Baseline Glomerular Filtration Rate Research Articles

#1519 Nutritional impact of ketoanalogue supplementation with protein-restricted diets in advanced chronic kidney disease

Abstract Background and Aims The benefits and risks of a protein-restricted diet supplemented with ketoanalogues (KA) in patients with chronic kidney disease (CKD) are still being explored. Combining KA supplementation with a protein-restricted diet may potentially preserve the glomerular filtration rate (GFR) in CKD patients. However, concerns about protein-energy wasting and the nutritional benefits of KA supplementation remain uncertain. Previous systematic reviews have often included crossover or non-randomized studies and combined data from CKD and dialysis patients, potentially introducing heterogeneity when assessing the effects of KA supplementation in CKD patients. We aim to provide an updated and comprehensive assessment of the impact of combining KA supplementation with a protein-restricted diet on the nutritional status of advanced CKD patients compared to the effects of a protein-restricted diet alone. Method We conducted systematic literature searches of PubMed, Embase, Scopus, and Cochrane Library up to September 2023. We selected parallel-design randomized controlled trials comparing KA supplementation to a low- or very low-protein diet (VLPD) versus a low-protein diet (LPD) alone in adults with stages 3-5 CKD. Outcomes included serum albumin, triceps skinfold (TSF), and mid-arm muscle circumference (MAMC). Pooled estimates of effect measures were calculated using the random-effects model and presented as standardized mean differences (SMDs) with 95% confidence intervals (CIs). Given the variation in CKD stages among the included studies, subgroup analyses were conducted based on baseline renal function (GFR < 20 vs. ≥ 20 mL/min/1.73 m²). To assess the robustness of our meta-analyses, we conducted sensitivity analyses by excluding studies with an in-trial follow-up duration of less than one year. Results We identified 13 trials with 974 participants and a median follow-up of 12 months. KA supplementation combined with an LPD or a VLPD significantly increased TSF compared to an LPD alone (SMD, 0.25; 95% CI, 0.04, 0.45; P = 0.02; Fig. 1). No significant differences were observed in serum albumin (SMD, 0.28; 95% CI, -0.05, 0.61; P = 0.10; Fig.) and MAMC (SMD, 0.10; 95% CI, -0.12, 0.32; P = 0.37; Fig. 1). KA supplementation significantly increased serum albumin in patients with a baseline GFR ≥ 20 mL/min/1.73 m² (SMD 0.52; 95% CI, 0.20, 0.84; P = 0.001), but not in those with a baseline GFR < 20 mL/min/1.73 m² (SMD, -0.04; 95% CI, -0.41, 0.34; P = 0.85), and this difference between the subgroups was statistically significant (P = 0.03; Fig. 2). Sensitivity analysis that excluded studies with an in-trial follow-up duration of less than one year yielded results similar to the main analysis, except that the difference in TSF between the intervention and control arms became nonsignificant. Conclusion In patients with stages 3-5 CKD, KA supplementation with a protein-restricted diet did not adversely affect nutritional status. These findings remained consistent in sensitivity analyses of RCTs with a follow-up of more than one year and in subgroup analyses based on baseline GFR. The addition of KAs to protein-restricted diets improved serum albumin levels in patients with a baseline GFR of ≥ 20 mL/min/1.73 m². Our analyses confirmed the efficacy and safety of KA supplementation on nutritional status in advanced CKD patients over a one year follow-up period.

#2404 Predictors of mortality in patients with chronic kidney disease stages 3-4 without heart disease

Abstract Background and Aims Cardiovascular disease is common in patients with chronic kidney disease (CKD). This may, at least in part, explain the high risk of mortality in this patient group. The aim of the present study was to identify factors associated with mortality in patients with CKD stages 3 and 4 without a diagnosis of heart disease. Method Study subjects were derived from a cohort of patients with CKD stages 3 and 4 who were recruited from our Nephrology Outpatient Clinic between February 2009 and December 2011. Ninety-one patients without a diagnosis of heart disease were included in this cross-sectional study. Mortality data were collected in April 2023. Results All-cause mortality was 28.6% (26 patients) during a mean follow-up of 11.2 ± 2.7 years. Comparison of baseline data between non-survivors and survivors showed that non-survivors were significantly older, had lower glomerular filtration rate (GFR), higher ambulatory systolic blood pressure (ASBP), less nocturnal dipping of ASBP, higher carotid–femoral pulse wave velocity (cfPWV) and higher serum levels of troponin T (TnT) and N-terminal pro-brain natriuretic peptide (NT-proBNP) [Tables 1 and 2]. In addition, the proportion of patients with diabetes and on treatment with beta-blockers was elevated in non-survivors [Tables 1 and 2]. There were no statistically significant differences between groups in smoking history, treatment with angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, diuretics, calcium channel blockers, alpha-blockers, statins, active vitamin D analogs, calcium-based or non-calcium-based phosphate binders. In a binary logistic regression analysis, to identify independent predictors of mortality, we included age, gender, baseline GFR, serum NT-proBNP, TnT, cfPWV, percent of nocturnal dipping of ASBP, diagnosis of diabetes, and treatment with beta-blockers. Only less nocturnal dipping of ASBP (Exp [β] value of 0.86, 95% CI 0.77–0.97, p = 0.016) and advancing age (Exp [β] value of 0.91, 95% CI 0.84–0.99, p = 0.024) significantly predicted all-cause mortality. Conclusion In patients with CKD stage 3 and 4 without a diagnosis of heart disease only older age and less nocturnal dipping of ASBP were independently associated with mortality. Although baseline levels of serum NT-proBNP and TnT were elevated in non-survivors, neither serum NT-proBNP nor TnT showed independent associations with mortality in this cohort.

