Krisanapan, Pajaree

Chain-of-thought prompting enhances the abilities of large language models (LLMs) significantly. It not only makes these models more specific and context-aware but also impacts the wider field of artificial intelligence (AI). This approach broadens the usability of AI, increases its efficiency, and aligns it more closely with human thinking and decision-making processes. As we improve this method, it is set to become a key element in the future of AI, adding more purpose, precision, and ethical consideration to these technologies. In medicine, the chain-of-thought prompting is especially beneficial. Its capacity to handle complex information, its logical and sequential reasoning, and its suitability for ethically and context-sensitive situations make it an invaluable tool for healthcare professionals. Its role in enhancing medical care and research is expected to grow as we further develop and use this technique. Chain-of-thought prompting bridges the gap between AI’s traditionally obscure decision-making process and the clear, accountable standards required in healthcare. It does this by emulating a reasoning style familiar to medical professionals, fitting well into their existing practices and ethical codes. While solving AI transparency is a complex challenge, the chain-of-thought approach is a significant step toward making AI more comprehensible and trustworthy in medicine. This review focuses on understanding the workings of LLMs, particularly how chain-of-thought prompting can be adapted for nephrology’s unique requirements. It also aims to thoroughly examine the ethical aspects, clarity, and future possibilities, offering an in-depth view of the exciting convergence of these areas.

Background and Objectives: Limited evidence exists regarding the safety and efficacy of glucagon-like peptide-1 receptor agonists (GLP-1RAs) in type 2 diabetes mellitus (T2DM) patients with advanced chronic kidney disease (CKD) or end-stage kidney disease (ESKD). Thus, we conducted a systematic review and meta-analysis to assess the safety and efficacy of GLP-1RAs in T2DM patients with advanced CKD and ESKD. Materials and Methods: We performed a systematic literature search in MEDLINE, EMBASE, and Cochrane database until 25 October 2023. Included were clinical trials and cohort studies reporting outcomes of GLP-1RAs in adult patients with T2DM and advanced CKD. Outcome measures encompassed mortality, cardiovascular parameters, blood glucose, and weight. Safety was assessed for adverse events. The differences in effects were expressed as odds ratios with 95% confidence intervals (CIs) for dichotomous outcomes and the weighted mean difference or standardized mean difference (SMD) with 95% confidence intervals for continuous outcomes. The Risk of Bias In Non-randomized Studies—of Interventions (ROBIN-I) tool was used in cohort and non-randomized controlled studies, and the Cochrane Risk of Bias (RoB 2) tool was used in randomized controlled trials (RCTs). The review protocol was registered in the International Prospective Register of Systematic Reviews (CRD 42023398452) and received no external funding. Results: Eight studies (five trials and three cohort studies) consisting of 27,639 patients were included in this meta-analysis. No difference was observed in one-year mortality. However, GLP-1RAs significantly reduced cardiothoracic ratio (SMD of −1.2%; 95% CI −2.0, −0.4) and pro-BNP (SMD −335.9 pmol/L; 95% CI −438.9, −232.8). There was no significant decrease in systolic blood pressure. Moreover, GLP-1RAs significantly reduced mean blood glucose (SMD −1.1 mg/dL; 95% CI −1.8, −0.3) and increased weight loss (SMD −2.2 kg; 95% CI −2.9, −1.5). In terms of safety, GLP-1RAs were associated with a 3.8- and 35.7-time higher risk of nausea and vomiting, respectively, but were not significantly associated with a higher risk of hypoglycemia. Conclusions: Despite the limited number of studies in each analysis, our study provides evidence supporting the safety and efficacy of GLP-1RAs among T2DM patients with advanced CKD and ESKD. While gastrointestinal side effects may occur, GLP-1RAs demonstrate significant improvements in blood glucose control, weight reduction, and potential benefit in cardiovascular outcomes.

