Cases Of End-stage Renal Disease Research Articles

END STAGE RENAL DISEASE

Objectives: To study hematological profile in geriatric cases undergoinghemodialysis and compare with non-geriatric. Study Design: Descriptive Cross SectionalStudy. Setting: Department of Nephrology & Medicine, Rawal Institute of Health SciencesIslamabad. Study Duration: 12 months (June 2016-June 2017). Material and Methods: Adultpatients (>18years) diagnosed as end stage renal disease (ESRD), undergoing maintenancehemodialysis for >3 months included after ethical approval and consent. Group A had 88geriatric ESRD cases (>65 years); group B had 88 non-geriatric (<65 years). Data analyzedby SPSS version 17. Hematological profile and other variables compared between two groupsby Chi-Square and t-test (significant p<0.05). Results: Among 166 ESRD cases (69% malesand 31% females), mean age was 54.9+10.6 years. Anemia present in 89% (group A) vs.74% (group B; p=0.012). Mean hemoglobin was 8.57+2.00 (group A) vs. 9.27+2.39 (groupB; p=0.035). Mean platelets count was lower among geriatrics; however leukocyte countscomparable between two groups. Mean eGFR was 7.95+2.68 (group A) vs. 9.16+4.04(group B; p=0.020). Diabetes and hypertension were frequent in geriatric group (p<0.05).No difference in hepatitis B, C and congestive cardiac failure observed. BMI was 26.74+5.87(group A) vs. 22.43+4.83 (group B; p<0.0001). Lack of social support observed in 25% (groupA) vs. 9% (group B). Conclusion: Anemia is frequent observation in ESRD hemodialysis cases.Geriatric ESRD hemodialysis cases have significantly low hemoglobin levels than non-geriatric.Hence, suggested that old age to be considered as an additional risk factor for anemia in ESRDhemodialysis cases. Geriatric ESRD hemodialysis cases should undergo frequent anemiascreening and timely intervention. Iron supplementation, dietary modification, erythropoietinadministration and blood transfusion as per indication needs to be individualized in geriatriccases to improve hematological parameters and quality of life.

HEMATOLOGICAL PROFILE IN GERIATRIC END STAGE RENAL DISEASE HEMODIALYSIS CASES

Objectives: To study hematological profile in geriatric cases undergoinghemodialysis and compare with non-geriatric. Study Design: Descriptive Cross SectionalStudy. Setting: Department of Nephrology & Medicine, Rawal Institute of Health SciencesIslamabad. Study Duration: 12 months (June 2016-June 2017). Material and Methods: Adultpatients (>18years) diagnosed as end stage renal disease (ESRD), undergoing maintenancehemodialysis for >3 months included after ethical approval and consent. Group A had 88geriatric ESRD cases (>65 years); group B had 88 non-geriatric (<65 years). Data analyzedby SPSS version 17. Hematological profile and other variables compared between two groupsby Chi-Square and t-test (significant p<0.05). Results: Among 166 ESRD cases (69% malesand 31% females), mean age was 54.9+10.6 years. Anemia present in 89% (group A) vs.74% (group B; p=0.012). Mean hemoglobin was 8.57+2.00 (group A) vs. 9.27+2.39 (groupB; p=0.035). Mean platelets count was lower among geriatrics; however leukocyte countscomparable between two groups. Mean eGFR was 7.95+2.68 (group A) vs. 9.16+4.04(group B; p=0.020). Diabetes and hypertension were frequent in geriatric group (p<0.05).No difference in hepatitis B, C and congestive cardiac failure observed. BMI was 26.74+5.87(group A) vs. 22.43+4.83 (group B; p<0.0001). Lack of social support observed in 25% (groupA) vs. 9% (group B). Conclusion: Anemia is frequent observation in ESRD hemodialysis cases.Geriatric ESRD hemodialysis cases have significantly low hemoglobin levels than non-geriatric.Hence, suggested that old age to be considered as an additional risk factor for anemia in ESRDhemodialysis cases. Geriatric ESRD hemodialysis cases should undergo frequent anemiascreening and timely intervention. Iron supplementation, dietary modification, erythropoietinadministration and blood transfusion as per indication needs to be individualized in geriatriccases to improve hematological parameters and quality of life.