#1356 Kidney phenotype in interstitial lung disease associated with ANCA-vasculitis: European Multicentre Study

Abstract Background and Aims Interstitial lung disease (ILD) in ANCA-associated vasculitis (AAV) has the appearance of a progressive fibrotic disease on imaging and primarily affects the interstitial lung compartment and is usually associated with MPO-ANCA. Whether patients with AAV-ILD display a similar fibrotic pattern in their kidneys is unclear. Method A European multicentre retrospective study included patients with AAV-ILD. The diagnosis of ILD was confirmed by a CT chest pattern of usual interstitial pneumonia (UIP), non-specific interstitial pneumonia (NSIP), organising pneumonia or chronic hypersensitivity pneumonia. We aimed to determine if kidney involvement in AAV-ILD exhibited a more fibrotic pattern compared to AAV-related nephritis without ILD, using data from the Cambridge AAV cohort. Results 135 patients with AAV-ILD were included; 94 (70%) had also kidney involvement, in whom the mean age was 71 ± 11 years and 87% MPO-ANCA positive. The ILD diagnosis preceded AAV in 17%, 64% presented concurrently with kidney involvement, 20% with pulmonary haemorrhage. The most common lung radiological pattern was UIP (67%). At presentation, the median glomerular filtration rate (GFR) was 27 ml/min per 1.73 m2 (interquartile range 12-50), with a median albumin-to creatinine ratio 23 mg/mmol (IQR 10-97). Among 72 patients with available kidney biopsy, the most prevalent Berden class was focal in 45%, followed by mixed in 33%, crescentic in 18% and sclerotic in 4%. Although, the prevalence of Berden classes did not significantly differ between ILD-nephritis and no ILD-nephritis groups, the former group had a higher baseline GFR (p = 0.05), lower albuminuria level (p = 0.002), higher percentage of normal glomeruli (p = 0.027), lower glomerular necrosis percentage (p = 0.002) and higher interstitial fibrosis score (p = 0.049). Within five years, the ILD-nephritis group demonstrated renal recovery, as indicated by an adjusted mean delta GFR of 13.4 ml/min per 1.73 m2, without a significant difference compared to the no ILD-nephritis group. Over a median follow-up of 4.9 years (IQR 2-9), the progression to end-stage kidney disease (ESKD) was comparable between the groups. However, notably, the ILD-nephritis group experienced significantly poorer survival rates (mean 10.9 years vs 17.9 years, log-rank p < 0.001). Conclusion In AAV-ILD, kidney involvement is often characterized by fewer inflammatory and a higher prevalence of fibrotic lesions than on non-ILD-AAV. Despite initial differences in renal pathology and kidney function between these groups, both demonstrated similar risks of progressing to ESKD. Nevertheless, it's crucial to underscore the significant influence of ILD on the overall outcomes of AAV patients with kidney involvement.

Assessment of temporal changes in glomerular filtration rate following clamp ischemia in male and female rats using transcutaneous FITC-sinistrin clearance

