Keyword: Chronic Kidney Disease

ABSTRACT: Background: Chronic kidney disease (CKD) is very important to have biomarker that can be detected in time before kidney function is impaired, because it is only detected at very late stages. CD44 is a potential biomarker for kidney injury, involved in inflammation and fibrosis.
Methods: This cross-sectional study included 137 participants: The concentration of CD44 urine was measured by enzyme-linked immunosorbent assay (ELISA), and proteomic analysis was performed by mass spectrometry. For assessment, estimated glomerular filtration rate (eGFR) and 24-hour proteinuria have been monitored, while accounting for clinical and laboratory parameters. The correlation between kidney function and CD44 levels was determined using Spearman’s rank correlation.
Results: The level of CD44 in urine, as detected by ELISA, was higher in healthy controls than in CKD patients (p = 0.007). In addition, a positive correlation was observed between CD44 levels and eGFR (Spearman’s rho = 0.2808, p = 0.0052), indicating that higher CD44 levels are associated with kidney function. Proteomic analysis confirmed these results, showing a significant relationship between CD44 expression and kidney function parameters.
Conclusion: The research results demonstrate that CD44 levels in urine differ significantly between healthy individuals and CKD patients, suggesting that CD44 may be a candidate biomarker associated with kidney function. Further investigation in large-scale studies is required to confirm its clinical applicability.

ABSTRACT: Background: Intradialytic hypotension (IDH) is one of the most common complications of hemodialysis and may manifest as weakness, dizziness, syncope, and poor tolerance of treatment. The risk is increased in elderly patients and those with diabetes mellitus or cardiovascular disease. A key mechanism is an imbalance between ultrafiltration rate and plasma refilling of the intravascular compartment. We present a case of recurrent IDH in a high-risk patient with stage 5 chronic kidney disease (CKD), type 2 diabetes mellitus, and hypertensive heart and kidney disease.Case Presentation
A female patient, born in 1952, had stage 5 CKD (N18.5), extracorporeal dialysis (Z49.1), anemia in chronic disease (D63.8), type 2 diabetes mellitus (E11), and hypertensive heart and kidney disease (I13). Diabetes mellitus had been diagnosed in 2010, with longstanding arterial hypertension.
On December 15, 2022, following a fall and osteosynthesis of the right femur, serum creatinine was 481 μmol/L and blood urea 29.1 mmol/L. Repeat testing showed creatinine 505 μmol/L and urea 32 mmol/L. A double-lumen catheter was placed and renal replacement therapy initiated. On February 27, 2023, an arteriovenous fistula was created. The patient subsequently continued maintenance hemodialysis at Fresenius Medical Care Kazakhstan LLP, Talgar.
Baseline blood pressure was 160/90 mmHg. During every hemodialysis session, approximately 30 minutes after initiation, blood pressure decreased to 80/50 mmHg without adjustment of dialysis parameters.
Management included individualized dialysis prescription. Dry weight was assessed by bioimpedance spectroscopy (BCM), with adjustment of ultrafiltration volume and rate. Dialysate temperature was reduced to 35.5–36.5°C. Dialysate sodium, potassium, and calcium concentrations were 138, 3, and 1.5 mmol/L, respectively. Ultrafiltration profiling was used when fluid overload exceeded 3% of body weight. During hypotensive episodes, the patient was placed in the Trendelenburg position with elevated lower extremities, and ultrafiltration and dialysis parameters were adjusted. AF81 dialysate was used.
Following optimization, intradialytic blood pressure remained approximately 100/60–120/70 mmHg without significant hypotensive episodes. Post-dialysis blood pressure was 130/80 mmHg. Treatment tolerance improved, with clinical observations indicating improved quality of life.
Conclusion: Individualized hemodialysis prescription, including accurate dry-weight assessment, optimized ultrafiltration, reduced dialysate temperature, appropriate dialysate composition, ultrafiltration profiling, timely Trendelenburg positioning, and regular blood pressure monitoring, contributed to improved hemodynamic stability and reduced IDH severity in this high-risk patient.

