Dialysis-free Survival Research Articles

Renal outcomes with renin-angiotensin system blockers after unilateral nephrectomy

IntroductionDespite the benefits of renin-angiotensin system (RAS) blockers, their immediate use after nephrectomy has been limited because of concerns about impaired renal adaptation. We aimed to evaluate the effect of RAS blockers immediately following unilateral nephrectomy on renal adaptation. MethodsThis single-center retrospective cohort study included 580 patients who underwent elective unilateral nephrectomy between 2010 and 2020 and had pre-existing hypertension with antihypertensive medications. Patients were divided into groups according to the post-nephrectomy RAS blocker use. The primary outcome was renal adaptation defined as post-nephrectomy estimated glomerular filtration rate (eGFR) / pre-nephrectomy eGFR × 100 at 1 month after surgery. Secondary outcomes included hyperkalemia during the first year and mortality or end-stage kidney disease within three years. ResultsThe mean age was 65.2 years, 406 (70%) were male, and 308 (53.1%) received RAS blockers after nephrectomy. The RAS blocker group was younger (63.8 vs 66.8 years) and had a higher eGFR (79.4 vs 75.5 ml/min/1.73 m2) than the control group. There were no differences between the groups in renal adaptation at one month (67.1% vs. 66.8%, P = 0.711) or in the incidence of hyperkalemia until one year postoperatively. The RAS blocker use was associated with better dialysis-free survival [Adjusted hazard ratio of multivariable Cox-regression model, 0.531; 95% confidence interval, 0.329-0.857; P = 0.010]. ConclusionThe immediate use of RAS blockers after unilateral nephrectomy did not deteriorate renal adaptation or increase hyperkalemia. Furthermore, the RAS blockers was associated with improved prognosis in terms of end-stage kidney disease and mortality.

The effect of primary renal disease upon outcomes after renal transplant.

This study investigated whether nature of primary renal disease affects clinical outcomes after renal transplantation at a single center in the United Kingdom. This was a retrospective cohort study of 961 renal transplant recipientsfollowed up at a large renal center from 2000 to 2020. Separation of diseases responsible for end-stage kidney disease included glomerulonephritis, diabetic kidney disease, hypertensive nephropathy, autosomal dominant polycystic kidney disease, unknown cause, other causes and chronic pyelonephritis. Outcome data included graft loss, cardiovascular events, malignancy, post-transplant diabetes mellitus and death, analyzed according to primary disease type. The mean age at transplantation was 47.3 years. During a mean follow-up of 7.6 years, 18% of the overall cohort died corresponding to an annualised mortality rate of 2.3%. Death with a functioning graft occurredat a rate of 2.1% per annum, with the highest incidence observed in in patients with diabetic kidney disease (4.1%/year). Post-transplant cardiovascular events occurred in 21% of recipients(2.8% per year), again highest in recipients with diabetic kidney disease (5.1%/year) and hypertensive nephropathy (4.5%/year). Post-transplant diabetes mellitus manifested in 19% of the cohort at an annualized rate of2.1% while cancer incidence stood at 9% with an annualized rate of 1.1% . Graft loss occurred in 6.8% of recipients at the rate of1.2% per year with chronic allograft injury, acute rejection and recurrent glomerulonephritis being the predominant causative factors. Median + IQR dialysis-free survival of the whole cohort was 16.2 (9.9 ->20) years, being shortest for diabetic kidney disease (11.0 years) and greatest for autosomal dominant polycystic kidney disease (18.2 years) .The collective mean decline in eGFR over time was -1.14ml/min/year. Recipients with Pre-transplant diabetic kidney disease exhibited the fastest rate of decline(-2.1ml/min/year) a statistically significant difference in comparison to the other native kidney diseases with Autosomal dominant polycystic kidney disease exhibiting the lowest rate of decline(-0.05ml/min/year) CONCLUSION: Primary renal disease can influence the outcome after renal transplantation, with patients with prior diabetic kidney disease having the poorest outcome in terms of dialysis-free survival and loss of transplant function. Autosomal polycystic kidney disease, other cause and unknown cause had the best outcomes compared to other primary renal disease groups.

Functional recovery after partial nephrectomy in a solitary kidney

ObjectivesPartial nephrectomy (PN) is the reference standard for renal mass in a solitary kidney (RMSK), although factors determining functional recovery in this setting remain poorly defined. Patients/MethodsSingle center, retrospective analysis of 841 RMSK patients (1975–2022) managed with PN with functional data, including 361/435/45 with cold/warm/zero ischemia, respectively. A total of 155 of these patients also had necessary studies for detailed analysis of parenchymal volume preserved. Acute kidney injury (AKI) was classified by RIFLE (Risk/Injury/Failure/Loss/Endstage). Recovery-from-ischemia (Rec-Ischemia) was defined as glomerular filtration rate (GFR) saved normalized by parenchymal volume saved. Logistic regression identified predictive factors for AKI and predictors of Rec-Ischemia were analyzed by multivariable linear regression. ResultsOverall, median preoperative GFR was 56.7 ml/min/1.73m2 and new-baseline and 5-year GFRs were 43.1 and 44.5 ml/min/1.73m2, respectively. Median follow-up was 55 months; 5-year dialysis-free survival was 97%. In the detailed analysis cohort, a primary focus of this study, median warm (n = 70)/cold (n = 85) ischemia times were 25/34 minutes, respectively; and median preoperative, new-baseline and 5-year GFRs were 57.8, 45.0, and 41.7 ml/min/1.73m2, respectively. Functional recovery correlated strongly with parenchymal volume preserved (r = 0.84, p < 0.001). Parenchymal volume loss accounted for 69% of the total median GFR decline associated with PN, leaving only 3 to 4 ml/min/1.73m2 attributed to ischemia and other factors. AKI occurred in 52% of patients and the only independent predictor of AKI was ischemia time. Independent predictors of reduced Rec-Ischemia were increased age, warm ischemia, and AKI. ConclusionThe main determinant of functional recovery after PN in RMSK is parenchymal volume preservation. Type/duration of ischemia, AKI, and age also correlated, although altogether their contributions were less impactful. Our findings suggest multiple opportunities for optimizing functional outcomes although preservation of parenchymal volume remains predominant. Long-term function generally remains stable with dialysis only occasionally required.

