Concomitant Chronic Kidney Disease Research Articles

Plasma Concentrations of Tranylcypromine in Depressed Patients With Chronic Kidney Disease: Two Case Reports.

The prevalence of comorbid depression and chronic kidney disease (CKD) is high. The aim of this brief report was to review 2 cases of treatment with tranylcypromine (TCP) in patients with treatment-resistant depression (TRD) and CKD. Tests of the plasma concentration of TCP were included. Medical and psychiatric notes of the 2 patients were reviewed with plasma concentrations of TCP as a key aspect of the discussion. The data are evaluated in the context of relevant medical and pharmacokinetic literature. Plasma concentrations of TCP are highly variable both in patients with and without CKD. Plasma concentrations of TCP were not increased in the 2 cases with CKD as compared with literature data of patients without CKD. No signs of intoxication were detected in 2 cases with CKD that impaired continuous treatment of depression with TCP. TCP may be considered in selected cases of TRD with concomitant CKD. More clinical data and tests of plasma concentrations of TCP are needed in patients with CKD.

Overview of the focal update (2023) of the recommendations of the European Society of Cardiology on the diagnosis and treatment of heart failure in 2021

In August 2021, the European Society of Cardiology published guidelines for the diagnosis and treatment of heart failure. In these recommendations, the main focus was on the treatment of patients with a low left ventricular ejection fraction (LVEF) ≤40 %, while the level of evidence for patients with LVEF between 41 % and 49 % was rather weak – IIbC. The studies that were conducted at that time were not specifically focused on patients with moderately reduced LVEF. Over the next two years, new data were obtained on the treatment of patients with moderately reduced and preserved LVEF, patients with concomitant chronic kidney disease (CKD), type 2 diabetes (type 2 diabetes), and iron deficiency. Therefore, in 2023, a focal update of the recommendations for the treatment of HF was published, the main provisions of which are presented in this review.

Cognitive function status in polymorbid patients with arterial hypertension, atrial fibrillation and chronic kidney disease

Background. Cognitive impairment is a public health problem. Polymorbid patients with arterial hypertension (AH), atrial fibrillation (AF), and chronic kidney disease (CKD) are at high risk of developing cognitive impairment, resulting in impaired quality of life, difficulty in medication adherence, and increased risk of mortality.Objective. To evaluate the cognitive status of polymorbid patients aged 60 years and older with essential AH and FP depending on the presence and stage of CKD.Materials and methods. 165 patients aged 60 years and older with essential AH and AF (80 [48.5 %] men, 85 [51.5 %] women, mean age was 82 [76; 85] years) were included and divided into three groups depending on the presence and stage of CKD: 55 (33.3 %) patients with AH and AF without CKD, 55 (33.3 %) patients with AH, AF, and CKD C 3a, and 55 (33.3 %) patients with AH, AF, and CKD C 3b. All patients included in the present study were examined for cognitive functions using a series of neuropsychological tests.Results. In the study of cognitive functions (Mini-mental State Examination, MMSE, Alzheimer Disease Assessment Scale-Cognitive (ADAS-cog), Digit Symbol Substitution Test (DSST), literature Association Test), it was found that the severity of cognitive impairment increased with increasing stage of CKD.Conclusions. The obtained results of the study indicate an unfavorable effect of CKD on cognitive functions in elderly and elderly patients with AH and FP. Thus, there is a need for regular monitoring and examination of patients with concomitant CKD for cognitive impairment.

Рrevention of contrast-induced nephropathy during interventional treatment of acute coronary syndrome

The aim of the work was to determine the risk factors of contrast-induced nephropathy in patients with acute coronary syndrome and to evaluate the effectiveness of methods of its prevention. There were examined 62 patients admitted to the interventional cardiology department during 9 months of routine practice with a diagnosis of acute coronary syndrome and concomitant chronic kidney disease. Among them, 56.45% have diabetic nephropathy, 21% – hypertensive nephro­pathy, 19.35% – chronic pyelonephritis, 3.2% – gouty nephropathy. According to the stages of chronic kidney disease: I stage – 8.1%, II stage – 46.8%, III A stage – 30.6%, III B stage – 14.5% of patients. The control group consisted of 32 patients with acute coronary syndrome without kidney pathology. All patients underwent urgent percutaneous coronary intervention using a water-soluble low-osmolarity radiocontrast medium. The risk of contrast-induced nephropathy was determined according to the Mehran scale. Contrast-induced nephropathy was diagnosed by an increase in serum creatinine over 24-48 hours by >25%. Prevention of contrast-induced nephropathy according to existing recommendations was carried out by prescribing early statin therapy and diuresis-controlled combined hydration in 22 patients with concomitant chronic kidney disease. Mathematical processing was performed using Statistica 8.0 software (StatSoft Inc, USA). Patients with chronic kidney disease had a high and very high risk of contrast-induced nephropathy in 19.4% and 3.2% of cases, among them in 91.6% of high and in 100% very high-risk contrast-induced nephropathy developed. Patients in the control group had a low to moderate risk, none of them developed contrast-induced nephropathy. It has been shown that the risk of contrast-induced nephropathy depends on the stage of chronic kidney disease and is associated with a decrease in the ejection fraction of the left ventricle (≤40%), acute left ventricle failure of the III and IV classes according to Killip, a decrease in diuresis in the first 12-24 hours after urgent percutaneous coronary intervention up to ≤0.6 ml/h/kg; in patients with diabetic nephropathy taking metformin 6-12 hours before the administration of the X-ray contrast medium and the glomerular filtration rate ≤45 ml/min./1.73 m2. In patients who underwent prevention of contrast-induced nephropathy in its entirety, its development was not registered.

