3b Chronic Kidney Disease Research Articles

Low-dose spironolactone and cardiovascular outcomes in moderate stage chronic kidney disease: a randomized controlled trial.

Chronic kidney disease (CKD) is associated with a substantial risk of progression to end-stage renal disease and vascular events. The nonsteroidal mineralocorticoid receptor antagonist (MRA), finerenone, offers cardiorenal protection for people with CKD and diabetes, but there is uncertainty if the steroidal MRA, spironolactone, provides the same protection. In this prospective, randomized, open, blinded endpoint trial, we assessed the effectiveness of 25 mg spironolactone in addition to usual care or usual care alone for reducing cardiovascular outcomes in stage 3b CKD among an older community cohort (mean age = 74.8 years and s.d. = 8.1). We recruited 1,434 adults from English primary care, of whom 1,372 (96%) were included in the primary analysis. The primary outcome was time from randomization until the first occurrence of death, hospitalization for heart disease, stroke, heart failure, transient ischemic attack or peripheral arterial disease, or first onset of any condition listed not present at baseline. Across 3 years of follow-up, the primary endpoint occurred in 113 of 677 participants randomized to spironolactone (16.7%) and 111 of 695 participants randomized to usual care (16.0%) with no significant difference between groups (hazard ratio = 1.05, 95% confidence interval: 0.81-1.37). Two-thirds of participants randomized to spironolactone stopped treatment within 6 months, predominantly because they met prespecified safety stop criteria. The most common reason for stopping spironolactone was a decrease in the estimated glomerular filtration rate that met prespecified stop criteria (n = 239, 35.4%), followed by participants being withdrawn due to treatment side effects (n = 128, 18.9%) and hyperkalemia (n = 54, 8.0%). In conclusion, we found that spironolactone was frequently discontinued due to safety concerns, with no evidence that it reduced cardiovascular outcomes in people with stage 3b CKD. Spironolactone should not be used for people with stage 3b CKD without another explicit treatment indication. ClinicalTrials.gov registration: ISRCTN44522369 .

Features of preeclampsia in patients with chronic kidney disease

Aims: to study the characteristics of preeclampsia (PE) in women with chronic kidney disease (CKD) compared to PE in the general population.Method: a prospective observational study analyzed the course of PE in 24 women with a previously established diagnosis of CKD (Group 1) and 39 women in the general population (Group 2) without a complicating somatic history. In patients with CKD with a known pregestational creatinine level, the physiological response of the kidneys to pregnancy was assessed, defined as a decrease in serum creatinine by more than 10% in the first trimester. The angiogenic ratio (sFlt-1/PLGF) was studied in 13 patients with CKD.Results: the two groups did not differ in age or parity. In the first group, 16 patients had CKD stage 1-2, 5 had CKD 3A, and one patient each had CKD 3B, 4 and 5 (the later receiving hemodialysis). Nineteen (79%) of women with CKD had hypertension, proteinuria (PU), renal impairment or a combination of these factors before conception. Only 3 out of 16 patients had a physiological renal response. Early PE developed in 58.3% of patients with CKD compared to 35.3% in second group (p = 0.082). The duration of PE inversely correlated with the stage of CKD (r = -0.630; p = 0.001). As pregnancy progressed in patients with CKD, PU increased, reaching nephrotic level in 54% of women by the time of PE. HELLP syndrome or isolated hematological signs of TMA were noted in 8 patients in the general population group, and in 1 in the CKD group. The average sFlt-1/PLGF value in patients with early stages of CKD (n = 9) was 81.0±24.0, with late stages (n = 4) it was 14±8.Conclusion: the study identified the features of PE in CKD: early onset, increased PU reaching nephrotic level in half of the cases by the time PE is diagnosed, and the absence of a histological renal response to pregnancy in the 1st trimester. The lack of changes in the angiogenic coefficient in women with PE and late-stage CKD requires further study in a larger group of patients.

Thiazide Discontinuation in Chronic Kidney Disease Hypertension Management: A Retrospective Chart Review.

