Commencement Of Dialysis Research Articles

MO569: Assessment of Inflammation Using Neutrophil-Lymphocyte Ratio Among Non-Dialyzed Chronic Kidney Disease Patients—A Prospective Observational Study

Abstract BACKGROUND AND AIMS Persistent low-grade inflammation is intimately linked to the pathophysiology of chronic kidney disease and contributes grossly to poor nutritional status and mortality. There is insufficient evidence on inflammation in relation to diabetic status, stages of CKD among chronic kidney disease patients before the commencement of dialysis. This study has characterized the prevalence and factors of inflammation among pre-dialysis chronic kidney disease patients at a tertiary care public teaching hospital. METHOD This longitudinal observational study adopted neutrophil–lymphocyte ratio (>3.53) to evaluate the inflammatory status among pre-dialysis chronic kidney disease patients. Glomerular filtration rate (eGFR) calculated by CKD-EPI equation from National Kidney Foundation was used as a measure of renal function. Multiple/multinomial regression analysis was also performed to determine the predictors of inflammatory status. RESULTS A total of 450 non-dialysis chronic kidney disease patients with or with diabetes were recruited during the period of study, consisting of 265 males and 185 females. Patients were aged 53.9 ± 14.2 years. According to neutrophil–lymphocyte ratio, the prevalence of inflammation among chronic kidney disease patients was found to be 91 (20.2%). The chronic kidney disease patients with diabetes 51(11.3%) were found to have higher rates of inflammation than non-diabetic chronic kidney disease patients 40 (8.9%). The adult age group 57 (12.7%) suffered more with inflammation than the elderly 34 (7.6%). Patients with severe malnutrition 42 (9.3%) were noted to have higher prevalence of inflammation followed by well-nourished 27 (6.0%) and mild/moderately malnourished population 22 (4.9%). The extent of inflammation was found to increase {CKD stage 1–2 (0.6%), CKD stage 3a-3b 34 (7.6%), CKD stage 4–5 54 (12.0%)} with decrease in renal residual function. Serum albumin, nutritional status and serum phosphorous have shown a significant association with the inflammatory status among chronic kidney disease patients. CONCLUSION The current findings demonstrate that the inflammation should be regarded as a familiar comorbid condition in chronic kidney disease. The intensity of inflammation is greater in patients with poorer renal function, comorbid diabetes and higher age. Future work needs to be aligned with respect to comprehensive understanding of inflammation mechanisms among patients with chronic kidney disease.

Changes in patient activation in people starting dialysis: A prospective longitudinal, observational study.

IntroductionIncreased patient activation is associated with improved health outcomes; however, little is known about patient activation in people with end‐stage kidney disease at the start of their dialysis journey. This study aimed to measure activation status changes over the first 4 months of dialysis.MethodsProspective, longitudinal, and observational study. Incident patients initiating dialysis at 25 in‐center hemodialysis and 17 home dialysis programs across three US states managed by the same dialysis provider completed the 13‐item Patient Activation Measure (PAM‐13) survey at baseline (month 1 after commencement of dialysis) and follow‐up (month 4). The survey yields a score (0–100) that corresponds to four levels (1–4), with higher scores or levels indicating higher activation.FindingsOne hundred eighty‐two participants (139 center, 43 home) completed both baseline and follow‐up surveys. Mean age was 60 ± 15 years, 40% female. Mean PAM‐13 scores were 65.1 ± 16.8 and 64.8 ± 17.8 at baseline and follow‐up, respectively; mean intraindividual change: −0.3 ± 17.3. The proportions of patients at levels 1–4 at baseline were 11%, 23%, 35%, and 31% respectively. At follow‐up, 50%, 64%, 52%, and 37% of participants at levels 1–4, respectively, changed to a different PAM level (Spearman correlation = 0.47; p < 0.001). Home dialysis was associated with higher PAM scores when compared to in‐center hemodialysis in multivariable analyses, adjusted for sociodemographic variables, comorbidities, and predialysis nephrology care (β = 5.74, 95% confidence intervals [CI]: 0.11–11.37 and 9.02, 95% CI: 3.03–15.02, at baseline and follow–up, respectively).DiscussionAlthough aggregated group scores and levels remained stable, intra‐individual patient activation changed significantly during the first 4 months of dialysis. This novel finding is foundational to future projects aiming to design interventions to improve patient activation.

Influence of formalized Predialysis Education Program (fPEP) on the chosen and definitive renal replacement therapy option.