Transcatheter left atrial appendage occlusion in patients with chronic kidney disease: a systematic review and meta-analysis.

Chronic kidney disease (CKD) is a risk factor for embolic stroke, and many nonvalvular atrial fibrillation (NVAF) patients have concomitant CKD. Anticoagulation therapy can be challenging in CKD due to increased bleeding risk, and left atrial appendage occlusion (LAAO) may be a promising alternative. This systematic review aimed to consolidate current evidence on the safety and effectiveness of transcatheter LAAO in patients with CKD and end-stage renal disease (ESRD). Medline, Cochrane, and Embase databases were searched from inception to September 2, 2022. We conducted a meta-analysis if an outcome was evaluated in at least two similar studies. We included 15 studies with 77,780 total patients. Of the 15 studies, 11 had a cohort design (five prospective and six retrospective), and four were case series. Patients with CKD were older and had a higher prevalence of comorbidities than non-CKD patients. The two groups did not differ in procedural failure rate, vascular complications, or pericardial tamponade. CKD patients exhibited higher odds of in-hospital acute kidney injury (AKI) and bleeding, longer-term bleeding, and mortality than those without CKD. The risk of in-hospital and longer-term cardioembolic events was similar between CKD and non-CKD populations (odds ratio = 1.01 [95% CI 0.70-1.15] and 1.05 [95% CI 0.55-2.00], respectively). Patients with ESRD had higher odds of in-hospital mortality and cardioembolic events than non-ESRD patients, with no differences in risk of pericardial tamponade. Based on observational studies, LAAO may be an effective option to prevent cardioembolic events in CKD. However, CKD patients may have higher odds of AKI and in-hospital and long-term bleeding and mortality. The adverse clinical outcomes observed in CKD patients may be attributed to this population's high burden of comorbidities, especially among those with ERSD, rather than the LAAO procedure itself. To ensure maximum clinical benefit, careful patient selection, management, and surveillance involving multidisciplinary teams are essential for CKD patients undergoing LAAO. Transcatheter Left Atrial Appendage Occlusion (laao) Can Prevent Cardioembolic Events In Chronic Kidney Disease (ckd) Patients. However, Ckd Patients, Particularly Those With End-stage Renal Disease/dialysis (esrd), May Face Increased Odds Of Acute Kidney Injury, In-hospital And Long-term Bleeding, And Mortality. Notably, These Adverse Outcomes In Ckd Patients May Be Linked To Their High Comorbidity Burden, Particularly In Those With Esrd, Rather Than The Laao Procedure Itself. Careful Patient Selection, Management, And Surveillance Involving Multidisciplinary Teams Are Essential For Ckd Patients Undergoing Laao To Ensure Maximum Clinical Benefit Transcatheter left atrial appendage occlusion (LAAO) can prevent cardioembolic events in chronic kidney disease (CKD) patients. However, CKD patients, particularly those with end-stage renal disease/dialysis (ESRD), may face increased odds of acute kidney injury, in-hospital and long-term bleeding, and mortality. Notably, these adverse outcomes in CKD patients may be linked to their high comorbidity burden, particularly in those with ESRD, rather than the LAAO procedure itself. Careful patient selection, management, and surveillance involving multidisciplinary teams are essential for CKD patients undergoing LAAO to ensure maximum clinical benefit.

Albuminuria in transthyretin cardiac amyloidosis: Prevalence, progression and prognostic importance.

Transthyretin cardiac amyloidosis (ATTR-CA) is an infiltrative cardiomyopathy that commonly presents with concomitant chronic kidney disease. Albuminuria is common in heart failure and associated with worse outcomes, but its prevalence and relationship to outcome in ATTR-CA remains unclear. A total of 1181 patients with ATTR-CA were studied (mean age 78.1 ± 7.9 years; 1022 [86.5%] male; median estimated glomerular filtration rate 59 ml/min/1.73m2 [interquartile range: 47-74]). Albuminuria was present in 563 (47.7%) patients (499 [88.6%] with microalbuminuria and 64 [11.4%] with macroalbuminuria). Patients with albuminuria had a more severe cardiac phenotype evidenced by higher serum cardiac biomarkers (median N-terminal pro-B-type natriuretic peptide [NT-proBNP]: 4027 ng/L [2173-6889] vs. 1851 ng/L [997-3209], p < 0.001; median troponin T: 69 ng/L [46-101] vs. 48 ng/L [34-68], p < 0.001) and worse echocardiographic indices of systolic (longitudinal strain: -10.0 ± 3.6% vs. -11.6 ± 3.8%, p < 0.001) and diastolic function (E/e': 17.5 ± 6.4 vs. 16.4 ± 6.7, p < 0.001) than those with a normal urinary albumin to creatinine ratio (UACR). Microalbuminuria and macroalbuminuria were independently associated with mortality in the overall population (hazard ratio [HR] 1.47, 95% confidence interval [CI] 1.13-1.92, p = 0.005 and HR 1.87, 95% CI 1.15-3.05, p = 0.012, respectively). In a subgroup of patients (n = 349) without concomitant hypertension, diabetes mellitus or chronic kidney disease, albuminuria was also associated with mortality (HR 2.98, 95% CI 1.72-5.17, p < 0.001). At 12 months, 330 patients had a repeat UACR measurement; those in whom UACR increased by 30% or more (n = 148, 44.8%) had an increased risk of mortality (HR 1.84, 95% CI 1.06-3.19, p = 0.030). Albuminuria is common in patients with ATTR-CA, and more prevalent in those with a more severe cardiac phenotype. Albuminuria at diagnosis and a significant increase in UACR during follow-up are associated with mortality.

