Clinical Journal of the American Society of Nephrology

Secondary hyperparathyroidism persists in the majority of kidney transplant recipients and is associated with adverse graft and cardiovascular outcomes. The immunosuppressive drug class used post-transplant may modulate parathyroid hormone (PTH) levels through distinct mechanisms: calcineurin inhibitors (CNI) stabilize PTH mRNA, while mTOR inhibitors (mTORi) suppress parathyroid cell proliferation in experimental models. We report supporting evidence from two independent analyses. In a multinational real-world database analysis (TriNetX Global Collaborative Network), kidney transplant recipients with documented mTORi use and eGFR in the target range had lower PTH than those on CNI across eGFR strata examined (15-30, 30-45, 45-60, 60-75, >75 mL/min/1.73 m2), with risk ratios for PTH >130 pg/mL ranging from 0.47 to 0.67 in propensity-matched analyses (all p < 0.05). The known confounders - calcium (higher in CNI) and phosphate (higher in mTORi) - both act to oppose this pattern, strengthening the possibility of a drug effect. In a longitudinal single-center cohort (n = 118; 796 PTH measurements), a linear mixed-effects model with time-varying mTORi exposure confirmed a 42% lower PTH during on-mTORi periods after adjustment for eGFR, transplant vintage, diabetes, age, and sex (fold-change 0.58 [95% CI 0.50-0.68]; p < 0.0001). These findings suggest a direct PTH-lowering effect of mTORi. Immunosuppression choice may be considered in the management of post-transplant hyperparathyroidism in selected patients.

Non-HLA donor-recipient (D-R) genetic mismatches contribute to kidney allograft injury and long-term graft loss, but their clinical use is limited by the unavailability of donor DNA after transplantation. We tested whether non-invasively obtained, recipient-derived samples could be used to infer donor genotype and D-R mismatches. Genomic DNA (g-DNA) of 11 unselected kidney transplant recipients and donors underwent whole-exome sequencing (100x). Additional customized probes were added for intronic coverage (300x) of 55 targeted non-HLA genes of reported clinical relevance. Variants identified from sequencing results were compared with plasma cell-free DNA (cfDNA), urine cell-pellet DNA (U-DNA) obtained from the same recipients. Genome-wide-, exonic-, or non-synonymous exonic- mismatches in transmembrane or secreted proteins, and mismatches within target genes were benchmarked using donor g-DNA to generate mismatch scores for each D-R pair. Within each of these genomic scales of mismatch, U-DNA identified D-R mismatches significantly better than the corresponding cfDNA (P<0.001 for each comparison). U-DNA also identified gene-level mismatches in the LIMS1 gene, and correctly inferred established donor-origin risk alleles, including SHROOM3 and APOL1. Our findings demonstrate proof-of-concept that U-DNA in tandem with recipient genome, can non-invasively infer relevant non-HLA loci/mismatches circumventing the need for the donor genomic DNA.

Introduction: APOL1 high-risk variants markedly increase susceptibility to kidney disease among individuals of African ancestry; however, only a subset of carriers develops clinically significant CKD or ESKD. This discrepancy highlights a gap between genetic risk and clinical trajectory. Current prognostic tools rely primarily on eGFR and albuminuria, which incompletely reflect the underlying biological processes driving APOL1-associated kidney injury. We hypothesized that plasma biomarkers reflecting inflammatory and tubular injury pathways could identify biologically active disease states within this genetically high-risk population and improve prognostic stratification. Methods: Participants from the Mount Sinai BioMe Biobank carrying two APOL1 high-risk alleles (G1, G1; G1, G2; or G2 G2) were followed for a median of 6 years. Baseline plasma biomarkers of inflammation and tubular injury (TNFR1, TNFR2, KIM-1, MCP-1, YKL-40, IL-18, suPAR) were measured. The composite outcome was sustained 40% decline in eGFR or ESKD. Multivariable Cox models assessed associations between biomarkers and outcomes. A weighted biomarker risk score was derived from tertile-based hazard ratios and categorized into low-, moderate-, and high-risk groups. Results: Among 498 participants (median eGFR 83 ml/min/1.73 m2), 80 (16.1%) reached the composite outcome. Higher concentrations of TNFR1, TNFR2, suPAR, KIM-1, and IL-18 were independently associated with kidney events after multivariable adjustment. Event rates were 7% in the low-risk group, 16% in the moderate-risk group, and 36% in the high-risk group. Conclusions: Plasma biomarkers reflecting inflammatory and tubular injury pathways reveal marked heterogeneity in kidney outcomes among individuals with high-risk APOL1 genotypes. Integration of these signals into a biology-weighted score identifies distinct prognostic phenotypes beyond genotype and traditional clinical measures, supporting multidomain biomarker frameworks for risk stratification and potential trial enrichment in APOL1-associated kidney disease.