Thiazides are utilized in general hypertension management, however, their role in chronic kidney disease (CKD) hypertension management remains unclear. Although data support thiazide efficacy in advanced CKD, the adverse effect profile (including estimated glomerular filtration rate [eGFR] decline and electrolyte abnormalities) may lead to thiazide discontinuation. The authors assessed the thiazide discontinuation rate in Kaiser Permanente Southern California members with moderate-to-severe CKD and hypertension. This study was a multicenter retrospective analysis evaluating Kaiser Permanente Southern California members with hypertension and CKD 3B or 4 who filled a thiazide prescription in 2021, with follow-up through 2022. The outcomes were thiazide discontinuation rate, reason for thiazide discontinuation, time to thiazide discontinuation, and discontinuing practitioner specialty. Mean changes in blood pressure and eGFR from baseline were also evaluated. Of the 401 patients followed for 1 year after thiazide initiation, 65 patients discontinued a thiazide (discontinuation rate: 16.2%, mean time to discontinuation: 7.5 months). Of the 201 patients followed for 2 years after thiazide initiation, 57 patients discontinued a thiazide (discontinuation rate: 28.4%, mean time to discontinuation: 15.5 months). The most commonly documented thiazide discontinuation reason was increased serum creatinine (30% of total reasons at 1 year and 39% of total reasons at 2 years). Most patients with hypertension and CKD 3B or 4 continued on a thiazide with favorable blood pressure lowering effects and modest eGFR decline. Thiazides may be considered viable antihypertensive options with close renal function monitoring for patients with moderate-to-severe CKD.

Low rate of severe-end-stage kidney disease after SABR for localised primary kidney cancer

BackgroundStereotactic ablative body radiotherapy (SABR) is an emerging treatment for patients with primary renal cell carcinoma (RCC). However, its impact on renal function is unclear. This study aimed to evaluate incidence and clinical factors predictive of severe to end-stage chronic kidney disease (CKD) after SABR for RCC.Methods and materialsThis was a Single institutional retrospective analysis of patients with diagnosed primary RCC receiving SABR between 2012–2020. Adult patients with no metastatic disease, baseline estimated glomerular filtration rate (eGFR) of ≥ 30 ml/min/1.73 m2, and at least one post-SABR eGFR at six months or later were included in this analysis. Patients with upper tract urothelial carcinoma were excluded. Primary outcome was freedom from severe to end-stage CKD, determined using the Kaplan–Meier estimator. The impact of baseline CKD, age, hypertension, diabetes, tumor size and fractionation schedule were assessed by Cox proportional hazard models.ResultsSeventy-eight consecutive patients were included, with median age of 77.8 years (IQR 70–83), tumor size of 4.5 cm (IQR 3.9–5.8) and follow-up of 42.2 months (IQR 23–60). Baseline median eGFR was 58 mls/min; 55% (n = 43) of patients had baseline CKD stage 3 and the remainder stage 1–2. By last follow-up, 1/35 (2.8%) of baseline CKD 1–2, 7/27 (25.9%) CKD 3a and 11/16 (68.8%) CKD 3b had developed CKD stage 4–5. The estimated probability of freedom from CKD stage 4–5 at 1 and 5 years was 89.6% (CI 83.0–97.6) and 65% (CI 51.4–81.7) respectively. On univariable analysis, worse baseline CKD (p < 0.0001) and multi-fraction SABR (p = 0.005) were predictive for development of stage 4–5 CKD though only the former remained significant in multivariable model.ConclusionIn this elderly cohort with pre-existing renal dysfunction, SABR achieved satisfactory nephron sparing with acceptable rates of severe to end-stage CKD. It can be an attractive option in patients who are medically inoperable.

Interaction between anemia and renal dysfunction in relation to long-term survival following acute myocardial infarction.

Anemia and chronic kidney disease (CKD) adversely affect prognosis following acute myocardial infarction (AMI). We aimed to assess their interaction regarding long-term survival post-AMI. This is a single-center, retrospective analysis of consecutive AMI survivors. Stratified by admission-time anemia status and CKD grade, as determined by hemoglobin and creatinine levels, the cohort was evaluated for all-cause mortality at 10 years after hospital discharge. A total of 11,395 patients (69.1% males, mean age 65.8 ± 13.9 years, 49.6% with ST elevation MI) were included, of whom 29.9% had anemia and 15.9% -grade 3b or higher CKD. CKD was more advanced among anemic patients and the prevalence of anemia rose as CKD grade increased (p for trend < 0.001). At 10 years, 47.8% of patients died. Notwithstanding differences in baseline characteristics, presentation, and treatment between those with various anemia status and CKD grades, anemia presence (HR 1.40, 95% CI 1.32-1.49, p < 0.001) and increasing CKD grade (HR 1.10, 95% CI 1.02-1.20, p for trend < 0.001) were independently associated with a higher mortality risk. The incremental hazard imposed by either anemia or more advanced CKD was limited to patients with normal renal function and up to grade 3a (in the total cohort and the conservative treatment subgroup) or 4 (in the invasive revascularization subgroup) CKD. The added risk associated with increasing CKD grade also affected non-anemic individuals irrespective of the specific CKD grade. Anemia and more advanced CKD are associated with reduced long-term survival post-AMI, inflicting higher risk when conjoined in lower-grade CKD.