Impact of diabetes status and chronic kidney disease on myocardial infarction mortality among elderly patients - a retrospective analysis of data from an ongoing nationwide registry

Abstract Background Prevalence of diabetes (DM) is rapidly increasing. With high rate of concomitant chronic kidney disease (CKD) in the elderly population the risk of cardiovascular (CV) complications is very high. Purpose Aim of our study was to evaluate the effect of DM status and CKD on mortality among elderly patients after acute myocardial infarction (AMI). Methods EMIR is an ongoing nationwide registry recording data from all patients in Estonia diagnosed with AMI (ICD-10 I21-I22). The study included all patients aged &amp;gt; 65 years who were hospitalized with the first AMI from 2012 to 2019. Data on glycated haemoglobin (HbA1c) in the time frame of 30 days prior to 7 days after admission, estimated glomerular filtration (eGFR) and creatinine levels within 24 hours of admission were obtained from the hospitals’ databases. Mortality data was acquired by linking the database to the Estonian population register. Follow up period lasted until the end of 2021. Prediabetes was defined as HbA1c ≥ 5,7 – 6,4 %, new DM as HbA1c ≥ 6,5 % without previous DM diagnosis. Information about previous DM diagnosis was acquired from EMIR. Statistical analysis was done using Cox proportional hazards regression model adjusted for age, sex, DM status and renal function. Results A total of 8902 patients (50.5 % women) were identified. Among female patients there was a larger proportion of diabetics and patients with lower eGFR (Table 1). We found that 30 day, 1-year and long – term (median 5.5 years) mortality was higher for both newly diagnosed (30 days: HR 1.6 (95 % CI 1.14 – 2.23); 1–year: HR 1.57 (95 % CI 1.25 – 1.99); long–term: HR 1.53 (95 % CI 1.29 – 1.81)) and known DM (30 days: HR 1.39 (95 % CI 1.19 – 1.61); 1–year: HR 1.28 (95 % CI 1.15 – 1.42); long–term: HR 1.47 (95 % CI 1.37 – 1.58)) patients. Prediabetes did not increase post MI mortality. In all follow up periods mortality increased progressively in accordance with declining renal function from eGFR below 59 ml/min/1.73m2 (Figure 1). Conclusions Our study suggests that newly diagnosed and known DM status and CKD have a considerable effect on elderly patients’ mortality after AMI, both in short and long term. Timely diagnosis and treatment of DM and CKD and meticulous secondary prevention can add to lowering mortality after AMI. However, our data also indicates that a more lenient medical management of prediabetes and mild CKD would be adequate for the elderly AMI patients in the current polypharmacotherapy era.Table 1.Figure 1.

Abstract 13981: Computed Tomography Angiography Measures of Carotid Artery Plaque Burden in Patients With Atherosclerotic Carotid Artery Disease Stratified by Status of Chronic Kidney Disease

Introduction: Atherosclerotic carotid artery disease (ACAD) is associated with an increased risk of cerebrovascular mortality and morbidity. We have analyzed associations of computed tomography angiography (CTA) measures of carotid artery (CA) plaque burden with chronic kidney disease (CKD). Hypothesis: CTA-based measures of CA plaque burden in patients with ACAD differ across stages of CKD. Methods: A total of 63 ACAD patients (13 without CKD, 50 with CKD), who completed CTA imaging and had demographic data were included in a retrospective analysis of patients from the Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC), Houston, Texas. CA plaque burden measures include the normalized wall index (NWI), wall area (WA), and lumen area (LA) at three distinct CA locations: CA bifurcation (BF), maximum total vessel cross-sectional area (MTVA) of the internal CA (ICA), and ICA peak stenosis (PS). CTA measures and patient demographics were compared across three CKD classes (no disease: n=13; CKD stages 1 and 2: n=31; and CKD stage 3 and above; n=19). Results: Baseline characteristics differed among CKD groups for the estimated glomerular filtration rate (p=&lt;0.0001) and the body mass index (p=0.046). Inter-observer variability, assessed by intraclass correlation (ICC) analysis, was excellent for CA lumen area and wall area (0.964 (confidence interval [CI]: 0.946, 0.976); 0.865 (CI: 0.804, 0.908): n=100 CTA slices, both). The mean NWI differed significantly among the CKD groups for two of the three CA locations (BF: p=0.018, MTVA: p=0.01; PS: p=0.057). Similarly, lumen area significantly differed between CKD categories (BF: p=0.045, MTVA: p=0.013; PS: p=0.017) but not the wall area. Conclusion: CTA-based measures of carotid plaque burden in ACAD patients are highly reproducible and differed across CKD groups. Imaging-based measures of CA plaque burden may be of interest in stratifying risk assessment of ACAD patients with concomitant CKD.