Warm arterial clamping with reperfusion in rats is a commonly utilized model of ischemic kidney injury (IRI). Traditionally, changes in plasma creatinine or creatinine clearance have been utilized to assess kidney function in this model. A limitation of these approaches, however, is that changes in plasma creatinine are relatively slow to occur, resulting in low temporal fidelity. This limits our ability to relate changes in kidney function to histo-pathological changes observed during reperfusion of the kidneys. Transcutaneous assessment of FITC-sinistrin clearance enables accurate, repeated measurement of glomerular filtration rate in conscious animals over short segments of time (hours) without drawing blood. The goal of the current study was to characterize temporal changes in renal function in male and female rats after reperfusion from bi-lateral warm arterial clamp ischemia using transcutaneous FITC-sinistrin clearance. Our study was performed in age matched male (n=8) and female (n=5) Sprague Dawley rats (12-20wks of age). FITC sinistrin clearance was measured by affxing a miniaturized transcutaneous measurement device between the shoulder blades (MediBeacon) of rats. 50mg/kg of FITC-sinistrin was then injected i.v via the tail vein and the device allowed to record for ~3 hours. Measurements were taken either at pre-surgery (baseline), 1-3 hours, 24 hours or 7 days following reperfusion of the kidneys from warm bilateral arterial clamp ischemia. For the ischemic surgery, animals were anesthetized with isoflurane (2-5%, 95% O2) and the right and left kidneys were accessed by flank incisions. After being exposed, the renal arteries were separated from the renal veins via dissection. Both renal arteries were then clamped with microserrefines for 45 minutes. After the ischemic period, the clamps were removed, allowing blood flow to be restored to the kidneys. Body temperature was measured via a rectal probe and maintained at 37°C throughout the procedure by a servo-controlled heating table and UV heating lamp. The wounds were then closed, and the animals allowed to recover. Buprenorphine was administered as an analgesic. For each measurement, the ½ life of FITC sinistrin was determined using a 1-compartment model (MB Lab software) and glomerular filtration rate (GFR) per 100g of body weight rate calculated. Baseline GFR was 0.94±0.03ml/min/100g in males and 1.09±0.02/min/100g in females (PTTEST=0.04). Following 45 minutes of warm bilateral arterial ischemia and reperfusion, GFR fell to 0.24±0.08ml/min/100g in male and 0.36±0.15ml/min/100g in females within 1-3 hours of reperfusion. At 24 hours of reperfusion, GFR averaged 0.06±0.03ml/min/100g in males and 0.28±0.16ml/min/100g in females. GFR recovered in males and females by 7 days of reperfusion averaging 0.86±0.10ml/min/100g in males and 0.83±0.00ml/min/100g in females. There was no significant difference between FITC-sinistrin clearance between males and females at any time point after IRI. Our data indicate that most of the reduction in GFR is present immediately after releasing the clamp. This is consistent with continued vascular disturbances mediating the initial decline in glomerular filtration rate in this model (i.e. vasospasm). The absence of sex differences in GFR decline using this method suggests that sex-differences detected using plasma creatinine may be, at least in part, secondary to the more rapid production of creatinine in males than in females or greater baseline filtration/body weight ratio in females compared to males rather than differences in renal function decline to ischemia. American Heart Association Transformational Project Award 970585 to Paul O'Connor. This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Factors associated with post-hospitalization dialysis dependence in ECMO patients who required continuous renal replacement therapy

Objective This single center retrospective study aimed to describe the variables associated with outpatient dialysis dependence in extracorporeal membrane oxygenation (ECMO) patients who needed continuous renal replacement therapy (CRRT) for acute kidney injury (AKI) during their hospitalization. Methods Retrospective study of patients who required ECMO-CRRT. Results Between the years of 2016 and 2022, 202 patients required ECMO-CRRT. One hundred and six patients (52.5%) survived their hospitalization and were followed up for a median of 391 [133, 1005] days. Eighty-one patients (76.5%) recovered kidney function and were dialysis-free before hospital discharge. Twenty-five patients (23.5%) were hemodialysis-dependent after hospitalization. On multivariate regression analysis, hyperlipidemia (odds ratio, OR 6.08 [1.67–22]) and CRRT duration (OR 1.09 [1.03–1.15]) were associated with the need for dialysis post-hospitalization. In this group, 16 patients eventually became dialysis-free, after a median of 49 [34.7, 78.5] days. These patients had a higher median baseline glomerular filtration rate (GFR) compared to those who never recovered renal function (93 mL/min/1.73 m2 [82.4, 104.3] vs. 63.8 mL/min/1.73 m2 [37.9, 83], p = .009). Their follow-up GFR was lower compared to those who recovered renal function before hospital discharge; (87 mL/min/1.73 m2 [68.2, 98.9] vs. 99 mL/min/1.73 m2 [79, 118], p = .07). Conclusions AKI requiring CRRT was associated with high mortality in patients receiving ECMO. Nonetheless, most ECMO survivors became dialysis-free before hospital discharge. Variables associated with the need for outpatient dialysis included hyperlipidemia and prolonged need for CRRT during hospitalization.

How renal toxins respond to renal function deterioration and oral toxic adsorbent in pH-controlled releasing capsule.

The number of patients with chronic kidney disease (CKD) is increasing. Oral toxin adsorbents may provide some value. Several uremic toxins, including indoxyl sulfate (IS), p-cresol (PCS), acrolein, per- and poly-fluoroalkyl substances (PFAS), and inflammation markers (interleukin 6 [IL-6] and tumor necrosis factor [TNF]-alpha) have been shown to be related to CKD progression. A total of 81 patients taking oral activated charcoal toxin adsorbents (AC-134), which were embedded in capsules that dissolved in the terminal ileum, three times a day for 1 month, were recruited. The renal function, hemoglobulin (Hb), inflammation markers, three PFAS (PFOA, PFOS, and PFNA), and acrolein were quantified. Compared with the baseline, an improved glomerular filtration rate (GFR) and significantly lower acrolein were noted. Furthermore, the CKD stage 4 and 5 group had significantly higher concentrations of IS, PCS, IL-6, and TNF but lower levels of Hb and PFAS compared with the CKD Stage 3 group at baseline and after the intervention. Hb was increased only in the CKD Stage 3 group after the trial (p = .032). Acrolein did not differ between the different CKD stage groups. Patients with improved GFR (responders) (about 77%) and nonresponders had similar baseline GFR. Responders had higher acrolein and PFOA levels throughout the study and a more significant reduction in acrolein, indicating a better digestion function. Responders had higher acrolein and PFOA levels throughout the study and a more significant reduction in acrolein, while PFOA increased in responders. Both the higher PFOA and lower acrolein may be related to improved eGFR (and possibly to improvements in proteinuria, which we did not measure. Proteinuria is associated with PFAS loss in the urine), AC-134 showed the potential to improve the GFR and decrease acrolein, which might better indicate renal function change. Future studies are needed with longer follow-ups.

