End-stage Renal Disease Registry Research Articles

Status and trends in epidemiologic characteristics of diabetic end-stage renal disease: an analysis of the 2021 Korean Renal Data System.

Korean Renal Data System (KORDS) is a nationwide end-stage renal disease (ESRD) registry database operated by the Korean Society of Nephrology (KSN). Diabetes mellitus is currently the leading cause of ESRD in Korea; this article provides an update on the trends and characteristics of diabetic ESRD patients. The KORDS Committee of KSN collects data on dialysis centers and patients through an online registry program. Here, we analyzed the status and trends in characteristics of diabetic chronic kidney disease stage 5D (CKD 5D) patients using data from 2001 to 2021. In 2021, the dialysis adequacy of hemodialysis (HD) was lower in diabetic CKD 5D patients than in nondiabetic CKD 5D patients, while that of peritoneal dialysis (PD) was similar. Diabetic CKD 5D patients had a higher proportion of cardiac and vascular diseases and were more frequently admitted to hospitals than nondiabetic CKD 5D patients, and the leading cause of death was cardiac disease. From 2001 to 2020, diabetic CKD 5D patients had a higher mortality rate than nondiabetic CKD 5D patients, but in 2021 this trend was reversed. Diabetic PD patients had the highest mortality rate over 20 years. The mortality rate of diabetic HD patients was higher than that of nondiabetic HD patients until 2019 but became lower starting in 2020. There was a decreasing trend in mortality rate in diabetic CKD 5D patients, but cardiac and vascular diseases were still prevalent in diabetic CKD 5D patients with frequent admissions to hospitals. More specialized care is needed to improve the clinical outcomes of diabetic CKD 5D patients.

#3619 CKD EPI 2021 EQUATION FOR EGFR HAS GOOD EFFICACY TO PREDICT CLINICAL OUTCOMES IN A LARGE PROSPECTIVE COHORT OF ADULT KOREANS

Abstract Background and Aims A new eGFR equation using serum creatinine (CKD-EPI 2021) without race were developed by Chronic Kidney Disease Epidemiology Collaboration in 2021. We projected the changes of eGFR, CKD prevalence, and incidence of end stage renal disease (ESRD) and mortality in a large prospective cohort of adult Koreans who had voluntary health check-ups, using current (CKD-EPI 2009) and new equation (CKD-EPI 2021). Method We included 112,772 adult participants, aged 18 years or older, who had voluntary routine health check-ups including serum creatinine at three medical centers in Korea from 2003 to 2009. We compared the difference of eGFR and predictability of mortality and ESRD between eGFR values calculated by CKD-EPI 2009 and CKD-EPI 2021. Serum creatinine was expressed as the IDMS-traceable creatinine according to the manufacturer's conversion formula from the original value measured by the alkaline picrate Jaffe kinetic method. The incidence of mortality data was extracted from Statistics Korea and the ESRD data from the ESRD registry of the Korean Society of Nephrology. Results At baseline study, there were 60,723 males (53.8%). Age was 48.9 ± 12.0 years. The value of IDMS-traceable serum creatinine was 0.86 ± 0.21 mg/dl. Levels of eGFR at baseline study were 93.5 ± 15.6 ml/min/1.73 m2 by CKD-EPI2009, and 97.1 ± 15.0 ml/min/1.73 m2 by CKD-EPI2021. Values subtracted eGFRs by CKD-EPI2009 from eGFR by CKD-EPEI2021 were 3.6 ± 1.2 (range: -32.9∼6.1) ml/min/1.73 m2. The difference of eGFR was higher in males compared to females (p<0.001), was the highest in the oldest group among patients aged 18–44 years, 45–64 years, and 65 years or more (p<0.001). Patients with diabetes mellitus (DM) or hypertension showed higher difference of eGFR compared patients without DM or hypertension, respectively (each p<0.001). Patients with eGFR ≥120.0 ml/min/1.73 m2 by CKD-EPI 2009 showed the highest difference between two eGFRs compared to patients with the other values. CKD stage was improved in 11,828 (10.5%) participants using eGFR calculated by CKD-EPI 2021 instead of CKD-EPI 2009, however, only 0.63% of participants with eGFR <60 ml/min/1.73 m2 by CKD-EPI equation was reclassified into eGFR ≥60 ml/min/1.73 m2 by CKD-EPI 2021.During 11.6 ± 2.0 years, 3354 (3.00%) subjects were dead and 151 (0.13%) subjects had end stage renal disease (ESRD) before death. Any eGFR or stage of eGFR was an independent risk factors to ESRD or mortality estimated by Cox's hazard proportional model adjusted by related factors. AUC to estimate renal survival by eGFRs was not different between eGFRs by CKD-EPI2021 and CKD-EPI2009 [0.739 (0.687-0.790) vs 0.740(0.688-0.792), p = 0.170]. p<0.001]. AUC to estimate survival by eGFRs calculated through CKD-EPI equation was slightly higher than that by CKD-EPI2021 equation [0.673(0.664-0.682) vs 0.667(0.658-0.676), p<0.001], however, the difference of AUC was negligible [standard error of AUC difference by two eGFRs; 0.96 (95% CI; 0.006-0.007)]. Conclusion The eGFR calculated by CKD-EPI2021 was higher compared to eGFR calculated by CKD-EPI2009. The power to estimate renal survival was not different between eGFRs by CKD-EPI2021 and CKD-EPI2009.

