CKD Stage Research Articles

Chronic kidney disease and survival of patients with tricuspid regurgitation

Abstract Introduction Chronic kidney disease (CKD) patients are under-represented in clinical trials examining transcatheter interventions for tricuspid regurgitation (TR). The purpose of the current analysis was to investigate how CKD modifies the association of severe TR with overall survival. Methods Consecutive echocardiographic reports linked to clinical data from the largest medical center in Israel (2007-2022) were reviewed. Patients were dichotomized into four mutually exclusive TR groups (none/trivial, mild, moderate and severe), following by stratification according to CKD stage classification. The primary outcome was all-cause mortality. Kaplan Meier, Multivariate Cox regression and interaction analysis models were applied. Results Final study population included 78,147 patients with a median age of 67 (IQR: 55-78 years), 2,989 (4%) of whom had severe TR. There were 19,910 (25%) patients with estimated glomerular filtration rate [eGFR] < 60 mL/min/1.73 m2, 14,359 (18%) with eGFR between 30-60 and 5,551 (7%) with eGFR <30. During a median follow-up period of 4 years (IQR: 1-7 years), 28,112 patients (36%) died. Kaplan-Meier survival analysis demonstrated an increased risk of death with both increasing severity of TR and/or CKD grade (log-rank p<.001 for both). Multivariate Cox analysis with adjustment for age, sex, left heart disease and pulmonary pressures demonstrated that compared to the none/trivial group, patients with severe TR were 38% more likely to die during follow up (95% CI 1.30-1.47, p<.001). The association of tricuspid regurgitation with poor survival was CKD-dependent, such that in the eGFR>60 group severe TR was associated with 19% increased risk of death, whereas among patients with eGFR<60 the risk was significantly higher and reached 34% in the same multivariate model (p for interaction <.001). Interestingly, the modification effect of CKD was mediated by RV function, such that the interaction analysis was no longer significant when RV function was incorporated into the multivariate model. Sub analysis limited to patients with isolated TR yielded consisted results. Conclusions While the association of severe TR with poor survival is consistent across all CKD groups, it is more pronounced among patients with advanced CKD. This association may be modulated through right ventricular function. When examining data and outcome of tricuspid clinical trials , special emphasis should be given to CKD status.Consort like figureHR modification by CKD

Abstract 13315: Recurrent Cardiac Tamponade Due to Minoxidil Associated Drug Induced Lupus Erythematosus

Case description A 59 year old man with history of MGUS, CKD stage 2, DM, HTN, and OSA presented with gradual worsening of dyspnea and intermittent dizziness over the past few days. Echocardiography showed diastolic collapse of the RV, RA collapse, IVC plethora, marked tricuspid in-flow velocities, and pericardial effusion suggestive of cardiac tamponade (CT). Subxiphoid pericardial window was emergently performed. Serosanguineous fluid 900 mL was drained, and fluid analysis was negative for malignancy or infection. Pericardial biopsy revealed fibro-connective tissue with mild peri-vascular chronic inflammation. He significantly improved and was discharged after 5 days. One month later, he presented again with 1 day symptom of severe dyspnea due to recurrent pericardial effusion with CT physiology. Emergent pericardiocentesis was performed to remove 1,800 ml of serous fluid. Serologic workup for autoimmune disease was strongly positive for anti-histone antibody. ESR (124 mm/hr) and c-reactive protein (5.8 mg/dL) were elevated. Upon review of prescription list, he had been treated for HTN in the past 5 years with minoxidil, amlodipine, lisinopril, and carvedilol. Discussion The use of topical minoxidil, a potent peripheral arterial vasodilator, has been approved for androgenetic alopecia in both men and women for decades, whereas oral minoxidil is limited to refractory hypertension due to side effects such as reflex tachycardia, fluid retention, hypertrichosis, and, rarely, idiosyncratic pericardial effusion. Pericardial effusion was reported in approximately 3-5% of patients receiving minoxidil therapy, which could be attributed to volume overload associated with underlying renal insufficiency. Besides hydralazine, another direct arterial vasodilator commonly implicated in drug-induced lupus erythematosus (DILE), minoxidil also carries a trivial risk of DILE, as suggested by a positive anti-histone antibody and biopsy-proven serositis. Although the association between topical minoxidil and pericardial effusion has never been reported, receding hairline has become a major cosmetic concern and the clinicians should be aware of this rare, but serious, complication associated with minoxidil due to its widespread use.