Acetazolamide and Hydrochlorothiazide in Patients With Acute Decompensated Heart Failure: Insights From Recent Trials.

Acetazolamide and thiazide diuretics have been combined with loop diuretics to overcome diuretic resistance in heart failure patients. However, recent studies have assessed the upfront combination of acetazolamide and hydrochlorothiazide with loop diuretics in hospitalized patients with acute decompensated heart failure without loop diuretic resistance. We reviewed two recent randomized controlled trials on the upfront use of acetazolamide and thiazide diuretics in acute decompensated heart failure, respectively. When the two trials on acetazolamide are considered together, adding oral or intravenous acetazolamide to loop diuretics in decompensated heart failure patients resulted in increased diuresis and natriuresis. However, the effects were significantly higher in patients with serum bicarbonate ≥ 27 mmol/L and those with higher baseline glomerular filtration rate (GFR). Similarly, when the two trials on thiazide diuretics are considered together, adding hydrochlorothiazide to loop diuretics in decompensated heart failure patients resulted in increased diuresis and weight loss. However, it increases the risk of impaired renal function. When all the trials are considered together, the upfront use of acetazolamide may be helpful in carefully selected patients, including patients with underlying elevated bicarbonate levels (≥ 27 mmol/L) and those with good renal function (GFR > 50). Conversely, though the upfront use of thiazide diuretic added to intravenous furosemide improved diuretic response in acute decompensated heart failure, it causes an increased risk of worsening renal function and lack of clear evidence of reducing hospital length of stay.

Limitations of Parenchymal Volume Analysis for Estimating Split Renal Function and New Baseline Glomerular Filtration Rate After Radical Nephrectomy.

Accurately predicting new baseline glomerular filtration rate (NBGFR) after radical nephrectomy (RN) can improve counseling about RN vs partial nephrectomy. Split renal function (SRF)-based models are optimal, and differential parenchymal volume analysis (PVA) is more accurate than nuclear renal scans (NRS) for this purpose. However, there are minimal data regarding the limitations of PVA. Our objective was to identify patient-/tumor-related factors associated with PVA inaccuracy. Five hundred and ninety-eight RN patients (2006-2021) with preoperative CT/MRI were retrospectively analyzed, with 235 also having NRS. Our SRF-based model to predict NBGFR was: 1.25 × (GlobalGFRPre-RN × SRFContralateral), where GFR indicates glomerular filtration rate, with SRF determined by PVA or NRS, and with 1.25 representing the median renal functional compensation in adults. Accuracy of predicted NBGFR within 15% of observed was evaluated in various patient/tumor cohorts using multivariable logistic regression analysis. PVA and NRS accuracy were 73%/52% overall, and 71%/52% in patients with both studies (n = 235, P < .001), respectively. PVA inaccuracy independently associated with pyelonephritis, hydronephrosis, renal vein thrombosis, and infiltrative features (all P < .03). Ipsilateral hydronephrosis and renal vein thrombosis associated with PVA underprediction, while contralateral hydronephrosis and increased age associated with PVA overprediction (all P < .01). NRS inaccuracy was more common and did not associate with any of these conditions. Even among cohorts where PVA inaccuracy was observed (22% of our patients), there was no significant difference in the accuracies of NRS- and PVA-based predictions. PVA was more accurate for predicting NBGFR after RN than NRS. Inaccuracy of PVA correlated with factors that distort the parenchymal volume/function relationship or alter renal functional compensation. NRS inaccuracy was more common and unpredictable, likely reflecting the inherent inaccuracy of NRS. Awareness of cohorts where PVA is less accurate can help guide clinical decision-making.

Optimization of Kidney Health in Liver Transplant Candidates: Pretransplant Considerations and Modalities.

