Concomitant End-stage Renal Disease Research Articles

Abstract 12835: Predictors of Utilization of Multi-Vessel Percutaneous Coronary Revascularization vs. Bypass Surgery in Patients Hospitalized With Non-ST Wave Elevation Myocardial Infarction and Comorbid End-Stage Renal Disease: A Nationwide Analysis

Introduction: The appropriate strategy for revascularization in patients with coronary artery disease (CAD) and concomitant end-stage renal disease (ESRD) is unknown. The aim of this study was to determine the hospital and patient levels predictors of the type of revascularization strategy pursued in patients hospitalized with non-ST wave elevation myocardial infarction (NSTEMI) and ESRD. Methods: Study cohorts were derived from the Nationwide Inpatient Sample (NIS) 2016-19. Study variables were identified using ICD-10-CM-codes. Patients presenting with cardiogenic shock were excluded. The primary outcomes were the predictors of the type of revascularization strategy pursued. Multivariable logistic regression was used to adjust for potential confounders. Results: There were a total of 87,800 hospitalizations for NSTEMI with comorbid ESRD, out of which 8060 (53%) underwent multi-vessel PCI and 6909 (46%) underwent CABG. Patients undergoing CABG were younger, had a lower proportion of females, and higher burden of comorbidities (including arrhythmias, coagulopathy, valvular heart disease, morbid obesity, and active drug abuse disorder) than those undergoing MvPCI. Multivariate patient-level and hospital-level predictors are demonstrated in Figure 1. As expected, CABG was associated with significantly higher odds of in-hospital mortality (OR:2.01 (1.3-3.1), p<0.01), length of stay (8.9 days longer, p<0.01), and total hospitalization charges (152,527$ higher, p<0.01) as compared to MvPCI. There was no difference in the odds of stroke between both cohorts. Conclusion: Patient-level factors (including female gender, age, comorbidities (arrhythmias, peripheral vascular disease, diabetes, coagulopathy, history of CABG or PCI, prior stroke/TIA), and hospital levels factors (bed size, hospital procedural volume) independently predicted the type of revascularization strategy pursued in patients hospitalized for NSTEMI with ESRD.

Abstract 11740: Outcomes of Durable Left Ventricular Assist Device Implantation in Patients With End Stage Renal Diseases- Latest Outcomes From Nationwide Inpatient Sample (2015-2018)

Introduction: Left ventricular assist devices (LVAD) improve survival in patients with advanced heart failure however their use in patients with concomitant end stage renal disease (ESRD) is limited. Previous studies demonstrate higher mortality and morbidity in this subset of patients. Our aim was to assess in-hospital outcomes in patients who undergo LVAD implantation with and without ESRD in a national cohort. Methods: Using Nationwide Inpatient Sample (NIS) for years 2015-2018, all patients who underwent LVAD implantation during the hospitalization were identified. Cohort was divided into two groups, with and without ESRD. Baseline characteristics, comorbidities, in-hospital outcomes were compared between both the groups. Statistical significance was assigned at p<0.05. Analysis was performed using STATA. Results: A total of 7185 patients underwent LVAD implantation between 2015-2018. 150 patients (2.09%) had ESRD at baseline. Despite having similar baseline characteristics and comorbidities in both groups (Table 1), the in-hospital mortality was significantly higher in patients with ESRD (43.33% vs 7.46% p-value: 0.001). Similarly, patients in ESRD group had longer length of stay (92.56 ±11.6 days vs a 33.72±0.73 days, p=0.001) and their cost of stay was also significantly higher ($2,179,827 vs $915,699, p=0.001). After multivariable analysis, ESRD remained an independent predictor of inpatient mortality (OR: 3.68, 95% CI (1.06-12.6), p=0.03). The bleeding, infectious and thromboembolic outcomes (Table 2) were also significantly higher in patients with ESRD undergoing LVAD implantation. Conclusions: Patients who are ESRD and receive LVAD during their admission are at higher risk of mortality, bleeding, infectious and thromboembolic events. More studies are required to improve management strategies and identify specific subgroup of patients who would benefit from LVAD implantation in this subset.

Comparative analysis of revascularization with percutaneous coronary intervention versus coronary artery bypass surgery for patients with end-stage renal disease: a nationwide inpatient sample database