BackgroundPatients with kidney failure undergoing maintenance hemodialysis suffer high rates of major adverse cardiovascular events(MACE) that are not accurately predicted by traditional cardiovascular risk models. There is an urgent need to identify novel, modifiable cardiovascular risk factors for these patients. MethodsWe analyzed associations of 6287 circulating proteins with MACE among 1048 participants undergoing hemodialysis in the Chronic Renal Insufficiency Cohort(CRIC) (14-year follow-up) with validation in the Predictors of Arrhythmic and Cardiovascular Risk in End-Stage Renal Disease study(PACE) (7-year follow-up). In both cohorts, proteins were measured shortly after dialysis initiation and one year later. We compared protein-based risk models derived by elastic net regression to the Pooled Cohort Equations(PCE) optimized for these cohorts(Refit PCE), and to an Expanded Refit PCE that included Troponin T and N-terminal pro-B-type natriuretic peptide. ResultsIn CRIC, 149 proteins were associated with MACE at false discovery rate<0.05. Among 22 proteins significant at Bonferroni p<8x10-6, proteins that validated in PACE included Sushi von Willebrand factor type A EGF and pentraxin domain-containing protein 1(SVEP1), Complement component C7, R-spondin 4, Tenascin, Fibulin-3 and Fibulin-5. Complement pathways were prominent in network analyses. SVEP1 surpassed other markers by statistical significance, with CRIC HR per log2 1.8 (p=2.1x10-12) and HR per annual doubling 1.6 (p=6.8x10-6). For 2-year MACE, AUC(95%CI) for SVEP1 alone was 0.72(0.59, 0.84) in CRIC, and 0.73(0.63, 0.81) in PACE. SVEP1 surpassed the Expanded Refit PCE in CRIC (0.61 (0.48, 0.73)) (p=0.038). In the pooled CRIC + PACE cohort, SVEP1 AUC(95%CI) (0.79(0.70, 0.88)) surpassed Refit PCE (0.61(0.51, 0.72)) (p=0.004). ConclusionsSVEP1, a 390 kDa protein unlikely to be renally cleared, surpassed over 6000 other proteins and by itself outperformed traditional clinical risk models in predicting MACE in two populations of patients undergoing maintenance hemodialysis. Future studies should provide mechanistic insights behind these findings. Key PointsO_LIPatients with kidney failure undergoing hemodialysis have 20-fold higher cardiovascular mortality compared to the general population, and conventional risk factors have low prognostic utility for these patients. C_LIO_LIBy applying large-scale circulating proteomics in two independent hemodialysis cohorts, we have discovered >20 novel proteins that predict major adverse cardiovascular events(MACE). C_LIO_LISushi von Willebrand factor type A EGF and pentraxin domain-containing protein 1(SVEP1) surpassed >6000 individual proteins and clinical factors for predicting MACE. C_LI

Background and hypothesis: Sodium-glucose cotransporter-2 inhibitors (SGLT2-inhibitors) slow chronic kidney disease progression, but evidence in non-diabetic kidney transplant recipients is limited. We evaluated associations between SGLT2-inhibitor use and major adverse kidney events (MAKE), major adverse cardiovascular events (MACE), and all-cause mortality. Methods: In this retrospective cohort study using the TriNetX federated research network, adult non-diabetic kidney transplant recipients transplanted between January 2015 and January 2022 were identified. SGLT2-inhibitor users initiating therapy [&ge;]1000 days post-transplant were compared with non-users after 1:1 propensity score matching. The primary outcome was MAKE, defined as dialysis initiation or death. Secondary outcomes included all-cause mortality and MACE. Results: Propensity score matching yielded 867 pairs of SGLT2-inhibitor users and non-users. SGLT2-inhibitor use was associated with lower risks of MAKE (adjusted hazard ratio [aHR] 0.64, 95% CI 0.45-0.91) and all-cause mortality (aHR 0.55, 95% CI 0.36-0.85). No significant association was observed for MACE (aHR 0.86, 95% CI 0.64-1.17). No increased risk of urinary tract infections was observed among SGLT2-inhibitor users. Conclusion: SGLT2-inhibitor use was associated with lower risks of MAKE and all-cause mortality in non-diabetic kidney transplant recipients.

