Diet In Renal Disease Method Research Articles

MO548PREVALENCE AND INCIDENCE OF ANAEMIA IN PATIENTS WITH NON-DIALYSIS DEPENDENT (NDD) CHRONIC KIDNEY DISEASE (CKD), AND EVALUATION OF TREATMENT PATTERNS WITH ERYTHROPOIESIS-STIMULATING AGENTS (ESAS): A RETROSPECTIVE DATABASE STUDY IN ITALY

Abstract Background and Aims Anaemia is a common complication in patients with NDD-CKD, and its prevalence increases with advancing CKD stage.1,2 It is a risk factor for both CKD progression and other adverse outcomes, including major adverse cardiac events, hospitalisation and all-cause mortality.1 We aim to report the prevalence of NDD-CKD stage 3a–5 in Italy, and to evaluate the prevalence and incidence of anaemia among patients with NDD-CKD. Of those patients with anaemia, we seek to establish the size of the patient pool eligible for ESAs, and consequently, the proportion of patients treated with ESAs. Method Patients ≥18 years of age with a record of NDD-CKD stage 3a–5 between 1 January 2014 and 31 December 2016 were identified from databases of five Local Health Units (LHUs) across Italy. NDD-CKD stage 3a–5 in our study was defined as either ≥1 hospitalisation record with discharge diagnosis of CKD (ICD-9-CM 585.x, where x = 3, 4, or 5) or ≥1 record of estimated glomerular filtration rate (eGFR) <60 mL/min. eGFR values were estimated using the Modification of Diet in Renal Disease method and were as reported by LHUs. Patient classification into CKD stage 3a–5 based on eGFR was done according to KDIGO guidelines.3 Anaemia was defined as Hb <13 g/dL (males) or <12 g/dL (females). Prevalence was defined as the presence of ≥1 record of NDD-CKD stage 3a–5 or anaemia in the entire period preceding the timepoint of interest, or as incident NDD-CKD/anaemia; incidence was defined as a first record of the condition in the year of interest (no record of the condition in the patient’s history). Point prevalence (at 31 December of each reported year) and annual incidence were age- and sex-standardised using census data from 1 January of the following year. Among patients with anaemia of NDD-CKD stage 3a–5, eligibility for ESA was defined as at least one record of Hb <10 g/dL,4 and patients with a record of ESA prescription were categorised as ESA treated. Results For 2016, the prevalence of NDD-CKD stage 3a–5 in the population aged ≥18 years was 5.6% (83,625/1,507,391): CKD stage 3a was the most common (4.2%; 62,683/1,507,391), while the prevalence of each of the stages 3b–5 was ≤1.0% (Table). The prevalence and incidence of anaemia among patients with NDD-CKD stage 3a–5 in 2016 was 33.8% and 11.4%, respectively. The prevalence of anaemia increased with CKD stage: from 28.2% among patients with stage 3a to 78.9% among those with stage 5. A similar trend was observed for incidence, which increased from 9.3% for stage 3a to 32.8% for stage 5. The proportion of patients with NDD-CKD stage 3a–5 and anaemia who were eligible for ESA treatment from 2014–2016 ranged from 51.9% to 75.6% across the CKD stages. In 2016, the proportion of patients with incident NDD-CKD anaemia who were eligible for ESAs but not treated was 42.3%. This proportion was similar across the CKD stages, except for stage 5, for which the proportion of patients who were eligible but not ESA treated was 51.1%. Conclusion In Italy, we found that higher CKD stages are associated with increased prevalence and incidence of anaemia in NDD-CKD, a finding which is supported by previous research in other countries worldwide.1,2 Despite this, almost half of patients with anaemia of NDD-CKD stage 3a–5 were eligible for ESA treatment but did not receive ESAs. This suggests that anaemia may not be adequately controlled in patients with NDD-CKD stage 3a–5, and may need further attention and treatment.

Serum creatinine level at 1-month posttransplant can independently predict long-term graft survival and functional status.