Sex disparity in dialysis and kidney transplantation over 20 years in Korea.

Sex disparity is prevalent in organ transplantations worldwide. This study aimed to understand sex disparities in dialysis and kidney transplantation in Korea over the last 20 years. Data for incident dialysis, waiting list registration, and donors and recipients were retrospectively collected between January 2000 and December 2020 from the Korean Society of Nephrology end-stage renal disease registry and the database of the Korean Network for Organ Sharing. Data regarding the proportion of females for dialysis, waiting list, and kidney transplantation donors or recipients were analyzed using linear regression analysis. The average proportion of females on dialysis over the past 20 years was 40.5%. The proportion of females on dialysis was 42.8% in 2000, and decreased to 38.2% in 2020, showing a decreasing trend. The average proportion of women on the waiting list was 38.4%, which was lower than that for dialysis. The average proportion of female recipients in living donor kidney transplantation and female living donors were 40.1% and 53.2%, respectively. The overall proportion of female donors in living donor kidney transplantation showed an increasing trend. However, there was no change in the proportion of female recipients in living donor kidney transplantation. Sex disparities in organ transplantation exist, including an increasing trend of female donors in living donor kidney transplantation. Further studies are needed to identify the biological and socioeconomic factors involved to resolve these disparities.

MO249: Characteristics of Glomerulonephritis (GN) with Dominant C1Q Precipitation Compared to Corresponding GN without C1Q Staining on Immunofluorescent Examination

Abstract BACKGROUND AND AIMS Although C1q nephropathy (C1QN) was introduced three decades ago, the clinical significance and renal outcomes of C1QN remain unclear. Furthermore, it is uncertain whether the diagnosis of C1QN could be a new pathologic entity with clinical meanings. This study aimed to compare the clinical characteristics of the GN reclassified into C1QN based on the criteria described by Jennette and Falk (Pediatr Nephrol 2010: 25: 1385–1396) and corresponding GN not included in C1QN. METHOD We enrolled 21 212 patients with native kidney biopsy between 1979 and 2018 from 18 hospitals throughout Korea, retrospectively. We primarily adopted the findings and diagnosis by the pathologist in each hospital and then reclassified into C1q nephropathy (C1QN) on the basis of the criteria as follows: (i) presence of ≥ 2 + C1q in the mesangium on immunofluorescence (IF), (ii) corresponding mesangial or para-mesangial electron dense deposits on electron microscopy (EM), and (iii) lack of clinical and pathological evidence of systemic lupus erythematosus. Among 21212 patients, 77 patients were selected as C1QN with the criteria; however, six patients were excluded because of presence of primary diseases, such as renal amyloidosis, Henoch-Schölein Nephritis and systemic vasculitis, and myeloma cast nephropathy. The data of final outcomes, incidences of end-stage renal disease (ESRD) and death, were gathered from each hospital’s data registry, from the ESRD registry of the Korean Society of Nephrology, and from the Statistics of Korea, and were merged based on the identifier of Koreans. The follow-up duration for ESRD was 69.1 ± 67.8 months and, for mortality, 77.9 ± 65.5 months. RESULTS There were pathologic findings of 71 patients reclassified into C1QN including 41 (57.7%) males. Mean age of patients were 42.9 ± 18.9 years. There were 9 (12.7%) patients with DM and 39 (54.9%) hypertensive patients. The levels of creatinine, eGFR, and UPCR were 1.24 ± 0.92 mg/dL, 84 ± 43 mL/min/1.73 m2 and 2.58 ± 2.80 g/g creatinine, respectively. There were 22 (31.0%) patients with eGFR < 60 mL/min/1.73 m2 and 22 (31.0%) patients with UPCR ≥ 3.5 g/g creatinine. There were various pathologic diagnoses classified into C1QN, such as, original C1QN (21), IgA nephropathy (IGAN) (21), membranous nephropathies (MN) (11), focal segmental glomerulosclerosis (7), mesangial glomerulopathy (6), diabetic nephropathy (3), minimal change lesion (1), and acute tubulointerstitial nephritis (1). We compared the characteristics among the pathologic finding classified into C1QN, the pathologic finding without C1q stain, and the pathologic finding with non-dominant C1q stain which did not fulfill the criteria of C1QN. The identified GNs, which included enough number of patients to compare, were FSGS, IGAN and MN. Some differences of clinico-pathologic findings and incidence of ESRD were not evident after re-analysis with groups matched age and gender with 1:3 manner between the GN re-categorized into C1QN and the corresponding GN without C1q staining. The only difference was lesser amount of proteinuria in MN patients re-classified into C1QN compared with MN patients without C1q staining. Immunoglobulins showed higher intensity in IF staining of C1QN compared with non-C1QN of the corresponding GN. Intensity of C3 was also higher in IGAN and MN re-categorized into C1QN compared with the corresponding IGAN and MN not included in C1QN, respectively. CONCLUSION Reclassification into C1QN with the pre-defined criteria did not indicate a different clinico-pathologic identity based on comparison with the original diagnosis of GN. Activation of C1q, presumed activation of classical complement pathway in kidney tissues, in so-called C1QN could not be classified into new disease entity. Further studies on this topic are needed.