Abstract 14799: Temporal Trends and In-Hospital Outcomes of Patients Undergoing Leadless Pacemaker Placement: Highlights From National Inpatient Sample 2016-2020

Introduction: Leadless pacemakers (LPM) were introduced to address rates of pocket and lead-related complications associated with transvenous pacemakers (TPM) and to improve clinical outcomes in those who may be at high risk for TPM placement. Limited data exists on in-hospital outcomes and temporal trends of LPM placement. Methods: National Inpatient Sample 2016-2020 was used to query pacemaker (PM) placements and these were grouped into LPM and TPM cases using appropriate ICD procedure codes. Logistic regression was used to compare baseline characteristics and in-hospital outcomes. Results: 740,240 PM placements were observed between 2016 and 2020, with 3.9% (29,015) LPM cases and 96.1% (711,225) TPM cases. As shown in Table 1, there was an increasing temporal trend in LPM placement from 2016 with an overall stable trend in TPM during the same time. The LPM group had a higher proportion of cases that underwent extraction of an old pacemaker (8.9% -vs- 6.9%, p=0.004). A majority of procedures in both groups were performed in the Southern United States and predominantly in large bedsize, urban teaching hospital systems. As shown in Table 2, LPM group had higher proportions of atrial fibrillation, CKD (stage 3 or greater), and ESRD. Length of stay (LOS, 9.7 -vs- 5.9 days) and overall mortality (5.0% -vs- 1.5%, p=0.001) were also higher in the LPM group. Conclusions: There has been a significant increase in LPM placement from 2016 through 2020 as seen with an increasing temporal trend. Use of LPM in medically complex cases or in cases that are high risk for TPM placement continues to increase. Further research needs to be performed to analyze long-term outcomes in this group.

Abstract 17801: Age-Specific Normal Values for Myocardial Blood Flow on 82rb Positron Emission Tomography

Introduction: Positron emission tomography (PET) myocardial perfusion imaging (MPI) is utilized to evaluate ischemia along with myocardial blood flow (MBF). The ability to adequately augment blood flow, measured by myocardial blood flow reserve (MBFR), is a measure of overall health of the coronary circulation and associated with lower major adverse cardiovascular events (MACE) and all-cause mortality. The age-specific ranges of MBFR in patients without demonstrable coronary artery disease (CAD) has not been well established. Hypothesis/Aim: To determine the effect of age on MBF and MBFR in a cohort of patients without demonstrable CAD. Methods: Patients who underwent PET MPI studies from 2012-2022 on Siemens PET/CT cameras were included if Summed Stress Score=0, coronary calcium score=0, and left ventricular ejection fraction ≥50%. Those with prior history of MI or coronary intervention, heart/kidney/liver transplant, cirrhosis, or CKD stage IV+ were excluded. MBF was calculated using a net retention model (ImagenQ, Cardiovascular Imaging Technologies, Kansas City, MO) and multivariable linear regression models were developed to predict MBF. Results: Among 3,235 patients (age 59.5+/-12.6 years, 24.2% male) with median rest MBF 0.74 [0.61-0.92] and stress MBF 1.71 [1.41-2.10], MBFR was 2.28 [1.93-2.72]. With increasing age, rest MBF remained fairly stable while stress MBF and MBFR decreased, such that for every 10 years of age, stress MBF decreased by 0.07 [95% CI 0.05-0.08] mL/min/g and MBFR decreased by 0.12 [95% CI 0.11-0.14] after multivariable adjustment. Age-specific predicted MBFR values are documented in the Table. Conclusions: In patients without demonstrable CAD, the MBFR decreases with age. Abnormal MBFR values under 2.0 may be seen in a significant number of older patients.