Sex modulates the association of fibroblast growth factor 21 with end-stage renal disease in Asian people with Type 2 diabetes: a 6.3-year prospective cohort study.

To study whether plasma fibroblast growth factor 21 independently predicts the risk of end-stage renal disease in Asian people with Type 2 diabetes. In this prospective cohort study, 1700 Asian people with Type 2 diabetes were followed for a mean of 6.3 years in a regional hospital in Singapore. Incident end-stage renal disease was identified by linkage with a national renal registry. The association of baseline fibroblast growth factor 21 levels with risk of progression to end-stage renal disease was studied using survival analyses. Participants were aged 60 ± 10 years, with an average diabetes duration of 12 years. Their estimated GFR was 73 ± 28 ml/min/1.73 m2 and 62% had albuminuria at baseline. A total of 179 incident end-stage renal disease cases were identified. Plasma fibroblast growth factor 21 interacted with sex in its association with end-stage renal disease (Pinteraction = 0.003). A 1-sd increment in fibroblast growth factor 21 (natural log-transformed) was associated with a 1.32-fold (95% CI 1.05-1.66, P = 0.02) increased hazard for end-stage renal disease in women, after adjustment for traditional risk factors including estimated GFR and albuminuria. Taking death as a competing risk did not materially change the outcome [sub-distribution hazard ratio 1.35 (95% CI 1.11-1.66, P = 0.003)]. Fibroblast growth factor 21 did not predict end-stage renal disease risk in men after adjustment for baseline estimated GFR and albuminuria [hazard ratio 1.07 (95% CI 0.89-1.28, P = 0.49)]. Plasma fibroblast growth factor 21 level independently predicted risk of progression to end-stage renal disease in women with Type 2 diabetes. The pathophysiological relationships among FGF21, sex and renal progression warrant further study.

Genetic markers for urine haptoglobin is associated with decline in renal function in type 2 diabetes in East Asians

Urine haptoglobin (uHP) level prospectively predicts diabetic kidney disease (DKD) progression. Here, we aim to identify genetic determinants of uHP level and evaluate association with renal function in East Asians (EA) with type 2 diabetes (T2D). Genome-wide association study (GWAS) among 805 [236 Chinese (discovery) and 569 (57 Malay and 512 Chinese) (validation)] found that rs75444904/kgp16506790 variant was robustly associated with uHP level (MetaP = 1.21 × 10−60). rs75444904 correlates well with plasma HP protein levels and multimerization in EA but was not in perfect LD (r2 = 0.911 in Chinese, r2 = 0.536 in Malay) and is monomorphic in Europeans (1000 G data). Conditional probability analysis indicated weakening of effects but residual significant associations between rs75444904 and uHP when adjusted on HP structural variant (MetaP = 8.22 × 10−7). The rs75444904 variant was associated with DKD progression (OR = 1.77, P = 0.014) independent of traditional risk factors. In an additional validation-cohort of EA (410 end-stage renal disease (ESRD) cases and 1308 controls), rs75444904 was associated with ESRD (OR = 1.22, P = 0.036). Furthermore, increased risk of DKD progression (OR = 2.09, P = 0.007) with elevated uHP level through Mendelian randomisation analysis provide support for potential causal role of uHP in DKD progression in EA. However, further replication of our findings in larger study populations is warranted.

Abstract MP52: Population Health Impact of Sodium Glucose Co-Transporter 2 Inhibitors and Glucagon-Like Peptide-1 Receptor Agonists in US Adults With Type 2 Diabetes

