Initial Creatinine Research Articles

P050 Influence factors in mortality of COVID-19 pateints with underlying rheumatological disorders

Background/Aims Since the outbreak and rapid spread of COVID-19, rheumatologists have sought to provide the best solutions to provide proper shielding of patients vulnerable to COVID-19. Set aside from social distancing and self-isolating, the British Society for Rheumatology proposed pragmatic guidance for different groups of patients for shielding. Clinical presentation, epidemiology, and potential treatment opinions of the management of COVID-19 patients with rheumatic disease had been reported, but a few reports which show a comparison between survivors and non-survivors in relation to their co-morbidities. Methods We collected data from a search identifying 1,200 patients testing positive for SARS-COV-2 with an identified rheumatological condition until 31st April 2020 at Imperial College NHS Trust. A positive laboratory finding is defined as one or more positive result for SARS-COV-2 PCR on nasopharyngeal swab done for inpatients. Results Among 1,200 patients, 39 patients had underlying rheumatological diseases.12 patients died, and 27 patients were discharged. 50% of the patients who died had chronic kidney disease as an existing comorbidity (OR 26, 95%CI ( 2.6-258.1), p value 0.001) compared with only 3% of patients who survived. All the patients with heart failure in this sample died in hospital (33%, OR 29, 95%CI (1.4-597.4, p value 0.006). Regarding drug therapy, 50% of patients who died were receiving more than one immunosuppressant compared with 37% of those who survived. There was a significant association linking non-survivors with a high CRP value (54% , OR 25.2, 95% CI ( 2.44-258.2), p value 0.009) compared with only 4.5% in patients who survived. 70% of patients who died had d-dimer of (>2000ng/ml) compared with 16% of those who survived (OR 11.6, 95% CI ( 1.86-73.06), p value 0.011). Creatinine level also had a significant link with non-survival. 58% patients who died had an initial creatinine (>140umol/l) compared with 18% of survivors (p value 0.0232). Additionally the patients with an elevated creatinine prior to deterioration (which is an indication of acute kidney injury) represented 32% of the total sample and of those, 66% did not survive compared with 13% who did (p value 0.007).We also reviewed the medication adjustment according to NICE guideline. In our study, it was observed that medications were properly adjusted after discussion with rheumatologist. Conclusion Patients with chronic kidney disease and cardiovascular disease should be strictly shielded as a same priority as patient who are taking high dose of immunosuppressive therapy. Follow-up could only be considered for remote consultation in virtual clinic apart from severity of sickness that require for hospital admission. I believe many questions remain for the rheumatology society: How will we continue better rheumatology service during and beyond the pandemic? How particularly important to shield the high-risk patients by widespread adoption of the virtual clinic? Disclosure W.W. Soe: None. F. Hassan: None. W. Phyu: None.

A Uremic Goat Model Created by Subtotal Renal Artery Embolization and Gentamicin.

