations of HbA1c.Key studies demonstrate the utility of CGM in different CKD settings,including hemodialysis and peritoneal dialysis patients,as well as kidney transplant recipients.Despite challenges like sensor accuracy fluctuation,CGM proves valuable in monitoring glycemic trends and mitigating the risk of hypo-and hyperglycemia,to which CKD patients are prone.The review also addresses the limitations of CGM in CKD patients,emphasizing the need for further research to optimize its utilization in clinical practice.Altogether,this review advocates for integrating CGM into managing glycemia in CKD patients,highlighting its superiority over traditional markers and urging clinicians to consider CGM a valuable tool in their armamentarium.

Role of vitamin D in diabetes mellitus and chronic kidney disease

Approximately 30%-50% of people are recognized to have low levels of vitamin D,and insufficiency and deficiency of vitamin D are recognized as global health problems worldwide.Although the presence of hypovitamin D increases the risk of rickets and fractures,low vitamin D levels are also associated with hypertension,cancer,and cardiovascular disease.In addition,diabetes mellitus(DM) and chronic kidney disease(CKD) are also related to vitamin D levels.Vitamin D deficiency has been linked to onset and progression of DM.Although in patients with DM the relationship between vitamin D and insulin secretion,insulin resistance,and β-cell dysfunction are pointed out,evidence regarding vitamin D levels and DM is contradictory,and well controlled studies are needed.In addition,vitamin D influences the renin-angiotensin system,inflammation,and mineral bone disease,which may be associated with the cause and progression CKD.There is increasing evidence that vitamin D deficiency may be a risk factor for DM and CKD;however,it remains uncertain whether vitamin D deficiency also predisposes to death from DM and CKD.Although at this time,supplementation with vitamin D has not been shown to improve glycemic control or prevent incident DM,clinical trials with sufficient sample size,study periods,and optimal doses of vitamin D supplementation are still needed.This review focuses on the mechanism of vitamin D insufficiency and deficiency in DM or CKD,and discusses the current evidence regarding supplementation with vitamin D in patients with these diseases.

Diabetes mellitus increases the prevalence of anemia in patients with chronic kidney disease:A nested case-control study

AIM: To compare anemia prevalence between matched chronic kidney disease(CKD) patients with and without diabetes mellitus(DM) and to assess factors associated with anemia development.METHODS: This is a nested case-control study of 184 type-2 diabetic and 184 non-diabetic CKD patients from a prospectively assembled database of a Nephrology outpatient clinic, matched for gender, age and estimated glomerular filtration rate(eG FR). Prevalence of anemia(hemoglobin: Men: < 13 g/dL, women: < 12 g/dL and/or use of recombinant erythropoietin) was examined in comparison, in the total population and by CKD Stage. Univariate and multivariate logistic regression analyses were conducted to identify factors associated with anemia.RESULTS: The total prevalence of anemia was higher in diabetics(47.8% vs 33.2%, P = 0.004). Accordingly, prevalence was higher in diabetics in CKD Stage 3(53.5% vs 33.1%, P < 0.001) and particularly in Stage 3a(60.4% vs 26.4%, P < 0.001), whereas it was nonsignificantly higher in Stage 4(61.3% vs 48.4%; P = 0.307). Serum ferritin was higher in diabetics in total and in CKD stages, while serum iron was similar between groups. In multivariate analyses, DM(OR = 2.206, 95%CI: 1.196-4.069), CKD Stages 3a, 3b, 4(Stage 4: OR = 12.169, 95%CI: 3.783-39.147) and serum iron(OR = 0.976, 95%CI: 0.968-0.985 per mg/d L increase) were independently associated with anemia.CONCLUSION: Prevalence of anemia progressively increases with advancing stages of CKD and is higher in diabetic than matched non-diabetic CKD patients and diabetes is independently associated with anemia occurrence. Detection and treatment of anemia in diabetic CKD patients should be performed earlier than non-diabetic counterparts.

