End-stage Renal Disease Death Research Articles

Temporal trends in hypertension related end stage renal disease mortality rates: an analysis of gender, race/ethnicity, and geographic disparities in the United States.

According to one USA Renal Data System report, 57% of end-stage renal disease (ESRD) cases are attributed to hypertensive and diabetic nephropathy. Yet, trends in hypertension related ESRD mortality rates in adults ≥ 35 years of age have not been studied. The aim of this retrospective study was to analyze the different trends hypertension related ESRD death rates among adults in the United States. Death records from the CDC (Centers for Disease Control and Prevention Wide-Ranging OnLine Data for Epidemiologic Research) database were analyzed from 1999 to 2020 for hypertension related ESRD mortality in adults ≥ 35 years of age. Age-Adjusted mortality rates (AAMRs) per 100,000 persons and annual percent change (APC) were calculated and stratified by year, sex, race/ethnicity, place of death, and geographic location. Hypertension-related ESRD caused a total of 721,511 deaths among adults (aged ≥ 35 years) between 1999 and 2020. The overall AAMR for hypertension related ESRD deaths in adults was 9.70 in 1999 and increased all the way up to 43.7 in 2020 (APC: 9.02; 95% CI: 8.19-11.04). Men had consistently higher AAMRs than woman during the analyzed years from 1999 (AAMR men: 10.8 vs women: 9) to 2020 (AAMR men: 52.2 vs women: 37.2). Overall AAMRs were highest in Non-Hispanic (NH) Black or African American patients (45.7), followed by NH American Indian or Alaska Natives (24.7), Hispanic or Latinos (23.4), NH Asian or Pacific Islanders (19.3), and NH White patients (15.4). Region-wise analysis also showed significant variations in AAMRs (overall AAMR: West 21.2; South: 21; Midwest: 18.3; Northeast: 14.2). Metropolitan areas had slightly higher AAMRs (19.1) than nonmetropolitan areas (19). States with AAMRs in 90th percentile: District of Columbia, Oklahoma, Mississippi, Tennessee, Texas, and South Carolina, had roughly double rates compared to states in 10th percentile. Overall hypertension related ESRD AAMRs among adults were seen to increase in almost all stratified data. The groups associated with the highest death rates were NH Black or African Americans, men, and populations in the West and metropolitan areas of the United States. Strategies and policies targeting these at-risk groups are required to control the rising hypertension related ESRD mortality.

Autosomal dominant polycystic kidney disease with ectopic unilateral multicystic kidney: a case report

BackgroundAutosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary renal disorder and the fourth cause of death of end-stage renal disease. The disease has a prevalence of 1:400–1:1000 accounting for 10% of patients on dialysis. In most ADPKD patients, bilateral kidneys are similarly affected, with numerous fluid-filled cysts arising from different nephron segments. Only a few cases of ADPKD with ectopic unilateral multicystic kidney have been reported. It has been observed that the deterioration of their kidney function seemed to be quicker than their age- and sex-matched controls and siblings especially when the ectopic kidney is dysplastic.Case presentationWe report a case of a 46-year-old Ghanaian male patient who presented with left flank pain and hematuria with high BP and deranged renal function. Abdominal ultrasonography showed both kidneys to be larger than normal and had multiple cysts of varying sizes with the right kidney located in the right iliac fossa. Follow up Abdominopelvic computer tomographic scan (CT–Scan) without contrast showed enlarged kidneys with the renal parenchyma replaced by innumerable cyst of varying sizes. The right kidney was ectopically located in the right aspect of the pelvis. A diagnosis of ADPKD with right pelvic ectopic multicystic kidney was made. He was put on antihypertensives, analgesia for the left flank pain and to have follow up at the urology and nephrology departments.ConclusionIn most ADPKD patients, bilateral kidneys are similarly affected. Only a few cases of ADPKD with ectopic unilateral multicystic kidney have been reported. It has been observed that the deterioration of their kidney function seemed to be quicker than their age- and sex-matched controls and siblings especially when the ectopic kidney is dysplastic.

Retinal changes and cardiac biomarker assessment in relation to chronic kidney disease: a single centre study