Initiation patterns of anticoagulants for atrial fibrillation among older UK adults with and without chronic kidney disease, 2010–2020

BackgroundThere is a paucity of data on the initiation patterns of anticoagulants among older atrial fibrillation patients with and without chronic kidney disease (CKD).Setting and methodsWe used the UK Clinical...

Assessment of cardiovascular risk in patients with type 2 diabetes and albuminuric diabetic kidney disease phenotype

Introduction. The aim of this study is analysis of cardiovascular risk in non-albuminuric and albuminuric patients with type 2 diabetes and diabetic kidney disease. Material and Methods. The study included 136 patients with type 2 diabetes and chronic kidney disease (estimated glomerular filtration rate &lt;90 ml/ min/1.73 m2). Patients were divided into two groups: Group A (patients without albuminuria) and Group B (patients with albuminuria). The cardiovascular risk was assessed through a retrospective analysis of data from electronic medical records. Results. We found statistically significantly more patients with stage 3a (Group A: 10% vs. Group B: 54%) and stage 3b (Group A: 7% vs. Group B: 13%; p&lt;0.05) chronic kidney disease in the albuminuric group. These patients also had a longer duration of diabetes (Group A: 13.43?9.56 vs. Group B: 17.14?9.17 years; p&lt;0.05), a higher frequency of male subjects (Group A: 44% vs. Group B: 63.9%; p&lt;0.05) and a higher prevalence of smokers. The presence of hypertension was significantly more frequent in Group B (Group A: 89% vs. Group B: 97.2%; p&lt;0.05). There was no significant difference between the groups in terms of age and metabolic control. However, coronary heart disease (Group A: 36% vs. Group B: 55.6%; p&lt;0.05), peripheral artery disease (Group A: 16% vs. Group B: 22.2%; p&lt;0.05), and stroke (Group A: 5% vs. Group B: 22.2%; p&lt;0.05) were significantly more common in patients with type 2 diabetes and albuminuria. Conclusion. The albuminuric phenotype of diabetic kidney disease is associated with greater kidney function impairment, a longer duration of diabetes, and a higher prevalence in men. The presence of albuminuria significantly increases cardiovascular risk in people with type 2 diabetes and chronic kidney disease. Using renoprotective antihyperglycemic agents is essential in this group of patients, as they have an increased mortality risk.

Risk factors for COVID-19 hospitalization and mortality in patients with chronic kidney disease: a nationwide cohort study.

Several studies have demonstrated an increased risk of severe coronavirus disease 2019 (COVID-19) in chronic kidney disease (CKD) patients. However, few have investigated the impact of CKD stage and dialysis modality. The primary aim of this study was to investigate the association between CKD stage, dialysis modality and risk of severe COVID-19. Secondly, we aimed to study the impact of comorbidities and drugs on the risk of severe COVID-19 in the CKD population. This nationwide observational study was based on data from the Swedish Renal Registry and three other national registries. Patients with non-dialysis CKD stage 3b-5 or dialysis on 1 January 2020 were included and followed until 31 December 2021. The primary outcome was COVID-19 hospitalization; the secondary outcome was COVID-19 mortality. Associations were investigated using logistic regression models, adjusting for confounders. The study population comprised 7856 non-dialysis CKD patients and 4018 dialysis patients. The adjusted odds ratios (aOR) for COVID-19 hospitalization and mortality were highest in the dialysis group [aOR 2.24, 95% confidence interval (CI) 1.79-2.81; aOR 3.10, Cl 95% 2.03-4.74], followed by CKD 4 (aOR 1.33, 95% CI 1.05-1.68; aOR 1.66, Cl 95% 1.07-2.57), as compared with CKD 3b. No difference in COVID-19 outcomes was observed between patients on hemodialysis and peritoneal dialysis. Overall comorbidity burden was one of the strongest risk factors for severe COVID-19 and the risk was also increased in patients prescribed insulin, proton pump inhibitors, diuretics, antiplatelets or immunosuppressants. Worsening CKD stage and comorbidity are independent risk factors for severe COVID-19 in the Swedish CKD population.

Prevalence of Chronic Kidney Disease Among US Adults With Hypertension, 1999 to 2018.