Simple SummaryTo improve the treatment of patients with kidney disease, new renal replacement therapies are being developed. Prior to their use in humans with end-stage kidney disease (ESKD), these therapies need to be tested in animals with kidney disease. Goats seem particularly suitable because they are docile, have bodyweights comparable to humans and easily accessible neck veins to obtain blood access and tolerate frequent blood sampling, allowing for repeated monitoring. To obtain high blood concentrations of waste solutes that accumulate in patients with kidney disease and allow for the evaluation of solute removal by the new renal replacement therapies, we established kidney failure in five goats by partially blocking the blood supply of the kidneys via radiographic embolization. This resulted in stable moderate kidney disease. The administration of high-dose gentamicin caused a temporary further decline in kidney function. Although the response varied with animal, blood concentrations of waste solutes were representative of those found in ESKD patients. These animals can survive for more than ten months in good condition, allowing for the repetitive testing of new therapies in one animal, and therefore limiting the use of laboratory animals.A large animal model of (end-stage) kidney disease (ESKD) is needed for the preclinical testing of novel renal replacement therapies. This study aimed to create stable uremia via subtotal renal artery embolization in goats and induce a temporary further decline in kidney function by administration of gentamicin. Renal artery embolization was performed in five Dutch white goats by infusing polyvinyl alcohol particles in branches of the renal artery, aiming for the embolization of ~80% of one kidney and complete embolization of the contralateral kidney. Gentamicin was administered to temporarily further increase the plasma concentrations of uremic toxins. After initial acute kidney injury, urea and creatinine plasma concentrations stabilized 1.5 ± 0.7 months post-embolization and remained elevated (12 ± 1.4 vs. 5.6 ± 0.8 mmol/L and 174 ± 45 vs. 65 ± 5.6 µmol/L, resp.) during follow-up (16 ± 6 months). Gentamicin induced temporary acute-on-chronic kidney injury with a variable increase in plasma concentrations of small solutes (urea 29 ± 15 mmol/L, creatinine 841 ± 584 µmol/L, phosphate 2.2 ± 0.3 mmol/L and potassium 5.0 ± 0.6 mmol/L) and protein-bound uremic toxins representative of patients with ESKD. A uremic goat model characterized by stable moderate uremia was established via subtotal renal artery embolization with the induction of temporary severe acute-on-chronic kidney injury by the administration of gentamicin, allowing preclinical in vivo validation of novel renal replacement technologies.

Chronic kidney disease progression in aged patients.

Chronic kidney disease (CKD) is a major morbidity, and its prevalence increases with age. However, there appears to be some confusion about the prognosis of CKD in aged patients, because, it has its own characteristics different from youngers. In this study, we investigated the progression of CKD and related factors in aged patients. This was a retrospective study including 334 patients over 80years of age that were diagnosed with stage 3-4 CKD at our CKD clinic. CKD progression was assessed as an annual decline in the estimated glomerular filtration rate (eGFR). Comorbidities were globally categorized with the Charlson comorbidity index (CCI), but diabetes mellitus, hypertension, and cardiac morbidities were evaluated separately. Patients were grouped as either 'progression to end-stage renal disease (ESRD)' or 'others'. During the follow-up period, 191 (57.2%) patients exhibited progression; the annual median eGFR declined by 0.8ml/min/1.73m2. Only 27 (8.1%) of these patients progressed to ESRD. In univariant and multivariate models, respectively, progressing to ESRD was significantly associated with cardiac comorbidities (p < 0.001, p < 0.001), proteinuria (p < 0.001, p = 0.03), and the baseline eGFR value (p < 0.001, p < 0.001). In aged patients, CKD progressed slowly, but particularly high initial creatinine levels and proteinuria could be indicator of progression. In addition, cardiac comorbidities may facilitate progression to ESRD.

Predictors of graft outcome in renal transplant recipients with antibody-mediated rejection

Abstract. Active and chronic antibody-mediated rejection (ABMR) is a common cause of graft failure. Prognostic markers of this complication are not well defined. We aimed to find out the demographic, histopathological and clinical characteristics of transplant recipients who developed ABMR and evaluate the impact of these features, and anti-rejection treatment modalities on graft survival. &#x0D; Methods. Thirty-two patients who developed ABMR (22 male; mean age 40.59±12.52 years) were included in this study. Data were evaluated retrospectively and graft survival was analyzed. All transplant biopsies were evaluated according to Banff's 2013 classification.&#x0D; Results. Among the 32 cases, 26 were transplanted from living donors. Mean serum creatinine at the time of biopsy was 1.99 ±0.09 mg/dL. Proteinuria was 1566.06±353.92 mg/day at the time of biopsy. The need for hemodialysis was significantly related with initial creatinine (p = 0.003); creatinine after three months (p &lt; 0.001) and final creatinine (p &lt; 0.001) as well as initial proteinuria (p = 0.005); proteinuria after three months (p &lt; 0.001) and final proteinuria (p &lt; 0.001). 6 cases showed diffuse C4d positivity, 26 cases showed focal c4d positivity. Five of 6 patients with diffuse C4d staining in renal biopsy were hemodialyzed at first and third months despite anti-rejection therapy (p=0.029 and 0.041, respectively).&#x0D; Mean survival time was 1654.67±220.40 (95% CI 1222.68-2086.66) days for focal staining C4d cases and 366.16±36.44 (95% CI 294.73-437.60) days for diffuse staining C4d cases. The difference was statistically significant (p=0.012). Two of the patients died, 15 experienced graft loss and 17 survived with functioning grafts. Mean survival time between anti-rejection treatment modalities showed no statistical significance (p=0.15)&#x0D; Conclusions. Serum creatinine, proteinuria at the time of biopsy, diffuse peritubular C4d staining were significantly associated with graft survival. Early diagnosis is important to improve success in the treatment of ABMR and graft survival

