Wearables in Nephrology: Fanciful Gadgetry or Prêt-à-Porter?

Telemedicine and digitalised healthcare have recently seen exponential growth, led, in part, by increasing efforts to improve patient flexibility and autonomy, as well as drivers from financial austerity and concerns over climate change. Nephrology is no exception, and daily innovations are underway to provide digitalised alternatives to current models of healthcare provision. Wearable technology already exists commercially, and advances in nanotechnology and miniaturisation mean interest is also garnering clinically. Here, we outline the current existing wearable technology pertaining to the diagnosis and monitoring of patients with a spectrum of kidney disease, give an overview of wearable dialysis technology, and explore wearables that do not yet exist but would be of great interest. Finally, we discuss challenges and potential pitfalls with utilising wearable technology and the factors associated with successful implementation.

COVID - 19 in two dialysis centers situated in two neighbouring states of the Western Balkans.

BACKGROUND: Bosnia and Herzegovina (BiH) and Serbia are countries in the Western Balkans that share parts of their social and political legacy from the former Yugoslavia, such as their health care system and the fact that they are not members of European Union. There are very scarce data on COVID - 19 pandemic from this region when compared to other parts of the world and even less is known about its impact on the provision of renal care or differences between countries in the Western Balkans. MATERIALS AND METHODS: This observational prospective study was conducted in two regional renal centres in BiH and Serbia, during the COVID - 19 pandemic. We obtained demographic and epidemiological data, clinical course and outcomes of dialysis and transplant patients with COVID - 19 in both units. Data were collected a via questionnaire for two consecutive time periods: February - June 2020 with a total number of 767 dialysis and transplant patients in the two centres, and July - December 2020 with a total number of 749 studied patients, corresponding to two of the largest waves of the pandemic in our region. Departmental policies and infection control measures in both units were also recorded and compared. RESULTS: For a period of 11 months, from February to December 2020, 82 patients on in-centre haemodialysis (ICHD), 11 peritoneal dialysis patients and 25 transplant patients who tested positive for COVID-19. In the first study period, the incidence of COVID - 19 positive in Tuzla was 1.3% among ICHD patients, and there were no positive peritoneal dialysis patients, or any transplant patients who tested positive. The incidence of COVID-19 was significantly higher in both centres in the second time period, which corresponds to the incidence in general population. Total deaths of COVID-19 positive patients was 0% in Tuzla and 45.5% in Nis during first, and 16.7% in Tuzla and 23.4% in Nis during the second period. There were notable differences in the national and local/departmental approach to the pandemic between the two centres. CONCLUSION: There was poor survival overall when compared to other regions of Europe. We suggest that this reflects the lack of preparedness of both of our medical systems for such situations. In addition, we describe important differences in outcome between the two centres. We emphasize the importance of preventative measures and infection control and highlight the importance of preparedness.

Have we missed AINything? Acute interstitial nephritis in SARS-CoV-2 infection and vaccination.

Acute interstitial nephritis (AIN), defined by the presence of interstitial inflammation accompanied by tubulitis, is an often overlooked cause of acute kidney injury (AKI). It is now well established that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can cause a wide variety of kidney injuries, most commonly acute tubular injury and collapsing glomerulopathy. In comparison, AIN is rarely documented in association with SARS-CoV-2 both anecdotally and in larger series of autopsy or biopsy studies. In this issue of the Journal, León-Román describe five cases of AIN in patients with a history of coronavirus disease 2019 (COVID-19) and highlight AIN as a possibly under-reported or ignored facet of renal disease associated with SARS-CoV-2. They describe three scenarios in which AIN can be seen: (i) SARS-CoV-2 infection after diagnosis of AIN, (ii) AIN followed by SARS-CoV-2 infection in the same admission and (iii) Severe SARS-CoV-2 and AIN possibly associated with SARS-CoV-2 itself. Overall, AIN remains rare in SARS-CoV-2 and causality is difficult to ascertain. Interestingly, AIN is not only seen in association with the disease itself but also with SARS-CoV-2 vaccination. This scenario is equally rare and causality is no less difficult to prove. A history of preceding SARS-CoV-2 infection and vaccination should be actively sought when patients present with otherwise unexplained AIN.

Have we missed AINything? Acute interstitial nephritis in SARS-CoV-2 infection and vaccination

Acute interstitial nephritis (AIN), defined by the presence of interstitial inflammation accompanied by tubulitis, is an often overlooked cause of acute kidney injury (AKI). It is now well established that SARS-CoV-2 infection can cause a wide variety of kidney injuries, most commonly acute tubular injury and collapsing glomerulopathy. In comparison, AIN is rarely documented in association with SARS-CoV-2 both anecdotally and in larger series of autopsy or biopsy studies. In this issue of the Journal, León-Román describe 5 cases of AIN in patients with a history of COVID-19 and highlight AIN as a possibly under-reported or ignored facet of renal disease associated with SARS-CoV-2. They describe three scenarios in which AIN can be seen: 1) SARS-CoV-2 infection after diagnosis of AIN, 2) AIN followed by SARS-CoV-2 infection in the same admission and 3) Severe SARS-CoV-2 and AIN possibly associated with SARS-CoV-2 itself. Overall, AIN remains rare in SARS-CoV-2 and causality is difficult to ascertain. Interestingly, AIN is not only seen in association with the disease itself but also with SARS-CoV-2 vaccination. This scenario is equally rare and causality is no less difficult to prove. A history of preceding SARS-CoV-2 infection and vaccination should be actively sought when patients present with otherwise unexplained AIN.

