Etiology Of End-stage Renal Disease Research Articles

MO883: Cardiorenal Syndrome in Dialysis: Outcomes and Prognosis in Comparison With a Control Population

Abstract BACKGROUND AND AIMS The interactions of both organs in Cardiorenal Syndrome (CRS) exacerbate the damage and determine a worse prognosis in these patients [1]. The aim of our study is to compare the development and prognosis of CRS patients compared with control patients. METHOD: In a retrospective fashion, we assigned 60 patients with CRS who underwent dialysis, and we compared them with a control population of 60 patients without CRS in dialysis. We analyzed baseline characteristics of the patients and the dialysis parameters. Survival rates at 1 and 5 years were determined. RESULTS The baseline characteristics were similar between groups. The mean age was 72 ± 9 years in CRS and 68 ± 12 years in the control group. Men were more prevalent in both groups CRS (55%) and control (53%). Charlson's Score was 8 ± 2 points in the CRS group and 7 ± 3 points in the control group. Diabetic nephropathy was the most frequent etiology of end-stage renal disease in CRS patients (37%), followed by nephroangiosclerosis (20%). In the control group, the most common etiologies were nephroangiosclerosis (32%), diabetic (22%) and interstitial nephropathy (11%). CRS patients had more diabetes mellitus (55% versus 35%; P < 0.05), dyslipidemia (63% versus 38%; P < 0.05), ischemic cardiopathy (50% versus 31%; P < 0.05), atrial fibrillation (66% versus 21%; P < 0.05) and valvular heart disease (27% versus 6%; P < 0.05). There were no differences in hypertension (80% versus 76%; P = 0.58), ictus (31% versus 23%; P = 0.30) and peripheral arterial disease (40% versus 33%; P = 0.44) between groups. CRS patients had more hospitalizations due to heart failure before starting dialysis than the control group (52% versus 1.7%; P < 0.05) Haemodialysis was the most common technique in both groups CRS (98%) and control (95%). The use of permanent tunneled catheters as definite vascular access was more common in CRS patients (60% versus 26%; P < 0.05). There were no differences in the duration of haemodialysis sessions (252 ± 18 versus 257 ± 23 min), neither in interdialytic weight gain (2.3 ± 0.7 versus 2.4 ± 0.9 Kg). CRS patients had worse ultrafiltration tolerance with a hypotension rate of 48% in CRS versus 10% in the control group (P < 0.05). The median time in dialysis was inferior in the CRS group [24 (8–42) versus 61 (26–106) months; P < 0.05] compared with controls and the survival rates at 1 and 5 years were worse in the CRS group (71% versus 93%; P < 0.05) and (15% versus 50%; P < 0.05), respectively. The main cause of death was the cardiovascular events in both groups (35% versus 20%; P = 0.06). However, tumor as a cause of death was superior in the control group (18% versus 0%; P < 0.05). CONCLUSION CRS patients have more cardiovascular risk factors and cardiovascular disease as expected, as well as more hospitalizations caused by heart failure before starting dialysis. They have more frequent use of a permanent tunneled catheter. It could be explained because of worse tolerance to the use of arteriovenous fistula in these patients. - The survival rates at 1 and 5 years are significantly inferior in the CRS group, which highlights the poor prognosis of these patients [2,3]. - The tumor as a cause of death was superior in the control group due to greater time in dialysis of these patients compared with CRS patients

New-Onset Diabetes after Transplantation (NODAT) in Renal Transplant Recipients, A Retrospective Single Centre Study

Objective: New onset diabetes after transplant (NODAT) is a known post-transplant complication contributing to morbidity and mortality. This study was aimed to find out the frequency of NODAT in kidney disease patients after one year. Methods and subjects: The study was conducted retrospectively on 275 Asian patients who underwent kidney transplant. The demographic and clinical data was evaluated at the time, as well as 3, 6, and 12 months after kidney transplant. The etiology of end-stage renal disease (ESRD) or comorbidities was also documented. Every patient received a combination of Tacrolimus (Tac), Mycophenolate Mofetil (MMF), and Prednisone (Pred) as post-transplant immunosuppression. Patients who developed NODAT were compared with those who did not. RESULTS: One year after the transplantation, the incidence of NODAT was 4.3 percent. Patients diagnosed with NODAT were older (p = 0.001) and had renal failure owing to Chronic glomerulonephritis with hypertension (p = 0.001), according to the results of the univariate analysis. The NODAT group had significantly greater rates of high blood pressure after transplantation (p = 0.01), heart failure (p = 0.02), and dyslipidemia (p = 0.001) than the other groups. Through the use of logistic regression, it was shown that high blood pressure after transplant, and dyslipidemia are all independently linked with NODAT. Conclusion: Asian patients who had high blood pressure and dyslipidemia had a higher incidence of NODAT compared to those who did not have. Keywords: kidney transplantation, prevalence, new-onset diabetes after trasplant