Abstract 12297: A Rare Case of May-Thurner Syndrome Due to External Compression of the Right and Left Common Iliac Veins

Description of Case: A 54yr male with HTN and CKD stage IIIa presented with asymmetric right greater than left lower extremity (LE) edema. Vital signs were normal. His exam showed asymmetric right greater than left LE edema to the mid-thighs. ECG revealed sinus rhythm. Medical therapy with increasing titration of diuretics was unsuccessful in resolving his asymmetric LE edema. A TTE showed EF of 55-60% with normal bi-ventricular size and function and no significant valve abnormalities. Bilateral duplex US showed no DVT. CT abdomen pelvis showed no hydronephrosis or compressive masses. Right heart catheterization revealed normal bi-ventricular filling pressures. Bilateral peripheral venogram showed bilateral common iliac vein stenosis (Figure 1A). IVUS showed external compression of the right common iliac vein (RCIV) between the right external and internal iliac arteries with external compression of the left common iliac vein (LCIV) by the right common iliac artery (RCIA) against the lumbar spine (Figure 1A). A diagram of the compression observed in this case is included (Figure 1B). The RCIV had an 18mmHg gradient with no significant gradient on the LCIV. The RCIV was stented using an 18x60mm self-expanding stent and balloon dilation. Final IVUS and venogram showed no residual stenosis, edge dissection or perforation (Figure 1D). The patient was discharged on dual-antiplatelet therapy for three months and aspirin thereafter with continued diuretics. He had significant reduction in asymmetric LE edema with marked improvement in ambulation capacity and no further LE asymmetry at the 30-day follow-up visit. Discussion: Here we present a rare case of May-Thurner Syndrome via compression of the LCIV by the RCIA and RCIV by the right internal and external iliac arteries with successful management. We also illustrate the importance of a broad differential diagnosis in patients with persistent asymmetric LE edema refractory to diuretic management

Abstract 12450: Mystifying Masquerade: Renal Cell Carcinoma Associated Arteriovenous Fistula Presenting as High-Output Heart Failure

Case Presentation: 59 year-old woman with CKD stage 3b and hypertension presented with 3 months of progressive dyspnea, abdominal distension, bilateral lower extremity edema, and a 60-pound weight gain. Physical exam noted diffuse anasarca, with stable hemodynamics on room air. EKG revealed low voltage leads and chest X-ray demonstrated an enlarged cardiac silhouette. CT abdomen was remarkable for significant ascites, body wall edema, and a suspicious large right renal mass. Diagnostic paracentesis indicated cardiac ascites. Echocardiogram showed preserved ejection fraction, moderate pericardial effusion and an enlarged right side of the heart. Right heart catheterization confirmed high-output heart failure (HOHF). A suspected renal mass-related arteriovenous fistula (AVF) was confirmed through inferior vena caval and renal venogram blood gas sampling, indicating arteriovenous shunting within the renal mass. Hepatic venogram excluded portal hypertension. MRI abdomen confirmed a large necrotic right renal mass consistent with renal cell carcinoma (RCC). Symptoms significantly improved after nephrectomy, with aggressive diuresis, and therapeutic paracenteses leading to an 80-pound weight loss. Postoperative echocardiography illustrated decrease in pericardial effusion and right ventricular size. Cardiac MRI and stress test were unremarkable prior to planned immunotherapy for stage III RCC. Discussion: AVF and HOHF associated with malignancy are unusual presentations. RCC is the most prevalent underlying malignancy linked with AVF and is hypothesized to be a result of hypervascularity caused by a VHL gene mutation. The most often utilized imaging modalities for detecting a tumor-related AVF are contrast enhanced CT or MRI. When imaging is inconclusive, a venogram with blood gas sample, as observed in our case, may be considered to establish an RCC-associated AVF.

Strategies to Guide Preemptive Waitlisting and Equity in Waittime Accrual by Race/Ethnicity.