It is widely accepted that patients with chronic kidney disease (CKD) should play an active role in the selection of renal replacement therapy (RRT) option. However, patients' knowledge about CKD and treatment options is limited. The implementation of structured education program and shared decision-making may result in a better preparation to RRT, more balanced choice of dialysis modalities and better access to kidney transplantation (TX). The aim of this long-term study was to assess the impact of formalized Predialysis Education Program (fPEP) on knowlege on RRT options, as well as on selected and definitive therapy. The study included 435 patients (53% men, mean age 60 years) with CKD stage 4 and 5, participating in fPEP at our center. The program included at least 3 visits, during which balanced information about all RRT options was presented and self-care and informed decision-making were encouraged. The knowledge about RRT options before and after fPEP attendance, and selected and definitive RRT options were assessed. Ninety-two percent of patients received prior nephrology care. After fPEP completion, in most patients, the knowledge about CKD and RRT options and selected preferred modality improved - 40% of participants chose hemodialysis (HD), 32% peritoneal dialysis (PD) and 18% TX. During the observation period, 4% of patients died before commencement of dialysis, 2.7% received preemptive kidney transplant, 8.6% were placed on transplant waiting list, and 94% started dialysis (30% PD and 70% HD). Among those who chose PD, 69% started PD and 24% started HD; the leading causes of the discrepancy between choosing and receiving PD was the deterioration in clinical condition (50%) and change of decision (32%). The fPEP increases CKD patients' knowledge on RRT methods. The implementation of a decision-making process based on fPEP leads to a satisfying distribution between modalities, with a good concordance between chosen and definitive modality.

Comparison of catheters or new arteriovenous fistulas for commencement of haemodialysis in pregnant women with chronic kidney disease: an international observational study

BackgroundEvidence surrounding vascular access options for commencing dialysis in pregnancy complicated by chronic kidney disease (CKD) is limited. Creation of new arteriovenous fistulas (AVFs) in pregnant women is rare.MethodsRetrospective cohort study of approaches to vascular access in pregnancy in centres in Australia, the United Kingdom (UK) and Canada (2002–2018).ResultsTwenty-three women with advanced CKD commenced dialysis in pregnancy (n = 20) or planned to commence (n = 3). Access at dialysis start was a tunnelled catheter (n = 13), temporary catheter (n = 1), AVF created pre-conception but used in pregnancy (n = 3) and AVF created during pregnancy (n = 3). No women commencing dialysis with an AVF required a catheter. No differences in perinatal outcomes were observed comparing AVFs and catheters at dialysis commencement. No AVFs were created in pregnancy in Canadian women. From Australia and the UK, 10 women had a new AVF created in pregnancy, at median gestation 14.5 weeks (IQR 12.5, 20.75). Four women still needed a catheter for dialysis initiation and 3 eventually used the new AVF. Six AVFs were successfully used in pregnancy at median gestation 24 weeks (IQR 22.5, 28.5), 2 were successfully created but not used and 2 had primary failure. No catheter-associated complications were identified except one episode of catheter-related sepsis.ConclusionsCatheter-related complications were minimal. In selected women, with sufficient pre-planning, an AVF can be created and successfully used during pregnancy to minimise catheter use if preferred. Pre-conception counselling in advanced CKD should include discussing vascular access options reflecting local expertise and patient preferences.Graphic abstract

Dialysis attendance patterns and health care utilisation of Aboriginal patients attending dialysis services in urban, rural and remote locations

BackgroundAboriginal people in the Northern Territory (NT) suffer the heaviest burden of kidney failure in Australia with most living in remote areas at time of dialysis commencement. As there are few dialysis services in remote areas, many Aboriginal people are required to relocate often permanently, to access treatment. Missing dialysis treatments is not uncommon amongst Aboriginal patients but the relationship between location of dialysis service and dialysis attendance (and subsequent hospital use) has not been explored to date.AimTo examine the relationships between location of dialysis service, dialysis attendance patterns and downstream health service use (overnight hospital admissions, emergency department presentations) among Aboriginal patients in the NT.MethodsUsing linked hospital and dialysis registry datasets we analysed health service activity for 896 Aboriginal maintenance dialysis patients in the NT between 2008 and 2014. Multivariate linear regression and negative binomial regression analyses explored the associations between dialysis location, dialysis attendance and health service use.ResultsWe found missing two or more dialysis treatments per month was more likely for Aboriginal people attending urban services and this was associated with a two-fold increase in the rate of hospital admissions and more than three-fold increase in ED presentations. However, we found higher dialysis attendance and lower health service utilisation for those receiving care in rural and remote settings. When adjusted for age, time on dialysis, region, comorbidities and residence pre-treatment, among Aboriginal people from remote areas, those dialysing in remote areas had lower rates of hospitalisations (IRR 0.56; P < 0.001) when compared to those who relocated and dialysed in urban areas.ConclusionThere is a clear relationship between the provision and uptake of dialysis services in urban, rural and remote areas in the NT and subsequent broader health service utilisation. Our study suggests that the low dialysis attendance associated with relocation and care in urban models for Aboriginal people can potentially be ameliorated by access to rural and remote models and this warrants a rethinking of service delivery policy. If providers are to deliver effective and equitable services, the full range of intended and unintended consequences of a dialysis location should be incorporated into planning decisions.

