End-stage Chronic Kidney Disease Research Articles

Outcomes of leadless pacemaker in chronic kidney disease patients: real-world data from the i-LEAPER registry

Abstract Background Chronic kidney disease (CKD) represents a major risk factor for patients requiring transvenous pacemaker (TV-PM), resulting in a high rate of operative complications and PM-related infection rate (21.9% and 12.5%, respectively), with both complications parallels to severity of CKD. Moreover, TV leads represent an important concern for end-stage CKD patients, often needing vascular access patency for renal replacement therapy. In this setting leadless pacemakers (LPMs) represent an attractive alternative to TV-PM for their lower device-related infection rate and the absence of TV leads. To date, limited data on LPM safety and efficacy profile in CKD patients are available. Purpose to assess operative and long-term safety and efficacy of LPMs implantation in patients with different stages of CKD in the real-world setting. Methods Consecutive patients who underwent LPM implantation in 12 European centers joining the i-LEAPER registry were retrospectively enrolled. CKD stage was assessed according to CKD-EPI equation for eGFR. Patients with CKD stage G3a/b (N=245) and stage G4/G5 (N=67) were compared with patients with normal kidney function (NKF) (N=867). Primary safety endpoint was LPM-related major complications rate at implant and during follow-up (FU). Additionally, the rate of patients showing sub-optimal electrical performance (pacing threshold [PT] >1V@0.24ms) was compared between groups. Results 1179 patients were enrolled and followed for a median of 33 [IQR 24-47] months. When compared with the NKF group, patients with CKD stage G3a/b and stage G4/G5 showed a higher burden of cardiovascular comorbidities (Table 1). The choice of a LPM was mainly due to vascular concern in the CKD stage G4/G5 group, while a perceived highest infective risk was reported in CKD stage G3a/b group (Table 1). Major complication rate at implant and during FU did not differ between groups, regardless of renal impairment stage (Table 2). All-cause mortality incidence resulted higher in CKD stage G4/G5 group when compared with NKF group (17.9% vs 6.8%; HR 4.24; 95%CI 4.25-7.94, p<0.001) (Figure A). The rate of patients with PT>V1@0.24ms during FU did not differ between groups, not exceeding 13.8%, and therefore remaining consistent with historical data for LPM (Figure B). Conclusion In the real-world setting, LPM showed a remarkable safety and efficacy profile in CKD patients regardless of renal impairment stage that was comparable to NKF population. LPM should be considered as first choice in CKD patients requiring a PM.

#2460 Haemodialysis-related periarticular calcifications as cause of recurrent severe inflammatory state

Abstract Background and Aims End stage chronic kidney disease (CKD) and haemodialysis (HD) are associated with disturbances in mineral and bone turnover ultimately leading to chronic kidney disease–mineral and bone disorder (CKD-MBD), which affects more than 90 % of patients with stage 5D CKD. The primary changes observed in CKD–MBD involve elevated phosphorus levels, decreased calcium levels, insufficient serum vitamin D, and heightened release of parathyroid hormone from the parathyroid glands, leading to secondary hyperparathyroidism. CKD-MBD leads to vascular calcification, increasing cardiovascular risk. There is also a correlation between abnormal bone remodeling activity in CKD-MBD and the likelihood of calcification in soft tissues. In rare instances, profound calcification occurs in periarticular tissues, resulting in severe inflammation and manifesting as systemic disease with articular involvement clinically. The objective of this case report is to demonstrate a recurrent inflammatory condition caused by severe periarticular calcification in a patient on HD. Case report We present a case of a middle-aged white male diagnosed with hypertension, hypercholesterolemia, chronic obstructive pulmonary disease, hepatitis C, and end-stage renal disease caused by hydronephrosis. He was undergoing HD since July 2020. From summer 2021 the patient experienced recurrent fever and arthralgias in the hips, elbows, and shoulders. Frequent acute hospitalizations were needed due to recurring fevers and severe inflammatory response with markedly elevated acute phase reactants (CRP was repeatedly >200 mg/l), raising suspicion of infection. Laboratory and imaging tests however showed no clear signs of infection, and antibiotic therapy was ineffective. An x-ray of the right AC-joint showed multiple periarticular calcifications dorsally from the AC-joint. Later, due to severe pain and swelling an MRI-scan of right elbow joint was conducted, revealing an osteomyelitis-suspect finding of the olecranon, and olecranon bursitis. No bacteria were detected in the punctate of olecranon bursa. X-ray scans of the elbows revealed bilateral soft tissue calcification dorsally from the proximal ulna. The x-ray scan of the right shoulder revealed calcific expansion in the AC-joint area, leading to total destruction of the lateral part of the clavicle. MRI and CT scans showed severe periarticular calcification around AC- and glenohumeral joints without inflammatory involvement of the synovium. Bony erosions were observed due to the pressure of calcified tissue on the bone. Whole-body CT-scan showed no sites of infection but there was a periarticular calcification observed around the hip joints. A PET-CT scan of the whole body, neck, and upper extremities revealed no signs of malignancy or infections, but there was an increased uptake of 18F-fluorodeoxyglucose detected in several periarticular sites, indicating a multi-site inflammatory process resulting from severe periarticular calcifications. A dual-energy CT-scan of upper extremities was performed, excluding the accumulation of monosodium urate crystals. The cycle of multiple hospitalizations and antibacterial therapies was broken with the diagnosis of CKD and HD-related inflammatory periarticular calcification. Initially, the inflammation was addressed with high-dose glucocorticoids. However, the dose was successfully tapered during the first month of treatment, and the patient continued to do well on a maintenance dose of 5 mg/day of prednisolone. Subsequently, hospitalizations, antibiotics, or surgical procedures were no longer required. Conclusion Severe CKD and HD cause disturbances in mineral and bone metabolism, that can lead to periarticular calcification. Like in our presented case, multi-site calcifications may mimic infection or autoimmune rheumatoid conditions making the way to correct diagnosis cumbersome and costly. Imaging techniques help us distinguish periarticular deposits from inflammatory and infectious arthritis. In our case low-dose prednisolone effectively reduced inflammation, obviating hospitalizations and minimizing healthcare burden.