Acute interstitial nephritis following SARS-CoV-2 virus vaccination.

A number of reports have described new onset or relapse of existing glomerular disease after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination. More and more of these cases continue to emerge, and the European Medicines Agency (EMA) has recently launched an in-depth investigation to ascertain the true frequency of such renal side effects. In comparison, acute interstitial nephritis after SARS-CoV-2 vaccination has only been described in 1 solitary case. Here, we describe a case of acute kidney injury due to biopsy-proven acute interstitial nephritis soon after SARS-CoV-2 vaccination with the Astra-Zeneca vaccine. The patient responded well to steroids, although he required temporary renal replacement therapy. A thorough medical history failed to elucidate any plausible explanation or trigger other than the preceding vaccination. We acknowledge the possibility that other factors could have triggered acute interstitial nephritis in the case described here. Similar uncertainty exists regarding glomerular disease reported in conjunction with SARS-CoV-2 vaccination. However, we note that acute interstitial nephritis associated with vaccination has been described before the pandemic, and we therefore feel that a link is possible. We suggest that nephrologists should be vigilant when they see cases of unexplained acute interstitial nephritis. A history of preceding SARS-CoV-2 vaccination should be explored, and cases should be reported within national systems of pharmacovigilance.

Remote digital urinalysis with smartphone technology as part of remote management of glomerular disease during the SARS-CoV-2 virus pandemic: single-centre experience in 25 patients.

Background: The COVID-19 pandemic has necessitated the provision of healthcare through remote and increasingly digitalized means. The management of glomerular pathology, for which urinalysis is crucial, has been notably affected. Here we describe our single-centre experience of using remote digital urinalysis in the management of patients with glomerular disease during the COVID-19 pandemic. Method: All patients with native kidney glomerular disease who consented to participate in digital smartphone urinalysis monitoring between March 2020 and July 2021 were included. Electronic health records were contemporaneously reviewed for outcome data. Patient feedback was obtained through the testing portal. Results: Twenty-five patients utilized the digital urinalysis application. A total of 105 digital urinalysis tests were performed for a wide variety of indications. Four patients experienced a relapse (detected remotely) and two patients underwent three successful pregnancies. The majority of patients were managed virtually (60%) or virtually and face to face (F2F) combined (32%). The average number of clinic reviews and urine tests performed during the pandemic either virtually and/or F2F was comparable to levels pre-pandemic and the ratio of reviews to urinalysis (R:U) was stable (pre-pandemic 1:0.9 versus during the pandemic 1:0.8). Patients seen exclusively F2F with supplementary home monitoring had the highest R:U ratio at 1:2.1. A total of 95% of users provided feedback, all positive. Conclusion: Remote urinalysis proved a safe and convenient tool to facilitate decision-making where traditional urinalysis was difficult, impractical or impossible. Our approach allowed us to continue care in this vulnerable group of patients despite a lack of access to traditional urinalysis.

Time to press the reset button-can we use the COVID-19 pandemic to rethink the process of transplant assessment?

Coronavirus disease 2019 has taken a severe toll on the transplant community, with significant morbidity and mortality not just among transplant patients and those on the waiting list, but also among colleagues. It is therefore not surprising that clinicians in this field have viewed the events of the last 18 months as predominantly negative. As the pandemic is gradually ebbing away, we argue that this is also a unique opportunity to rethink transplant assessment. First, we have witnessed a step-change in the use of technology and virtual assessments. Another effect of the pandemic is that we have had to make do with what was available-which has often worked surprisingly well. Finally, we have learned to think the unthinkable: maybe things do not have to continue the way they have always been. As we emerge on the other side of the pandemic, we should rethink which parts of the transplant assessment process are necessary and evidence-based. We emphasize the need to involve patients in the redesign of pathways and we argue that the assessment process could be made more transparent to patients. We describe a possible roadmap towards transplant assessment pathways that are truly fit for the 21st century.

Opportunities in the cloud or pie in the sky? Current status and future perspectives of telemedicine in nephrology.

The use of telehealth to support, enhance or substitute traditional methods of delivering healthcare is becoming increasingly common in many specialties, such as stroke care, radiology and oncology. There is reason to believe that this approach remains underutilized within nephrology, which is somewhat surprising given the fact that nephrologists have always driven technological change in developing dialysis technology. Despite the obvious benefits that telehealth may provide, robust evidence remains lacking and many of the studies are anecdotal, limited to small numbers or without conclusive proof of benefit. More worryingly, quite a few studies report unexpected obstacles, pitfalls or patient dissatisfaction. However, with increasing global threats such as climate change and infectious disease, a change in approach to delivery of healthcare is needed. The current pandemic with coronavirus disease 2019 (COVID-19) has prompted the renal community to embrace telehealth to an unprecedented extent and at speed. In that sense the pandemic has already served as a disruptor, changed clinical practice and shown immense transformative potential. Here, we provide an update on current evidence and use of telehealth within various areas of nephrology globally, including the fields of dialysis, inpatient care, virtual consultation and patient empowerment. We also provide a brief primer on the use of artificial intelligence in this context and speculate about future implications. We also highlight legal aspects and pitfalls and discuss the 'digital divide' as a key concept that healthcare providers need to be mindful of when providing telemedicine-based approaches. Finally, we briefly discuss the immediate use of telenephrology at the onset of the COVID-19 pandemic. We hope to provide clinical nephrologists with an overview of what is currently available, as well as a glimpse into what may be expected in the future.