ANCA-Associated Vasculitis in Hong Kong: Clinical Presentation, Treatment and Outcomes from a Multi-centre Retrospective Study

Background ANCA-associated vasculitis (AAV) is a rare disease with significant mortality and morbidity, exhibiting different spectrums among ethnic groups. Chinese patients are more likely to be diagnosed with microscopic polyangiitis (MPA), be MPO-positive, and have renal involvement. However, reliable epidemiological data on AAV in China is scarce. This study aims to provide detailed information on the epidemiology, clinical features, treatment, and outcomes of AAV patients in Hong Kong. Methods Patients diagnosed with Granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), or eosinophilic granulomatosis with polyangiitis (EGPA) and followed up in 8 public hospitals from 2013-2023 in Hong Kong were identified using the Hospital Authority Clinical Data Retrieval System (CDARS) with ICD-10 diagnostic codes. Diagnoses were confirmed by designated rheumatologist specialists at each center. Data on demographics, clinical presentations, laboratory results, biopsy findings, treatments, and outcomes were recorded. Overall survival, relapse-free survival, and dialysis-free survival, along with their associated risk factors, were analyzed using the Kaplan-Meier method and Cox Regression. Data of GPA and MPA patients are presented here. Results A total of 35 GPA and 127 MPA patients were identified, with 91 (56.2%) being female. The mean age of onset was 67.73 years. Forty-six patients (28.4%) were PR3 positive, and 134 patients (82.7%) were MPO positive. Most patients had organ-threatening or life-threatening disease, with 127 patients (78.4%) having an FFS [Formula: see text]2. The mean BVAS score was 15.7. Pulmonary haemorrhage occurred in 35 patients (21.6%), and advanced renal insufficiency (Cr &gt; 4g/L or dialysis) occurred in 49 patients at presentation (30.2%). Thirty-four patients received rituximab, and 83 received cyclophosphamide for induction. PLEX was performed in 30 patients. Over a median follow-up period of 39 months, mortality occurred in 64 patients (39.5%). The 1-year mortality rate was 22.2%, and the 5-year mortality rate was 33.3%. Infections accounted for most of the mortality (46.7%), followed by active vasculitis (15%), renal failure (11.7%), cardiovascular/cerebrovascular events (10%) and malignancy (1.9%). Factors associated with mortality included MPO positivity (OR 4.25, p=0.01), PR3 positivity (OR 3.87, p=0.01), FFS [Formula: see text]2 (OR 2.54, p=0.04) and pulmonary haemorrhage (OR 2.13, p=0.01) in multivariate analysis. Relapse occurred in 30 patients (18.5%), and 30 patients (18.5%) required dialysis. Conclusion AAV patients in Hong Kong, predominantly MPA and MPO positive, often present with severe organ or life-threatening manifestations. There is a high mortality risk among these patients, with MPO or PR3 positivity, FFS[Formula: see text]=2 and pulmonary haemorrhage being significant predictors of mortality.

Pickering Syndrome: An Overlooked Renovascular Cause of Recurrent Heart Failure.

ABSTRACTRecurring and rapidly developing (flash) pulmonary edema is the hallmark of Pickering syndrome, affecting patients with hypertension and atherosclerotic renal artery stenosis (either bilateral or unilateral) in a solitary functioning kidney, and impaired renal function. We herein report on a series of consecutive patients with recurrent hospital admissions for pulmonary edema, impaired renal function (chronic kidney disease class 4-5), and atherosclerotic bilateral renal artery stenosis, in whom Pickering syndrome had been long neglected. We also describe a streamlined diagnostic strategy entailing little or no need for contrast medium, thus carrying no risks of further worsening of renal function. This allowed us to make the correct diagnosis and opened the way to revascularization by percutaneous transluminal renal angioplasty with stent, which provided swift recovery of kidney function with resolution of pulmonary congestion and long-term pulmonary edema- and dialysis-free survival in all cases. In summary, these findings support the following key messages: (1) considering the diagnosis of Pickering syndrome, followed by searching atherosclerotic renal artery stenosis, is an essential step toward a life-saving revascularization that avoids dialysis and an otherwise poor outcome; and (2) a simplified strategy entailing little or no need for contrast medium, carrying no associated risks of deteriorating renal function, permits the diagnosis of Pickering syndrome.

#4706 THERAPEUTIC AND PROGNOSTIC IMPACT OF KIDNEY BIOPSY FINDINGS IN PATIENTS AGED 80 YEARS AND OLDER: A MULTICENTER RETROSPECTIVE COHORT STUDY (KB-OLD)

Abstract Background and Aims The great phenotypic heterogeneity in the presentation of kidney diseases makes the diagnostic strategy all the more complex in the elderly. While kidney biopsy should play a pivotal role, its non-negligible risk of bleeding complications (2-5% in the general population) justifies a certain reluctance to its application in the elderly. To date, however, there is little data on the benefit-risk ratio of kidney biopsy in the elderly. Most of these studies have focused on a relatively young population (60-70 years old) and on a limited number of patients. Concerning patients aged 80 years and older, very few studies have described the real therapeutic influence of kidney biopsy findings with regard to the rate of complications. Moreover, none of these studies have evaluated the long-term prognostic impact of therapeutic changes induced by the results of the kidney biopsy. The main objectives of this study are to describe the indications, diagnoses, complication rate, therapeutic influence and the prognostic impact of a change in therapeutic management after native kidney biopsies performed in patients aged 80 years and older. Method The KB-Old study (Kidney Biopsy for Old) is a retrospective multicenter cohort that consecutively included all patients aged 80 years and older who underwent percutaneous native kidney biopsy in 17 centers in the northern region of France, between 2010 and 2020. Clinical, biological and anatomopathological data as well as post-biopsy follow-up (therapeutic strategy, occurrence of complications) were collected from medical records. All pathology examinations were analyzed centrally by a team of experienced nephropathologists. Events of death or kidney failure were identified by specific registry cross-linking. To analyze the prognostic impact of therapeutic management following kidney biopsy (either initiation of a specific treatment or simple nephroprotection) on the risk of kidney failure and death, we performed Cox models weighted by propensity score (Inverse Probability of Treatment Weighting -IPTW-) in the population potentially eligible for treatment (exclusion of diseases without specific treatment). The areas under Kaplan Meier curves were calculated up to 6 years of follow-up (Restricted Mean Survival Time - RMST) and compared according to the initiation of a specific treatment after the kidney biopsy. This study was approved by Institutional Review Board (#AUG-20-707). Results Overall, the cohort included 453 patients (54% men, median age 83 years), half of whom underwent biopsy in the context of acute kidney injury (median serum creatinine level 3.0 mg/dl). The main diagnoses were nephroangiosclerosis (15%), renal involvement of hematological malignancies (13%), acute tubulointerstitial nephritis (12%) and vasculitis (10%). The complication rate was approximately 10%, with only 2.8% of serious complications requiring therapeutic intervention (mostly transfusion). The kidney biopsy identified a disease potentially accessible to a specific treatment in 73% of cases. After exclusion of patients with ineligible diseases, a specific treatment was initiated in about one out of two cases (163/332, 49%). After weighting on propensity score, the two treatment groups were globally balanced. A beneficial effect of treatment on dialysis-free survival was observed (HR = 0.51 [0.28-0.92], p = 0.02), without any major influence on mortality (Figure 1). Over a 6-year follow-up period, there was a gain in dialysis-free survival in the treated group estimated by the delta RMST at +10.46 months [3.39 - 17.54] compared with the untreated group (p = 0.004), with no difference in overall life expectancy. Conclusion To the best of our knowledge, this is the largest multicenter cohort of patients aged 80 years and over who have undergone kidney biopsy. It seems to confirm the interest and safety of this examination for specific indications, and a potentially important benefit on the prognosis when it leads to an adapted therapeutic management.