OA11 Osteoporosis, denosumab, and hypocalcaemia in multimorbid renal impairment

Abstract Introduction Osteoporosis affects approximately 30% of patients with chronic kidney disease (CKD) at stages 3-5, with 10% of women and 5% of men experiencing a fragility fracture within a given three-year follow up period. First-line management of osteoporosis with bisphosphonates is often precluded in CKD, with alendronate and zoledronate being contraindicated in creatinine clearances of &amp;lt; 35mL/min, and risedronate if &amp;lt; 30mL/min. Denosumab, a RANK-ligand inhibiting monoclonal antibody, can be used in cases of poorer renal function, however causes hypocalcaemia more commonly than bisphosphonates. Concomitant CKD compounds this risk if creatinine clearance falls below 30mL/min, presenting additional challenges for management. Case description A 75-year old woman with known osteoporosis and chronic kidney disease secondary to hypertension and a pauci-immune necrotising glomerulonephritis was found to have a serum calcium of 2.08mmol/L approximately three months after commencing six-monthly denosumab. Her lumbar spine T-score on dual x-ray absorptiometry showed severe osteoporosis at −2.9, with a fragility fracture of the humerus sustained four years prior. Her baseline eGFR was 23mL/min/1.73m2, and creatinine clearance was 22mL/min. Her past medical history was extensive and included secondary hyperparathyroidism due to CKD and resulting vitamin D deficiency, with a PTH of 23.0pmol/L, serum calcium of 2.26mmol/L, and a serum 25-OH vitamin D3 level of 33.5nmol/L four months prior to denosumab therapy. The history also included Sjögren’s syndrome on long-term daily prednisolone 7.5mg, alternate-day hydroxychloroquine 200mg, and daily leflunomide 10mg for accompanying synovitis of the hands, hypothyroidism controlled with daily levothyroxine 50mcg, hypertension controlled with daily 2.5mg bisoprolol, peripheral neuropathy secondary to vitamin B12 deficiency on three-monthly hydroxocobalamin, myocardial infarction with percutaneous coronary intervention to three arteries, diverticular disease with abscess perforation requiring laparotomy and intensive care admission, and a previous deep vein thrombosis on long-term anticoagulation with apixaban. The patient had received risedronate in the past while her creatinine clearance still permitted this. Her vitamin D deficiency had been managed orally with Adcal-D3 and colecalciferol 800IU once daily, which was uptitrated to 1600IU once daily prior to commencing denosumab. However, despite the patient’s serum vitamin D levels rising from 33.5 to 37.2nmol/L in the months preceding her first denosumab infusion, serum calcium had fallen below normal range on post-infusion blood tests. Serum phosphate returned at 0.91mmol/L, and vitamin D had fallen to 23.1nmol/L in the three months following denosumab treatment. Consequently, the patient was commenced on longer term intensive vitamin D supplementation. Discussion This case raises the issue of multifactorial hypocalcaemia against a backdrop of osteoporosis, persistent vitamin D deficiency, and medical comorbidity limiting management options. The significance of CKD in this case highlights the importance of monitoring and replacing vitamin D. While the hypocalcaemia detected at three months post-infusion may have occurred in part due to the direct effect of denosumab, the patient’s vitamin D deficiency no doubt also played a role in this, and failing to detect the deficiency may have resulted in premature termination of denosumab treatment. This case also highlights the extended timeframe in which such hypocalcaemia may present. Case-series literature describes hypocalcaemia manifesting at, on average, eight days post-infusion in patients with CKD-associated hyperparathyroidism. However we demonstrate here that extended lag times up to twelve weeks are possible; the patient was symptomatic with leg cramping at the time of clinic follow up. Future practice may benefit from establishing monitoring regimes for those with CKD and osteoporosis receiving denosumab, or bisphosphonates toward the lower end of permitted renal function. Key learning points Chronic kidney disease both limits available management options in osteoporosis, and increases the likelihood of complications from the remaining available agents – illustrated here with hypocalcaemia. Hypocalcaemia in a patient with chronic kidney disease and osteoporosis may be driven by several factors: hyperphosphataemia, vitamin D deficiency, and the effect of denosumab to prevent mobilisation of calcium from bone to serum can all be culprits. Calcium, phosphate, and vitamin D all need to be tightly monitored in medically complex patients on treatment for osteoporosis.