Introduction: Recently, sodium glucose co-transporter 2 inhibitors (SGLT2i) and glucagon-like peptide-1 (GLP-1) receptor agonists have been introduced as novel antidiabetic agents, but their potential health impact in the US is unknown. We assessed the number of potentially eligible type 2 diabetes (T2D) patients, as well as projected changes in death and complication rates for nationwide use. Methods: Based on inclusion criteria of SGLT2i and GLP-1 receptor agonist RCTs, we determined eligibility in a weighted sample of 69.2M T2D patients from 2007-2014 National Health and Nutrition Examination Survey (NHANES) data. We employed a validated microsimulation model based on the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial to simulate virtual life courses of eligible US patients. Pooled hazard ratios from meta-analyses of published RCTs were applied to model death and non-fatal adverse event rates with SGLT2i and GLP-1 receptor agonist use. Results: The proportion eligible in NHANES was 9.2% (95% CI 7.3-11.1), which translates into ~6.4M US adults. Simulated 10-year mortality (32.5%) decreased by 4.6% (95% CI 2.7-7.3) with SGLT2i and by 2.9% (95% CI 1.6-4.8) with GLP-1 receptor agonists. Mean life expectancy was 16.5 y, and increased by 1.3 y (95% CI 0.6-2.2) with SGLT2i and by 0.8 y (95% CI 0.4-1.5) with GLP-1 receptor agonists. With SGLT2i, lifetime heart failure risk decreased by 7.4% (95% CI 4.1-12.3) and end-stage renal disease (ESRD) risk decreased by 0.4% (95% CI -0.1-0.9). Improvements in these event risks were uncertain with GLP-1 receptor agonist use (Figure). With lifetime SGLT2i use, fracture risk increased from 16.9 to 22.4% (95% CI of Δ 2.5-9.6) and amputation risk rose from 5.7 to 11.2% (95% CI of Δ 2.3-9.5). Conclusions: Nationwide use of SGLT2i or GLP-1 receptor agonists may save over 8 or 5M life years, respectively. Moreover, SGLT2i may avoid over 470K new cases of heart failure and over 28K ESRD cases. Further research should illuminate whether these benefits outweigh additional costs and harms.

Survival probabilities of end stage renal disease patients on renal replacement therapy in Iran.

To bridge the gap in the current knowledge, the present study was conducted to obtain evidences relating to clinical outcomes of the end-stage renal disease (ESRD) population in Iran over the last two decades. The records of 84652 incident ESRD patients from 1995 up to and including 2014 in the national registry of ESRD patients were analyzed retrospectively. Data were collected from dialysis and transplant centres in Iran from 1995 to 2008 via paper forms and from 2009 to 2014 through web-based records. Mean age (SD) in incident cases of ESRD (57.7% male) was 52.5 (16.6) years. The prevalence of ESRD patients grew on average 14.9% and 5.3% annually in the periods of 1995-2004 and 2005-2014, respectively. Adjusted mortality rate among dialysis patients in 1995, 2005, and 2014 was 145, 154, and 177/ 1000 patient-years, respectively. Median graft half-life (IQR) and median expected remaining life-years (IQR) for dialysis patients in the 2003 incident patient cohort were 4.4 (1.9-8.3) and 4.2 (1.8-8.2) years, respectively. The overall slightly decreasing, and still comparable, survival trend in dialysis patients, despite the accessible and free dialysis treatment, may be the result of the counterbalance of different contributory factors, including increased age and the higher proportion of patients with co-morbidities resulting from diabetes and hypertension. The half-lives of renal allografts were generally shorter compared to thus far shared evidence, which may be due to tissue incompatibility. The decreasing trend, in this context, can be attributable to the increased number of transplantation from deceased donors with expanded criteria.

Epidemiology of primary systemic vasculitis in children: a population-based study from southern Sweden

Objectives: To estimate the annual incidence rate of paediatric primary systemic vasculitis (PSV) in a defined geographical area in southern Sweden.Methods: Potential cases of PSV [IgA vasculitis (IgAV, Henoch–Schönlein purpura), Kawasaki disease (KD), granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), eosinophilic granulomatosis with polyangiitis (EGPA), polyarteritis nodosa (PAN), and Takayasu’s arteritis (TAK)] were identified in a comprehensive regional healthcare register. The study area is Skåne, the southernmost county of Sweden (population 1.29 million; 21.4% aged <18 years). Case records for children (0–17 years) assigned a diagnosis code between M300 and M319 and/or D690 were reviewed to ascertain diagnosis. Only patients diagnosed between 2004 and 2014 were included.Results: In total, 556 patients with PSV were identified. The annual incidence rate per million children (95% confidence interval) was estimated to be 200 (183–217) for all PSV, 175.5 for IgAV (160–191), 20.1 for KD (14.9–25.4), 1.4 (0–2.8) for each of GPA and MPA, 0.7 (0–1.7) for PAN, and 0.4 (0–1.1) for each of EGPA and TAK. Among children aged <10 years, 99.5% of cases were either IgAV or KD, both exhibiting a seasonal pattern paralleling infections. There were no deaths, but three cases of end-stage renal disease were noted, all in MPA.Conclusions: Vasculitis is relatively common during childhood. Mild cases associated with the infection season are most common in the youngest age groups, while during adolescence a substantial proportion has more severe forms of vasculitis.

