Hyperkalemia (HK) is a frequent condition in patients with chronic kidney disease (CKD) that is associated with high morbidity and mortality. Patiromer has recently been introduced as a potassium binder. Data on patiromer use in patients with CKD in the real-world setting in Europe are lacking. We describe time to discontinuation and changes in serum potassium levels among German CKD stage 3-5 patients starting patiromer. Duration of patiromer use was estimated by Kaplan-Meier curve, starting at patiromer initiation and censoring for death, dialysis, transplant or loss to follow-up. Serum potassium levels and renin-angiotensin-aldosterone system inhibitor (RAASi) use are described at baseline and during follow-up, restricted to patients remaining on patiromer. We identified 140 patiromer users within our analysis sample [81% CKD stage 4/5, 83% receiving RAASi, and median K+ 5.7 (5.4, 6.3) mmol/L]. Thirty percent of patiromer users had prior history of polystyrene sulfonate use. Overall, 95% of patiromer users stayed on treatment past 1 month, with 53% continuing for over a year. Mean serum potassium levels decreased after patiromer initiation and remained stable under treatment during follow-up (up to 180 days). Among these patients, 73%-82% used RAASis during the time periods before and after patiromer initiation, with no obvious trend indicating discontinuation. Real-world evidence of patiromer use in Germany shows that, in line with what has been observed in clinical trials, patients on patiromer have a reduction in serum potassium when used long-term. Moreover, most patients on patiromer do not discontinue treatment prior to 1 year after initiation.

Abstract BACKGROUND AND AIMS Hemodialysis (HD) patients (pts) with atrial fibrillation (AF) are at high risk for cardiovascular events, severe bleeding and rapid vascular/valvular calcification. Thus, antivitamin-K based oral anticoagulation (VK-OAC) for HD patients is debated, since prospective trials are missing and US register studies are often limited to 3–6 months OAC use. We studied AF risk-factors, long-term antithrombotic therapies and clinical outcomes in a large German HD cohort. METHOD We analysed pseudonymized benchmarking data in a German out-patient dialysis center network (Verband Deutsche Nierenzentren, DN) based on quarterly electronically transmitted data. Diagnoses coded by ‘International Classification of Diseases (ICD)’ and ‘Anatomical Therapeutical Chemical (ATC)’ drug codes of adult HD patients 2013–2018. RESULTS In 2013, 2753 (18%) of 15 682 HD-pts had AF as coded diagnosis. Baseline CHA2DS2-VASc (4.0/1.5 mean/SD) and HAS-BLED (3.2/0.9) risk-scores indicated high risk for embolism and bleeding. Charlson Comorbidity Index (CCI) was high (6.4/2.8) and median observation was 2.1 years (range 0.01–6 years). Beside HD-related heparin, four main OAC approaches were applied: no active therapy, VK-OAC+/-aspirin/clopidogrel (VK-OAC+/-Asp/Clop), heparin-based therapy (heparin+/-Asp/Clop) or 1–2 antithrombocyte drugs (Asp/Clop). A total of 959 pts (35%) changed therapy, but 1794 pts (65%) had no change in OAC regime during the 6 year study period and were used for final therapy-related outcome analysis (Table 1). Both AF risk-scores overestimated de-novo events. Total 6-year event rate was low (7.5%; <1.3% per year) and comparable for all anticoagulant therapies, especially for cerebral ischemic events (2.8%; range 1.2–3.7; NS). All three antithrombotic therapies had similar overall events as without active therapy (7.6 versus 7.3%), including cerebral adverse events (ischemic: 3.0 versus 2.6%; bleeding: 0.7 versus 0.6%; NS). Survival (Kaplan–Meier) was analysed for matched controls by propensity-score based on mortality risk factors in multivariate Cox regression: age (HR 1.05), sex (female HR 0.78), CCI (HR 1.07) and albumin (HR 0.93). Six-year mortality rates were high (63%) and matched analysis showed significant lower survival (P < 0.001) without anticoagulant (median 1.8 years) or on heparin-based therapy (1.7 years) than on Asp/Clop (2.9 years) or VK-OAC based therapy (2.8 years). This relation was similar for subgroups on age, CCI or changed therapy. CONCLUSION Our large study showed that baseline CHA2DS2-VASc and HAS-BLED scores had no predictive value for clinical events in HD pts with AF. Cerebral ischemic event rates over 6 years were low (<0.7%/year) and similar for all three antithrombotic therapies and even no active therapy, suggesting major benefit of regular dialysis-related heparin supply. Since median survival on Asp/Clop is similar to VK-OAC therapy and even 1 year better than on no active or heparin-based therapy, we conclude that antithrombotic therapy in HD patients with AF can effectively be done with Asp/Clop and VK-OAC should be avoided. For future prospective trials, we recommend to apply Asp/Clop as first-line control therapy evaluating new direct-acting oral anticoagulants (DOAK) and/or interventional approaches (i.e. left atrial appendage closure) in HD patients with AF.