Immunoglobulin A nephropathy in paediatrics: An up‐to‐date

Immunoglobulin A nephropathy is the main cause of glomerulonephritis globally and an important aetiology of end-stage renal disease in children. It has been considered an autoimmune disease that can lead to the production of autoantibodies against abnormal IgA1 and formation of immune complexes. These autoantibodies and immune complexes deposit in the glomeruli, resulting in renal injury. At the beginning of IgA nephropathy course, most patients are asymptomatic and the first clinical manifestations in children are macroscopic hematuria and proteinuria. The diagnosis is defined by the detection of IgA mesangial deposits in kidney biopsy using immunofluorescence techniques. The Oxford MEST-C score is the most used classification to associate histological findings and clinical outcomes, being validated for application in children. Recommended treatment options are antihypertensive and antiproteinuric therapy, corticosteroids, immunosuppressive agents, and other non-pharmacological approaches. There is no ideal prognosis indicator but new perspectives are in science's scope to find possible biomarkers of the disease through OMICS's research. This review aims to summarize and to up-to-date the scientific literature on paediatric IgA nephropathy, focusing on pathophysiology, clinical findings, histopathology, current treatment, prognosis, and future perspectives.

Low Muscle Mass in Patients Receiving Hemodialysis: Correlations with Vascular Calcification and Vascular Access Failure.

Background: Sarcopenia involves an age-related decline in skeletal muscle mass with functional disability or low muscle strength. Vascular calcification (VC) occurs commonly in patients with chronic kidney disease, in whom it is associated with cardiovascular disease. We aimed to investigate the correlations of low muscle mass with the quantified vascular calcification score (VCS) of the arm of vascular access, as well as whether low muscle mass is associated with the incidence of vascular access failure. Methods: The VCS was measured on non-contrast, arm computed tomography using the Agatston method. The lower muscle mass (LMM) group comprised subjects whose skeletal muscle mass of the lower extremities, as measured using bioelectrical impedance, was lower than the median. Higher VC was defined as a score of 500 or above, corresponding to the highest 40% of VCS. The relationship between LMM and VC was explored using univariate and multivariate logistic regression analyses. Results: Seventy-five patients were included, of whom forty-two (56.0%) were men. The median age was 64 years (interquartile range 58–72 years). Of the 75 patients, 73 satisfied the diagnostic criteria for sarcopenia. The median hemodialysis vintage was 49.4 months (range 32.1–99.2 months). No significant differences were found between the non-LMM and LMM groups in sex, end-stage renal disease etiology, and type of vascular access, although the LMM group showed significantly older age and hemodialysis vintage. LMM presented a significant association with VC (hazard ratio (HR) 3.562; 95% CI, 1.341–9.463; p = 0.011). Upon adjustment for hemodialysis vintage, diabetes, and systolic blood pressure, LMM demonstrated an independent association with VC (HR, 10.415; 95% CI, 2.357–46.024; p = 0.002). The risk of vascular access failure was higher in the LMM group (HR, 3.652; 95%, CI 1.135–11.749; p = 0.03). VC was a full mediator in the relationship of LMM with recurrent vascular access failure. Conclusions: We quantified LMM via bioimpedance analysis and found a heretofore-unreported association between LMM and vascular access failure. LMM increases the risk of VC and has the potential to predict vascular access failure.