BackgroundAfter the year 2000, kidney transplants with high immunologic risk and deceased donors increased rapidly in Korea. At the same time, the medical community developed special pretransplant and early posttransplantation management protocols. Our team evaluated the effect of early graft stabilization on long-term graft survival and functional status using databases from a high-volume kidney transplantation center.MethodsWe included 1,895 kidney transplant patients from a total of 1,976 performed between 2005 and 2018. Early graft failure within 1 month (n=9), loss to follow-up (n=2), pediatric recipient or donor (n=37), and combined organ transplantation (n=33) cases were excluded. We grouped the cases at 1-month posttransplantation by serum creatinine quantiles (1.0 mg%, 1.23 mg%, and 1.52 mg%).ResultsAfter an average of 95 months of follow-up (maximum 189 months), the high-serum creatinine group (4th quantile) showed significantly poorer graft survival than other groups (1st to 3rd quantile) (P<0.05). In multiple Cox regression analysis, a high serum creatinine level (4th quantile) at 1-month posttransplant is an independent risk factor for graft failure with a hazard ratio of 1.799 (P=0.013). The quantile group by serum creatinine shows a persistent, significant difference of functional graft status (glomerular filtration rate by Modification of Diet in Renal Disease method) among quantile groups beyond ten years posttransplant.ConclusionsSerum creatinine level at 1-month posttransplant is a strong independent predictor of graft survival and functional graft status beyond ten years posttransplant.

Comparison between Statistical Models and Machine Learning Methods on Classification for Highly Imbalanced Multiclass Kidney Data.

This study aims to compare the classification performance of statistical models on highly imbalanced kidney data. The health examination cohort database provided by the National Health Insurance Service in Korea is utilized to build models with various machine learning methods. The glomerular filtration rate (GFR) is used to diagnose chronic kidney disease (CKD). It is calculated using the Modification of Diet in Renal Disease method and classified into five stages (1, 2, 3A and 3B, 4, and 5). Different CKD stages based on the estimated GFR are considered as six classes of the response variable. This study utilizes two representative generalized linear models for classification, namely, multinomial logistic regression (multinomial LR) and ordinal logistic regression (ordinal LR), as well as two machine learning models, namely, random forest (RF) and autoencoder (AE). The classification performance of the four models is compared in terms of accuracy, sensitivity, specificity, precision, and F1-Measure. To find the best model that classifies CKD stages correctly, the data are divided into a 10-fold dataset with the same rate for each CKD stage. Results indicate that RF and AE show better performance in accuracy than the multinomial and ordinal LR models when classifying the response variable. However, when a highly imbalanced dataset is modeled, the accuracy of the model performance can distort the actual performance. This occurs because accuracy is high even if a statistical model classifies a minority class into a majority class. To solve this problem in performance interpretation, we not only consider accuracy from the confusion matrix but also sensitivity, specificity, precision, and F-1 measure for each class. To present classification performance with a single value for each model, we calculate the macro-average and micro-weighted values for each model. We conclude that AE is the best model classifying CKD stages correctly for all performance indices.

Experience and Security of the Hand-Assisted Laparoscopic Nephrectomy of a Living Donor in a Public Health Center

BackgroundHand-assisted laparoscopic nephrectomy (HALDN) is currently the procedure of choice for obtaining living donor kidneys for transplantation. In our institution, it has been the standard procedure for 5 years. Previous studies have shown the same function of the graft as that obtained by open surgery, with a lower rate of bleeding and no differences in complications. We sought to demonstrate the experience and safety of HALDN compared with open donor nephrectomy in healthy donors for kidney transplantation. MethodsA retrospective analytical observational study was conducted, reviewing the records of the living donors for kidney transplant undergoing open donor nephrectomy or HALDN in our center from March 1, 2009, to March 1, 2016. Renal function was assessed by the estimated glomerular filtration rate by the Modification of Diet in Renal Disease method before and after donation, as well as bleeding (mL), and complications (according to Clavien), performing a comparative analysis between the two techniques using parametric or nonparametric tests. ResultsA total of 179 living donor nephrectomies were performed during the study period—31 open donor nephrectomy (17.3%) and 148 HALDN (82.7%)—without relevant baseline differences, except for creatinine. HALDN has a shorter surgical time (156,473 ± 87.75 minutes vs 165,484 ± 69.95 minutes) and less bleeding (244.59 ± 416.08 mL vs 324.19 ± 197.986 mL) and a shorter duration of hospital stay (3.74 ± 1.336 days vs 4.75 ± 1.226 days). There were no significant differences in surgical complications at 30 days, or graft loss reported; there were 3 conversions (1.7%) from the HALDN to the open technique. There were no differences in renal function in the donors or recipients at the 5th day or the month after surgery. ConclusionsLaparoscopic nephrectomy has replaced open surgery as the gold standard for living kidney donors. HALDN is a safe and feasible procedure when compared with open donor nephrectomy, achieving a shorter surgical time with less bleeding, and no difference in the number of complications. This procedure lowers costs by decreasing the duration of the hospital stay, making is feasible to perform it at any institution with appropriately trained personnel.