Abstract Background and Aims Hemodialysis (HD) patients with atrial fibrillation (AF) are at high risk for cardio-vascular events, severe bleeding and rapid vascular/valvular calcification. Thus, higher than low standard dialysate Mg (d-Mg) may improve outcome by less arrhythmic or calcification impact, but clinical data are missing. Our study evaluated applied d-Mg, risk-factors and antithrombotic therapies on long-term outcome in a large representative German HD-cohort. Method We used pseudonymized benchmarking data (2013-2018) of 16226 adult chronic HD patients (informed consent) from DNeV dialysis network. Diagnoses were coded by “International Classification of Diseases (ICD)” and drugs via “Anatomical Therapeutical Chemical (ATC)” codes. Risk scores (Carlson Comorbidity Index=CCI, CHA2DS2-VASc and HAS-BLED) were tested for de-novo outcome prediction. Results At baseline, 2752 (17%) HD-patients had coded AF. CHA2DS2-VASc (4.0/SD1.5) and HAS-BLED (3.2/0.9) estimated high risk for embolism/bleeding. Standard dialysate-Mg (sd-Mg; 0.5 mmol/L) was used by 1317 (48%), d-Mg 0.75 had 331 (12%), d-Mg >1.0 had 134 (5%) and 970 (35%) patients changed from 0.5 to 0.75 during the study period (change group). Median study time was 2.1 yrs (Range=R: 0.01–6 yrs.). Overall 6-yr mortality was high (63%; Kaplan Meier median survival of 2.9 yrs. Unchanged d-Mg levels were significantly (p<0.02) related to survival: Patients on sd-Mg had lower median survival (2.7 yrs.) than on 0.75 (3.1 yrs; p<0.05) or >1.0 (3.4 yrs; p=0.02). The change group had the same survival (3.1 yrs) as the 0.75 group (p<0.03 vs. 0.5). Cox-Regression (multivariate, sd-Mg=ref.) revealed d-Mg >1.0 (hazard ratio=HR 0.74), d-Mg 0.75 (HR 0.79), serum albumin (HR 0.93), age (HR 1.04) and CCI (HR 1.06) as independently related to mortality (p=0.002). Sd-Mg had higher (p<0.05) cerebral adverse events (5.2%) than 0.75 (1.8%) and >1.0 group (3.7%). Apart from dialysis-related heparin-supply four main approaches regarding anti-coagulation were identified: No therapy, VK-OAC, Heparin or only Aspirin/Clopidogrel (Asp/Clop): VK-OAC and Asp/Clop had same median survival (2.8 yrs) both better (p<0.001) than no therapy (1.3 yrs) or Heparin (1.6 yrs), but VK-OAC had higher bleeding rates (6.4%; p<0.001) than Asp/Clop (3.5%). Cerebral adverse events (3,8% in 6 yrs) were much lower than estimated and similar for all four regimes (R: 3.9-4.4%). Conclusion Use of higher d-Mg in HD-patients with AF significantly improved survival and cerebral outcome, is a feasible cost-effective approach and has more relative impact than well established survival risk-factors such as age, comorbidity (=CCI) and serum albumin. Our data warrant prospective trials comparing higher d-Mg levels with anti-thrombotic drugs and/or left atrial appendage occlusion for better evidence. So far, therapy of HD patients with AF should base on implementation of higher d-Mg, prefer Asp/Clop as best anti-thrombotic drugs and clearly avoid more harmful VK-OAC.

