Chronic End-stage Renal Disease Research Articles

MO765: Should We have to Create A Proximal Fistula in First Instance for Patients ≥75 Years Old?

Abstract BACKGROUND In France, the Network Epidemiology and Information in Nephrology evaluated the incidence of cases of chronic end-stage renal disease (ESRD), treated by dialysis, of patients aged ≥75 years at 39.8% (2015). Timely placement and development of functional fistulas for haemodialysis remain difficult logistical problems along with their high failure rate. Cardiovascular (CV) morbidity-mortality increases when patients initiate catheter-based treatment. The recommendations call for a glomerular filtration rate (GFR) between 15 and 30 mL/min/1.73m² (EBPG 2007 and Canadian 2006) to implement a fistula. The older the patients, the more the quality of the venous network deteriorates. In this population, clinicians face a simple problem: creating a too early fistula and preparing patients for an adequate supply. The surgery of vascular approaches tries to avoid two pitfalls: ‘too much to preserve’ the vascular capital, ‘too much to privilege’ the permeability of the first by creating proximal approaches (Barrou B.). The guidelines [Kidney Disease Outcomes Quality Initiative (K/DOQI) 2006] recommend the most distal vascular approach possible. Since 2016, CKD patients aged ≥75 years, have been implanted with arteriovenous fistula (native or prosthetic), localized in the first line of the humero-cephalic vein, huméro-basilique, or humero-axillary. Our primary objective is to assess primary permeability in a population of patients aged ≥75 years with stage IV/V chronic kidney disease (CKD) after the first-line proximal fistula. METHOD All patients aged ≥75 years for which a first-line proximal VA was created between 1 January 2016 and 31 December 2019 have been retrospectively reviewed in an observational study. They were followed for 12 months. A quarterly compilation of data has been produced. RESULTS A total of 31 patients (74% of men) benefit from the creation of a native fistula (90.3%) or prosthetic. During follow-up, 8 patients were excluded. 29% of patients had started catheter haemodialysis treatment prior to the creation of their first fistula. A total of 7 changed fistula from initial surgery during the study, of which 2 after the first use. At the creation of the vascular access, the median age of patients is 81 years, of which 35.5% have vascular nephropathy and 19.4% have diabetic nephropathy. The location of the anastomosis is as follows: 84% FAV brachiocephalic, 10% FAV brachiobasilic and 6% FAV axillary. At 12 months, 16 patients were still under observation. A total of 5 patients had thrombosis of their VA (80% of native fistulas). The average interval between the creation of the first, and the thrombosis is 2.18 months. Patients dialyzed with VA were 68%. On a scale from 0 (no difficulty) to 10 (puncture not performed), the average difficulty score of the first puncture is 2.2. The average time in the day between the first puncture and first ‘effective’ dialysis on the first 13.9 days and the average weekly duration of dialysis at the first effective puncture is 11.29 hours. There are 28 hospitalizations, 21% of which are related to VA, 37 ultrasound, 9 angiography and 4 surgical repairs were performed on VA. Only one ischaemia of the hand is observed, treated medically. Estimates of the risk of thrombosis associated with diabetes are confirmed [P = 0.02; 95% confidence interval (95%CI); hazard ratio (HR): 0.054–0.332]. At 12 months, 94% of the surroundings are permeable without any thrombosis. CONCLUSION This study confirms the interest in a proximal vascular approach in people aged ≥75. We have voluntarily included patients from the creation of their VA and for the majority before the time of starting haemodialysis. The average age is high in a high-risk epidemiological context (HTA, diabetes) and the number of early deaths (16%). The quality of the surroundings is confirmed by the percentage of native fistula at nearly 90% in accordance with the guidelines. The surgical team is motivated and sensitized in this collaborative project. A total of 52% of patients remained in observation at M12 and 94% had a permeable first with satisfactory dialysis quality. These results are encouraging and require a broader multicentre prospective and comparative study like other problems in managing vascular access for haemodialysis.