Role of Physical Activity in Lowering Risk of End-Stage Renal Disease

ObjectiveTo investigate the association between the amount and intensity of leisure-time physical activity (LTPA) and the risk of end-stage renal disease (ESRD). MethodsThe study examined a cohort of 543,667 participants aged 20 years and older who participated in a health screening program from January 1, 1996, through December 31, 2017. We identified 2520 individuals undergoing dialysis or who had a kidney transplant by linking participants’ encrypted personal identification with the registry for ESRD with a median follow-up of 13 years. We classified participants into 5 categories measured by metabolic equivalent of tasks. Within each category, we analyzed the effect of moderate- and vigorous-intensity LTPA in reducing risk of ESRD. We used a Cox proportional hazards model to calculate hazard ratios (HRs). ResultsWe observed a dose-response relationship between LTPA and the risk of ESRD. The fully active group had a 12% lower hazard of ESRD compared with the no reported LTPA group (HR, 0.88; 95% CI, 0.80 to 0.98) adjusting for covariates including baseline estimated glomerular filtration rate and proteinuria. Within the same category of LTPA, vigorous-intensity exercise carried a 35% lower HR for ESRD compared with moderate-intensity exercise (HR, 0.65; 95% CI, 0.52 to 0.81). The effect was observed stronger among men, younger participants, and participants with diabetes or hyperlipidemia. ConclusionSustained LTPA (≥ 150 minutes per week), particularly with vigorous intensity, significantly lowered the ESRD risk, even among individuals with comorbidities such as diabetes or hyperlipidemia. This finding suggested that patients with no reported LTPA with cardiovascular risks should engage in more LTPA to lower their risk of ESRD.

Outcomes of cardiac surgery in patients with end-stage renal disease: Insights from the Israel national registries.

End-stage renal disease (ESRD) has been shown to be associated with increased mortality in patients undergoing cardiac surgery. We aimed to compare the short- and mid-term mortality after cardiac surgery of patients with dialysis-dependent ESRD (DD-ESRD) to patients with normal renal function (NRF), using national registries: the ESRD registry, the adult cardiac surgery registry (ACSR), and the National Mortality Registry. The study population comprised 8207 adult patients who underwent either isolated coronary artery bypass grafting (CABG), isolated aortic valve replacement (AVR), isolated mitral valve replacement (MVR), or CABG + valve-related procedure, between January 2017 and April 2019. Data were retrospectively extracted and reported to the ACSR by the department of medical records of each medical center. One hundred and four DD-ESRD patients (mean age 63.2 ± 8.8 years, 83.7% males) were compared with 8103 NRF patients (mean age 64.9 ± 9.8 years, 77.6% males). Median follow-up for the total cohort was of 32.0 months (IQR; 25.0, 40.0). In DD-ESRD compared to NRF patients, 30-day mortality was higher (14.4% vs. 2.3%, respectively, p = 0.0001) and 4-year survival was significantly lower (44% ± 0.06 vs. 91% ± 0.04, respectively, p = 0.0001). Fifty-three percent of DD-ESRD 30-day mortality was caused by sepsis. Risk factors associated with reduced midterm survival included: DD-ESRD patients (HR = 4.7, 95% CI; 1.2-18.2), MVR procedure (HR = 1.5, 95% CI; 1.04-2.1) and combined CABG + valve-related procedure (HR = 1.6, 95% CI; 1.2-2.04). Preoperative DD-ESRD was associated with a significant increase in 30-day and mid-term mortality after cardiac surgery. The highest mortality rate was observed in valvular and combined procedures.

