Advanced Chronic Kidney Disease Group Research Articles

Evaluation of platelet indices in chronic kidney disease

Objective: Chronic kidney disease (CKD) is characterized by an irreversible decrease in kidney functions and accumulation of uremic toxins in the body. Platelet indices have the potential to predict the inflammatory status and disease progression in patients with CKD. In this study it was aimed to investigate platelet indices and their relations with renal function and comorbid conditions in CKD patients. Method: In this study it was included 411 CKD patients. We looked for associations between platelet indices and estimated glomerular filtration rate (eGFR). We generated linear regression models for platelet indices that may be associated with eGFR. We evaluated CKD patients for possible associations between platelet indices and comorbid conditions such as diabetes, hypertension, and cardiovascular diseases. Results: The mean age of CKD patients was 60.5 and the GFR value was 40.1+24.8 mL/min/1.73m2. While the mean platelet count, MPV, PCT, PDW, P-LCR values were lower in the advanced CKD group, hematocrit adjusted platelet count (HAPC), MPV/Lymphocyte ratio and SII parameters were higher in the advanced CKD group (p

Congenital Risk Factors for Chronic Kidney Disease in Patients With Persistent Cloaca: Results From a Nationwide Survey in Japan

BackgroundWe conducted a nationwide survey of persistent cloaca (PC) to investigate the renal function outcomes and factors affecting chronic kidney disease (CKD) in patients with PC. MethodInformation from 466 patients with PC was obtained via a questionnaire in this study. The 290 patients (62.2%) with renal function data were classified into 2 groups based on their estimated glomerular filtration rate: advanced CKD group (<30 mL/min/1.73 m2 [or post-renal replacement therapy]) and non-advanced CKD group (≥30 mL/min/1.73 m2). Univariate and multivariate analyses were performed to identify risk factors for CKD that may affect the renal function, including renal and urinary tract malformations, associated anomalies, and urinary tract treatment. The advanced CKD group was divided into two groups based on age to evaluate age-related differences (younger- and older-age CKD groups). ResultsA regression analysis revealed that congenital renal malformations (odds ratio [OR]: 14.06, 95% confidence interval [CI]:3.07–131.65, p < 0.0001), urinary tract obstruction (OR:4.28, 95%CI:1.12–24.23, p < 0.05), and sacral agenesis (OR:4.54, 95% CI:0.84–30.67, p < 0.05) were significantly associated with advanced CKD. In the univariate analysis of factors affecting the renal prognosis, clean intermittent catheterization (CIC) (OR:4.18, 95%CI:1.21–16.45, p = 0.015), vesicostomy (OR:3.65, 95%CI:1.11–12.98, p = 0.019), and surgery for vesicoureteral reflux (OR:5.43, 95%CI:1.41–22.73, p = 0.006) were significantly associated with advanced CKD. Based on the univariate analysis, hydrometrocolpos was significantly more prevalent in the older-age CKD group compared to the younger-age CKD group (p < 0.05). ConclusionCKD development in patients with PC is influenced by a complex interplay of factors, including renal malformations and neurogenic bladder dysfunction due to spinal anomalies. Level of EvidenceIII (Study of Diagnostic Test, Study of nonconsecutive patients, and/or without a universally applied “gold” standard).

Higher inpatient mortality following percutaneous coronary intervention in patients with advanced chronic kidney disease.

Advanced chronic kidney disease (ACKD) is common in patients undergoing percutaneous coronary intervention (PCI) and is associated with adverse outcomes. These patients are often excluded from revascularization studies. The goal of this study was to evaluate the impact of ACKD in patients undergoing PCI. We analyzed the national inpatient sample database to compare the inpatient mortality rate for ACKD patients [chronic kidney disease (CKD) stage 3 and above] who underwent PCI between 2006 and 2011 to patients without ACKD. Specific ICD-9 CM codes were used to identify these patients. A total of 1 826 536 PCIs were performed during the study period, of which 113 018 (6.2%) were patients with advanced CKD. The age-adjusted inpatient mortality rates were significantly higher in the ACKD group in all years studied compared to the no CKD group. For the first year studied in 2006, the age-adjusted mortality rate for patients undergoing PCI was 149 per 100 000 vs. 48 per 100 000 in patients without ACKD (P < 0001). In the last year studied in 2011, age-adjusted mortality was 124.1 per 100 000 vs. 40.4 per 100 000 in patients with no ACKD, (P < 0.0001). The presence of ACKD remained independently associated with higher mortality despite multivariate adjustment (odds ratio: 1.32, confidence interval: 1.27-1.36, P < 0.001). ACKD is independently associated with higher mortality in patients undergoing PCI. Therefore, PCI in these patients should be performed with more caution.