Association of Nutrition Status at Dialysis Start With Long-Term Survival: A 10-Year Retrospective Study

The objectives of the study are to explore the association between nutritional status at the initiation of dialysis and the improvement or worsening of nutrition status during first 3months of dialysis and first 5years of survival on dialysis. Two hundred ninety-seven patients who started dialysis between March 2009 and March 2019 were enrolled in the study. The nutritional status of the patients at dialysis commencement was evaluated by the method of The Integrative Clinical Nutrition Dialysis Score (ICNDS). Improvement or worsening of nutrition status was monitored by calculating the ICNDS slope for each patient enrolled in the study from 3 ICNDS values from the first 3months on dialysis. The baseline ICNDS and the slope of 3 subsequent monthly ICNDS values were tested for correlation with the odds of all-cause mortality for each of the first 5years on dialysis. There was a significant difference between the survival odds of patients who started dialysis with an ICNDS at 75 and those who started dialysis with an ICNDS <75 (hazard ratio [HR] 2.505, confidence interval [Cl] 1.235-5.079, P=.011 after 1year on dialysis;, HR 1.543, Cl 1.083-2.198, P=.016 after 5years). Deterioration of nutritional status (a negative ICNDS slope) during the first 3months of dialysis was associated with increased mortality during 1-3years after dialysis start, compared to a positive ICNDS slope indicating a stable or improved nutritional status (HR 1.732, Cl 1.151-2.607, P=.008 after 3years on dialysis). Nutritional status at initiation of dialysis is associated with long-term (5years) survival. Deterioration of nutritional status during the first 3months on dialysis significantly increases the risk of death during the first 3years on dialysis.

The IDEAL trial in Australia and New Zealand: clinical and economic impact.

The impact of research findings on clinical practice usually remains uncertain and unmeasured. To address this problem, we examined the long-term clinical and economic impact of the Initiating Dialysis Early and Late (IDEAL) trial using data from the Australia and New Zealand Dialysis and Transplant Registry. We performed a registry-based study including all incident adult dialysis patients in Australia and New Zealand from July 2000 to June 2018. A piecewise linear regression model was used to examine differences in mean estimated glomerular filtration rate (eGFR) at dialysis commencement for the years prior to (2000-2010) and following (2010-2018) publication of the IDEAL trial results. The return on investment (ROI) was calculated using the total cost of performing the IDEAL trial and the cost or savings accruing in Australia and New Zealand from changes in dialysis initiation practice. From July 2000 to June 2010, mean eGFR at dialysis commencement increased at a rate of 0.21 mL/min/1.73 m2/year [95% confidence interval (CI) 0.19-0.23]. After the IDEAL trial results were published, mean eGFR at dialysis commencement did not show any temporal change [-0.01 mL/min/1.73 m2/year (95% CI -0.03-0.01)]. The ROI of the IDEAL trial was AU$35.70/AU$1 spent, an estimated savings to the Australian and New Zealand health systems of up to AU$84 million/year. The previous trend to higher eGFR at dialysis commencement changed following publication of the IDEAL trial results to a steady eGFR that has continued for a decade, avoiding unnecessary dialysis treatments and accruing savings to the Australian and New Zealand health systems.

MO609PREVALENCE OF MALNUTRITION AND INFLAMMATION IN NONDIALYZED PATIENTS WITH CHRONIC KIDNEY DISEASE: A CLINICAL STUDY

Abstract Background and Aims The prevalence of chronic kidney disease (CKD) in India varies from 0.16–0.78%. The reported incidence of malnutrition in CKD patients is 37–84%. There is a paucity of data on the quantification of malnutrition and inflammation in undialyzed patients of CKD from north east of India. This study analyzed the prevalence and causes of malnutrition and inflammation in patients with CKD before the initiation of dialysis treatment. Method This study was conducted from May 2017 to May 2019 in the department of nephrology Guahati medical college hospital. Assessment of nutritional and inflammatory status was carried out in patients with CKD before initiation of dialysis. Serum albumin; body mass index (BMI); triceps skin fold thickness (TST); mid-arm muscle circumference (MAMC); and subjective global assessment (SGA) scoring were used for assessment of nutritional parameters. Serum C-reactive protein; serum albumin and serum ferritin level were used to assess the inflammatory status in these patients. Results A total of 528 (male:female= 359:169) patients with CKD participated in this study. Diabetic Nephropathy (35%) was the most common; followed by; hypertension (23%) and chronic glomerulonephritis (20 %). The evidence of malnutrition was noted in 344 (65%). The mean age of patients with malnutrition was 52.8±12.45 years with a male predominance (68%). On the basis of SGA score; malnutrition was noted in 344 patients (mild moderate [36%]; severe; [30%]); remaining (34%) were well nourished. Thus; evidence of Malnutrition was noted in 65% of patients with CKD.). Serum total protein &amp; albumin were higher in the non-malnourished patients in comparison to malnourished (5.83±1.0 vs 5.31±1.12 p&amp;lt;0.05; 3.65±0.7 vs 2.62±0.74) The inflammatory markers (serum ferritin &amp; C reactive protein) were elevated significantly in patients with malnutrition in comparison to those without malnutrition (308.15±60.18 mg/dL vs. 251.64±63.14 mg/dL; p &amp;lt; 0.001; 77% vs. 50%; p &amp;lt; 0.01). Conclusion Malnutrition and inflammation are common in patients with CKD before the commencement of dialysis. This indicates that an emphasis should be placed on the assessment and prevention or correction of malnutrition and inflammatory burden in these patients with CKD.