Association of Monoclonal Gammopathy with Progression to End-Stage Renal Disease Among a National Cohort of US Veterans

Introduction : Testing for monoclonal proteins may be undertaken as part of the diagnostic evaluation for chronic kidney disease. However, the clinical significance of monoclonal gammopathy detected in this context is often uncertain. Here we examined the association of a positive test for monoclonal protein with progression to end-stage renal disease (ESRD) (dialysis or kidney transplant) among United States (US) veterans.Methods : We used national Veterans Health Administration (VA) clinical and administrative data to identify and characterize a national cohort of veterans with at least one serum creatinine measurement within the VA between October 1, 2000 and September 30, 2001. We used a text search algorithm for keywords pertaining to monoclonal protein contained in laboratory test results in the VA Corporate Data Warehouse within a two-year window of serum creatinine measurement to identify cohort members who had at least one test for monoclonal proteins (serum protein or urine electrophoresis or immunofixation), and to score test results as positive, negative, or unclassifiable. The text-search algorithm was validated by manual review of a random selection of 2% of records (training set) by an attending hematologist. A second manual review of a random selection of 737 records provided a validation set for the search algorithm, demonstrating a sensitivity of 0.73 (95% confidence interval (CI)) of 0.66-0.79, and specificity of 0.94 (95% CI 0.91-0.96), excluding unclassifiable tests. Patients were followed from the time of their first serum creatinine measurement during fiscal year 2001 through September 30, 2011 for the outcome of ESRD using linked data from the US Renal Data System, a national registry for ESRD. Cox proportional hazards regression stratified by glomerular filtration rate (eGFR ml/min/1.73 m2) was used to estimate hazard ratios (HR) with 95% CI for ESRD for patients with a positive vs. negative paraprotein test adjusted for age, sex, race, diabetes, congestive heart failure, vascular disease, and Charlson comorbidity index.Results : Among a cohort of over 2.1 million veterans with a serum creatinine test, we identified 19,993 who underwent paraprotein testing. Overall, 96% of the cohort were male, 69% were ≥ 55 years old, and 23% were ≥ 75 years old. Of those tested, 4,112 (20.5%) had a positive test, 14,541 had a negative test (72.7%) and 6.7% were unclassifiable. Among those with an eGFR <60, 2% (n=8,293) underwent paraprotein testing, as compared with 0.7% (N=11,700) of those with an eGFR≥60. For all levels of eGFR, the crude incidence of ESRD was higher among patients who were tested vs. not tested. For patients with eGFR ≥60 who underwent testing for monoclonal gammopathy, there was an increased crude rate of ESRD among those with a positive vs. negative test result (4.9 vs 2.2 per 1,000 person years) with an adjusted HR of 2.01 (95% CI 1.50-2.71). For patients with lower levels of eGFR, in whom the absolute rate of ESRD was much higher, the adjusted HR for ESRD for those with a positive vs negative test result was attenuated and varied little by eGFR (Figure).Conclusions : Among a large national cohort of US veterans, the risk of progression to ESRD in patients with a reduced eGFR who were tested for monoclonal gammopathy was similar regardless of whether the test result was positive or negative. Although there was an increased risk of ESRD among patients with preserved eGFR, the absolute risk of ESRD in these patients was very low. Evaluating different paraprotein sub-types and correlation with quantitative test results, including serum free light chain (kappa/lambda) ratios may further improve assessment of renal prognosis in patients with monoclonal gammopathy. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

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

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

Safety of Oral Bisphosphonates in Moderate-to-Severe Chronic Kidney Disease: A Binational Cohort Analysis

Bisphosphonates are the first-line treatment for preventing fractures in osteoporosis patients. However, their use is contraindicated or to be used with caution in chronic kidney disease (CKD) patients, primarily because of a lack of information about their safety and effectiveness. We aimed to investigate the safety of oral bisphosphonates in patients with moderate to severe CKD, using primary-care electronic records from two cohorts, CPRD GOLD (1997-2016) and SIDIAP (2007-2015) in the UK and Catalonia, respectively. Both databases were linked to hospital records. SIDIAP was also linked to end-stage renal disease registry data. Patients with CKD stages 3b to 5, based on two or more estimated glomerular filtration rate measurements less than 45 mL/min/1.73 m2 , aged 40 years or older were identified. New bisphosphonate users were propensity score-matched with up to five non-users to minimize confounding within this population. Our primary outcome was CKD stage worsening (estimated glomerular filtration rate [eGFR] decline or renal replacement therapy). Secondary outcomes were acute kidney injury, gastrointestinal bleeding/ulcers, and severe hypocalcemia. Hazard ratios (HRs) were estimated using Cox regression and Fine and Gray sub-HRs were calculated for competing risks. We matched 2447 bisphosphonate users with 8931 non-users from CPRD and 1399 users with 6547 non-users from SIDIAP. Bisphosphonate use was associated with greater risk of CKD progression in CPRD (sub-HR [95% CI]: 1.14 [1.04, 1.26]) and SIDIAP (sub-HR: 1.15 [1.04, 1.27]). No risk differences were found for acute kidney injury, gastrointestinal bleeding/ulcers, or hypocalcemia. Hence, we can conclude a modest (15%) increased risk of CKD progression was identified in association with bisphosphonate use. No other safety concerns were identified. Our findings should be considered before prescribing bisphosphonates to patients with moderate to severe CKD. © 2020 American Society for Bone and Mineral Research (ASBMR).

Clinical outcomes of infection-related hospitalization in incident peritoneal dialysis patients.