Left atrial appendage occlusion in patients suffering from advanced chronic kidney disease (stage 4 and 5). Long-term follow-up.

Advanced chronic kidney disease (A-CKD) combined with atrial fibrillation increases the risk of both thrombogenic and bleeding events. Left atrial appendage occlusion (LAAO) may be an alternative to oral anticoagulation to prevent thromboembolic events. We aimed to evaluate the outcomes of LAAO in patients with A-CKD. Comparison at long-term follow-up of patients diagnosed with and without A-CKD (eGFR<30 mL/min/1.73 m2 ) who underwent LAAO between 2009 and May 2022. Five hundred seventy-three patients were included. Eighty-one (14%) were diagnosed with A-CKD. There were no differences in sex, age, and cardiovascular risk factors, except for diabetes which was more frequent in patients with A-CKD. The control group had higher rates of stroke, both ischemic and hemorrhagic. There were no differences in the CHA2 DS2 -VASc score, although A-CKD patients had a higher bleeding risk according to the HASBLED scale. Global procedural success was 99.1%. At follow-up, there were no differences in stroke rate: at 1-year (HR: 1.22, IC-95%: 0.14-10.42, p = 0.861); at 5-years (HR: 0.60, IC-95%: 0.08-4.58, p = 0.594). Although bleeding events were higher in the A-CKD group, no differences were found in major bleeding (defined BARC ≥ 3) at 1-year (HR: 1.34, IC-95%: 0.63-2.88, p = 0.464) or at 5-years follow-up (HR: 1.30, IC-95%: 0.69-2.48, p = 0.434). Mortality rate at 5 years was higher in the A-CKD patients (HR: 1.84, IC-95%: 1.18-2.87, p = 0.012). LAAO is an effective and safe treatment in A-CKD patients to prevent ischemic events and bleeding. This strategy could be an alternative to oral anticoagulation in this high-risk group of patients.

Quantifying carotid stiffness in chronic kidney disease using ultrafast ultrasound imaging.

The mortality and disability of chronic kidney disease (CKD) are highly linked to the incidence of atherosclerotic cardiovascular events. Numerous clinical biochemical indicators of renal function often only increase in advanced stages of CKD, driving an urgent need for reliable indicators of atherosclerosis in early CKD. Ultrafast pulse wave velocity (ufPWV) can evaluate the stiffness of the straight carotid in vivo and quantitatively reflect the degree of early atherosclerosis. However, the use of ufPWV in CKD has not yet been reported. In this study, we aimed to explore the association between carotid stiffness, quantified using ufPWV, and renal function in CKD patients. This cross-sectional study enrolled a total of 582 participants between March 2017 and May 2022 in the Affiliated Hospital of Nanjing University of Traditional Chinese Medicine. Among those, 205 individuals without a history of CKD and estimated glomerular filtration rate (eGFR) ≥90 mL/min/1.73 m2 were included as controls. According to the Kidney Disease Outcomes Quality Initiative (K/DOQI) expert group of the American Kidney Foundation staging for CKD, 44 stages 1 and 2 CKD patients were included in the early CKD group, whereas 49 stages 3, 4, and 5 CKD patients were included in the advanced CKD group. Clinical and serum parameters, ultrasonic characteristics including carotid intima-media thickness (cIMT), and pulse wave velocity at the beginning of systole (PWV-BS) and pulse wave velocity at the end of systole (PWV-ES) of systole were analyzed. One-way analysis of variance (ANOVA) and least significant difference (LSD) tests were performed to compare cIMT, PWV-BS, and PWV-ES among subgroups in pairs. Pearson's correlation analysis, scatter plots, and subgroups correlation analysis were used to determine the relationships among ultrasound characteristics (cIMT, PWV-BS, PWV-ES), and major cardiovascular risk factors. PWV-BS and PWV-ES for the early and advanced CKD groups were significantly higher than those for controls (all P<0.05). PWV-ES had the greatest correlation with age (r=0.474, P<0.001). PWV-ES had the greatest increase with age in the early CKD group (r=0.698, P<0.001). ufPWV can be used for the quantitative evaluation of carotid stiffness in CKD patients. PWV-ES may be more advantageous in the assessment of carotid atherosclerosis in early CKD patients.

An integrated machine learning predictive scheme for longitudinal laboratory data to evaluate the factors determining renal function changes in patients with different chronic kidney disease stages.