La calciphylaxie urémique

Uremic calciphylaxis is a rare disease that affects patients with chronic end-stage renal disease. It is a pathology of the microvessels of the dermis and hypodermis which are calcified and whose thrombosis leads to skin necrosis. Calciphylaxis lesions can be distal and axial. They lead to pain, infection and are associated with denutrition and in high mortality rate (40–80% at 1 year). This general review describes the clinical and para-clinical presentations of calciphylaxis. It summarizes the current knowledge on its pathogenesis and the therapeutical options that can be proposed to improve the management and attempt to reduce the mortality of patients with uremic calciphylaxis.

Uremic Pruritus: From Diagnosis to Treatment.

Uremic pruritus, or chronic kidney disease-associated pruritus, is common, bothersome, and sometimes debilitating in patients with chronic kidney disease or end-stage renal disease. Due to its variable clinical manifestations, the diagnosis of uremic pruritus requires exquisite evaluation. Excluding itch resulting from other dermatological causes as well as other systemic conditions is essential for a proper diagnosis. The pathophysiology of uremic pruritus remains uncertain. Hypotheses including toxin deposition, immune system dysregulation, peripheral neuropathy, and opioid imbalance are supposed. This review summarizes the way to accurately diagnose uremic pruritus and describes the latest treatment options.

Outcomes in Patients With Chronic Kidney Disease and End-stage Renal Disease and Durable Left Ventricular Assist Device: Insights From the United States Renal Data System Database

BackgroundThere is paucity of data regarding durable left ventricular assist device (LVAD) outcomes in patients with chronic kidney disease (CKD) stages 3–5 and CKD stage 5 on dialysis (end-stage renal disease [ESRD]). Methods and ResultsWe conducted a retrospective study of Medicare beneficiaries with ESRD and a 5% sample of patients with CKD with an LVAD (2006–2018) to determine 1-year outcomes using the United States Renal Data System database. The LVAD implantation, comorbidities, and outcomes were identified using appropriate International Classification of Diseases, 9th and 10th edition codes. We identified 496 patients with CKD and 95 patients with ESRD who underwent LVAD implantation. The patients with ESRD were younger (59 years vs 66 years; P < .001), had more Blacks (40% vs 24.6%, P = .009), compared with the CKD group. The 1-year mortality (49.5% vs 30.9%, P < .001) and index mortality (27.4% vs 16.7%, P = .014) rates were higher for patients with ESRD. A subgroup analysis showed significantly higher mortality in ESRD vs CKD 3 (49.5% vs 30.2%, adjusted P = .009), but no significant difference in mortality between stage 3 vs 4/5 (30.2% vs 30.8%, adjusted P = .941). There was no significant difference in secondary outcomes (bleeding, stroke, and sepsis/infection) during follow-up between the 2 groups. ConclusionsPatients with ESRD undergoing LVAD implantation had significantly higher index and 1-year mortality rates compared with patients with CKD.

Outcomes of axillofemoral and aortofemoral bypass for intermittent claudication may be similar