BackgroundThe prevalence of chronic kidney disease (CKD) is rising in Malaysia. Early detection is necessary to prevent disease progression, especially in terms of cardiovascular (CV) risk, the main cause of death in end-stage renal disease (ESRD). Retinal changes have proven to be a good predictor of CKD whereas cardiac biomarkers are useful in cardiovascular risk stratification. We aimed to demonstrate the correlation between retinal changes and cardiac biomarkers with CKD.MethodsThis single-centre cross-sectional study was conducted among patients with CKD stages 3, 4, and 5 (not on dialysis) from the Nephrology Clinic, Universiti Kebangsaan Malaysia Medical Centre. A total of 84 patients were recruited with an even distribution across all three stages. They underwent fundus photography where images were analysed for vessel calibre (central retinal venular equivalent (CRVE), central retinal arterial equivalent (CRAE), and tortuosity indices. Optical coherence tomography was used to measure macular volume. Blood samples were sent for laboratory measurement of high-sensitivity C-reactive protein (hs-CRP) and asymmetric dimethylarginine (ADMA). These parameters were analysed in relation to CKD.ResultsThe mean age was 58.8 ± 11.7 years, with 52.4% male and 47.6% female patients. Among them, 64.3% were diabetics. Retinal vessel tortuosity (r = -0.220, p-value = 0.044) had a negative correlation with the estimated glomerular filtration rate (eGFR). CRVE showed a positive correlation with proteinuria (r = 0.342, p = 0.001) but negative correlation with eGFR (r = -0.236, p = 0.031). Hs-CRP positively correlated with proteinuria (r = 0.313, p = 0.04) and negatively correlated with eGFR (r = -0.370, p = 0.001). Diabetic patients had a higher CRVE compared to non-diabetic patients (p = 0.02). History of ischaemic heart disease was associated with a smaller macula volume (p = 0.038). Male gender (r2 = 0.066, p = 0.031) and HbA1c had a positive influence (r2 = 0.066, p = 0.047) on retinal vessel tortuosity. There was a positive influence of age (r2 = 0.183, p = 0.012) and hs-CRP (r2 = 0.183, p = 0.045) on CRVE. As for macula volume, it negatively correlated with diabetes (r2 = 0.015, p = 0.040) and positively correlated with smoking (r2 = 0.015, p = 0.012).ConclusionOur study showed that eGFR value affects retinal vessel tortuosity, CRVE and hs-CRP. These parameters bear potential to be used as non-invasive tools in assessing CKD. However, only macula volume may be associated with CVD risk among the CKD population.

Association of Hypoalbuminemia with Risk of Death in Pediatric Patients with End Stage Renal Disease undergoing Hemodialysis: A Tertiary Care Experience in Pakistan

Background: One of the most important and common feature of chronic kidney disease is Hypoalbuminemia and is considered a poor prognostic factor. Low levels of Serum albumin are a predictor of growth failure and are strongly associated with increase death rate in pediatric patients undergoing hemodialysis with End Stage Renal Disease (ESRD), especially a challenge in underdeveloped countries. Aim: To evaluate the association of serum albumin level with hospitalization and rate of death in ESRD hemodialyzed pediatric patients. Study Design: Cohort study Place and Duration of Study: Department of Pediatric Nephrology, University of Child Health Sciences, Lahore from 1st January 2018 to 31st January 2022 Methodology: Ninety two children on hemodialysis and aged 5-16 years were included. Data including patient demographics, anthropometry, date of dialysis initiation, diagnosis, systolic and diastolic blood pressure, dialysis access (HD line/AV fistula), laboratory parameters, compliance to dialysis prescription, and frequency of hospitalization and combined duration of hospital stay was recorded. Results: The mean age at dialysis was 10.6±2.7 years with male to female ratio of 1.3:1. The mean duration on dialysis was 2.03±0.9 years. In our study, CAKUT (42.4%) was the most commonly occurring underlying etiology of end stage renal disease, followed by cystic renal disease (27.2%) and glomerular disease (15.2%) respectively. Regarding the systolic hypertension 22.9% were hypertensive and 35.8% were pre-hypertensive (BP 90th to 95th percentile). For diastolic hypertension, 18.5% were hypertensive and 42.4%were noted as pre-hypertensive. Majority of patients (87%) had hypoalbuminemia (serum albumin < 3.5 gm/dl) at dialysis initiation. In our study the value of serum albumin has inverse relationship with \risk of mortality in ESRD hemodialyzed patients even after adjustment to other factors. There is a 70% higher risk of death with each 1gm/dl decline in serum albumin value (hazard ratio=0.300(0.122-0.740) P<0.009). In addition, AVF access group has a significantly lower risk of death compared to the catheter group (hazard ratio=0.444 (0.246-0.801), P = 0.007). On generation of ROC curves, AUC obtained for serum albumin was statistically significant (AUC=0.838, 95% CI 0.758–0.918). In our study, no correlation was found between hypoalbuminemia and annual frequency of hospitalization (P<0.812) and total duration of stay (P<0.997).For mortality prediction, our study demonstrated a cut off value of albumin of 3g/dl with sensitivity of 80% and specificity of 68.7%. Conclusion: The independent prognostic value of serum albumin in mortality prediction at a cut off value of 3g/dl. In the final model even after adjustment of other covariates, hypoalbuminemia at dialysis initiation and type of vascular access continued to be vital indicator of risk of death in pediatric ESRD patients. However, no statistically significant association was observed between hypoalbuminemia and hospitalization in dialysis patients. Keywords: ESRD, Hypoalbuminemia, Growth failure, Haemodialysis

Trends in epidemiologic characteristics of end-stage renal disease from 2019 Korean Renal Data System (KORDS).

BackgroundThe Korean Society of Nephrology (KSN) has maintained a nationwide end-stage renal disease (ESRD) registry data from Korean Renal Data System (KORDS) since 1985, as the representative registry of ESRD patients in Korea. This review is aimed to update the status of domestic ESRD and to provide evidence on the direction of dialysis therapy.MethodsThe KORDS Committee of KSN has collected data on dialysis centers and patients through an online registry program, and the data from 1986 to 2019 were analyzed.ResultsThe incidence and prevalence of ESRD patients in Korea are increasing. The ESRD population numbered more than 100,000 in 2019, doubling during the 10 years since 2010. The proportion of diabetes mellitus as a major cause of ESRD seems to have reached a plateau. The increasing number of elderly dialysis patients is a constant trend, with more than half for the proportion of patients older than 65 years old in 2019. All-cause mortality decreased for the last approximately 20 years, regardless of sex, age, and cause of ESRD. The 5-year patient survival rate in both hemodialysis and peritoneal dialysis increased from 2001 to 2013. Since 2013, the patient survival rates in peritoneal dialysis were similar to those in hemodialysis. Cardiovascular complications were the leading cause of death in ESRD patients.ConclusionThe incidence and prevalence of Korean ESRD patients have increased over time, although patient survival has also steadily increased. The establishment of a surveillance method to address the major cause of mortality in ESRD patients will help improve outcomes.