Chronic kidney disease (CKD) is a global health concern. This study aims to identify key factors associated with renal function changes using the proposed machine learning and important variable selection (ML&IVS) scheme on longitudinal laboratory data. The goal is to predict changes in the estimated glomerular filtration rate (eGFR) in a cohort of patients with CKD stages 3-5. A retrospective cohort study. A total of 710 outpatients who presented with stable nondialysis-dependent CKD stages 3-5 at the Shin-Kong Wu Ho-Su Memorial Hospital Medical Center from 2016 to 2021. This study analyzed trimonthly laboratory data including 47 indicators. The proposed scheme used stochastic gradient boosting, multivariate adaptive regression splines, random forest, eXtreme gradient boosting, and light gradient boosting machine algorithms to evaluate the important factors for predicting the results of the fourth eGFR examination, especially in patients with CKD stage 3 and those with CKD stages 4-5, with or without diabetes mellitus (DM). Subsequent eGFR level after three consecutive laboratory data assessments. Our ML&IVS scheme demonstrated superior predictive capabilities and identified significant factors contributing to renal function changes in various CKD groups. The latest levels of eGFR, blood urea nitrogen (BUN), proteinuria, sodium, and systolic blood pressure as well as mean levels of eGFR, BUN, proteinuria, and triglyceride were the top 10 significantly important factors for predicting the subsequent eGFR level in patients with CKD stages 3-5. In individuals with DM, the latest levels of BUN and proteinuria, mean levels of phosphate and proteinuria, and variations in diastolic blood pressure levels emerged as important factors for predicting the decline of renal function. In individuals without DM, all phosphate patterns and latest albumin levels were found to be key factors in the advanced CKD group. Moreover, proteinuria was identified as an important factor in the CKD stage 3 group without DM and CKD stages 4-5 group with DM. The proposed scheme highlighted factors associated with renal function changes in different CKD conditions, offering valuable insights to physicians for raising awareness about renal function changes.

Association of a low protein diet with depressive symptoms and poor health-related quality of life in CKD

ObjectivesA low protein diet (LPD) for chronic kidney disease (CKD) is a core dietary therapy to slow CKD progression. A study showed depressive symptoms are more common in populations with an LPD. In this cross-sectional study, we evaluated depressive symptoms and health-related quality of life (HRQOL) in patients with CKD. MethodsA total of 571 CKD patients were enrolled in this study. The LPD was defined with dietary protein intake ≤0.8 g/kg/day. We divided the CKD into mild CKD and advanced CKD according to severity, as well as diabetic kidney disease (DKD) and non-DKD according to DM. The logistic regression analysis was performed to evaluate the association between an LPD and depressive symptoms as well as HRQOL in CKD patients and each subgroup. ResultsAn LPD had significantly higher unadjusted Odds Ratio (OR) (1.81, [95% for Confidence Interval (CI), 1.18–2.76]) and multivariate-adjusted OR (1.80, [1.15–2.81]) for depressive symptoms. Moreover, an LPD showed significantly higher unadjusted OR (2.08, 1.44–3.01]) and multivariate OR (2.04, [1.38–3.02]) for poor HRQOL. In DKD subgroups, an LPD had a significant increase in unadjusted OR (2.00, [1.12–3.57]) and multivariate OR (1.99, [1.01–3.44]) for depressive symptoms. The advanced CKD group also showed that an LPD had significantly higher unadjusted OR (1.97, [1.13–3.42]) and multivariate OR (2.03, [1.12–3.73]) for depressive symptoms. ConclusionsAn LPD for CKD patients was significantly associated with depressive symptoms and poor HRQOL. Subgroup analysis indicated that DKD and advanced CKD are more predisposed to depressive symptoms and poor HRQOL.

Indoxyl sulfate mediates low handgrip strength and is predictive of high hospitalization rates in patients with end-stage renal disease.

Sarcopenia has a higher occurrence rate in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) than in the general population. Low handgrip strength-and not sarcopenia per se-is associated with clinical outcomes in patients with CKD, including cardiovascular mortality and hospitalization. The factors contributing to low handgrip strength are still unknown. Accordingly, this study aimed to determine whether uremic toxins influence low handgrip strength in patients with CKD. This cohort study lasted from August 2018 to January 2020. The participants were divided into three groups: the control group [estimated glomerular filtration rate (eGFR) ≥ 60 ml/min], an advanced CKD group (eGFR = 15-60 ml/min), and an ESRD group (under maintenance renal replacement therapy). All participants underwent handgrip strength measurement, dual-energy X-ray absorptiometry, and blood sampling for myokines (irisin, myostatin, and interleukin 6) and indoxyl sulfate. Sarcopenia was defined according to the Asian Working Group for Sarcopenia consensus as low appendicular skeletal muscle index (appendicular skeletal muscle/height2 of < 7.0 kg/m2 in men and < 5.4 kg/m2 in women) and low handgrip strength (< 28 kg in men and < 18 kg in women). Among the study participants (control: n = 16; CKD: n = 17; and ESRD: n = 42), the ESRD group had the highest prevalence of low handgrip strength (41.6 vs. 25% and 5.85% in the control and CKD groups, respectively; p < 0.05). The sarcopenia rate was similar among the groups (12.5, 17.6, and 19.5% for the control, CKD, and ESRD groups, respectively; p = 0.864). Low handgrip strength was associated with high hospitalization rates within the total study population during the 600-day follow-up period (p = 0.02). The predictions for cardiovascular mortality and hospitalization were similar among patients with and without sarcopenia (p = 0.190 and p = 0.094). The serum concentrations of indoxyl sulfate were higher in the ESRD group (227.29 ± 92.65 μM vs. 41.97 ± 43.96 μM and 6.54 ± 3.45 μM for the CKD and control groups, respectively; p < 0.05). Myokine concentrations were similar among groups. Indoxyl sulfate was associated with low handgrip strength in univariate and multivariate logistic regression models [univariate odds ratio (OR): 3.485, 95% confidence interval (CI): 1.372-8.852, p = 0.001; multivariate OR: 8.525, 95% CI: 1.807-40.207, p = 0.007]. Handgrip strength was lower in the patients with ESRD, and low handgrip strength was predictive of hospitalization in the total study population. Indoxyl sulfate contributed to low handgrip strength and counteracted the benefits of myokines in patients with CKD.