Health Service Costs for a Predialysis Dietetic Clinic: A Retrospective Cost Analysis Study

Effect of dietetic consultation (DC) on clinical outcomes is an under-researched component of predialysis education. Predialysis DC has been associated with a 7.5-month delay in requiring dialysis commencement, having potential cost implications for health services. Limited studies have evaluated the possible impact of predialysis DC on health service costs. This study aimed to investigate the hospital health service costs associated for patients attending a predialysis dietetic clinic. A cost analysis comparing hospital health service costs over 4years in a cohort of predialysis patients with and without DC. Retrospective study data were used (n=246) along with outpatient renal clinic visits, hospital admissions records to estimate total hospital service costs. A generalized linear model evaluated associations between total cost and the marginal effects of DC and other variables on total costs. Mean total cost for patients (outpatient visits, admissions, and dialysis) was AUD$178,913 (95% confidence interval=$158,735-$199,090) or $185/day (95% confidence interval=$12-$161). The DC group total costs/day were lower than the no-DC group with a mean difference of $51/day ($155 vs. $206; P=.03). Patients in the DC group had less admissions compared to the no-DC group (6.32 vs. 8.06; P=.02). The highest marginal costs estimated for the entire cohort were lower estimated glomerular filtration rate at admission ($123,511, P=.001), inpatient admissions ($189,333, P<.001), commencing dialysis ($581,812, P<.001), having diabetes ($94,590, P=.014), and cerebrovascular disease ($177,080, P=.01). DC advice did not influence total costs. Patients who received DC had lower total health services costs/day compared to those who did not receive DC. Marginal cost analysis indicates the cost difference to be attributed to less time on dialysis and fewer hospital admissions in this retrospective observational cohort. An assessment of dietetic staffing in predialysis renal services is warranted.

Examining barriers to timely waitlisting for kidney transplantation for Indigenous Australians in Central Australia.

Indigenous Australians are disproportionately affected by end stage kidney disease. Despite this, they face significant delays being assessed and waitlisted for kidney transplant. To examine the kidney transplant waitlisting process in our region, to compare the workup process between Indigenous Australians and non-Indigenous patients, and identify major sources of delay. We analysed the records of all patients being treated by our service who were on the kidney transplant waitlist between January 2017 and June 2018. Between-group differences were used to compare the time between commencement of dialysis and completion of each component of assessment. Patients who had more than 1 year between commencement of dialysis and waitlisting were further analysed for major sources of delay. Twenty-five patients were included (20 Indigenous Australians and 5 non-Indigenous). The median time to waitlisting for transplant after commencing dialysis was significantly longer in the Indigenous group (1215 vs 264 days, P = 0.032). Indigenous Australian patients waited longer before commencing the transplant assessment process and before completing dental assessment, tissue typing and review by the transplant nephrologist and surgeon. Five patients (two Indigenous Australians, three non-Indigenous) were waitlisted within 1 year of commencing dialysis. Among the remaining 20 patients, cardiac and systems issues were the two most common major sources of delay. Indigenous Australian patients face significant delays accessing the kidney transplant waitlist. Cardiac assessment and systems issues are prominent sources of delay and efforts to address these areas may help to improve equity of access to kidney transplantation.

Current Trends Featuring the Bridge Between Stroke and End-Stage Renal Disease: A Review.

The relationship between end-stage renal disease (ESRD) and cerebral stroke is graded and cumulative, having a significant impact on morbidity and mortality. Ischemic stroke is more prevalent than hemorrhagic stroke and both stroke types have modifiable and non-modifiable risk factors. The presence of risk factors such as hypertension, diabetes, and atrial fibrillation (AF) before stroke occurrence in dialysis patients has a significant impact on the outcomes such as a discharge to rehabilitation, in-hospital mortality with the worst prognosis when compared to the general population. ESRD patients with either peritoneal or hemodialysis (HD) are at increased risk of stroke than the general population, with a high mortality rate at the commencement of dialysis and gradually decreases. Primary and secondary prevention of risk factors plays a significant role in this susceptible population and helps to mitigate better treatment and outcomes. Our review article focuses on the mechanisms, outcomes, treatment, and preventive aspects of stroke in the ESRD population.