Vitamin D levels in subjects with or without chronic kidney disease among Veterans with diabetes in North East United States

AIM To evaluate the prevalence of vitamin D deficiency and its relation to diabetes and kidney disease in Veterans residing in the North East United States(VISN 2). METHODS In this retrospective study, we used data from the computerized patient record system at Stratton Veterans Administration Medical Center at Albany, NY(VHA) for those patients who had 25-hydroxyvitamin D levels and 1,25(OH) vitamin D levels measured between 2007 and 2010. We collected demographic information including age, sex, body mass index and race; clinical data including diabetes, hypertension and CAD; and laboratory data including calcium, creatinine and parathyroid hormone(PTH)(intact). Vitamin D deficiency is defined as a serum 25-hydroxyvitamin D level of less than 20 ng/mL(50 nmol/L), and insufficiency is defined as a serum 25-hydroxyvitamin D level of 20 to 30 ng/mL(50 to 75 nmol/L). RESULTS Data was available for approximately 68000 subjects. We identified 64144 subjects for analysis after exclusion of duplicates. Among them, 27098 had diabetes. Themean age of subjects with diabetes was 68 ± 11 with a mean body mass index(BMI) of 32 ± 7 and duration of diabetes of 5.6 ± 3.2 years. The mean 25(OH) vitamin D level among subjects with diabetes was 27 ± 11.6. There was no significant difference in 25(OH) vitamin D levels between subjects with diabetes and glomerular filtration rate(e-GFR) < 60 compared to those with e-GFR ≥ 60. As expected, subjects with e-GFR < 60 had significantly lower 1,25(OH) vitamin D levels and significantly elevated PTH-intact. Of the 64144 subjects, 580 had end-stage renal disease. Of those, 407 had diabetes and 173 did not. Vitamin D levels in both groups were in the insufficiency range and there was no significant difference irrespective of presence or absence of diabetes. Subjects with vitamin D levels less than 20 ng/mL had a higher BMI and elevated PTH, and higher HbA 1C levels compared to those with vitamin D levels more than 20 ng/mL. CONCLUSION We conclude that we need to keep a close eye on vitamin D levels in subjects with mild chronic kidney disease as well as those with moderate control of diabetes.

Risk factors and urinary biomarkers of non-albuminuric and albuminuric chronic kidney disease in patients with type 2 diabetes

BACKGROUND A number of recent studies indicate a transformation in the natural course of chronic kidney disease(CKD)in type 2 diabetes(T2D)patients:an increasing prevalence of declined renal function without proceeding to the accompanying elevation of albuminuria.It has been suggested that albuminuric and nonalbuminuric CKD patterns could be different in their phenotypes and pathogenic mechanisms.AIM To identify the risk factors and biomarkers of albuminuric and non-albuminuric patterns of CKD in patients with T2D.METHODS Three hundred sixty patients with T2D duration≥10 years were included in this observational cross-sectional study.The associations of a panel of demographic and clinical characteristics,complications,comorbidities,and metabolic and hematology parameters with albuminuric and non-albuminuric CKD patterns were analyzed.The urinary excretion of nephrin and podocin,two podocytespecific markers,and WAP-four-disulfide core domain protein 2(WFDC-2),a marker of tubulointerstitial fibrosis,was determined by ELISA in comparison with healthy controls.RESULTS Non-albuminuric CKD was associated with age≥65 years(P=0.0001),female sex(P=0.04),diabetes duration≥15 years(P=0.0009),and the use of diuretics(P=0.0005).Male sex(P=0.01),smoking(P=0.01),waist-to-hip ratio>1.0(P=0.01)and hemoglobin A1c(HbA1c)>8.0%(P=0.005)were risk factors for elevated albuminuria not accompanied by a decrease in estimated glomerular filtration rate(eGFR).Duration of diabetes≥15 years and the use of calcium channel blockers were risk factors for albuminuria with decreased eGFR(both P=0.01).In multivariate logistic regression analysis,age,HbA1c,female sex and diuretics were significant predictors for reduced eGFR,while waist-to-hip ratio,HbA1c and male sex were associated with elevated urinary albumin-to-creatinine ratio(UACR).Excretion of nephrin and podocin was increased in patients with albuminuria,regardless of decline in renal function(P<0.001),correlating positively with UACR.The urinary excretion of WFDC-2 was markedly higher in men than in women(P<0.000001).Men with T2D demonstrated increased WFDC-2 levels independently of the CKD pattern(all P<0.05).In T2D women,WFDC-2 excretion was increased in those with reduced renal function(P≤0.01),correlating negatively with eGFR.CONCLUSION The data provide further evidence that albuminuric and non-albuminuric CKD phenotypes correspond to different pathways of diabetic kidney disease progression.