Patients with decompensated end-stage liver disease (ESLD) are at increased risk for mortality, and only liver transplantation (LT) offers meaningful hope for survival. These patients are at risk for kidney dysfunction through the continuum of care for ESLD including LT. We discuss the role of accurate estimation and measurement of baseline glomerular filtration rate in assessment of kidney dysfunction among those with ESLD. Optimizing kidney function is a vital goal in the management of these patients before LT. In this review, we summarize salient aspects of assessing and optimizing kidney function in this patient population. Precipitating factors and different causes of acute kidney injury are discussed, including hepatorenal syndrome. We further review treatment options for acute kidney injury including volume management. The role of vasopressor therapy, renal replacement therapy, and transjugular intrahepatic portosystemic shunting are discussed.

Short- and Long-Term Renal Function After Partial Nephrectomy: Comparison of Solitary and Multifocal Renal Masses.

Multifocal partial nephrectomy (MPN) is a critical management strategy for extirpation of multiple distinct renal masses; however, its short- and long-term impact on renal function remains poorly described. Herein we compared absolute glomerular filtration rate (GFR) and change from baseline at multiple time points after MPN and standard partial nephrectomy (SPN). Perioperative and pathologic characteristics of 1307 partial nephrectomies performed from 2009 to 2020 were identified. 3:1 propensity score methods were used to match MPN and SPN cohorts based on preoperative characteristics known to impact renal function. Differences in GFR, perioperative outcomes, and overall and recurrence-free survival were assessed. Absolute and relative change from baseline GFR was compared at 5 time points for 36 months after partial nephrectomy. After propensity score matching, 192 SPNs and 64 MPNs with a median GFR of 80.2 mL/min were compared. MPN was associated with a greater decline in GFR of between 11% and 18% for the first year compared to a decline of 7% to 10% for SPN. This difference stabilized after 24 months. However, no differences in overall survival or recurrence-free survival were observed. Median follow-up time was 46.7 months. Long-term renal function after MPN remains similar to SPN despite greater declines in the first year after excision of multifocal renal masses.

Association of cardiopulmonary bypass with acute kidney injury in patients undergoing coronary artery bypass grafting: a retrospective cohort study.

Association of cardiopulmonary bypass with acute kidney injury in patients undergoing coronary artery bypass grafting: a retrospective cohort study.

Role of Clinical Risk Factors and B-Type Natriuretic Peptide in Assessing the Risk of Asymptomatic Cardiotoxicity in Breast Cancer Patients in Kazakhstan

The asymptomatic progression of chemotherapy-induced cardiotoxicity poses a significant risk to breast cancer patients. In the present single-center cohort study, a predictive model for evaluating the risk of cardiotoxicity during or by the end of chemotherapy was designed. The risk-prediction nomogram was delineated and assessed. In total, 34 patients out of 120 developed asymptomatic cardiotoxicity (28.3%). Of six explored biomarkers, only B-type natriuretic peptide showed a reliable pattern of incremental increase, revealing statistical significance between cardiotoxicity “+” and “−” groups by visit 4 or by the 9th month of monitoring (p 0.006). The following predictors were included in the model: age, hypertension, diabetes mellitus, baseline glomerular filtration rate, 6 min walk test measured at visit 4, BNP values at visit 4, left ventricular ejection fraction levels at visit 4, a total dose of radiotherapy received, and anthracycline cumulative doses. The model’s AUC was 0.72 (95% CI 0.59; 0.86), evidencing the satisfactory predictive ability of the model; sensitivity 100% (95% CI 90.36; 100.0) at a specificity of 66.67% (95% CI 50.33; 79.79); PPV 54.1% [95% CI 47.13; 60.91]; PVN 100% [95% CI 94.64; 100.00]. The calibration plot showed satisfactory agreement between predicted and actual chances (p = 0.98). The designed model can be applied in settings lacking speckle tracking echocardiography.

Chronic kidney disease increases cost of care and readmission risk after shoulder arthroplasty

Chronic kidney disease (CKD) is associated with adverse outcomes and higher costs after lower extremity arthroplasty from higher rates of infection, aseptic loosening, and transfusion and longer hospital length of stay (LOS). The purpose of this study was to compare health care utilization and 90-day encounter charges after SA in patients with and without renal disease. A secondary aim was to define patient characteristics of patients with renal disease. We conducted a retrospective cohort study of all patients who underwent primary shoulder arthroplasty from January 2015 to December 2019 by a single surgeon at a single institution. Patients without a baseline glomerular filtration rate (GFR) were excluded. We evaluated results for patients with CKD (GFR ≤59) and without CKD (GFR ≥60). Univariate regression was performed to assess the influence of CKD on healthcare utilization, including length of stay (LOS), transfusion, and risk for ED revisit or readmission during the 90-day postoperative period. In addition, 90-day encounter charges, revisit charges, and ED charges for patients with CKD were compared with those for patients with normal renal function. Last, multivariable linear regression models were used to assess the effect of eGFR on total 90-day encounter charges. 514 patients met the study inclusion criteria. 125 had CKD, 389 had normal GFR. Patients with CKD were more likely to require transfusion [OR 16.2 (1.9, 139.7), p=0.011] despite similar intraoperative estimated blood loss (156.9±132.5mL versus 153.8±89.7mL, p=0.768). In addition, CKD patients had longer LOS (2.8±1.3 days versus 2.3±1.0 days, p<0.001), had higher 90-day readmission rates (p=0.001), were more likely to visit the ED within 90 days after shoulder arthroplasty (p=0.018), and had higher total 90-day encounter charges ($37,769±$6,901 versus $35,684±$5,312, p=0.001). Each unit increase in eGFR independently reduced total encounter charges by $67 (-$132, -$2, p=0.043); dialysis patients incurred higher total 90-day encounter charges compared to patients with less severe renal disease ($42,733 ± $8,985 v. $37,531± $6,749, p=0.002). Also, patients with CKD were older (73.2±8.9 versus 68.1±9.4 years, p<0.001); had lower preoperative Hg (12.4±1.5g/dL versus 13.4±1.5g/dL; p<0.001), higher ASA score (p<0.001), and more preoperative comorbidities (5.9±2.9 versus 5.0±3.1, p=<0.001); and were more likely to use opioids preoperatively (p=0.043). Patients with CKD have a higher risk for blood transfusion, ED visits, and readmission after shoulder arthroplasty, with higher total 90-day encounter charges. Identifying and optimizing this patient population before surgery can reduce costs and improve outcomes, which benefits patients, physicians, institutions, and payors.