#1816 CA 125 as a surrogate marker for plasma volume in patients with cardiorenal syndrome

Abstract Background and Aims Assessing volume status in heart failure (HF) and end-stage chronic kidney disease (CKD) is challenging. Plasma volume expansion is an early step in the pathophysiology of decompensated HF and an independent risk factor for death and HF hospitalization, and should be addressed early. Evaluating plasma volume, especially its variation with diuretic therapy, can be a useful clinical tool for guiding decongestive therapy. There's a growing need for accurate and simple tools to guide clinician decisions on patient volume management. Cancer antigen 125 (CA125), a glycoprotein produced in mesothelial cells in the pericardium, pleura, or peritoneum, is primarily associated with ovarian and gynecological malignancies. Recent studies link CA125 to inflammation and congestion. In acute HF, elevated CA125 is associated with fluid overload indicators like increased central venous and pulmonary wedge pressure. Elevated CA125 in acute HF patients is linked to worse outcomes in death and hospital stay length. Evidence supports CA125-guided therapy in acute HF, but its role in managing chronic volume overload is still uncertain. We aim to assess the relationship between CA125 levels and estimated plasma volume (ePV). Method A retrospective unicentric observational study was conducted between June 2022, and April 17, 2023, at the Renocardiac clinic of a tertiary hospital. Clinical data were extracted from electronic patient records. CKD staging was determined following the Kidney Disease Improving Global Outcomes (KDIGO) classification. ePV was calculated using the Kaplan-Hakim formula. CA125 and ePV were assessed for the same patient in 2 different visits and their variation was calculated. The correlation between CA125 and ePV, as well as CA125 and ePV variation, was evaluated using Spearman's rank correlation coefficient for bivariate analysis, conducted with IBM SPSS®. Results This study comprised 65 patients, totaling 124 hospital visits. The patient demographic was 67.7% male, with a mean age of 76.4 (±12.47) years. In terms of CKD staging, 48.5% were classified as KDIGO 5, 40.6% as KDIGO 4, 9.4% as KDIGO 3, and 1.5% as KDIGO 2. HF etiology distribution included 59% ischemic, 9.8% hypertensive, 6.5% valvular, and 24.5% other causes. The mean ejection fraction was 37.35 (±12.36)% and 19% had preserved ejection fraction; 75% of them were treated with prognostic-modifying medication, including SGLT2 inhibitors. This proportion was lower (19%) in patients with reduced ejection fraction, receiving ACE/angiotensin ± neprilysin inhibitor + mineralocorticoid receptor inhibitor + beta-blocker + SGLT2 inhibitor. During the follow-up period, 13 hospitalizations, 1 major adverse cardiovascular event (MACE), and 5 deaths were recorded. The mean CA125 level was 193.98 (±154.55) U/mL, and patients had a mean ePV of 2.41 (±1.19) L. A significant positive correlation was found between CA125 levels and ePV (r = 0.355, p = 0.000). However, there was no significant correlation between the variation of CA125 and ePV levels between visits (p = 0.535). Conclusion This study focuses on a population with limited implementation of disease-modifying therapy due to advanced CKD, complicating the clinical management of volume status, kidney function, potassium levels, and long-term prognosis in both CKD and HF. CA125 shows potential clinical utility as a marker of congestion, aiding clinicians in assessing volume status by correlating with plasma volume. However, this study found no correlation between CA125 variation and changes in plasma volume. The outpatient nature of the studied population, typically euvolemic, may hinder assessing the relationship between CA125 and ePV changes. Future studies with larger sample sizes are essential to clarify this relationship and potentially identify volume-expanded patients early.