Abstract Background and Aims ESRD (end stage renal disease) patients on hemodialysis (HD) with persistent atrial fibrillation (AF) are at high risk for cardio-vascular events, severe bleeding and rapid vascular/valvular calcification. In such patients standard vitamin-K based oral anticoagulation (VK-OAC) is debated, since prospective OAC studies are missing and smaller short-term register data showed conflicting results. Our study evaluated risk-factors, use of anticoagulants and clinical long-term outcome in a large representative German HD-cohort. Method After informed consent, we analysed pseudonymized benchmarking data (2013-2018) of 16226 adult chronic HD patients treated in a German outpatient dialysis network (Verband Deutsche Nierenzentren, DN) based on quarterly electronically transmitted data. Diagnoses were coded by “International Classification of Diseases (ICD)” and drugs via “Anatomical Therapeutical Chemical (ATC)” codes. Results At baseline in 2013, 2812 (17%) HD-patients had AF as coded diagnosis. AF-prevalence increased significantly (p<0.001) with age (< 65 yrs: 7%; 65-<75 yrs: 22% >75 yrs: 34%) without gender differences. Baseline CHA2DS2-Vasc (4.0/1.5) and HAS-Bled (3.2/0.9) risk scores indicated high risk for embolism and bleeding. Median observation time was 2.1 yrs (Range: 0–6 yrs.). Apart from dialysis-related heparin-supply four main approaches were applied: No active therapy, standard VK-OAC+/- aspirin/clopidogrel (VK-OAC+/-Asp/Clop), heparin-based therapy (Heparin+/-Asp/Clop) or only anti-thrombocyte drugs (Asp/Clop). Baseline risk scores were not related to any adverse events. Outcome data are shown in the Table: event rates were low (8.8%) and comparable for all anticoagulant therapies, especially for cerebral adverse events (3.8%, range 3.3-4.5%). Patients on any anti-thrombotic therapy had similar outcome rates as patients without anticoagulant therapy. The latter had fewer overall bleeding events (3.8% vs. 5.0%; NS). Finally, overall actual 6-yr mortality rates were high (55.8%; median survival 4.4 yrs) and significantly (p<0.001) lower for patients without anti-coagulant therapy (48.9%; median survival 6.0 yrs) than for patients on anti-coagulant therapy (59.5%; median survival 4.0 yrs) with highest mortality on VK-OAC based therapy (60.3%; p<0.001). Conclusion De-novo cerebral event-rates were rather low (<0.8%/yr) and similar for all anti-thrombotic therapies and even for patients with no active therapy, suggesting major beneficial impact of regular dialysis-related heparin-supply. Since actual 6-yr mortality was high and survival was significantly better in patients without anticoagulants than for VK-OAC or other active therapy, we need prospective studies comparing anticoagulants even with no drugs and/or new interventional approachs (i.e. left atrial appendage closure) to provide valid future guidelines.

BackgroundChronic kidney disease (CKD) progression among German patients in a representative setting has not been described previously. The Verband Deutsche Nierenzentren and Chronic Kidney Disease Outcomes and Practice Patterns Study established a longitudinal observational cohort among German CKD patients to research variations in patient care and outcomes in real-world nephrology practices.MethodsA cohort of CKD Stages 3 (25%) and 4 (75%) patients was established from German nephrologist-run CKD clinics in 2013–16. Linear models were used to determine the estimated glomerular filtration rate (eGFR) slope during follow-up and Cox models were used to assess outcomes of end-stage kidney disease (ESKD) and death.ResultsA total of 1834 patients (median age 75 years, 58% male, 42% diabetics, median baseline eGFR 25 mL/min/1.73 m2) were followed for a median of 29 months. More than 50% had slow or no decline and 17% declined ≥5 mL/min/1.73 m2/year. After 4.5 years, the incidence of ESKD was 8% and of deaths without ESKD 16% among patients with eGFR ≥30 mL/min/1.73 m2 and 37% and 19% for eGFR <30 mL/min/1.73 m2. Adjusted models showed higher risks of ESKD or death for patients with worse kidney function at baseline, male sex, diabetes and higher blood pressure; a higher risk of ESKD with higher albuminuria; and a higher risk of death with older age or cardiovascular comorbidity.ConclusionsRoutine nephrology care of patients in Germany comprises mostly elderly patients, many with slow CKD progression. Identification of risk factors for CKD progression and mortality may help guide resources by closer follow-up of high-risk patients.