Объем интраоперационной кровопотери и функциональное состояние почек при различных способах хирургического лечения крупных и сложных камней почек.

Introduction. Despite the development of minimally invasive technological methods for the treatment of urolithiasis, improving the functional state of the kidneys in the postoperative period does not lose its importance at the present time. The decrease and loss of renal function after surgical treatment of complex forms of nephrolithiasis in various ways creates the problem of choosing one or another surgical technique in order to avoid negative results of surgical treatment. modern urology. Purpose of the work: to assess the correlation between the volume of intraoperative blood loss and dynamic changes in glomerular filtration rate (GFR) in the postoperative period with various methods of surgical treatment of large and complex kidney stones. Purpose: to assess the correlation between the volume of intraoperative blood loss and dynamic changes in the GFR in the postoperative period with various methods of surgical treatment of large and complex kidney stones. Materials and methods. The study selected data from 97 patients with urolithiasis, large and complex kidney stones of the urological department of the city hospital No 2 of the city of Nur-Sultan of the Republic of Kazakhstan. The median age was 52 (23–73) years. The average area of a kidney stone was 428.3±36.1 mm2, its average density according to Hounsfield was 1042.9±34.8 HU. All patients were divided into 3 cohort comparison groups according to the method of surgical treatment: percutaneous nephrolithotripsy (PCNL) on prone position (1 group) – 44 patients (45.4%), PCNL on the supine position (2 group) – 29 patients (29.9%), laparoscopic pyelolithotomy (3 group)– 24 patients (24.7%). The median baseline GFR in the 1 group was 91 ml/min/1.73 m2, in the 2 group 95 ml/min/1.73 m2, in the 3 group 101 ml/min/1.73 m2. The average duration of surgical intervention for 1 group was 92.8±6.8 min, for 2 group – 119.6±10.9 min, for 3 group-146.9 ± 6.1 min. The mean blood loss in 1 group was 144.5±9.1 ml, in 2 group 235.3±19.1 ml, in 3 group 43.1±5.2 ml. Results. A decrease in GFR below 60 (ml/min/1.73 m2), corresponding to stage III of chronic kidney disease (CKD), was most pronounced in the 2 group: from 3 (3.1%) cases before surgery to 7 (7.2%) cases in postoperative period. A decrease in GFR below 30 (ml/min/1.73 m2), which corresponds to stage IV CKD, also had negative dynamics in the group of patients with 2 group: from 2 (2.1%) to 3 (3.1%) cases respectively. In the rest of the studied groups, there was no negative dynamics of GFR. A correlation was found between GFR in the postoperative period and intraoperative blood loss (r = 0.410, p&lt;0.001). Conclusions. Surgical treatment of urolithiasis of the kidneys is associated with risks of intraoperative blood loss, the volume of which directly correlates with the deterioration of the functional state of the kidneys in the postoperative period. Reducing the volume of intraoperative blood loss in various surgical methods for the treatment of urolithiasis helps to minimize the risk of developing acute kidney injury in the postoperative period.

Association Between Biomarkers of Kidney Disorders and Atrial Fibrillation: A Literature Review

Kidney diseases and atrial fibrillation often occur together. Renal impairment increases the risk of developing incident atrial fibrillation (AF) and is linked to it in a bidirectional manner, making it a prothrombotic and pro-hemorrhagic condition. In Japanese patients with nonvalvular AF, lower creatinine clearance values were associated with thromboembolism, all-cause death, and cardiovascular death, but not with major haemorrhage. Older individuals with elevated serum levels of cystatin C had a significantly higher prevalence of AF. Moderate to severe chronic kidney disease individuals with increased levels of fibroblast growth factor-23 were independently associated with prevalent and incident AF. A higher baseline glomerular filtration rate was associated with an increased risk of AF. Elevated levels of insulin-like growth factor binding protein-7 were also observed in AF patients, while reduced circulating tissue inhibitor of metalloproteinase 2 levels were also associated with an increased risk of AF. Patients with AF had higher levels of non-esterified fatty acids and liver type fatty acid binding protein. Interleukin-18 levels in blood plasma were also found to be higher in AF patients. Furthermore, higher baseline urea/blood urea nitrogen levels were significantly associated with the incidence of AF in women and kidney disease in both men and women.