The exponential growth of artificial intelligence (AI) has allowed for its integration into multiple sectors, including, notably, healthcare. Chatbots have emerged as a pivotal resource for improving patient outcomes and assisting healthcare practitioners through various AI-based technologies. In critical care, kidney-related conditions play a significant role in determining patient outcomes. This article examines the potential for integrating chatbots into the workflows of critical care nephrology to optimize patient care. We detail their specific applications in critical care nephrology, such as managing acute kidney injury, alert systems, and continuous renal replacement therapy (CRRT); facilitating discussions around palliative care; and bolstering collaboration within a multidisciplinary team. Chatbots have the potential to augment real-time data availability, evaluate renal health, identify potential risk factors, build predictive models, and monitor patient progress. Moreover, they provide a platform for enhancing communication and education for both patients and healthcare providers, paving the way for enriched knowledge and honed professional skills. However, it is vital to recognize the inherent challenges and limitations when using chatbots in this domain. Here, we provide an in-depth exploration of the concerns tied to chatbots’ accuracy, dependability, data protection and security, transparency, potential algorithmic biases, and ethical implications in critical care nephrology. While human discernment and intervention are indispensable, especially in complex medical scenarios or intricate situations, the sustained advancements in AI signal that the integration of precision-engineered chatbot algorithms within critical care nephrology has considerable potential to elevate patient care and pivotal outcome metrics in the future.

Background and Objectives: Literature reviews are foundational to understanding medical evidence. With AI tools like ChatGPT, Bing Chat and Bard AI emerging as potential aids in this domain, this study aimed to individually assess their citation accuracy within Nephrology, comparing their performance in providing precise. Materials and Methods: We generated the prompt to solicit 20 references in Vancouver style in each 12 Nephrology topics, using ChatGPT, Bing Chat and Bard. We verified the existence and accuracy of the provided references using PubMed, Google Scholar, and Web of Science. We categorized the validity of the references from the AI chatbot into (1) incomplete, (2) fabricated, (3) inaccurate, and (4) accurate. Results: A total of 199 (83%), 158 (66%) and 112 (47%) unique references were provided from ChatGPT, Bing Chat and Bard, respectively. ChatGPT provided 76 (38%) accurate, 82 (41%) inaccurate, 32 (16%) fabricated and 9 (5%) incomplete references. Bing Chat provided 47 (30%) accurate, 77 (49%) inaccurate, 21 (13%) fabricated and 13 (8%) incomplete references. In contrast, Bard provided 3 (3%) accurate, 26 (23%) inaccurate, 71 (63%) fabricated and 12 (11%) incomplete references. The most common error type across platforms was incorrect DOIs. Conclusions: In the field of medicine, the necessity for faultless adherence to research integrity is highlighted, asserting that even small errors cannot be tolerated. The outcomes of this investigation draw attention to inconsistent citation accuracy across the different AI tools evaluated. Despite some promising results, the discrepancies identified call for a cautious and rigorous vetting of AI-sourced references in medicine. Such chatbots, before becoming standard tools, need substantial refinements to assure unwavering precision in their outputs.

Patients with chronic kidney disease (CKD) necessitate specialized renal diets to prevent complications such as hyperkalemia and hyperphosphatemia. A comprehensive assessment of food components is pivotal, yet burdensome for healthcare providers. With evolving artificial intelligence (AI) technology, models such as ChatGPT, Bard AI, and Bing Chat can be instrumental in educating patients and assisting professionals. To gauge the efficacy of different AI models in discerning potassium and phosphorus content in foods, four AI models—ChatGPT 3.5, ChatGPT 4, Bard AI, and Bing Chat—were evaluated. A total of 240 food items, curated from the Mayo Clinic Renal Diet Handbook for CKD patients, were input into each model. These items were characterized by their potassium (149 items) and phosphorus (91 items) content. Each model was tasked to categorize the items into high or low potassium and high phosphorus content. The results were juxtaposed with the Mayo Clinic Renal Diet Handbook’s recommendations. The concordance between repeated sessions was also evaluated to assess model consistency. Among the models tested, ChatGPT 4 displayed superior performance in identifying potassium content, correctly classifying 81% of the foods. It accurately discerned 60% of low potassium and 99% of high potassium foods. In comparison, ChatGPT 3.5 exhibited a 66% accuracy rate. Bard AI and Bing Chat models had an accuracy rate of 79% and 81%, respectively. Regarding phosphorus content, Bard AI stood out with a flawless 100% accuracy rate. ChatGPT 3.5 and Bing Chat recognized 85% and 89% of the high phosphorus foods correctly, while ChatGPT 4 registered a 77% accuracy rate. Emerging AI models manifest a diverse range of accuracy in discerning potassium and phosphorus content in foods suitable for CKD patients. ChatGPT 4, in particular, showed a marked improvement over its predecessor, especially in detecting potassium content. The Bard AI model exhibited exceptional precision for phosphorus identification. This study underscores the potential of AI models as efficient tools in renal dietary planning, though refinements are warranted for optimal utility.