Effects of Bosutinib Treatment on Renal Function in Patients With Philadelphia Chromosome-Positive Leukemias.

The purpose of the study was to assess renal function in patients with Philadelphia chromosome-positive leukemias receiving bosutinib or imatinib. Patients received first-line bosutinib (n= 248) or imatinib (n= 251; phase III trial), or second-line or later bosutinib (phase I/II trial; n= 570). Adverse events (AEs) and changes from baseline in estimated glomerular filtration rate (eGFR) and serum creatinine were assessed. Time from the last patient's first dose to data cutoff was≥ 48 months. Renal AEs were reported in 73/570 patients (13%) receiving second-line or later bosutinib, and in 22/248 (9%) and 16/251 (6%) receiving first-line bosutinib and imatinib, respectively. eGFR in patients receiving bosutinib declined over time with more patients developing Grade≥ 3b eGFR (< 45 mL/min/1.73 m2 according to the Modification of Diet in Renal Disease method) with second-line or later bosutinib (139/570, 24%) compared with first-line bosutinib (26/248, 10%) and imatinib (25/251, 10%); time to Grade≥ 3b eGFR was shortest with second-line or later bosutinib. Similar proportions of patients receiving second-line or later bosutinib (74/139, 53%), first-line bosutinib (15/26, 58%), and first-line imatinib (15/25,60%) improved to≥ 45 mL/min/1.73 m2 eGFR as of the last follow-up. In a regression analysis, first-line treatment with bosutinib versus imatinib was not a significant predictor of Grade≥ 3b eGFR. Long-term bosutinib treatment is associated with an apparently reversible decline in renal function with frequency and characteristics similar to renal decline observed with long-term imatinib treatment. Patients with risk factors for Grade≥ 3b eGFR should be monitored closely.

Treatment of the Lymphocele After Kidney Transplantation: A Single-center Experience.

Lymphocele is one of the most common complications after kidney transplantation. It is usually asymptomatic, but can cause pressure on the kidney transplant, ureter, bladder, and adjacent vessels with deterioration of graft function, ipsilateral leg edema, and external iliac vein thrombosis. Peritoneal fenestration is a well-established method for treatment. In this report, we present the incidence of symptomatic lymphocele requiring treatment (LRT), demographic and surgical factors that influenced lymphocele formation, its clinical presentation, and 2 types of treatment: open and laparoscopic intraperitoneal drainage in the experience of our center. We retrospectively analyzed all kidney transplantations performed between January 2007 and December 2014 in Gdansk Transplantation Center (n= 740) and selected patients with LRT. LRT occurred in 59 cases (8%). All other patients transplanted during the same time (n= 681) were treated as a control group in the univariate and multivariate analysis of risk factors of the lymphocele formation. Surgical intraperitoneal drainage was performed in an open method in 53 cases and laparoscopically in 6 patients. We observed recurrence of lymphocele in 11 cases (18.6%). Acute rejection episodes (ARE) and delayed graft function (DGF) were more frequent in patients with LRT. ARE and age were independent risk factors for LRT in multivariate analysis. The mean estimated glomerular filtration rate by the Modification of Diet in Renal Disease method at 1 month after the fenestration was higher than before the operation (51.7 and 43.6mL/min, respectively). Fenestration is a safe and effective method of treatment of symptomatic lymphocele. ARE, DGF, and older age were associated with a greater risk of LRT.

Cardiac autonomic neuropathy and early progressive renal decline in patients with nonmacroalbuminuric type 1 diabetes.