ABSTRACT Background The role of percutaneous coronary intervention (PCI) vs coronary artery bypass grafting (CABG) in patients with coronary artery disease (CAD) and concomitant end-stage renal disease (ESRD) remains unknown. Research design & methods The National Inpatient Sample (NIS) (2002–2017) was queried to identify all cases of CAD and ESRD. The relative merits of PCI vs CABG were determined using a propensity-matched multivariate logistic regression model. Adjusted odds ratios (aOR) for mortality and other in-hospital complications were calculated. Results A total of 350,623 [CABG = 112,099 (32%) and PCI = 238,524 (68%)] hospitalizations were included in the analysis. The overall adjusted odds for major bleeding (aOR 1.28, 95% CI 1.25–1.31, P < 0.0001), post-procedure bleeding (aOR 5.19, 95% CI 4.93–5.47, P < 0.0001), sepsis (aOR 1.29, 95% CI 1.26–1.33, P < 0.0001), cardiogenic shock (aOR 1.23, 95% CI 1.20–1.26, P < 0.0001), and in-hospital mortality (aOR 1.65, 95% CI 1.61–1.69, P < 0.0001) were significantly higher for patients undergoing CABG compared with PCI. The need for intra-aortic balloon pump (IABP) placement (aOR 2.52, 95% CI 2.45–2.59, P < 0.001) was higher in the CABG group, while the adjusted odds of vascular complications were similar between the two groups (aOR 0.99, 95% CI 0.94–1.06, P = 0.82). As expected, patients undergoing CABG had a higher mean length of stay and mean cost of hospitalization. Conclusion CABG in ESRD may be associated with higher in-hospital complications, increased length of stay, and higher resource utilization.

National Trends for Peripheral Artery Disease and End Stage Renal Disease From the National Inpatient Sample Database.

Peripheral artery disease (PAD), and subsequent chronic limb-threatening ischemia (CLTI), are frequently encountered among patients with end-stage renal disease (ESRD). Their coexistence is less favorable in comparison to patients with ESRD alone. We sought to investigate trends, comorbidities, determinants for cost, and prognostic outcomes in patients with concomitant ESRD and PAD. A retrospective analysis was performed using data from the National Inpatient Sample database from the years 2005-2014. ICD-9 codes were used to identify patients with diagnoses of PAD, CLTI, and ESRD. Pearson’s Chi-square, T-test, ANOVA, and multivariate binary logistic regression were used in this analysis. 7,214,843 patients with ESRD were identified. Of these, 123,499 patients were diagnosed with PAD and 102,447 with CLTI. Compared to ESRD alone, mortality rates increased with PAD and CLTI (5.7% vs. 13.9% vs. 15.9%, P < 0.001). Length of stay in days (7.3 vs. 10.2 vs. 11.1, P < 0.001) and in-hospital costs (59,872 vs. 85,866 vs. 89,016, P < 0.001) were higher with PAD and CLTI, respectively. CLTI demonstrated the highest independent predictor of mortality [OR = 6.93 (6.43-7.46), P < 0.001]. A decreasing trend in the rate of PAD (2005: 1.9% vs. 2014: 1.4%, P < 0.001) and CLTI (2005: 1.6% vs. 2014: 1.1%, P < 0.001) was noted. The presence of coexisting PAD, and furthermore CLTI, in patients with ESRD significantly raised in-hospital mortality, cost, and length of stay. A negative trend in rates of PAD and CLTI were observed. Proactive identification of this high-risk population may lead to accurate diagnosis and tailored therapeutic strategies.

A Case of Schmidt Syndrome Masqueraded by End Stage Renal Disease

Autoimmune Polyendocrine Syndromes (APS) are a rare manifestation of autoimmune diseases, this syndrome is composed by 5 types, nevertheless Type I (or juvenile) and Type II (or Adult) syndromes are the most common. APS II englobes Adrenal Insufficiency associated with Autoimmune thyroid disease or/and Diabetes Mellitus Type 1 [1]. We present and interest case of a patient with Autoimmune Hypothyroidism and Adrenal insufficiency whose diagnosis was delayed by masquerade of diagnosis by concomitant End Stage Renal disease.

SAFETY AND EFFICACY OF RIVAROXABAN COMPARED WITH WARFARIN IN END-STAGE RENAL DISEASE WITH ATRIAL FIBRILLATION: A META-ANALYSIS

Warfarin is widely used in atrial fibrillation (AF) with concomitant end-stage renal disease (ESRD) for stroke prophylaxis but has been associated with a ten-fold higher bleeding risk due to labile INR levels. Rivaroxaban emerged as a potential alternative in these patients but its safety and

Cardiovascular disease-related mortality risk in end stage renal disease and type 2 diabetes: A systematic review.

Background:Patients with uncontrolled type 2 diabetes can have microvascular and macrovascular complications, including renal impairment and cardiovascular diseases. However, it is unknown how diabetes and renal disease could influence cardiovascular mortality.Objective:This study aims at examining the medical literature to evaluate the risk of cardiovascular death in concomitant end stage renal disease with type 2 diabetes.Method:Medical literature was reviewed through Medline, PubMed, Embase, and Ovid database in the duration between 2009 and 2019. Searching terms included were a combination of “type 2 diabetes mellitus” AND “end-stage renal disease” AND “cardiovascular mortality”. Following this, results were filtered to include only original research articles investigating cardiovascular mortality in concomitant diabetes and end-stage renal disease. Selected trials mentioned diabetes control as well as the follow-up duration of the included patients.Result:A total of 1508 articles were retrieved. Following the exclusion of articles on animals and including only trials on humans, 32 articles appeared. A total of eight articles were identified as eligible, covering a total of 2,06,492 diabetic patients with end-stage renal disease. All the studies were prospective studies, except for three studies that were retrospective.Conclusion:There is an elevated cardiovascular mortality risk in concomitant type 2 diabetes mellitus and end-stage renal disease, especially with uncontrolled blood glucose levels.