Despite almost 40 years of experience with axillofemoral grafts, there remains an absence of clear guidelines for their use, especially in treating intermittent claudication (IC). This motivated Levin et al1Levin S.R. Farber A. King E.G. Beck A.W. Osborne N.H. DeMartino R.R. et al.Outcomes of axillofemoral bypass for intermittent claudication.J Vasc Surg. 2021; 75: 1687-1694Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar to examine the Vascular Quality Initiative (VQI) database to evaluate the appropriateness of axillofemoral bypass for IC. Although apparently their aim was not to compare axillofemoral bypass data with aortofemoral bypass grafts, much of their paper is devoted to such a comparison. On the basis of this evaluation, they first conclude that axillofemoral bypass is associated with significant perioperative morbidity, mortality, and long-term complications, and second, serious consideration should be given before its use for IC. Critical review posits that their second conclusion is correct and admirable, but the first may not be entirely accurate. In assessing an operative technique that involves a bypass graft, all preoperative, intraoperative, and postoperative variables and outcomes need to be considered to determine its efficacy and clinical benefit. Although the VQI is a formidable database, concerning axillofemoral bypass many confounding factors were not recorded. These include the status of the donor subclavian/axillary artery, the use of heparin surfaced grafts, postoperative surveillance protocols, and interventions to maintain patency of the donor artery. Indeed, recent papers2Samson R.H. Showalter D.P. Lepore M.R. Nair D.G. Dorsay D.A. Morales R.E. Improved patency after axillofemoral bypass for aortoiliac occlusive disease.J Vasc Surg. 2018; 68: 1430-1437Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar,3Hardouin S. Cheng T.W. Farber A. Kalish J.A. Jones D.W. Malas M.B. et al.Axillarybifemoral and axillary-unifemoral artery grafts have similar perioperative outcomes and patency.J Vasc Surg. 2020; 71: 862-868Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar have demonstrated excellent patency rates when heparin-bonded axillofemoral polytetrafluoroethylene grafts had been used or with axillary arteries that were proven normal or endovascularly treated to be, or remain, an acceptable donor vessel. Further, it is critical that if axillofemoral grafts are compared with the "gold standard" aortofemoral procedures, variables must be equivalent. In this report, patients undergoing axillofemoral grafts were more often older, female, had noncommercial insurance, ambulated with assistance, had a previous inflow bypass, ipsilateral leg bypass, peripheral endovascular intervention, and major amputation. Further, they were more often hypertensive, more likely to have coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, diabetes, anemia, and end-stage renal disease (P < .05 for all). Despite these significant risk factors, axillofemoral bypass was accompanied by a shorter length of stay, fewer pulmonary and renal complications, and, assuming these results, possibly lower cost. Further, despite these morbidities, they did not suffer more postoperative medical complications or operative mortality. Extensive comorbidities may also explain the difference in survivors’ amputation rate (5.2% vs 2%) and graft occlusion (7% vs 3.6%). However, the latter difference may also result from failure to use the more current heparin-bonded polytetrafluoroethylene or dual antiplatelet and statin therapy. Further, researchers must be leery of combined end points where one of its constituents significantly outweighs the others. For example, the authors reveal that 1-year ipsilateral reintervention/amputation/death was more likely with axillofemoral grafts, yet it is notable that occlusion/death and amputation/death were similar between cohorts. What then is the takeaway? First, appropriately surgeons who enter data into the VQI are more likely to use axillofemoral bypass grafts for high-risk patients. Second, even aortofemoral bypass grafts have significant morbidity and mortality. Therefore, the authors’ conclusion is correct that serious consideration should be given before axillofemoral bypass for IC. However, this conservative approach applies equally to aortofemoral bypass procedures. The opinions or views expressed in this commentary are those of the authors and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery or the Society for Vascular Surgery. Outcomes of axillofemoral bypass for intermittent claudicationJournal of Vascular SurgeryVol. 75Issue 5PreviewAlthough endovascular therapy is often the first-line option for medically refractory intermittent claudication (IC) caused by aortofemoral disease, suprainguinal bypass is often performed. Although this will often be aortofemoral bypass (AoFB), axillofemoral bypass (AxFB) is still sometimes performed despite limited data evaluating its utility in the management of IC. Our goal was to assess the safety and durability of AxFB performed for IC. Full-Text PDF

Eplerenone inhibits UUO-induced lymphangiogenesis and cardiac fibrosis by attenuating inflammatory injury

Cardiorenal syndrome (CRS) is the leading cause of death associated with chronic kidney disease (CKD) and end-stage renal disease (ESRD). However, the underlying mechanisms of CRS are still poorly understood. Here, we studied a CKD model of unilateral ureteral obstruction (UUO) and observed pathological cardiac fibrosis and lymphangiogenesis in 180-day old UUO rats, in which inflammatory injury plays a major role. In addition, treatment of UUO rats with eplerenone, a mineralocorticoid receptor blocker (MRB), significantly reduced cardiac lymphangiogenesis and fibrosis. In conclusion, our experimental results showed that cardiac lymphangiogenesis in long-term UUO rats may be involved in the formation of cardiac fibrosis and that eplerenone can alleviate lymphangiogenesis and cardiac fibrosis by inhibiting inflammation.

Chronic Kidney Disease and Myocardial Infarction

The number of patients with chronic kidney disease (CKD) and end-stage renal disease is steadily growing. With the failure of kidney function, the risk of developing acute myocardial infarction (AMI) with severe coronary artery stenosis and hospital mortality is growing. Case management of CKD and AMI is a complicated task. This review reflects the distinctive features of the course of AMI in hemodialysis patients, patients with kidney transplantation, their diagnosis and treatment.