Use of eGFR to determine preemptive waitlisting eligibility may contribute to racial/ethnic disparities in access to waitlisting, which can only occur when the eGFR falls to ≤20 ml/min per 1.73 m 2 . Use of an alternative risk-based strategy for waitlisting may reduce these inequities ( e.g. , a kidney failure risk equation [KFRE] estimated 2-year risk of kidney failure) rather than the standard eGFR threshold for determining waitlist eligibility. Our objective was to model the amount of preemptive waittime that could be accrued by race and ethnicity, applying two different strategies to determine waitlist eligibility. Using electronic health record data, linear mixed models were used to compare racial/ethnic differences in preemptive waittime that could be accrued using two strategies: estimating the time between an eGFR ≤20 and 5 ml/min per 1.73 m 2 versus time between a 25% 2-year predicted risk of kidney failure (using the KFRE, which incorporates age, sex, albuminuria, and eGFR to provide kidney failure risk estimation) and eGFR of 5 ml/min per 1.73 m 2 . Among 1290 adults with CKD stages 4-5, using the Chronic Kidney Disease Epidemiology Collaboration equation yielded shorter preemptive waittime between an eGFR of 20 and 5 ml/min per 1.73 m 2 in Black (-6.8 months; 95% confidence interval [CI], -11.7 to -1.9), Hispanic (-10.2 months; -15.3 to -5.1), and Asian/Pacific Islander (-10.3 months; 95% CI, -15.3 to -5.4) patients compared with non-Hispanic White patients. Use of a KFRE threshold to determine waittime yielded smaller differences by race and ethnicity than observed when using a single eGFR threshold, with shorter time still noted for Black (-2.5 months; 95% CI, -7.8 to 2.7), Hispanic (-4.8 months; 95% CI, -10.3 to 0.6), and Asian/Pacific Islander (-5.4 months; -10.7 to -0.1) individuals compared with non-Hispanic White individuals, but findings only met statistical significance criteria in Asian/Pacific Islander individuals. When we compared potential waittime availability using a KFRE versus eGFR threshold, use of the KFRE yielded more equity in waittime for Black ( P = 0.02), Hispanic ( P = 0.002), and Asian/Pacific Islander ( P = 0.002) patients. Use of a risk-based strategy was associated with greater racial equity in waittime accrual compared with use of a standard single eGFR threshold to determine eligibility for preemptive waitlisting.

Comparative Safety of Antidepressants in Adults with CKD.

Depression is prevalent in patients with CKD and is related to poor prognosis. Despite the widespread use of antidepressants in the CKD population, their safety remains unclear. We identified adults with CKD stages G3-5 (eGFR <60 ml/min per 1.73 m 2 not treated with dialysis) and incident depression diagnosis during 2007-2019 from the Stockholm Creatinine Measurements project. Using the target trial emulation framework, we compared the following treatment strategies: ( 1 ) initiating versus not initiating antidepressants, ( 2 ) initiating mirtazapine versus selective serotonin reuptake inhibitors (SSRIs), and ( 3 ) initiating SSRIs with a lower dose versus a standard dose. Of 7798 eligible individuals, 5743 (74%) initiated antidepressant treatment. Compared with noninitiation, initiation of antidepressants was associated with higher hazards of short-term outcomes, including hip fracture (hazard ratio [HR], 1.23; 95% confidence interval [CI], 0.88 to 1.74) and upper gastrointestinal bleeding (HR, 1.38; 95% CI, 0.82 to 2.31), although not statistically significant. Initiation of antidepressants was not associated with long-term outcomes, including all-cause mortality, major adverse cardiovascular event, CKD progression, and suicidal behavior. Compared with SSRIs, initiation of mirtazapine was associated with a lower hazard of upper gastrointestinal bleeding (HR, 0.52; 95% CI, 0.29 to 0.96), but a higher hazard of mortality (HR, 1.11; 95% CI, 1.00 to 1.22). Compared with the standard dose, initiation of SSRIs with a lower dose was associated with nonstatistically significantly lower hazards of upper gastrointestinal bleeding (HR, 0.68; 95% CI, 0.35 to 1.34) and CKD progression (HR, 0.80; 95% CI, 0.63 to 1.02), but a higher hazard of cardiac arrest (HR, 2.34; 95% CI, 1.02 to 5.40). Antidepressant treatment was associated with short-term adverse outcomes but not long-term outcomes in people with CKD and depression.

CKD stage-specific utility of two equations for predicting 1-year risk of ESKD.