Cardiac autonomic neuropathy predicts future adverse renal outcomes in the general population. This study sought to determine its relationship with early progressive renal decline in type 1 diabetes. A subset of participants with normoalbuminuria (n=204) or microalbuminuria (n=166) from the First Joslin Kidney Study underwent assessment for cardiac autonomic neuropathy using heart rate variability during baseline visits performed from January 1991 to April 1992. Cardiac autonomic neuropathy was defined as an R-R variation (mean circular resultant) <20. Participants also had baseline and follow-up measurement of eGFR. Early progressive renal decline was evaluated according to two definitions: early GFR loss (slope of eGFR estimated by cystatin C <-3.3%/year) and incident advanced CKD (stage ≥3, defined by eGFR [calculated by Modification of Diet in Renal Disease method] <60 ml/min per 1.73 m(2)). Association with baseline cardiac autonomic neuropathy was assessed by adjusted logistic regression and Cox proportional hazards. Among the 370 participants, 47 (13%) had baseline cardiac autonomic neuropathy, 51 (14%) had early GFR loss, and 68 (18%) had incident advanced CKD over a median 14-year follow-up. Early GFR loss occurred in 15 (32%) of the 47 patients with baseline autonomic neuropathy and in 32 (10%) of the 323 without baseline autonomic neuropathy (P<0.001). Baseline autonomic neuropathy was strongly associated with odds of early GFR loss (adjusted odds ratio, 4.09; 95% confidence interval, 1.65 to 10.12; P=0.002). Incident advanced CKD was observed in 22 (47%) of those with baseline autonomic neuropathy and 46 (14%) of those without baseline autonomic neuropathy (P<0.001). Autonomic neuropathy was independently associated with incident advanced CKD (adjusted hazard ratio, 2.76; 95% confidence interval, 1.44 to 5.30; P=0.002). Cardiac autonomic neuropathy was a strong independent predictor of the long-term risk of early progressive renal decline in type 1 diabetes. Future research should explore the mechanisms by which autonomic neuropathy may be associated with renal function loss.

Renal Dysfunction in Stroke Patients: A Hospital-Based Cohort Study and Systematic Review

Renal dysfunction (i.e. a reduced estimated glomerular filtration rate, eGFR) is commonly found in hospitalized stroke patients but its associations with patients' characteristics and outcome require further investigation. We linked clinical data from stroke patients enrolled between 2005 and 2008 into two prospective hospital registers with routine laboratory eGFR data. The eGFR was calculated using the Modification of Diet in Renal Disease method and renal dysfunction was defined as <60 ml/min/1·73 m(2) . In addition we systematically reviewed studies investigating the association between eGFR and outcome after stroke. Of 2520 patients who had an eGFR measured on admission hospital, 805 (32%) had renal dysfunction. On multivariate analysis, renal dysfunction was significantly less likely in those with a predicted good outcome (OR 0·27, 95% CI 0·21, 0·36) based on the well-validated six simple variable model. After adjustment for other predictive factors, stroke patients with renal dysfunction were more likely to die in hospital compared with those without (odds ratio 1·59, 95% confidence intervals 1·26, 2·00). Of the 31 studies involving 41 896 participants included in the systematic review, 18 studies found that low eGFR was an independent predictor of death and 6 reported a significant association with death and disability. Our findings suggest that renal dysfunction on admission is common and associated with poor outcomes over the first year. Further work is required to establish to what extent these associations are causal and whether treating impaired renal function improves outcomes.

Incidence, dynamics, and prognostic value of acute kidney injury for death after cardiac surgery

This study relates long-term mortality after cardiac surgery to different methods of measuring postoperative renal function, classified according to the Risk, Injury, Failure, Loss, and End-stage (RIFLE) criteria. The dynamics of acute kidney injury during hospital stay were studied by comparing renal function preoperatively, at its poorest measurement, and at discharge. A total of 5746 patients undergoing coronary artery bypass grafting were studied in a Cox analysis, over a median follow-up time of 6.0 years (range, 2.5-9.5 years). Renal function was determined using the highest and discharge levels of plasma creatinine by Cockroft-Gault and Modification of Diet in Renal Disease formulae. Acute kidney injury was classified according to the RIFLE criteria. Renal recovery was studied in a 2-dimensional matrix, and the impact of renal function at different time points was related to survival. Although the p-creatinine classified most patients in the nonacute kidney injury and Risk class; the Cockroft-Gault and Modification of Diet in Renal Disease formulae classified more patients in Injury and Failure classes; and higher Risk, Injury, and Failure classes were associated with increased long-term mortality. The effect of renal recovery on long-term survival was only in part associated with improved outcome. In addition, the poorest renal function was a stronger predictor of mortality compared with preoperative and discharge levels. Classification using RIFLE criteria seems to be useful because it detects patients with renal impairment that affects long-term survival. The Modification of Diet in Renal Disease method seems to be the most robust method when predicting outcome, and the poorest renal function was the best predictor of outcome. Renal recovery was generally associated with better outcome.