Literature reviews are valuable for summarizing and evaluating the available evidence in various medical fields, including nephrology. However, identifying and exploring the potential sources requires focus and time devoted to literature searching for clinicians and researchers. ChatGPT is a novel artificial intelligence (AI) large language model (LLM) renowned for its exceptional ability to generate human-like responses across various tasks. However, whether ChatGPT can effectively assist medical professionals in identifying relevant literature is unclear. Therefore, this study aimed to assess the effectiveness of ChatGPT in identifying references to literature reviews in nephrology. We keyed the prompt “Please provide the references in Vancouver style and their links in recent literature on… name of the topic” into ChatGPT-3.5 (03/23 Version). We selected all the results provided by ChatGPT and assessed them for existence, relevance, and author/link correctness. We recorded each resource’s citations, authors, title, journal name, publication year, digital object identifier (DOI), and link. The relevance and correctness of each resource were verified by searching on Google Scholar. Of the total 610 references in the nephrology literature, only 378 (62%) of the references provided by ChatGPT existed, while 31% were fabricated, and 7% of citations were incomplete references. Notably, only 122 (20%) of references were authentic. Additionally, 256 (68%) of the links in the references were found to be incorrect, and the DOI was inaccurate in 206 (54%) of the references. Moreover, among those with a link provided, the link was correct in only 20% of cases, and 3% of the references were irrelevant. Notably, an analysis of specific topics in electrolyte, hemodialysis, and kidney stones found that >60% of the references were inaccurate or misleading, with less reliable authorship and links provided by ChatGPT. Based on our findings, the use of ChatGPT as a sole resource for identifying references to literature reviews in nephrology is not recommended. Future studies could explore ways to improve AI language models’ performance in identifying relevant nephrology literature.

The utilization of vasopressin receptor antagonists, known as vaptans, in the management of hyponatremia among patients afflicted with the syndrome of inappropriate antidiuretic hormone (SIADH) remains a contentious subject. This meta-analysis aimed to evaluate the safety and efficacy of vaptans for treating chronic hyponatremia in adult SIADH patients. Clinical trials and observational studies were identified by a systematic search using MEDLINE, EMBASE, and Cochrane Database from inception through September 2022. The inclusion criteria were the studies that reported vaptans’ safety or efficacy outcomes compared to placebo or standard therapies. The study protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO; CRD 42022357307). Five studies were identified, comprising three RCTs and two cohort studies, enrolling a total of 1840 participants. Regarding short-term efficacy on days 4–5, vaptans exhibited a significant increase in serum sodium concentration from the baseline in comparison to the control group, with a weighted mean difference of 4.77 mmol/L (95% CI, 3.57, 5.96; I2 = 34%). In terms of safety outcomes, the pooled incidence rates of overcorrection were 13.1% (95% CI 4.3, 33.6; I2 = 92%) in the vaptans group and 3.3% (95% CI 1.6, 6.6; I2 = 27%) in the control group. Despite the higher correction rate linked to vaptans, with an OR of 5.72 (95% CI 3.38, 9.70; I2 = 0%), no cases of osmotic demyelination syndrome were observed. Our meta-analysis comprehensively summarizes the efficacy and effect size of vaptans in managing SIADH. While vaptans effectively raise the serum sodium concentration compared to placebo/fluid restriction, clinicians should exercise caution regarding the potential for overcorrection.