#2724 Renal amyloidosis cohort registry in our health area

Abstract Background and Aims Renal amyloidosis is the pathological phenomenon of amyloid deposition in the kidney with marked differences in renal function impairment, proteinuria, need for renal replacement therapy (RRT) and exitus, depending on the protein involved. Light chain amyloidosis (AL) and serum protein A (AA) amyloidosis are the most common. Typical symptoms are severe proteinuria, nephrotic syndrome, and end-stage chronic kidney disease (ESRD). Method Retrospective study of a cohort of patients with renal amyloidosis. Data extracted from the biopsy registry of the HUVM Nephrology Service (2013-2022). We collected demographic, clinical, analytical, histological and clinical outcome variables (RTT, Exitus). Results are analyzed using Mayo Clinic staging criteria. Results 19 patients with a mean age of 63.4a; 57.9% male. Mean laboratory values at diagnosis: creatinine (Cr) 1.56 mg/dl and proteinuria 3.9 g/24 h. Abdominal fat biopsy in 13 cases; 3 (23%) tested positive. Comparative analysis of AL vs non-AL forms, Cr values (1.14 vs 2.27 mg/dl respectively) (p=0.57) differed. Proteinuria according to the histological location of the amyloid: 4.6 g/24 h in glomerular involvement vs. 0.3 g/24 h in those who did not present it (p<0.05). 31.6% required RTT with a mean onset time of 250.6 d from biopsy. Exitus of 21.1%: average time of 426.5 d. (See analysis in attached table). Conclusion We did not observe significant deterioration of renal function, which is greater in non-AL forms of amyloidosis. Fat biopsy was less cost-effective than reported in the literature. Significantly lower levels of proteinuria were found in the amyloidosis group without glomerular involvement. In our series, the prognostic capacity associated with the MAYO staging was confirmed.

#2795 In-silico assessment of arteriovenous fistula maturation with patient-specific computational hemodynamic models

Abstract Background and Aims Native arteriovenous fistula (nAVF) is the preferred access for haemodialysis (HD) treatment. Both the quality and complications of the haemodialysis technique are closely related to vascular access. nAVF maturation process includes several morphological changes affecting haemodynamics, with previous studies suggesting that it is highly related to AVF failure. Computational Fluid Dynamics (CFD) simulations by using idealized morphologies or the analysis of one patient-specific geometry have been proposed to understand the pathophysiology of maturation failure. However, it is difficult to correlate with clinical practice and therefore limits its use. The aim is to develop a patient-specific modelling time pipeline, incorporating the haemodynamics of the blood flow to real anatomical and morphological characteristics. Method Design: prospective computational simulation analysis of nAVF in 3 patients at 3 different stages: after fistula creation, (1 week), maturation (1 month) and post-maturation (6 months). Analysis: morphological and haemodynamic. Inclusion criteria: >18 years and end-stage chronic kidney disease. Variables and data: Once morphology was extracted from nAVF magnetic resonance imaging, generated meshes were refined and compiled to obtain a volumetric mesh. The boundary conditions of the model were defined and extracted using ultrasound nAFV data. Data were analyzed at the 3 stages. Models: A 3-element Windkessel model was used to simulate the pressure waveform to feed the vein of the system. In this model, clinical data were also considered to classify the patient as normotensive or hypertensive to estimate waveform parameters. The Windkessel model estimates wall shear stress (WSS), velocity and flow for all the points located in the mesh by making an analogy from an electric circuit resistance model. As validation, the flow obtained from the Windkessel model was compared with the one obtained from the ultrasound scan of the patient. Results Different temporal points were analyzed for each nAVF. Results from the simulations in Fig. 1, illustrating the evolution over time and development. The geometrical characteristics were found to significantly impact on flow dynamics. The area most affected by flow was the juxta-anastomotic section which showed higher magnitude distribution of WSS and velocity for all time-points. According to the analysis of the simulations, a perpendicular junction between the vein and the artery potentially resulted in less damage in this area (in WSS terms), being important to mitigate the AVF failure. At maturation stage (1 month) the analysis shows WSS distribution mainly located in the juxta-anastomotic section and decreased in magnitude regarding one week; therefore, this can be marked as the stabilization point for nAFV maturation. Conclusion

#1681 Efficacy and safety of combined treatment with rituximab and low doses of cyclophosphamide for ANCA associated renal vasculitis