Anaemia and type 2 diabetes: implications from a retrospectively studied primary care case series

OBJECTIVES. To identify the prevalence of anaemia in Chinese type 2 diabetic patients managed in a primary care setting and to explore its associations with cardiovascular complications and kidney disease. DESIGN. Retrospective case series study. SETTING. General Out-patient Clinic of Hospital Authority, Hong Kong. PATIENTS. Chinese type 2 diabetic patients who had annual assessments between 1 January 2010 and 31 December 2011 were recruited. Their complete blood picture, serum creatinine, estimated glomerular filtration rate (calculated by Modification of Diet in Renal Disease method), haemoglobin A1c, and urine albumin-creatinine ratio were retrieved. Anaemia was defined as a haemoglobin level of <130 g/L in men and <120 g/L in women (World Health Organization criteria). Student's t test and analysis of variance were used to analyse continuous variables and the Chi squared test for categorical data. Pearson's correlation coefficient and multivariate logistic regression were used to examine associations between haemoglobin level and different variables including age, gender, serum creatinine level, estimated glomerular filtration rate, and urine albumin-creatinine ratio. All statistical tests were two-sided, and a P value of <0.05 was considered significant. RESULTS. Among 6325 Chinese type 2 diabetic patients fulfilling the inclusion criteria, 1441 were found to have anaemia with a period prevalence of 22.8%. The prevalence of anaemia increased significantly with deterioration of renal function. Compared with diabetic patients with normal haemoglobin levels, anaemic diabetic patients had a higher co-morbidity rate for stroke, ischaemic heart disease, hypertension, and chronic kidney disease (P<0.001). Independent predictors for haemoglobin level among diabetic patients were age, gender, serum creatinine level, estimated glomerular filtration rate, haemoglobin A1c, and urine albumin-creatinine ratio (P<0.001). Multivariate analysis showed that male gender, old age, increased serum creatinine level, decreased estimated glomerular filtration rate, elevated urine albumin-creatinine ratio, and co-morbidity with stroke or ischaemic heart disease were associated with greater odds for the presence of anaemia. CONCLUSION. Anaemia is common among Chinese type 2 diabetic patients, particularly those with impaired renal function or established cardiovascular disease. Early detection of anaemia and prompt referral to specialist care for optimal treatment, if associated with severe renal impairment or high-risk proteinuria at the primary care settings, is recommended.

Changes in Renal Function After Laparoscopic Partial Nephrectomy: Comparison With Laparoscopic Radical Nephrectomy

PurposeTo evaluate alterations in renal function after laparoscopic radical nephrectomy (LRN) and laparoscopic partial nephrectomy (LPN) for renal tumors.Materials and MethodsFrom March 2008 to August 2011, we performed 175 cases of laparoscopic kidney resection. Among these, we excluded patients who received perioperative immunotherapy or target therapy and also patients with a preoperative estimated glomerular filtration rate (eGFR) <60 mL/min. A total of 32 patients undergoing LPN and 92 patients undergoing LRN were enrolled. We retrospectively reviewed the changes in eGFR (by the modification of diet in renal disease method) at the following time points: preoperative, postoperative 1 week, and postoperative 1, 3, 6, and 12 months.ResultsThe mean warm ischemia time of the LPN group was 22 minutes (range, 0 to 47 minutes). Mean eGFR values (mL/min/1.73 m2) during postoperative week 1 and 1, 3, 6, and 12 months were 70.8, 71.5, 76.7, 76.0, and 75.3 in the LPN group and 52.1, 50.6, 52.8, 53.4, and 52.4 in the LRN group, respectively. One year after the operation, 6.3% (2 patients) of LPN patients and 68.5% (63 patients) of LRN patients had progressed to chronic renal insufficiency (eGFR<60 mL/min/1.73 m2).ConclusionsRenal function recovered slightly after LPN and LRN and was maintained constantly after 3 months. However, renal function showed different patterns of decrease. Despite the concern for warm ischemia, LPN can preserve renal function better than can LRN. LPN should be considered for selected patients to prevent chronic renal insufficiency.