INITIAL SERUM CREATININE AND NADIR CREATININE – PROGNOSTIC MARKERS FOR RENAL OUTCOME IN PATIENTS WITH PUV

Objective: This study aims to analyze the correlation between the initial creatinine and the nadir creatinine values and the risk of chronic kidney disease in patients with posterior urethral valves. Materials and methods: The medical records of all patients with PUV treated in the surgery department of The Emergency Children’s Hospital “Marie Curie” between January 2007 – January 2020 were analyzed. The age at presentation, serum creatinine, nadir creatinine, and glomerular filtration rate were noted. The patients were divided in three groups based on the marker values. Results: 77 patients were studied. The high-risk group (13%) was represented by patients with initial creatinine and nadir creatinine &gt;0.85 mg/dL, with 100% progression to CKD. The low-risk group (33%) showed a very low development of renal insufficiency for values of &lt;0.4 mg/dL.

Role of Preoperative Ureteric Stenting in Optimization of Patients with Retroperitoneal Tumors Associated with Obstructive Uropathy.

Retroperitoneal tumors can cause ureteric obstruction leading to obstructive uropathy. Early preoperative ureteric stenting helps to improve renal function and also helps in identifying ureters and prevent ureteric injury during surgery. This study was aimed at assessing the outcome of preoperative stenting in optimizing such patients. A total of 24 cases were enrolled. Of these, 15 patients who had obstructive uropathy were taken for ureteric stenting preoperatively and other 9 patients have undergone surgery without stenting. Twelve patients were stented successfully but 3 patients could not be stented (underwent percutaneous nephrostomy). All 24 patients underwent laparotomy, and of the 12 stented patients, 11 underwent successful resection and one had unresectable tumor. The patient's serum creatinine was assessed initially and then twice after stenting (48h and 5days). Serum creatinine was also estimated 24h after excision of the tumor. In the successfully stented and operated patients, mean initial creatinine was 7.85. The mean creatinine at 48h and 5days after stenting was 4.29 and 1.19 respectively. The mean creatinine 24h after resection of the tumor was 1.04. Of the non-stented patients, 3 had ureteric injury during surgery. We conclude that preoperative ureteric stenting is helpful for optimization of patients with retroperitoneal tumors with obstructive uropathy.

High terminal creatinine donors should not preclude simultaneous kidney and pancreas transplantation

BackgroundSimultaneous pancreas and kidney transplantation (SPK) in the setting of end-stage renal disease offers unmatched outcomes in insulin dependent diabetic patients. Donor pool expansion through the transplantation of kidneys with acute kidney injury (AKI) is controversial. Methods59 SPK transplants were classified by presence of donor AKI, defined as donor terminal creatinine ≥ 1.5x the initial creatinine or donor terminal creatinine > 4.0 mg/dL. Endpoints included graft and patient survival, delayed graft function (DGF), serum creatinine, glomerular filtration rate (GFR), Hemoglobin A1c (HbA1c) and acute rejection. ResultsThe donor AKI group (n = 35) had significantly higher rates of DGF (38 v. 9%, p = 0.01). There was no difference in creatinine or GFR at 1, 3, 6 and 12 months. HbA1c was comparable at 3, 6 and 12 months. There was no significant difference in the percentage of patients that required anti-diabetic agents after transplant (14 v. 4%, p = 0.56). ConclusionsWe observed increased rates of DGF in SPK recipients with donor AKI. However, equivalent outcomes of pancreas and kidney function in both groups were observed.