Comparison of the Quality of Sleep in Patients With Chronic Kidney Disease and End-Stage Renal Disease.

ObjectiveIn this study, we aimed to compare the quality of sleep between patients with (CKD) and those with end-stage renal disease (ESRD).MethodologyWe performed a cross-sectional study between August 2020 and January 2021. We included 240 patients, among which 178 (74.2%) were CKD patients and 62 (25.8%) were ESRD patients on maintenance hemodialysis (MHD). Demographic data were collected on a pre-designed proforma. The quality of sleep was evaluated using the Pittsburgh Sleep Quality Index (PSQI). PSQI assesses subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction. A PSQI score >5 indicates poor sleep quality.ResultsOut of the 240 patients, 159 (66%) had poor sleep quality. We found a significant difference in mean PSQI scores between CKD and ESRD patients (9.6 ± 12.4 vs. 11.4 ± 3.9 respectively), indicating poorer sleep quality in ESRD patients as compared to those with CKD (p<0.001). In our study, among all comorbidities, poor sleep was significantly associated with ischemic heart disease (IHD) (p = 0.025), after adjusting for confounding factors.ConclusionsOur study showed that two-thirds of the study population had poor sleep quality. ESRD patients suffered from more disturbed sleep as compared to CKD patients.

MicroRNA-214-3p aggravates ferroptosis by targeting GPX4 in cisplatin-induced acute kidney injury.

Acute kidney injury (AKI) induced by cisplatin (cis-AKI) involves indicators such as inflammation and oxidative stress (OS) in proximal tubules, although its underlying mechanisms remain largely unknown so far. Exploration of the molecular mechanisms underlying cisplatin-induced AKI is of great significance for AKI prevention and also for preventing its progression into chronic kidney disease (CKD) or end-stage renal disease (ESRD). OS and ferroptosis are mutually causal; they finally lead to the regulatory cell injury and death induced by the accumulation of reactive oxygen species (ROS). GPX4 is critical not only in OS, but studies established as the key regulator of ferroptosis. In this context, the present study focused on determining the biological function of miR-214-3p in the cisplatin-induced ferroptosis of tubular epithelial cell (TEC) and the underlying molecular mechanism. The relationship between TEC ferroptosis and cisplatin-induced AKI was investigated in vitro and in vivo. Ferrostatin-1(Fer-1), an inhibitor of ferroptosis, was observed to confer a protective effect against the renal tubular injury and renal failure induced by cisplatin. MicroRNAs (miRNAs) regulate the genes that have important functions in the development of cis-AKI. In the present study, GPX4 was predicted as a target of miR-214-3p. Moreover, inhibiting miR-214-3p enhanced the expressions of GPX4 and SLC7A11 while decreasing the ACSL4 expression. Furthermore, miR-214-3p down-regulation protected against TEC death and renal tubule damage both in vitro and in vivo. According to these findings, inhibiting miR-214-3p would alleviate TEC ferroptosis in cis-AKI via GPX4.

Interleukin-22 in Renal Protection and Its Pathological Role in Kidney Diseases.

Chronic kidney injury has gradually become a worldwide public health problem currently affecting approximately 10% of the population and can eventually progress to chronic end-stage renal disease characteristic by the result of epithelial atrophy. Interleukin-22 (IL-22) is a cytokine produced by activated immune cells, while acting mainly on epithelial cells ranging from innate immune response to tissue regeneration to maintain barrier integrity and promote wound healing. Accumulating data suggests that IL-22 has emerged as a fundamental mediator of epithelial homeostasis in the kidney through promoting tissue repair and regeneration, inhibiting oxidative stress, and producing antimicrobial peptides. Binding of IL-22 to its transmembrane receptor complex triggers janus kinase/tyrosine kinase 2 phosphorylation, which further activates a number of downstream cascades, including signal transducer and activator of transcription 3, MAP kinase, and protein kinase B, and initiates a wide array of downstream effects. However, the activation of the IL-22 signaling pathways promotes the activation of complement systems and enhances the infiltration of chemokines, which does harm to the kidney and may finally result in chronic renal failure of different autoimmune kidney diseases, including lupus nephritis, and IgA nephropathy. This review describes current knowledge of the basic features of IL-22, including structure, cellular origin and associated signaling pathways. Also, we summarize the latest progress in understanding the physiological and pathological effects of IL-22 in the kidney, suggesting the potential strategies for the specific application of this cytokine in the treatment of kidney disease.