Performance of Dexcom G5 and FreeStyle Libre sensors tested simultaneously in people with type 1 or 2 diabetes and advanced chronic kidney disease

BACKGROUND Advanced chronic kidney disease(CKD) is a common complication for people with type 1 and 2 diabetes and can often lead to glucose instability. Continuous glucose monitoring(CGM) helps users monitor and stabilize their glucose levels. To date, CGM and intermittent scanning CGM are only approved for people with diabetes but not for those with advanced CKD.AIM To compare the performance of Dexcom G5 and FreeStyle Libre sensors in adults with type 1 or 2 diabetes and advanced CKD.METHODS This was a non-randomized clinical trial that took place in two outpatient clinics in western Sweden. All patients with type 1 or 2 diabetes and an estimated glomerular filtration rate(eGFR) of < 30 mL/min per 1.73 m^(2) were invited to participate. Forty patients(full analysis set = 33) carried the Dexcom G5 sensor for 7 d and FreeStyle Libre sensor for 14 d simultaneously. For referencing capillary blood glucose(SMBG) was measured with a high accuracy glucose meter(HemoCue®) during the study period. At the end of the study, all patients were asked to answer a questionnaire on their experience using the sensors.RESULTS The mean age was 64.1(range 41-77) years, hemoglobin A1 c was 7.0% [standard deviation(SD) 3.2], and diabetes duration was 28.5(SD 14.7) years. A total of 27.5% of the study population was on hemodialysis and 22.5% on peritoneal dialysis. The mean absolute relative difference for Dexcom G5 vs SMBG was significantly lower than that for FreeStyle Libre vs SMBG [15.2%(SD 12.2) vs 20.9%(SD 8.6)], with a mean difference of 5.72 [95% confidence interval(CI): 2.11-9.32;P = 0.0036]. The mean absolute difference was also significantly lower for Dexcom G5 than for FreeStyle Libre, 1.21 mmol/L(SD 0.78) and 1.76 mmol/L(SD 0.78), with a mean diffrenec of 0.55(95%CI: 0.27-0.83;P = 0.0004).The mean difference(MD) was-0.107 mmol/L and-1.10 mmol/L(P = 0.0002), respectively. In all, 66% of FreeStyle Libre values were in the no risk zone on the surveillance error grid compared to 82% of Dexcom G5 values.CONCLUSION Dexcom G5 produces more accurate sensor values than FreeStyle Libre in people with diabetes and advanced CKD and is likely safe to be used by those with advanced CKD.

Research progress between gut microbiota, diabetes mellitus and chronic kidney disease

In recent years, gut microbiota has become one of the hot spots of research. A large number of studies have shown that gutmicrobiota are closely related to a variety of diseases. Diabetes and chronic kidney disease as a multifactorial cause are also affected by the gutmicrobiota. Inthefuture, gut microbiota may become a new therapeutic strategy. This article focuses on the relationship between gutmicrobiota and diabetes and chronic kidney disease, and reviews its research progress in the pathogenesis and treatment of diabetes and chronic kidney disease.

Can Peripheral Venous Gases Replace Arterial Gases in a Patient with Chronic Kidney Disease?