Abstract Background and Aims Current guidelines recommend the use of rituximab (RTX) or cyclophosphamide (CP) as induction treatment for ANCA-associated vasculitis (AAV) with renal involvement. Some authors have described the combination of CP and RTX in the treatment of severe AAV, and recently a regimen of 6 cycles of low-dose CP combined with RTX has been used with good results. The aim our study was to compare the efficacy and safety of combined treatment with even lower doses of intravenous CP (2-3 cycles) and RTX, compared to standard treatment with RTX. Method We conducted a retrospective study that included 14 patients with histologically confirmed AAV, treated with an induction treatment scheme of corticosteroids, RTX and 2-3 cycles of intravenous CP. A case-control analysis was performed with 16 patients who received only corticosteroids and RTX in the same period, matched by propensity score for age, creatinine at presentation and histological parameters (sclerosed glomeruli, epithelial crescents and normal glomeruli). We compared renal and overall survival, and complications from immunosuppression in both groups. Results At presentation, patients treated with the combined regimen had a mean age of 67 ± 12.1 years, a mean glomerular filtration rate estimated by CKD-EPI of 19.8 ± 11.1 ml/min/1.73 m2, proteinuria of 1.6 (0.81- 1.84) g/24 hours and initial BVAS score of 18.5 ± 6.9. 78.6% of the patients were anti-MPO positive and 21.4% were anti-PR3 positive. According to Berden's classification, 85.7% had a mixed variant, 7.1% crescentic and 7.1% sclerotic, in the renal biopsy. The mean dose of CP was 1445 ± 384 mg, and of RTX was 2g. 28.6% required dialysis at presentation, of which 75% recovered kidney function. The duration of steroid treatment was 8 (4.6-16.9) months. Remission rate at 6 months was 71.4%, and after a median follow-up of 20 (15-35) months, 92.9% had remitted. During follow-up, 50% had serious infections; and at the end, 7.1% progressed to end-stage chronic kidney disease (ESKD). 21.4% of the patients included ended up dying. In comparison with the control group, patients who received the combined treatment had a higher remission rate (92.9% vs. 75%), a lower relapse rate (15.4% vs. 35.7%), lower progression to ESKD (7.1% vs. 20%) and lower mortality (21.4% vs 37.5%), with no differences for serious infections. Conclusion The association of low doses of cyclophosphamide to rituximab induction treatment could improve the prognosis in patients with severe ANCA-associated renal vasculitis.

#896 Long-term renal outcome in childhood-onset lupus nephritis

Abstract Background and Aims Lupus nephritis (LN) is a common and severe complication of childhood-onset SLE. Little is known about the long-term renal outcome of childhood-onset LN. We investigated predictive factors of end-stage kidney disease (ESKD) and chronic kidney disease (CKD) in a paediatric cohort of patients with LN. Method This is a retrospective multicentre study including patients with childhood-onset (<18 years) biopsy-proven LN. Clinical features were analysed at disease onset, time of kidney biopsy, 12 and 24 months after biopsy, and last follow-up. We investigated the prognostic significance of clinical, laboratory and histologic characteristics on the incidence of ESKD and CKD stage 3-5. Results We included 73 patients with a median age of 14 years (IQR 11.5-17) . At the time of kidney biopsy, most subjects displayed an aggressive disease: 2 (3%) children required haemodialysis, 27 (38%) had an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2. The overall median eGFR was 70 mL/min/1.73 m2 (IQR 43-96) . Moreover, the median proteinuria was 4 g/24 h (IQR 1.35-7.41) , with 41 (59%) children displaying a nephrotic range proteinuria (i.e., >3 g/24 h) . The median follow-up was 13.3 years (IQR 4.7-25.4) . A total of 10 patients (13.7%) reached ESKD, the majority of whom (12%) within 10 years from kidney biopsy; during the subsequent follow-up the incidence of ESKD stabilised (Fig. 1). At last follow-up, around 50% of patients displayed an eGFR <90 mL/min/1.73 m2. A younger age at LN onset, a lower eGFR and central nervous system involvement at the time of kidney biopsy were identified as predictors of ESKD by a univariable Cox regression model (Table 1). The same features were significantly associated with the occurrence of CKD stage 3-5 at last follow-up at a univariable logistic regression analysis. Conclusion LN often presents with severe kidney function impairment and aggressive systemic involvement in children. In our cohort, whose follow-up was among the longest reported in the literature, 12% of patients reached ESKD within 10 years from kidney biopsy. Significant predictors of poor kidney outcome in the long term were a younger age at LN onset, a lower eGFR and the presence of neurological manifestations at the time of kidney biopsy.

#3014 Primary care perspective on management of chronic kidney disease in Tunisia