Exuberant Scleral Calcification from Secondary Hyperparathyroidism

A 38-year-old man with chronic end-stage renal disease and secondary hyperparathyroidism presented with bilateral ocular inflammation. Visual acuity was 20/40 in the right eye and 20/60 in the left eye with normal intraocular pressure and full extraocular motility in both eyes. Examination was notable for keratoconjunctivitis and proptosis in both eyes. Testing revealed normal thyroid function and stimulating immunoglobulin levels, but elevated phosphate (12.4 mg/ml). Computed tomography was unremarkable for orbital inflammation yet demonstrated diffuse scleral calcification (Fig A-B) confirmed on ultrasonography (Fig C).

Transcriptome Analysis Reveal Candidate Genes and Pathways Responses to Lactate Dehydrogenase Inhibition (Oxamate) in Hyperglycemic Human Renal Proximal Epithelial Tubular Cells.

Diabetic kidney disease (DKD) is the leading cause of both chronic kidney disease (CKD) and end-stage renal disease (ESRD). Previous studies showed that oxamate could regulate glycemic homeostasis and impacted mitochondria respiration in a hyperglycemia-dependent manner in the rat proximal tubular cells. To explore the transcriptome gene expression profiling of kidney tissues in human renal proximal epithelial tubular cell line (HK-2), we treated HK-2 cells with high D-glucose (HG) for 7 days before the addition of 40 mM oxamate for a further 24 hours in the presence of HG in this study. Afterwards, we identified 3,884 differentially expressed (DE) genes based on adjusted P-value ≤ 0.05 and investigated gene relationships based on weighted gene co-expression network analysis (WGCNA). After qRT-PCR validations, MAP1LC3A, MAP1LC3B (P-value < 0.01) and BECN1 were found to show relatively higher expression levels in the treated groups than the control groups, while PGC1α (P-value < 0.05) showed the lower expressions. Accordingly, enrichment analyses of GO terms and KEGG pathways showed that several pathways [e.g., lysosome pathway (hsa04142) and p53 signaling pathway (hsa04115)] may be involved in the response of HK-2 cells to oxamate. Moreover, via WGCNA, we identified two modules: both the turquoise and blue modules were enriched in pathways associated with lysosome. However, the p53 signaling pathway was only found using all 3,884 DE genes. Furthermore, the key hub genes IGFBP3 (adjusted P-value = 1.34×10-75 and log2(FC) = 2.64) interacted with 6 up-regulated and 12 down-regulated DE genes in the network that were enriched in the p53 signaling pathway. This is the first study reporting co-expression patterns of a gene network after lactate dehydrogenase inhibition in HK-2 cells. Our results may contribute to our understanding of the underlying molecular mechanism of in vitro reprogramming under hyperglycemic stress that orchestrates the survival and functions of HK-2 cells.

Statin Therapy for Hyperlipidemic Patients With Chronic Kidney Disease and End-Stage Renal Disease: A Retrospective Cohort Study Based on 925,418 Adults in Taiwan.

Background: For non-dialysis patients with hyperlipidemia, statins may provide clinical benefits in reducing mortality risk; however, the optimal treatment for dialysis patients with hyperlipidemia remains debatable. We evaluated the mortality risks for hyperlipidemic patients with renal disorders associated with statin therapy (ST), using the insurance claims data of Taiwan. Methods: From hyperlipidemic patients diagnosed in 2000–2011, we identified 555,153 patients receiving statin treatment for at least 90 days continuously and 1,141,901 non-statin users, and then randomly selected, from both groups, the propensity score-matched subcohorts of statin users and nonusers in a 1:1 pair by renal function: 415,453 pairs with normal renal function , 43,632 pairs with chronic kidney disease (CKD), and 3,624 pairs with end-stage renal disease (ESRD). We compared the mortalities, by the end of 2016, from all causes, cancer, heart disease, and septicemia between statin users and non-users and between hydrophilic-statin users and lipophilic-statin users. The Cox method estimated ST users to non-user hazard ratios. The time-dependent model was also conducted as sensitivity analysis. Results: The mean ages were 58.7 ± 10.7, 64.2 ± 10.7, and 62.2 ± 10.8 years in normal renal function, CKD, and ESRD groups, respectively. Compared with non-users, statin users had reduced mortality risks from all causes for 32%–38%, from cancer for 37%–46%, from heart disease for 6%–24%, and from septicemia for 17%–21% in all three renal groups. The hydrophilic statin therapy was superior than the lipophilic statin therapy, particularly for reducing deaths from all-causes and cancer. The results under the time-dependent model were similar. Conclusion: Statin therapy is associated with reduced all-causes and non-cardiovascular mortality in ESRD patients.