ABSTRACT: Introduction: Chronic kidney disease (CKD) is a progressive condition characterized by declining kidney function and altered urinary protein excretion. However, relationships between individual urinary proteins and kidney function remain incompletely understood. We aimed to compare urinary proteomic profiles between patients with CKD and healthy controls (HC) and identify proteins associated with estimated glomerular filtration rate (eGFR).
Methods: Urinary proteomics was performed in 79 patients with CKD and 54 HC using diaPASEF on a timsTOF Pro 2 platform. DIA-NN data were processed with MSstats using log2 transformation, median normalization, and Tukey's median polish without missing-value imputation. Differential abundance was assessed using limma models adjusted for log10 urinary creatinine and LC-MS run order with robust empirical-Bayes moderation. Protein associations with eGFR were evaluated separately in CKD and HC using Spearman correlation. Benjamini-Hochberg false-discovery rate (BH-FDR) <0.05 was used to define significance.
Results: CKD participants had lower eGFR and higher urine albumin-to-creatinine ratio than HC (both P < 0.001). Summed MaxLFQ intensity was higher in CKD (8.0 [7.7-8.2] vs 7.5 [7.4-7.6] log10; P < 0.001), despite fewer detected protein groups (4,338 vs 4,553) (Table 1).
Values are median (IQR), mean ± SD, n (%), or detected protein-group counts, as appropriate. P values compare HC with patients with CKD. Sex was compared using the Pearson chi-square test. Age, serum creatinine, urine ACR, and summed MaxLFQ intensity were compared using the Wilcoxon rank-sum test. Estimated GFR was compared using Welch’s two-sample t-test. Detected protein groups were reported descriptively and were not statistically tested. ACR, albumin-to-creatinine ratio; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; HC, healthy controls; IQR, interquartile range; MaxLFQ, maximum label-free quantification.
Creatinine-adjusted differential abundance analysis showed broad bidirectional changes in the CKD urinary proteome. Among the most significantly upregulated proteins were A1AG1, TRFE, AFAM, A1AG2, and A1AT, whereas MUC18, BCAM, CD248, ROBO4, and IBP7 were among the most significantly downregulated proteins (Figure 1).
No protein-eGFR association remained significant after BH-FDR correction in HC (3,316 proteins tested). In CKD, 125 of 1,905 tested proteins showed significant associations with eGFR. The strongest FDR-ranked associations included positive associations for F16P1 (ρ = 0.60) and UROK (ρ = 0.49), and negative associations for CFAD (ρ = -0.59), VSIG4 (ρ = -0.57), SH3L1 (ρ = -0.65), FABP4 (ρ = -0.62), PEDF (ρ = -0.50), RET4 (ρ = -0.50), B2MG (ρ = -0.49), and FHR4 (ρ = -0.67) (Figure 2).
Conclusions: CKD was characterized by a distinct urinary proteomic profile and numerous proteins associated with kidney function. The presence of 125 eGFR-associated proteins in CKD, with none surviving FDR correction in HC, suggests disease-related variation in the urinary proteome. These findings support further evaluation of urinary proteins as potential CKD biomarkers.

ABSTRACT: Background: Iron deficiency anemia is common in patients with chronic kidney disease (CKD) and is associated with adverse clinical outcomes. Ferric carboxymaltose (FCM) is an effective and well-tolerated treatment for iron deficiency anemia in CKD. However, its potential effects on renal function remain insufficiently understood. This study aimed to evaluate changes in renal function following FCM administration in patients with CKD stages 3–4 and to assess whether these changes were associated with the administered dose.
Methods: This prospective study included patients with CKD stages 3–4, anemia, and iron deficiency (serum ferritin <100 μg/L or <200 μg/L with transferrin saturation <20%) who received intravenous FCM (Fercari) and were followed for 24 weeks. Patients were stratified according to the administered dose: 500 mg or 1000 mg. Clinical and laboratory parameters were assessed at baseline and after 24 weeks. Renal function was evaluated using estimated glomerular filtration rate (eGFR) calculated by the CKD-EPI equation.
Results: A total of 56 patients were included; mean age was 64.3 ± 6.7 years, and 25 (44.6%) were men. Diabetes mellitus, chronic heart failure, and arterial hypertension were present in 34 (60.7%), 31 (55.3%), and 45 (80.3%) patients, respectively. CKD stage 3 was present in 20 (35.7%) patients and stage 4 in 36 (64.3%). Thirty-two patients (57.1%) received 1000 mg FCM. Baseline mean hemoglobin was 98.3 ± 4.23 g/L and mean eGFR was 39.18 ± 15.14 mL/min/1.73 m². After 24 weeks, hemoglobin increased by 12.3 ± 1.51 g/L in the overall cohort (P=0.001), with increases of 15.6 ± 3.71 g/L in the 1000 mg group and 8.8 ± 1.5 g/L in the 500 mg group (both P=0.001). Mean eGFR increased by 5.86 ± 2.13 mL/min/1.73 m² in the overall cohort (P=0.042). In the 1000 mg group, eGFR increased by 6.64 ± 2.55 mL/min/1.73 m² (P=0.049), whereas no statistically significant change was observed in the 500 mg group.
Conclusions: FCM effectively improved hemoglobin levels in patients with CKD stages 3–4 and iron deficiency anemia. Treatment with 1000 mg FCM was associated with a modest improvement in eGFR over 24 weeks, whereas no significant change was observed with 500 mg. These findings suggest a possible dose-related association between FCM treatment and renal function; however, controlled randomized studies are required to determine whether this represents a true nephroprotective effect.