BackgroundMicrovascular dysfunction is a key contributor to the development and progression of chronic kidney disease (CKD), yet direct and reproducible assessment of microvascular function in clinical CKD populations remains limited. Laser Doppler flowmetry (LDF) provides a noninvasive, dynamic assessment of skin microvascular blood flow and may serve as a surrogate measure of systemic microvascular health. However, the extent to which LDF-derived measures relate to kidney function, proteinuria, and kidney histopathology in CKD remains unclear. MethodsWe assessed cutaneous microvascular function in 150 participants with CKD (estimated glomerular filtration rate [eGFR] <90 mL/min/1.73 m{superscript 2}) using a standardized forearm LDF protocol. Baseline perfusion was recorded at [~]30{degrees}C, followed by local heating to 44 {degrees}C to induce hyperemia. The percentage change in perfusion unit (PU) was calculated and used to define microvascular functional reserve. Associations between LDF-derived measures with eGFR and urine protein-to-creatinine ratio (uPCR) were assessed using multivariable linear regression adjusted for demographic and clinical covariates. Unsupervised k-means clustering was performed to identify microvascular phenotypes based on resting PU and microvascular function reserve. Associations of LDF measures with glomerulosclerosis (GS) and interstitial fibrosis and tubular atrophy (IFTA) were evaluated in a subset of participants (n = 20) who underwent clinically indicated kidney biopsies. ResultsAmong 150 CKD participants, the mean (SD) age was 64 (14) years, 46% were female, 38% had diabetes, and 83% had hypertension. The mean eGFR was 42 (21) mL/min/1.73 m{superscript 2} and median uPCR was 0.21 (interquartile range (IQR) 0.11 to 1.20) mg/mg. Higher baseline PU ({beta} = -12; 95% CI, -24 to -1) and reduced percentage change in PU ({beta} = 7; 95% CI, 2 to 13) was associated with lower eGFR, independent of covariates. Baseline PU or percentage change in PU were not associated with uPCR. Unsupervised clustering identified four distinct microvascular phenotypes characterized by graded differences in resting perfusion and microvascular function reserve. Among participants with biopsy data, higher baseline PU and lower percentage change in PU were associated with greater severity of GS and IFTA. ConclusionIn persons with CKD, elevated resting perfusion and impaired microvascular functional reserve were associated with lower eGFR. These findings suggest that LDF-derived measures capture clinically relevant alterations in systemic microvascular function and may serve as a noninvasive biomarker of kidney function and underlying histopathologic injury in CKD.

Rationale & ObjectivePeriodontal disease(PD), a chronic inflammatory condition, may contribute to chronic kidney disease(CKD) through systemic inflammation, but its impact on CKD outcomes and the potential protective effects of periodontal treatment and routine dental prophylaxis remain uncertain. This study evaluated associations between PD, dental interventions, and kidney outcomes in a large U.S. veteran cohort. Study DesignRetrospective cohort study. Setting & ParticipantsUsing Veterans Health Administration data(2009-2019), we identified 86,376 adults eligible for comprehensive dental care with baseline eGFR >60 mL/min/1.73m{superscript 2} and followed them from their initial dental examination. ExposurePatients with PD (Cohort-A) were divided into those who received periodontal treatment (PD-Treated), those who did not receive treatment but had [&ge;]1 dental prophylaxis visit/year (PD-Prophylaxis), and those who received neither (PD-Untreated). Those without PD (Cohort-B) were grouped by presence or absence of regular dental prophylaxis ([&ge;]1 visit/year). OutcomeIncident CKD (eGFR <60 mL/min/1.73 m{superscript 2} and >25% decline from baseline), [&ge;]40% eGFR reduction, and incident albuminuria (>30 mg/g), each confirmed with repeat labs [&ge;]90 days apart. Analytical ApproachMultivariable logistic regression model ResultsOf 86,376 veterans (mean age 57.17{+/-}12.59 years; 91.4% male), 37.6% had PD. Adjusted model showed significantly lower odds of incident CKD, [&ge;]40% eGFR decline, and incident albuminuria noted in both PD-Treated [OR(95%CI): 0.80(0.70-0.91), 0.69(0.56-0.84), 0.88 (0.79-0.99)] and PD-Prophylaxis groups [OR(95%CI): 0.81(0.66-0.98), 0.60(0.43-0.82), 0.79(0.67-0.94)] compared to the PD-Untreated. Similarly, among patients without PD, regular dental prophylaxis was associated with reduced odds of Incident CKD, [&ge;]40% eGFR decline, and incident albuminuria [OR(95%CI): 0.87(0.78-0.96), 0.76(0.65-0.90), 0.85(0.78-0.93)]. LimitationsRetrospective design, unmeasured confounders, and reliance on electronic health records. ConclusionsPD is associated with increased risks of incident CKD, accelerated eGFR decline, and new-onset albuminuria. Periodontal treatment and routine dental prophylaxis mitigate these risks. Even in individuals without PD, regular dental prophylaxis appears protective against CKD development and progression.