Step length and fall risk in adults with chronic kidney disease: a pilot study

BackgroundPatients with chronic kidney disease commonly experience gait abnormalities, which predispose to falls and fall-related injuries. An unmet need is the development of improved methods for detecting patients at high risk of these complications, using tools that are feasible to implement in nephrology practice. Our prior work suggested step length could be such a marker. Here we explored the use of step length as a marker of gait impairment and fall risk in adults with chronic kidney disease.MethodsWe performed gait assessments in 2 prospective studies of 82 patients with stage 4 and 5 chronic kidney disease (n = 33) or end-stage renal disease (ESRD) (n = 49). Gait speed and step length were evaluated during the 4-m walk component of the Short Physical Performance Battery (SPPB). Falls within 6 months prior to or following enrollment were identified by questionnaire. Associations of low step length (≤47.2 cm) and slow gait speed (≤0.8 m/s) with falls were examined using logistic regression models adjusted for demographics and diabetes and peripheral vascular disease status.ResultsAssessments of step length were highly reproducible (r = 0.88, p < 0.001 for duplicate measurements at the same visit; r = 0.78, p < 0.001 between baseline and 3-month evaluations). Patients with low step length had poorer physical function, including lower SPPB scores, slower gait speed, and lower handgrip strength. Although step length and gait speed were highly correlated (r = 0.73, p < 0.001), one-third (n = 14/43) of patients with low step length did not have slow gait speed. Low step length and slow gait speed were each independently associated with the likelihood of falls (odds ratio (OR) 3.90 (95% confidence interval (CI) 1.05–14.60) and OR 4.25 (95% CI 1.24–14.58), respectively). Compared with patients who exhibited neither deficit, those with both had a 6.55 (95% CI 1.40–30.71) times higher likelihood of falls, and the number of deficits was associated with a graded association with falls (p trend = 0.02). Effect estimates were similar after further adjustment for ESRD status.ConclusionsStep length and gait speed may contribute additively to the assessment of fall risk in a general adult nephrology population.

Localized gastric amyloidosis in a patient diagnosed with Hodgkin lymphoma- A case report and review of literature

Gastrointestinal amyloidosis (GIA), a protein deposition disorder, has numerous etiologies and manifestations and poses a significant diagnostic and treatment challenge. GIA is either acquired or genetic, and it is most commonly caused by chronic inflammatory disorders (AA amyloidosis), hematologic malignancy (AL amyloidosis), and end-stage renal disease (Beta-2 amyloidosis). In AL amyloidosis, the amyloid forming protein is derived from the light chain component of a protein in the blood called monoclonal immunoglobulin. These light chains are produced by abnormal cells (known as plasma or B cells) found in the bone marrow. AL amyloidosis can be caused by abnormal light chains produced by lymphomas or chronic lymphocytic leukaemia(CLL) in rare cases. Hodgkin lymphoma has been found to be associated with systemic amyloidosis and particularly with renal amyloidosis with an incidence of less than 1%.Here we report a rare case of a 61-year old female patient who was previously diagnosed with Hodgkin lymphoma and underwent chemotherapy, now presented with anemia, dypnoea and was found to have a non healing ulcer in the body of the stomach. Histopathological examination revealed gastric amyloidosis which was confirmed with Congo red stain and apple green birefringence under polarized light.

Statins Reduce Hepatocellular Carcinoma Risk in Patients with Chronic Kidney Disease and End-Stage Renal Disease: A 17-Year Longitudinal Study.