Speckle-tracking echocardiography in comparison with ejection fraction for prediction of cardiovascular mortality in patients with end-stage renal disease.

BackgroundCardiovascular disease is the major cause of death in end-stage renal disease (ESRD). To develop better means to assess cardiovascular risk in these patients, we compared conventional echocardiography-derived left ventricular ejection fraction (EF) with the novel method of 2D speckle-tracking echocardiography to determine cardiac strain.MethodsPredictive performances of conventional EF and speckle-tracking echocardiography-derived global longitudinal strain (GLS) were compared using receiver-operator curve (ROC) analyses and calibration by calibration plots. We also took into account other known cardiovascular risk factors through multivariable logistic regression analysis. ResultsThe study comprised 171 ESRD patients (mean age 64 years, 64% male) on maintenance dialysis therapy (93% haemodialysis, 7% peritoneal dialysis) for an average period of 39 months. During 2.1 years of follow-up, 42 patients (25%) died from cardiovascular disease. ROC analysis of GLS resulted in an area under the curve of 0.700 [95% confidence interval (CI) 0.603–0.797] compared with an area under the curve of EF of 0.615 (95% CI 0.514–0.716) (P = 0.059 for difference). The total absolute deviation between predicted and observed outcome frequencies obtained by calibration plots were 13.8% for EF compared with only 6.4% for GLS. Best results of ROC analysis (area under the curve = 0.759; P = 0.06), calibration and goodness-of-fit (χ2 = 28.34, P ≤ 0.0001, R2 = 0.25) were achieved for GLS added to a baseline model consisting of known cardiovascular risk factors in a multivariate regression analysis. ConclusionsIn summary, in chronic dialysis patients, GLS is a more precise predictor of cardiovascular mortality than conventional echocardiography-derived EF.

Progression of coronary artery calcification in conventional hemodialysis, nocturnal hemodialysis, and kidney transplantation.

Cardiovascular disease is the leading cause of death in end-stage renal disease (ESRD) and is strongly associated with vascular calcification. An important driver of vascular calcification is high phosphate levels, but these become lower when patients initiate nocturnal hemodialysis or receive a kidney transplant. However, it is unknown whether nocturnal hemodialysis or kidney transplantation mitigate vascular calcification. Therefore, we compared progression of coronary artery calcification (CAC) between patients treated with conventional hemodialysis, nocturnal hemodialysis, and kidney transplant recipients. We measured CAC annually up to 3 years in 114 patients with ESRD that were transplantation candidates: 32 that continued conventional hemodialysis, 34 that initiated nocturnal hemodialysis (≥4x 8 hours/week), and 48 that received a kidney transplant. We compared CAC progression between groups as the difference in square root transformed volume scores per year (ΔCAC SQRV) using linear mixed models. Reference category was conventional hemodialysis. The mean age of the study population was 53 ±13 years, 75 (66%) were male, and median dialysis duration was 28 (IQR 12-56) months. Median CAC score at enrollment was 171 (IQR 10-647), which did not differ significantly between treatment groups (P = 0.83). Compared to conventional hemodialysis, CAC progression was non-significantly different in nocturnal hemodialysis -0.10 (95% CI -0.77 to 0.57) and kidney transplantation -0.33 (95% CI -0.96 to 0.29) in adjusted models. Nocturnal hemodialysis and kidney transplantation are not associated with significantly less CAC progression compared to conventional hemodialysis during up to 3 years follow-up. Further studies are needed to confirm these findings, to determine which type of calcification is measured with CAC in end-stage renal disease, and whether that reflects cardiovascular risk.

CARDIOVASCULAR DISEASE AFTER KIDNEY TRANSPLANTATION: A NATIONWIDE STUDY IN SOUTH KOREA

Background: Cardiovascular disease (CVD) is the most common cause of death in end-stage renal disease (ESRD). Kidney transplantation (KT) is an effective treatment for ESRD, and is known as lowering risk for CVD compared to the ESRD patients on the transplantation waiting list. However, there is a lack of large-population studies especially for Asians. Method: We analyzed the nationwide health insurance database of South Korea and identified patients who received kidney transplantation from the year of 2007 to 2015. Patients who were under 20 years of age, had previous CVD identified, or had multiorgan transplantation were excluded from the study. As controls, ESRD and GP groups were extracted after same exclusion and matching with KT recipients by age, sex, and inclusion year. CVD was defined as major cardiovascular events (MACEs) consisted of myocardial infarction, ischemic stroke, and all-cause mortality. Result: During the study period, a total of 13,179 patients received KT. After exclusion, 4,156 KT recipients were selected. The same number of ESRD and GP control were extracted after matching. Mean age was 41.3 ± 10.2 years and 55.2% were men in all 3 groups. KT recipients had similar proportions of diabetes and hypertension and a lower proportion of dyslipidemia compared with ESRD controls, although significantly higher co-morbidities than GP controls. The total number of MACEs was 76 (3.7 per 1000 person-year) in KT recipients, 377 (21.7 per 1000 person-year) in ESRD, 51 (2.5 per 1000 person-year) in GP, respectively. KT recipients showed a significantly lower MACE risk (adjusted HR 0.16, 95% CI 0.12-0.20, p <0.001) than ESRD controls. And the MACE risks were not significantly different between KT recipients and matched GP controls (adjusted HR 0.81, 95% CI 0.52-1.27, p=0.365). When subgroup analysis of age, sex, diabetes and hypertension was performed, similar trends were observed regardless of subgroups. Meanwhile, KT recipients who occurred MACE showed significant elevated risk of all-cause mortality and graft failure (HR 7.45, 95% CI 4.21-13.21, p<0.001 and HR 2.49, 95% CI 1.52-4.09, p<0.001, respectively). Conclusion: In this study, we found that the KT recipients had a lower risk of newly onset MACE after transplantation compared to patients maintaining dialysis in Korea, and showed a similar MACE risk compared to the general population.