DETECTION SINGLE NUCLEOTIDE POLYMORPHISMS IN UROMODULIN PROMOTER REGION ASSOCIATED WITH RENAL DISEASES USING SINGLE-STRAND CONFORMATION POLYMORPHISM-POLYMERASE CHAIN POLYMORPHISMS TECHNIQUE

Objective: The uromodulin, a glycoprotein, expressed and secreted by epithelial kidney cells lining the thick ascending limb of the Henle’s loop. It is encoded by the UMOD gene in humans. Our objective was to analyze single nucleotide polymorphisms (SNPs) in the UMOD promoter region in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD).Methods: The blood samples were collected from 100 patients with CKD (50) and ESRD (50), who admitted at Merjan Teaching Hospital in Babylon Province, Iraq (February-July 2016). In addition, 50 blood samples of healthy control. The SNPs of UMOD promoter region was investigated using single-strand conformation polymorphism-polymerase chain polymorphisms (SSCP-PCR) and DNA sequencing techniques.Results: UOMD promoter region polymorphisms using PCR-SSCP and sequencing DNA appeared three different conformational haplotypes, including A\G 49 haplotype (5 bands), A\G 49 and C\A 247 haplotype (5 bands), and C\G 45 and A\G 49 haplotype (6 bands) distributed among CKD and ESRD cases, due to the presence of three SNPs. There was no association between band numbers of PCR-SSCP with ESRD and CKD compared with a control group.Conclusion: SSCP-PCR is a good screening method to detect genetic variations in an uromodulin promoter region.

DETECTION SINGLE NUCLEOTIDE POLYMORPHISMS IN UROMODULIN PROMOTER REGION ASSOCIATED WITH RENAL DISEASES USING SINGLE-STRAND CONFORMATION POLYMORPHISM-POLYMERASE CHAIN POLYMORPHISMS TECHNIQUE

Objective: The uromodulin, a glycoprotein, expressed and secreted by epithelial kidney cells lining the thick ascending limb of the Henle’s loop. It is encoded by the UMOD gene in humans. Our objective was to analyze single nucleotide polymorphisms (SNPs) in the UMOD promoter region in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD).Methods: The blood samples were collected from 100 patients with CKD (50) and ESRD (50), who admitted at Merjan Teaching Hospital in Babylon Province, Iraq (February-July 2016). In addition, 50 blood samples of healthy control. The SNPs of UMOD promoter region was investigated using single-strand conformation polymorphism-polymerase chain polymorphisms (SSCP-PCR) and DNA sequencing techniques.Results: UOMD promoter region polymorphisms using PCR-SSCP and sequencing DNA appeared three different conformational haplotypes, including A\G 49 haplotype (5 bands), A\G 49 and C\A 247 haplotype (5 bands), and C\G 45 and A\G 49 haplotype (6 bands) distributed among CKD and ESRD cases, due to the presence of three SNPs. There was no association between band numbers of PCR-SSCP with ESRD and CKD compared with a control group.Conclusion: SSCP-PCR is a good screening method to detect genetic variations in an uromodulin promoter region.

Uric Acid and Diabetic Nephropathy Risk.