Evaluation of Glomerular Filtration Rate Trends in People Living With HIV Corrected by the Baseline Glomerular Filtration Rate.

Chronic kidney disease, for which estimated glomerular filtration rate (eGFR) trajectories are early markers, is frequent in people living with HIV. Identify eGFR trajectory patterns according to kidney function and assess associated factors over a 13-year follow-up period. We evaluated longitudinal changes and its associated factors in eGFR of 3366 participants according to kidney function with a 2-level, linear, mixed model. Participants with initial kidney dysfunction experienced a slight eGFR increase, whereas others showed a slight decrease. A weak relationship was observed between baseline eGFR and its variation over time. Baseline eGFR was affected by age, CD4 + count, viral load, hypertension, hyperlipidemia, AIDS-defining illness and tenofovir (TDF) with integrase inhibitor (INSTI) or efavirenz. Significant factors for eGFR change included the following: in kidney dysfunction, CD4 + cell count of >350 cells per cubic millimeter and undetectable viral load increased eGFR, whereas TDF + protease inhibitor decreased eGFR; in mildly decreased kidney function, CD4 + cell count of >350 cells per cubic millimeter, AIDS-defining illness, and TDF + efavirenz increased eGFR, whereas age, hypertension, hyperlipidemia, and TDF + INSTI decreased eGFR; in normal kidney function, age, CD4 + cell count of > 350 cells per cubic millimeter, undetectable viral load, hypertension, hyperlipidemia, and TDF + INSTI decreased eGFR, whereas TDF + efavirenz increased eGFR (all P value for interaction < 0.05). Our findings suggest that eGFR trajectories varied widely between individuals in people living with HIV. In the lower eGFR group, virus-related factors were more relevant, whereas traditional risk factors for renal dysfunction were more prominent in the highest eGFR group.

COVID-19-associated coagulopathy and acute kidney injury in critically ill patients.

The incidence of thrombotic events and acute kidney injury is high in critically ill patients with COVID-19. We aimed to evaluate and compare the coagulation profiles of patients with COVID-19 developing acute kidney injury versus those who did not, during their intensive care unit stay. Conventional coagulation and platelet function tests, fibrinolysis, endogenous inhibitors of coagulation tests, and rotational thromboelastometry were conducted on days 0, 1, 3, 7, and 14 following intensive care unit admission. Out of 30 patients included, 13 (43.4%) met the criteria for acute kidney injury. Comparing both groups, patients with acute kidney injury were older: 73 (60-84) versus 54 (47-64) years, p=0.027, and had a lower baseline glomerular filtration rate: 70 (51-81) versus 93 (83-106) mL/min/1.73m2, p=0.004. On day 1, D-dimer and fibrinogen levels were elevated but similar between groups: 1780 (1319-5517) versus 1794 (726-2324) ng/mL, p=0.145 and 608 (550-700) versus 642 (469-722) g/dL, p=0.95, respectively. Rotational thromboelastometry data were also similar between groups. However, antithrombin activity and protein C levels were lower in patients who developed acute kidney injury: 82 (75-92) versus 98 (90-116), p=0.028 and 70 (52-82) versus 88 (78-101) µ/mL, p=0.038, respectively. Mean protein C levels were lower in the group with acute kidney injury across multiple time points during their stay in the intensive care unit. Critically ill patients experiencing acute kidney injury exhibited lower endogenous anticoagulant levels. Further studies are needed to understand the role of natural anticoagulants in the pathophysiology of acute kidney injury within this population.

The feasibility of incremental peritoneal dialysis for older patients on peritoneal dialysis.

This study was performed to investigate the feasibility of incremental peritoneal dialysis (iPD) in older patients. In this retrospective cohort study, we enrolled peritoneal dialysis (PD) patients with age ≥ 60 years old at our center from 2008 to 2017. The patients were divided into two groups based on the daily PD exchanges: iPD group (≤3 × 2 L exchanges), and full dose group (≥4 × 2 L exchanges). Kaplan-Meier curves and multivariate Cox regression models were applied to evaluate the risks of anuria and mortalities between groups. A total of 238 patients (186 in full dose group and 52 in iPD group) were enrolled. The mean age was 67.8 ± 5.7 years, and 45.8% were females. The baseline glomerular filtration rate was 4.15 ± 2.39 mL/min/1.73 m2 . Multivariate Cox regression models showed that patients in the iPD group patients had significantly decreased risk of anuria (hazard ratio [HR], 0.44; 95% confidence interval [CI], 0.24-0.81; p = 0.008), and all-cause mortality (HR, 0.59; 95% CI, 0.36-0.98; p = 0.04). Additionally, the incidence of peritonitis was significantly lower in the iPD group than that in the full dose group (0.115 vs. 0.197 episodes per person-year, p = 0.03) during the 36 months of PD commencement. Older patients with iPD were independently associated with better preservation of residual kidney function and survival outcomes. Moreover, iPD regimens are also associated with reduced incidence of peritonitis. The iPD strategy might offer a feasible option for older patients.