Cardiovascular treatment in chronic kidney disease

Patients with combined cardiac and renal diseases are particularly challenging in the routine clinical practice due to the substantial risk profile for increased morbidity and mortality. As cardiorenal patients have often been underrepresented in randomized, controlled interventional trials, guideline recommendations regarding the choice of treatment are often weaker for these individuals than for cardiovascular patients without chronic kidney disease. Furthermore, there are limitations in the approval of certain medications depending on the kidney function. This review addresses some considerations in crucial treatment areas for patients with cardiovascular diseases, whose treatment is significantly influenced by concomitant chronic kidney disease.

Role of Invasive Strategy for Non–ST-Elevation Myocardial Infarction in Patients With Chronic Kidney Disease: A Systematic Review and Meta-Analysis

Patients with chronic kidney disease (CKD) have traditionally been excluded from randomized trials. We aimed to compare percutaneous coronary intervention versus conservative management, and early intervention (EI; within 24hours of admission) versus delayed intervention (DI; after 24 to 72hours of admission) in patients with non-ST-segment elevation myocardial infarction (NSTEMI) and concomitant CKD. An electronic literature search was performed to search for studies comparing invasive management to conservative management or EI versus DI in patients with NSTEMI with CKD. The primary outcome was all-cause mortality; secondary outcomes were acute kidney injury (AKI) or dialysis, major bleeding, and recurrent MI. Hazard ratios (HRs) for the primary outcome and odds ratios for secondary outcomes were pooled in random-effects meta-analyses. Eleven studies (140,544 patients) were analyzed. Invasive management was associated with lower mortality than conservative management (HR0.62, 95%confidence interval 0.57 to 0.67, p<0.001, I2=47%), with consistent benefit across all CKD stages, except CKD 5. There was no significant mortality difference between EI and DI, but subgroup analyses showed significant benefit for EI in stage 1 to 2 CKD (HR0.75, 95%confidence interval0.58 to 0.97, p=0.03, I2=0%), with no significant difference in stage 3 and 4 to 5 CKD. Invasive strategy was associated with higher odds of AKI or dialysis and major bleeding, but lower odds of recurrent MI compared with conservative management. In conclusion, in patients with NSTEMI and CKD, an invasive strategy is associated with significant mortality benefit over conservative management in most patients with CKD, but at the expense of higher risk of AKI and bleeding. EI appears to benefit those with early stages of CKD. Trial Registration: PROSPERO CRD42023405491.

Impedance-based remote monitoring in patients with heart failure and concomitant chronic kidney disease.

Remote monitoring (RM) of thoracic impedance represents an early marker of pulmonary congestion in heart failure (HF). Chronic kidney disease (CKD) may promote fluid overload in HF patients. We investigated whether concomitant CKD affected the efficacy of impedance-based RM in the OptiLink HF trial. Among HF patients included in the OptiLink HF trial, time to the first cardiovascular hospitalization and all-cause death according to the presence of concomitant CKD was analysed. CKD was defined as GFR<60mL/min/1.73m2 at enrolment. Of the 1002 patients included in OptiLink HF, 326 patients (33%) had HF with concomitant CKD. The presence of CKD increased transmission of telemedical alerts (median of 2 (1-5) vs. 1 (0-3); P=0.012). Appropriate contacting after alert transmission was equally low in patients with and without CKD (57% vs. 59%, P=0.593). The risk of the primary endpoint was higher in patients with CKD compared with patients without CKD (hazard ratio (HR), 1.62 [95% confidence interval (CI), 1.16-2.28]; P=0.005). Impedance-based RM independently reduced primary events in HF patients with preserved renal function, but not in those with CKD (HR 0.68 [95% CI, 0.52-0.89]; P=0.006). The presence of CKD in HF patients led to a higher number of telemedical alert transmissions and increased the risk of the primary endpoint. Inappropriate handling of alert transmission was commonly observed in patients with chronic HF and CKD. Guidance of HF management by impedance-based RM significantly decreased primary event rates in patients without CKD, but not in patients with CKD.

13-LB: Treatment Patterns of Patients with Type 2 Diabetes Mellitus and Chronic Kidney Disease in Colombia