Kidney Function and White Matter Disease in Young Stroke Patients

Impaired kidney function is thought to be associated with small vessel disease, outcome, and mortality in the general stroke population. Data are limited regarding young patients. The aim of this study was to investigate the association of kidney function and white matter hyperintensities (WMHs) in young patients with first ischemic stroke. We analyzed 2500 young (18-55 years) patients with first-ever ischemic stroke from the prospective observational Stroke in Young Fabry Patients (SIFAP1) study with available MRI data on WMH. Of these, 2009 had available data concerning estimated glomerular filtration rate (eGFR). Kidney function was expressed as eGFR by the Modification of Diet in Renal Disease method. Deep WMHs on MRI were classified by the Fazekas score. Multivariate analysis was performed using a regression model with random effects. Mean eGFR was 96.7 mL/min in those with WMH Grade 0 to 1 (none to mild), 90.7 mL/min in WMH Grade 2 (moderate), and 89 mL/min in WMH Grade 3 (severe). Univariate analysis revealed WMH to be associated with age (P<0.001), hypertension (P<0.001), cardiovascular disease (P=0.015), overweight (body mass index >25 kg/m(2); P=0.013), current smoking (P=0.044), and eGFR (P=0.009). In multivariate analysis, age, hypertension, and eGFR remained associated with WMH severity. In young patients with acute ischemic stroke, lower eGFR values in the normal range are associated with the presence of moderate to severe WMH. Clinical Trial Registration- URL: http://clinicaltrials.gov. Unique Identifier: NCT00414583.

Comparison of Drug-Eluting Stents in Acute Myocardial Infarction Patients with Chronic Kidney Disease

Background/AimsTo determine which drug-eluting stents are more effective in acute myocardial infarction (MI) patients with chronic kidney disease (CKD).MethodsThis study included a total of 3,566 acute MI survivors with CKD from the Korea Acute Myocardial Infarction Registry who were treated with stenting and followed up for 12 months: 1,845 patients who received sirolimus-eluting stents (SES), 1,356 who received paclitaxel-eluting stents (PES), and 365 who received zotarolimus-eluting stents (ZES). CKD was defined as an estimated glomerular filtration rate < 60 mL/min/1.73 m2 calculated by the modification of diet in renal disease method.ResultsAt the 12-month follow-up, patients receiving ZES demonstrated a higher incidence (14.8%) of major adverse cardiac events (MACEs) compared to those receiving SES (10.1%) and PES (12%, p = 0.019). The ZES patients also had a higher incidence (3.9%) of target lesion revascularization (TLR) compared to those receiving SES (1.5%) and PES (2.4%, p = 0.011). After adjusting for confounding factors, ZES was associated with a higher incidence of MACE and TLR than SES (adjusted hazard ratio [HR], 0.623; 95% confidence interval [CI], 0.442 to 0.879; p = 0.007; adjusted HR, 0.350; 95% CI, 0.165 to 0.743; p = 0.006, respectively), and with a higher rate of TLR than PES (adjusted HR, 0.471; 95% CI, 0.223 to 0.997; p = 0.049).ConclusionsOur findings suggest that ZES is less effective than SES and PES in terms of 12-month TLR, and has a higher incidence of MACE due to a higher TLR rate compared with SES, in acute MI patients with CKD.