Diabetic nephropathy (DN) is the leading cause of end-stage renal disease (ESRD) in the western world. Current treatment methods, with better control of glycemia and blood pressure, including renin-angiotensin system blockade (RASB), appear to have slowed the DN progression rate but have not substantially decreased the annual incidence of new DN ESRD cases. Thus, new treatment targets are needed. Higher levels of serum uric acid (UA) are associated with increased risk of the clinical manifestations of DN in persons with types 1 and 2 diabetes. Also, UA is a strong predictor of DN progression. Two small, short-term, proof-of-concept clinical trials in which a minority of the patients had diabetes suggested that reduction of UA with allopurinol could decrease the rate of glomerular filtration rate (GFR) loss in persons with chronic kidney disease (CKD). However, a definitive trial to check whether UA reduction can benefit DN progression has not been conducted as yet. Preventing Early Renal Loss in Diabetes (PERL) is an ongoing trial in persons with type 1 diabetes and early to moderate GFR reduction. This 3-year randomized placebo controlled trial in 530 subjects is to check whether UA reduction with allopurinol can slow the rate of GFR decline as determined by the plasma disappearance of iohexol. Key Message: If the results of the PERL trial are positive, initiation of UA reduction treatment while GFR is relatively well preserved could delay ESRD in DN by 8-10 years, that is, considerably longer than the period that has been demonstrated for RASB. This could have important implications for the treatment of DN in particular and of CKD in general.

Incidence of End-Stage Renal Disease in Patients With Type 1 Diabetes.

To investigate how risk of end-stage renal disease (ESRD) among patients with type 1 diabetes has changed over time and further how the risk is affected by age, sex, and time period of diagnosis of diabetes. A cohort including all patients <30 years old diagnosed with type 1 diabetes in Finland in 1965-2011 was followed until start of renal replacement therapy, death, or end of follow-up at the end of 2013. Altogether, 29,906 patients were included. The main outcome was cumulative risk of ESRD, accounting for death as a competing risk. The patients were followed up for a median of 20 years. During 616,403 patient-years, 1,543 ESRD cases and 4,185 deaths were recorded. The cumulative risk of ESRD was 2.2% after 20 years and 7.0% after 30 years from the diabetes diagnosis. The relative risk of ESRD was 0.13 (95% CI 0.08-0.22) among patients diagnosed in 1995-2011 compared with those diagnosed in 1965-1979. Patients <5 years old at the time of diagnosis had the lowest risk of ESRD after diagnosis. With the cumulative risk of ESRD estimated from time of birth, the patients aged 5-9 years at diabetes diagnosis were at highest risk. The cumulative risk of ESRD has decreased markedly during the past five decades. This highlights the importance of modern treatment of diabetes and diabetic nephropathy.

Danggui Shaoyao Powder Improves Diabetic Nephropathy without Altering Blood Glucose in Streptozotocin-Induced Diabetic Rats

Objectives Diabetic nephropathy (DN) is one of the most severe diabetic complications and is becoming a worldwide epidemic, accounting for approximately one-third of all cases of end-stage renal disease. In this study, we investigated its influence on Th1/Th2 cells balance, inflammation and lipid metabolism to assess whether Danggui Shaoyao Powder (DSS) ameliorates DN. Methods Wistar rats were randomly divided into control group, model group, DSS group and benazepril group. The model group was induced by injection intraperitoneally with streptozotocin after high-calorie foods were given for 1 month. Animals were treated orally with saline, DSS and benazepril daily for 8 weeks. At the end of 8 weeks, blood glucose, 24 hour urinary protein (24 hour UPr), creatinine clearance rate (Ccr), total cholesterol (TC), triglyceride (TG), low-density lipoprotein (LDL), high-density lipoprotein (HDL), serum levels of interferon (IFN)-gamma, tumour necrosis factor (TNF)-alpha, interleukin (IL)−4, and IL-10 were measured. Glomerular morphology was observed by light microscopy. Results Compared with rats in the control group, rats in the DN group had significantly increased 24 hour UPr, Scr, blood lipids and pro-inflammatory cytokines IFN-gamma and TNF-alpha secreted by Th1 cells. In addition, down-regulation of the proportion of Th2 cells and decrease of the anti-inflammatory cytokines IL-4 and IL-10 secreted by Th2 cells occurred. Compared with the model group, the DSS group had significantly decreased levels of 24 hour UPr, Scr, TC, TG, LDL, IFN-gamma and TNF-alpha, and increased IL-4 and IL-10. The renal pathological changes in the DSS treatment group were ameliorated. Conclusion This study suggests that DSS could improve renal function in streptozotocin-induced DN model rats. The mechanism may be related to regulating the Th1/Th2 cell balance and improved lipid metabolism in DN rats. Acknowledgment Supported by a project grant from The National Natural Science Foundation of China (Grant No. 81603527), Science and technology project of Henan Province (Grant No. 162102310466), Key scientific research projects of Henan Province Colleges and Universities (Grant No. 16A360010), Henan University of Traditional Chinese Medicine Scientific and technological innovation talent support program (Grant No. 2015XCXRC05), Science and technology project of Zhengzhou City (Grant No. 20150310).