SAT-201 ASSOCIATION BETWEEN SMOKING AND ALL-CAUSE AND CAUSE- SPECIFIC MORTALITY IN INCIDENT DIALYSIS PATIENTS-AN ANZDATA REGISTRY ANALYSIS

Smoking increases all-cause mortality and development of cardiovascular disease in patients with end-stage kidneydisease(1). No study to date has examined prevalence and outcomes amongst smokers in Australian and New Zealand dialysis patients. The aims of this study were to explore the prevalence of smoking in incident patients commencing dialysis and to evaluate the effect of smoking at commencement of dialysis on subsequent all-cause and cardiovascular mortality. We conducted a cohort study using the ANZDATA Registry (1990-2016) to explore the association of smoking status at commencement of renal replacement therapy (RT) with all cause and cardiovascular mortality in Australian and New Zealand. Inclusion criteria were adults (18 years or older) at commencement of renal replacement therapy (RRT) for >3 months. Patients who started with a transplant (pre-emptive) were excluded. Incidence of death was estimated by using survival analysis. In the final model of time to all-cause mortality, we adjusted for age, aboriginal, mode of dialysis, BMI, diabetes, history of chronic lung disease, history of coronary artery disease, history of perivascular disease and time dependent transplant status. The hazard ratios of death of current smokers versus non-smokers and former smokers and the 95% confidence interval was calculated from the adjusted model and a Kaplan Meier survival curves of commencement of dialysis until death were constructed. A total of 57838 patients commenced dialysis during 1990-2016, of whom 56512 individuals had data on smoking history: the mean age was 59.0 years, 45.6% reported they were non-smokers, 40.8% were former smokers and 13.6% current smokers. Forty-one % were female, 43% had diabetes, 29.2 % were obese, 38.5% were>65 years of age and 7.5% were Aboriginal and Torres Strait Islanders. During the median followup of 4.4 years with a mean of 6.1 years, 33547 died (59.4%), 13140 (23.3%) underwent a kidney transplant without lost to follow-up. Cardiovascular disease was the major cause of death, reported in 15174 (45.2% of deaths), 9.739 (17.2% of deaths ) died of a malignancy, 66 (0.1% of deaths) died of infection related cause and 301 (0.5% of deaths) died of respiratory failure and 5185 (9.2%) had a cancer diagnosis. Hazard ratio of all cause-mortality for smokers was 1.13 (95%CI :1.10-1.15, p<0.0001). Similarly smokers had a higher rate of death due to cardiovascular disease ( HR 1.16; 95% CI 1.12-1.20, p < 0.0001). In addition, smoking history was significantly associated with a higher rate of diagnosis of cancer (HR 1.26; 95% CI 1.19-1.33, p< 0.0001), infections ( HR 1.07; 95% CI 1.06-1.09, p<0.0001) and respiratory failure ( HR 1.06; 95% CI 1.05-1.07, p< 0.001). The death due to infections rate is higher for smokers but this is not significant ( HR 1.37; 95% CI 0.83,2.26, p=0.22) The cumulative incidence of death among smokers and non- smokers were 63.1% for smokers and 54.9% for non-smokers. Amongst patients commencing dialysis in Australia and New Zealand, 54% were either current or former smokers. Smoking history was an independent risk factor for all-cause mortality, cardiovascular mortality, diagnosis of cancer and respiratory failure. Smoking is an important risk factor and the patients should be encouraged to quit

Increased Proteinuria is Associated with Increased Aortic Arch Calcification, Cardio-Thoracic Ratio, Rapid Renal Progression and Increased Overall and Cardiovascular Mortality in Chronic Kidney Disease.

Background: Patients with chronic kidney disease (CKD) are associated with high prevalence rates of proteinuria, vascular calcification and cardiomegaly. In this study, we investigated relationships among proteinuria, aortic arch calcification (AoAC) and cardio-thoracic ratio (CTR) in patients with CKD stage 3A-5. In addition, we investigated correlations among proteinuria and decline in renal function, overall and cardiovascular (CV) mortality.Methods: We enrolled 482 pre-dialysis patients with CKD stage 3A-5, and determined AoAC and CTR using chest radiography at enrollment. The patients were stratified into four groups according to quartiles of urine protein-to-creatinine ratio (UPCR).Results: The patients in quartile 4 had a lower estimated glomerular filtration rate (eGFR) slope, and higher prevalence rates of rapid renal progression, progression to commencement of dialysis, overall and CV mortality. Multivariable analysis showed that a high UPCR was associated with high AoAC (unstandardized coefficient β: 0.315; p = 0.002), high CTR (unstandardized coefficient β: 1.186; p = 0.028) and larger negative eGFR slope (unstandardized coefficient β: -2.398; p < 0.001). With regards to clinical outcomes, a high UPCR was significantly correlated with progression to dialysis (log per 1 mg/g; hazard ratio [HR], 2.538; p = 0.003), increased overall mortality (log per 1 mg/g; HR, 2.292; p = 0.003) and increased CV mortality (log per 1 mg/g; HR, 3.195; p = 0.006).Conclusions: Assessing proteinuria may allow for the early identification of high-risk patients and initiate interventions to prevent vascular calcification, cardiomegaly, and poor clinical outcomes.