Hypertension is a major cause of end-stage renal disease. Assessing temporal trends in the prevalence of chronic kidney disease (CKD) in hypertension could provide information for public health policies and plans. From the National Health and Nutrition Examination Survey from 1999 to 2018, a probability sample of adults aged ≥20 years was collected. The primary outcomes were classified according to the estimated glomerular filtration rate and urinary albumin. Trend tests were performed to assess age-standardized prevalence trends of CKD, albuminuria, and macroalbuminuria in US adults with hypertension. A total of 23 120 US adults with hypertension were included in this study. The prevalence of any CKD, albuminuria, or macroalbuminuria in hypertension remained relatively stable. However, the age-standardized prevalence of stage 1 CKD in hypertension increased from 4.9% in 2003 to 2006 to 7.0% in 2015 to 2018 (P=0.0077 for trend). The age-standardized prevalence of stage 3b CKD in hypertension decreased from 2.9% in 2011 to 2014 to 2.1% in 2015 to 2018 (P=0.0350 for trend). A similar trend was observed for the age-standardized prevalence of stages 3 to 5 CKD in hypertension, which declined from 10.9% in 2011 to 2014 to 8.9% in 2015 to 2018 (P=0.0160 for trend). Among US adults with hypertension, the prevalence of any CKD, albuminuria, and macroalbuminuria remained relatively stable from 1999 to 2018, whereas the hypertensive population showed an increasing trend in stage 1 CKD from 2003 to 2006 to 2015 to 2018 and a decreasing trend in the prevalence of stages 3 to 5 and 3b CKD from 2011 to 2014 to 2015 to 2018.

Underdiagnosed CKD in Geriatric Trauma Patients and Potent Prevention of Renal Impairment from Polypharmacy Risks through Individual Pharmacotherapy Management (IPM-III)

The aging global patient population with multimorbidity and concomitant polypharmacy is at increased risk for acute and chronic kidney disease, particularly with severe additional disease states or invasive surgical procedures. Because from the expertise of more than 58,600 self-reviewed medications, adverse drug reactions, drug interactions, inadequate dosing, and contraindications all proved to cause or exacerbate the worsening of renal function, we analyzed the association of an electronic patient record- and Summaries of Product Characteristics (SmPCs)-based comprehensive individual pharmacotherapy management (IPM) in the setting of 14 daily interdisciplinary patient visits with the outcome: further renal impairment with reduction of eGFR ≥ 20 mL/min (redGFR) in hospitalized trauma patients ≥ 70 years of age. The retrospective clinical study of 404 trauma patients comparing the historical control group (CG) before IPM with the IPM intervention group (IG) revealed a group-match in terms of potential confounders such as age, sex, BMI, arterial hypertension, diabetes mellitus, and injury patterns. Preexisting chronic kidney disease (CKD) &gt; stage 2 diagnosed as eGFR &lt; 60 mL/min/1.73 m2 on hospital admission was 42% in the CG versus 50% in the IG, although in each group only less than 50% of this was coded as an ICD diagnosis in the patients’ discharge letters (19% in CG and 21% in IG). IPM revealed an absolute risk reduction in redGFR of 5.5% (11 of 199 CG patients) to 0% in the IPM visit IG, a relative risk reduction of 100%, NNT 18, indicating high efficacy of IPM and benefit in improving outcomes. There even remained an additive superimposed significant association that included patients in the IPM group before/beyond the 14 daily IPM interventions, with a relative redGFR risk reduction of 0.55 (55%) to 2.5% (5 of 204 patients), OR 0.48 [95% CI 0.438–0.538] (p &lt; 0.001). Bacteriuria, loop diuretics, allopurinol, eGFR ≥ 60 mL/min/1.73 m2, eGFR &lt; 60 mL/min/1.73 m2, and CKD 3b were significantly associated with redGFR; of the latter, 10.5% developed redGFR. Further multivariable regression analysis adjusting for these and established risk factors revealed an additive, superimposed IPM effect on redGFR with an OR 0.238 [95% CI 0.06–0.91], relative risk reduction of 76.2%, regression coefficient −1.437 including patients not yet visited in the IPM period. As consequences of the IPM procedure, the IG differed from the CG by a significant reduction of NSAIDs (p &lt; 0.001), HCT (p = 0.028) and Würzburger pain drip (p &lt; 0.001), and significantly increased prescription rate of antibiotics (p = 0.004). In conclusion, (1) more than 50% of CKD in geriatric patients was not pre-recognized and underdiagnosed, and (2) the electronic patient records-based IPM interdisciplinary networking strategy was associated with effective prevention of further periinterventional renal impairment and requires obligatory implementation in all elderly patients to urgently improve patient and drug safety.