Longer pre-transplant dialysis duration is known to be associated with worse post-transplant outcomes. Our study aimed to cluster kidney transplant recipients with prolonged dialysis duration before transplant using an unsupervised machine learning approach to better assess heterogeneity within this cohort. We performed consensus cluster analysis based on recipient-, donor-, and transplant-related characteristics in 5092 kidney transplant recipients who had been on dialysis ≥ 10 years prior to transplant in the OPTN/UNOS database from 2010 to 2019. We characterized each assigned cluster and compared the posttransplant outcomes. Overall, the majority of patients with ≥10 years of dialysis duration were black (52%) or Hispanic (25%), with only a small number (17.6%) being moderately sensitized. Within this cohort, three clinically distinct clusters were identified. Cluster 1 patients were younger, non-diabetic and non-sensitized, had a lower body mass index (BMI) and received a kidney transplant from younger donors. Cluster 2 recipients were older, unsensitized and had a higher BMI; they received kidney transplant from older donors. Cluster 3 recipients were more likely to be female with a higher PRA. Compared to cluster 1, cluster 2 had lower 5-year death-censored graft (HR 1.40; 95% CI 1.16–1.71) and patient survival (HR 2.98; 95% CI 2.43–3.68). Clusters 1 and 3 had comparable death-censored graft and patient survival. Unsupervised machine learning was used to characterize kidney transplant recipients with prolonged pre-transplant dialysis into three clinically distinct clusters with variable but good post-transplant outcomes. Despite a dialysis duration ≥ 10 years, excellent outcomes were observed in most recipients, including those with moderate sensitization. A disproportionate number of minority recipients were observed within this cohort, suggesting multifactorial delays in accessing kidney transplantation.

Background: Contrast-induced encephalopathy (CIE) is an infrequent but serious neurological condition that occurs shortly after the administration of contrast during endovascular and angiography procedures. Patients suffering from chronic kidney disease (CKD) or end-stage kidney disease (ESKD) are considered to be at a higher risk of contrast medium neurotoxicity, due to the delayed elimination of the contrast medium. However, the occurrence and characteristics of CIE in CKD/ESKD patients have not been extensively investigated. Methods: We conducted a comprehensive literature search, utilizing databases such as MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews, up to September 2022. The purpose was to identify documented cases of CIE among patients with CKD or ESKD. Employing a random-effects model, we calculated the pooled incidence and odds ratio (OR) of CIE in CKD/ESKD patients. Results: Our search yielded a total of eleven articles, comprising nine case reports and two observational studies. Among these studies, 2 CKD patients and 12 ESKD patients with CIE were identified. The majority of the CKD/ESKD patients with CIE (93%) had undergone intra-arterial contrast media and/or endovascular procedures to diagnose acute cerebrovascular disease, coronary artery disease, and peripheral artery disease. The male-to-female ratio was 64%, and the median age was 63 years (with an interquartile range of 55 to 68 years). In the two observational studies, the incidence of CIE was found to be 6.8% in CKD patients and 37.5% in ESKD patients, resulting in a pooled incidence of 16.4% (95% CI, 2.4%–60.7%) among the CKD/ESKD patients. Notably, CKD and ESKD were significantly associated with an increased risk of CIE, with ORs of 5.77 (95% CI, 1.37–24.3) and 223.5 (95% CI, 30.44–1641.01), respectively. The overall pooled OR for CIE in CKD/ESKD patients was 32.9 (95% CI, 0.89–1226.44). Although dialysis prior to contrast exposure did not prevent CIE, approximately 92% of CIE cases experienced recovery after undergoing dialysis following contrast exposure. However, the effectiveness of dialysis on CIE recovery remained uncertain, as there was no control group for comparison. Conclusions: In summary, our study indicates an association between CIE and CKD/ESKD. While patients with CIE showed signs of recovery after dialysis, further investigations are necessary, especially considering the lack of a control group, which made the effects of dialysis on CIE recovery uncertain.