Introduction: Metabolic acidosis (MA) is a frequent alteration in chronic kidney disease (CKD) that is associated with numerous complications, which is why its correction is recommended. Oral sodium bicarbonate is currently the treatment of choice. Objective: The objective is to determine if venous bicarbonate is equal to arterial bicarbonate in the follow-up of a patient with chronic kidney disease. Materials Methods: Single-center Cross-sectional studies in a cohort of adult patients with stage 4 - 5 CKD. Samples were taken between January 2022 and January 2023, in a Clinic in the city of Ibague/ Colombia obtained from the radial artery. The inclusion criteria were: not being treated with alkaline at the time of inclusion. Results: A total of 71 patients were included, 73.2% male (52) and 26.8% female (19), with different stages: stage 3 with 5.6% (4), stage 4 with 60.6% (43), stage 5 with 33.8% (23). 66.2% were diabetic, 88.7% had arterial hypertension, and 15.5% of the patients presented hematoma as a complication and pain associated with arterial puncture. The result of mean venous bicarbonate was 18.8 with a standard deviation of 2.3, arterial bicarbonate a mean of 19.4 with a standard deviation of 2.1 with a value of P 0.46, venous pH with a mean of 7.37 with a standard deviation of 0.48 and a mean arterial pH of 7.38 with a standard deviation of 0.48 with a P value of 0.01. Values of venous bicarbonate compared to arterial bicarbonate showed no statistically significant difference in patients with chronic kidney disease, but there were more complications such as hematoma and pain in patients in the arterial puncture cohort, because of this result venous bicarbonate corresponds to arterial bicarbonate, but has less risk of complications associated with the procedure. Conclusion: Metabolic acidosis is a frequent alteration in advanced chronic kidney disease, these results showed that the values of arterial and venous bicarbonate have no statistically significant differences, but there is a greater risk of complications with arterial blood gases, due to this, venous bicarbonate could be a useful tool for patients with chronic kidney disease.

Diabetic patients with chronic kidney disease: Non-invasive assessment of cardiovascular risk

The prevalence and burden of diabetes mellitus and chronic kidney disease on global health and socioeconomic development is already heavy and still rising.Diabetes mellitus by itself is linked to adverse cardiovascular events,and the presence of concomitant chronic kidney disease further amplifies cardiovascular risk.The culmination of traditional(male gender,smoking,advanced age,obesity,arterial hypertension and dyslipidemia)and non-traditional risk factors(anemia,inflammation,proteinuria,volume overload,mineral metabolism abnormalities,oxidative stress,etc.)contributes to advanced atherosclerosis and increased cardiovascular risk.To decrease the morbidity and mortality of these patients due to cardiovascular causes,timely and efficient cardiovascular risk assessment is of huge importance.Cardiovascular risk assessment can be based on laboratory parameters,imaging techniques,arterial stiffness parameters,ankle-brachial index and 24 h blood pressure measurements.Newer methods include epigenetic markers,soluble adhesion molecules,cytokines and markers of oxidative stress.In this review,the authors present several non-invasive methods of cardiovascular risk assessment in patients with diabetes mellitus and chronic kidney disease.

Percutaneous Angioplasty in Diabetic Patients with Critical Limb Ischemia and Chronic Kidney Disease

Introduction: Diabetes and Chronic Kidney Disease (CKD) are two strong risk factors for peripheral arterial disease (PAD) and Critical Limb Ischemia (CLI). Further renal insufficiency increases the risk of non healing wounds and major amputation. Primary amputation rates of 22% to 44% have been reported for ischaemic foot lesion in End-Stage Renal Disease (ESRD) patients. In our study we evaluated the outcomes after Percutaneus Transluminal Angioplasty (PTA) in diabetic patient in relation to different CKD classes. Materials and Methods: We studied a group of 456 diabetic patients with PAD complicated by foot lesion who underwent PTA because of a CLI. According to the estimated Glomerular Filtration Rate (eGFR mL/min/1.73 m2) we divided the patients into five CKD groups: group 1 eGFR > 90, group 2 eGFR 90 - 60 (n = 160), group 3 eGFR 60 - 30 (n = 152), group 4 eGFR 30 -15 (n = 34) and group 5 < 15 or in ESRD) (n = 60). The following outcomes were recorded: alive without major amputation, alive with major amputation and death. The follow-up was 16.7 ± 14.3 months. Results: Alive without major amputation, alive with major amputation and death were respectively: for group 1 (77.8%, 11.1%, 11.1%), for group 2 (74.4%, 12.5%, 13.1%), for group 3 (80.3%, 11.2%, 8.5%), for group 4 (82.3%, 8.8%, 8.8%). They were 60%, 18.3%, 21.7% for group 5 significantly different from the other CKD groups (χ2 = 0.0175). Our analysis did not highlight any relationship between eGFR and outcomes and eGFR did not show any significant difference according to the different outcomes, and were respectively 60.2 ± 1.3, 61.8 ± 3.4, 63.8 ± 3.5 (P = ns). Conclusion: The outcomes were similar for groups 1-4 and therefore, according to our data, they seemed not to be influenced by the decline of GFR. Outcomes worse significantly in group 5, but this group included only patients with ESRD in dialysis treatment. Although the outcomes after PTA in group 5 was significantly worse than the other groups, still a 60% limb salvage rate was obtained with PTA also in these very fragile patients. PTA was much less aggressive than by-pass and PTA was the only method used to treat CLI in our patients. This could explain why we recorded similar outcomes in all groups despite the decline of GFR that, generally speaking, mirrors a worsening of the general clinical conditions. Worse outcomes were recorded only in group 5 and in this group dialysis by itself might be responsible of the different outcomes.