BackgroundInfection is the second leading cause of death in patients undergoing long-term dialysis. Peritoneal dialysis (PD) is associated with an increased risk of infection-related hospitalization (IRH) when compared with hemodialysis. In this study, we investigated the influence of IRH on clinical outcomes in incident PD patients.MethodsIn total, 583 incident PD patients were selected from the Clinical Research Center Registry for End-Stage Renal Disease, a nationwide multicenter prospective observational cohort study in Korea. Incident PD patients who had been hospitalized for infection-related diseases were defined as the IRH group. The primary outcome was all-cause mortality and the secondary outcome was technical failure. The median follow-up period was 29 months.ResultsSeventy-three PD patients (12.5%) were categorized in the IRH group. Multivariable logistic regression analysis showed that diabetes mellitus was a significant independent predictor for IRH (odds ratio, 2.43; 95% confidence interval [CI], 1.12 to 5.29; P = 0.007). The most common causes of IRH were peritonitis (63.0%) and respiratory tract infection (9.6%). Multivariable Cox proportional hazard model analysis showed that IRH was a significant independent risk factor for all-cause mortality (hazard ratio [HR], 2.51; 95% CI, 1.12 to 5.62; P = 0.026) and for the technical failure of PD (HR, 3.23; 95% CI, 1.90 to 5.51; P < 0.001).ConclusionOur data showed that after initiation of PD, IRH was significantly associated with higher risk of all-cause mortality and technical failure.

P0180U-SHAPED RELATIONSHIP BETWEEN SERUM URIC ACID LEVEL AND THE RISK OF END STAGE RENAL DISEASE AND ALL-CAUSE MORTALITY IN MEN

Abstract Background and Aims High uric acid level was known as a risk factor to incident chronic kidney disease, mortality, or cardiovascular mortality. However, it is obscure which level of uric acid (UA) is safe to prevent end stage renal disease (ESRD) and mortality. We searched the optimal range of UA level to escape the incident ESRD and death in a large cohort of general population. Method We enrolled 143,762 adult subjects participated in voluntary health check-up program from three referral hospitals in Korea between 1995 and 2009. We defined 48,147 control subjects (CONTROL) without risk factors of high UA level, to calculate 5, 20, 80, and 95 percentiles of UA level and allocated whole participants into five groups (G1, G2, G3, G4, G5) according to the criteria in each gender. We merged the incident data of ESRD from the Korean ESRD registry by December 2017 and the mortality data from the Ministry of the Interior and Safety by May 2018 based on the identifier of Koreans. This project was approved by institutional review boards of the three hospitals. Results The UA levels of 5, 20, 80, 95 percentiles in CONTROL were 2.9 mg/dL, 3.5 mg/dL, 4.9 mg/dL, and 5.7 mg/dL in females, and 4.1 mg/dL, 5.0 mg/dL, 6.8 mg/dL, and 7.8 mg/dL in males. There were 76,784 (53.4%) males and 66,978 (46.6%) females. The age was 50.5 ± 12.2 years and the level of GFR by CKD-EPI equation was 94.3 ± 15.2 ml/min/1.73 m2 at enrollment. Among females, ESRD was developed in 110 subjects (0.2%) and 1,922 subjects (2.9%) were dead during more than 12 years. The level of UA and groups of UA were not independent risk factors to mortality or incident ESRD in females. Among males, there were 162 subjects with ESRD (0.2%) and 4293 subjects (5.6%) were dead. Compared to G3 group (5.0 mg/dL ≤ UA&amp;lt;6.8 mg/dL), other groups showed higher risk of incident ESRD adjusted with related factors by Cox’s hazard proportional model in males (p=0.016). The Hazard ratios (HRs) for incident ESRD in G1 group (&amp;lt;4.1 mg/dL), G4 group (6.8 mg/dL ≤ UA&amp;lt; 7.8 mg/dL), and G5 group (7.8 mg/dL ≤ UA) were 2.409 (95% CI, 1.312-4.423, P=0.005), 1.710 (95% CI, 1.080-2.707, P=0.022), and 1.742 (95% CI, 1.098-2.762, P=0.018), respectively. The HRs for all-cause mortality in G1, G4, and G5 group were 1.203 (95% CI, 1.017-1.346, P=0.001), 1.099 (95% CI, 1.006-1.201, P=0.037), and 1.137 (95% CI, 1.015-1.272, P=0.026), respectively. We found there were 591 subjects died from cardiovascular disease (CVD) among 3,352 deaths with valid cause of death. G1 and G5 group showed higher risk for CVD-mortality compared to G3 group in men (p&amp;lt;0.001). Conclusion Serum uric acid level showed U-shaped pattern of HRs for incident ESRD and all-cause mortality in men, only. The appropriate uric acid level might be 4.1-6.7 mg/dL in men.