Variability in Total Cholesterol Is Associated With the Risk of End-Stage Renal Disease: A Nationwide Population-Based Study.

Recent data suggest that visit-to-visit variability of cholesterol is associated with cardiovascular events. We evaluated the role of lipid variability as a determinant of end-stage renal disease (ESRD). Using nationally representative data from the Korean National Health Insurance System, 8 493 277 subjects who were free of ESRD and who underwent ≥3 health examinations during 2005 to 2010 were followed to the end of 2015. Total cholesterol (TC) variability was measured using the coefficient of variation, SD, and the variability independent of the mean. The primary outcome was the development of ESRD, defined as a combination of the relevant disease code and the initiation of renal replacement therapy. There were 11 247 cases of ESRD during a median follow-up of 6.1 years. There was a graded association between a higher TC variability and incident ESRD. In the multivariable adjusted model, the hazard ratios and 95% confidence intervals comparing the highest versus lowest quartiles of coefficient of variation of TC were 2.66 (95% confidence interval, 2.52-2.82). The results were consistent when the variability of TC was modeled using SD and variability independent of the mean and were independent of preexisting chronic kidney disease. Increasing TC variability was associated with an increasing incidence of ESRD.

Polycystic Kidney Disease.

Renal cysts, which arise from renal tubules, can be seen in a variety of hereditary and nonhereditary entities. Common mechanisms associated with renal cyst formation include increased cell proliferation, epithelial fluid secretion, and extracellular matrix remodeling. Hereditary polycystic kidney disease (PKD) is seen as a component of numerous diseases. Autosomal dominant (AD) PKD is the most common potentially fatal hereditary disease in humans, causes renal failure in approximately 50% of affected individuals, and accounts for approximately 5% of end stage renal disease cases in the United States. ADPKD is caused by mutation in one of two genes-85% of cases are caused by mutation in PKD1 on chromosome 16 and 15% of cases are caused by mutation in PKD2 on chromosome 4. Polycystin-1, encoded by PKD1, is a large protein, has multiple transmembrane spanning domains, has extracellular regions suggesting a role in cell-cell or cell-matrix interactions, has intracellular domains suggesting a role in signal transduction, and can physically interact with Polycystin-2. Polycystin-2 is smaller, has transmembrane domains, can act as a cation channel with calcium permeability, and may be regulated by Polycystin-1. These proteins, and many others associated with cystic kidney disease, localize to primary cilia, which may act as flow sensors in the kidney; cystic kidney diseases have also been termed ciliopathies. An increasing number of intracellular mechanisms, which are abnormally regulated in PKD, have been described and are potential targets for therapy, which is lacking in this common hereditary disease. © 2017 American Physiological Society. Compr Physiol 7:945-975, 2017.