Prevalence of diarrhea in end-stage renal disease patients initiating hemodialysis

BackgroundDiarrhea is one of the symptoms occasionally seen in patients initiating hemodialysis. When they have diarrhea, they need several additional cares for defecation during the hemodialysis sessions and for infection control at dialysis facilities.MethodsWe retrospectively examined the prevalence and the characteristics of the patients with diarrhea initiating hemodialysis. Data were collected from medical records.ResultsOf 243 patients who initiated hemodialysis therapy, 46 patients (19%) had diarrhea. The age, gender, and etiology of end-stage renal disease did not differ between the patients with diarrhea and those without diarrhea. Body weight in the patients with diarrhea was lighter than those without diarrhea. The prevalence of concomitant diseases, such as cardiovascular diseases, malignancies, and diabetes, was not different between the groups, whereas the patients with diarrhea were complicated more frequently with infectious diseases. Antibiotics and steroids had been used more frequently in the patients with diarrhea (59% and 26%, respectively) than those without diarrhea (10% and 10%, respectively). Inflammatory markers, such as white blood cell numbers, C-reactive protein levels, and body temperature, were significantly higher in the patients with diarrhea. Serum levels of total protein, albumin, and creatinine were significantly lower in the patients with diarrhea, while urea nitrogen levels did not differ between the groups.ConclusionResults of the present study showed, for the first time, that 19% of the patients initiating hemodialysis had diarrhea and suggest that incident hemodialysis patients with infectious diseases and those under treatment with antibiotics and/or steroids are high-risk for diarrhea.

An accessible insight into genetic findings for transplantation recipients with suspected genetic kidney disease

Determining the etiology of end-stage renal disease (ESRD) constitutes a great challenge in the context of renal transplantation. Evidence is lacking on the genetic findings for adult renal transplant recipients through exome sequencing (ES). Adult patients on kidney transplant waitlist were recruited from 2017 to 2019. Trio-ES was conducted for the families who had multiple affected individuals with nephropathy or clinical suspicion of a genetic kidney disease owing to early onset or extrarenal features. Pathogenic variants were confirmed in 62 from 115 families post sequencing for 421 individuals including 195 health family members as potential living donors. Seventeen distinct genetic disorders were identified confirming the priori diagnosis in 33 (28.7%) families, modified or reclassified the clinical diagnosis in 27 (23.5%) families, and established a diagnosis in two families with ESRD of unknown etiology. In 14.8% of the families, we detected promising variants of uncertain significance in candidate genes associated with renal development or renal disease. Furthermore, we reported the secondary findings of oncogenes in 4.4% of the patients and known single-nucleotide polymorphisms associated with pharmacokinetics in our cohort to predict the drug levels of tacrolimus and mycophenolate. The diagnostic utility of the genetic findings has provided new clinical insight in most families that help with preplanned renal transplantation.

Etiology of end-stage renal disease amongst hemodialysis patients in Makkah city, Saudi Arabia

In recent years, the number of hemodialysis (HD) patients has increased in the Kingdom of Saudi Arabia. End-stage renal disease (ESRD) is associated with increased rates of hospital admission, morbidity, and mortality. Globally, the most common causes of ESRD are diabetic nephropathy, hypertension, glomerulonephritis, infections, and chronic obstruction. However, very limited data have been presented regarding the etiology of ESRD in Saudi Arabia, especially in Makkah City. Therefore, this cross-sectional study is designed to determine the underlying etiologies of ESRD in hemodialysis patients. The study was conducted among 306 patients who were recruited from Makkah hospitals and HD centers. The obtained data showed that diabetes was the most common cause of ESRD (34.3%), followed by hypertension (20.9%), drug misuse (12.1%), hereditary conditions (10.1%), urinary tract obstruction, and urinary retention (9.8%), unknown reason (8.2%), and chronic inflammation of the kidneys (3.3%). In conclusion, this study highlights the most important factors contributing to ESRD in the Makkah region. Thus, national campaigns should be performed to increase awareness about these factors and to possibly reduce the incidence of the disease.