P0468RENAL OUTCOME AND MORTALITY OF GLOMERULONEPHRITIS IN A THAI TERTIARY CARE CENTER

Abstract Background and Aims Glomerulonephritis (GN) is a common cause of End-stage renal disease (ESRD) in Asia and around the world. Most studies from renal registries have focused on the prevalence or clinical characteristics of patients with GN. Only a few registry-based data have focused on mortality and ESRD risks of different types of GN. There is limited data from low to middle income countries or from Southeast Asia. The objectives of this study were to evaluate the mortality and ESRD rates among patients with different types of GN referred for a kidney biopsy at a Thai tertiary care hospital. Method In this retrospective study, the data of patients (n=1,025) referred for a kidney biopsy at Ramathibodi Hospital from 1 January 2011 to 31 December 2017 were reviewed. Patients were classified in to 11 different types of GN. Patient death and cause of death data was obtained from National Census office. ESRD data was obtained from the Thailand Nephrology Society ESRD registry which includes all patients on renal replacement therapies for greater than 3 months. Results Patients with inadequate specimen (n=66) or non-glomerular diseases (n=95) were excluded. Data from 864 patients with GN was analyzed. The age at kidney biopsy was 43.9 ± 16.8 years, median eGFR (CKD-EPI) was 42 (IQR 13-83) mL/min/1.73m2. The male:female ratio was 0.6. The prevalence of GN were: Lupus nephritis (26.8%), IgA nephropathy (18.2%), focal segmental glomerulosclerosis (FSGS 12.6 %), membranous nephropathy (11.9 %), diabetic nephropathy (10.8%), minimal change disease (9.7%), hypertensive nephrosclerosis (4.3%), pauci-immune complex glomerulonephritis (2.3%), membranoproliferative glomerulonephritis (MPGN 1.6%) and multiple myeloma (1.4%) Median time follow up was 42 (IQR 23-62) months. Overall mortality was 13 %. Lupus nephritis accounted for highest proportion of all deaths (25%), followed by diabetic nephropathy (19.1%), FSGS (9%). Listed causes of deaths were: sepsis 22% and chronic kidney disease 8%. Mortality rates by disease were: multiple myeloma (50%), diabetic nephropathy (28.7%), MPGN (21.4%), pauci-immune complex GN (20%), hypertensive nephrosclerosis (15.8%), lupus nephritis (14.6%), membranous nephropathy (8.7%), FSGS (8.2%), minimal change disease (5.8%), IgA nephropathy (4.4%) The incidence of ESRD was 14 %. LN accounted for the highest proportion (29%) of all ESRD, followed by IgA nephropathy (14%), and membranous nephropathy (13%). The rates of ESRD by disease were: multiple myeloma (33.3%), lupus nephritis (15%), membranous nephropathy (14.5%), minimal change disease (14.3%), MPGN (14.2%), IgA nephropathy (10.1%), FSGS (10.1%), diabetic nephropathy (7.4%), pauci-immune complex glomerulonephritis (5%), hypertensive nephroclerosis (2.6%). Conclusion Lupus nephritis is the most common GN and accounted for the highest proportion of all deaths and ESRD in this Thai cohort. IgA nephropathy is the most common primary GN and an important cause of ESRD, but the mortality rate is low compared to other GN. Membranous nephropathy has comparable prevalence to FSGS, but is a more important contributor to ESRD. Diabetic nephropathy has higher rate of mortality than ESRD. Multiple myleloma has the highest rate of both death and ESRD.

P15185 YEAR ALL-CAUSE MORTALITY ACCORDING TO PRIMARY RENAL DISEASE IN HEMODIALYSIS PATIENTS

Abstract Background and Aims The Korean Society of Nephrology (KSN) collected data of end-stage renal disease registry since 1985 and internet registry program was available since 2001. We explored the hypothesis that the 5-year mortality of hemodialysis patients was different depending on primary renal disease. Method From 2004 to 2015, in total, 32,163 patients starting hemodialysis were determined. The cause of primary renal disease were divided to diabetic nephropathy (49.9%, n=16,038), hypertensive nephrosclerosis (18.5%, n=5,958), histologically confirmed glomerulonephritis 3.3% (n=1,067), cystic kidney disease (2.0%, n=656) and the miscellaneous (26.3%, n=8,444). The miscellaneous included renal tuberculosis, interstitial nephritis, lupus nephritis, kidney tumor. Results The 5-year mortality of hemodialysis patients was 16.9 % (N=5,435) and ratio of unknown state was 24.9 % (N=7,996). The mortality of diabetic nephropathy, hypertensive nephrosclerosis, histologically confirmed glomerulonephritis, cystic kidney disease and the miscellaneous were 27.1% (n=3,323), 17.0% (n=768), 8.4% (n=62), 13.9% (n=67), and 19.7% (n=5,435), respectively. Kaplan-Meier survival analysis showed that diabetic nephropathy was worst survival rate following hypertensive sclerosis, cystic kidney disease and the miscellaneous, while histologically confirmed glomerulonephritis showed highest survival rate (log-rank p &amp;lt; 0.001). After adjusting for confounders, cox-proportional regression analysis revealed that 5-year mortality was associated with diabetic nephropathy compared hypertensive nephrosclerosis (HR, 1.62 CI, 1.17-2.24) while histologically confirmed glomerulonephritis was not significant. Conclusion The overall mortality was associated with primary renal disease in hemodialysis paitents. This result suggests that hemodialysis patients with diabetic nephropathy require further medical attention.