#5507 ANTIHYPERTENSIVE PRESCRIBING PATTERNS IN CKD: FINDINGS FROM THE SALFORD KIDNEY STUDY

Abstract Background and Aims Hypertension is the second leading cause of chronic kidney disease (CKD) following diabetes and occurs in most patients with CKD. Finding an optimal treatment regime for hypertension remains challenging due to the complex bidirectional cause-and-effect relationship between hypertension and CKD, and hypertensive CKD patients may require treatment with multiple antihypertensive drugs. Database studies and practice guidelines have continued to demonstrate international variability in antihypertensive treatment practices. We analysed data from the Salford Kidney Study (SKS) database in relation to antihypertensive prescribing patterns amongst study patients. Method The SKS is an ongoing prospective study recruiting patients with CKD since the year 2002. Data including patient demographics, comorbidities, physical parameters, concurrent medications, and biochemical results are collected at baseline (study enrolment). All patients are followed up annually until they reach their endpoints [reaching end-stage kidney disease (ESKD), death, or discharge from follow-up] individually, with updates in their medical records including a list of medications. We have used Cox regression analysis and Kaplan Meier charts to investigate the associations between Renin-Angiotensin-Aldosterone System inhibitor (RAASi) use and the number of antihypertensive agents (binary groups of ≤3 or &amp;gt;3), and clinical outcomes (ESKD and all-cause mortality). Results A total of 3230 patients recruited between October 2002 and December 2019 were included in this analysis. At baseline, the median age of the cohort was 67 years with a predominance of males (62%) and those of white ethnicity (96%). 90% had a history of hypertension and 32% were diabetic. The median blood pressure was 138/75 mmHg. Previous myocardial infarction was recorded in 15%, congestive cardiac failure in 17% and cerebrovascular disease in 7.7% of the patients. The median estimated glomerular filtration rate (eGFR) was 30 ml/min/1.73 m2 and the median urine protein creatinine ratio (uPCR) was 33 mg/mmol. RAASi agents (ACEi &amp; ARB) (56%) were the most common antihypertensive medications to be prescribed, followed by diuretics (50%), calcium channel blockers (45%), and beta blockers (34%). The proportion of patients prescribed RAASi was associated with greater proteinuria (43 vs 33%, p&amp;lt;0.001). CKD patients with preexisting cardiovascular comorbidities were more likely to be prescribed beta blockers (44 vs 27%, p&amp;lt;0.001), diuretics (58 vs 39%, p&amp;lt;0.001) and mineralocorticoid antagonists (6.4 vs 1.85%, p&amp;lt;0.001). An increasing number of CKD patients were being prescribed ARBs over 24-month follow-up (34 vs 28%, p = 0.02). In a multivariable Cox-regression analysis, RAASi intake was not associated with reaching ESKD (HR 0.91; p = 0.49) but was associated with a significant survival benefit (HR 0.84; p = 0.001) (Figure 1). Use of a higher number of antihypertensive agents (i.e. &amp;gt;3) was associated with both greater mortality (HR 1.28; p = 0.02) and worse dialysis-free survival (HR 1.46; p = 0.007) (Figure 2). Conclusion Antihypertensive prescribing patterns in the SKS were consistent with current guidelines in the U.K. (e.g. NICE guidance 2022), with RAASi being predominantly prescribed as the first-line antihypertensive agent. An overall survival benefit was noted with RAASi use, although there was no signal for reducing progression towards ESRD. Outcomes were poor in patients with resistant hypertension needing multiple antihypertensive agents. Considering existing variations between the U.K. and other international guidelines regarding antihypertensive treatment in CKD, continued research is indicated to bridge the gaps between these recommendations and optimise patient outcomes.

Selective Use of Neoadjuvant Targeted Therapy Is Associated with Greater Achievement of Partial Nephrectomy for High-complexity Renal Masses in a Solitary Kidney

BackgroundPartial nephrectomy (PN) is preferred for a renal mass in a solitary kidney (RMSK), although tumors with high complexity can be challenging. ObjectiveTo evaluate the evolution of RMSK management with a focus on achievement of PN. Design, setting, and participantsPatients with nonmetastatic RMSK (n = 499) were retrospectively reviewed; 133 had high tumor complexity, including 80 in the pre-tyrosine kinase inhibitor (TKI) era (1999–2008) and 53 in the TKI era (2009–2022). After 2009, 23/53 patients received neoadjuvant TKI and 30/53 had immediate-surgery. Outcome measurements and statistical analysisFunctional outcomes, adverse events and complications, dialysis-free survival, and recurrence-free survival (RFS) were the measures evaluated. Mann-Whitney and χ2 tests were used to compare cohorts, and the log-rank test was applied for survival analyses. Results and limitationsOverall, the median RENAL score was 10 and the median tumor diameter was 5.2 cm. Demographic characteristics, tumor diameter, and RENAL scores were similar between the pre-TKI-era and TKI-era groups. In the TKI era, 23/53 patients (43%) with clear-cell histology were selected for neoadjuvant TKI. These 23 patients had a greater median tumor diameter (7.1 vs 4.4 cm; p = 0.02) and RENAL score (11 vs 10; p = 0.07). After TKI treatment, the median tumor diameter decreased to 5.6 cm and the RENAL score to 9, and tumor volume was reduced by 59% (all p < 0.05). PN was accomplished in 21/23 (91%) the TKI-treated cases and in 27/30 (90%) of the immediate-surgery cases (2009–2022). PN was only accomplished in 52/80 (65%) of the patients from the pre-TKI era (p < 0.01). The 5-yr dialysis-free survival rate was 59% in the pre-TKI-era group and 91% in the TKI-era group. The 5-yr RFS rate was lower in the TKI-era group (59% vs 74%; p = 0.21), which was mostly related to more aggressive tumor biology, as reflected by a predominance of systemic rather than local recurrences. ConclusionsManagement of RMSK with high tumor complexity is challenging. Selective use of TKI therapy was associated with greater use of PN, although a randomized study is needed. RFS mostly reflected aggressive tumor biology rather than failure of local management. Patient summaryFor complex kidney tumors in patients with a single kidney, management is challenging. Use of drugs called tyrosine kinase inhibitors before surgery was associated with reductions in tumor size and greater ability to achieve partial kidney removal for cancer control. Most recurrences were metastatic, which reflects aggressive tumor biology rather than failure of surgery.