Abstract Background and Aims Chronic Kidney Disease (CKD) represents a significant public health challenge. The primary care physician holds a crucial position in facilitating its early detection, serving as a linchpin in the comprehensive management of patients often with multiple comorbidities. The objective of our study was to investigate CKD management in primary care practitioners in Tunisia and their relationship with nephrologists. Method We conducted a cross-sectional study involving family physicians and general practitioners. This involved a self-administered questionnaire using Google Forms, aiming to investigate CKD management in the context of primary care in Tunisia, along with an examination of collaboration with nephrologists. Results Our study included 43 practitioners with a gender ratio of M/F = 0.3. The average age of participants was 30.7 years [25-53 years]. Of the 43 participants, 95% practiced in urban areas, and 74% were in training. They worked in university hospitals (53%), primary care centers (21%), regional hospitals (19%), and private practices (7%). When asked about their feelings during the management of a patient with CKD, the main response was anxiety (65%) followed by indifference (18%), confidence (12%), and fear (5%). According to practitioners, the uniqueness of CKD management was due to the polypathological nature of patients (79%), the difficulty in managing certain cases (74%), the difficulty in applying certain recommendations (60%), the lack of medications (2%), and the difficulty in accessing complementary tests in primary care (2%). The means of training and sources of information on CKD mentioned were specialized medical journals (49%), medical websites (40%), peer groups (4%), pharmaceutical industry representatives (2%), and no source (5%). The means of training included additional studies certificates (23%), workshops/plenary sessions (44%), specialized webinars (30%), intra-hospital medical days (46%), nephrology internships (28%), and no available means (16%). Regarding the relationship with the nephrologist in joint management, 42% had a corresponding nephrologist. Thirty percent declared no difficulty in referring patients to nephrology when necessary. In case of difficulty, it would be related to long delays in obtaining a consultation with the nephrologist (60%), the geographical distance of nephrology centers (30%), and sometimes patient refusal (23%). When discovering CKD, 60% immediately referred patients to the nephrologist. On a scale of 0 to 5, communication and coordination of care between nephrologists and primary care physicians were estimated at 0 by 12%, 1 by 16%, 2 by 30%, 3 by 30%, 4 by 12%. Regarding end stage CKD management, practitioners informed patients about kidney transplantation (9%), hemodialysis (53%), peritoneal dialysis (16%), and 55% stated they did not have to inform patients about these techniques. Sixty-three percent continued to follow patients after the initiation of renal replacement therapy. Conclusion Our work revealed that the predominant sentiment when dealing with CKD patients in primary care is anxiety. This emotion appears to stem from the intricate nature of CKD management, primarily associated with the polypathological profile of patients and challenges in implementing recommended guidelines, compounded by difficulties in accessing nephrologist consultations. The imperative challenge lies in enhancing information accessibility for practitioners to optimize CKD management within this medical context.

#2935 Kidney transplantation outcomes following non-kidney solid organ transplantation

Abstract Background and Aims Approximately 15% of recipients of non-kidney solid organ transplantation (NKSOT) develop end-stage chronic kidney disease (CKD), requiring kidney transplantation (KT). There are controversy whether KT after NKSOT outcomes are poor or whether these patients should be prioritized. Method Retrospective analysis of KT after NKSOT in Andalusia between 1978-2023. We performed a case-control study, choosing 2 controls for each case (1 recipient of a second KT [reKT] and 1 recipient of a first KT without previous NKSOT), the closest ones with KT date and similar age and gender between donor and recipient. Patients with renopancreatic transplantation were excluded. We compared clinical characteristics and outcomes. Results During this period, we followed 12217 KT in Andalusia. Of these, 35 (0.003%) are KT after NKSOT: 26 (74.3%) liver transplant recipients, 7 (20%) heart transplant recipients and 2 (5.7%) lung transplant recipients. All of them are recipients of a first KT. When comparing KT after NKSOT vs. reKT and first KT recipients, demographic characteristics and donor type are similar in all 3 groups. The reKT recipients were on dialysis longer before receiving the second KT, with no difference between the other 2 groups. Graft survival of reKT patients was lower than the rest (vs. KT after NKSOT, p = 0.014; vs. first KT p < 0.001). Survival between KT after NKSOT and first KT was slightly worse in those who had received a previous NKSOT, but without significant differences. In multivariate analysis, adjusted for time on waiting list, reKT remained a risk factor at the limit of statistical significance (p = 0.072). There was no difference in patient survival. Conclusion KT after NKSOT has similar graft and patient survival outcomes to recipients of a first KT, and better than in recipients of a second KT.

Correction of hyperphosphatemia in a patient with end-stage chronic kidney disease and a complex case of anemia. A clinical case

Iron supplements and/or blood transfusions in combination with recombinant human erythropoietin injections are routinely used to correct renal anemia, which is a common complication of end-stage renal disease. However, massive blood transfusions and inadequate intravenous iron supplementation can lead to iron overload syndrome, and anemia is not always nephrogenic. A rare clinical case of a patient with end-stage chronic kidney disease with complex genesis of anemia, who is on hemodialysis, is presented. The case is interesting because the prescription of first-line drugs was life-threatening in nature, and sevelamer was the drug chosen for the correction of mineral-bone disorders.