Controlling Nutritional Status (CONUT) score as immune-nutritional predictor of outcomes in patients undergoing peritoneal dialysis.

The Controlling Nutritional Status (CONUT) score was designed to assess the immune-nutritional status in patients. The aim of this study was to investigate the prognostic value of the CONUT score at the commencement of peritoneal dialysis (PD) for all-cause mortality, cardiovascular disease (CVD), and technique failure. This is a STROBE-compliant, retrospective, observational, single center study. A total of 252 patients with end stage renal disease initially undergoing PD were enrolled in the study. Baseline data were collected from The Third Affiliated Hospital of Soochow University Peritoneal Dialysis database. The primary outcome during follow-up was all-cause mortality. The secondary outcomes were CVD and technique failure. Univariate and multivariate Cox regression analyses were performed to estimate the association between confounding factors and outcomes. The area under the curve represented the test discriminative power of CONUT score and relevant clinical parameters. The Kaplan-Meier curve was used to compare the outcomes of the patients according to the cut-off CONUT score. During a median follow-up period of 1.9 years, 35 patients (13.9%) died, 38 (15.1%) experienced CVD events, 58 (23.0%) experienced technique failure. The high CONUT group (CONUT score>3) had significantly higher all-cause mortality (p=0.02), CVD prevalence (p<0.01), and technique failure rates (p<0.01) than the low CONUT group (CONUT score≤3). The CONUT score was an independent predictor of all-cause mortality (hazard ratio [HR]: 1.565; 95% CI: 1.305-1.876; p<0.001), CVD (HR: 1.346; 95% CI: 1.136-1.594; p=0.001), and technique failure (HR: 1.144; 95% CI: 1.006-1.302; p=0.041). The CONUT score is a straightforward and inexpensive indicator to evaluate the immune-nutritional status; it could be a reliable prognostic marker of all-cause mortality, CVD, and technique failure risk in patients undergoing PD.

Vascular age is associated with the risk of dialysis or death in chronic kidney disease.

Increased arterial stiffness is associated with progressive renal deterioration and poor clinical outcomes in patients with chronic kidney disease (CKD). Assessment of vascular age as derived from arterial stiffness parameters might be an important clinical marker of cardiovascular risks. The aim of the present study is to evaluate whether the difference (△age) between vascular age and chronological age can predict the risk of reaching dialysis or death in patients with known CKD. This longitudinal study enrolled 94 male Chinese CKD patients, aged 40-62 years. Vascular age was calculated by brachial-ankle pulse wave velocity, and measured by an ankle-brachial index-form device. The study endpoints were the commencement of renal replacement therapy or death. After a stepwise multivariate analysis, △age was associated independently with increased urine protein-to-creatinine ratio (β = 0.32; P = 0.001) and decreased baseline estimated glomerular filtration rate (β = -0.24; P = 0.008). During a median follow-up period of 62 (interquartile range = 55-66) months, the 4-year cumulative incidence of reaching the study endpoint in patients with △age = 0 and △age > 0 year was 4.9% and 25%, respectively (log-rank test, P = 0.009). Multivariate forward Cox regression analysis identified that higher △age (hazard ratio (HR) = 1.05; P = 0.027), lower baseline estimated glomerular filtration rate (HR = 0.93; P < 0.001), and history of cardiovascular disease (HR = 5.90; P = 0.031) were independently associated with progression to commencement of dialysis or death. Thus, the assessment of the difference between vascular age and chronological age may provide an alternative method to identify CKD patients at a high risk of progression to dialysis or death.

SUN-095 Patient Reported Outcome Measures Over the First Three Months of Dialysis: Interim Results from the Multidisciplinary Assessment at Dialysis Entry (MADE) Study