Integrated Osteoporosis Care to Reduce Denosumab-Associated Hypocalcemia for Patients with Advanced Chronic Kidney Disease and End-Stage Renal Disease.

The incidence of hypocalcemia is high in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) undergoing denosumab treatment. Since 2018, we have carried out a "multidisciplinary integrated care program for osteoporosis among patients with CKD and ESRD" in our hospital. The aim of this study was to compare the incidence of denosumab-associated hypocalcemia among patients with advanced CKD and ESRD before and after the integrated care program. We retrospectively reviewed the records of patients on their first dose of denosumab treatment from January 2012 to December 2021. A total of 3208 patients were included in our study. Among the 3208 patients, there were 101 dialysis patients, 150 patients with advanced CKD (stage 4 and 5), and 2957 patients with an estimated glomerular filtration rate (eGFR) higher than or equal to 30. The incidence of post-treatment severe hypocalcemia (corrected calcium level less than 7.0 mg/dl) within 30 days was significantly higher in the dialysis and advanced CKD group than in patients with an eGFR higher than or equal to 30 (6.9% vs. 2.0% vs. 0.1%, respectively, p < 0.001). Based on the results of the multivariate regression model, poor renal function (p < 0.05) and lower baseline corrected calcium level (p < 0.05) were associated with severe hypocalcemia within 30 days following the first dose of denosumab treatment. The incidence of post-treatment severe hypocalcemia within 30 days in advanced CKD and dialysis patients was significantly lower after the integrated care program (6.8% vs. 0.8%, p < 0.05). Our study shows that multidisciplinary integrated care may reduce the incidence rate of denosumab-associated severe hypocalcemia among patients with advanced CKD and ESRD.

Abstract 11967: Benefit of Implantable Cardioverter Defibrillator Therapy in Patients With Advanced Renal Impairment: A Competing Risk Analysis From the MADIT Trials

Introduction: The life-saving benefit of the implantable cardioverter defibrillator (ICD) in patients with advanced chronic kidney disease (A-CKD) is still controversial. This is possibly due to a higher risk of dying from non-arrhythmic causes in A-CKD patients, and thereby die prior to receiving therapy from the ICD. We aimed to evaluate the competing risk for ventricular tachycardia/fibrillation (VT/VF) vs. death without prior VT/VF in ICD recipients by renal function. Methods: The study population comprised 3953 patients with an ICD enrolled in the landmark MADIT trials, categorized by renal function into: A-CKD (estimated Glomerular Filtration Rate [eGFR] ≤40 ml/min/1.73 m 2 [N=403]; Moderate CKD (eGFR 41-60 ml/min/1.73 m 2 [N=995]); and No-CKD (eGFR &gt;60 ml/min/1.73 m 2 [N=2555)). Cumulative incidence function curves were used to display the rate of fast VT/VF (&gt;200 bpm) and the competing risk of death without experiencing prior fast VT/VF using the Fine and Gray method. Results: At 4-years of follow-up, patients in the A-CKD group had a significantly lower cumulative incidence of VT/VF compared to patients with Moderate-CKD and No-CKD (13%, 17%, and 20%, respectively; p=0.006 for the overall difference [Figure: left panel]). In contrast, the corresponding 4-year rates of death without experiencing prior fast VT/VF were significantly highest among patients with A-CKD and attenuated among those with Moderate- and No-CKD (28%, 17%, and 9%, respectively; p&lt;0.001 for the overall difference [Figure: right panel]). Conclusion: Our data from 4 landmark primary prevention ICD trials show significant differences in the risk of VT/VF vs the competing risk of death without experiencing prior VT/VF by renal function. This suggests an attenuated benefit of ICD therapy with declining renal function.

