Sodium-glucose cotransporter-2 (SGLT-2) inhibitors are now foundational therapy for diabetic chronic kidney disease (CKD), yet their ketogenic metabolic effects in this population remain incompletely characterised. While euglycaemic diabetic ketoacidosis is a recognised complication, the prevalence and clinical determinants of subclinical asymptomatic ketonemia in patients with diabetic CKD receiving SGLT-2 inhibitors have not been systematically evaluated. We aimed to determine the prevalence of asymptomatic ketonemia, defined by point-of-care capillary β-hydroxybutyrate (β-HB) positivity, and to identify its independent clinical predictors in this population. This cross-sectional study enrolled 211 consecutive adult outpatients with diabetic CKD receiving SGLT-2 inhibitor therapy (empagliflozin or dapagliflozin). Capillary β-HB was measured under standardised fasting conditions using a point-of-care ketone meter; positivity was defined as β-HB ≥ 0.6 mmol/L. Univariate comparisons were performed using the Mann-Whitney U test, independent-samples t-test, χ² test, or Fisher's exact test as appropriate. Given the low number of outcome events (n = 16), Firth's penalised logistic regression was employed as the primary multivariable analysis to mitigate small-sample bias. Asymptomatic ketonemia was detected in 16 of 211 patients (7.6%), all of whom were clinically asymptomatic at measurement. In Firth's penalised logistic regression, heart failure (OR 4.46; 95% CI 1.48-13.51; p = 0.008), absence of statin use (OR 4.94; 95% CI 1.54-15.86; p = 0.007), and higher HbA1c per 1% increment (OR 1.35; 95% CI 1.01-1.81; p = 0.041) were independent predictors of ketone positivity. Systolic blood pressure showed a borderline inverse association (OR 0.97 per mmHg; 95% CI 0.93-1.00; p = 0.063). No ketone-positive patient was receiving thiazide diuretics (0% vs. 30.3%; p = 0.007). SGLT-2 inhibitor type was not independently associated with ketonemia. Findings were robust on sensitivity analysis with standard logistic regression (Hosmer-Lemeshow p = 0.217; Nagelkerke R²=0.234). Asymptomatic ketonemia is present in approximately one in thirteen outpatients with diabetic CKD receiving SGLT-2 inhibitors. Heart failure, absence of statin therapy, and suboptimal glycemic control independently identify a higher-risk metabolic phenotype, while ketonemia appears unrelated to CKD stage. Although these findings are exploratory and require confirmation in larger prospective studies, they suggest that targeted ketone monitoring may be warranted in selected higher-risk patients.

Background: Finerenone is associated with a lower, yet clinically relevant, risk of hyperkalemia compared with steroidal mineralocorticoid receptor antagonists in diabetic kidney disease (DKD) trials. However, real-world data on hyperkalemia and its associated factors are lacking. Methodology: FINE-TURK is a national, observational cohort of DKD patients who were initiated on finerenone. Eligible adults were included; demographic, clinical, and laboratory data were evaluated. The primary outcome (PO) was hyperkalemia risk signal (potassium ≥ 5.0 mEq/L), and the secondary outcome (SO) was clinically meaningful hyperkalemia (potassium ≥ 5.5 mEq/L). Multivariate logistic regression (LR) was used to define features associated with both PO and SO. LR, random forest (RF), gradient boosting, and CatBoost classifiers were used to define important features associated with the PO. Results: 699 patients were included. 259 (37.1%) reached the PO, and 51 (7.3%) reached the SO. Baseline potassium and estimated glomerular filtration rate (eGFR) were the most important variables associated with both outcomes and were consistently identified as the top features across all models. Thiazide use, presence of diabetic retinopathy, and diabetes duration were also associated with the PO. LR demonstrated the highest recall; random forest achieved the highest precision in performance. Discussion: Real-world data suggest that the risk of clinically meaningful hyperkalemia is similar to that in the clinical trials. In parallel with the safety analysis of clinical trials, baseline potassium and eGFR were consistently the most important factors associated with hyperkalemia risk.

Background/Objectives: Peritoneal membrane failure remains a major limitation of peritoneal dialysis (PD). Systemic inflammation contributes to membrane dysfunction, yet simple predictive biomarkers are lacking. The uric acid-to-HDL cholesterol ratio (UHR) represents a novel integrative marker of metabolic-inflammatory burden, but its association with membrane failure has not been investigated. Methods: This retrospective cohort study included adult patients who initiated PD between 1997 and 2023. Baseline UHR was calculated from laboratory measurements obtained within the first three months after PD initiation. The primary outcome was peritoneal membrane failure, defined as permanent transfer to hemodialysis due to ultrafiltration failure, inadequate solute clearance, or progressive membrane dysfunction. Receiver operating characteristic, Kaplan–Meier, and Cox regression analyses were used to evaluate the association between UHR and membrane failure. Results: Among 214 patients, 62 (29%) developed membrane failure during follow-up. Baseline UHR was significantly higher in patients with membrane failure. A UHR cut-off value of 14 was identified for risk stratification. In multivariable Cox regression analysis, UHR >14 was independently associated with an increased risk of membrane failure (hazard ratio 1.836, 95% CI 1.040–3.241). A history of kidney transplantation prior to PD initiation also emerged as a strong independent predictor of membrane failure. Conclusions: Elevated baseline UHR is independently associated with peritoneal membrane failure in PD patients. As a simple and readily available biomarker, UHR may support early risk stratification and individualized management. Prospective multicenter studies are warranted to validate these findings.