Patient reported outcome measures (PROMs) assess outcomes of importance to patients. They include measures of a patients’ health or health care from the patient’s perspective. The benefits of measuring PROMs can include identifying unmet physical and psychological need, facilitating enhanced staff/patient communication and improving the quality of care. The aim of the Multidisciplinary Assessment at Dialysis Entry (MADE) study was to identify PROMs that impact upon the quality of the patient’s illness experience in the first 6 months of dialysis in order to develop a validated tool to be embedded within standard practice. We report results from the first 3 months of data. Longitudinal descriptive design. Participants commenced dialysis (hemodialysis or peritoneal dialysis) over a 6-month period (November 2017 to June 2018) in the Central & Northern Adelaide Renal & Transplantation Service (CNARTS) in South Australia. Study approved by the health service human research ethics committee with fully informed consent. Participants completed a 169 item questionnaire within 2 weeks of commencing dialysis and completed the same questionnaire at 12 weeks following commencement of dialysis. The instrument measured: illness and symptom perception (Palliative Care Outcome Scale-Renal (IPOS-Renal) Brief Illness Perception Questionnaire (B-IPQ), Illness Intrusiveness Ratings Scale (IIRS)); psychosocial health (Depression Anxiety and Stress Scales (DASS-21), Brief COPE Inventory, Emotional Thermometer (ET)); gastro-intestinal health (Gastrointestinal Symptom Rating Scale, Bristol Stool Chart, Food Frequency Questionnaire (FFQ)); sleep (Pittsburgh Sleep Quality Assessment (PSQI)), and health literacy (Brief Health Literacy Screening tool, Morisky Medication Adherence Scale (MMAS-8)). In addition, cognitive function (Montreal Cognitive Assessment (MoCA)) and physical function measures (Grip Strength, Timed Up and Go (TUG) were performed. A patient participant focus group was formed to provide study feedback. From a population frame of 64 incident dialysis patients 43 participants were enrolled (67% response rate), 28% female, mean age 62.1 years (SD 14.4) and 37% with diabetes. 33 out of 43 participants completed the survey at 12 weeks demonstrating non-significant trended improvement in items related to shortness of breath, energy, drowsiness, appetite, itching, mobility, cognition, anxiety, bowel health, social relations, physical function, health literacy and sleep quality. There was a non-significant decline in the participants’ perceptions of developing coping strategies as measured by the COPE Scale. Study participant focus group members were positive regarding patient participation in this ESKD PROMs study. The majority of PROMs over the first 3 months of dialysis revealed non-significant improvement. Current and further analysis will contribute to the development of a more concise tool to be embedded within standard practice.

SUN-042 C3 GLOMERULOPATHY AND IMMUNE COMPLEX MEDIATED MEMBRANOPROLIFERATIVE GLOMERULONEPHRITIS: COMPARING DIALYSIS AND TRANSPLANT OUTCOMES

Membranoproliferative glomerulonephritis (MPGN) is a rare cause of end stage kidney disease (ESKD) that is comprised of two separate pathogenic entities: C3 glomerulopathy (C3GN) and immune complex mediated MPGN (ICMPGN). Whether these conditions have different clinical outcomes is currently unknown. We used the Australian and New Zealand Dialysis and Transplant (ANZDATA) Registry to compare the characteristics and outcomes of patients with ESKD secondary to C3GN and ICMPGN. All patients with ESKD secondary to MPGN who commenced dialysis or kidney transplantation in Australia and New Zealand between 1996 and 2016 were included. Patients with ESKD secondary to C3GN were compared to those with ESKD secondary to ICMPGN. Dialysis patient survival, transplant patient survival and death-censored graft survival were evaluated by Kaplan-Meier and multivariable Cox proportional hazards model analyses. Competing risks regression was performed as a sensitivity analysis. Competing events were transplantation and renal recovery for dialysis patient survival, allograft failure for transplant patient survival and patient death for death-censored allograft survival. Of the total ESKD population of 53,729 patients, 76 had C3GN (mean age 52 ± 20 years, 36% female) and 380 had ICMPGN (mean age 50 ± 18 years, 39% female). Baseline demographic and clinical characteristics were comparable between the two groups. Patients with C3GN had lower 5-year dialysis survival rates compared to those with ICMPGN (42% vs. 62%, p=0.05; Cox-adjusted hazard ratio [HR] 1.40, 95% CI 0.94-2.08; competing risks HR 1.34, 95% CI 1.01-1.8). Renal recovery following dialysis commencement was significantly less common with C3GN compared to ICMPGN (0% vs. 4%, p<0.01). 37 patients with C3GN and 171 patients with ICMPGN proceeded to kidney transplantation. Death-censored graft survival was similar between C3GN and ICMPGN (5 year survival 68% vs. 74%, p=0.42; Cox-adjusted HR 1.47, 95% CI 0.74-2.89; competing risk HR 1.47, 95% CI 0.84-2.55). Graft loss due to disease relapse was a common cause of graft loss in both groups occurring in 16% of patients with C3GN and 9% of those with ICMPGN (p=0.35). Transplant patient survival was comparable between the two groups (5 year survival 96% vs. 92%, p=0.35; Cox-adjusted HR 0.39, 95% CI 0.05-2.97; competing risk HR 0.35, 95% CI 0.06-1.85). Compared to patients with ESKD due to ICMPGN, those with C3GN had poorer survival on dialysis, lower rates of dialysis-independent renal recovery and comparable kidney transplant outcomes. Both groups had high rates of disease relapse causing graft loss. These findings support the notion that ICMPGN and C3GN are different clinical entities.