Simple SummaryStatins are medicines used to treat patients with high lipid levels (hyperlipidemia). Studies have reported that patients undergoing statin therapy are at reduced risk of developing liver cancer. In this study, we compared the risk of developing liver cancer among hyperlipidemic patients with and without statin therapy in three patient groups classified by renal function: normal renal function (NRF) group, chronic kidney disease (CKD) not requiring dialysis, and dialysis-dependent end stage of real disease (ESRD). Our results showed that the risk of developing liver cancer increased progressively from NRF group to CKD and ESRD groups, but was lower for patients receiving statins treatment than non-treated patients. We also found that the statin therapy effectiveness was better in patients taking hydrophilic statins than in those taking lipophilic statins, and in patients taking statin-ezetimibe combination than in those taking statin alone, particularly in the NRF group. Ezetimibe is also an effective option of treating hyperlipidemia.Hepatocellular carcinoma (HCC) is the most common cancer in end-stage renal disease (ESRD) patients in Taiwan. Whether statin therapy associated with the HCC risk in hyperlipidemic patients with chronic kidney disease (CKD) and ESRD is unclear. Using population-based insurance claim data from Taiwan, we identified from hyperlipidemic patients taking statins or not (677,364 versus 867,707) in 1999–2015. Among them, three pairs of propensity score matched statin and non-statin cohorts were established by renal function: 413,867 pairs with normal renal function (NRF), 46,851 pairs with CKD and 6372 pairs with ESRD. Incidence rates of HCC were compared, by the end of 2016, between statin and non-statin cohorts, between hydrophilic statins (HS) and lipophilic statins (LS) users, and between statin-ezetimibe combination therapy (SECT) and statin monotherapy (SM) users. The HCC incidence increased progressively from NRF to CKD and ESRD groups, was lower in the statin cohort than in the non-statin cohort, with the differences of incidence per 10,000 person-years increased from (7.77 vs. 21.4) in NRF group to (15.8 vs. 37.1) in CKD group to (19.1 vs. 47.8) in ESRD group. The incidence increased with age, but the Cox method estimated hazard ratios showed a greater statin effectiveness in older patients. Among statin users, the HCC incidence was lower in HS users than in LS users, and lower in SECT users than in SM users, but the difference was significant only in the NRF group. Hyperlipidemic patients with CKD and ESRD receiving statins are at reduced HCC risks; the treatment effectiveness is superior for HS users than for LS users, and for SECT users than for SM users, but not significant.

POS-362 DEVELOPMENT OF BIOMARKERS FOR PREDICTING DKD PROGRESSION IN NON-PROTEINURIC TYPE 2 DIABETES: THE NTUH-DKD COHORT STUDY

Diabetic kidney disease (DKD) is one of the leading causes of chronic kidney disease (CKD) and end-stage renal disease (ESRD) worldwide. Despite being a diagnostic criterion for DKD, the predictive value of urine albumin-creatinine ratio (UACR) on the progression toward advanced CKD is limited, due to the heterogeneous disease nature. Better predictive biomarkers are urgent needed to help us to better manage DKD patients. In this prospective cohort study, we evaluated the potential of incorporating a novel DKD Biomarker, a post-Translational Modification (PTM) fragment of Fetuin-A, into clinical parameters for predicting short-term DKD Progression in non-proteinuric type 2 diabetes (T2DM).

Prevalence of chronic kidney disease and end-stage renal disease in a bariatric versus nonbariatric population: a retrospective analysis of the U.S. National Inpatient Sample database.