The Kidney Failure Risk Equation (KFRE) and Kaiser Permanente Northwest (KPNW) models have been proposed to predict progression to ESKD among adults with CKD within 2 and 5 years. We evaluated the utility of these equations to predict the 1-year risk of ESKD in a contemporary, ethnically diverse CKD population. We conducted a retrospective cohort study of adult members of Kaiser Permanente Northern California (KPNC) with CKD Stages 3-5 from January 2008-September 2015. We ascertained the onset of ESKD through September 2016, and calculated stage-specific estimates of model discrimination and calibration for the KFRE and KPNW equations. We identified 108,091 eligible adults with CKD (98,757 CKD Stage 3; 8,384 CKD Stage 4; and 950 CKD Stage 5 not yet receiving kidney replacement therapy), with mean age of 75 years, 55% women, and 37% being non-white. The overall 1-year risk of ESKD was 0.8% (95%CI: 0.8-0.9%). The KFRE displayed only moderate discrimination for CKD 3 and 5 (c = 0.76) but excellent discrimination for CKD 4 (c = 0.86), with good calibration for CKD 3-4 patients but suboptimal calibration for CKD 5. Calibration by CKD stage was similar to KFRE for the KPNW equation but displayed worse calibration across CKD stages for 1-year ESKD prediction. In a large, ethnically diverse, community-based CKD 3-5 population, both the KFRE and KPNW equation were suboptimal in accurately predicting the 1-year risk of ESKD within CKD stage 3 and 5, but more accurate for stage 4. Our findings suggest these equations can be used in1-year prediction for CKD 4 patients, but also highlight the need for more personalized, stage-specific equations that predicted various short- and long-term adverse outcomes to better inform overall decision-making.

Chronic Hyponatremia Is Independently Associated with Mortality at Each Stage of CKD

Chronic Hyponatremia Is Independently Associated with Mortality at Each Stage of CKD

Dietary Sodium and Potassium Intake Estimations in Different Stages of CKD by Multiple 24-Hour Urine Collections

Dietary Sodium and Potassium Intake Estimations in Different Stages of CKD by Multiple 24-Hour Urine Collections

Kidney Clearances of Protein-Bound Uremic Toxins in Various Stages of CKD and Their Predictive Role for Clinical Prognosis

Kidney Clearances of Protein-Bound Uremic Toxins in Various Stages of CKD and Their Predictive Role for Clinical Prognosis

Concordance Between Laboratory- and ICD-10 Code-Defined Stages of CKD Among Patients Hospitalized with Heart Failure in a Large US Integrated Health System

Concordance Between Laboratory- and ICD-10 Code-Defined Stages of CKD Among Patients Hospitalized with Heart Failure in a Large US Integrated Health System

Risk Factors for Progression to Kidney Failure in Patients with CKD Stages 3B and 4 in a Singaporean Cohort

Risk Factors for Progression to Kidney Failure in Patients with CKD Stages 3B and 4 in a Singaporean Cohort

Identifying CKD Stage 3 with Excess Disease Burden

Identifying CKD Stage 3 with Excess Disease Burden

Predictors for the Development of CKD Stage 2 or Higher in Repeat Pediatric Heart Transplant Recipients

Predictors for the Development of CKD Stage 2 or Higher in Repeat Pediatric Heart Transplant Recipients

Indexing to Body Surface Area Diminishes GFR Estimation and Increases CKD Staging in Overweight and Obese Population

Indexing to Body Surface Area Diminishes GFR Estimation and Increases CKD Staging in Overweight and Obese Population

Serum Myostatin Is Independently Associated with Endothelial Dysfunction in Non-Dialysis CKD Stages 3 to 5

Serum Myostatin Is Independently Associated with Endothelial Dysfunction in Non-Dialysis CKD Stages 3 to 5

The Relationship of Polypharmacy with Increasing CKD Stage

The Relationship of Polypharmacy with Increasing CKD Stage

Potential Value of Near Real-Time Transdermal GFR Measurement: Estimated GFR Results by CKD-EPI Serum Creatinine Misclassifies CKD Stage in One of Three Adults

Potential Value of Near Real-Time Transdermal GFR Measurement: Estimated GFR Results by CKD-EPI Serum Creatinine Misclassifies CKD Stage in One of Three Adults