PD43-04 MANAGEMENT OF RENAL MASS SOLITARY KIDNEY WITH HIGH TUMOR COMPLEXITY

You have accessJournal of UrologyCME1 Apr 2023PD43-04 MANAGEMENT OF RENAL MASS SOLITARY KIDNEY WITH HIGH TUMOR COMPLEXITY Worapat Attawettayanon, Yosuke Yasuda, JJ Zhang, Nityam Rathi, Carlos Munoz-Lopez, Kieran Lewis, Snehi Sha, Jianbo Li, Joao Accioly, Rebecca Campbell, Jihad Kaouk, Georges-Pascal Haber, Mohamad Eltemamy, Venkatesh Krishnamurthi, Robert Abouassaly, Christopher Weight, and Steven Campbell Worapat AttawettayanonWorapat Attawettayanon More articles by this author , Yosuke YasudaYosuke Yasuda More articles by this author , JJ ZhangJJ Zhang More articles by this author , Nityam RathiNityam Rathi More articles by this author , Carlos Munoz-LopezCarlos Munoz-Lopez More articles by this author , Kieran LewisKieran Lewis More articles by this author , Snehi ShaSnehi Sha More articles by this author , Jianbo LiJianbo Li More articles by this author , Joao AcciolyJoao Accioly More articles by this author , Rebecca CampbellRebecca Campbell More articles by this author , Jihad KaoukJihad Kaouk More articles by this author , Georges-Pascal HaberGeorges-Pascal Haber More articles by this author , Mohamad EltemamyMohamad Eltemamy More articles by this author , Venkatesh KrishnamurthiVenkatesh Krishnamurthi More articles by this author , Robert AbouassalyRobert Abouassaly More articles by this author , Christopher WeightChristopher Weight More articles by this author , and Steven CampbellSteven Campbell More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003353.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Partial nephrectomy (PN) is preferred for renal mass in solitary kidney (RMSK), although tumors with high complexity (R.E.N.A.L=10-12) can be very challenging. Our objective was to evaluate the evolution of management for such patients, with focus on the pre-TKI (1999-2008) vs TKI (2009-2022) eras. METHODS: 499 RMSK were managed from 1999-2022 at our center; 133 had high R.E.N.A.L., including 80/53 patients in the early/late timeframes, respectively. After 2009, 23 patients received tyrosine kinase inhibitor (TKI) before surgery, and 30 had immediate surgery. Achievement of PN was the primary outcome; other outcomes included adverse events and surgical complications related to TKI, and recurrence-free and overall survival (RFS/OS). RESULTS: Overall, median R.E.N.A.L. and tumor diameter were 10/5.2 cm, respectively. Demographics, tumor diameter, and R.E.N.A.L were all similar in the early vs late cohorts. Non-confined pathology was found in 51%/58% of the early/late cohorts, respectively. In the late cohort, 23/53(43%) patients were selected for pre-surgical TKI. These 23 patients were the most challenging with increased median tumor diameter (7.1 vs. 4.4cm, p=0.02) and increased median R.E.N.A.L.(11 vs. 10, p=0.07). After TKI, median tumor diameter and R.E.N.A.L. were reduced to 5.6 cm and 9, and median tumor volume was reduced 59%. PN was accomplished in 21/23 (91%) of this cohort, and PN was also accomplished in 27/30 (90%) of the immediate surgery cases. In contrast, PN was only accomplished in 52/80(65%) patients in the pre-TKI era. 5-year dialysis-free survival was 91% vs 59% in the late vs early cohorts, respectively. Grade 3 adverse events related to TKI were observed in 11 patients (49%), and in this cohort, 5 urine leaks and one post-op. bleed were all managed successfully with conservative measures. Median follow-up was 41months; 5-year OS was 66%/71% in the early/late cohorts, respectively (p=0.5), while 5-year RFS were 73%/56%, respectively (p=0.07). Most recurrences were metastatic reflecting aggressive tumor biology, rather than failure of local management. CONCLUSIONS: RMSK with high tumor complexity is often locally advanced and challenging. Selective use of TKI may reduce the need for RN and augment dialysis-free survival. RFS mostly reflected aggressive tumor biology rather than failure of local management. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1119 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Worapat Attawettayanon More articles by this author Yosuke Yasuda More articles by this author JJ Zhang More articles by this author Nityam Rathi More articles by this author Carlos Munoz-Lopez More articles by this author Kieran Lewis More articles by this author Snehi Sha More articles by this author Jianbo Li More articles by this author Joao Accioly More articles by this author Rebecca Campbell More articles by this author Jihad Kaouk More articles by this author Georges-Pascal Haber More articles by this author Mohamad Eltemamy More articles by this author Venkatesh Krishnamurthi More articles by this author Robert Abouassaly More articles by this author Christopher Weight More articles by this author Steven Campbell More articles by this author Expand All Advertisement PDF downloadLoading ...