Simultaneous pancreas-kidney transplantation for end-stage renal failure in type 1 diabetes mellitus: Current perspectives

Type 1 diabetes mellitus(T1DM)is one of the important causes of chronic kidney disease(CKD)and end-stage renal failure(ESRF).Even with the best available treatment options,management of T1DM poses significant challenges for clinicians across the world,especially when associated with CKD and ESRF.Substantial increases in morbidity and mortality along with marked rise in treatment costs and marked reduction of quality of life are the usual consequences of onset of CKD and progression to ESRF in patients with T1DM.Simultaneous pancreas-kidney transplant(SPK)is an attractive and promising treatment option for patients with advanced CKD/ESRF and T1DM for potential cure of these diseases and possibly several complications.However,limited availability of the organs for transplantation,the need for long-term immunosuppression to prevent rejection,peri-and post-operative complications of SPK,lack of resources and the expertise for the procedure in many centers,and the cost implications related to the surgery and postoperative care of these patients are major issues faced by clinicians across the globe.This clinical update review compiles the latest evidence and current recommendations of SPK for patients with T1DM and advanced CKD/ESRF to enable clinicians to care for these diseases.

Effects of glycaemic management on diabetic kidney disease

Hyperglycaemia contributes to the onset and progression of diabetic kidney disease(DKD). Observational studies have not consistently demonstrated a glucose threshold, in terms of HbA1c levels, for the onset of DKD. Tight glucose control has clearly been shown to reduce the incidence of micro-or macroalbuminuria. However, evidence is now also emerging to suggest that intensive glucose control can slow glomerular filtration rate loss and possibly progression to end stage kidney disease. Achieving tight glucose control needs to be balanced against the increasing appreciation that glucose targets for the prevention of diabetes related complications need be individualised for each patient. Recently, empagliflozin which is an oral glucose lowering agent of the sodium glucose cotransporter-2 inhibitor class has been shown to have renal protective effects. However, the magnitude of empagliflozin's reno-protective properties are over and above that expected from its glucose lowering effects and most likely largely result from mechanisms involving alterations in intra-renal haemodynamics. Liraglutide and semaglutide, both injectable glucose lowering agents which are analogues of human glucagon like peptide-1 have also been shown to reduce progression to macroalbuminuria through mechanisms that remain to be fully elucidated. Here we review the evidence from observational and interventional studies that link good glucose control with improved renal outcomes. We also briefly review the potential reno-protective effects ofnewer glucose lowering agents.

Diabetes treatment in patients with renal disease: Is the landscape clear enough?