ABSTRACT: Background: Pregnancy in women with kidney disease is associated with an increased risk of maternal and obstetric complications, including preeclampsia, preterm delivery, and deterioration of kidney function. The magnitude of risk increases with advancing chronic kidney disease (CKD) stage and is further influenced by hypertension and proteinuria. However, evidence describing the spectrum of kidney disease and predictors of adverse pregnancy outcomes in Central Asian populations remains limited. This study aimed to characterize the clinical and laboratory features of pregnant women with kidney disease and identify factors associated with adverse pregnancy outcomes.
Methods: We conducted a retrospective single-center cohort study including 80 hospitalizations of 79 pregnant women with kidney disease between 2022 and 2026. Demographic characteristics, kidney disease categories, comorbidities, laboratory parameters, and available pregnancy outcomes were analyzed. A combined adverse outcome was defined as at least one of the following: CKD progression, dialysis initiation, preeclampsia, eclampsia, HELLP syndrome, pregnancy termination for medical indications. Bias-reduced logistic regression was used to identify factors associated with adverse outcomes.
Results: Urinary tract infections accounted for 49.4% of kidney-related diagnoses and glomerular diseases for 35.4%. Hypertension was present in 28.8% and anemia in 61.8% of cases. Women with glomerular diseases had significantly higher 24-hour proteinuria than women with other kidney disorders (1.3 [0.6–3.3] vs 0.1 [0.0–0.5] g/day; p<0.001). A combined adverse outcome occurred in 10/80 (12.5%) hospitalizations. The incidence was markedly higher in women with CKD stage ≥3 than in those with CKD stage <3 or without CKD (83.3% vs 7.2%; p<0.001). In univariable analysis, CKD stage ≥3 (OR 43.00; 95% CI 5.07–364.80), hypertension (OR 24.68; 95% CI 3.93–154.88), higher admission creatinine (OR 2.70 per 1 SD; 95% CI 1.43–5.09), and higher 24-hour proteinuria (OR 2.20 per 1 SD; 95% CI 1.17–4.16) were associated with adverse outcomes. In the multivariable model, CKD stage ≥3 (OR 20.29; 95% CI 1.58–260.05) and hypertension (OR 18.62; 95% CI 2.61–132.74) remained independently associated with adverse outcomes.
Conclusion: Advanced CKD and hypertension were the strongest predictors of adverse pregnancy outcomes. Assessment of kidney function, blood pressure, and quantitative proteinuria may facilitate early risk stratification and identify women requiring intensive multidisciplinary nephrology and obstetric surveillance.
 

ABSTRACT: Background: The early onset of chronic kidney disease often lacks symptoms, leading to delayed diagnosis and treatment. Regular laboratory testing can detect the disease before it begins, which helps clinicians determine the appropriate treatment for patients. This review sought to assess how ongoing tracking of estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (UACR) contributes to understanding the progression of chronic kidney disease (CKD) and determining the risk levels for patients.
Methods: A thorough review of evidence from international clinical practice guidelines, systematic reviews, meta-analyses, and extensive observational cohort studies was conducted. Special attention was given to how eGFR and UACR changed over time and how these changes were linked to the development of advanced CKD, kidney failure, cardiovascular issues, and death. The most recent recommendations from the 2024 KDIGO CKD guideline were included.
Results: Evidence shows that regularly checking eGFR and UACR is essential for effectively monitoring chronic kidney disease. In a group of 91,319 people, a reduction of 30% or more in estimated glomerular filtration rate (eGFR) was linked to a significantly higher risk of developing advanced chronic kidney disease, with a hazard ratio of 7.53 (95% CI, 6.70–8.45).Similarly, an increase of 30% or more in urinary albumin-to-creatinine ratio (UACR) was associated with a hazard ratio of 1.78 (95% CI, 1.59–1.98). At the same time, when both UACR increased and eGFR decreased, the hazard ratio was 15.15 (95% CI, 12.43–18.46) compared to when these values remained stable. KDIGO suggests that patients with chronic kidney disease should have their glomerular filtration rate and albuminuria checked at least once every year.For those at greater risk, more regular check-ups are advised, especially if the results could impact treatment choices. Even though these recommendations were provided, a systematic review of 59 studies that included 3,036,41 patients showed significant shortcomings in standard monitoring practices: the estimated glomerular filtration rate (eGFR) was checked in 81.3% of patients, but testing for albuminuria was done in just 47.4%.
Conclusion: Regular laboratory testing, especially repeated checks of eGFR and UACR, is important for early identification of CKD progression and for assessing individual risk levels. The continued limited use of albuminuria testing highlights a significant gap in care that aligns with established guidelines. Integrating structured laboratory surveillance into routine clinical practice may facilitate timely therapeutic optimization and contribute to delaying kidney failure and reducing cardiorenal complications.