PD43-03 FUNCTIONAL RECOVERY AFTER PARTIAL NEPHRECTOMY IN A SOLITARY KIDNEY

You have accessJournal of UrologyCME1 Apr 2023PD43-03 FUNCTIONAL RECOVERY AFTER PARTIAL NEPHRECTOMY IN A SOLITARY KIDNEY Worapat Attawettayanon, Yosuke Yasuda, JJ Zhang, Nityam Rathi, Carlos Munoz-Lopez, Kieran Lewis, Ben Ponvilawan, Snehi Sha, Jianbo Li, Joao Accioly, Rebecca Campbell, Joseph Zabell, Jihad Kaouk, Georges-Pascal Haber, Mohamad Eltemamy, Venkatesh Krishnamurthi, Robert Abouassaly, Christopher Weight, and Steven Campbell Worapat AttawettayanonWorapat Attawettayanon More articles by this author , Yosuke YasudaYosuke Yasuda More articles by this author , JJ ZhangJJ Zhang More articles by this author , Nityam RathiNityam Rathi More articles by this author , Carlos Munoz-LopezCarlos Munoz-Lopez More articles by this author , Kieran LewisKieran Lewis More articles by this author , Ben PonvilawanBen Ponvilawan More articles by this author , Snehi ShaSnehi Sha More articles by this author , Jianbo LiJianbo Li More articles by this author , Joao AcciolyJoao Accioly More articles by this author , Rebecca CampbellRebecca Campbell More articles by this author , Joseph ZabellJoseph Zabell More articles by this author , Jihad KaoukJihad Kaouk More articles by this author , Georges-Pascal HaberGeorges-Pascal Haber More articles by this author , Mohamad EltemamyMohamad Eltemamy More articles by this author , Venkatesh KrishnamurthiVenkatesh Krishnamurthi More articles by this author , Robert AbouassalyRobert Abouassaly More articles by this author , Christopher WeightChristopher Weight More articles by this author , and Steven CampbellSteven Campbell More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003353.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Partial nephrectomy (PN) is the reference standard for management of renal mass in a solitary kidney (RMSK), although factors determining functional recovery in this setting remain ill-defined. METHODS: 841 RMSK patients (1975-2022) managed with PN with functional data were identified, including 361/435/45 with cold/warm/zero ischemia, respectively. 155 patients also had necessary studies for detailed analysis of parenchymal volume preserved. Acute kidney injury (AKI) was classified by RIFLE (Risk/Injury/Failure/Loss/Endstage). Recovery from ischemia (Rec-Ischemia) was defined as glomerular filtration rate (GFR) saved normalized by parenchymal volume saved. Multivariable analysis was utilized to identify predictive factors for AKI and Rec-Ischemia. RESULTS: Overall, median preoperative GFR was 56.7ml/min/1.73m2 and median new baseline and 5-year GFRs were 43.1 and 44.5 ml/min/1.73m2, respectively. Median follow-up was 55 months; 5-year dialysis-free survival was 97%. In the detailed analysis cohort, median warm (n=70)/cold(n=85) ischemia times were 25/34 minutes, respectively, and median preoperative, new baseline and 5-year GFRs were 57.8, 45.0 and 41.7 ml/min/1.73m2, respectively. Functional recovery correlated strongly with parenchymal volume preserved (r=0.84, p<0.001). Loss of parenchymal volume accounted for 69% of the total median GFR decline associated with PN, leaving only an average of 3-4 ml/min/1.73m2 due to ischemia and other factors. AKI occurred in 52% of patients and was Grade 2/3 in 20%. The only independent predictor of AKI was ischemia time, and independent predictors of Rec-Ischemia were age, warm ischemia, and AKI grade. CONCLUSIONS: The main determinant of functional recovery after PN in RMSK is parenchymal volume preservation. Type and duration of ischemia, AKI, and age also correlated, although altogether their contributions were less impactful. Our findings suggest multiple opportunities for optimizing functional outcomes although preservation of vascularized parenchymal volume remains predominant. Long-term function generally remains stable with dialysis only occasionally required. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1118 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Worapat Attawettayanon More articles by this author Yosuke Yasuda More articles by this author JJ Zhang More articles by this author Nityam Rathi More articles by this author Carlos Munoz-Lopez More articles by this author Kieran Lewis More articles by this author Ben Ponvilawan More articles by this author Snehi Sha More articles by this author Jianbo Li More articles by this author Joao Accioly More articles by this author Rebecca Campbell More articles by this author Joseph Zabell More articles by this author Jihad Kaouk More articles by this author Georges-Pascal Haber More articles by this author Mohamad Eltemamy More articles by this author Venkatesh Krishnamurthi More articles by this author Robert Abouassaly More articles by this author Christopher Weight More articles by this author Steven Campbell More articles by this author Expand All Advertisement PDF downloadLoading ...

Intrarenal and Urinary Glycogen Synthase Kinase-3 Beta Levels in Diabetic and Nondiabetic Chronic Kidney Disease

Background: Renal glycogen synthase kinase-3 beta (GSK3β) overactivity has been associated with a diverse range of kidney diseases. GSK3β activity in urinary exfoliated cells was reported to predict the progression of diabetic kidney disease (DKD). We compared the prognostic value of urinary and intrarenal GSK3β levels in DKD and nondiabetic chronic kidney disease (CKD). Methods: We recruited 118 consecutive biopsy-proved DKD patients and 115 nondiabetic CKD patients. Their urinary and intrarenal GSK3β levels were measured. They were then followed for dialysis-free survival and rate of renal function decline. Results: DKD group had higher intrarenal and urinary GSK3β levels than nondiabetic CKD (p < 0.0001 for both), but their urinary GSK3β mRNA levels were similar. Urinary p-GSK3β level is statistically significantly correlated with the baseline estimated glomerular filtration rate (eGFR), but urinary GSK3β level by ELISA, its mRNA level, the p-GSK3β level, or the p-GSK3β/GSK3β ratio had no association with dialysis-free survival or the slope of eGFR decline. In contrast, the intrarenal pY216-GSK3β/total GSK3β ratio significantly correlated with the slope of eGFR decline (r = −0.335, p = 0.006) and remained an independent predictor after adjusting for other clinical factors. Conclusion: Intrarenal and urinary GSK3β levels were increased in DKD. The intrarenal pY216-GSK3β/total GSK3β ratio was associated with the rate of progression of DKD. The pathophysiological roles of GSK3β in kidney diseases deserve further studies.

OVERVIEW ON ROLE OF PRIMARY CARE IN MANAGEMENT OF CHRONIC KIDNEY DISEASE

Chronic kidney disease (CKD) is characterised by the presence of kidney damage or an estimated glomerular filtration rate (eGFR). Patients with more advanced stage 3 or stage 4 CKD experience a higher incidence of cardiovascular events and mortality. Because chronic kidney disease is a growing health concern, family physicians must be equipped to care for this unique patient population. Practice recommendations encourage proactive care of cardiovascular risk, the side effects of metabolic bone disease, and anaemia in these individuals as well as surveillance for increasing kidney disease. Primary care physicians (PCPs) are on the front lines of identifying and treating CKD as early as possible. However, the majority of PCPs frequently miss the existence of CKD. Additionally, the majority of patients with stages 3 and 4 CKD are not co-managed by nephrologists, despite the fact that increasing nephrologists' engagement in the care of these patients has been associated with improved dialysis-free survival. Early detection and treatment of these issues can stop the onset of subsequent sequelae, thus they shouldn't wait till nephrology is involved. This patient population also need appropriate counselling and health maintenance, both of which should be provided by the family doctor overseeing the patient's care.