Racial Disparities in Fluid Intake and Plasma Copeptin in Young Adults

INTRO: Underhydration, or habitual low water intake, is associated with increased plasma copeptin, a surrogate marker of arginine vasopressin. Importantly, plasma copeptin is associated with development of cardiovascular disease (CVD) and chronic kidney disease (CKD). Compared with White individuals, Black individuals are more likely to be underhydrated, to develop CVD and end-stage CKD, and exhibit higher plasma copeptin in middle-age and older adulthood. However, there is limited information on potential racial differences in plasma copeptin in young apparently healthy adults, which may have implications for incident CVD and CKD. Therefore, we sought to determine whether young Black adults reported lower fluid intake and exhibited higher plasma copeptin concentration when compared with young White adults. Methods: We analyzed pre-existing data from two registered clinical trials (NCTs 04576338 and 05132556). Participants (n=86, sex; 40F/46M, race; White n=48, Black n=38, age; 21±2 years, BMI; 25±4 kg/m2) completed a three-day food and fluid log and underwent a venous blood draw to measure plasma copeptin concentration (BRAHMS Copeptin proAVP KRYPTOR). Food and fluid records were analyzed using the Nutrition Data System for Research for % fluid from food or water. Separately, records were used to operationalize beverage intake into 8 categories (water, sugar-sweetened beverages (SSB), milk/non-dairy alternatives, 100% juice, non-caloric beverages, plain coffee or tea, milk/sugar added coffee or tea, and alcohol). Statistical analyses included Mann-Whitney U tests for fluid intake data and ANCOVA for plasma copeptin concentration (controlled for site). Plasma copeptin was log transformed. Additionally, we assessed relations between fluid intakes and plasma copeptin concentration using Spearman’s (ρ) correlations. We set α at ≤ 0.05. Results: Compared with White adults, Black adults consumed less total fluid (Black; 1981 ±1035 vs. White; 2780±1242mL), water, alcohol, and coffee/tea (plain and milk/sugar-added), but more juice (all p’s<0.05). There were no differences in % fluid from food or water, milk/non-dairy alternatives, non-caloric beverages, or SSBs. Black individuals exhibited ~22% higher plasma copeptin concentration (Black; 5.5±2.8 vs. White; 4.5±2.8pmol/L, ANCOVA p=0.022). Irrespective of race, copeptin was negatively correlated with water intake (ρ=-0.230, p=0.034). CONCLUSION: Black young adults reported a significantly lower fluid intake and exhibited higher plasma copeptin concentration when compared with White young adults. Future studies should attempt to address racial disparities in hydration practices, which may attenuate racial differences in copeptin and corresponding health disparities. NIH-K01HL147998 (ATR), Auburn University Offce of Vice President for Research Support Program (ATR). This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Challenges in perioperative blood transfusions in kidney transplantation and the need for Patient Blood Management.

Anemia is highly prevalent in end-stage chronic kidney disease patients, increasing their risk of receiving blood transfusions during and on the days after a kidney transplant (KTx) surgery. However, there is currently a lack of data that thoroughly describes this phenomenon in this population, the associated risk factors, and how they could benefit from the application of Patient Blood Management (PBM) guidelines. Observational study. All adult patients who received a KTx between January 1st, 2020, and December 31st, 2021, were included and followed up to six months after transplantation. Those who received a multiorgan transplant, whose data was missing in the electronic health records, and who had primary non-function were excluded. We recorded donor and recipient characteristics, cold ischemia time, preoperative hemoglobin concentration, iron status deficiency biomarkers, incidence of delayed graft function and biopsy-proven graft rejections, and graft function at discharge and 6 months after transplantation. We found that a high amount (39%) of KTx recipients required at least one blood transfusion during the perioperative period. And that 1) most of these patients had anemia at the time of transplantation (85.4%), 2) iron status upon admission was associated with the transfusion of more blood units (3.9 vs 2.7, p=0.019), 3) surgical reintervention (OR 7.28, 2.35-22.54) and deceased donor donation (OR 1.99, 1.24-3.21) were associated with an increased risk of transfusion, and finally, 4) there was an association between a higher number of blood units transfused and impaired kidney graft function six months after hospital discharge (1.6 vs 1.9, p=0.02). In conclusion, PBM guidelines should be applied to patients on the KTx deceased donor waiting list and especially those scheduled to receive a transplant from a living donor. This could potentially increase the utilization efficiency of blood products and avoid transfusion-related severe adverse effects.

SGLT-2 Inhibitors: Focus on Dapagliflozin.

Dapagliflozin (trade name FARXIGA) is a sodium-glucose cotransporter-2 (SGLT-2) inhibitor that has transcended its initial antidiabetic application to demonstrate benefits in cardiac and renal diseases. It was first approved by the food and department administration for type 2 diabetes in 2014. Since then, it has gained food and department administration approval for chronic kidney disease in 2021, heart failure with reduced ejection fraction in 2020, and heart failure with preserved ejection fraction in 2023. Thus, dapagliflozin plays a pivotal role in improving patient outcomes. By competitive binding to renal SGLT-2 cotransporters, dapagliflozin effectively prevents glucose and sodium reabsorption, leading to glucosuria. Its pharmacokinetic profile involves minimal cytochrome P450-induced metabolism, rapid absorption with an 18-hour duration of action, and stable effects. Clinical trials have revealed dapagliflozin's efficacy in glycemic control without the risk of hypoglycemia, making it an advantageous choice for patients insufficiently managed on other antidiabetic drugs. Comparative analysis with other SGLT-2 inhibitors suggests dapagliflozin's potential superiority in preventing heart failure. Compared to empagliflozin, it has more extended effects, contributing to stable sodium diuresis, reduced blood pressure fluctuations, and potentially lower cardiovascular disease risks. However, it leads to less urinary glucose excretion compared with canagliflozin. Dapagliflozin has specific contraindications, such as type 1 diabetes and end-stage chronic kidney disease. Adverse effects include an increased risk of genital infections, urinary tract infections, and Fournier's gangrene. A nuanced understanding of dapagliflozin's benefits and limitations is imperative for informed clinical decision-making in the management of diabetes and its complications.