P1504RELATIONSHIP OF LOW BODY MASS INDEX AND SURVIVAL IN HEMODIALYSIS PATIENTS

Abstract Background and Aims Malnutrition is common in patients with hemodialysis and major risk factor of mortality. The Korean Society of Nephrology (KSN) collected data of end-stage renal disease registry since 1985. We evaluated whether body mass index (BMI) can affect mortality in patient with hemodialysis. Method From 2004 to 2015, a total of 32,163 patients starting hemodialysis were included. The patients were divide four groups according quartiles of BMI measurement. Results At baseline, mean age was 59.0 ± 14.3 years old, and 60.0% were men. The 5-year mortality of hemodialysis patients was 16.9 % (N=5,435) and ratio of unknown state was 24.9 % (N=7,996). The mean of BMI in each quartiles were 18.2 ± 1.2, 20.8 ± 0.5 22.8 ± 0.6, 26.4 ± 2.6 kg/m2 respectively. The mean of BMI between survivor and non-survivor were different (22.3 ± 3.3 vs. 21.5 ± 3.2 kg/m2). Cox-proportional regression multivariate analysis revealed that the 5-year all-cause mortality was associated with age (HR 1.04, CI 1.03-1.05), diabetes (HR 1.34, CI 1.07-1.7) coronary heart disease or heart failure (HR 1.3, CI 0.9-1.7), 2nd BMI quartile (HR 0.7, CI 0.5-0.9), 3rd BMI quartile (HR 0.6, CI 0.46-0.88), 4th BMI quartile (HR 0.59, CI 0.43-0.82), hypoalbuminemia (HR 2.9, CI 2.3-3.7) and anemia (HR 1.6, CI 1.2-2.0) . Conclusion Higher quartiles of BMI was significantly associated with better survival rate in hemodialysis patients in Korea. Traditional risk factors of malnutrition, such as hypoalbuminemia, anemia were also independent risk factor for mortality. This result suggests that hemodialysis patients needed to nutritional support.

Linking disease registries and nationwide healthcare administrative databases: the French renal epidemiology and information network (REIN) insight

BackgroundRecord linkage is increasingly used in health research worldwide. Combining the patient information available in healthcare, administrative and clinical databases broadens the research perspectives, particularly for chronic diseases. Recent guidelines highlight the need for transparency on the used record linkage processes and the extracted data to be used by researchers.MethodsTherefore, the aim of this study was to describe the deterministic iterative approach used to link the French Epidemiology and Information Network (REIN), a French national End-Stage Renal Disease registry, with the Système National des Données de Santé (SNDS), a French nationwide medico-administrative healthcare database.ResultsAmong the 22,073 patients included in the REIN registry who started renal replacement therapy between 2014 and 2015 in France, 19,223 (87.1%) were matched with patients in the SNDS database. Comparison of matched and unmatched patients confirmed the absence of any major selection bias. Then, the record linkage was evaluated using the comorbidity status (diabetes).ConclusionsThis fast and efficient method of record linkage with pseudonymized data and without unique and direct identifier might inspire other research teams. It also opens the path for new research on chronic kidney disease.

Dialysis modality-related disparities in sudden cardiac death: hemodialysis versus peritoneal dialysis.

BackgroundPatients require risk stratification and preventive strategies for sudden cardiac death (SCD) based on the dialysis modality because the process of dialysis is a risk factor for SCD. This study aimed to compare the risk of SCD in patients undergoing hemodialysis (HD) versus peritoneal dialysis (PD).MethodsPatients on HD and PD were included in the end-stage renal disease registry of the Korean Society of Nephrology between 1985 and 2017. The incidence and associated factors of SCD were analyzed based on the dialysis modality.ResultsOf 132,083 patients, 34,632 (26.2%) died during 94.8 ± 73.6 months of follow-up. In patients on HD and PD, 22.2% and 19.6% of total deaths were SCDs. In the propensity score-matched population, SCD accounted for 21.7% and 19.6% of total deaths in patients on HD and PD, respectively. HD was independently associated with SCD even after adjusting for age and significant comorbidities. Hypertension, coronary artery disease, and congestive heart failure, and age at the time of death < 65 years were independent risk factors for SCD in patients on HD but not in those on PD. Diabetes was significantly associated with SCD regardless of the dialysis modality.ConclusionCompared with patients on PD, Korean patients on HD have a higher risk of SCD, which is attributable to cardiac comorbidities.