POS-750 THROMBOEMBOLISM IN KIDNEY TRANSPLANT RECIPIENTS: PREVALENCE AND OUTCOMES OVER 13 YEARS

Thromboembolism is more common in kidney transplant recipients(KTR) than the general population. As the number of studies evaluating arterial andvenous thromboembolism (VTE) in KTR are very scarce, the magnitude and the riskfactors are undefined. Thromboprophylaxis poses a challenge as the risk ofthrombosis must be balanced against the risk of bleeding. It was a retrospective analysis of 2124 patients of age more than 18 yearsold, who had undergone kidney transplantation between January 2007 to December 2019. A VTE was defined as a radiographically diagnosed pulmonary embolism (PE)or deep venous thrombosis (DVT) with or without clinical symptoms. No patient wasgiven chemoprophylaxis. The primary outcome was to assess prevalence of the VTEepisode. Secondary outcomes were assessment of the timing of occurrence of thethromboembolic events after transplantation, determining the risk factors, estimationof rate of recurrence after thromboprophylaxis withdrawal, and outcomes. Multipleorgan transplant recipients and early graft loss due to vascular complications werenot included in the study. Of 2124 patients, 67 (3.1%) patients were found to have VTE (1 deceased-donor and 66 living donor recipients). 70 percent of patients were male. The median follow-up was 3.9 years (range 6 months -13 years). The mean age at transplantation was 42 years (± 10). A total of 75 VTE events were recorded. Twenty events were asymptomatic. No episode of VTE was recorded in the first-month post-transplantation. Four patients experienced a recurrence of VTE. 52 cases were diagnosed with lower limb DVT, 5 cases were upper limb DVT, 6 cases with pulmonary embolism, 2 cases were cerebral venous sinus thrombosis and 2 cases were of iliofemoral thrombosis. Cytomegalovirus infection and cancer were found to be related to higher chances of VTE. No increased risk of VTE was observed among patients receiving cyclosporine, a mammalian target of rapamycin inhibitors. The risk was not affected by the patient’s age, obesity, primary etiology of end-stage renal disease, prior dialysis modality, or acute rejections. The over-all estimated 5-year graft survival of the VTE group was 70.3%. The data suggest that kidney transplant surgery is a moderate risk for. Chemoprophylaxis should be considered in patients with hypercoagulable disease states at the time of transplant. Further prospective studies are needed to further describe the risk of VTE in KTRs.

Ocular manifestations in renal allograft recipients: An Indian perspective.

Purpose:The aim of this study was to report the ocular findings in renal allograft recipients in India.Methods:A cross-sectional, comprehensive ophthalmic evaluation was performed, at least three months postrenal transplant, in 152 renal allograft recipients for the ocular findings. In addition, ocular findings were assessed for an association with the clinical variables like major etiologies of end-stage renal disease, pre-transplant dialysis duration, post-transplant duration, and dosage of immunosuppressive drugs.Results:72.36% of the recipients (mean age, 38.16 ± 10.04 years) had at least one ocular finding at 3 ± 2.6 years (range, 0.3-14 years), postrenal transplant. Hypertensive retinopathy was the commonest ocular finding followed by posterior subcapsular cataract (20.4%), nuclear sclerosis (19.7%), diabetic retinopathy (15.1%), dry eye (11.2%), allergic conjunctivitis (9.9%), pterygium (6.6%), open-angle glaucoma (3.3%), meibomitis (3.3%), pinguicula (2.6%), chalazion (1.3%), subconjunctival haemorrhage (1.7%), central serous chorioretinopathy (1.7%), healed ocular toxoplasmosis (1.7%), papilledema (1.7%), and dry ARMD (1.7%). In addition, a significant association existed between some of the ocular findings with major aetiologies of ESRD, post-transplant duration, and dosage of immunosuppressive drugs. However, no association existed between the ocular findings and pre-transplant dialysis duration.Conclusion:Ocular findings are seen in 72.36% of the renal transplant recipients with hypertensive retinopathy being the commonest one. Hence, a mandatory regular ophthalmic screening of the recipients is recommended for an early detection and timely intervention to improve the quality of life.

Association between Parathyroid Hormone and Anemia: A Cross-Sectional Observational Study of maintenance Hemodialysis Patients of a Tertiary Care Center

Objective
 The objective of this study was to assess the relationship between intact parathyroid hormone levels (iPTH) and hemoglobin (Hb) levels in patients with end-stage renal disease (ESRD) who were on hemodialysis.
 Material and methods 
 An observational, cross-sectional study was conducted in the Department of Nephrology at Jinnah Postgraduate Medical Centre in Karachi, Pakistan. Patients were enrolled in this study after consent and institutional review board approval. Serum samples were collected for Hb level, iPTH level, vitamin D, urea and creatinine, ferritin, and transferrin saturation. 
 Results
 Ninety four patients were inducted into this study; men comprised 66.0% of the patients, and Diabetes mellitus was the commonest etiology of ESRD.
 Most of the patients were on dialysis for more than 5 years on twice per week hemodialysis. Mean Hemoglobin was 9.29g/dl, iPTH 576.59ng/dl and Vitamin D 25.47ng/ml. Significant inverse correlation was found between anemia and i-PTH levels.
 Conclusion
 Hyperparathyroidism is one of the major contributor anemia among maintenance hemodialysis patients.