SO011OXALATE-DEGRADING ACTIVITY IN FECAL MICROBIOTA ASSOCIATED WITH BLOOD LIPID PROFILE IN DIALYSIS PATIENTS

Abstract Background and Aims Cardiovascular disease (CVD) remains the leading cause of morbidity and death in end-stage renal disease (ESRD) patients. Thus, the accumulation of oxalate due to ESRD can increase the risk of CVD. Also, the ability of fecal oxalate-degrading activity (ODA) to reduce plasma oxalate levels has been discussed. On the other hand, despite a key role of atherogenic dyslipidemia in the development of CVD, only a few studies have shown a potential role of microbiota in the regulation of blood lipid profiles in the general population. However, at present, there is a general lack of research on this topic in dialysis patients. The present study aimed to investigate the association between oxalate-degrading activity (ODA) in fecal microbiota and blood lipid profiles in ESRD patients. Method We represented the data of a cross-sectional pilot study examining ODA in fecal microbiota, plasma oxalate concentration (POx) and blood lipid profile markers in 32 ESRD patients. Among the patients, there were 21 hemodialysis (HD) patients and 11 peritoneal dialysis (PD) patients. The average age of the patients was 52.5 [39; 65] years. The redoximetric titration with KMnO4 was adopted to evaluate total ODA in fecal microbiota. The results were expressed in % oxalate degradation per 0.01 g of feces. The blood lipid spectrum was determined in all patients: total cholesterol level (TC), high (HDL), low (LDL) and very low (VLDL) density cholesterol, triglycerides (TG) and atherogenic index of plasma (AIP). The median (Me) and interquartile ranges [Q25; Q75] were calculated using the nonparametric Kruskal-Wallis test. The Spearman test was used for the correlation analysis. Chi-square tests were used for comparison of 2 proportions. All statistical analyses were performed using MedCalc. Results Dyslipidemia defined as an increase in atherogenic lipoprotein fractions and inhibition of HDL cholesterol was identified in 13/32 (40.6%) ESRD patients. Negative ODA in fecal microbiota (≤ 0 % /0.01 g) was observed in 14/32 (43.7%) patients. Among them, there were 5/21 (23.8%) HD patients and 7/11 (63.6%) PD patients (χ2=3.9, p=0.04). Significantly lower ODA in fecal microbiota was observed in the patients with atherogenic dyslipidemia in comparison with dyslipidemia-free patients (-5.0 [-8.7; 3.7] vs 3.0 [0.5; 9] %/0.01 g of feces, p=0.02) (Fig. 1). Less ODA in fecal microbiota was, higher levels of TG (r=-0.5, p=0.004) (Fig. 2), VLDL (r=-0.34, p=0.05) (Fig. 3) and, accordingly, AIP (r=-0.38, p=0.03) (Fig. 4) occurred. Conclusion The results of our study have provided preliminary evidence on the fact that a decrease in total ODA in fecal microbiota is associated with atherogenic dyslipidemia. Further studies are needed to determine the role of fecal ODA in the formation of dyslipidemia.