Background.Renoprotective therapies - SGLT2 inhibitors, finerenone, and renin-angiotensin system inhibitors (RASi) - remain underutilisedin chronic kidney disease (CKD). Large language models (LLMs) may detect therapy omissions, but their performance acrossCKD severity strata and at clinical decision boundaries has not been evaluated.Methods.We constructed 100 synthetic CKD vignettes (G3a-G5D; 75 with prespecified omissions, 25 decoys) and queried four LLMsthree times each at temperature 0 (1,200 calls). Omission criteria were adapted from KDIGO 2024, including an investigator-defined gray-zone RASi initiation criterion at eGFR<15. Two nephrologists independently classified a stratified 20-casesubset.Results.For SGLT2 inhibitor and finerenone omissions, all models achieved near-ceiling sensitivity (97-100%). For RASi, performancediverged at the eGFR<15 boundary: Grok 4.1 Fast 85% versus GPT-5.4 55%, Gemini 10%, DeepSeek 10%. Gap-detectioninter-rater agreement was perfect (kappa = 1.000). Clinically incorrect reasoning rates ranged from 0% (GPT-5.4) to 27%(DeepSeek R1); of 52 instances, 31 were factual pharmacology errors and 21 reflected conservative boundary-discordantreasoning. Reproducibility (Jaccard) ranged from 0.74 to 0.93.Conclusions.This boundary-aware synthetic benchmark showed that aggregate sensitivity can conceal clinically important operational-rulediscordance. Rule-based SGLT2 inhibitor and finerenone omissions were detected with near-ceiling sensitivity, whereas aninvestigator-defined gray-zone RASi criterion at eGFR<15 exposed model-specific boundary behaviour. Evaluation of LLM-based CKD decision support should report boundary-specific performance, reproducibility, and clinically incorrect reasoningalongside aggregate metrics.

Background. Chronic kidney disease (CKD) affects 10-13% of adults worldwide but remains largely undiagnosed until advanced stages. Hospitalization provides an opportunity for early detection through opportunistic urine albumin-to-creatinine ratio (UACR) measurement. Methods. We conducted a prospective three-arm study of opportunistic CKD screening in general internal medicine wards at Hadassah Mt. Scopus (MS), Hadassah Ein Kerem (EK), and Shaare Zedek Medical Center (SZMC) in Jerusalem (Protocol HMO-23-0300). Adult inpatients without known CKD or recent UACR were enrolled. Pathological UACR was defined as [&ge;]30 mg/g. Confirmed CKD required two pathological measurements [&ge;]90 days apart (KDIGO-compatible). eGFR was computed using the 2021 CKD-EPI race-free equation. Pooled proportions were estimated by fixed-effects logit meta-analysis; odds ratios by DerSimonian-Laird random-effects models. Results. A total of 158 patients were enrolled (MS n=50, EK n=57, SZMC n=51). Pathological first UACR was identified in 43/158 patients (27.2%; 95% CI 21.3-34.1%; I2=0% across centers). Of 24 patients with a second UACR available, 14 (58%) confirmed CKD, yielding a pooled confirmed-CKD rate of 8.9% of all screened patients. In-hospital mortality was significantly higher among patients with pathological UACR (9.3% vs ~2%; Fisher's exact p=0.012). In per-center multivariate logistic regression, three predictors reached pooled significance: BUN (OR 1.10 per mg/dL, 95% CI 1.04-1.17, p=0.002, I2=0%), heart failure (OR 3.21, 95% CI 1.34-7.70, p=0.009, I2=0%), and diabetes mellitus (OR 2.54, 95% CI 1.11-5.82, p=0.028, I2=17%). Cardiac/vascular admissions had the highest pathological UACR rate (~42%); GI/hepatic admissions had 0%. Conclusions. Opportunistic inpatient UACR screening identifies previously unrecognized CKD in approximately 9% of general internal medicine patients, with consistent results across three independent centers. BUN elevation, heart failure, and diabetes are the strongest independent predictors. Pathological UACR carries significant short-term mortality risk, supporting integration of routine screening into inpatient care pathways.

Background: Cardiac surgery using cardiopulmonary bypass uses controlled hypoperfusion which leads to relative organ damage. Acute kidney injury is the most frequent and most important organ failure, in particular in patients with chronic kidney disease. To date, there are no approved drug treatments that could effectively prevent acute kidney injury. SP16, an agonist of the low-density lipoprotein receptor-related protein 1, has been shown to exert both reno- and cardioprotective effects in preclinical trials. Early clinical use of SP16 in phase I trials was safe. Administration of SP16 had beneficial trends on inflammatory response and infarct size in patients with ST-segment elevation myocardial infarction. The primary objective of this phase IIa trial is to demonstrate that injection of SP16 is safe and superior to placebo in preventing cardiac surgery-associated acute kidney injury within 7 days after surgery. Methods: This randomised, double-blinded, placebo-controlled, single centre study evaluates the efficacy and safety of SP16 in 120 high-risk chronic kidney disease patients with disease stadium G2-G3b undergoing cardiac surgery who are randomised into one of two treatment groups in a 1:1 ratio: SP16 (12 mg) or placebo. The study medication is administered via two subcutaneous injections, with the first dose given before surgery, followed by an additional dose after 9 h. Primary endpoints are the incidence of acute kidney injury during 7 days post-surgery and the frequency of adverse events within 72 h after index surgery. Important secondary endpoints include the incidence of major adverse kidney events at day 90 and impact on cardiac function. Safety assessments encompass adverse events, vital signs, electrocardiograms and routine safety laboratory tests. Additional evaluations include pharmacokinetics and immunological biomarkers. Discussion: This single-centre phase IIa trial will assess the incidence of cardiac surgery-associated acute kidney injury, describing the renoprotective potential of SP16 and its safety profile in patients undergoing cardiac surgery.