Main determinants of tunneled cuffed catheters infection in hemodialysis patients

Introduction: Despite all efforts to prevent tunneled-cuffed catheter (TCC) infection, the incidence of this infection has remained considerably high. Objectives: The present study aimed to assess risk determinants affecting TCC infection in hemodialysis patients. Patients and Methods: This case-control study was performed on 165 consecutive patients as known cases of end-stage renal disease on maintenance hemodialysis through double-lumenTCC. The patients were assigned into two groups as the case group with the clinical evidences of TCC infection and the control group with noninfectious condition. Results: In the group with TCC infection, the most common microorganisms cultured in the medium included Staphylococcus aurous and Staphylococcus epidermidis with the overall prevalence of 17.6% and 15.3% in blue lumen and 14.1% and 14.1% in red lumen, respectively. Overall, 75.3% of the lumens were positive for infection, while 52.9% of blood cultures were positive. Multivariable logistic regression modeling showed that female gender, insertion catheter through jugular vein, higher C-reactive protein (CRP) level, lower serum iron level and higher serum ferritin level could predict TCC infection in dialysis patients. According to ROC curve analysis, measuring CRP level, serum iron and serum ferritin could effectively discriminate TCC infection from noninfectious condition. Particularly, serum CRP >16 mg/ dL, ferritin > 200 ng/mL and serum iron <40 mg/dL could predict TCC infection. Conclusion: Around 75% of samples extracted from catheter lumens are positive for TCC infection. The main determinants of TCC infection included female gender, insertion catheter by jugular vein, higher CRP level, lower serum iron level, and higher serum ferritin level.

ESRD After Heart Failure, Myocardial Infarction, or Stroke in Type 2 Diabetic Patients With CKD

How cardiovascular (CV) events affect progression to end-stage renal disease (ESRD), particularly in the setting of type 2 diabetes, remains uncertain. Observational study. 4,022 patients with type 2 diabetes, anemia, and chronic kidney disease from the Trial to Reduce Cardiovascular Events With Aranesp Therapy (TREAT). Postrandomization CV events. ESRD (defined as initiation of dialysis for >30 days, kidney transplantation, or refusal or nonavailability of renal replacement therapy) and post-ESRD mortality within 30 days and during overall follow-up after an intercurrent CV event. Population limited to clinical trial participants with diabetes and anemia. 155 of 652 (23.8%) ESRD cases occurred after an intercurrent CV event; 110 (16.9%) cases followed heart failure, 28 (4.3%) followed myocardial infarction, 12 (1.84%) followed stroke, and 5 (0.77%) followed multiple CV events. ESRD rate was higher within 30 days in individuals with an intercurrent CV event compared with those without an intercurrent event (HR, 22.2; 95% CI, 17.0-29.0). Compared to no intercurrent CV events, relative risks for ESRD were higher after the occurrence of heart failure overall (HR, 3.4; 95% CI, 2.7-4.2) and at 30 days (HR, 20.1; 95% CI, 14.5-27.9) than after myocardial infarction or stroke (P<0.001). Compared withindividuals without pre-ESRD events, those with ESRD following intercurrent CV events were older, were more likely to have prior CV disease, and had higher (24.4 vs 23.1mL/min/1.73m2; P=0.01) baseline estimated glomerular filtration rates (eGFRs) and higher eGFRs at last measurement before ESRD (18.6 vs 15.2mL/min/1.73m2; P<0.001), whereas race, sex, and medication use were similar. Post-ESRD mortality was similar (P=0.3) with and without preceding CV events. Most ESRD cases occurred in individuals without intercurrent CV events who had lower eGFRs than individuals with intercurrent CV events, but similar post-ESRD mortality. Nevertheless, intercurrent CV events, particularly heart failure, are strongly associated with risk for ESRD. These findings underscore the need for kidney-specific therapies in addition to treatment of CV risk factors to lower ESRD incidence in diabetes.

Prehypertension among 2.19 million adolescents and future risk for end-stage renal disease.