Predictive value of triglyceride/high-density lipoprotein cholesterol for major clinical outcomes in advanced chronic kidney disease: a nationwide population-based study.

BackgroundDyslipidemia is an essential parameter in the prediction of cardiovascular disease (CVD). We aimed to explore whether lipid profiles could predict major outcomes in patients with advanced chronic kidney disease (CKD).MethodsWe retrospectively reviewed the National Health Insurance Service database for people who received nationwide health screening in 2009. All subjects exposed to a lipid-lowering agent before screening were excluded. The population was divided into control, early [estimated glomerular filtration rate (eGFR) 45–59 mL/min/1.73 m2] and advanced (eGFR <45 mL/min/1.73 m2) CKD groups. The hazard ratios (HRs) of outcomes were calculated using multivariate Cox regression models.ResultsA total of 3 634 873 participants were included in this study, with 404 298 (11.1%) and 66 805 (1.8%) having early and advanced CKD, respectively. For all populations, levels of triglyceride/high-density lipoprotein cholesterol (TG/HDL-C) showed a linear association with major cardiovascular and cerebrovascular events (MACCEs) and all-cause mortality, while low-density lipoprotein cholesterol (LDL-C) showed a different pattern of association with MACCEs (linear association) from all-cause mortality (U-shaped association). The significance between the levels of LDL-C and outcomes was attenuated in the advanced CKD group. For TG/HDL-C, although the significance was decreased, the linear patterns with both MACCEs and all-cause mortality were maintained in the advanced CKD group.ConclusionsThe pattern and significance of lipid profiles were different according to the grade of kidney function. TG/HDL-C should be additionally considered as a predictive marker for CVD and mortality along with LDL-C in patients with CKD.

Advanced Chronic Kidney Disease is a Strong Predictor of Hypogonadism and is Associated with Decreased Lean Tissue Mass.

PurposeIn patients with chronic kidney disease (CKD), hypogonadism is more frequent than in the general population and its prevalence ranges between 40% and 60%. The aim of the study was to investigate the prevalence of hypogonadism and its association with kidney function, body composition, inflammatory markers and lipid disorders in patients with CKD.Materials and MethodsThe study population consisted of 112 men aged ≥40 years in different stages of CKD: 33 participants with eGFR ≥60 mL/min/1.73 m2, 27 men with eGFR 30–59 mL/min/1.73 m2, 17 predialysis patients with eGFR <30 mL/min/1.73 m2, and 35 men on hemodialysis therapy three times a week for more than 3 months (G5D stage). Total testosterone (TT) levels were measured and free testosterone (FT) levels were calculated. Body composition was assessed using bioimpedance spectroscopy (Body Composition Monitor, FMC). Statistical analysis was performed using Statistica version 13.1.ResultsCKD stage was a strong predictor of hypogonadism (providing an information value of 0.83). The weight of evidence technique allowed us to differentiate the high-risk group, which was a group of patients with advanced CKD, defined as eGFR <30 mL/min/1.73 m2. In this group, the likelihood of hypogonadism was 69.23%. Another significant predictor of hypogonadism was lean tissue index (LTI). TT and FT levels were significantly lower in the advanced CKD group in comparison to the control group, whereas prolactin, luteinizing hormone and C-reactive protein levels were significantly higher in the advanced CKD group. The LTI was significantly lower in advanced CKD and was positively correlated with TT and FT.ConclusionDecreased eGFR and decreased LTI are predictors of hypogonadism associated with CKD. The study results suggest that hypogonadism screening should be carried out when eGFR deceases below 30 mL/min/1.73 m2.

MO024WHAT IS THE BEST PREDICTABLE LIPID SUBFRACTION FOR CARDIOVASCULAR OUTCOMES AND ALL-CAUSE MORTALITY IN PATIENTS WITH ADVANCED CHRONIC KIDNEY DISEASE?