Importance: Recently, proteinuria has been accepted as a surrogate end point for clinical trials in focal segmental glomerulosclerosis (FSGS) ang IgA nephropathy. However, proteinuria has not been evaluated in Apolipoprotein L1 (APOL1)-mediated kidney disease (AMKD). Methods: Real world data (RWD) analysis of 128 patients of African ancestry with APOL1 high risk genotypes, without diabetes, enrolled in the Million Veteran Program (MVP; n=109) or the biorepository at Vanderbilt University (BioVU; n=19), who had urine albumin-creatinine ratio (UACR) >= 420 mg/g (PCR~0.9 g/g) with a concurrent GFR value. The main predictor was change in the log-UACR at 12 months. The primary outcome was annual GFR slope over 24 months. Secondary outcomes included a kidney composite of a sustained 30% GFR decline, end stage kidney disease (ESKD) or death and ESKD as a single outcome. Linear regression and Cox proportional hazards models were used to assess the effect of changes in UACR and the outcomes. Results: In the pooled analysis the mean age was 56.8 (SD 15.5) y, 116 were male (90.6%) and three patients had diagnosis of FSGS at baseline. Mean baseline eGFR was 46.8 (SD 16.1) mL/min/1.73m2, mean baseline UACR was 1240.8 (1107.7) mg/g, mean eGFR slope was -4.67[-6.00, -3.33] mL/min/1.73m2/year and the geometric mean percentage changes in the UACR at 12 months were -57.5% [-65.0%, -48.4%]. For every 1 unit of log (UACR) increment at 12 months, the annual eGFR slope decreased by -1.80 [-2.56, -1.03] mL/min/1.73m2 in the pooled analysis. For every 1 unit of log (UACR) increment at 12 months, the Cox regression showed a 61% increase in the risk of a kidney composite (p=0.002) and a 98% increase in the risk of ESKD (p<0.001). It was estimated that a 50% reduction of UACR at 12 months was associated with a 28% reduction in the kidney composite endpoint (adjusted hazard ratio [aHR]=0.72; 95% confidence interval [CI]:0.59-0.88; p=0.002), and a 38% reduction in the risk of ESKD (aHR=0.62; 95% CI:0.49-0.80; p<0.001). Conclusions and relevance: Changes in UACR at 12 months significantly modify the rate of decline of GFR over 24 months and clinically meaningful endpoints, supporting the use of UACR changes as surrogate endpoint in AMKD.

BackgroundThe first 1000 days from conception to age 2 years represent a critical window for kidney development, during which nutritional exposures may have lifelong programming effects. Whether early-life sugar restriction reduces long-term kidney disease risk remains unknown. MethodsUsing the UK sugar rationing policy (1942-1953) as a natural experiment, we compared risks of chronic kidney disease (CKD) and acute kidney injury (AKI) among 64,942 UK Biobank participants born around the rationing period. Duration of early-life exposure was categorised. Cox proportional hazards models estimated hazard ratios (HRs). Negative control analyses included non-UK-born UK Biobank participants and the Chinese CHARLS cohort. Mediation analyses integrated clinical phenotypes and metabolomic profiles. FindingsCompared with never-exposed individuals, those exposed to sugar rationing throughout the first 1000 days (in utero to age 2 years) had lower risks of CKD (adjusted HR 0.78, 95% CI 0.66-0.93) and AKI (0.79, 0.69-0.90). Negative control analyses showed null associations. Mediation analyses indicated that metabolic efficiency (basal metabolic rate), body composition (fat-free mass), and lipid metabolism mediated 4-9% of the protective association. A distinct metabolomic signature characterised by higher polyunsaturated fatty acids and lower VLDL subfractions was identified. InterpretationSugar restriction during the first 1000 days is associated with lower risks of CKD and AKI in adulthood, partially mediated by favorable metabolic efficiency, body composition, and lipid profiles. These findings identify early-life sugar exposure as a modifiable developmental programming factor for lifelong kidney health and support public health strategies to reduce added sugar intake during pregnancy and early childhood. FundingNational Natural Science Foundation of China, and others