In the past five 5 years our team has studied the effects of bariatric surgery on chronic kidney disease (CKD) at our institution. The objective of this study was to assess the impact of bariatric surgery (BaS) on the prevalence and likelihood of CKD and end-stage renal disease (ESRD) nationwide. Academic hospital, United States. We conducted a retrospective analysis of the U.S. National Inpatient Sample (NIS) database for the years 2010-2015 and compared. Univariate and multivariable analysis were performed to assess the impact of BaS on the point prevalence and the probability of CKD and ESRD. Similarly, a multivariable logistic regression was conducted to measure the impact of the most important risk factors for CKD exclusively in a severely obese population. Data on 296,041 BaS cases and 2,004,804 severely obese controls was extracted from the NIS database and relative to controls, all baseline CKD risk factors were less common among bariatric surgery cases. Nonetheless, even after adjusting for all CKD risk factors, controls exhibited marked increases in the odds of CKD-stage III (odds ratio [OR] 3.10 [3.05-3.14], P < .0001) and modes increase for ESRD (OR 1.13 [1.09-1.18], P < .0001). Overall, even after adjusting for risk factors we observed that the rate of CKD is significantly higher in the control group, 12% when compared with 5.3% in the bariatric surgery group (P < .0001). In this retrospective, case control study of a large, representative national sample of patients with severe obesity, BaS was found to be associated with significantly reduced point-prevalence and likelihood for CKD when adjusted for baseline CKD risk factors as compared with patients with obesity who did not undergo BaS. Overall, BaS resulted in a reduced rate and a moderate decrease in the likelihood of ESRD.

POS-071 CIRCULATING MITOCHONDRIAL DYSFUNCTION IS ASSOCIATED WITH ACUTE KIDNEY INJURY IN CHRONIC KIDNEY DISEASE PATIENTS RECEIVING CONTRAST MEDIA

Contrast-induced acute kidney injury (CI-AKI) is the third common cause of acute kidney injury (AKI) in hospitalized patients leading to prolonged hospitalization especially in high risk. In the irreversible cases, AKI can be developed to chronic kidney disease (CKD) or end-stage renal disease (ESRD), which need long-term dialysis and increasing mortality. Three pathophysiological mechanisms have been proposed including direct tubular toxicity, intrarenal vasoconstriction, and excessive production of reactive oxygen species (ROS), leading to impaired renal function.

Risk factors for mortality within 5 years of carotid endarterectomy for asymptomatic stenosis

ObjectiveThe current Society for Vascular Surgery guidelines for the treatment of patients with asymptomatic carotid stenosis recommend endarterectomy for patients with >70% stenosis and acceptable surgical risk. The reduced rate of stroke with modern medical therapy has increased the importance of careful selection in deciding which patients should undergo elective carotid endarterectomy (CEA) for asymptomatic disease. It would, therefore, be very prudent to investigate preexisting variables predictive of 5-year mortality for patients meeting the criteria to undergo CEA. MethodsThe Vascular Quality Initiative was queried from 2003 onward for all cases of CEA. Inclusion in the study required the following: (1) documentation of survival status; (2) complete data on all incorporated demographic study variables; and (3) asymptomatic neurologic status. The variables present at surgery were investigated using binary logistic regression to identify multivariate predictors of 5-year mortality. The highest risk variables were then interrogated for an additive effect regarding long-term mortality. A subanalysis was performed for patients aged >80 years. ResultsA total of 30,615 patients met the inclusion criteria, 5414 (18%) of whom had died within 5 years. The highest risk variables were classified as those that had had an adjusted odds ratio >1.25, P < .001, and beta coefficient of ≥0.25. These included a body mass index <20 kg/m2, diabetes mellitus, a history of congestive heart failure, renal insufficiency, end-stage renal disease, chronic obstructive pulmonary disease, living status other than home, prior lower extremity bypass, prior major amputation, Black race relative to other races combined, hemoglobin <10 mg/dL, a history of neck irradiation, and a history of smoking. Age had an annual odds ratio of 1.04 (P < .001). Other variables that achieved a statistically significant (P < .05) association with 5-year mortality were coronary artery disease, a positive stress test or the occurrence of myocardial infarction within 2 years, lower extremity arterial intervention, aneurysm repair, and P2Y12 inhibitor therapy at surgery. The use of statin and aspirin therapy at surgery were both protective against 5-year mortality (P < .001). ConclusionsWe identified 12 particularly high-risk variables, which, in combination, progressively predicted for increasing mortality within 5 years of CEA performed for asymptomatic stenosis. Special attention should be given to patients aged >80 years and patients with any history of congestive heart failure regardless of current symptoms, chronic obstructive pulmonary disease, renal insufficiency or end-stage renal disease, peripheral artery disease, diabetes, and variables associated with frailty (BMI under 20, anemia, assisted living status).