Factors Affecting Employment in Maintenance Hemodialysis Patients in Egypt

Background: Most of hemodialysis patients are unemployed and the few who are working are at risk of losing their jobs. Therefore, factors affecting employment need to be studied. Objective: Our aim was to access factors affecting employment among working-age patients on hemodialysis all over Egypt as it was not assessed before. Patients and Methods: This study was conducted between October 2012 and April 2015 in multiple hemodialysis centers by direct interview of the patients and collecting the data from the medical record in a special data collection sheet. Results: The study was conducted on 16280 hemodialysis patients in 19 Egyptian governorates. 21.2% of the patients were employed, 81.6% of the employed patients were men, and their mean age was 47.25+11.31. Hypertension was the most common etiology of end-stage renal disease (ESRD) and was the commonest comorbidity in employed patients. Employment was affected by age, gender, ESRD etiology and most comorbid conditions apart from comorbid chronic liver disease and chronic obstructive pulmonary disease. Factors affecting employment was dialysis frequency, duration, complications, dialyzer type, material, and surface area, dialysate type, dialysate Na, K and vascular access, haemoglobin (Hb) level, Ca/PO4 ratio, parathormone (PTH), iron injection, blood transfusion, erythropoietin intake, vitamin B complex intake, L carnitine intake, phosphate binders, cinacalcet and folic acid intake while Kt/v and urea reduction ratio and vitamin D supplements did not affect employment. Conclusion: Similar to the other studies we found that employment was not common among hemodialysis patients, which was affected by age, gender, ESRD etiology and comorbidities apart from chronic obstructive pulmonary disease (COPD) and chronic liver disease (CLD) which differed from other studies.

Factors Affecting Employment in Maintenance Hemodialysis Patients in Egypt

Background: Most of hemodialysis patients are unemployed and the few who are working are at risk of losing their jobs. Therefore, factors affecting employment need to be studied. Objective: Our aim was to access factors affecting employment among working-age patients on hemodialysis all over Egypt as it was not assessed before. Patients and Methods: This study was conducted between October 2012 and April 2015 in multiple hemodialysis centers by direct interview of the patients and collecting the data from the medical record in a special data collection sheet. Results: The study was conducted on 16280 hemodialysis patients in 19 Egyptian governorates. 21.2% of the patients were employed, 81.6% of the employed patients were men, and their mean age was 47.25+11.31. Hypertension was the most common etiology of end-stage renal disease (ESRD) and was the commonest comorbidity in employed patients. Employment was affected by age, gender, ESRD etiology and most comorbid conditions apart from comorbid chronic liver disease and chronic obstructive pulmonary disease. Factors affecting employment was dialysis frequency, duration, complications, dialyzer type, material, and surface area, dialysate type, dialysate Na, K and vascular access, haemoglobin (Hb) level, Ca/PO4 ratio, parathormone (PTH), iron injection, blood transfusion, erythropoietin intake, vitamin B complex intake, L carnitine intake, phosphate binders, cinacalcet and folic acid intake while Kt/v and urea reduction ratio and vitamin D supplements did not affect employment. Conclusion: Similar to the other studies we found that employment was not common among hemodialysis patients, which was affected by age, gender, ESRD etiology and comorbidities apart from chronic obstructive pulmonary disease (COPD) and chronic liver disease (CLD) which differed from other studies.

Renal replacement therapy in patients with familial Mediterranean fever

One of the causes of end-stage renal disease (ESRD) in some countries is the renal involvement caused by the complications of the familial Mediterranean fever (FMF). Amyloidosis is of the most important complications of FMF that can lead to ESRD. We report our experiences of FMF patients with ESRD who received hemodialysis and kidney transplantation over the past 17 years. Of nine patients, four had amyloidosis, two had focal segmental glomerulosclerosis (FSGS), one had IgA nephropathy, and two did not undergo biopsy because their kidneys were atrophic. Of the nine patients, one died of amyloidosis. Seven patients had kidney transplantation and one patient is currently undergoing dialysis. Six patients were transplanted from a living donor and one from a cadaver. The ultrasound examination revealed that five patients had bilateral kidney atrophy, four patients had normal size kidney with amyloidosis. None of the seven patients who underwent renal transplantation had a history of rejection. Kidney transplantation and hemodialysis in patients with FMF is similar to those with other ESRD etiologies.

