Korean Society of Nephrology 2022 Recommendations on controversial issues in diagnosis and management of hyponatremia

The Korean Society for Electrolyte and Blood Pressure Research, in collaboration with the Korean Society of Nephrology, has published a clinical practice guideline (CPG) document for hyponatremia treatment. The document is based on an extensive evidence-based review of the diagnosis, evaluation, and treatment of hyponatremia with the multidisciplinary participation of representative experts in hyponatremia with methodologist support for guideline development. This CPG consists of 12 recommendations (two for diagnosis, eight for treatment, and two for special situations) based on eight detailed topics and nine key questions. Each recommendation begins with statements graded by the strength of the recommendations and the quality of the evidence. Each statement is followed by rationale supporting the recommendations. The committee issued conditional recommendations in favor of rapid intermittent bolus administration of hypertonic saline in severe hyponatremia, the use of vasopressin receptor antagonists in heart failure with hypervolemic hyponatremia, and syndrome of inappropriate antidiuresis with moderate to severe hyponatremia, the individualization of desmopressin use, and strong recommendation on the administration of isotonic fluids as maintenance fluid therapy in hospitalized pediatric patients. We hope that this CPG will provide useful recommendations in practice, with the aim of providing clinical support for shared decision-making to improve patient outcomes

High Triglyceride-Glucose Index with Renal Hyperfiltration and Albuminuria in Young Adults: The Korea National Health and Nutrition Examination Survey (KNHANES V, VI, and VIII)

Background: High triglyceride-glucose (TyG) index, a surrogate marker of insulin resistance, is associated with an increased risk of albuminuria in adults. However, the relationship between high TyG index associated with renal hyperfiltration (RHF) and albuminuria among young adults is unclear. Methods: A total of 5420 participants aged 19–39 years were enrolled from the Korean National Health and Nutrition Examination Survey (2011–2014 and 2019) and their TyG index levels were analyzed. RHF was defined as eGFR with residuals > 90th percentile after adjusting for age, sex, weight, and height. Albuminuria was defined as urinary albumin-to-creatinine ratio ≥ 30 mg/g Cr. Logistic regression analyses were used to evaluate the association between TyG index, RHF, and albuminuria. Results: The mean age was 30.7 ± 6.0 years and 46.4% were male. The prevalence of albuminuria and RHF was higher in the higher tertiles of TyG index. In our multivariable model, high TyG index showed higher risk of albuminuria (odds ratio (OR) per 1.0 increase in TyG index, 1.56; 95% confidence interval (CI), 1.24–1.95 and OR in the highest tertile, 1.65; 95% CI, 1.08–2.52). High TyG index was associated with higher risk of RHF (OR per 1.0 increase in TyG index, 1.56; 95% CI, 1.32–1.84 and OR in the highest tertile, 1.73; 95% CI, 1.31–2.30). When participants were divided into with or without RHF, high-TyG index-associated high risk of albuminuria was only observed in those with RHF. Participants with concurrent high TyG index and RHF showed the highest risk of albuminuria. Mediation analysis showed that 54.2% of the relation between TyG index and albuminuria was mediated by RHF (95% CI of indirect effect, 0.27–0.76). Finally, incorporating TyG index into our basic model improved the predictive value for albuminuria only in participants with RHF. Conclusion: High TyG index associated with RHF was the strongest risk factor for albuminuria in this study. Early identification of high TyG index with RHF may prevent future development of CKD in relatively healthy and young adults