ABSTRACT: Background: Chronic kidney disease (CKD) is characterized by progressive loss of kidney function associated with intraglomerular hypertension, hyperfiltration, podocyte injury, tubular damage, and tubulointerstitial fibrosis. Sodium–glucose cotransporter 2 (SGLT2) inhibitors have demonstrated nephroprotective effects beyond glycemic control. This study aimed to quantitatively assess the effect of SGLT2 inhibitors on CKD progression and to summarize the morphological mechanisms underlying their nephroprotective effects.
Methods: A systematic review and quantitative meta-analysis of randomized controlled trials (RCTs) evaluating SGLT2 inhibitors and renal outcomes was performed. The primary quantitative analysis included the CREDENCE, DAPA-CKD, and EMPA-KIDNEY trials. Pooled hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated using a random-effects model. Statistical heterogeneity was assessed using the I² statistic and Cochran’s Q test. Published evidence on morphological and structural renal changes associated with SGLT2 inhibition was additionally analyzed.
Results: SGLT2 inhibitors reduced the risk of the primary renal composite endpoint in CREDENCE (HR 0.70; 95% CI 0.59–0.82), DAPA-CKD (HR 0.61; 95% CI 0.51–0.72), and EMPA-KIDNEY (HR 0.72; 95% CI 0.64–0.82). The pooled analysis demonstrated a significant reduction in the risk of CKD progression (HR 0.68; 95% CI 0.62–0.75), corresponding to an approximately 32% relative risk reduction. Heterogeneity between studies was low (I²=17.5%). Morphological evidence demonstrated attenuation of glomerular hyperfiltration, preservation of podocytes and the glomerular filtration barrier, reduction of tubular injury, and attenuation of tubulointerstitial fibrosis.
Conclusion: SGLT2 inhibitors are associated with a significant reduction in the risk of CKD progression. Their nephroprotective effects appear to involve complementary hemodynamic, glomerular, tubular, and tubulointerstitial mechanisms. The consistency between clinical trial findings and morphological evidence supports a multifactorial basis for SGLT2 inhibitor-mediated nephroprotection.

ABSTRACT: Background: Treatment of rheumatoid arthritis (RA) in patients with end-stage chronic kidney disease (CKD stage 5D) on maintenance hemodialysis is challenging because of limited therapeutic options and increased drug toxicity. Stevens–Johnson syndrome (SJS) is a rare, life-threatening drug reaction that may cause severe systemic complications. This case is noteworthy for severe SJS complicated by sepsis and progressive coagulation abnormalities in a patient with seropositive RA, secondary renal amyloidosis, and CKD stage 5D.
Case Presentation: A 61-year-old woman with seropositive RA (anti-CCP+, RF+), late-stage disease, high activity (DAS28 5.3), secondary renal amyloidosis, and CKD stage 5D had received maintenance hemodialysis since December 2025. From January 21 to February 2, 2026, she was hospitalized due to RA exacerbation. Before therapy, hemoglobin was 106 g/L, erythrocytes 3.64 × 10¹²/L, leukocytes 21.57 × 10⁹/L, hematocrit 32.4%, neutrophils 17.99 × 10⁹/L, ESR 30 mm/h. Creatinine was 405 μmol/L, urea 14.1 mmol/L, total protein 63 g/L, potassium 4.05 mmol/L, glucose 6.77 mmol/L, ALT 18 U/L, AST 16 U/L. Hemostasis lab tests: PTI 79%, INR 1.24, fibrinogen 684 mg/dL, aPTT 26.0 s. Therapy included methotrexate 15 mg, colchicine 1.0 mg, infliximab 200 mg, denosumab 60 mg, and prednisolone 10 mg. Subsequently, severe stomatitis and generalized skin eruptions developed. On March 24, she was hospitalized; on March 25, was diagnosed drug-induced SJS. On March 27, she was transferred to the intensive care unit. At admission, hemoglobin was 67 g/L, leukocytes 1.68 × 10⁹/L, platelets 88 × 10⁹/L, creatinine 605.3 μmol/L, urea 21.99 mmol/L, and total protein 53.6 g/L. By March 29, platelets decreased to 12 × 10⁹/L, total protein to 36.3 g/L, and albumin to 17.6 g/L. Hemostasis lab tests deteriorated: PTI 79%-74%-59%, INR 1.24-1.31-1.60, and aPTT 26.0-26.9-77.3 s (January 21, March 24, and March 29, respectively). Sepsis developed, requiring antibacterial and antifungal therapy, platelet concentrates, fresh frozen plasma, and maintenance hemodialysis. Despite intensive treatment, her condition progressively deteriorated. Treatment was stopped at her family's request.
Conclusion: This case highlights the high risk of severe drug-related complications in patients with RA and CKD stage 5D on hemodialysis. Individualized antirheumatic therapy, careful assessment of drug toxicity and renal status, early recognition of severe mucocutaneous reactions, and prompt multidisciplinary management of SJS, sepsis, and coagulation abnormalities are essential to improve outcomes. Early withdrawal of suspected offending agents and close monitoring of hematological and hemostatic parameters are critical to prevent progression.

ABSTRACT: Objective: To assess dietary practices and challenges in managing hyperphosphatemia in CKD patients from nephrology specialists’ perspective.
Methods: An online survey of 68 nephrologists, hemodialysis physicians, and nurses at the Republican Specialized Medical Center of Nephrology and Kidney Transplantation (Tashkent, Uzbekistan) evaluated dietary habits, phosphorus awareness, and adherence difficulties. Descriptive statistics were applied.
Results: 64.7% reported increased consumption of ready-to-eat foods, 70.6%—phosphate-containing products, and 82.4% noted higher patient awareness. Adherence challenges were greatest among hemodialysis patients (51–75%). Most specialists (76.5%) emphasized equal importance of protein intake and phosphorus restriction.
Conclusion: Despite improved awareness, dietary adherence remains difficult. Increased processed and phosphate-rich food consumption complicates hyperphosphatemia management, highlighting the need for enhanced dietetic support.