Prevalence and etiology of end-stage renal disease patients on maintenance hemodialysis

Objectives The objective of this work is to study the prevalence and etiology of end-stage renal disease (ESRD) patients on maintenance hemodialysis (HD) in a central governmental Hospital of El-Sharkia governorate, Egypt. Background ESRD has become a public health concern worldwide as the total number of ESRD patients requiring renal replacement therapy has been growing dramatically. The main problem in developing countries is the lack and inaccuracy of data registry. Patients and methods This descriptive study had been done in the El-Sharkia governorate central governmental hospitals on adult patients' resident in the El-Sharkia governorate with ESRD on maintenance HD for more than or equal to 3 months. The study was done during the period from February 2017 to November 2017. Results The prevalence of ESRD patients on maintenance HD in the Sharkia governorate is 442 per million populations (pmp). The etiology of the studied ESRD patients: hypertension (30.1%), undetermined etiology (19.5%), diabetes mellitus (17.6%), recurrent urinary stone (10.3%), recurrent urinary tract infection (8.5%), analgesic nephropathy (4.3%), chronic glomerulonephritis (4.1%), autosomal dominant polycystic kidney disease (2.9%), systemic lupus erythematosus (1.5%), and gout (1.1%). Of the studied ESRD patients, 44.7% had positive antibodies for hepatitis C virus (+ve) and patients with hepatitis B virus surface antigen (+ve) were 2.2%. Conclusion The total prevalence of ESRD patients on maintenance HD in 2017 in Sharkia governorate, Egypt is 442 per million populations (0.0442%). The highest proportion of patients with ESRD was between 50 and 59 years (30.8%). Most of the ESRD patients were from the rural area (60.4%).

Systemic lupus erythematosus diagnosis impacts clinical outcomes of arteriovenous fistulas in comparison to other end-stage renal disease etiologies.

Arteriovenous fistulas primary patency at one-year occurs in 43-85% of the patients with end-stage renal disease. The diagnosis attributable to end-stage renal disease has been suggested to impact arteriovenous fistulas outcomes. The objective was to compare primary patency at one week, 1, 3, 6, and 12 months of follow-ups, among systemic lupus erythematosus patients and two control groups; additionally, we evaluated the impact of systemic lupus erythematosus to predict early patency loss. A retrospective review of charts from arteriovenous fistulas created between 2008 and 2017 was performed. One-hundred thirty-four patients were identified and classified according to end-stage renal disease attributable diagnosis as: systemic lupus erythematosus cases (N = 14), control-group-1 (91 patients with primarily diabetes and hypertension), and control-group-2 (29 patients with idiopathic end-stage renal disease). A case-control matched design (1:2:1) was proposed. Logistic regression analysis and Kaplan-Meier curves were used. Institutional Review Board approval was obtained. More systemic lupus erythematosus patients lost primary patency at 3 (28.6%) and 12 months (71.4%) than patients from control-groups-1 (vs. 3.6% and 35.7%, respectively) and -2 (vs. 0% and 14.3%, respectively), (p ≤ 0.011 for both). Days of primary patency survival were shorter in systemic lupus erythematosus patients (p = 0.003). Systemic lupus erythematosus diagnosis was the only factor associated with early patency loss, HR: 3.141, 95%CI: 1.161-8.493 (systemic lupus erythematosus diagnosis vs. control-group-1) and HR: 12.582, 95%CI: 1.582-100.035 (systemic lupus erythematosus diagnosis vs. control-group-2). Diagnosis attributable to end-stage renal disease has a major impact on arteriovenous fistula outcomes in patients. Systemic lupus erythematosus patients have an increased risk of arteriovenous fistulas patency loss within the first six months of follow-up. Patients with idiopathic end-stage renal disease had an excellent one year arteriovenous fistula patency survival.