Chronic kidney disease (CKD) is increasingly prevalent in the elderly population, necessitating precise diagnostic approaches such as renal biopsy. However, concerns about procedural risk often deter clinicians from performing biopsies in older adults. To evaluate the clinical indications, histopathological findings, and complication rates of native kidney biopsies in patients aged 65 years and older. This retrospective single-center study included 165 elderly patients who underwent native kidney biopsy between 2008 and 2024. Demographic, clinical, laboratory, and histopathological data were analyzed. Biopsies of transplanted kidneys and those with inadequate clinical or pathological information were excluded. The mean age of the cohort was 70.7±4.9 years, and 60.6% were male. The most common indication for biopsy was nephrotic syndrome (63%), followed by acute kidney injury (24.2%). Membranous glomerulopathy (18.8%) was the most frequent histopathological diagnosis, followed by pauci-immune glomerulonephritis (13.9%) and AA amyloidosis (10.9%). Renal replacement therapy was required in 20.6% of cases. Biopsy-related complications were infrequent, including hematoma (1.8%), transfusion requirement (1.8%), and angiographic intervention (0.6%), with no procedure-related mortality. Renal biopsy in the elderly demonstrates high diagnostic yield and a low complication rate. Membranous glomerulopathy, pauci-immune glomerulonephritis, and AA amyloidosis were the leading treatable diagnoses. These findings support perform renal biopsy in older patients when clinically indicated, emphasizing that advanced age alone should not preclude histopathologic evaluation.

Introduction: Medication non-adherence (MNA) is a leading cause of graft loss and mortality in renal transplant recipients. Smartphone addiction (SPA) is associated with cognitive impairment and poor time management, but its relationship with MNA remains unclear. This is the first study to investigate the association between SPA and MNA in renal transplant recipients. Material and methods: This cross-sectional study included 140 renal transplant recipients. SPA was assessed using the Smartphone Addiction Scale-Short Version (SAS-SV) and weekly screen time. MNA was measured using the Immunosuppressant Therapy Adherence Scale (ITAS), classifying adherence as perfect (12), acceptable (10–11), or poor (≤9). Univariate and multivariate logistic regression were performed to identify predictors of MNA. Results: Patients with poor adherence had longer weekly screen time (27 ± 10 hours) than those with perfect (20 ± 10) or acceptable adherence (21 ± 11) (p22 hours remained an independent predictor (OR: 4.106, 95% CI: 1.366–12.336, p=0.012), while SAS-SV scores lost significance. Conclusions: Excessive smartphone use, particularly prolonged screen time, is independently associated with MNA in renal transplant recipients. Integrating screen time tracking into routine transplant care may help identify at-risk patients. Future studies should determine whether reducing screen exposure improves adherence.

Background/Objectives: Finerenone improves cardiovascular and renal outcomes in diabetic kidney disease (DKD), but hyperkalemia remains a key safety concern. Patients with elevated baseline potassium levels (≥4.9 mEq/L) are largely excluded from clinical trials, and real-world data in this population are scarce. Methods: In this retrospective multicenter cohort study derived from the FINE-TURK cohort, adults with DKD who initiated finerenone with baseline potassium ≥ 4.9 mEq/L were included. The primary outcome was clinically significant hyperkalemia (K ≥ 5.5 mEq/L) within three months. Multivariable logistic regression analyses were used to identify associated factors, with multiple sensitivity analyses performed. Results: A total of 166 patients were included, of whom 47 (28.3%) had baseline potassium levels between 5.1 and 5.5 mEq/L. Of the 166 patients, 35 (21.1%) reached the primary outcome, and 10 (6%) patients had follow-up potassium ≥ 6.0 mEq/L. 126 (76.8%) patients required no intervention, 24 (14.6%) were initiated on potassium binders, and finerenone was discontinued in only 12 (7.3%) patients. Lower baseline estimated glomerular filtration rate, baseline urinary albumin, loop diuretic use and 20 mg finerenone dose were associated with the primary outcome. In contrast, baseline potassium was not associated with the primary outcome. Conclusions: In patients with DKD and elevated baseline potassium levels, finerenone initiation was associated with manageable rates of hyperkalemia. Our findings support the cautious use of finerenone in selected patients under close monitoring, as well as highlight the need for a multidimensional approach to hyperkalemia risk assessment.