#4485 CLINICAL CASE OF MOSAICISM IN ADPKD PATIENT

Abstract Background and Aims Autosomal Dominant Polycystic Kidney Disease (ADPKD) it's mainly characterized by renal involvement with progressive bilateral development of renal cysts and volumetric increase of the kidneys, responsible for the progressive loss of renal function that leads to chronic kidney disease (CKD) and the need of renal replacement therapy. There are some cases (doubtful, uncertain) in which it is necessary to perform genetic testing to achieve a definitive diagnosis. It looks like in ADPKD patients, mosaicism could modulate the clinical course of the disease. Mosaicism is characterized by few cell populations with different genomes. In these special cases the diagnosis is very difficult and the genetic analysis could be an important and helpful tool. With this report, we want to highlight the importance of the use of several diagnostic methods in those ‘atypical’ cases where otherwise the analysis would have been negative from a first molecular approach. Method A 47 years old woman came to our attention with typical picture of ADPKD, arterial hypertension and chronic kidney disease CKD (3b). She had no ADPKD family history, but since she had a son, genetic testing was performed. According to our workflow, first level analysis includes Next Generation Sequencing (NGS). Second level analysis, performed to investigate other genes and large rearrangement, was based on Multiplex Ligation-dependent Probe Amplification (MLPA) analysis of PKD1 and PKD2 genes, using Salsa MLPA ProbeMix P352 PKD1PKD2 kit and ProbeMix P351 PKD1 kit ©MRC Holland. Results NGS did not detect the presence of any genomic variants. Therefore, second-level genetic analysis (several approaches), showed a large deletion in heterozygosis of the portion comprising the 3-33 exons of PKD1 gene in mosaic in percentage close to the resolution limits of the used technique (25-30%). The same analysis was confirmed in another laboratory. Conclusion We concluded that the identified large deletion, without establishing the real borders due to MLPA technical restrictions, was present as mosaicism. The variant is not reported, but due to the type of mutation and the clinical picture of the patient, it is to be considered as likely pathogenic. A stepwise genetic approach might be useful in those cases where standard methods do not allow to reach a definitive diagnosis.

THE PREVALENCE OF CHRONIC KIDNEY DISEASE IN PATIENTS WITH ARTERIAL HYPERTENSION

Objective: To study the prevalence of chronic kidney disease (CKD) markers in patients with arterial hypertension(AH). Design and method: Retrospective analysis of 188 case histories of patients with AH of 1-3 degrees (ESC/ESH, 2018) who received inpatient treatment was carried out. 109 women and 79 men were studied. Mean age 62.8 ± 10.2 years. CKD stages were established according the modern KDIGO 2013 classification. Results: Among the examined patients there were 18% patients with CKD 1(n = 34); 56.3% patients with CKD 2 (n = 106); 17.5% patients with CKD 3A(n = 33); 5.3% patients with CKD 3B (n = 10); 2.6% patients with CKD 4 (n = 5) (p&lt;0.00001). It should be noted that patients with stage 4 CKD were significantly older (55±8 vs 62±9 vs 68±8 vs 69±9 vs 74±16; p = 0.00001). According to the level of SBP, DBP, heart rate, the patients did not differ significantly. SBP (p = 0.26). DBP (p = 0.25). Patients with stage 4 CKD had severe abdominal obesity. WC: 102.4 ± 10 vs 104.7 ± 13.6 vs 103.2 ± 10.7 vs 101.5 ± 12.4 vs 110 ± 27.3 (p = 0.68). Mean creatinine in the groups was 70.6 ± 14.7 vs 85.2 ± 14.4 vs 102.3 ± 14.6 vs 121.6 ± 25.3 vs 209.6 ± 45.5 (p&lt;0.00001) . Mean eGFR 98.2 ± 7.3 vs 72.9 ± 7.4 vs 53.7 ± 4.2 vs 37.5 ± 4.1 vs 22.6 ± 3.8 p (p&lt;0.00001). The analysis showed that as the stage of CKD increases, the level of microalbuminuria increases. Thus, MAU indicators were 31.05 ± 25.5 vs 41.6 ± 50.2 vs 38.6 ± 46 vs 96.6 ± 144.7 vs 308.8 ± 147.5 (p&lt;0.00001). It should be noted, that the high stages of CKD are characterized by significantly more pronounced asymptomatic hyperuremia. At the same time, the level of uric acid in group I was 5.4 ± 1.4 vs 6.5 ± 4.7 vs 6.5 ± 1.7 vs 7.5 ± 1.7 vs 7.8 ± 1.01 (p &lt;0.00001). Conclusions: Among patients with hypertension, the prevalence of CKD is significantly high (82%), which additionally increases the cardiovascular risk of this category of patients.