The frequency of renal impairment in patients suspected of heparin induced thrombocytopenia syndrome (HIT)

Background Most heparin induced thrombocytopenia syndrome (HIT) clinical trials involve therapeutics with little evidence of safety and efficacy in renal impairment: all direct thrombin inhibitors accumulate in renal failure; fondaparinux is renally eliminated and relatively contraindicated in renal failure. Aims To determine frequency of renal impairment in patients suspected of HIT. Method Demographics and serum creatinine levels were recorded for every adult patient with HIT screen performed (1/11/2008-1/6/ 2010) ( n = 204). All screening was performed by solid phase ELISA using PF4 IgG by GTi Diagnostics. Results Median age 79, males 61%. Median and average serum creatinine at the time of HIT screening 104 μmol/L and 176 ± 25 μmol/L, respectively ( p = 0.05). Twenty-one screens positive, four equivocal. Twenty-five ‘non-negative’ patients: mean estimated glomerular filtration rate (eGFR) 58 ± 18 mL/min/1.73 m 2 ( p = 0.05) (abbreviated Modification of Diet in Renal Disease method); 48% eGFR 2 ; 64% serum creatinine >90 μmol/L. One hundred and fourteen HITS screens ordered from critical care units: 13 positive screens; 62% eGFR 2 , 77% serum creatinine >90 μmol/L. Discussion Renal impairment is common in patients suspected of HIT. In pivotal HAT studies (1994-1997), only 97 of 366 (26%) serum creatinine >90 μmol/L but these patients had three-fold increased risk of bleeding while on lepirudin. Critically unwell patients have high frequency of renal impairment. Clinical trials in HIT need to refocus on patients with renal impairment.

Modified diet in renal disease method overestimates renal function in selected elderly patients

the Modification of Diet in Renal Disease (MDRD) method of renal function estimation has not been extensively assessed in elderly patients. We needed to assess which renal function estimate was most suited for drug dose estimation in our population. we compared MDRD with an optimised version of the Cockcroft-Gault (CG(opt)) method in a hospital population, using gentamicin clearance as a baseline. MDRD overestimated gentamicin clearance by 29% (P < 0.001, n = 68), while CG(opt) underestimated by 10% (P < 0.01). Overestimation by MDRD increased with increasing age. This was 12%, 26% and 69% in age groups <65, 65-80 and >80 years respectively (P < 0.001). CG(opt) underestimated renal function by -5%, -16% and -4% respectively (P = NS). Bias and precision of renal function estimations for the three age groups were less for CG(opt) than for MDRD. Age significantly influenced MDRD overestimation in this population (P = 0.037). MDRD overestimated renal function as age increased. While CG(opt) underestimated renal function, this was of a smaller magnitude, consistent across age, and thus better suited for dose calculation, especially in the elderly. Larger-scale studies using gold standard markers of renal function estimation are urgently needed to determine the accuracy of MDRD in elderly hospitalised patients.

Chronic Kidney Disease, Cardiovascular Risk, and Response to Angiotensin-Converting Enzyme Inhibition After Myocardial Infarction

Persons with end-stage renal disease and those with lesser degrees of chronic kidney disease (CKD) have an increased risk of death after myocardial infarction (MI) that is not fully explained by associated comorbidities. Future cardiovascular event rates and the relative response to therapy in persons with mild to moderate CKD are not well characterized. We calculated the estimated glomerular filtration rate (eGFR) using the 4-variable Modification of Diet in Renal Disease method in 2183 Survival And Ventricular Enlargement (SAVE) trial subjects. SAVE randomized post-MI subjects (3 to 16 days after MI) with left ventricular ejection fraction < or =40% and serum creatinine <2.5 mg/dL to captopril or placebo. Cox proportional hazards models were used to evaluate the relative hazard rates for death and cardiovascular events associated with reduced eGFR. Subjects with reduced eGFR were older and had more extensive comorbidities. The multivariable adjusted risk ratio for total mortality associated with reduced eGFR from 60 to 74, 45 to 59, and <45 mL x min(-1) x 1.73 m(-2) (compared with eGFR > or =75 mL x min(-1) x 1.73 m(-2)) was 1.11 (0.86 to 1.42), 1.24 (0.96 to 1.60) and 1.81 (1.32 to 2.48), respectively (P for trend =0.001). Similar adjusted trends were present for CV mortality (P=0.001), recurrent MI (P=0.017), and the combined CV mortality and morbidity outcome (P=0.002). The absolute benefit of captopril tended to be greater in subjects with CKD: 12.4 versus 5.5 CV events prevented per 100 subjects with (n=719) and without (n=1464) CKD, respectively. CKD was associated with a heightened risk for all major CV events after MI, particularly among subjects with an estimated glomerular filtration rate <45 mL x min(-1) x 1.73 m(-2). Randomization to captopril resulted in a reduction of CV events irrespective of baseline kidney function.