ABSTRACT: Introduction: Chronic kidney disease (CKD) is frequently diagnosed after clinically meaningful loss of kidney function. Creatinine-based estimated glomerular filtration rate (eGFR) may fail to identify early renal dysfunction, while cystatin C, albuminuria and artificial intelligence (AI)-based prediction models may improve early detection and risk stratification. This umbrella review synthesizes current evidence regarding the diagnostic and prognostic value of these approaches and identifies limitations to their clinical implementation.
Methods: We synthesized published systematic reviews and meta-analyses evaluating adults with CKD or individuals at risk of CKD. Evidence addressing cystatin C, albuminuria, or AI/machine-learning models for CKD detection or progression was considered. Outcomes included diagnostic accuracy, sensitivity, specificity, area under the receiver operating characteristic curve (AUC), and prognostic associations. Findings were summarized descriptively according to reported pooled estimates and study limitations.
Results: A meta-analysis of 19 studies evaluating serum cystatin C for CKD detection reported pooled sensitivity of 0.85 (95% CI, 0.81–0.89), specificity of 0.87 (95% CI, 0.84–0.90), and AUC of 0.92 (95% CI, 0.90–0.94). Another meta-analysis including 35 studies and 23,667 participants found that the combined creatinine/cystatin C CKD-EPI equation achieved 7.50% higher accuracy than creatinine-based eGFR alone. A 2025 systematic review of risk-factor-based CKD screening included 24 studies from 11 countries; eGFR was used in 22 studies and albumin-creatinine ratio in 14, while confirmed CKD prevalence ranged from 4.4% to 17.1%. For AI, a systematic review identified 68 eligible studies from 648 records, but only 6/68 were conducted in clinical settings. A subsequent meta-analysis of 33 AI studies reported pooled sensitivity of 0.43, specificity of 0.92 and AUC of 0.89, with substantial heterogeneity.
Conclusion: Cystatin C and combined creatinine/cystatin C assessment demonstrate improved diagnostic performance compared with creatinine-based assessment alone. Albuminuria remains an important component of targeted CKD screening, while AI models show promising predictive performance but limited clinical validation. Prospective multicenter studies integrating biomarkers and interpretable AI models are warranted to establish whether these approaches improve clinically meaningful early CKD detection.

ABSTRACT: Background: Evidence on chronic kidney disease (CKD) in Central Asia remains limited, particularly for community-based detection using both kidney function and albuminuria. This study assessed the frequency of CKD markers among adults in three cities of Kazakhstan and examined whether point-of-care (POC) creatinine testing could support community screening.
Methods: Adults were recruited through community screening events in Astana, Ust-Kamenogorsk, and Turkestan. Laboratory serum creatinine was used to calculate eGFR with the CKD-EPI 2021 equation, and urine albumin-to-creatinine ratio (ACR) was measured to identify albuminuria. Participants were classified as having screening-detected CKD markers if eGFR was <60 mL/min/1.73 m² and/or ACR was ≥30 mg/g on a single assessment. Multivariable logistic regression was used to examine associated factors. Capillary POC creatinine was compared with laboratory creatinine, and its diagnostic performance for identifying eGFR <60 mL/min/1.73 m² was evaluated.
Results: Of 1,022 participants with complete laboratory kidney measurements, 100 (9.8%; 95% CI 8.1–11.8) had screening-detected CKD markers. Albuminuria was identified in 7.7%, while reduced eGFR was present in 3.4%. Among participants with CKD markers, 52.0% reported no previous awareness of abnormal kidney findings. Hypertension was associated with approximately twice the adjusted odds of CKD markers (aOR 2.05, 95% CI 1.24–3.41). POC and laboratory creatinine were available for 987 participants. POC creatinine exceeded laboratory values by an average of 18.5 µmol/L, with wide limits of agreement. For identifying laboratory-defined reduced eGFR, POC-derived eGFR had 84.4% sensitivity, 83.4% specificity, 14.5% positive predictive value, 99.4% negative predictive value, and an AUC of 0.919.
Conclusions: CKD markers were detected in roughly one in ten screened adults, and albuminuria accounted for a substantial proportion of identified abnormalities. The high proportion of previously unrecognized findings supports greater use of combined eGFR and ACR assessment in CKD case-finding. POC creatinine may be useful for triage because of its strong rule-out performance, but positive findings should be confirmed with standardized laboratory testing.