Diabetes is the most important risk factors for chronic kidney disease(CKD). The risk of CKD attributable to diabetes continues to rise worldwide. Diabetic patients with CKD need complicated treatment for their metabolic disorders as well as for related comorbidities. They have to treat, often intensively, hypertension, dyslipidaemia, bone disease, anaemia, and frequently established cardiovascular disease. The treatment of hypoglycaemia in diabetic persons with CKD must tie their individual goals of glycaemia(usually less tight glycaemic control) and knowledge on the pharmacokinetics and pharmacodynamics of drugs available to a person with kidney disease. The problem is complicated from the fact that in many efficacy studies patients with CKD are excluded so data of safety and efficacy for these patients are missing. This results in fear of use by lack of evidence. Metformin is globally accepted as the first choice in practically all therapeutic algorithms for diabetic subjects. The advantages of metformin are low risk of hypoglycaemia, modest weight loss, effectiveness and low cost. Data of UKPDS indicate that treatment based on metformin results in less total as well cardiovascular mortality. Metformin remains the drug of choice for patients with diabetes and CKD provided that their estimate Glomerular Filtration Rate(eGFR) remains above 30 mL/min per square meter. For diabetic patients with eGFR between 30-60 mL/min per square meter more frequent monitoring of renal function and dose reduction of metformin is needed. The use of sulfonylureas, glinides and insulin carry a higher risk of hypoglycemia in these patients and must be very careful. Lower doses and slower titration of the dose is needed. Is better to avoid sulfonylureas with active hepatic metabolites, which are renally excreted. Very useful drugs for this group of patients emerge dipeptidyl peptidase 4 inhibitors. These drugs do not cause hypoglycemia and most of them(linagliptin is an exception) require dose reduction in various stages of renal disease.

Stop chronic kidney disease progression: Time is approaching

Progression of chronic kidney disease （CKD） is inevitable. However, the last decade has witnessed tremendous achievements in this field. Today we are optimistic; the dream of withholding this progression is about to be realistic. The recent discoveries in the field of CKD management involved most of the individual diseases leading the patients to end-stage renal disease. Most of these advances involved patients suffering diabetic kidney disease, chronic glomerulonephritis, polycystic kidney disease, renal amyloidosis and chronic tubulointer-stitial disease. The chronic systemic inflammatory status and increased oxidative stress were also inve-stigated. This inflammatory status influences the anti-senescence Klotho gene expression. The role of Klotho in CKD progression together with its therapeutic value are explored. The role of gut as a major source of infam-mation, the pathogenesis of intestinal mucosal barrier damage, the role of intestinal alkaline phosphatase and the dietary and therapeutic implications add a novel therapeutic tool to delay CKD progression.

Patient selection and preparation strategies for the use of contrast material in patients with chronic kidney disease

The prevalence of chronic kidney disease and peripheral arterial disease is increasing.Thus,it is increasingly problematic to image these patients as the number of patients needing a vascular examination is increasing accordingly.In high-risk patients with impaired kidney function,intravascular administration of iodinated contrast media can result in contrast-induced acute kidney injury and Gadolinium can induce nephrogenic systemic fibrosis(NSF).It is important to identify these highrisk patients by means of se-creatinine/e glomerular filtration rate.The indication for contrast examination should counterbalance the increased risk.One or more alternative examination methods without contrast media,such as CO 2 angiography,Ultrasound/Doppler examination or magnetic resonance angiography without contrast should be considered,but at the same time,allow for a meaningful outcome of the examination.If contrast is deemed essential,the patient should be well hydrated,the amount of contrast should be restricted,the examination should be focused,metformin and diuretics stopped,and renal function monitored.Sodium bicarbonate and N-acetylcysteine are popular but their efficiency is not evidence-based.There is no evidence that dialysis protects patients with impaired renal function from contrast-induced nephropathy or NSF.

Uric acid and chronic kidney disease: A time to act?

A role for uric acid in the pathogenesis and progression of renal disease had been proposed almost a century ago, but, too hastily dismissed in the early eighties. A body of evidence, mostly accumulated during the last decade, has led to a reappraisal of the infuence of uric acid on hypertension, cardiovascular, and renal disease. The focus of this review will be solely on the relationship between serum uric acid and renal function and disease. We will review experimental evidence derived from ani-mal and human studies, evidence gathered from a num-ber of epidemiological studies, and from the few （up to now） studies of uric-acid-lowering therapy. Some space will be also devoted to the effects of uric acid in special populations, such as diabetics and recipients of kidney allografts. Finally we will briefy discuss the challenges of a trial of uric-acid-lowering treatment, and the recent suggestions on how to conduct such a trial.