Abstract Background and Aims Dyslipidemia is an essential parameter for the prediction of cardiovascular disease (CVD). We aimed to investigate the most valuable subfraction of lipid for predicting CVD in patients with chronic kidney disease (CKD). Method We retrospectively reviewed the National Health Insurance Service database for people who received nationwide health screening in 2009. All subjects exposed with lipid-lowering agent before screening were excluded. The population was divided as control, early CKD (eGFR 45-60 ml/min/m2), and advanced CKD (eGFR &amp;lt;45 ml/min/m2) by estimated glomerular filtration rate. Each subfraction of lipid profile, including LDL, TG, HDL, and TG/HDL, was categorized by decile, and the reference was the fifth decile. The end-point of the study was major adverse cardiovascular events (MACCE). The hazard ration (HR) of MACCE was calculated using Cox regression models after adjustment of multiple covariates. Results A total of 3,634,915 examiners were included in this study, with 66,810 (1.8%) and 404,315 (11.1%) in advanced and early CKD, respectively. For all populations, LDL, TG, HDL, and TG/HDL showed a linear relationship to MACCE. Except HDL, all subfraction showed positive correlation with the risk for MACCE: adjusted HR (aHR) in tenth decile, 1.45 (1.42-1.49) in LDL; 1.25 (1.22-1.28) in TG; 1.30 (1.27-1.33) in TG/HDL; 0.88 (0.85-0.90) in HDL. Although these patterns were similar in TG, HDL, and TG/HDL for all-cause mortality, only LDL showed different pattern for the two outcomes. In the subgroup analysis using LDL, according to the renal function, the significance for the outcomes and a linear pattern was decreased in the advanced CKD group. For the TG/HDL, although the significance was deceased, the linear pattern has maintained in the advanced CKD group (Fig 1). Conclusion The pattern and significance of lipid subfraction were different according to the grade of renal function. Thus, TG/HDL should be additionally considered with LDL as a target variable in patients with advanced CKD.

SAT-151 A DILEMMA OF CALCITRIOL IN PRE-DIALYTIC CHRONIC KIDNEY DISEASE: A 1-YEAR STUDY FOR COMBINATION THERAPY OF CALCITRIOL AND RENIN-ANGIOTENSIN ALDOSTERONE BLOCKER IN CHRONIC KIDNEY DISEASE

Renin-angiotensin aldosterone system blockers (RASB) is main stream of management of chronic kidney disease (CKD). Vitamin D (vitD) is known as a potent negative regulator of renin-angiotensin aldosterone system via vitamin D receptor. VitD deficiency often presents, even in early CKD. However, there is no a definite guideline of use of vitD in CKD. In addition, the use of vitD should be given a careful attention due to development of hypercalcemia or vascular calcification in CKD. Now, we report results of a 1-year study for combination therapy of calcitriol and RASB in patients with pre-dialytic CKD and vitD deficiency. Forty five patients with pre-dialytic CKD and proteinuria >500 mg/day despites of RASB during at least 6 months were enrolled. We prescribed calcitriol of 0.5 μg, thrice weekly only in patients with serum calclium <10 mg/dL and 25(OH)vitD of <15 ng/mL. Only a total 27 patients received combination therapy of calcitriol and RASB, and laboratory data were retrospectively analyzed. Urine albumin-creatinine ratio (UACR) at baseline was measured. UACR and serum creatinine were followed with 6-month interval. We also divided the enrolled patients into two groups, early CKD and advanced CKD group, based on eGFR of 60 mL/min/1.73m2. We performed a comparative analysis for impacts of combination therapy on albuminuria and renal function in the groups based on eGFR. Total 27 patients used calcitriol and RASB. Eleven patients among the 27 patients were classified into early CKD group and sixteen patients were classified into advanced CKD group. Total 18 patients used only RASB. Twelve patients among the 18 patients were classified into early CKD group and six patients were classified into advanced CKD group. (Table 1,2: not shown in the abstract) In combination group, UACR were 3.15 g/g ± 3.82 at baseline and fell to 2.28 g/g ± 2.90 and 1.91 g/g ± 2.75 after 6 and 12 months. (p=0.031 and p=0.096, respectively) (Table 3) Moreover, in RASB only group, UACR were 1.05 g/d ± 1.71 at baseline and fell to 0.34 g/g ± 0.37 and 0.74 g/g ± 1.13 after 6 and 12 months. (p=0.039 and p=0.133, respectively) (Table 4) Change of UACR after 6 months from baseline did not show statistical significance in both groups. However, in combination group, when subgroup analyses were performed in early CKD and advanced CKD, UACR were 3.61 g/g ± 4.13 at baseline and significantly fell to 2.44 g/g ± 3.04 and 1.17 g/g ± 1.68 after 6 and 12 months (p=0.005 and p=0.022, respectively) in only early CKD. In addition, change of GFR in early CKD patients received combination therapy did not decrease significantly during 12 months. (p=0.099) (Table 3) Moreover, we performed a comparative analysis between combination and RASB only to identify effect of calcitriol on UACR according to time. The difference of decreasing UACR between combination and RASB only group was not statistically significant in both groups, however, in early CKD patients, the difference based on time between both groups seemed to be significant. (p=0.05) (Table 4 and Figure 1) View Large Image Figure ViewerDownload Hi-res image Download (PPT) Our study didnot show a significant impact on albuminuria of vitD combination therapy compared with only RASB therapy. However, if sample size and study-duration are expanded, combination therapy might show negative impact on albuminuria, particularly in early CKD patients with persistent proteinuria despites of use of RASB.