P1263ASSOCIATION OF LEFT VENTRICULAR HYPERTROPHY AND ADIPOCYTOKINES IN PATIENTS ON DIALYSIS

Abstract Background and Aims Cardiovascular (CV) disease events are the major cause of death in end-stage renal disease (ESRD) patients on dialysis. Left ventricular hypertrophy, myocardial stress and disturbances in nutritional status are common findings in ESRD patients on dialysis. The adipokines, adiponectin and leptin, are known as important mediators of cardiometabolic risk in obesity, although their role in ESRD patients is poorly clarified. N-terminal pro B-type natriuretic peptide (NT-proBNP) is synthesized within cardiac myocytes, in response to cardiac wall stress. Our aim was to study the association of left ventricular hypertrophy with adipokines (adiponectin and leptin), myocardial stress (ProBNP) and nutritional status (BMI and albumin) in ESRD patients on dialysis. Method This study included 196 ESRD patients on dialysis (hemodiafiltration and high-flux hemodialysis). LVH was defined by a value of LVMI &amp;gt; 115 g/m2 in men and 95 g/m2 in women. Patients were divided into two groups - LVH (n=131) and non-LVH (n=65). Left ventricular mass (LVM) was evaluated through echocardiographic studies, corrected for body surface area and the values are presented as LVM index (LVMI). LVMI, clinical and analytical variables (age, body mass index, dialysis vintage, dialysis adequacy, albumin, adiponectin, leptin, NT-proBNP and hemoglobin concentration) were evaluated. Results The prevalence of LVH was 66.8%; LVH patients presented significantly higher levels for NT-proBNP, and significantly lower levels for hemoglobin, when compared with non-LVH patients; a trend towards (P=0.052) lower leptin values were observed. No differences were observed between groups, for age, BMI, dialysis vintage, URR, Kt/V, eKt/V, ultrafiltration volume, albumin and adiponectin. In LVH patients, we found that LVMI presented significant positive correlations with NT-proBNP and with adiponectin; and, significant negative correlations with markers of dialysis adequacy (URR and eKt/V) and leptin. Conclusion Our data suggest that a higher LVMI in ESRD patients is associated with higher myocardial stress, with lower leptin and higher adiponectin levels, showing no association of these adipokines with increased cardiovascular risk and with worsening of left ventricular hypertrophy. Further studies are needed to understand the roles of these adipokines, considering the controversial association with left ventricular hypertrophy, a cardiovascular risk condition. Acknowledgments: The work was supported by UIDB/04378/2020 with funding from FCT/MCTES through national funds, by North Portugal Regional Coordination and Development Commission (CCDR-N)/NORTE2020/Portugal 2020 (Norte-01-0145-FEDER-000024) and by REQUIMTE-Rede de Química e Tecnologia-Associação in the form of a researcher (S. Rocha) – project Dial4Life co-financed by FCT/MCTES (PTDC/MEC-CAR/31322/2017) and FEDER/COMPETE 2020 (POCI-01-0145-FEDER-031322).

P1581IMPACT OF ACHIEVING LDL CHOLESTEROL LOWER THAN 100 MG/DL WITH STATINS, ON LIPID PROFILE AND INFLAMMATION IN END-STAGE RENAL DISEASE PATIENTS

Abstract Background and Aims Dyslipidemia is common in chronic kidney disease (CKD) and cardiovascular disease (CVD)-related events are the main causes of death in end-stage renal disease (ESRD) patients on dialysis. Concerning lipid management, clinical practice emphasized treatment escalation to achieve specific low-density lipoprotein cholesterol (LDLc) targets, which implies repeated LDLc evaluations, and enhancement of statin doses or combination of lipid-lowering therapies. However, the LDLc target is not consensual, with some entities suggesting 100 mg/dl and others a more conservative level. It has been hypothesized that lipoprotein’s quality (size, composition and functionality) may be more important than their total circulating levels, as CVD risk factor. Our aim was to evaluate and compare, in ESRD patients on dialysis and under statins treatment, the levels of lipoprotein fractions and subfractions and inflammatory markers, between patients who achieved LDLc levels &amp;lt; 100 mg/dl and those who did not achieve that target. Method We studied 110 ESRD patients on dialysis (high-flux hemodialysis or hemodiafiltration) and under statin therapy; 87 presented a LDLc &amp;lt; 100 mg/dl (group 1) and 23 a value &amp;gt; 100 mg/dl (group 2); levels of high-sensitivity C-reactive protein (hsCRP), interleukin(IL)-6, lipid profile including lipoprotein fractions/subfractions, and oxidized LDL (oxLDL) were evaluated. Results Group 1, as compared to group 2, presented lower values of total cholesterol (TC), triglycerides, oxLDL, TC/high-density lipoprotein cholesterol (HDLc) and LDLc/HDLc ratios. Concerning lipoprotein fractions/subfractions, group 1 presented significantly higher larger and intermediate LDL, and a trend towards lower small LDL (P=0.063), higher large HDL (P=0.069) and lower small HDL (P=0.080); no significant alterations were found for very-low-density lipoprotein and intermediate-density lipoprotein. Regarding inflammatory markers, no significant differences were observed between the 2 groups. Conclusion Patients who achieved the LDLc &amp;lt; 100 mg/dl target presented a better non-conventional lipid profile, including lower oxLDL levels and an increase in larger (less atherogenic) LDL subfractions. According to our data, a lower LDLc level associates with a better lipid profile; the benefits of this improvement on HDL fractions and CVD-related events in ESRD patients on dialysis needs to be better clarified.

Dialysis patients who smoke are more hypertensive, more fluid overloaded and take more antihypertensive medications than nonsmokers

Background Smoking remains a powerful risk factor for death in end-stage renal disease (ESRD) and so is the presence of fluid overload. The relationship between smoking, blood pressure (BP) control and volume overload is insufficiently explored in patients on maintenance dialysis. Methods This is a retrospective cross-sectional cohort study, utilizing existing patients’ data generated during routine ESRD care, including bimonthly protocol bioimpedance fluid assessment of the volume status. Results We analyzed the data of 63 prevalent patients receiving thrice weekly maintenance hemodiafiltration treatments at one rural dialysis unit in Hungary. The cohort’s mean ± SD age was 61.5 ± 15.3 years; 65% male, 38% diabetic, with a mean arterial blood pressure (MAP) 99.5 ± 16.8 mmHg and Charlson score 3.79 ± 2.04. Of these, 38 patients were nonsmokers and 25 smokers. The nonsmokers’ MAP was 94.3 ± 14.0 versus smokers’ 105.9 ± 18.9 mmHg (p: .002); nonsmokers took an average 0.73 ± 0.92 antihypertensive medications vs. 1.73 ± 1.21 for smokers (p: .0001). The distribution of taking more antihypertensive medications is skewed toward a higher number among the smokers (2x5 chi square p: .004). By bioimpedance spectroscopy, nonsmokers had an average 10.93 ± 7.65 percent overhydration (OH) over the extracellular space compared to 17.63 ± 8.98 in smokers (p: .005). Conclusions Smoking may be a significant mediator of not only BP but also of chronic fluid overload in ESRD patents. Additional, larger studies are needed to explore the mechanistic link between smoking and volume overload.