Abstract In general, micropore size acts as one of the most significant influencing factors on the fatigue strength of aluminium castings. Hence, an in-depth knowledge of the occurrence of micropore sizes and their local distributions in different locations in complexly-shaped lightweight components is of great interest to the casting industry. In this work, the local properties of AlSi8Cu3 and AlSi7Cu0.5Mg cylinder heads and AlSi8Cu3 crankcases were analyzed. Extensive X-ray computed tomography (CT) scans of three specimen positions revealed significant differences in micropore size and distribution. Two CT scan resolutions were selected, with respect to different micropore size populations in the cast components, to enable accurate detection of the microporosity, in addition to an adequate scanning volume, in order to achieve a statistically approved parameter study. Thereby, specimen positions exhibiting smaller mean micropore sizes were scanned at 3 μm/voxel scanning resolution and ones with larger micropore sizes at 8 μm/voxel. A statistical assessment of all of the alloy specifications and specimen positions indicates that the general extreme value and lognormal distribution appropriately describe the micropore size distributions. Finally, an extensive sensitivity study is presented, aimed at examining micropore size characteristics, such as the porosity, sphericity, maximum and mean values and standard deviation, and to investigate their relationships in the investigated cast specimens.

The paper presents the results obtained during the experiments carried out in order to establish the influence of the processing method applied to the refractory electrodes, used in Tungsten Inert Gas (TIG) welding, on the shape and stability of the welding arc, but also on some geometric parameters related to the deposit process, such as penetration. The variations of the dimensions of the welding arc, caused by the change of the geometrical shape at the top of the electrode, are presented in graphical form.

Aluminium light alloys are employed in commercial automotive and aerospace applications due to their high specific strength and corrosion resistance [1]. Precipitation hardening is one of the most important ways to improve the alloy performance. By tailoring precipitate size, aspect ratio, and distribution, the precipitation hardening can be significantly enhanced. The interfacial structure between precipitates and matrix is the critical factor being thought to manipulate the precipitate growth, but the fundamental understanding of these interfaces remains poor due to both limitations in atomic‐resolution compositional characterisation techniques and computational capacity of first principle calculations. Al‐Cu is a textbook binary alloy having precipitate strengthener θ′ (Al 2 Cu) phase, but recent work showed its semi‐coherent interfaces is not as simple as previously thought [2]. In fact, a complex metastable θ′ t phase is sandwiched in‐between θ′′ and θ′ precipitates, indicating a non‐intuitive energetically favourable phenomenon. Gold (Au) has strong negative solute formation enthalpy with aluminium and thereby its precipitation is directly linked to η′ and η phases without precursor Guinier–Preston (GP) zone [3]. How such element affects the interfacial structure is still unclear. In this work, we have used atomic‐resolution high angle annular dark‐field (HAADF) via aberration‐corrected scanning transmission electron microscopy (AC‐STEM) for detailed investigations of the influence of Au on the heterophase interfacial structure in an Al‐Cu alloy. We have experimentally determined the effect of Au and ageing temperature on the complex interfacial structure between solid solution (α) and θ′ (Al 2 Cu). We have observed the sandwiched interfacial structure in Al‐Cu‐Au alloys aged at 200°C (See Fig. 1a) as discovered in Ref. [2], while in comparison some partially direct θ′‐α interface was found (see Fig. 1b) in rare probability. However, Au addition was observed to clearly destabilise the complex interfaces (see fig. 1c) at higher temperature ageing (350°C), whereas the corresponding binary Al‐Cu alloy still somehow displays complex interfacial structures (Fig. 1d). The complex interface was also proved to provide the first solution to the four‐decades‐old mystery where experimental precipitate coarsening rate was found to be hundreds of times that of theoretical predictions based on the direct θ′‐α interface in the Ref. [4].