Aim: Describe treatment patterns of patients with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD) in outpatient setting from Colombia. Methods: We conducted a cross-sectional study characterizing treatment patterns of T2DM and CKD using the Audifarma S.A. drug dispensing database and included all patients with both diagnoses using ICD-10 codes and at least one disease-related prescription from April 1st 2019 to March 31st 2020. Sociodemographic variables, comorbidities, treatment received and combinations were evaluated. Drugs were classified as those for management of T2DM (oral antidiabetic agents, insulins, SGLT2i, GLP-1 analogs (GLP1a), dipeptidyl peptidase-4 inhibitors (DPP4i)), and others including renin angiotensin aldosterone system blockers (angiotensin converting enzyme inhibitors-ACEI, angiotensin receptor antagonists-ARBs) and mineralocorticoid receptor antagonists (MRAs). A descriptive analysis with frequencies and proportions, means and standard deviation was carried out. Results: Of a total of 194,023 patients with a primary diagnosis of T2DM, it was possible to identify that 14,722 (7.5%) had concomitant CKD, during the observation period. A total of 7513 (51%) were men, and the mean age was 74.7±10.9 years. The main comorbidities were hypertension (n=10665; 72.4%) and hypothyroidism (n=1138; 7.7%). The most used drugs were metformin (n=9901; 67.3%) alone or associated with some other antidiabetic, followed by 52.2% used DPP4i (n=7691), 17.0% an SGLT2i (n=2500), and 5.2% GLP-1a (n=766). Additionally, 67.2% (n=9895) of patients were under treatment with ARBs, 15.8% (n=2325) with ACEIs and 10.9% (n=1598) with MRAs. Conclusions: This contemporary study from Colombia further highlights the complexity and heterogeneity of treating patients with T2DM and CKD, which could be improved if the beneficial properties of newer agents that have shown positive anti-hyperglycemic and renal outcomes were implemented in the local treatment strategy. Disclosure M. Machado: Research Support; Bayer Inc., Pfizer Inc. A. Gaviria-mendoza: Employee; Audifarma S. A, Research Support; Bayer Inc., Pfizer Inc. J. S. Franco: Employee; Bayer Inc. M. D. R. Forero: Employee; Bayer Inc. D. Vizcaya: Employee; Bayer Inc. L. F. Valladales restrepo: Research Support; Bayer Inc., Pfizer Inc. J. E. Machado-alba: None. Funding Bayer AG

Glucagon-like peptide-1 receptor agonists use for type 2 diabetes mellitus in end-stage renal disease

BackgroundManagement of type 2 diabetes mellitus (T2DM) in patients with end-stage renal disease (ESRD) remains a challenge given limited data. Although current guidelines recommend use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) for the treatment of T2DM in patients with concomitant chronic kidney disease, supporting safety and efficacy evidence is lacking for patients with ESRD or hemodialysis. ObjectiveThis retrospective study was conducted to evaluate the efficacy and safety of GLP-1 RAs for the treatment of T2DM in patients with ESRD. Design, setting, and participantsThis is a single-centered, multifacility retrospective cohort analysis. Patients were included if they had a diagnosis of T2DM and ESRD and were prescribed a GLP-1 RA. Patients were excluded if the GLP-1 RA was prescribed solely for weight loss. Outcome measuresThe primary outcome was change in A1C. Secondary outcomes included (1) incidence of acute kidney injury (AKI), (2) change in weight, (3) change in estimated glomerular filtration rate, (4) ability to discontinue basal or bolus insulin, and (5) incidence of emergent hypoglycemia. ResultsThere were 46 unique patients and 64 individual GLP-1 RA prescriptions included. The mean reduction in A1C was 0.8%. There were 10 incidences of AKI, although none occurred in the semaglutide cohort. Emergent hypoglycemia occurred in 3 patients who were all prescribed concomitant insulin. ConclusionResults from this retrospective review provide additional real-world data on use of GLP-1 RAs in this unique population. Prospective studies to control for confounding factors are warranted given that GLP-1RAs are a safer alternative to insulin in this high-risk population.

Predictors of re-admission after COVID-19 hospitalizations in patients with underlying gastrointestinal malignancy.

e16327 Background: COVID-19 infections have been known to cause worse outcomes in patients with underlying co-morbid conditions. Currently, there is limited data regarding re-admissions in such patients after COVID-19 infection. So, we pursued to assess the rates, predictors, and causes of re-admission after COVID-19 infection in patients who had underlying gastrointestinal malignancy. Methods: The National Readmission Database for 2020 was analyzed to identify patients with COVID-19 hospitalizations who also had a co-diagnosis of GI malignancy. Data for re-admission was gathered, at 30 and 90 days after initial hospitalization. Multivariate logistic and linear regression analysis was used accordingly to adjust for possible confounders. Results: For 30 days: A total of 2,726 COVID-19 hospitalizations had a co-diagnosis of GI malignancy. The mean LOS (length of stay) for index admission was 8.7 days. The mean TOTCHG (total hospital charge) for index admission was $85,747. Within 30 days from discharge, 462 (21%) were re-admitted. The in-hospital mortality in re-admissions (18.4%) was quite similar to that for index hospitalization (18.5%). Positive predictors of re-admission include shorter length of stay during initial hospitalization (&lt;3 days), anemia, renal insufficiency/chronic kidney disease, and atherosclerosis of the aorta. Females had a lower chance of re-admission compared to males. Among the top causes of re-admission were ongoing COVID-19 infection (27%), sepsis (16.3%), acute kidney injury (2.4%), and metabolic encephalopathy (1.2%). For 90 days: A total of 1,782 COVID-19 hospitalizations had a co-diagnosis of GI malignancy. The mean LOS (length of stay) for index admission was 9.2 days. The mean TOTCHG (total hospital charge) for index admission was $90,908. Within 90 days from discharge, 411 (29%) were re-admitted. The in-hospital mortality in readmissions (14%) was lower than that for index hospitalization (20.3%). Predictors of re-admissions include secured insurance, anemia, renal insufficiency/chronic kidney disease, and cerebrovascular accidents. Top causes of re-admission were ongoing COVID-19 infection (18.5%), aspiration pneumonitis (2.9%), pneumonia (2.3%), and acute kidney injury (1.4%). Conclusions: Infections were the leading cause of re-admission, which is an important factor to consider when managing patients with GI malignancies due to sub-optimal immunity. Among these patients, those with concomitant anemia and chronic kidney disease were more prone to being re-admitted. Patients with GI malignancies also tended to have a higher length of stay, leading to higher charges, more exposure to nosocomial infections, and delays in cancer treatment leading to worse cancer outcomes. Pre-mature discharges, without medical optimization, can also potentially predispose to higher rates of re-admissions.