ABSTRACT: Patient T., 43 years old. End-stage chronic kidney disease (CKD) was diagnosed in 2013, and emergency kidney replacement therapy with maintenance hemodialysis was initiated. Prior to this, the patient had not been followed by a nephrologist. Throughout the course of hemodialysis treatment, the patient failed to comply with medical recommendations regarding regular laboratory monitoring of mineral metabolism.
In 2024, a markedly elevated parathyroid hormone (PTH) level (>1,935 pg/mL; October 2024) was detected for the first time. The patient had not received any specific medical therapy. Clinical manifestations included generalized weakness, bone and joint pain, impaired mobility (waddling gait), and skeletal deformities involving the sternum and tibial bones.
Scintigraphy performed on December 13, 2024, demonstrated increased functional activity of all four parathyroid glands (Figure 1). Despite prolonged combined medical therapy with cinacalcet 90 mg/day and paricalcitol 15 μg three times weekly, laboratory markers of calcium-phosphate metabolism continued to deteriorate, with the PTH level rising to 2,338 pg/mL. Bone mineral density assessment by dual-energy X-ray absorptiometry (DXA) revealed a Z-score of −5, consistent with severe secondary osteoporosis (Figure 2).
In December 2024, the patient underwent cervical exploration with removal of the hyperplastic left superior, left inferior, and right inferior parathyroid glands at Poytaxt Medical Clinic. In the postoperative period, a significant reduction in serum PTH was observed, decreasing to 492 pg/mL (December 27, 2024) compared with the preoperative level of 2,338 pg/mL.
During the one-year follow-up after parathyroidectomy, the patient's condition remained stable, with no recurrence of hyperparathyroidism. As replacement therapy, the patient has been receiving long-term calcium supplementation and alfacalcidol.
Biochemical blood tests performed in August–September 2025 demonstrated total serum calcium levels ranging from 1.79 to 2.71 mmol/L (reference range: 2.1–2.6 mmol/L) and serum phosphorus levels of 1.0–1.15 mmol/L (reference range: 0.81–1.45 mmol/L).
In November 2025, dysfunction of the patient's arteriovenous fistula (AVF) resulted in complete loss of vascular access. The exact etiology could not be established because of insufficient diagnostic evaluation; however, vascular wall calcification was considered a possible contributing factor. A temporary central venous catheter was inserted for hemodialysis, followed by successful creation of a new arteriovenous fistula.
According to the most recent laboratory evaluation performed on January 7, 2026, the PTH level remained within the target range (200 pg/mL), serum phosphorus was 0.98 mmol/L, and alkaline phosphatase was 410.5 U/L.
Conclusion: This clinical case illustrates the consequences of delayed diagnosis and inadequate management of secondary hyperparathyroidism, resulting from both poor patient adherence to treatment and systemic healthcare limitations, including insufficient long-term follow-up, limited access to regular laboratory monitoring, and shortcomings in the standard management of maintenance hemodialysis patients.
Although parathyroidectomy is effective in improving quality of life and reducing cardiovascular mortality, it is associated with postoperative complications and is generally performed only in advanced stages of the disease, when irreversible disorders of mineral and bone metabolism have already developed.
Therefore, early diagnosis and timely initiation of long-term medical therapy remain the cornerstone of secondary hyperparathyroidism management, allowing better disease control and reducing the need for surgical intervention.

ABSTRACT: Introduction: Advances in dialysis, kidney transplantation, and conservative kidney care have significantly increased the life expectancy of patients with chronic kidney disease (CKD) and end-stage kidney disease (ESKD). At the same time, technological progress has created complex ethical dilemmas related to the initiation or withdrawal of dialysis, informed consent, quality of life, end-of-life care, organ transplantation, and equitable allocation of limited healthcare resources. These issues require not only clinical assessment but also philosophical reflection on autonomy, human dignity, justice, and moral responsibility.
Aim: To analyze the main bioethical challenges arising in nephrology and to determine the philosophical principles that can improve decision-making in the management of patients with CKD and ESKD.
Materials and Methods: A philosophical and comparative bioethical analysis of scientific literature published between 2008 and 2025 was conducted. Peer-reviewed publications in nephrology, bioethics, palliative medicine, and philosophy of medicine were examined. The study used critical literature review, conceptual analysis, comparison of ethical approaches, and synthesis of the principles of autonomy, beneficence, non-maleficence, justice, and respect for human dignity.
Results: The analysis demonstrated that the traditional individualistic interpretation of patient autonomy is insufficient for resolving many contemporary ethical problems in nephrology. Patients with advanced CKD may experience cognitive impairment, emotional distress, severe comorbidity, and dependence on family and healthcare professionals. Therefore, treatment decisions are rarely made in complete social isolation.
The concept of relational autonomy provides a more comprehensive ethical framework. It recognizes that patient preferences and choices are formed within family, cultural, social, and institutional relationships. Accordingly, nephrologists should ensure meaningful communication among patients, relatives, and members of the multidisciplinary team while preserving the patient’s right to self-determination.
The initiation or withdrawal of dialysis represents one of the most difficult ethical decisions. Dialysis may prolong life but can also increase treatment burden without providing a meaningful improvement in functional status or quality of life. Ethical decision-making should therefore consider clinical prognosis, treatment benefits and burdens, patient values, expected quality of life, psychosocial consequences, and family perspectives. Shared decision-making is considered the most appropriate approach because it combines professional medical judgment with the informed preferences of the patient.
Justice is another fundamental challenge, particularly in settings with limited access to dialysis and kidney transplantation. Transparent allocation criteria are required to prevent discrimination based on age, ethnicity, socioeconomic status, disability, or social position. Palliative and conservative kidney care should also be recognized as ethically acceptable patient-centered options rather than as abandonment of treatment.
Conclusion: Contemporary nephrology requires an integrated ethical model that combines autonomy, beneficence, non-maleficence, justice, human dignity, and relational responsibility. Relational autonomy offers a more realistic framework than an exclusively individualistic approach because it considers the social and cultural context of decision-making. The proposed approach may improve communication, support shared decision-making, reduce non-beneficial treatment, and promote patient-centered care in CKD and ESKD. Further research should focus on adapting this model to different cultural traditions and healthcare systems.