Clinical impact of advanced chronic kidney disease on outcomes and in-hospital complications of Takotsubo Syndrome (broken-heart-syndrome): Propensity-matched national study

Multiple studies evaluated the outcomes and complications rate of Takotsubo Syndrome (TTS) in patients with and without advanced chronic kidney disease (CKD), revealed conflicting results. This study aims to assess the clinical outcomes and impact of advanced CKD on patients hospitalized with Takotsubo Syndrome. Patients who presented with Takotsubo cardiomyopathy between 2010 and 2014 were identified in the National Inpatient Sample (NIS) database using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), and subsequently were divided into two groups, with advanced CKD and without advanced CKD. NIS is the largest all-payer inpatient stays database in the United States. The primary outcome was the effect of advanced CKD on inpatient mortality in comparison to the non-advanced CKD group. Secondary outcomes were the impact of CKD on TTS in-hospital complications. We also evaluated the length of hospital stay and the cost of hospitalization. Propensity score-matched analysis was performed to address potential confounding. The advanced CKD group had no significant increase in the risk of In-hospital mortality (OR 0.99; 95% CI 0.75–1.31, P = 0.269). However, advanced CKD patients were more likely to develop acute kidney injury (AKI) requiring dialysis (OR: 5.12, 95% CI: 3.16–8.30, P = <0.0001), and were more likely to stay longer at the hospital (OR 1.12; 95% CI 1.03 to 1.22, P 0.010). In conclusion, advanced chronic kidney disease does not increase immediate in-hospital mortality, neither most of the TTS in-hospital complications, apart from AKI and hospital length of stay, in comparison to the patients with non-advanced CKD.

Predictors of 1-Year Mortality After Transcatheter Aortic Valve Implantation in Patients With and Without Advanced Chronic Kidney Disease

Advanced chronic kidney disease (CKD) is an independent predictor of mortality in patients undergoing transcatheter aortic valve implantation (TAVI). We aimed to identify predictors of 1-year mortality in patients after TAVI stratified by the presence or absence of advanced CKD (defined as estimated glomerular filtration rate ≤30 ml/min/1.73 m2 or permanent renal replacement therapy). Patients (n = 1204) from 10 centers in Europe, Japan, and Israel were included: 464 with and 740 without advanced CKD. Advanced CKD was associated with a 2-fold increase in the adjusted risk of 1-year all-cause death (p <0.001), and a 1.9-fold increase in cardiovascular death (p = 0.016). Interaction-term analysis was used to identify and compare independent predictors of 1-year mortality in both groups. Impaired left ventricular ejection fraction and poor functional class were predictive of death in the advanced CKD group (odds ratio [OR] 2.27, p = 0.002 and OR 3.87, p = 0.003, respectively) but not in patients without advanced CKD (p for interaction = 0.035 and 0.039, respectively), whereas bleeding was a predictor of mortality in the nonadvanced CKD group (OR 3.2, p = 0.005) but not in advanced CKD (p for interaction = 0.006). Atrial fibrillation was associated with a 2.2-fold increase (p = 0.032) in the risk of cardiovascular death in the advanced CKD group but not in the absence of advanced CKD (p for interaction = 0.022). In conclusion, the coexistence of advanced CKD and either reduced left ventricular ejection fraction or poor functional class has an incremental effect on the risk of death after TAVI. In contrast, bleeding had a greater effect on risk of death in patients without advanced CKD.

Impact of chronic kidney disease on clinical outcomes in patients with non-ST elevation myocardial infarction receiving percutaneous coronary intervention — A five-year observational study

BackgroundPatients with chronic kidney disease (CKD) experience poor outcomes after acute myocardial infarction. This study investigated how CKD affects clinical outcomes in patients with non-ST segment elevation myocardial infarction (NSTEMI) receiving PCI. MethodsThis retrospective study analyzed record-linked data for 314 patients who had received PCI for NSTEMI between January 2008 and September 2010. The 141 patients with advanced CKD were compared with 173 patients who had mild or no CKD. The primary endpoint was long-term mortality. The secondary endpoint was long-term major adverse cardiac events. ResultsCompared to the control group, the advanced CKD group had older patients, more females, and more patients with diabetes mellitus and hypertension. The advanced CKD group also had a lower left ventricular ejection fraction and more patients with advanced HF and pulmonary edema. The advanced CKD group and the control group did not significantly differ in total in-hospital mortality, cardiac death or temporary hemodialysis post-PCI. The advanced CKD group had a significantly higher rate of long-term events. Finally, multiple stepwise Cox regression analysis showed that old age, advanced CKD and advanced HF were independent predictors of primary endpoint. The best predictors of secondary endpoint were post-PCI Thrombolysis in Myocardial Infarction-3 flow, multiple vessel disease, advanced HF and advanced CKD. ConclusionsIn NSTEMI patients undergoing PCI, in-hospital mortality does not significantly differ between patients with and without advanced CKD. However, long-term follow up of CKD patients consistently reveals poor outcomes.