In-Hospital outcome of acute coronary syndrome in patients with Diabetes Mellitus with and without chronic Kidney disease

Background: Chronic kidney disease (CKD) and Diabetes Mellitus (DM) are highly prevalent, morbid diseases in every population. They are even more common among patients presenting with acute coronary syndromes (ACS). Objective: The present study was, conducted to see the outcome of ACS patients with concurrent DM and CKD. Methods: The cohort study was carried out in the Department of Medicine, Dhaka Medical College &amp; Hospital, Dhaka over a period six months from July 2017 to December 2017. All acute coronary syndrome patients having DM with or without CKD admitted in Medicine and Cardiology (CCU) Departments were the study population. ACS patients with concurrent DM with CKD formed the cohort group (n = 75) and DM without CKD were termed as control group (n = 75). Result: The study was concluded that the ACS patients with concomitant CKD and DM (cohort) are usually older and more often hypertensive than the ACS patients with CKD alone (control) (63.9 vs. 55.9 years, p &lt; 0.001 and 92% vs. 64%, p &lt; 0.001 respectively). The typical chest pain is less commonly observed (68% vs. 86.7%, p = 0.003) and dyspnoea is more often present in this cohort than those in the control (92% vs. 52%, p &lt; 0.001). NSTEMI is significantly present in the cohort compared that in the control group (p &lt; 0.001). Serum Troponin I, CKMB and eGFR were significantly higher in the former group than those in the latter group (p = 0.044, p = 0.050 and p &lt; 0.001 respectively). Almost all the outcome parameters demonstrated their significance. Conclusion: The diabetic with CKD (cohort group) is less likely to have ST elevations but is significantly prevalent having NSTEMI. Typical angina is less and dyspnea is more in cohort group. Bangladesh Medical Res Counc Bull 2022; 48: 133-137

A Retrospective Analysis of Sacubitril/Valsartan in Heart Failure and Chronic Kidney Disease.

Background: Sacubitril/valsartan has demonstrated benefit for patients with heart failure (HF); however, patients with advanced stages of chronic kidney disease (CKD) as defined by the National Kidney Foundation have historically been underrepresented in landmark HF trials. Objective: The goal of this study is to examine the safety and efficacy of sacubitril/valsartan in patients with HF and concomitant CKD stages III to V. Methods: This multicenter, retrospective, observational study included adult patients with HF and CKD stages III to V prescribed sacubitril/valsartan during hospital admission or upon discharge from January 2017 through March 2022. The primary outcome was the comparison of estimated glomerular filtration rate (eGFR) from baseline to 90 days. Key secondary outcomes included the comparison of the ejection fraction (EF) at 180 days, the rate of all-cause- and HF-related readmissions within 30 days, and adverse events. Results: Fifty patients were included in the analysis, with most patients (56%) having CKD stage IIIa. There was no difference in eGFR between baseline and 90 days (45.3 (11.2) mL/min/1.73 m2 vs 45.5 (18.6) mL/min/1.73 m2; P = 0.91). EF improved between baseline and 180 days (median 22.5% [17.5-27.5] vs 30.0% [22.5-42.5]; P < 0.001). Three patients (6%) were rehospitalized within 30 days for HF-related causes. There were 6 episodes (12%) of hyperkalemia greater than 5.0 milliequivalents per liter (mEq/L), and 2 episodes (4%) greater than 5.5 mEq/L. Conclusion: There was no significant difference in eGFR from baseline to 90 days in patients with HF and CKD prescribed sacubitril/valsartan during hospitalization, though there was an observed increase in EF.

Vessel-by-Vessel Computed Tomography Calcium Scoring of the Foot in Peripheral Artery Disease: Association with Patient-Level Factors.

Objective: Peripheral artery disease (PAD) is associated with increased risk of nonhealing ulcers, amputation, and mortality due to occlusive atherosclerotic plaques. Computed tomography (CT) imaging detects vascular calcification in PAD; however, quantitative vessel-by-vessel analysis of calcium burden in the feet of PAD patients has not been assessed. This study sought to perform quantitative analysis of vessel-specific calcium burden and examine the patient-level determinants of foot calcium burden in PAD patients. Approach: PAD patients (n = 41) were prospectively enrolled and underwent CT imaging of the lower extremities. Manual segmentation of the medial plantar, lateral plantar, and dorsalis pedis arteries was performed. CT image Hounsfield units (HUs) were obtained for each artery to quantify vessel-by-vessel calcium mass using a cutoff value of ≥130 HU. Univariate analyses were performed to evaluate patient-level determinants of calcium burden for each foot artery. STROBE guidelines were used for reporting of data. Results: Univariate analyses revealed that body mass index, diabetes mellitus (DM), and chronic kidney disease (CKD) were significant determinants of foot calcium burden in PAD patients. Image analysis demonstrated that PAD patients with DM had significantly higher calcium mass for the medial plantar (p = 0.005), lateral plantar (p = 0.039), and dorsalis pedis (p = 0.001) arteries compared with PAD patients without DM. Innovation: This is the first study to use CT imaging to quantify vessel-specific calcium burden in the feet of patients with PAD and evaluate the patient-level determinants of foot calcium burden in the setting of PAD. Conclusion: CT imaging quantifies vessel-specific calcification in the feet of PAD patients, which is exacerbated with concomitant DM, CKD, and/or obesity.