Comprehensive Management of Renal Masses in Solitary Kidneys

BackgroundA renal mass in a solitary kidney (RMSK) has traditionally been managed with partial nephrectomy (PN), although radical nephrectomy (RN) is occasionally required. Most RMSK studies have focused on patients for whom PN was achieved. ObjectiveTo provide a comprehensive analysis of the management strategies/outcomes for an RMSK and address knowledge deficits regarding this challenging disorder. Design, setting, and participantsA total of 1024 patients diagnosed with an RMSK (1975–2022) were retrospectively evaluated. Baseline characteristics and pathologic/functional/survival outcomes were analyzed. InterventionPN/RN/cryoablation (CA)/active surveillance (AS). Outcome measurements and statistical analysisFunctional outcomes, perioperative morbidity/mortality, and 5-yr recurrence-free survival (RFS) were evaluated. Kruskal-Wallis and chi-square tests were used to compare cohorts, and log-rank test and Cox proportional hazard model were used for survival analysis. Results and limitationsOf 1024 patients, 842 underwent PN (82%), 102 CA (10%), 54 RN (5%), and 26 AS (3%). The median tumor size and RENAL([R]adius [tumor size as maximal diameter], [E]xophytic/endophytic properties of tumor, [N]earness of tumor deepest portion to collecting system or sinus, [A]nterior [a]/posterior [p] descriptor, and [L]ocation relative to polar lines) score were 3.7 cm and 8, respectively. The median follow-up was 53 mo. For PN, 95% were clamped, and the median warm and cold ischemia times were 22 and 45 min, respectively. For PN, the median preoperative glomerular filtration rate (GFR) was 57 ml/min/1.73 m2, and the median new baseline and 5-yr GFRs were 47 and 48 ml/min/1.73 m2, respectively. Dialysis-free survival for PN was 97% at 5 yr. Twenty-two (2.1%) patients with clear-cell renal cell carcinoma and RENAL score ≥10 (median = 11) received tyrosine kinase inhibitors (TKIs) to facilitate PN, leading to 57% median decrease of tumor volume; PN was accomplished in 20 (91%). Forty-one patients had planned RN (4.0%), most often due to severe pre-existing chronic kidney disease (CKD), and 13 were converted from PN to RN (1.5%). Clavien III–V perioperative complications were observed in 80 (8%) patients and 90-d mortality was 0.6%. Five-year RFS for PN, CA, and RN were 83%, 80%, and 72%, respectively (p = 0.03 for PN vs RN). ConclusionsNephron-sparing approaches are feasible and successful in most RMSK patients. PN for an RMSK is often challenging but can be facilitated by selective use of TKIs. RN is occasionally required due to severe CKD, over-riding oncologic concerns, or conversion from PN. This is the first large RMSK study to provide a comprehensive analysis of all management strategies/outcomes. Patient summaryKidney cancer in a solitary kidney is a major challenge for achieving cancer-free status and avoiding dialysis. Although partial nephrectomy is the principal treatment for a renal mass in a solitary kidney, other options are occasionally required to optimize outcomes.

Urinary and Kidney Podocalyxin and Podocin Levels in Diabetic Kidney Disease: A Kidney Biopsy Study

Diabetic kidney diseases (DKDs) are the most common cause of dialysis-dependent kidney disease around the world. Previous studies have suggested that urinary level of podocyte-associated molecules may predict the prognosis of DKD. Observational cohort. 118 consecutive patientswith biopsy-proven DKD; 13 nondiabetic patients with hypertensive nephrosclerosis as controls. Urinary podocalyxin and podocin levels were obtained by quantitative polymerase chain reaction and enzyme-linked immunosorbent assay (ELISA) and the corresponding intrarenal levels by western blotting. Dialysis-free survival; kidney event-free survival; rate of kidney function decline in 12 months. Correlation and time to event analysis. Urinary podocalyxin level was closely correlated with its messenger RNA (mRNA) level(r=0.562, P<0.001), but this did not predict the progression of DKD. Intrarenal podocalyxin level had only modest correlation with its urinary mRNA and ELISA levels, was an independent predictor of dialysis-free survival (adjusted HR, 1.85; 95% CI, 1.21-2.82; P=0.005), and showed an insignificant trend of predicting kidney event-free survival (adjusted HR, 1.36; 95% CI, 0.94-1.95; P=0.10). Urinary podocin level by ELISA had a modest correlation with the rate of kidney function decline (r=0.238, P=0.01) but did not predict dialysis-free survival. Small sample size; lack of serial measurement. Intrarenal podocalyxin level, but not its urinary level, was an independent predictor of dialysis-free survival, whereas urinary podocin level by ELISA correlated with the rate of kidney function decline. Although intrarenal podocalyxin level has prognostic value, it may not be suitable for routine clinical use.

Kidney Transplant-Associated Viral Infection Rates and Outcomes in a Single-Centre Cohort.

Opportunistic infections remain a significant cause of morbidity and mortality after kidney transplantation. This retrospective cohort study aimed to assess the incidence and predictors of post-transplant DNA virus infections (CMV, EBV, BKV and JCV infections) in kidney transplant recipients (KTR) at a single tertiary centre and evaluate their impact on graft outcomes. KTR transplanted between 2000 and 2021 were evaluated. Multivariate logistic regression analysis and Cox proportional hazard analyses were used to identify factors associated with DNA virus infections and their impact on allograft outcomes respectively. A sub-analysis of individual viral infections was also conducted to describe the pattern, timing, interventions, and outcomes of individual infections. Data from 962 recipients were evaluated (Mean age 47.3 ± 15 years, 62% male, 81% white). 30% of recipients (288/962) had infection(s) by one or more of the DNA viruses. Individually, CMV, EBV, BKV and JCV viruses were diagnosed in 13.8%. 11.3%, 8.9% and 4.4% of recipients respectively. Factors associated with increased risk of post-transplant DNA virus infection included recipient female gender, higher number of HLA mismatch, lower baseline estimated glomerular filtration rate (eGFR), CMV seropositive donor, maintenance with cyclosporin (rather than tacrolimus) and higher number of maintenance immunosuppressive medications. The slope of eGFR decline was steeper in recipients with a history of DNA virus infection irrespective of the virus type. Further, GFR declined faster with an increasing number of different viral infections. Death-censored graft loss adjusted for age, gender, total HLA mismatch, baseline eGFR and acute rejection was significantly higher in recipients with a history of DNA virus infection than those without infection (adjusted hazard ratio (aHR, 1.74, 95% CI, 1.08-2.80)). In contrast, dialysis-free survival did not differ between the two groups of recipients (aHR, 1.13, 95% CI, 0.88-1.47). Post-transplant DNA viral infection is associated with a higher risk of allograft loss. Careful management of immunosuppression and close surveillance of at-risk recipients may improve graft outcomes.