Persistent hypertension in adulthood is a leading cause of end-stage renal disease (ESRD). Whether lower blood pressure (BP) values, in the range of prehypertension, are also associated with future occurrence of ESRD is unclear. Even less clear is the potential risk of early prehypertension appearing in adolescence. To address this question, we examined whether BP measurements in the prehypertensive range at age 16-19 years predict adult ESRD. Medical data on 2194 635 16-19-year-old adolescents examined for medical fitness prior to military service from 1977 to 2013 were linked to the Israeli ESRD registry in this nationwide population-based cohort study. Incident cases of ESRD were recorded. Survival models were applied. During 35 007 506 person-years of follow-up (median follow-up 16.8 years), there were 690 ESRD cases, with an overall incidence rate of 1.97 cases per 100 000 person-years. Examinees with elevated BP readings in the prehypertensive range (BP between the 90th and 95th percentiles or between 120 and 139/80-89 mmHg) had increased incidence of ESRD with a hazard ratio of 1.32 (95% confidence interval, 1.11-1.58) adjusted for year of birth, age at examination, sex, BMI, education, socioeconomic status, and country of origin. Hypertension (BP above the 95th percentile or above 140/90 mmHg) was associated with a hazard ratio of 1.44 (95% confidence interval, 1.17-1.79). A spline model demonstrated a nadir of risk at SBP values as low as 94 mmHg. Asymptomatic, healthy adolescents with prehypertension have a 32% increased risk for subsequent ESRD, compared with adolescents with optimal BP.

Randomised controlled trial of prolonged treatment in the remission phase of ANCA-associated vasculitis

ObjectivesA prospective randomised trial to compare two different durations of maintenance immunosuppressive therapy for the prevention of relapse in anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV).MethodsPatients with AAV were recruited 18–24...

Systematic review of mixed cryoglobulinemia associated with hepatitis E virus infection: association or causation?

Background and aim: Mixed cryoglobulinemia (MC) has been associated with several viral infections, and chronic hepatitis C is recognized as a major cause. MC associated with hepatitis E virus (HEV) has been described and little is known about this rare association. The aim of this study is to perform a systematic review of MC associated with HEV, and examine the presence of a causal relationship. Methods: An experienced librarian conducted a search of databases from each database’s inception to 12 December 2016 based on a priori criteria. The risk of bias was assessed, and Hill’s criteria were applied to determine causality. Results: Five publications met inclusion criteria, with a total of 15 cases. Three studies had low, one low to moderate and one moderate risk of bias. Median age was 43 years, and all patients came from Western Europe. Two patients were immunocompetent, while 13 were immunosuppressed, post solid organ transplant and had chronic hepatitis E. Renal involvement was observed in seven patients, mild to moderately severe cryoglobulinemic disease in one patient and severe cryoglobulinemic disease in three patients. One patient improved spontaneously, and another was treated with immunosuppressant reduction leading to viral clearance. Ten patients treated with peg-interferon or ribavirin for 3 months achieved loss of cryoglobulinemia and end-of-treatment response, but sustained virologic response was reported and achieved in two. Immunosuppressant achieved loss of cryoglobulinemia in three patients. One case of chronic renal failure, three cases of end-stage renal disease and one death were observed. Five of the nine Hill’s criteria were fulfilled. Conclusion: MC has been described with HEV infection. A causal relationship between HEV infection and cryoglobulinemia is highly probable.

Increased body mass index is a risk factor for end-stage renal disease in the Chinese Singapore population

The relationship between body mass index (BMI) and end-stage renal disease (ESRD) is confounded by co-morbidities associated with both conditions. Furthermore, the association at low range BMI is controversial. We studied this association in the Singapore Chinese Health Study, a population-based prospective cohort that recruited Singaporean Chinese men and women 45-74 years of age from 1993 to 1998. Self-reported weight, height, lifestyle factors, usual diet, and medical history were collected viaan interviewer-administered questionnaire. Incident ESRDcases were identified via record linkage with the nationwide ESRD registry. The computed Cox proportional hazard regression was adjusted for potential risk factors. After an average follow-up of 15.5 years, 827 incident ESRD cases were identified. Compared with a normal BMI of 18.5 to under 23 kg/m2, the hazard ratios and (95% confidence intervals) of ESRD risk for BMIs under 18.5, 23 to under 27.5, and 27.5 kg/m2 or more were 0.54 (0.37-0.79), 1.40(1.20-1.64) and 2.13 (1.74-2.59), respectively. This significantly trended, linear, dose-dependent association was only present among those with no history of diabetes, hypertension, coronary heart disease, and stroke at baseline, but not significantly among those with any of these co-morbidities. Thus, BMI itself isarisk factor for ESRD in the general population and thisassociation is present in those without pre-existing diabetes, hypertension, coronary heart disease, and stroke.