The Impact of Comorbidity Burden on The Association between Vascular Access Type and Clinical Outcomes among Elderly Patients Undergoing Hemodialysis

The optimal vascular access type for elderly hemodialysis patients is controversial. We evaluated the impact of comorbidity burden on the association between vascular access type and mortality risk among 23,100 hemodialysis patients aged ≥65 years from the Korean Society of Nephrology End-Stage Renal Disease registry data. Subjects were stratified into tertiles according to the simplified Charlson comorbidity index (sCCI), and the survival and hospitalization rates were compared with respect to vascular access type: arteriovenous fistula (AVF), arteriovenous graft (AVG), and central venous catheter (CVC). Among all tertiles of sCCI, CVC use showed highest risk of mortality than AVF use. In the lowest to middle tertile, no difference was observed in survival rates between the use of AVF and AVG. However, in the highest tertile, AVG use showed higher risk of mortality than AVF use. When subjects were classified according to a combination of sCCI tertile and access type (AVF vs. AVG), patients with the highest CCI with AVG showed 1.75-folded increased risk of mortality than those with the lowest sCCI with AVF. Hospitalization rates due to access malfunction were highest in patients with CVC in all sCCI tertiles. In the highest tertile, patients with AVG showed increased rates of hospitalization compared to those with AVF due to access malfunction. However, hospitalization rates due to access infection were highest in patients with AVG in all tertiles. The use of AVF may be of benefit and switching to AVF should be considered in elderly hemodialysis patients with a high burden of comorbidity.

Computationally efficient inference for center effects based on restricted mean survival time.

Restricted mean survival time (RMST) has gained increased attention in biostatistical and clinical studies. Directly modeling RMST (as opposed to modeling then transforming the hazard function) is appealing computationally and in terms of interpreting covariate effects. We propose computationally convenient methods for evaluating center effects based on RMST. A multiplicative model for the RMST is assumed. Estimation proceeds through an algorithm analogous to stratification, which permits the evaluation of thousands of centers. We derive the asymptotic properties of the proposed estimators and evaluate finite sample performance through simulation. We demonstrate that considerable decreases in computational burden are achievable through the proposed methods, in terms of both storage requirements and run time. The methods are applied to evaluate more than 5000 US dialysis facilities using data from a national end-stage renal disease registry.

SUN-075 IMPACT OF BODY MASS INDEX ON SURVIVAL IN CAPD PATIENTS: ANALYSIS OF THE INSAN MEMORIAL ESRD REGISTRY DATA (1985–2014), KOREA

Significant increases in the prevalence of obesity have been observed among patients with end-stage renal disease (ESRD). The impact of body mass index (BMI) on survival remains unknown in Korean patients undergoing peritoneal dialysis (PD). Among data of 80674 patients with PD between 1985 and 2014 from the Insan Memorial ESRD registry data, 6075 cases were selected. Subjects were classified by baseline BMI:<21.19 kg/m2(quartile 1, n=1519), 21.19-23.18 kg/m2(quartile 2=reference, n=1454), 23.19-25.71 kg/m2(quartile 3,n=1584), and >25.71 kg/m2(quartile 4, n=1518).All-cause mortality analysis was performed. Patients’ mean age was 65.8±13.7 years, and baseline BMI was 23.57±3.63 kg/m2. The numbers of male and diabetic patients were 3492 (57.5%) and 2192 (36.1%), respectively. Among 6075 cases, 2229 (36.7%) all-cause deaths occurred. The log rank of the Kaplan-Meier survival curves according to the BMI quartiles was 19.53 (P=0.001). Overall, all-cause mortality of quartiles 1 and 3 weresimilar to the reference. All-cause mortality was significantly higher in quartile 4 than in the reference (hazard ratio [HR]=1.154, 95% confidence interval [CI], 1.025–1.300; P=0.018). There were no statistical differencesin all-cause mortality among the BMI quartiles in diabetic patients with PD.In non-diabetic patients, all-cause mortality of quartiles 1 and 3 was not different from the reference, but the HR was 1.176 times higher in quartile 4 than in the reference (95% CI, 1.024–1.350;P=0.022). Baseline BMI>25.71 kg/m2 seems to be an important risk factor for all-cause mortality in Korean patients with PD.

Analysis of mortality risk from Korean hemodialysis registry data 2017.

The End-stage Renal Disease Registry Committee of the Korean Society of Nephrology collects data on the dialysis therapy in Korea through an internet-based registry program and reports it annually. In this article, the method and clinical implications of the mortality hazard ratio analyses of various clinical parameters in the 2017 registry report have been described, with the inclusion of data on four additional parameters. The mortality risk based on clinical parameters was analyzed only for hemodialysis patients. The number of registered patients with laboratory data was 13,943 (8,446 male and 5,497 female patients), and death was reported in 3,139 patients. Analysis of the effects of various clinical parameters on mortality was performed using non-linear Cox proportional hazard model with the R statistics program. For all clinical parameters, univariate and adjusted multivariate hazard ratio analyses were performed. Analysis of the mortality hazard ratio showed that low body mass index, low hemoglobin, low serum albumin, low serum phosphorus, and low urea reduction ratio were associated with a significantly increased mortality risk, whereas paradoxically high serum creatinine levels were associated with low mortality risk.