THE INFLUENCE OF GLP-1RAS (ORAL SEMAGLUTIDE) ON TENSIONAL CONTROL IN DIABETIC PATIENTS WITH CHRONIC RENAL DISEASE

Objective: GLP-1 receptor agonists (GLP-1RAs) represent one of the pharmacological groups of choice for the diabetic management of patients with cardiovascular disease and chronic kidney disease (CKD). Their hypotensive effect has not been sufficiently evaluated in association with the usual antihypertensive drugs. The main objective is to study the hypotensive effect of oral semaglutide at a maintenance dose of 7mg per day in a cohort of patients with stage 3b CKD (glomerular filtration rate -GFR- 44 to 30ml/min by CKD-EPI) with poor diabetic control and without previous treatment with GLP-1 receptor agonists or iSGLT2. Design and method: Sixteen patients of both sexes were selected and divided into two follow-up arms of eight patients each. In one arm, the combination of oral semaglutide with an angiotensin receptor blocker (ARB) (such as losartan at a maintenance dose of 50-100mg per day) is evaluated, and in the other, dietary measures are intensified together with ARB at the same doses. After 4 months of treatment, the primary and secondary variables were assessed: body weight, glycosylated haemoglobin (HbA1c), renal function and albuminuria (albumin/creatinine ratio - ACC). Results: Mean age was similar in both groups (69 vs 70 years). The reduction in mean blood pressure (BP) values obtained with standardised measurements in a nephrology consultation in the semaglutide + ARB arm was -12mmHg (systolic) and -5mmHg (diastolic) compared to those in the ARB arm alone (-5mmHg systolic and -3mmHg diastolic), with statistical significance (p&lt;0.05). The other comparative variables between the two groups were: reduction in body weight (-2.5kg vs -0.5kg, p&lt;0.05); reduction in mean HbA1c (-1.2% vs -0.1%, p&lt;0.05); changes in eGFR (+2ml/min/1.73m2 vs -3ml/min/1.73m2, p&gt;0.05) and mean reduction in ACC (-257mg/g vs +12mg/g, p&lt;0.05). Conclusions: Orally administered GLP-1 receptor agonists (semaglutide) are drugs with a hypotensive potential complementary to renin angiotensin system inhibitors in diabetic renal patients. This property, together with their antiproteinuric effect, makes them an ideal choice in situations of hypertension and moderate renal dysfunction. Larger, controlled studies are needed to measure the renal effect alongside the various antihypertensive groups.

Endoscopic management of food impaction following endoscopic ultrasound-guided gallbladder drainage using lumen-apposing metal stent.

A 61-year-old man was referred to our center for severe acute cholecystitis. Given his serious comorbidities (previous dissection of an aortic aneurysm with residual disease awaiting surgical reintervention; stage 3b chronic kidney disease; alcohol-related liver disease), the patient underwent transgastric endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using a 10 × 10 mm lumen-apposing metal stent (LAMS) ([Fig. 1]). In the following months the patient experienced two episodes of food impaction of LAMS, which were treated endoscopically with placement of two double-pigtail plastic stents coaxially through the LAMS. Then, 3 months after the procedure, the patient was admitted for a third recurrence of acute cholecystitis. Computed tomography revealed a distended gallbladder, 19 cm in the long axis and completely occupied by food ([Fig. 2]). After a multidisciplinary evaluation, surgery was again excluded, and an endoscopic attempt was performed.

Selection criterion for endovascular aortic repair in those with chronic kidney disease

ObjectiveEndovascular aortic repair (EVAR) is the preferred method of repair for abdominal aortic aneurysms (AAAs). However, patients with advanced chronic kidney disease (CKD) are a high-risk group, and it is unknown which patients with CKD benefit from EVAR vs continued surveillance. The purpose of this study was to identify which patients with advanced CKD may benefit from EVAR. MethodsThe Vascular Quality Initiative Database was utilized to identify elective EVARs for AAAs. Patients were excluded if they underwent urgent or emergent repairs. CKD stages were categorized based on preoperative estimated glomular filtration rate (eGFR) and dialysis status. Predicted 1-year mortality of untreated AAAs was calculated by modifying a validated comorbidity score that predicts 1-year mortality (Gagne Index) without repair. The primary outcome was actual 1-year mortality, which was compared with the predicted 1-year mortality without repair. ResultsA total of 34,926 patient met study criteria. There were differences in Gagne Indices among the varying classes of CKD. Patients with CKD 4 and CKD 5 had the highest 1-year mortality rates, followed by CKD 3b, which was significantly higher than those with CKD 1 and CKD 2. Patients with CKD 4 had no differences between actual 1-year mortality with EVAR and predicted 1-year survival without EVAR across all AAA sizes. Those with CKD 5 had worse actual 1-year survival with EVAR than predicted 1-year survival without EVAR for AAAs <5.5 cm. Patients with CKD 5 only experienced an actual mortality benefit with EVAR compared with predicted 1-year mortality without EVAR for AAAs ≥7.0 cm. ConclusionsThe current data suggest that patients with CKD 3b, 4, and 5 represent a high-risk group who may not benefit from elective EVAR utilizing traditional size criteria. Patients with CKD 4 and 5 with AAAs <5.5 cm do not benefit from elective EVAR. In patients with CKD 5, elective EVAR may need to be reserved for AAAs ≥7.0 cm unless there are other concerning anatomic characteristics.