Abstract Background Alport Syndrome (AS), caused by pathogenic variants in type IV collagen genes COL4A3/4/5, is a leading monogenic cause of Kidney Failure (KF). Clinical course varies widely, and disease specific predictors of progression relevant to clinical care and trial design remain incompletely defined. Methods In this retrospective cohort study of individuals with AS in the UK National Registry of Rare Kidney Diseases, patients were classified as having AS or heterozygous genotypes and followed to assess proteinuria progression, eGFR slope and kidney survival. Proteinuria and eGFR trajectories were analysed using mixed effects regression models; kidney survival using Kaplan Meier analysis. Results Among 1032 participants (median follow up 11.6 years; 47% female), 475 (46%) had AS genotypes (Male XLAS or autosomal recessive AS). eGFR decline accelerated with advancing CKD stage across all genotypes (p<0.001). Proteinuria increased as eGFR declined and occurred earlier in AS genotypes. After reaching proteinuria thresholds of more than 1.0 and 3.0g/g, kidney survival over the subsequent 5 years did not differ significantly between genotypes (logrank p=0.14, p=0.17, respectively), although modest differences emerged over longer follow-up. Across eGFR thresholds (90, 60, and 45mL/min/1.73m2), higher proteinuria was associated with shorter time to KF; for example, at eGFR 45mL/min/1.73m2, median time to KF was 3.0 years (IQR, 1.6-5.4) for above-median vs 6.5 years (5.1-not estimable) for below-median proteinuria (p<0.0001). Almost all patients who reached KF had developed proteinuria of more than 0.3g/g. Conclusion In this national cohort, eGFR decline accelerated with CKD stage and proteinuria was strongly associated with progression to KF across genotypes. The non linearity of eGFR decline may inform its interpretation in clinical practice and use as a trial endpoint. Once comparable proteinuria levels were reached, differences in outcomes by genotype were attenuated, supporting proteinuria as a key prognostic marker and strengthening rationale for its use as a surrogate endpoint in AS clinical trials

Background: Clinical LLM benchmarks rarely test whether algorithmic rankings agree with expert clinical judgment. We developed a trap-embedded peritoneal dialysis (PD) benchmark comparing multiple scoring constructs with blinded nephrologist ratings. Methods: We generated 125 synthetic PD cases containing 13 ISPD-aligned trap types. Five LLMs (Claude Sonnet 4.5, GPT-5.4, Gemini 3.1 Pro, DeepSeek-R1, Grok 4.1 Fast) evaluated each case three times at temperature 0 (1,875 calls). Primary outcome was must-identify TDR_must, analyzed with GEE and case-clustered bootstrap. Secondary analyses included a verbosity-sensitive alarm-burden proxy, WCS, relaxed-match scoring, WCS sensitivity analyses, and a 25-output blinded expert adequacy substudy. Must-identify kappa was 0.89 in Stage 1 and 0.92 in Stage 2. Results: Rankings were discordant. Recall ranked Claude (0.977) and GPT-5.4 (0.955) above the other models (0.86-0.90, p<0.0001). The alarm-burden proxy favored concise models (Grok 0.689; 21.6 vs 2.4 issues/case), while WCS produced a third ordering. In the expert substudy, inter-rater concordance was strong (rho 0.977), but WCS did not show a positive association with expert adequacy (rho -0.17, p=0.41). Conclusion: Clinical LLM rankings in PD prescription review depend strongly on scoring construct. Algorithmic metrics should be reported alongside blinded expert adequacy ratings and should not alone determine deployment.

BackgroundSingle-nephron glomerular filtration rate (GFR) represents a nephron-level functional index that may reveal key pathophysiological mechanisms driving progression in patients with diabetic nephropathy. However, its clinical relevance remains incompletely understood. This cross-sectional study assessed single-nephron estimated GFR (eGFR) across different chronic kidney disease (CKD) stages in patients with advanced diabetic nephropathy. MethodsNephron number was estimated as the number of nonglobally sclerotic glomeruli per kidney using computed tomography-derived cortical volume combined with biopsy stereology. Single-nephron eGFR was calculated by dividing eGFR by the nephron number of both kidneys. Patients were stratified according to CKD stage at kidney biopsy. Associations between CKD stages and single-nephron eGFR were evaluated using multivariable linear regression models adjusted for age, sex, urinary protein excretion, and eGFR. ResultsThe study included 105 patients with biopsy-proven diabetic nephropathy and overt proteinuria (median age 59 years, 83% male, HbA1c 6.6%, 57% had nephrotic range proteinuria). The percentage of globally sclerotic glomeruli, mesangial expansion score, and prevalence of nodular lesions increased significantly with advancing CKD stage. Median nephron number declined from 529,178 to 224,458 per kidney, whereas glomerular volume remained constant. Single-nephron eGFR decreased markedly with CKD stage and remained significantly inversely associated with CKD stage after adjustment for clinicopathologic covariates (P for trend <0.001). ConclusionIn overt diabetic nephropathy, single-nephron eGFR decreased with advancing CKD stage, despite relatively preserved glomerular volume. At this stage of disease, structural alterations specific to diabetic nephropathy may impair effective single-nephron filtration capacity.