Erectile dysfunction in chronic kidney disease:From pathophysiology to management

Chronic kidney disease(CKD) is encountered in millions of people worldwide,with continuously rising incidence during the past decades,affecting their quality of life despite the increase of life expectancy in these patients.Disturbance of sexual function is common among men with CKD,as both conditions share common pathophysiological causes,such as vascular or hormonal abnormalities and are both affected by similar coexisting comorbid conditions such as cardiovascular disease,hypertension and diabetes mellitus.The estimated prevalence of erectile dysfunction reaches 70% in end stage renal disease patients.Nevertheless,sexual dysfunction remains under-recognized and under-treated in a high proportion of these patients,a fact which should raise awareness among clinicians.A multifactorial approach in management and treatment is undoubtedly required in order to improve patients' quality of life and cardiovascular outcomes.

Interplay between metabolic dysfunction-associated fatty liver disease and chronic kidney disease:Epidemiology,pathophysiologic mechanisms,and treatment considerations

The recently proposed nomenclature change from non-alcoholic fatty liver disease to metabolic dysfunction-associated fatty liver disease(MAFLD)has resulted in the reappraisal of epidemiological trends and associations with other chronic diseases.In this context,MAFLD appears to be tightly linked to incident chronic kidney disease(CKD).This association may be attributed to multiple shared risk factors including type 2 diabetes mellitus,arterial hypertension,obesity,dyslipidemia,and insulin resistance.Moreover,similarities in their molecular pathophysiologic mechanisms can be detected,since inflammation,oxidative stress,fibrosis,and gut dysbiosis are highly prevalent in these pathologic states.At the same time,lines of evidence suggest a genetic predisposition to MAFLD due to gene polymorphisms,such as the PNPLA3 rs738409 G allele polymorphism,which may also propagate renal dysfunction.Concerning their management,available treatment considerations for obesity(bariatric surgery)and novel antidiabetic agents(glucagon-like peptide 1 receptor agonists,sodiumglucose co-transporter 2 inhibitors)appear beneficial in preclinical and clinical studies of MAFLD and CKD modeling.Moreover,alternative approaches such as melatonin supplementation,farnesoid X receptor agonists,and gut microbiota modulation may represent attractive options in the future.With a look to the future,additional adequately sized studies are required,focusing on preventing renal complications in patients with MAFLD and the appropriate management of individuals with concomitant MAFLD and CKD.

Diabetic kidney disease:Are the reported associations with singlenucleotide polymorphisms disease-specific?

BACKGROUND The genetic backgrounds of diabetic kidney disease(DKD)and end-stage kidney disease(ESKD)have not been fully elucidated.AIM To examine the individual and cumulative effects of single-nucleotide polymorphisms(SNPs)previously associated with DKD on the risk for ESKD of diabetic etiology and to determine if any associations observed were specific for DKD.METHODS Fourteen SNPs were genotyped in hemodialyzed 136 patients with diabetic ESKD(DKD group)and 121 patients with non-diabetic ESKD(NDKD group).Patients were also re-classified on the basis of the primary cause of chronic kidney disease(CKD).The distribution of alleles was compared between diabetic and nondiabetic groups as well as between different sub-phenotypes.The weighted multilocus genetic risk score(GRS)was calculated to estimate the cumulative risk conferred by all SNPs.The GRS distribution was then compared between the DKD and NDKD groups as well as in the groups according to the primary cause of CKD.RESULTS One SNP(rs841853;SLC2A1)showed a nominal association with DKD(P=0.048;P>0.05 after Bonferroni correction).The GRS was higher in the DKD group(0.615±0.260)than in the NDKD group(0.590±0.253),but the difference was not significant(P=0.46).The analysis of associations between GRS and individual factors did not show any significant correlation.However,the GRS was significantly higher in patients with glomerular disease than in those with tubulointerstitial disease(P=0.014)and in those with a combined group(tubulointerstitial,vascular,and cystic and congenital disease)(P=0.018).CONCLUSION Our results suggest that selected SNPs that were previously associated with DKD may not be specific for DKD and may confer risk for CKD of different etiology,particularly those affecting renal glomeruli.