Lower Extremity Edema and Lesions Not Responsive to Conservative Therapy

A 66-year-old man with at least 2 years of progressively worsening unilateral left lower extremity edema and recurrent episodes of cellulitis of the anterior left lower leg, treated repeatedly with diuresis and antibiotic therapy, was referred by his rural family physician to the community paramedic (CP) service for diuresis, compression wrapping, wound care, and self-management education. His medical history included prior stroke with residual left-sided hemiplegia; insulin-treated type 2 diabetes complicated by peripheral neuropathy, retinopathy, and stage 3b chronic kidney disease; and obesity with body mass index 39 kg/m.

A Hybrid Risk Factor Evaluation Scheme for Metabolic Syndrome and Stage 3 Chronic Kidney Disease Based on Multiple Machine Learning Techniques.

With the rapid development of medicine and technology, machine learning (ML) techniques are extensively applied to medical informatics and the suboptimal health field to identify critical predictor variables and risk factors. Metabolic syndrome (MetS) and chronic kidney disease (CKD) are important risk factors for many comorbidities and complications. Existing studies that utilize different statistical or ML algorithms to perform CKD data analysis mostly analyze the early-stage subjects directly, but few studies have discussed the predictive models and important risk factors for the stage-III CKD high-risk health screening population. The middle stages 3a and 3b of CKD indicate moderate renal failure. This study aims to construct an effective hybrid important risk factor evaluation scheme for subjects with MetS and CKD stages III based on ML predictive models. The six well-known ML techniques, namely random forest (RF), logistic regression (LGR), multivariate adaptive regression splines (MARS), extreme gradient boosting (XGBoost), gradient boosting with categorical features support (CatBoost), and a light gradient boosting machine (LightGBM), were used in the proposed scheme. The data were sourced from the Taiwan health examination indicators and the questionnaire responses of 71,108 members between 2005 and 2017. In total, 375 stage 3a CKD and 50 CKD stage 3b CKD patients were enrolled, and 33 different variables were used to evaluate potential risk factors. Based on the results, the top five important variables, namely BUN, SBP, Right Intraocular Pressure (R-IOP), RBCs, and T-Cho/HDL-C (C/H), were identified as significant variables for evaluating the subjects with MetS and CKD stage 3a or 3b.

ODP302 Cushing's Disease: A Challenging Diagnosis in Patients with Underlying Co-Morbidities

Abstract Introduction Cushing's disease (CD) is a rare endocrine disorder with significant morbidity and mortality. This case is a complicated ACTH (adrenocorticotropic hormone)-dependent hypercortisolism with a negative pituitary MRI inthe setting of underlying liver cirrhosis and chronic kidney disease. Hypercortisolism work up was challenging due to liver and kidney disease. Case Presentation A 42-year-old woman with a history of liver cirrhosis(MELDscore: 19) and stage 3b chronic kidney disease (CKD) presented with nausea, vomiting and abdominal pain. She reported proximal muscle weakness. On examination, she had central adiposity with large purple abdominal striae and proximal muscle wasting. Medical history was pertinent for uncontrolled hypertension and type 2 diabetes mellitus. Due to concern for Cushing's syndrome, an overnight 1 mg dexamethasone suppression test (DST) was performed. She had an inappropriately elevated morning cortisol of 10.1 mcg/dL (n &amp;lt; 1.8 mcg/dL), but suboptimal dexamethasone level of 104 ng/dL (140-295 ng/dL), suggesting incomplete absorption secondary to emesis. A repeat DST was not performed given concerns for reduced dexamethasone clearance with her underlying renal and liver disease. Her 24-hour urine free cortisol (UFC) was elevated at 55 ug/24 hr (6-42 ug/24 hr). A repeat 24-hour UFC was again elevated at 265 ug/24 hr (6-42 ug/24 hr). Three late night salivary cortisol levels were also elevated at 0.231 ug/dL, 0.429 ug/dL and 0.19 ug/dL (n &amp;lt;0. 01-0. 09 ug/dL). Diagnosis of Cushing's syndrome was confirmed. ACTH level obtained was detectable at 70.1 pg/mL (7.2-63.3 pg/mL), suggestive of ACTH-dependent Cushing's syndrome. Pituitary MRI without contrast was obtained due to CKD. MRI reported no pituitary abnormalities. High dose DST was not performed due to concerns for aforementioned reduced dexamethasone clearance and due to lack of availability of CRH (corticotropin-releasing hormone), CRH stimulation testing was not done. She underwent inferior petrosal sinus sampling (IPSS) which showed central to peripheral ACTH ratio of 2.11 at baseline and ratios of 3.53, 3.45 and 3.32 at 5 minutes, 10 minutes and 15 minutes respectively after vasopressin stimulation, solidifying the diagnosis of Cushing's disease. Patient is now scheduled for an exploration of the sella via endoscopic endonasal approach. Conclusion This case highlights the limitations of biochemical tests and imaging modalities in the workup of hypercortisolism, notably in patients with underlying liver and kidney disease. The ordering physician should be mindful of the caveats associated with each biochemical testing. ACTH-dependent Cushing's syndrome can be difficult to diagnose properly in the setting of a negative pituitary MRI. IPSS, although an expensive and invasive test, has the best diagnostic accuracy. This case further demonstrates the importance of performing an IPSS to diagnose CD and distinguish from an ectopic source when imaging is non-diagnostic. Presentation: No date and time listed