The value of malnutrition-inflammation-atherosclerosis (MIA) syndrome for predicting mortality in patients with end-stage renal disease at Hue Central Hospital

Background: the role of malnutrition, inflammation, atherosclerosis, and particularly the combination of these three factors were closely related to cardiovascular events, hospitalisation frequency, and death in end-stage renal disease (ESRD) patients. This study examines the relationship between malnutrition-inflammation-atherosclerosis (MIA) syndrome and mortality among these patients during an 18-month period.Subjects and methods: in this prospective observational cohort study, all cause-mortalitywas evaluated during an 18-month follow-up period. A total of 174 patients with ESRD (including 57 non-dialysis patients, 56 peritoneal dialysis patients, and 61 hemodialysis patients) were enrolled. M (malnutrition) was assessed by the seven-point subjective global assessment (SGA), serum albumin. I (inflammation) was assessed by serum hs-CRP, serum IL-6. A (atherosclerosis) was defined asIMT ≥0.9 mm or the presence of plaque in the carotid artery. The patients are classified into four groups by number of components (MIA0, MIA1, MIA2, MIA3). Results: 73.6% of patients had at least one component of MIA syndrome. The proportion of patients with malnutrition, inflammation, and atherosclerosis accounted for 36.8%, 21.3%, and 50.6%, respectively. The proportion of patients with 3, 2, 1 component accounted for 4.0, 27.0, and 42.5%. There was no difference between MIA groups based on age, sex, percentage suffering from dyslipidemia, anemia, or Hb levels. Relative to patients experiencing no elements of MIA syndrome, patients with three components experienced a 13.16 times higher risk of mortality. Only malnutrition was a strong predictor of mortality with HR (95% CI): 5.90 (2.46-14.14).Conclusion: clinical physicians should attend more closely to and provideearly assessments ofMIA syndrome in patients with ESRD. They should care for nutrition conditions and thereby provide early and effective treatments. This can contribute to enhancements in quality of life, and decrease mortalityrates inpatients.

Risk of Cardiovascular Disease and Mortality in Young Adults With End-stage Renal Disease

Cardiovascular disease (CVD) is a leading cause of death among patients with end-stage renal disease (ESRD). Young adult (ages 22-29 years) have risks for ESRD-associated CVD that may vary from other ages. To test the hypothesis that young adult-onset ESRD is associated with higher cardiovascular (CV) hospitalizations and mortality with different characteristics than childhood-onset disease. This population-based cohort study used the US Renal Data System to categorize patients who initiated ESRD care between 2003 and 2013 by age at ESRD onset (1-11, 12-21, and 22-29 years). Cardiovascular hospitalizations were identified via International Classification of Diseases, Ninth Revision discharge codes and CV mortality from the Centers for Medicare & Medicaid ESRD Death Notification Form. Patients were censored at death from non-CVD events, loss to follow-up, recovery, or survival to December 31, 2014. Adjusted proportional hazard models (95% CI) were fit to determine risk of CV hospitalization and mortality by age group. Data analysis occurred from May 2016 and December 2017. Onset of ESRD. Cardiovascular mortality and hospitalization. A total of 33 156 patients aged 1 to 29 years were included in the study population. Young adults (aged 22-29 years) had a 1-year CV hospitalization rate of 138 (95% CI, 121-159) per 1000 patient-years. Young adults had a higher risk for CV hospitalization than children (aged 1-11 years; hazard ratio [HR], 0.41 [95% CI, 0.26-0.64]) and adolescents (aged 12-21 years; HR, 0.86 [95% CI, 0.77-0.97]). Of 4038 deaths in young adults, 1577 (39.1%) were owing to CVD. Five-year cumulative incidence of mortality in this group (7.3%) was higher than in younger patients (adolescents, 4.0%; children, 1.7%). Adjusted HRs for CV mortality were higher for young adults with all causes of ESRD than children (cystic, hereditary, and congenital conditions: HR, 0.22 [95% CI, 0.11-0.46]; P < .001; glomerulonephritis: HR, 0.21 [95% CI, 0.10-0.44]; P < .001; other conditions: HR, 0.33 [95% CI, 0.23-0.49]; P < .001). Adolescents had a lower risk for CV mortality than young adults for all causes of ESRD except glomerulonephritis (cystic, hereditary, and congenital conditions: HR, 0.45 [95% CI, 0.27-0.74]; glomerulonephritis: HR, 0.99 [95% CI, 0.76-1.11]; other: HR, 0.47 [95% CI, 0.40-0.57]). Higher risks for CV hospitalization and mortality were associated with lack of preemptive transplant compared with hemodialysis (hospital: HR, 14.24 [95% CI, 5.92-34.28]; mortality: HR, 13.64 [95% CI, 8.79-21.14]) and peritoneal dialysis [hospital: HR, 8.47 [95% CI, 3.50-20.53]; mortality: HR, 7.86 [95% CI, 4.96-12.45]). Nephrology care before ESRD was associated with lower risk for CV mortality (HR, 0.77 [95% CI, 0.70-0.85]). Cardiovascular disease accounted for nearly 40% of deaths in young adults with incident ESRD in this cohort. Identified risk factors may inform development of age-appropriate ESRD strategies to improve the CV health of this population.