Analysis of Graft Survival in Pediatric Patients Undergoing Kidney Transplantation

Introduction: Kidney transplantation is the gold standard therapy for end-stage chronic kidney disease (CKD). However, aspects related to the characteristics of the donor and the recipient, the surgical technique, the immunosuppression protocol and comorbidities can impact graft survival. Objectives: To evaluate factors associated with graft survival in pediatric patients undergoing kidney transplantation. Methods: Descriptive, retrospective cohort study, which included all patients aged 1 to 18 years who underwent kidney transplantation at Unidade Renal Pediátrica of Instituto de Medicina Integral Prof. Fernando Figueira (IMIP), Recife, Brazil, from January 2017 to December 2021, with a minimum follow-up time of 10 months, totaling 51 patients. The IMIP ethics and research committee approved the study under CAAE: 52023921.1.0000.5201. Results: The median age of patients undergoing kidney transplantation was 12 years(9-13); 27 (52.9%) were male and eight (15.6%) were younger than 5 years of age. The main etiologies of CKD were congenital anomalies of the kidney and urinary tract (n = 25; 49%). As for kidney transplants, 49 (96.1%) were from a deceased donor and the median follow-up time was 32 (14-42) months. After transplantation, 58% of the population were hypertensive, while 80.4% had dyslipidemia. The 5-year graft and patient survival rates, assessed using the Kaplan Meier curve, were 86.3 and 90.2%, respectively. Seven (n = 5) patients lost the graft, the most common cause being renal vein thrombosis. Nonglomerular causes of CKD showed lower graft survival when compared to glomerular causes (log rank p = 0.035). Conclusion: Our sample’s graft and patient survival rates are similar to national and global data. The most frequent causes of graft loss were thromboembolic events. Furthermore, we observed a high prevalence of hypertension and dyslipidemia. These results direct us to establish strategies to improve survival in pediatric kidney transplants.

Multidisciplinary management of penile calciphylaxis in a patient undergoing hemodialysis

Penile necrosis in end-stage chronic kidney disease patients on hemodialysis presents complex pathophysiology involving vascular, metabolic, and dialysis-related factors. This clinical case emphasizes the significance of prompt multidisciplinary management. Surgical interventions like penectomy with scrotal pedicled flaps offer effective reconstruction, preventing complications. Long-term success mandates diligent oversight of metabolic and vascular issues. A comprehensive approach integrating urology, vascular surgery, and nephrology specialists is essential for optimal patient outcomes and quality of life.

Fragility Fractures in End-Stage Chronic Kidney Disease (CKD) Population: Patient-Related and CKD-Related Factor Analysis-A Single-Center Experience.

Background: Chronic kidney disease (CKD) stands as a prevalent global health concern, and mineral and bone disease are among the most impactful consequences. A severe complication arising from mineral and bone disease is the occurrence of fragility fractures, which disproportionately affect individuals with CKD compared to the general population. The prevalence of these fractures impacts both survival rates and quality of life. The aims of this study are analyzing and identifying (i) patient-related risk factors and (ii) CKD-related risk factors to contribute to the development of preventive measures for fragility fractures for this population. Methods: A retrospective, single-center observational study was conducted, encompassing patient data from the years 2021 to 2023. Registry data were recorded, including patient-related and CKD-related data. Patients were interviewed about traumatological history, and their answers were recorded. Logistic regression analysis was employed to investigate the association between independent variables and dependent variables. Results: Eighty-four patients, with a mean age of 64.3 ± 15.2 years and a male percentage of 58.3%, were included in this study. Among them, 19.5% exhibited smoking habits. The mean Charlson Comorbidity Index was 3.06 ± 1.21. All patients were diagnosed with end-stage chronic kidney disease, with mean durations of 208 months from the diagnosis and 84.5 months from the beginning of dialysis. The logistic regression analysis, adjusted for age, sex, and CCI, revealed that smoking habits play a significant role as a risk factor for fragility fractures in lower limbs (p: 0.011 *). The incidence of fragility fractures increases directly proportionally to the time since diagnosis (p-value: 0.021 *) and the beginning of dialysis treatment (p-value: 0.001 *). Conclusions: Among patient-related factors, smoking habits seem to significantly affect lower-limb fracture rates (p < 0.05), whereas among CKD-related factors, time since CKD diagnosis and time since the beginning of dialysis treatment are directly related to higher risks of fragility fractures. No relevant correlations emerged in the studied treatments, except for a reduction in proximal femur fracture occurrence when patients underwent a combined treatment of a calcimimetic and a vitamin D analog.