Impact of complex percutaneous coronary intervention features on clinical outcomes in patients with or without chronic kidney disease.

Patients with chronic kidney disease (CKD) are at higher risk of ischemic and bleeding events after percutaneous coronary intervention (PCI). Complex PCI (CPCI) is associated with higher rates of ischemic complications. Whether CPCI confers an additive risk of adverse events in CKD patients is unclear. Patients who underwent PCI at a single tertiary-care-center between 2012 and 2019 were stratified by CKD status and CPCI. The primary outcome was major adverse cardiac events (MACE), a composite of all-cause death, myocardial infarction (MI), and target-vessel revascularization (TVR) at 1-year follow-up. Secondary outcomes included the individual components of the primary outcome and major bleeding. Out of 15,071 patients, 4537 (30.1%) had CKD and 10,534 (69.9%) had no CKD. Patients undergoing CPCI were 1151 (25.4%) and 2983 (28.3%) in the two cohorts, respectively. At one year, CPCI compared with no CPCI was associated with higher risk of MACE in both CKD (Adj. HR1.72, 95% confidence interval [CI] 1.45-2.06, p < 0.001) and no-CKD patients (Adj.hazard ratios [HR]2.19, 95% CI 1.91-2.51, p < 0.001; p of interaction 0.057), determined by an excess of death, MI and TVR in CKD patients and of TVR and MI only in no-CKD. CPCI was related with a consistent increase of major bleeding in the CKD (Adj. HR1.49, 95% CI 1.18-1.87, p < 0.001) and no-CKD group (Adj. HR1.23, 95% CI 0.98-1.54, p = 0.071, p of interaction 0.206). At 1-year follow-up, CPCI was associated with higher risk of MACE and major bleeding irrespective of concomitant CKD. CPCI predicted mortality in CKD patients only.

Vessel-by-vessel analysis of lower extremity 18F-NaF PET/CT imaging quantifies diabetes- and chronic kidney disease-induced active microcalcification in patients with peripheral arterial disease

BackgroundPositron emission tomography (PET)/computed tomography (CT) imaging with fluorine-18 (18F)-sodium fluoride (NaF) provides assessment of active vascular microcalcification, but its utility for evaluating diabetes mellitus (DM)- and chronic kidney disease (CKD)-induced atherosclerosis in peripheral arterial disease (PAD) has not been comprehensively evaluated. This study sought to use 18F-NaF PET/CT to quantify and compare active microcalcification on an artery-by-artery basis in healthy subjects, PAD patients with or without DM, and PAD patients with or without CKD. Additionally, we evaluated the contributions of DM, CKD, statin use and established CT-detectable calcium to 18F-NaF uptake for each lower extremity artery.MethodsPAD patients (n = 48) and healthy controls (n = 8) underwent lower extremity 18F-NaF PET/CT imaging. Fused PET/CT images guided segmentation of arteries of interest (i.e., femoral-popliteal, anterior tibial, tibioperoneal trunk, posterior tibial, and peroneal) and quantification of 18F-NaF uptake. 18F-NaF uptake was assessed for each artery and compared between subject groups. Additionally, established calcium burden was quantified for each artery using CT calcium mass score. Univariate and multivariate analyses were performed to evaluate DM, CKD, statin use, and CT calcium mass as predictors of 18F-NaF uptake in PAD.ResultsPAD patients with DM or CKD demonstrated significantly higher active microcalcification (i.e., 18F-NaF uptake) for all arteries when compared to PAD patients without DM or CKD. Univariate and multivariate analyses revealed that concomitant DM or CKD was associated with increased microcalcification for all arteries of interest and this increased disease risk remained significant after adjusting for patient age, sex, and body mass index. Statin use was only associated with decreased microcalcification for the femoral-popliteal artery in multivariate analyses. Established CT-detectable calcium was not significantly associated with 18F-NaF uptake for 4 out of 5 arteries of interest.Conclusions18F-NaF PET/CT imaging quantifies vessel-specific active microcalcification in PAD that is increased in multiple lower extremity arteries by DM and CKD and decreased in the femoral-popliteal artery by statin use. 18F-NaF PET imaging is complementary to and largely independent of established CT-detectable arterial calcification. 18F-NaF PET/CT imaging may provide an approach for non-invasively quantifying vessel-specific responses to emerging anti-atherogenic therapies or CKD treatment in patients with PAD.