SAT-193 CLINICAL AUDIT OF THE VALIDATION OF A MODEL TO PREDICT PROGRESSION OF CHRONIC KIDNEY DISEASE TO END STAGE KIDNEY DISEASE

Patients with chronic kidney disease (CKD) are at increased risk of cardiovascular events or progression to kidney failure requiring either renal replacement therapy or conservative management. Clinical decision making for CKD is challenging due to disease heterogeneity and variability in rates of progression. Accurate prediction of risk may facilitate individualized decision making, enabling appropriate patient care. There are various instruments for predicting CKD progression. Tangri et al describes four and eight variable equations that predict the 2 and 5-year probability of treated kidney failure (dialysis or transplantation) for patients with CKD stage 3 to 4. Four variable equations use sex, age, eGFR and urine albumin: creatinine. Eight variable equations add serum phosphate, calcium, bicarbonate and albumin. Our audit aims to validate these prognostication models for clinical estimation of 2 and 5-year probability of progression of chronic kidney disease 3/4 to chronic kidney disease stage 5 requiring dialysis or transplant (CKD5D/T) in Australia. We analysed patients referred to the ‘Chronic Kidney Team’ (CKT) clinic; a multidisciplinary comprehensive care service for patients with CKD 3-5 in Metro North Hospital & Health Service. We included patients who were referred to CKT between 2008 and 2012 who subsequently progressed to CKD5D/T up to 2018. We excluded patients who did not have sufficient clinical data for 8-variable progression risk to be calculated. 47 patients had progression of CKD3/4 to CKD5D/T. 30/47 (64%) patients were male. The median age at referral to CKT was 60 years. 34 (72%) patients had CKD stage 4 on referral to the service. 12/34 had low risk of progression to CKD5D/T at 2 years of whom 2/12 progressed to CKD5D/T. 8 patients had predicted high risk of whom 6 progressed as expected to dialysis commencement. 13 (28%) patients had CKD stage 3. 6/13 had low predicted risk of progression at 5 years of whom 4/6 progressed unexpectedly. 1/13 was identified as having high risk at 5 years and that 1 patient progressed to CKD5D/T. 6/18 CKD 3/4 patients with predicted low risk progressed to CKD5D/T unexpectedly. 1/6 had emergency abdominal surgery, 1/6 patient had unexplained rapid progression and 4/6 had acute upper gastro-intestinal haemorrhage causing terminal decline of kidney function. The number of patients analysed was small. The 8-variable equation accurately predicted high risk of progression to CKD5D/T in 7/9 CKD3/4 patients.

Angiotensin-converting enzyme inhibitors or angiotensin receptor blocker monotherapy retard deterioration of renal function in Taiwanese chronic kidney disease population

It remains unclear how different uses of angiotensin-converting inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) influence the progression of chronic kidney disease (CKD). This study explored CKD progression in a multicentre, longitudinal cohort study that included 2639 patients with CKD stage 1–5 and hypertension. Patients treated with ACEI or ARB for ≥90 days during a 6-mo period comprised the study group, or no treatment, comprised the control group. The study group was subdivided on the basis of treatment: ACEI monotherapy or ARB monotherapy. Progression of renal deterioration was defined by an average eGFR decline of more than 5 mL/min/1.73 m2/yr or the commencement of dialysis. With at least 1-year follow up, a progression of renal deterioration was demonstrated in 29.70% of the control group and 25.09% of the study group. Patients in the study group had significantly reduced progression of CKD with adjusted odds ratio 0.79 (95% confidence interval: 0.63–0.99). However, when ACEI monotherapy and ARB monotherapy were analyzed separately, none of their associations with CKD progression was statistically significant. In conclusion, ACEI or ARB monotherapy may retard the deterioration of renal function among patients with CKD and hypertension.

A Longitudinal Study on the Prevalence and Risk Factors for Depression and Anxiety, Quality of Life, and Clinical Outcomes in Incident Peritoneal Dialysis Patients.

Starting dialysis is an important life event. The prevalence and evolution of psychological symptoms at commencement of long-term dialysis is unclear. We examined the prevalence of and risk factors for depression and anxiety, and the quality of life (QOL) of incident peritoneal dialysis (PD) patients, and also the change of these parameters in the first year of PD in relation to clinical outcomes under the PD-first policy. All patients commencing long-term PD from March 2011 to April 2015 were asked to complete the Hospital Anxiety and Depression Scale (HADS), World Health Organization Quality of Life-BREF and the Kidney Disease Quality of Life Instrument Short Form questionnaire. Patient demographics and the incidence of hospitalization, peritonitis, exit-site infection, and all-cause mortality were studied. The HADS was repeated after 9 - 12 months. A high depression score was present in 39.6% of 191 patients at commencement of PD and was more common in diabetes patients (odds ratio [OR] 2.03, 95% confidence interval [CI] 1.09 - 3.81). A high anxiety score was present in 23.6%, and the risk factors included younger age (OR 0.96 per year, 95% CI 0.94 - 0.99) and diabetes (OR 2.59, 95% CI 1.20 - 5.57). Both high depression and anxiety scores were associated with an inferior QOL, overall and across most QOL domains. Depression and anxiety symptoms did not change in the first year of PD and were not associated with short-term clinical outcomes. High depression and anxiety scores were prevalent in incident PD patients where PD-first policy is adopted and were associated with inferior QOL. There was no improvement after 1 year of PD. The impact of strategic interventions targeting patient groups at risk such as those with diabetes or of younger age warrants further investigation.