Does HbA1c Level or Glomerular Filtration Rate Affect the Clinical Response to Endothelial Growth Factor Therapy (Ranibizumab or Aflibercept) in Diabetic Macular Edema? A Real-Life Experience.

Anti-vascular endothelial growth factor (VEGF) therapy is the first-line treatment for diabetic macular edema (DME). We investigated the effect of initial glycosylated hemoglobin (HbA1c) level and glomerular filtration rate (GFR) on treatment outcomes in patients with DME receiving anti-VEGF injections in routine clinical practice. A retrospective analysis of data from the prospective, multi-center, observational Fight Retinal Blindness! registry was performed. A total of 178 eyes with DME treated with anti-VEGF agents (ranibizumab or aflibercept) from 1 January 2010 to 31 March 2019 were enrolled in the analysis, with the long study period to allow for up to 24months of follow-up. Data for eyes were tracked in the Fight Retinal Blindness! registry, and clinical parameters were collected by using local software. Changes in visual (best-corrected visual acuity [BCVA], in letters) and anatomic outcomes (central subfield thickness [CST], in microns) between subgroups of patients according to baseline HbA1c level (≤ 7% vs. > 7%) and GFR (> vs. ≤ 60ml/min/m2 at 24months were assessed. The multivariate adjusted mean improvement in BCVA at 24months of treatment was + 5.2 and + 6.8 letters in subgroups with baseline HbA1c level ≤ 7% and > 7%, respectively (p = 0.541), and + 6.9 and + 6.4 letters in subgroups with GFR > 60 and < 60ml/min/1.73 m2, respectively (p = 0.852). The multivariate adjusted mean CST reduction was -89.9 and -76.4µm in subgroups with baseline HbA1c level ≤ 7% and > 7%, respectively (p = 0.505), and -85 and -115µm in subgroups with baseline GFR > 60 and ≤ 60ml/min/1.73 m2, respectively (p = 0.130). These results seem to indicate that visual and anatomical improvement in patients receiving intravitreal VEGF inhibitors for DME are independent of baseline HbA1c level and GFR, leading to the conclusion that high HbA1c levels or low GFR should not dictate injection timing in routine clinical practice. This study offers valuable insights for ophthalmologists, enabling a personalized treatment approach and optimizing DME patient outcomes.

Cardiovascular Autonomic Neuropathy and Risk of Kidney Function Decline in Type 1 and Type 2 Diabetes: Findings From the PERL and ACCORD Cohorts.

Previous studies have suggested that cardiovascular autonomic neuropathy (CAN) may predict rapid kidney function decline among persons with diabetes. We analyzed the association between baseline CAN and subsequent glomerular filtration rate (GFR) decline among individuals with type 1 diabetes (T1D) from the Preventing Early Renal Loss in Diabetes (PERL) study (N=469) and with type 2 diabetes (T2D) from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study (N=7,973). Baseline CAN was ascertained using ECG-derived heart rate variability indices. Its association with GFR slopes, rapid kidney function decline (GFR loss ≥-5 ml/min/1.73 m2/year), and ≥40% GFR loss was evaluated by linear mixed effect, logistic, and Cox regression, respectively. Participants with CAN experienced more rapid GFR decline, by an excess 1.15 (95%CI [-1.93, -0.37], P= 4.0x10-3) ml/min/1.73m2/year in PERL and 0.34 (95%CI [-0.49, -0.19], P= 6.3x10-6) ml/min/1.73m2/year in ACCORD. This translated in 2.11 (95% CI [1.23-3.63], P=6.9x10-3) and 1.39 (95% CI [1.20-1.61], P=1.1x10-5) odds ratios of rapid kidney function decline in PERL and ACCORD, respectively. Baseline CAN was also associated with a greater risk of ≥40% GFR loss events during follow-up (HR=2.60, 95%CI [1.15-5.45], p=0.02 in PERL and HR=1.54, 95%CI [1.28-1.84], P=3.8×10-6 in ACCORD). These associations remained significant after adjustment for potential confounders, including baseline GFR and albuminuria. Our findings indicate that CAN is a strong, independent predictor of rapid kidney function decline in both T1D and T2D. Further studies of the link between these two complications may help develop new therapies to prevent kidney function decline in patients with diabetes.