P1497INCIDSENCE OF CANCER IN HEMODIALYSIS-TREATED PATIENTS

Abstract Background and Aims In recent decades, there has been an increase in the incidence and prevalence of patients with end stage renal disease (ESRD) worldwide. Previous studies have shown an increased incidence of malignancies among ESRD patients, compared to age-matched controls, although it was unclear whether different etiologies of ESRD ( diabetes, hypertension, cystic disease) confer different risk ratio. Our present study intends to re-examine relationships between ESRD, classified according to the etiology of renal disease, cancer incidence and types of malignancies in hemodialysis treated patients. Method We conducted a retrospective study, analyzing hemodialysis (HD) treated patients over the age of 18 at the Wolfson Medical Center in Holon, Israel, from 2008-2017. Patients diagnosed with cancer prior to dialysis or with history of transplantation were excluded. Data on etiology of chronic kidney disease and ESRD, comorbidities and cancer diagnosis was collected from patients' files and verified using the Israeli National Cancer Registry. A single, multivariate survival analysis was conducted to examine the relationship between the various predictors and the incidence of cancer. Results The study included 333 patients, 211 (63.4%) were males, mean age 67.2±13.1 years. The median follow was 4 years (95% CI: 2-6.5). Twenty eight (8.4%), developed primary malignancy during hemodialysis, annual rate: 2.1%, Vs 0.35% age-adjusted annual rate in Israeli general population. The average age of all patients diagnosed with cancer over the study period was higher than that of patients without cancer (72.3±7.7 Vs 66.7±13.4 years. P=0.001). The most common sites of malignancy were colon (33%), bladder (16.7%), kidney (10%) and prostate (10%). Older age was the only risk factor associated with the onset of malignancy. No statistically significant relationship was found between ESRD etiology, comorbidities and occurrence of malignancy. Conclusion Among our cohort of patients on chronic hemodialysis, annual cancer incidence rate is 6 times higher than age matched controls in the Israeli general population. Older age is a risk factor associated with onset of malignancy. We did not found associations between ESRD etiology, comorbidities and cancer incidence. This study constitutes a platform for a longer period multicenter study.

Alpha1-Antitrypsin in Urinary Extracellular Vesicles: A Potential Biomarker of Diabetic Kidney Disease Prior to Microalbuminuria.

PurposeDiabetic kidney disease (DKD), which is related to inflammation and immune response, is the primary vascular complication of diabetes mellitus and also the leading etiology of end-stage renal disease. Urinary extracellular vesicles (UEVs) are an attractive source for biomarker detection as they involve molecular constituents derived from their parental sections of the nephron. In this study, we aimed to search for a potential biomarker in UEVs for the early diagnosis and prediction of DKD, especially before the emergence of microalbuminuria.Patients and MethodsUEVs were isolated from the urine of healthy subjects, pre-diabetic, and diabetic patients with varying degrees of kidney damage by ultracentrifugation, and the extracted UEVs were used to measure alpha1-antitrypsin (α1-AT) by Western blot. To explore the function of α1-AT in the inflammatory process leading to DKD, we silenced the expression of α1-AT in renal tubular epithelial cells using cell transfection techniques to assess the differential expression of the inflammatory factors such as MCP-1 and TNF-α using qRT-PCR.ResultsThere was no expression of α1-AT in the UEVs of either healthy or pre-diabetic subjects. Its expression was significantly increased in the UEVs of diabetic patients with normoalbuminuria (prior to microalbuminuria), which was more sensitive and more stable than other renal indexes to predict DKD. Additionally, the expression of α1-AT in UEVs was gradually upregulated with the aggravation of DKD and the decline of renal function. In vitro, the mRNA expression of MCP-1 and TNF-α was significantly decreased when the generation of α1-AT in tubular epithelial cells was inhibited under high glucose stimulation.ConclusionOur results suggest that α1-AT derived from UEVs, especially in diabetic patients with normoalbuminuria, might serve as a potential noninvasive biomarker for diagnosis of DKD early in the development of the disease and may predict the future decline of renal function.

The necessity of voiding cystourethrogram for the evaluation of recipient candidates in adult renal transplantation

