Jaturapisanukul, Solos

Key Points Both sodium zirconium cyclosilicate and patiromer effectively lower serum potassium and provide clinical benefits. Sodium zirconium cyclosilicate is associated with higher risk of edema. Patiromer is associated with the increased risk of constipation and hypokalemia. Background Sodium zirconium cyclosilicate (SZC) and patiromer have recently been approved for the treatment of hyperkalemia. However, their efficacy in lowering serum potassium according to the phase of intervention, safety profile, and impact clinical outcomes remains to be fully defined. This study aims to assess their efficacy and tolerability in the management of hyperkalemia. Methods A comprehensive search of PubMed, Scopus, and Cochrane Central Register of Controlled Trials was conducted up to June 6, 2025. Eligible studies included randomized controlled trials reporting the effects of SZC and patiromer on laboratory parameters, clinical outcomes, and safety profiles. Meta-analyses were synthesized using a random-effects model, with results presented as weighted mean differences (WMD) or relative risks (RR), along with 95% confidence intervals (CI). Results Nineteen randomized controlled trials involving 3627 patients (1911 on SZC; 1716 on patiromer) were analyzed. During the initial 48–72 hours, only SZC significantly reduced serum potassium levels (WMD, −0.45 mEq/L; 95% CI, –0.61 to –0.29). At the end of treatment, both agents effectively lowered serum potassium (SZC: WMD, –0.50 mEq/L; 95% CI, –0.63 to –0.38; patiromer: WMD, –0.36 mEq/L; 95% CI, –0.51 to –0.21). SZC significantly normalized serum potassium and reduced hyperkalemia incidence, while patiromer enabled renin-angiotensin-aldosterone system inhibitor optimization by supporting target dosing and reducing discontinuation due to hyperkalemia. However, SZC was associated with a higher incidence of edema (RR, 2.92; 95% CI, 1.08 to 7.90) and patiromer with increased rates of constipation (RR, 2.96; 95% CI, 1.21 to 7.22) and hypokalemia (RR, 1.46; 95% CI, 1.05 to 2.03). Conclusions Both SZC and patiromer effectively lower serum potassium and provide clinical benefits, with distinct safety considerations. Therapy selection should be guided by treatment goals and the patient's individual risk profile.

Hemodiafiltration (HDF) is increasingly used because of its enhanced theoretical clearance of diverse uremic toxins, particularly middle molecules and inflammatory cytokines, relative to conventional hemodialysis (HD), yet evidence on its biochemical benefits remains conflicting. Therefore, this meta-analysis was performed to evaluate the effects of HDF versus HD on uremic toxins, inflammation, anemia, and nutritional parameters. A systematic literature search was conducted using PubMed, Scopus, and the Cochrane Central Register of Controlled Trials to identify relevant studies. Only randomized controlled trials (RCTs) were included. Random-effects meta-analyses were performed to evaluate changes in the prespecified outcomes. Twenty-four RCTs involving 6072 dialysis patients were included. Compared with conventional HD, HDF was associated with significant reductions in serum phosphorus (weighted mean difference [WMD] −0.28 mg/dL; 95% CI −0.44 to −0.12) and β2-microglobulin (WMD −4.84 mg/dL; 95% CI −6.13 to −3.54). HDF also significantly reduced serum urea and C-reactive protein (CRP) levels, along with weekly erythropoietin requirements. Serum albumin levels were slightly but significantly lower in the HDF group than in the conventional HD group (WMD –0.06 g/dL; 95% CI −0.10 to −0.01); however, the clinical significance of such a difference remains uncertain. Higher convective volumes were identified as a key determinant of greater reductions in β2-microglobulin and CRP. Compared with conventional HD, HDF demonstrated superior reductions in several surrogate endpoints, including serum phosphorus, urea, β2-microglobulin, CRP, and weekly erythropoietin requirements. Reduced need for phosphate binders and anemia management may lower treatment-related costs.

ABSTRACT Monoclonal gammopathy of renal significance (MGRS) is a heterogeneous group of clonal B cell or plasma cell proliferative disorders that cause kidney injury without meeting criteria for overt malignancy. Advances in diagnostic techniques have enhanced the identification and classification of MGRS lesions. Clone-directed therapies such as proteasome inhibitors, anti-CD38 and anti-CD20 monoclonal antibodies are now central to treatment, targeting a deep haematologic response that is strongly associated with improved renal outcomes and reduced risk of recurrence following kidney transplantation. Despite these advances, management remains challenging in patients without detectable clones. This review highlights recent progress in the diagnosis and treatment of MGRS, with an emphasis on therapeutic strategies, transplant considerations and evolving clinical challenges.