MO987: Risk Predictors and Impact of Post-Transplant Cardiovascular Disease in A 20-Year Cohort of Kidney Transplant Recipients

Abstract BACKGROUND AND AIMS Although improvement in histocompatibility matching, immunosuppressive therapy and antimicrobial treatment have led to improved long-term allograft survival, cardiovascular diseases (CVD) remain the major cause of morbidity and mortality in kidney transplant recipients (KTR). In addition to the accumulated risks due to chronic kidney disease and dialysis, kidney transplantation conveys its own unique risk factors for CVD. These include the metabolic effects of immunosuppressive treatments such as post-transplant hyperglycaemia, dyslipidaemia and hypertension as well as the effects of suboptimal kidney function including volume overload, anaemia, mineral bone disease and left ventricular hypertrophy. The predictors of cardiovascular diseases in KTR, however, have not been clearly defined. This study aimed to first ascertain the incidence of post-transplant CVD in those KTR without a prior confirmed history of CVD, then identify the predictors of CVD transplant associated CVD risk factors and finally evaluate the impact of CVD on graft and patient survival in this era of modern immunosuppressive medications. METHOD We evaluated 962 KTR transplanted between 2000 and 2020 and followed in a single centre. About 328 KTR with a history of pre transplant CVD were excluded. CVD was defined as a composite of Ischaemic heart disease, myocardial infarction, heart failure, stroke or peripheral vascular disease. Logistic regression analyses were performed to identify the risk predictors of post-transplant CVD. Kaplan–Meier plots and multivariate Cox proportional hazards regression analysis were used to identify and characterize predictors of dialysis free survival. RESULTS Among 634 KTR included in the analysis (mean age: 45 ± 15 years), CVD was reported in 101 KTR (16%) during a median follow-up of 95.9 months. About 274(43%) were females, 531(84%) were Caucasians. KTR with post-transplant CVD were likely to be older (50 ± 13 versus 44 ± 15 years; P &amp;lt; 0.001), had spent more time on dialysis [median (IQR) 21 (1–51) versus 11 (0–3) months; P = 0.004] and received cyclosporin maintenance (18% versus 7%; P = 0.01). Incidence of post-transplant CVD was independently predicted by older age [OR: 1.40 (1.15–1.70: P = 0.001)], tacrolimus therapy [OR: 0.81 (0.71–0.93), P = 0.002], mean haemoglobin concentration [OR: 0.86 (0.75–1.00), P = 0.049] and average C-reactive protein (CRP) level [OR: 1.13 (1.02–1.25), P = 0.02] (Figure 1). The median dialysis free survival was significantly lower in KTR who developed post-transplant CVD (14.7 versus 20 years, P = 0.009). In the multivariate Cox regression analysis, the factors associated with worse dialysis free survival in our cohort (survival with a functioning graft) were older age at transplantation [hazard ratio (HR): 1.03; P &amp;lt; 0.001), a history of post-transplant CVD (HR: 1.68; P = 0.006), higher post-transplant parathormone levels (HR: 1.02; P &amp;lt; 0.001), higher mean urine protein creatinine ratio (uPCR) (HR: 1.003: P &amp;lt; 0.001), a greater annual rise in uPCR (HR: 1.002; P &amp;lt; 0.001) and a history of acute rejection (HR: 1.56; P = 0.03). Statin treatment was associated with better dialysis free survival outcome (HR: 0.60; P = 0.01). CONCLUSION The incidence of post-transplant CVD in KTR with no history of pre-transplant CVD was 16%. Age at transplantation and average CRP were independent predictors of post-transplant CVD whereas treatment with Tacrolimus was associated with a lower risk of CVD. Statin therapy was associated with better dialysis free survival whereas a higher PTH was linked to poor survival. It was interesting to note that diabetes was not independently associated with the risk and outcome of post-transplant CVD in our cohort.

MO986: Incidence And Predictors of Post-Transplant De-Novo Malignancy: A Single-Centre Retrospective Cohort Study

Abstract BACKGROUND AND AIMS Improvement in short to medium term kidney transplant outcomes and increasingly successful transplantation older patients have led to increasing occurrence of long-term complications of transplantation. Amongst these complications, cancer has become an important cause of mortality following kidney transplantation necessitating the need to better understand the risk factors for the development of de novo malignancy. This study aimed to evaluate the prevalence and the risk factors of de-novo malignancy in a single UK tertiary nephrology centre. METHOD This retrospective cohort study included all kidney transplant recipients (KTR) at our centre, that underwent kidney transplantation between 2000 and 2020 and followed up at our centre. The incidence and types of malignancies excluding non-melanoma skin cancer (NMSC) were analysed. The characteristics of KTR with post-transplant malignancy (excluding NMSC) were compared to those without post-transplant malignancy. Univariate and multivariate logistic regression analyses were conducted to identify the risk predictors of post-transplant cancers. Graft survival and dialysis free survival and death with functioning graft were assessed using Kaplan-Mayer analysis and Cox-regression. RESULTS We analysed the records of 962 KTR (mean age = 47 ± 15 years), followed-up over a median period of 16 years. About 365 (38%) were women, and 783(81%) were Caucasian. 268(32%) had a pre-emptive transplant and 277(29%) had a live donor transplant. Post-transplant malignancy was diagnosed in 84(9%) KTR. KTR with post-transplant cancers were likely to be older (53 ± 14 versus 47 ± 15 years; P = 0.004), on long-term steroid maintenance therapy (64% versus 47%; P = 0.004) and have a history of post-transplant DNA virus infection (40% versus 29%; P = 0.029). Conversely, those with cancers are less likely to be on mycophenolic acid (MPA) therapy (65% versus 78%; P = 0.023). The most common cancers diagnosed were genitourinary cancers (27%) followed by gastrointestinal (24%) and haematological cancers (24%). Respiratory, neurological and others accounted for 10%, 2.4% and 11% of the diagnosed cancers. In multivariate logistic regression analysis, increasing risk of post-transplant cancer was associated with older age at transplantation [OR: 1.81 (1.3–2.5; P &amp;lt; 0.001)], male gender [OR 2.3 (1.3–8.3; P = 0.01)], corticosteroid maintenance [OR 2.3 (1.1–5.2: P = 0.03)], Tobacco smoking [OR: 3.33 (1.2–8.9: P = 0.01)], higher Baseline estimated glomerular filtration rate (eGFR), [OR: 1.2 (1.0–1.4; P = 0.02)], and post-transplant DNA-virus infection [OR: 2.3 (1.0–5.1; P = 0.02)] (Figure 1). There was no difference in the death censored graft survival between the cancer group and the no-cancer group (log-rank, P = 0.51). However, those with cancers had a significantly worse dialysis free survival (log-rank; P = 0.04) and significantly higher death with functioning graft (log-rank; P = 0.02). In the multivariate Cox regression, adjusted for several confounders, dialysis free survival did not differ significantly between the cancer and non-cancer groups (adjusted hazard ratio; aHR: 1.6; P = 0.10). However, age (aHR: 1.16; P = 0.01), male gender (aHR: 1.6; P = 0.01), cardiovascular disease (CVD) (HR: 1.6; P = 0.01) and acute rejection (aHR: 1.7; P = 0.02) were predictors of lower dialysis free survival. CONCLUSION Post-transplant cancers occurred in 9% of our cohort during a median follow-up of 16years. Genitourinary cancers were the most commonly occurring cancers. Older age, male gender, corticosteroid maintenance, smoking and DNA virus infections were the risk factors of malignancy. There was no significant difference in dialysis free survival between the cancer group and the no cancer groups. Lower dialysis free survival was predicted by age, gender, CVD and a history of acute rejection.