WCN24-1268 End-Stage Kidney Disease (ESKD) and Chronic Kidney Disease (CKD) Progression among a Hispanic/Latino Population with Primary Immunoglobulin A Nephropathy (IgAN)

WCN24-1268 End-Stage Kidney Disease (ESKD) and Chronic Kidney Disease (CKD) Progression among a Hispanic/Latino Population with Primary Immunoglobulin A Nephropathy (IgAN)

Les défis de la transplantation rénale avec artères multiples

Renal transplantation is a crucial procedure for treating end-stage chronic kidney disease, but the shortage of grafts has led to the utilization of kidneys with more complex anatomical features, such as multiple arteries. This article aims to provide surgeons with various surgical strategies based on the number of arteries, their topography, as well as the presence or absence of an associated patch. It also offers guidance on adapting organ retrieval techniques and perfusion machine setup in this type of complex anatomy.

Recurrence of Idiopathic Membranous Nephropathy in the Kidney Allograft: A Systematic Review.

The recurrence of idiopathic membranous nephropathy (iMN) after kidney transplantation is common, although its exact clinical significance remains unclear. This systematic review aims to elucidate the effects of iMN recurrence on graft survival. A literature search was performed by systematically searching Medline, Scopus, Web of Science, and Google Scholar from inception. Cohort studies examining iMN recurrence after kidney transplantation were deemed eligible. Meta-analysis was performed by fitting random-effects models. Twelve (12) articles published from 1995 to 2016 reporting on 139 transplant patients with recurrent iMN were included. The median time of the diagnosis of recurrent iMN was 18 months during follow-up from 35 to 120 months. Risk factors for iMN recurrence in the renal allograft are a positive serum test for anti-PLA2R antibodies pretransplant, female sex, younger age, high proteinuria pretransplant, the longest interval from initial disease to end-stage chronic kidney disease, and the combination of alleles HLA DQA1 05:01 and HLA DQB1 02:01. In the pretransplant period, 37 (26.61%) patients had a positive serum test and 18 (12.94%) patients had a positive biopsy stain for anti-PLA2R antibodies. The sensitivity of the pretransplant positive serum test for these antibodies ranges from 57% to 85.30% and the specificity is 85.10-100%. A total of 81.80% of patients who received rituximab as treatment for iMN recurrence achieved complete and partial remission, while 18.20% had no response to treatment. iMN recurrence was not associated with significantly different rates of graft loss (odds ratio = 1.03, 95% CI: 0.52-2.04, p = 0.524, I2 = 0.00%). Recurrence of iMN was not associated with increased risk of graft loss independently of whether patients were treated with rituximab (OR: 0.98, 95% CI: 0.39-2.50, I2: 0%) or not (OR: 1.22, 95% CI: 0.58-2.59, I2: 3.8%). Patients with iMN recurrence who achieved remission had significantly reduced risk of graft loss (OR: 0.14, 95% CI: 0.03 to 0.73). The main outcome from this systematic review is that there is no statistically significant difference in graft survival in patients with iMN recurrence compared to those without recurrence in long-term follow-up. The achievement of remission is associated with significantly reduced risk of graft loss.

EPIDEMIOLOGY OF CHRONIC KIDNEY DISEASE IN PATIENTS WITH TYPE 2 DIABETES MELLITUS IN UKRAINE

The article reports on the prevalence of chronic kidney disease (CKD) in Ukrainian diabetic patients. A total of 194 patients who seeking an appointment with an endocrinologist underwent CKD screening. Materials and methods. The mean age of the patients was 64.82±0.88 years, and the duration of diabetes mellitus amounted to 9.29±0.60 years. Of these, 53.1% were female and 46.9% were male. Out of the screened patients, 79.4% had type 2 diabetes mellitus, 3.6% had type 1 diabetes mellitus, 9.3% had prediabetes, and 7.7% had other types of diabetes. We diagnosed CKD by calculating the estimated glomerular filtration rate (GFR) based on the creatinine level using the CKD-EPI Creatinine formula and determining albuminuria as the albumin-to-creatinine ratio. Results. Among diabetic patients, 26.8% had stage 1 CKD, 42.3% had stage 2, 21.6% had stage 3a, 8.2% had stage 3с, and 0.5% had each of stage 4 and 5. 70.6% of patients were found to have albumin-to-creatinine ratio (ACR) A1, 21.6% – A2, and 7.7% – A3. Of these, 30.0% were at high and very high risk of developing end-stage CKD. The regression analysis revealed a negative correlation between the duration of diabetes mellitus and the level of GFR, B (95% CI) = -0.102 (-0.179/-0.26), p = 0.009, and a positive correlation with ACR, B (95% CI) = 2.87 (0.089/5.605), p = 0.043. Conclusions. Among the examined patients with diabetes mellitus, 73.2% had stage 2-5 chronic kidney disease, and 29.3% had stage A2 and A3 albuminuria. Of these, 30% belong to the high- and very high-risk group for developing end-stage chronic kidney disease, requiring regular monitoring of glomerular filtration rate and albuminuria at least 3-4 times a year and conservative treatment. The duration of diabetes is a negative risk factor for chronic kidney disease. Hence, chronic kidney disease screening should be performed in all patients with diabetes with no exception.