ABSTRACT: Background: Diabetic chronic kidney disease (DKD) is a leading cause of kidney failure and cardiovascular morbidity worldwide. Although albuminuria and estimated glomerular filtration rate (eGFR) remain central markers of risk stratification, early progression is frequently driven by a broader cluster of metabolic, hemodynamic, inflammatory, and cardiometabolic factors. Identification of simple clinical predictors may support earlier intensification of nephroprotective therapy. This study aimed to evaluate clinical, biochemical, and renal predictors associated with early DKD progression.
Methods: This prospective observational study included 112 patients with type 2 diabetes mellitus and established chronic kidney disease. Baseline assessment included age, sex, diabetes duration, body mass index, systolic and diastolic blood pressure, glycated hemoglobin (HbA1c), fasting plasma glucose, lipid profile, serum creatinine, eGFR, urinary albumin-to-creatinine ratio (UACR), hemoglobin, uric acid, C-reactive protein, smoking status, hypertension, obesity, dyslipidemia, and cardiovascular disease history. Early CKD progression was defined as clinically significant eGFR decline during follow-up. Patients were divided into early progression and stable/slow progression groups. Between-group comparisons and multivariable logistic regression were performed.
Results: Early DKD progression was observed in 34 of 112 patients (30.4%), while 78 patients (69.6%) had stable or slowly progressive disease. Patients with early progression had longer diabetes duration (12.8±4.1 vs 8.9±3.6 years; p<0.05), higher systolic blood pressure (148±16 vs 134±14 mmHg; p<0.05), higher HbA1c (8.7±1.1 vs 7.6±0.9%; p<0.01), greater UACR (286 [164–420] vs 118 [62–210] mg/g; p<0.01), and lower baseline eGFR (52.4±13.8 vs 64.7±15.2 mL/min/1.73 m²; p<0.05). Progressors also had higher body mass index (31.2±4.6 vs 28.7±4.2 kg/m²; p=0.006), triglycerides (2.3±0.7 vs 1.8±0.6 mmol/L; p<0.01 ), uric acid (421±76 vs 368±69 µmol/L; p=0.05), and C-reactive protein (5.8 [3.4–8.6] vs 3.1 [1.8–5.2] mg/L; p=0.002), with lower hemoglobin (118±14 vs 126±13 g/L; p=0.004). In multivariable analysis, independent predictors of early progression were UACR above 300 mg/g (odds ratio [OR] 3.42, 95% confidence interval [CI] 1.48-7.91; p=0.004), HbA1c at least 8.0% (OR 2.76, 95% CI 1.27-6.01; p=0.011), uncontrolled hypertension (OR 2.58, 95% CI 1.17-5.68; p=0.018), and hyperuricemia (OR 2.21, 95% CI 1.02-4.79; p=0.044).
Conclusion: Early DKD progression affected nearly one-third of patients. Albuminuria, poor glycemic control, uncontrolled hypertension, hyperuricemia, reduced baseline eGFR, obesity, dyslipidemia, inflammation, and anemia were associated with accelerated renal decline. These clinically accessible variables may improve early risk stratification and guide individualized nephroprotective management.

ABSTRACT: Background: Rapid identification of patients at risk of contrast-associated acute kidney injury (AKI) is essential in acute settings such as acute myocardial infarction and ischemic stroke. Point-of-care (POC) creatinine testing provides immediate assessment of kidney function; however, its reliability for clinical risk stratification relative to standard laboratory measurements remains uncertain. This study evaluated the agreement between laboratory- and POC creatinine-based risk stratification and their association with subsequent AKI after contrast angiography.
Methods: In this prospective observational study, 295 adults undergoing contrast-enhanced angiography for acute myocardial infarction or acute ischemic stroke were enrolled. Serum creatinine was measured using both standard laboratory methods and a POC device before contrast administration. Estimated glomerular filtration rate (eGFR) was calculated using the CKD-EPI 2021 equation, and predicted risk of post-contrast AKI was assessed using the Mehran risk score. AKI was defined according to KDIGO criteria (≥1.5-fold increase from baseline or ≥26.5 µmol/L increase within 7 days). Agreement between laboratory- and POC-derived risk categories was evaluated using weighted Cohen’s kappa.
Results: The median age was 64 years (interquartile range 57–70), and 66.8% of participants were male. Based on laboratory measurements obtained in the hospital central laboratory, categories were low in 8.8%, moderate in 37.3%, high in 25.4%, and very high in 28.5% of patients. Among patients with available follow-up creatinine measurements (n = 127), CA-AKI occurred in 11.0% (14/127). Agreement between laboratory- and POC-based risk classifications was near-perfect (κ = 0.97, 95% CI 0.95–0.98). The correlation between laboratory and POC creatinine values was moderate (r = 0.63, p < 0.001).
Conclusion: POC creatinine–based Mehran risk stratification shows excellent diagnostic agreement with laboratory-based assessment for identifying patients at risk of post-contrast AKI. POC testing may facilitate rapid bedside risk assessment in patients undergoing angiography for acute myocardial infarction or ischemic stroke without compromising risk classification reliability.