Introduction Acute interstitial nephritis is an important differential diagnosis in patients with deteriorating kidney function. Diagnosis currently requires kidney biopsy, an invasive procedure associated with risks. We hypothesized that urinary T cells may serve as a non-invasive biomarker for acute interstitial nephritis. Methods A total of 320 patients undergoing clinically indicated kidney biopsy were enrolled in a discovery cohort at Charite Berlin (n = 80), an internal validation cohort at Charite (n = 100), and an external validation cohort at The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou (n = 140). Urinary immune cells were assessed by flow cytometry. Renal T cell infiltration was evaluated by immunofluorescence in kidney biopsy specimens from the discovery and internal validation cohorts, including 16 patients with acute interstitial nephritis and 9 patients without acute interstitial nephritis. Additionally, CXCL9 was measured by ELISA in 102 urine samples from these cohorts. Results Across all cohorts, 27 patients (8.4%) were diagnosed with acute interstitial nephritis. In the discovery cohort, multiple urinary T cell subsets were increased in acute interstitial nephritis, with activated CD4+ effector memory T cells expressing CD38 and HLA-DR showing the strongest diagnostic performance. This marker outperformed urinary monocytes, eosinophils, and CXCL9 and was validated in both independent cohorts. Across all cohorts, the area under the receiver operating characteristic curve was 0.84 and increased to 0.91 after exclusion of 8 patients receiving corticosteroids. A cutoff of 211 activated CD4+ effector memory T cells per 100 mL urine yielded a sensitivity of 78% and a specificity of 81%. Urinary activated CD4+ effector memory T cell counts correlated with renal CD4+ and CD4+ CD38+ T cell infiltration in acute interstitial nephritis. Conclusions Urinary activated CD4+ effector memory T cells expressing CD38 and HLA-DR represent a promising non-invasive biomarker for the diagnosis of acute interstitial nephritis.

Introduction The hemoglobin, albumin, lymphocytes and platelets (HALP) score, a novel nutritional and inflammatory biomarker, has been used in various chronic disease studies. However, the relationship between the HALP score and chronic kidney disease (CKD) remains poorly elucidated. This study aimed to explore the possible association between the HALP score and CKD. Methods Our analysis encompassed 25,160 adult participants drawn from NHANES cycles spanning 2009 through 2018. Weighted multivariable logistic regression and generalized additive models (GAMs) were employed to evaluate the independent associations between the HALP score and CKD, albuminuria, and low-estimated glomerular filtration rate (eGFR). Threshold effects were examined using two-piecewise linear regression. Subgroup and sensitivity analyses were performed to assess robustness. Receiver operating characteristic (ROC) curve analyses were applied to compare the discriminative capacity of the HALP score with the prognostic nutritional index (PNI), systemic immune-inflammation index (SII), lymphocyte-to-monocyte ratio (LMR), and platelet-to-lymphocyte ratio (PLR). The clinical findings were further validated in a 5/6 nephrectomy rat model. Results After adjustment for multiple confounders, higher HALP scores were inversely associated with the risk of CKD (OR = 0.97, 95% CI: 0.94-0.99) and albuminuria (OR = 0.97, 95% CI: 0.93-0.99). However, after full adjustment for demographic characteristics, physical examination indices and laboratory parameters (Model 3), the correlation between the HALP score and low-eGFR was no longer statistically significant. Non-linear analyses revealed a threshold effect, with CKD risk declining as the HALP score increased up to an inflection point of 52.43 (OR = 0.97, 95% CI: 0.95-0.99), beyond which no further protective effect was observed. A similar threshold effect was identified for albuminuria. Subgroup and interaction analyses indicated no meaningful effect modification by age, sex, BMI, hypertension, or diabetes. Sensitivity analyses confirmed the robustness of the results. ROC analysis demonstrated that the HALP score showed superior discriminative ability for CKD and albuminuria compared with PNI, SII, LMR, and PLR. In the animal experiment, CKD model rats exhibited significantly lower HALP scores than controls. Inverse correlations were observed between the HALP score and serum creatinine (Scr), blood urea nitrogen (BUN), and urinary albumin-to-creatinine ratio (UACR), with UACR showing the strongest correlation, which was consistent with the clinical findings. Conclusion Lower HALP scores are independently associated with increased prevalence of CKD and albuminuria. As an affordable and readily measurable biomarker, the HALP score may facilitate CKD risk assessment.