Risk Factors Associated with Chronic Kidney Disease in Infants With Posterior Urethral Valve: A Single Center Study of 110 Patients Managed By Valve Ablation And Bladder Neck Incision.

Concurrent valve ablation and bladder neck incision is suggested as an effective and safe treatment approach in posterior urethral valve children with prominent bladder neck. We evaluated chronic kidney disease risk factors in these children. We retrospectively reviewed medical records of children with posterior urethral valve and included those younger than 18 years old who underwent valve ablation and bladder neck incision at our institution. We recorded patient demographics, presenting symptoms, laboratory and radiographic data. Our primary outcome was chronic kidney disease defined as stage 3 chronic kidney disease or higher. Renal outcome risk factors such as preoperative vesicoureteral reflux and serum creatinine, age at diagnosis, adjuvant urinary diversion were analyzed. A total of 110 patients met our inclusion criteria. Median age at diagnosis was 10.4 months (range 14 days to 12 years). Prenatal diagnosis in 72.7% was the most common presentation. Mean follow-up duration was 3 years and 12(10.9%) patients progressed to chronic kidney disease. Preoperative serum creatinine greater than one mg/dL was the only factor associated with progression to chronic kidney disease. In our group of children with posterior urethral valve ablation and bladder neck incision, initial creatinine value of greater than one mg/dL is more probably associated with renal impairment while; vesicoureteral reflux, age at diagnosis, presenting symptoms and adjuvant urinary diversion were not significant prognostic factors. Further randomized controlled evaluations are required to analyze the effects of concurrent valve ablation and bladder neck incision on renal outcome.

Vascular inflow after renal transplantation: Does the arteriotomy technique impact early allograft perfusion and function?

There are two main techniques for arterial reconstruction in RT: TA using a stab longitudinal incision which creates an elliptical opening and AP which fashions a circular defect. We hypothesized that AP creates a natural anastomosis lumen, similar to the donor renal artery, which optimizes RT perfusion. A retrospective review of a single-institution database was performed between 2000 and 2018. Twenty patients who underwent AP arteriotomy were compared to 40 TA-matched controls. Data were collected on creatinine (preoperative, nadir, and time to nadir), and DUS RI and PSV at 1week, 3months, and 6-12months post-RT. ttNC was shorter in the AP group (5±4 vs 12±13days; P=.03). PSV at 1week was lower in the AP group (186±65cm/s vs 232±89cm/s; P=.04). There was no difference in nadir creatinine value (P=.26), preoperative creatinine (P=.66), and initial postoperative creatinine (P=.80). RI at week 1 were not different between groups (P=.37). Follow-up DUS showed the difference in PSV between groups became non-significant (1month P=.50 and 6-12months P=.53). AP arteriotomy in RT improves early perfusion and function parameters (ttNC and initial PSV) as compared to TA. AP arteriotomy optimizes early allograft reperfusion, which may have important long-term implications and deserves further evaluation.

Risk of Acute Kidney Injury in Combat-Injured Patients Associated With Concomitant Vancomycin and Extended-Spectrum β-Lactam Antibiotic Use.