Low Incidence of Bleeding Events With a Restrictive Platelet Transfusion Protocol in Patients With Cirrhosis and Concomitant End Stage Renal Disease

Introduction: Management of ascites in cirrhosis with concomitant end-stage renal disease (ESRD) presents a challenge as diuretic titration and transjugular portosystemic shunt (TIPS) effectiveness are limited. Patients are often managed with serial large volume paracentesis (LVPs); both quantitative and qualitative platelet dysfunction may increase LVP bleed risk. Society guidelines differ with respect to minimum platelet thresholds for safe LVP. The primary aim of this study was to characterize rate of bleeding in a population with cirrhosis and ESRD receiving LVP with a restrictive platelet transfusion strategy. Methods: Retrospective study of consecutive inpatients LVP at a tertiary medical center between January 2016 and December 2017. Institutional clinical census developed a protocol in which no patients received fresh frozen plasma (FFP), platelets or desmopressin prior to ultrasound guided LVP. Records tabulated: date/time of LVP, complete blood profile (CBC), INR and model for end stage liver disease (MELD score) on day of procedure, any blood products transfused during inpatient stay, and any angiogram procedures performed. Details of any secondary hospital encounter within 2 weeks of LVP reviewed. Results: 757 inpatients underwent usLVP. Mean INR, platelet count and MELD was 2.1 (1.7-2.8), 124 (11-157k) and 24 (21-36) respectively. 35% of patients had INRs > 2.0. 131 patients (17%) had platelet counts < 50k and 32 patients (4%) had < 30k. 260 patients (34%) were on renal replacement therapy RRT) at the time of usLVP. An additional 52 patients had Cr >2.0 (7%). Only 1 of 757 patients (0.13%) had post-LVP bleeding requiring transfusion of 2 units of packed red blood cells. No patient required angiogram intervention for bleeding and no patient died from LVP related complications. Conclusion: Incidence of bleeding with ultrasound guided LVP is very rare, even in a high risk patient population with severe renal dysfunction and thrombocytopenia. Prophylactic product transfusion or desmopressin do not appear warranted in this high risk population.

Does Losartan Prevent Progression of Early Diabetic Nephropathy in American Indians With Type 2 Diabetes?

Approximately 346 million individuals worldwide and 25.8 million individuals in the U.S. have diabetes (1,2). The high prevalence of diabetes results in a persistently increased prevalence of diabetic nephropathy, which is the leading cause of kidney failure and premature cardiovascular mortality (3). In the U.S., diabetic nephropathy is represented disproportionately in several minority populations including American Indians (4). Of the American Indian tribes in which type 2 diabetes develops at an alarming rate in children as a result of childhood obesity, the Pima Indians tend to have even higher rates of diabetic nephropathy (up to 65%; age-group 45–74 years) and concomitant end stage renal disease (ESRD; as high as 3.5 times) compared with white Americans (5–7). Fasting hyperglycemia and hemoglobin A1C are strong predictors of albuminuria in Pima Indians. Research has established that strict control of plasma glucose in the prediabetic stage can preempt a diagnosis of diabetes in some indigenous peoples (8). Further, in Pima Indians, the combination of macroalbuminuria and worsening estimated glomerular filtration rate (eGFR) strongly predict ESRD and death (9). Several large, well-designed clinical trials in diabetic cohorts have shown that blockade of the renin angiotensin system (RAS) prevents the progression of microalbuminuria to macroalbuminuria as well as the progression of macroalbuminuria to overt proteinuria and subsequent ESRD (10–12). Despite the fact that RAS blockade has shown no effect on primary prevention of diabetic nephropathy in mainly white, normotensive, normoalbuminuric, type 1 diabetic individuals, the importance of defining the renal outcome of RAS blockade in high-risk Pima Indians in particular cannot be overstated. Indeed, primary prevention of diabetic nephropathy in Pima Indians could potentially …

Successful treatment of bortezomib-refractory multiple myeloma derived from monoclonal gammopathy of undetermined significance with dose-adjusted lenalidomide therapy in a patient with concomitant end-stage renal disease due to diabetic nephropathy requiring haemodialysis.

Malignancy is a fatal complication of end-stage renal disease (ESRD) requiring haemodialysis. However, the successful treatment of haematological malignancies has been rarely reported. We describe the case of a 63-year-old man who presented with IgA-type multiple myeloma (MM; Durie-Salmon stage IIIB) derived from monoclonal gammopathy of undetermined significance concomitant with ESRD due to diabetic nephropathy. First, haemodialysis was initiated before chemotherapy, and bortezomib and dexamethasone were found to be ineffective. Subsequently, 8 courses of dose-adjusted lenalidomide therapy were administered according to the degree of haematological and renal functions. The patient remained in partial remission without disease progression for 21months. Thus, lenalidomide therapy is effective for bortezomib-refractory MM concomitant with ESRD.