Antibacterial mechanisms of nanocrystalline diamond film and graphene sheet

In this study, we investigated the antibacterial activities of a nanocrystalline diamond (NCD) thin film and graphene sheet. In addition, we functionalized the surfaces of the NCD film and graphene sheet with fluorine by plasma treatments to increase their antibacterial activities. The antibacterial activities of the NCD film and graphene sheet were confirmed by both colony forming unit (CFU) counting and adenosine triphosphate (ATP) bioluminescence assay based on the drop-test method. The CFU counting showed that the ratios of surviving bacteria on the NCD film and graphene sheet were 27.5% and 13.9%, respectively. The ratios of surviving bacteria on the fluorinated NCD (F-NCD) film and fluorinated graphene (F-graphene) sheet were decreased to 15.2% and 9.3%, respectively, which indicated that the antibacterial activities of the F-NCD film and F-graphene sheet increased upon fluorine functionalization. In addition, an ATP bioluminescence assay was employed based on the concentration of ATP released from cultured Escherichia coli (E. coli), which confirmed that the fluorinated surface had high antibacterial activity. The ratios of metabolism-cultured E. coli on the F-NCD film and F-graphene sheet were 15.0% and 7.4%, respectively. Furthermore, we observed the morphologies of E. coli cultured on the NCD film and graphene sheet. The antibacterial activity was attributed to the destruction of the E. coli membranes. These results show that the antibacterial activities of the NCD film and graphene sheet depend on their surface functional groups and conductivities. Keywords: Fluorine functionalization, Antibacterial activity, Colony forming unit, Adenosine triphosphate production, Nanocrystalline diamond, Graphene shee

Early initiation of continuous renal replacement therapy improves survival of elderly patients with acute kidney injury: a multicenter prospective cohort study

Background Continuous renal replacement therapy (CRRT) is essential in the management of critically ill patients with acute kidney injury (AKI). However, the optimal timing for initiating CRRT remains controversial, especially in elderly patients. Therefore, we investigated the outcomes of early CRRT initiation in elderly patients with AKI. Methods A total of 607 patients ≥65 years of age who started CRRT due to AKI between August 2009 and December 2013 were prospectively enrolled. They were divided into two groups based on the median 6-hour urine output immediately before CRRT initiation. Propensity score matching was used to compare the overall survival rate, CRRT duration, and hospitalization duration. Results The median age of both groups was 73.0 years, and 60 % of the patients were male. The most common cause of AKI was sepsis. In the early CRRT group, the mean arterial pressure was higher, but the prothrombin time and total bilirubin, aspartate aminotransferase, and alanine aminotransferase levels were lower. The overall cumulative survival rate was higher in the early CRRT group (log-rank P < 0.01). Late CRRT initiation was associated with a higher mortality rate than early initiation after adjusting for age, sex, the Charlson comorbidity index, systolic arterial pressure, prothrombin time, the total bilirubin, aspartate aminotransferase, and alanine aminotransferase levels, cumulative fluid balance and diuretic use (hazard ratio, 1.35; 95 % confidence interval 1.06, 1.71, P = 0.02). Following propensity score matching, patient survival was significantly better in the early CRRT group than in the late CRRT group (P < 0.01). The total duration of hospitalization from the start of CRRT was shorter among the survivors when CRRT was started earlier (26.7 versus 39.1 days, P = 0.04). Conclusion A better prognosis can be expected if CRRT is applied early in the course of AKI in critically ill, elderly patients

Korean Society of Nephrology 2022 Recommendations on controversial issues in diagnosis and management of hyponatremia

The Korean Society for Electrolyte and Blood Pressure Research, in collaboration with the Korean Society of Nephrology, has pub-lished a clinical practice guideline (CPG) document for hyponatremia treatment. The document is based on an extensive evi-dence-based review of the diagnosis, evaluation, and treatment of hyponatremia with the multidisciplinary participation of representa-tive experts in hyponatremia with methodologist support for guideline development. This CPG consists of 12 recommendations (two for diagnosis, eight for treatment, and two for special situations) based on eight detailed topics and nine key questions. Each recom-mendation begins with statements graded by the strength of the recommendations and the quality of the evidence. Each statement is followed by rationale supporting the recommendations. The committee issued conditional recommendations in favor of rapid inter-mittent bolus administration of hypertonic saline in severe hyponatremia, the use of vasopressin receptor antagonists in heart failure with hypervolemic hyponatremia, and syndrome of inappropriate antidiuresis with moderate to severe hyponatremia, the individualiza-tion of desmopressin use, and strong recommendation on the administration of isotonic fluids as maintenance fluid therapy in hospi-talized pediatric patients. We hope that this CPG will provide useful recommendations in practice, with the aim of providing clinical support for shared decision-making to improve patient outcomes.N