ABSTRACT: A 68-year-old asian man was admitted with decompensated chronic heart failure with a left ventricular ejection fraction of 20%, permanent arterial fibrillation, and chronic kidney disease. Sacubitril/Valsartan (Uperio) was prescribed. This review details the initiation of sacubitril/valsartan in an Asian patient with heart failure with low ejection fraction (20%) and comorbidities. The paper highlights the pharmacodynamic and pharmacokinetic profiles of Sacubitril/Valsartan. The focus is on a thorough review of clinical trials to assess the therapeutic efficacy and potential adverse events associated with Sacubitril/Valsartan administration in this specific patient group.
Since 2014, sacubitril/valsartan has been widely prescribed for heart failure. Nevertheless, the coexistence of additional diseases such as arthritis, renal insufficiency, diabetes mellitus, or chronic lung disease with the heart failure syndrome should logically require a modification of treatment, outcome assessment, or follow-up care.

ABSTRACT: Background: Chronic kidney disease (CKD) is an increasing global health concern and a major contributor to cardiovascular morbidity and mortality. Although its global prevalence is estimated at about 13%, data from Central Asia are limited.
Objective: To assess the prevalence, structure, and key determinants of CKD among adults in the Kyrgyz Republic.
Methods: A population-based cross-sectional study was conducted among adults aged ≥18 years across different regions. CKD was defined according to Kidney Disease: Improving Global Outcomes (KDIGO) criteria as an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m² and/or a urinary albumin-to-creatinine ratio (UACR) ≥30 mg/g. Disease severity was staged by eGFR and albuminuria categories. Logistic regression identified independent predictors of CKD.
Results: The overall CKD prevalence was 10.8%, comparable to global estimates. Prevalence increased with age, reaching 25.0% among participants ≥70 years, of whom 64.3% had reduced kidney function. CKD was more common in women than in men (p<0.001). Major etiologic factors included diabetes mellitus (29%), chronic glomerulonephritis (23%), chronic pyelonephritis (17%), and hypertension (10%). In multivariable analysis, diabetes, hypertension, dyslipidemia, obesity (BMI ≥30), and rural residence were independent predictors of CKD (p<0.05).
Conclusion: CKD is highly prevalent among adults in the Kyrgyz Republic. Risk factors align with international data, but regional patterns show higher rates of chronic glomerulonephritis and pyelonephritis. Strengthening early detection, integrating CKD screening into national health programs, and focusing on high-risk groups—older adults, women, and rural populations—are crucial to reducing the CKD burden in Kyrgyzstan.

ABSTRACT: Background: Chronic kidney disease (CKD) is a major global health challenge, yet population-based data from Central Asia are scarce. We conducted a population-based screening study to assess kidney function distribution and associated risk factors in Astana, Kazakhstan.
Methods: In March 2024, 636 adults were screened through convenience sampling at four major institutions in Astana. After excluding incomplete data, 569 participants were analyzed. Demographic, lifestyle, and clinical information were collected, and serum creatinine was used to estimate glomerular filtration rate (eGFR). Reduced renal function was defined as eGFR <90 mL/min/1.73 m². Group comparisons and logistic regression analyses were performed to identify risk factors for reduced renal function.
Results: The median age of participants was 46 years (IQR 33–55), and 79.8% were women. Median eGFR was 92.8 (IQR 79.8–111.3) mL/min/1.73 m²; 54.1% had eGFR ≥90, 42.4% had eGFR 60–89, and 3.5% had eGFR 45–59. Reduced renal function was more common among older adults, females and those with hypertension and heart failure. In multivariable analysis, older age and female sex were independent predictors of reduced renal function. Awareness was low: only 15.0% of individuals with eGFR 45–59 reported having CKD.
Conclusion: This study provides the population-based evidence on kidney function in Astana, Kazakhstan. Reduced renal function was common, particularly among older adults. Findings highlight the importance of population-based screening and targeted prevention strategies to address kidney health in Kazakhstan.

ABSTRACT: A 46-year old male was admitted to the University Medical Center (UMC) hospital with the following symptoms of anuria, abdominal fullness, hypotension, exertional dyspnea, and peripheral edema. The purpose of his visit was the insertion of a peritoneal dialysis catheter. He had chronic kidney disease stage 5 as a consequence of diabetic nephropathy, liver cirrhosis due to hepatitis C infection, and HIV. His disease course was further complicated by the presence of a urinary tract infection. As a result of his multiple comorbidities, he underwent a complex treatment regimen which included renal replacement therapy with ultrafiltration, blood transfusions for his anemia, platelet transfusions for his thrombocytopenia, albumin infusion for his hypoalbuminemia, and antibiotic treatment for his concurrent infection. Additionally, he received diuretic treatment for his hypervolemia and anti-hypertensives to control his blood pressure. After peritoneal dialysis (PD) insertion, the patient successfully underwent PD and was discharged home.