Objective . While international guidelines necessitate Voiding Cystourethrogram (VCUG) for pediatric patients, it is unnecessary for the evaluation of adult patients without urological disorders as renal transplant candidates. The objective of this study was to evaluate the results of adult candidates who underwent VCUG before transplantation and to demonstrate the necessity for this imaging. Methods . A retrospective study of the data of 1265 adult candidates who underwent VCUG before transplantation at our center, was undertaken. VUR, the presence of Postvoiding residual urine (PVR) (>100 ml), Low bladder capacity (LBC) (<100 ml), and urethral pathologies were evaluated with VCUG. Results . The mean age was 42.3 ± 1.3. The mean dialysis period was 27.8 ± 4.2 months. According to the VCUG results, 19.2% of the patients had pathological findings. On the other hand, the rate of urological disorders was only 5.1%, according to end-stage renal disease (ESRD) etiologies. VCUG outcomes indicated bilateral high-grade reflux in native kidneys in 4.4% (n = 56) of the candidates, unilateral high-grade reflux in 4.1% (n = 52), bilateral low grade reflux in 2.1% (n = 26), unilateral low-grade reflux in 2.4% (n = 30), and reflux in rejected transplanted kidney in 2.3% (n = 29). In addition, significant LBC was noted in 4.8% (n = 61), significant PVR in 1.1% (n = 14), and urethral stricture in 0.5% (n = 6) of the candidates. Conclusion . VCUG should be considered as a part of routine evaluation in adult renal transplant recipient candidates as well as in pediatric candidates, even if their ESRD etiologies are not due to urological disorders.

The efficacy of percutaneous transluminal angioplasty for the endovascular management of arteriovenous fistula dysfunction: a retrospective analysis in patients with end-stage renal disease.

To evaluate efficacy of percutaneous transluminal angioplasty (PTA) for the endovascular management of arteriovenous fistula (AVF) dysfunction in patients with end-stage renal disease (ESRD). A total of 135 consecutive patients with ESRD (mean±SD age: 58.8±9.4 years, 74.8% were males) who underwent endovascular treatment for a dysfunctional native AVF were included in this retrospective single-center study. Data on patient demographics, etiology of ESRD, characteristics of AVF, stenotic segments, PTA parameters and postoperative recurrence and patency rates within the 12 months were recorded. Technical and clinical success rates of PTA were 100.0% and 97.0%, respectively. Dysfunction recurrence rate was 30.4%. In patients with vs. without presence of recurrent AVF dysfunction, there was higher percentage of males (P=0.030), older age (P=0.018), diabetic or hypertensive rather than polycystic etiology (P<0.001), younger AVF (P<0.001), longer-segment stenosis (P=0.019) and lower median number (P=0.038) of stenotic segments. Presence of hypertension (OR 12.23, 95% CI: 4.29 to 34.85, P<0.001) and age of the AVF (OR 1.04, 95% CI: 1.00 to 1.08, P=0.029) were significant determinants of increased risk of recurrent AVF dysfunction. Our findings emphasize favorable safety and efficacy of PTA in the management of dysfunctional hemodialysis AVFs in terms of high technical and clinical success and low rates of residual stenosis, complications and post-PTA recurrence of AVF dysfunction. Male gender, older patient age, younger AVF and longer-segment stenosis were associated with higher likelihood of AVF failure, whereas hypertension and age of AVF were the two significant determinants of increased risk of post-PTA recurrence of AVF dysfunction.

Pulmonary hypertension in patients with end stage renal disease undergoing hemodialysis.

Pulmonary hypertension (PH) is a serious cardiovascular complication in patients with end stage renal disease (ESRD) undergoing hemodialysis (HD) via arterio-venous fistulas (AVF). The aim of this study was to assess pulmonary vascular resistance (PVR), AVF flow volume (AVF-FV) and cardiac output (CO) and to highlight the impact of their augmentation, as well as of the duration of HD, on the occurrence of PH in patients with ESRD. Our study group consisted of 51 dialyzed patients, with ESRD, without history of PH. We determined by ultrasonography the systolic pulmonary arterial pressure (PAPs), the left ventricular ejection fraction (EF), the cardiac output (CO), PVR and AVF-FV. We documented PH in 27 (52.94%) patients. All had elevated PVR, higher AVF-FV and CO comparing to patients without PH. They were undergoing HD for a longer period and had lower EF than those without PH. For all patients, we documented strong correlations between PAPs and PVR (r = 0.933, P < 0.001) and the duration of HD (r = 0.702, P < 0.001), but moderate ones with AVF-FV (r = 0.583, P < 0.001) and CO (r = 0.519, P < 0.001). In patients with ESRD undergoing HD, PH was a common finding being associated with increased PVR, a longer duration of HD and chronic glomerulonephritis as etiology for ESRD. The majority of patients with PH had altered left ventricular systolic function, predisposing them to an increased risk to develop heart failure.