Prognostic value of proteinuria and glomerular filtration rate on Taiwanese patients with diabetes mellitus and advanced chronic kidney disease: a single center experience.

Several risk factors were associated with poor outcomes in diabetic patients with chronic kidney disease (CKD). However, few studies addressed the prognostic implications of these factors in advanced CKD. Our study aimed to provide more evidence for risk factor stratification of diabetic patients with advanced CKD. A total of 447 diabetic patients with advanced CKD, age of 18-80, who visited the nephrology out-patient clinic were enrolled. All patients were in stage 3B-5 CKD. The primary outcomes included long-term renal replacement therapy and mortality. The occurrence of cardiovascular events was also analyzed as secondary outcome. Multivariate Cox regression models were used to address each risk factor in this cohort. We also used this cohort to evaluate the validity of the modified diabetic nephropathy score. Patients with lower estimated glomerular filtration rate (eGFR) were associated with higher degree of proteinuria. In the multivariate Cox regression model, eGFR and the degree of proteinuria were both strong outcome predictors. The effects of glycosylated hemoglobin and blood pressure in this advanced CKD cohort were minimal. Elder patients with advanced CKD had a higher mortality rate, but commenced less renal replacement therapy. Applying these indicator analyses, we proposed a modified diabetic nephropathy score for outcome prediction. Our analysis demonstrated the impact of eGFR and proteinuria in the advanced CKD group. Indicators in early CKD possessed a different prognostic profile in this advanced CKD cohort, therefore, necessitating a modified scoring system.

Dietary phosphorus restriction by a standard low-protein diet decreased serum fibroblast growth factor 23 levels in patients with early and advanced stage chronic kidney disease

Elevated serum fibroblast growth factor 23 (FGF23) levels are associated with mortality, cardiovascular disease, and disease progression in patients with chronic kidney disease (CKD). Although recent studies demonstrated that FGF23 levels decreased in response to dietary restriction of phosphorus and/or use of phosphate binders, research on the effects of a standard low-protein diet is lacking. The effects of a standard low-protein diet on serum FGF23, intact parathyroid hormone, and 1,25-dihydroxyvitamin D levels were investigated in patients with early (n = 15) and advanced (n = 20) CKD. Serum FGF23 levels decreased in both groups. Changes in FGF23 levels correlated with changes in 24 h urinary phosphorus excretion in the advanced CKD group. Decreased serum intact parathyroid hormone levels were observed only in the advanced CKD group and increased serum 1,25-dihydroxyvitamin D levels only in the early CKD group. These findings suggest that consuming standard low-protein diet decreased serum FGF23 levels in patients with CKD. Serum FGF23 levels may therefore be a useful marker to monitor the effects of a low-protein diet in early and advanced stage CKD.

Influence of renal replacement therapy on immune response after one and two doses of the A(H1N1) pdm09 vaccine.

Please cite this paper as: Quintana et al. (2012) Influence of renal replacement therapy on immune response after one and two doses of the A(H1N1) pdm09 vaccine. Influenza and Other Respiratory Viruses DOI: 10.1111/irv.12024. Background Patients with end‐stage renal disease have a reduced response to vaccination because of the general suppression of the immune system associated with uraemia. Objectives We evaluated the immune response and differential factors in the immunogenecity to an adjuvanted A(H1N1) pdm09 vaccine (Pandemrix®) in four populations of renal patients after one and two doses of vaccine. Patients Methods 151 patients were included in this study: 58 chronic haemodialysis patients, 52 renal allograft recipients, 14 peritoneal dialysis patients and 27 patients with advanced chronic kidney disease in preparation for kidney replacement therapy. Influenza‐specific antibody levels were measured by monitoring A(H1N1) pdm09 titres using a haemagglutination inhibition assay. Results The seroconversion rate at 42 days after two vaccine doses was 80% in the haemodialysis group, 64·9% in the renal allograft recipients group, 100% in the advanced chronic kidney disease group and 71·4% in the peritoneal dialysis group (P = 0·041). Conclusions Immune response to two doses of the influenza A H1N1 vaccine is dissimilar in the four renal conditions, confirming that seroprotection in pre‐dialysis, haemodialysis and peritoneal dialysis is similar to that in the general population vaccinated with one dose. In contrast, renal transplant recipients with good allograft function showed inadequate protection and triple immunosuppressive therapy including calcineurin inhibitors, mycophenolate and steroids negatively influenced seroconversion after vaccination in renal recipients.