MO491: Low Income is Associated With Late Nephrology Referral in Portugal: A Retrospective Study

Abstract BACKGROUND AND AIMS Social disparities in chronic kidney disease (CKD) are a reality. Low socioeconomic status is associated with an increased incidence of CKD and overall worse outcomes. In Portugal, similarly to many European countries, a National Health System (NHS) was established to provide equity in healthcare access, but its impact in specialized CKD care is unclear. This study aims to compare the effects of economic insufficiency in referral and overall specialized kidney care in a Portuguese centre. METHOD Retrospective cohort study evaluating maintenance haemodialysis patients of a Public Portuguese Nephrology Centre from 2017 through 2021. Medical records were compared for the presence of Low-Income status (LIs), with primary outcome as baseline estimated glomerular filtration rate (eGFR) at nephrology referral and secondary outcomes as presence of kidney replacement therapy options appointment (KRTOa), timely vascular access assessment and time to dialysis from referral. RESULTS A total of 212 participants were evaluated, 96 with LIs. This group presented higher sCr and lower eGFR at referral (2.35 versus 3.29 mg/dL, P &amp;lt; .001; 27.63 versus 18.47 mL/min/1.73 m2 P &amp;lt;.001, respectively). LIs associated with absence of KRTOa {OR: 2.7, [95% confidence interval (95% CI): 1.44–5.08]; P = .003} and late vascular access evaluation (OR: 2.77, 95% CI: 1.55–4.98; P = .001). Dialysis-free survival analysis revealed shorter time to dialysis in the LIs group (15.77 versus 20.71 months; P &amp;lt; .001) with a higher cumulative incidence in dialysis at 24 months (HR: 2.11, 95% CI: 1.39–3.21; P &amp;lt; .001), a difference that was not verified after adjusting for eGFR at referral (HR: 1.16, 95% CI: 0.74–1.80; P = .53). CONCLUSION Low-Income CKD Portuguese patients are at risk of late nephrology referral, an established factor for adverse outcomes. Shorter time to dialysis appears significative in reducing adequate kidney care access, which can be attenuated through education of primary care providers and general population for CKD.

Low income is associated with late nephrology referral in Portugal: A retrospective study

Introduction: Social disparities in chronic kidney disease are a reality. Low socioeconomic status is associated with increased incidence of chronic kidney disease and overall worse outcomes. In Portugal, similarly to many European countries, a National Health System was established to provide equity in healthcare access, but its impact in specialized chronic kidney disease care is unclear. This study aims to compare the effects of economic insufficiency in referral and overall specialized kidney care in a Portuguese center. Subjects and Methods: Retrospective cohort study evaluating maintenance hemodialysis patients of a Public Portuguese Nephrology Center from 2017 through 2021. Medical records were compared for presence of low-income status, with primary outcome as baseline estimated glomerular filtration rate at Nephrology referral and secondary outcomes as presence of kidney replacement therapy options appointment, timely vascular access assessment and time to dialysis from referral. Results: A total of 212 participants were evaluated, 96 with low-income status. This group presented higher serum creatinine and lower estimated glomerular filtration rate at referral (2.35 vs. 3.29 mg/dl, p&lt;0.001; 27.63 vs. 18.47 ml/min/1.73 m2, p&lt;0.001; respectively). Low-income status associated with absence of kidney replacement therapy options appointment (OR 2.7, 95% CI: 1.44-5.08; p=0.003) and late vascular access evaluation (OR 2.77, 95% CI: 1.55-4.98, p=0.001). Dialysis-free survival analysis revealed shorter time to dialysis in the low-income status group (15.77 vs. 20.71 months, p&lt;0.001) with a higher cumulative incidence in dialysis at 24 months (HR: 2.11, 95% CI: 1.39-3.21, p &lt; 0.001), a difference that was not verified after adjusting for estimated glomerular filtration rate at referral (HR: 1.16, 95 % CI: 0.74 – 1.80, p = 0.53). Conclusion: Low-Income chronic kidney disease Portuguese patients are at risk for late Nephrology referral, an established factor for adverse outcomes. Shorter time to dialysis appears significative in reducing adequate kidney care access, which can be attenuated through education of primary care providers and general population for chronic kidney disease.

Management of severe renal disease in anti-neutrophil-cytoplasmic-antibody-associated vasculitis: the place of rituximab and plasma exchange?

The optimal induction therapy for severe glomerulonephritis of ANCA-associated vasculitis (AAV) is debated. We compared the efficacy of glucocorticoid and rituximab (RTX) or CYC induction therapy for severe AAV-related glomerulonephritis and evaluated the potential benefit of plasma exchange (PE) as adjunct therapy to CYC. This retrospective, multicentre study included AAV patients with severe renal active disease (serum creatinine level ≥350 µmol/l and/or estimated glomerular filtration ratio ≤15 ml/min/1.73 m2). Propensity-score analysis was used to adjust for potential confounders. Between 2005 and 2017, 153 patients with AAV-related glomerulonephritis were studied (96 [60%] men; mean [s.d.] age 63 [13.1] years): 19 (12%) were treated with RTX and 134 (88%) with CYC. Remission rates did not differ between RTX- and CYC-treated groups. Although more patients with RTX than CYC were dialysis-free at month (M) 12 (79% vs 68%), the difference was not significant after adjustment. Among 134 patients with CYC-treated glomerulonephritis, 76 (57%) also had PE. M3 and M6 remission rates were comparable for weighted CYC groups with or without PE. For weighted groups, the dialysis-free survival rate with CYC was higher with than without PE at M6 (72% vs 64%; odds ratio 2.58) and M12 (74% vs 60%; odds ratio 2.78) reaching statistical significance at M12. We could not find any difference between RTX and CYC as induction therapy for patients with severe AAV-related glomerulonephritis. In patients receiving CYC induction regimen, the addition of PE conferred short-term benefits with higher dialysis-free rate at M12.