Objective: To determine the absolute risk of starting dialysis versus mortality among adults with chronic kidney disease (CKD) treated at EsSalud from 2013 to 2022, utilizing data from the Renal Health Surveillance system (VISARE). Methods: This retrospective cohort study analyzed clinical records from the VISARE system (EsSalud). We estimated rates of dialysis initiation and death using Fine & Gray competitive risk models. Additionally, we calculated Restricted Mean Survival Time (RMST), adjusting for age, sex, clinical stage, and geographic region. Results: Among 142,770 adults with confirmed CKD and available glomerular filtration rate data, only 15.2% had albumin-to-creatinine ratio measurements, allowing KDIGO staging of 40,404 patients (28.3%). Mortality without having previously started dialysis exceeded the probability of starting renal replacement therapy (RRT) from G1, becoming more marked in G3 of chronic kidney disease (CKD); the possibility of dialysis is only greater, as expected, in G5. This outcome was most prevalent in regions with limited healthcare coverage. The combination of diabetes, hypertension, and age over 55 (the triad) was associated with reduced restricted mean survival time at both 5- and 10-year horizons across all enrollment cohorts. While Lima saw the highest rates of renal replacement therapy initiation, the Andean and Amazonian regions reported the lowest indicators. Conclusions Death without prior dialysis was the dominant outcome from G1 to G3 in this Peruvian cohort with national insurance, with direct implications for prognostic counseling, recalibration of renal failure risk equations, and equitable expansion of nephrology services in underserved regions. Keywords: Renal Insufficiency, Chronic; Competitive Risk; Diabetes Mellitus; Hypertension; Mortality; Mass Screening.

Background: Initiation of emergency dialysis, often requiring temporary catheter owing to unprepared definitive vascular access, is associated with infectious and vascular complications and suggests advanced chronic kidney disease (CKD) care gaps. Previous studies focused on kidney failure or dialysis timing. This study aimed to predict initiation of emergency dialysis using machine learning and baseline data. Methods: This retrospective cohort study used the Japan Medical Data Center claims data (2014-2022). Adults with an estimated glomerular filtration rate (eGFR) <15 mL/min/1.73 m2 were included. The primary outcome was initiation of emergency dialysis (temporary catheter code without evidence of previous access preparation). Participants were randomly divided into derivation (80%) and validation (20%) cohorts. Logistic regression, support vector machine, XGBoost, LightGBM, and random forest models were evaluated using internal cross-validation, post-hoc calibration of the selected model, and bootstrap confidence intervals. Results: The cohort included 3,062 individuals (derivation; n=2,449, validation; n=613). Emergency dialysis was initiated in 237 participants (7.7%); 185 (7.6%) and 52 (8.5%) in the derivation and validation cohorts, respectively. Validation area under the receiver operating characteristic curve ranged from 0.781-0.799, with the highest value observed for random forest (0.799, 95% confidence interval; 0.740-0.850). Risk stratification showed clear event enrichment in higher predicted risk categories. SHAP analyses identified hemoglobin, proteinuria, baseline eGFR, diabetes history, and diuretic use as key predictors. Decision curve analysis showed greater net benefit than eGFR alone at lower threshold probabilities. Conclusions: Baseline machine learning models showed moderate discrimination for initiation of emergency dialysis and identified clinically plausible predictors. These findings support potential use for risk stratification, although external validation and evaluation within pre-specified care pathways are needed before implementation.

Background: Renal effects of statins in type 2 diabetes mellitus (T2DM) remain uncertain. We evaluated whether statin exposure is associated with time to dialysis initiation. Methods: We conducted a retrospective cohort study of adults with T2DM, indexing follow-up at diagnosis during first hospital admission (day 0) between january 2017 and march 2025. Statin use was modeled as time-varying from statin days; (classified in 3 categories: baseline users, new users, and never users). The primary outcome was dialysis. Analysis estimated cause-specific hazards, censoring deaths; proportional hazards were checked with prespecified windows of statin exposure (0?1, 1?3, > 3 years). Competing-risk analyses (Fine?Gray) assessed the sub-distribution hazard of dialysis with death as a competing event in two models: (i) prevalent users at baseline and (ii) new-users with post-initiation intervals of 30 and 90 days. An Observational Medical Outcomes Partnership Common Data Model standardized dataset of a Brazilian quaternary hospital, and the Real-World Data tool MD Clone were used in the study. Results: Of 36,246 adults identified, 32,125 entered the time-varying cohort (39,943 risk intervals; 656 dialysis events); median follow-up among censored patients was 753 days. At baseline, 70.3% never used statins, 5.5% were users (? 0 days), and 24.2% initiated after diagnosis. Crude dialysis incidence was 4.51 vs. 12.31 per 1,000 patient-years during unexposed vs. exposed time. In the adjusted time-varying Cox model, current statin exposure was associated with a modestly higher hazard of dialysis (HR = 1.043, 95% CI 1.011?1.077). In the new-users analysis, HRs were 0.83 (95% CI 0.66?1.05), and 0.73 (95% CI 0.57?0.92) with a 30-day and 90-day intervals, respectively. Conclusions: In this retrospective cohort of hospitalized diabetic patients at baseline, statin initiation at least 90-days in advance is associated with reduced indication of renal replacement therapy.