The Protective Role of Adiponectin for Lipoproteins in End-Stage Renal Disease Patients: Relationship with Diabetes and Body Mass Index.

Cardiovascular disease (CVD) events are the main causes of death in end-stage renal disease (ESRD) patients on dialysis. The number and severity of CVD events remain inappropriate and difficult to explain by considering only the classic CVD risk factors. Our aim was to clarify the changes and the relationship of lipoprotein subfractions with other CVD risk factors, namely, body mass index (BMI) and adipokines, inflammation and low-density lipoprotein (LDL) oxidation, and the burden of the most prevalent comorbidities, diabetes mellitus (DM) and hypertension (HT). We studied 194 ESRD patients on dialysis and 22 controls; lipid profile, including lipoprotein subpopulations and oxidized LDL (oxLDL), C-reactive protein (CRP), adiponectin, leptin, and paraoxonase 1 activity were evaluated. Compared to controls, patients presented significantly lower levels of cholesterol, high-density lipoprotein cholesterol (HDLc), LDLc, oxLDL, and intermediate and small HDL and higher triglycerides, CRP, adiponectin, large HDL, very-low-density lipoprotein (VLDL), and intermediate-density lipoprotein- (IDL) B. Adiponectin levels correlated positively with large HDL and negatively with intermediate and small HDL, oxLDL/LDLc, and BMI; patients with DM (n = 17) and with DM+HT (n = 70), as compared to patients without DM or HT (n = 69) or only with HT (n = 38), presented significantly higher oxLDL, oxLDL/LDLc, and leptin and lower adiponectin. Obese patients (n = 45), as compared to normoponderal patients (n = 81), showed lower HDLc, adiponectin, and large HDL and significantly higher leptin, VLDL, and intermediate and small HDL. In ESRD, the higher adiponectin seems to favor atheroprotective HDL modifications and protect LDL particles from oxidative atherogenic changes. However, in diabetic and obese patients, adiponectin presents the lowest values, oxLDL/LDLc present the highest ones, and the HDL profile is the more atherogenic. Our data suggest that the coexistence of DM and adiposity in ESRD patients on dialysis contributes to a higher CVD risk, as showed by their lipid and adipokine profiles.

TpTe and TpTe/QT: novel markers to predict sudden cardiac death in ESRD?

ABSTRACTIntroduction:Reliable markers to predict sudden cardiac death (SCD) in patients with end stage renal disease (ESRD) remain elusive, but echocardiogram (ECG) parameters may help stratify patients. Given their roles as markers for myocardial dispersion especially in high risk populations such as those with Brugada syndrome, we hypothesized that the Tpeak to Tend (TpTe) interval and TpTe/QT are independent risk factors for SCD in ESRD.Methods:Retrospective chart review was conducted on a cohort of patients with ESRD starting hemodialysis. Patients were US veterans who utilized the Veterans Affairs medical centers for health care. Average age of all participants was 66 years and the majority were males, consistent with a US veteran population. ECGs that were performed within 18 months of dialysis initiation were manually evaluated for TpTe and TpTe/QT. The primary outcomes were SCD and all-cause mortality, and these were assessed up to 5 years following dialysis initiation.Results:After exclusion criteria, 205 patients were identified, of whom 94 had a prolonged TpTe, and 61 had a prolonged TpTe/QT interval (not mutually exclusive). Overall mortality was 70.2% at 5 years and SCD was 15.2%. No significant difference was observed in the primary outcomes when examining TpTe (SCD: prolonged 16.0% vs. normal 14.4%, p=0.73; all-cause mortality: prolonged 55.3% vs. normal 47.7%, p=0.43). Likewise, no significant difference was found for TpTe/QT (SCD: prolonged 15.4% vs. normal 15.0%, p=0.51; all-cause mortality: prolonged 80.7% vs. normal 66.7%, p=0.39).Conclusions:In ESRD patients on hemodialysis, prolonged TpTe or TpTe/QT was not associated with a significant increase in SCD or all-cause mortality.

The role of kidney transplantation and phosphate binder use in vitamin K status.