Pregnancy in patients with stage 3-5 CKD: Maternal and fetal outcomes.

To investigate pregnancy outcomes and the effects of pregnancy on kidney function in patients with stage 3-5 chronic kidney disease (CKD). This was a retrospective study. The clinical data of women with pregnancies complicated by stage 3-5 CKD who delivered in the Peking University First Hospital from January 1st, 2013, to December 31st, 2020, were analyzed. Fifty-three patients with 54 pregnancies were studied. The mean levels of serum creatinine and eGFR in the first trimester were 138.4±76.7μmol/l and 44.9±13.5ml/min/1.73m2, respectively. The perinatal mortality rate was 1.92%. The mean gestational age at birth was 35.4weeks, and the average infant birth weight was 2333g. The average gestational week at delivery of patients with stage 3a CKD was 36.8±2.1weeks and there were no adverse neonatal outcomes. Compared with that in early pregnancy, the mean eGFR at 6months after delivery decreased (52.3±7.3 vs 44.8±10.5ml/min per 1.73m2, P<0.01) in patients with stage 3a CKD and urine protein≥1g/24h and in patients with stage 3b CKD and urine protein≥1g/24h (38.0±2.7 vs. 26.9±10.1ml/min per 1.73m2, P=0.03). The pregnancy outcomes of patients with stage 3a CKD and proteinuria<1g/24h are acceptable. Pregnancy accelerates renal function deterioration more significantly among patients with stage 3-5 CKD and urinary protein concentrations above 1g/24h.

Antiphospholipid antibodies and vitamin D deficiency in COVID-19 infection with and without venous or arterial thrombosis: A pilot case-control study.

Coronavirus disease-2019 (COVID-19) is associated with thromboembolism. Antiphospholipid antibody (APLa) formation is one of the mechanisms. Vitamin D deficiency has been associated with thrombosis in antiphospholipid antibody syndrome. Measure APLa and vitamin D in hospitalized COVID-19 patients with and without thrombosis to evaluate if thromboembolism is associated with concomitant APLa and vitamin D deficiency. Case-control study. Hospitalized COVID-19 patients with a thromboembolic event (ischemic stroke, myocardial infarction, deep venous thrombosis/pulmonary embolism, Cases n = 20). Controls (n = 20): Age, sex-matched without thromboembolic events. Patients with autoimmune disorders, antiphospholipid antibody syndrome, thrombophilia, anticoagulation therapy, prior thromboembolism, chronic kidney disease 3b, 4, end-stage renal disease, and malignancy were excluded. Given the limited current literature on the role of concomitant antiphospholipid antibodies and vitamin D deficiency in causing venous and/or arterial thrombosis in hospitalized COVID-19 patients, we enrolled 20 patients in each arm. Anti-cardiolipin IgG/IgM, beta-2 glycoprotein-1 IgG/IgM, lupus anticoagulant and vitamin D levels were measured in both groups. Cases were 5.7 times more likely to be vitamin D deficient (OR:5.7, 95% CI:1.3-25.6) and 7.4 times more likely to have any one APLa (OR:7.4, 95% CI: 1.6-49.5) while accounting for the effects of sex. Patients with both APLa and vitamin D deficiency had significantly more thrombosis compared to patients who were antibody positive without vitamin D deficiency (100% vs 47.4%; p = 0.01). Thrombosis in COVID-19 was associated with concomitant APLa and vitamin D deficiency. Future studies in COVID-19 should assess the role of vitamin D in reducing thrombosis.