Urinary angiotensinogen level is associated with potassium homeostasis and clinical outcome in patients with polycystic kidney disease: a prospective cohort study

Abstract Background Guidelines for general hypertension treatment do not recommend the combined use of renin-angiotensin-aldosterone system (RAAS) inhibitors due to the risk of hyperkalemia. However, a recent clinical trial showed that polycystic kidney disease (PKD) patients had infrequent episodes of hyperkalemia despite receiving combined RAAS inhibitors. Because intrarenal RAAS is a main component for renal potassium handling, we further investigated the association between intrarenal RAAS activity and serum potassium level in patients with chronic kidney disease, particularly in PKD patients, and examined whether intrarenal RAAS activity has a prognostic role in patients with PKD. Methods A total of 1788 subjects from the KoreaN cohort study for Outcome in patients With Chronic Kidney Disease (KNOW-CKD) were enrolled in this study. Intrarenal RAAS activity was assessed by the measurement of urinary angiotensinogen (AGT). The primary outcome was the composite of all-cause mortality and renal function decline. Results Patients with PKD had a significantly lower serum potassium level in chronic kidney disease stages 1 to 3b than non-PKD patients. In logistic regression analysis, after adjusting for multiple confounders, PKD patients had a significantly lower risk of hyperkalemia than non-PKD patients. In multivariable linear regression analysis, the urinary AGT/creatinine (Cr) ratio was negatively correlated with the serum potassium level (β = − 0.058, P = 0.017) and positively correlated with the transtubular potassium gradient (TTKG, β = 0.087, P = 0.001). In propensity score matching analysis, after matching factors associated with serum potassium and TTKG, PKD patients had a significantly higher TTKG (P = 0.021) despite a lower serum potassium level (P = 0.004). Additionally, the urinary AGT/Cr ratio was significantly higher in PKD patients than in non-PKD patients (P = 0.011). In 293 patients with PKD, high urinary AGT/Cr ratio was associated with increased risk of the composite outcome (hazard ratio 1.29; 95% confidence interval, 1.07–1.55; P = 0.007). Conclusions High activity of intrarenal RAAS is associated with increased urinary potassium excretion and low serum potassium level in patients with PKD. In addition, intrarenal RAAS activity can be a prognostic marker for mortality and renal function decline in these patients

Body mass index is inversely associated with mortality in patients with acute kidney injury undergoing continuous renal replacement therapy

Background: Many epidemiologic studies have reported on the controversial concept of the obesity paradox. The presence of acute kidney injury (AKI) can accelerate energy-consuming processes, particularly in patients requiring continuous renal replacement therapy (CRRT). Thus, we aimed to investigate whether obesity can provide a survival benefit in this highly catabolic condition. Methods: We conducted an observational study in 212 patients who had undergone CRRT owing to various causes of AKI between 2010 and 2014. The study end point was defined as death that occurred within 30 days after the initiation of CRRT. Results: Patients were categorized into three groups according to tertiles of body mass index (BMI). During ≥30 days after the initiation of CRRT, 39 patients (57.4%) in the highest tertile died, as compared with 58 patients (78.4%) in the lowest tertile (P = 0.02). In a multivariable analysis adjusted for cofounding factors, the highest tertile of BMI was significantly associated with a decreased risk of death (hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.37–0.87; P = 0.01). This significant association remained unaltered for 60-day (HR, 0.64; 95% CI, 0.43–0.94; P = 0.03) and 90-day mortality (HR, 0.66; 95% CI, 0.44–0.97; P = 0.03). Conclusion: This study showed that a higher BMI confer a survival benefit over a lower BMI in AKI patients undergoing CRRT

Additional file 1: Table S1. of The impact of disease severity on paradoxical association between body mass index and mortality in patients with acute kidney injury undergoing continuous renal replacement therapy

Multivariate Cox regression analyses for 30-day mortality by WHO classification. (DOCX 18 kb