BackgroundCardiovascular disease is the leading cause of death in end-stage renal disease and is strongly associated with vascular calcification. Both kidney transplantation and phosphate binders may lower the risk of vascular calcification. Vascular calcification is actively inhibited by vitamin-K-dependent matrix γ-carboxyglutamic acid protein (MGP). Whether kidney transplantation or phosphate binders affect vitamin K status is unknown. Therefore, we studied the influence of kidney transplantation and phosphate binder use on vitamin K status.MethodsWe measured plasma desphospho-uncarboxylated MGP (dp-ucMGP), a marker reflecting low vitamin K status, in a cross-sectional study of patients on hemodialysis (n = 82), peritoneal dialysis (n = 31) or who recently received a kidney transplantation (n = 36). By medication inventory, we assessed phosphate binder use. With linear regression, we assessed the influence of kidney transplantation and phosphate binder use on natural-log-transformed dp-ucMGP, adjusting for potential confounders.ResultsMean age of patients was 52±13 years; 102 (68%) were male. Dp-ucMGP levels were significantly lower in kidney transplant recipients (median 689 pmol/L) compared to patients on dialysis (median 1537 pmol/L, p<0.001). Eighty-nine patients on dialysis used phosphate binders. Using any phosphate binder was not associated with dp-ucMGP levels (median 1637 pmol/L, p = 0.09) compared to no phosphate binders (median 1142 pmol/L). Twenty-six patients used sevelamer monotherapy, which was associated with higher dp-ucMGP levels (median 1740 pmol/L, p = 0.04) after adjusting for age, sex and vitamin K antagonist use.ConclusionsRecent kidney transplantation is associated with lower dp-ucMGP levels suggesting improved vitamin K status after transplantation. Sevelamer monotherapy is associated with higher dp-ucMGP levels suggesting worsening of vitamin K status. Both findings warrant more attention to vitamin K status in patients on dialysis, as vitamin K is necessary for protection against vascular calcification.

Monitoring Volume Status Using Bioelectrical Impedance Analysis in Chronic Hemodialysis Patients.

Fluid overload can be an independent risk factor of cardiovascular events and all-cause death in end-stage renal disease (ESRD) patients on chronic hemodialysis. We performed a retrospective study to investigate whether intermittent control of fluid status decreases the rate of these complications using bioelectrical impedance analysis (BIA). In ESRD patients on chronic hemodialysis, we identified the ratio of extracellular water to total body water (ECW/TBW) every 6 months using InBody S10 (Biospace, Seoul, Korea), which was measured within 30 minutes after dialysis initiation on the first dialysis day of the week. The uncontrolled group included 57 (40.1%) patients with all ECW/TBW measurements ≥0.40; in contrast, the controlled group included 85 (59.9%) with any measured ECW/TBW <0.40. Included patients were followed for 29 (12-42) months. The risk of cardiovascular events was higher in the uncontrolled group (hazard ratio [HR], 2.4; 95% confidence interval [CI], 1.2-5.1; p < 0.05) than it was in the controlled group; however, this difference disappeared after adjusting for age, sex, and Charlson comorbidity index (not significant). On the other hand, the patients in the uncontrolled group had a higher risk of all-cause death than did those in the controlled group, independent of age, sex, and Charlson comorbidity index (HR, 4.7; 95% CI, 1.4-16.1; p < 0.05). In conclusion, monitoring volume status using BIA may help to predict all-cause death in chronic hemodialysis patients. Further controlled studies are needed to confirm that strict volume control could reduce the rates of cardiovascular events and mortality in this population.

Clinical Factors and Outcomes of Dialysis-Dependent End-Stage Renal Disease Patients with Emergency Department Septic Shock

BackgroundInfection is the second leading cause of death in end-stage renal disease (ESRD) patients. Prior investigations of acute septic shock in this specific population are limited. ObjectiveWe aimed to evaluate the clinical presentation and factors associated with outcome among ESRD patients with acute septic shock. MethodsWe reviewed patients prospectively enrolled in an emergency department (ED) septic shock treatment pathway registry between January 2014 and May 2016. Clinical and treatment variables for ESRD patients were compared with non-ESRD patients. A second analysis focused on ESRD septic shock survivors and nonsurvivors. ResultsAmong 4126 registry enrollees, 3564 (86.4%) met inclusion for the study. End-stage renal disease was present in 3.8% (n = 137) of ED septic shock patients. Hospital mortality was 20.4% and 17.1% for the ESRD and non-ESRD septic shock patient groups (p = 0.31). Septic shock patients with ESRD had a higher burden of chronic illness, but similar admission clinical profiles to non-ESRD patients. End-stage renal disease status was independently associated with lower fluid resuscitation dose, even when controlling for severity of illness. Age and admission lactate were independently associated with mortality in ESRD septic shock patients. ConclusionESRD patients comprise a small but important portion of patients with ED septic shock. Although presentation clinical profiles are similar to patients without ESRD, ESRD status is independently associated with lower fluid dose and compliance with the 30-mL/kg fluid goal. Hyperlactatemia is a marker of mortality in ESRD septic shock.

Associations of genetic variants of endothelin with cardiovascular complications in patients with renal failure

BackgroundCardiovascular (CV) complications are the main cause of death in end-stage renal disease (ESRD) patients. The high CV risks are attributable to the additive effects of multiple factors. Endothelin (EDN) is a potent vasoconstrictor and plays a role in regulating vascular homeostasis. However, whether variants of the EDN gene are associated with risks of CV events is not known. We conducted a study to investigate associations of variants of the EDN gene with CV events in ESRD patients.MethodsA cohort of 190 ESRD patients was recruited, and 19 tagged single-nucleotide polymorphisms within the EDN gene family were selected for genotyping through a TaqMan assay. Data on clinical characteristics and hospitalizations for CV events were collected. Associations of genetic variants of the EDN gene with CV events were analyzed.ResultsIn this cohort, 62% (n = 118) of patients were hospitalized for a CV event. The EDN1 rs4714384 (CC/TC vs. TT) polymorphism was associated with an increased risk of a CV event after multiple testing (p < 0.001). Further functional exploration showed that it was a quantitative trait locus which may significantly alter gene expression in the tibial artery.ConclusionsEDN1 rs4714384 is very likely an important biomarker of CV events in ESRD patients.