Multidrug-resistant infections complicating combat-related trauma necessitate the use of broad-spectrum antimicrobials. Recent literature posits an association between vancomycin (VANC) and piperacillin-tazobactam (VPT) combination therapy and acute kidney injury (AKI). We examined whether therapy with VPT was associated with an increased risk of AKI compared to VANC and other broad-spectrum β-lactam antibiotics (VBL) following combat-related injuries. Patients within the Trauma Infectious Disease Outcomes Study (TIDOS) who received ≥48 hours concomitant VPT or VBL started within 24 hours of each other were assessed. Exclusion criteria were receipt of renal replacement therapy and baseline creatinine >1.5 mg/dL. Acute kidney injury was defined by meeting any of the Risk, Injury, Failure, Loss, End Stage Renal Disease (RIFLE), AKIN, or VANC consensus guidelines criteria 3 to 7 days after therapy initiation. Variables significantly associated with AKI were used in inverse probability treatment weighting to perform univariate and subsequent logistic regression multivariate modeling to determine significant risk factors for AKI. Sixty-one patients who received VPT and 207 who received VBL were included. Both groups had a median age of 24 years and initial median creatinine of 0.7 mg/dL. The VBL patients were more likely to have sustained blast injuries (P = .001) and received nephrotoxic agents (amphotericin [P = .002] and aminoglycosides [P < .001]). In the VBL group, AKI incidence was 9.7% compared to 13.1% in the VPT group (P = .438). Multivariate analysis identified a relative risk of 1.727 (95% CI: 1.027-2.765) for AKI associated with VPT exposure. Acute kidney injury severity generally met RIFLE Risk criteria and was 1 day in duration. Only 1 patient had persistent renal dysfunction 30 days after therapy completion. In this young and previously healthy, severely ill combat-injured population, VPT was associated with nearly twice the risk of AKI compared to VBL. Nevertheless, AKI was of low severity, short duration, and had high rates of renal recovery.

Nefrectomía parcial laparoscópica y asistida por robot en pacientes con tumor renal

Antecedentes: El cáncer renal representa, en México, el 2% de las causas de muerte por cáncer. La nefrectomía parcial se ha adoptado como el tratamiento de elección para tumores renales &lt;4 cm, esta se puede realizar de formas mínimamente invasivas.&#x0D; Objetivo: Reportar las características perioperatorias, oncológicas y seguimiento de pacientes postoperados de nefrectomía parcial laparoscópica y asistida por robot en nuestra institución.&#x0D; Métodos: Se realizó una serie de casos retrospectiva y descriptiva de los pacientes sometidos a nefrectomía parcial mínimamente invasiva, en el Centro Médico Naval de febrero del 2016 a febrero de 2019.&#x0D; Resultados: En dieciséis pacientes se encontró IMC &gt;25 kg/m2, la creatinina inicial fue de 0.97 mg/dl. Tiempo quirúrgico de 202 minutos, el sangrado fue de 300 ml y se realizó isquemia caliente en 13 pacientes con una mediana de 24 minutos. La estancia hospitalaria fue de 3 días, 2 pacientes presentaron complicaciones y la creatinina sérica a los 30 días fue de 1.05 mg/dl. Se encontró cáncer en 17 pacientes, 100% tumor de células claras, grado nuclear de 2 en 13 pacientes y bordes positivos en 3 pacientes.&#x0D; Conclusiones: Reportamos resultados similares a la literatura internacional con buenos resultados oncológicos y funcionales a corto plazo, sin embargo, es difícil compararlo con literatura nacional, debido a la falta de estudios con abordaje robótico.

P0476THE ABSENCE OF REMISSION PREDICTS MORTALITY IN RAPIDLY PROGRESSIVE GLOMERULONEPHRITIS

Abstract Background and Aims Rapidly progressive glomerulonephritis (RPGN) encompasses a group of diseases with a common histology in which the absence of treatment progress to end-stage renal disease. Induction treatment includes the use of immunosuppressants, and in certain cases, plasmapheresis. The final objective of this study was to determine the long-term prognosis of the RPGN. Method A retrospective observational study was conducted, including patients diagnosed with RPGN between 2004 and 2019. Baseline epidemiological data and comorbidities were collected, as well as renal function and treatment at the time of diagnosis. During the follow up [median of 42 (5-101 months)], we analyzed the evolution of renal function, mortality and associated factors. Results Forty-three patients (65% women) were included, with a mean age of 70 ± 16 years. At the time of diagnosis, mean creatinine was 4.8 ± 2.6 mg/dl, proteinuria 1094 ± 856 mg/day and 37 patients (86%) presented hematuria Thirty-one patients (72%) presented positivity for antibodies against the neutrophil cytoplasm, 7 (16%) for antibodies against the glomerular basement membrane and 5 (12%) for both. Regarding the induction treatment, 41 patients received cyclophosphamide and corticoids and two patients received rituximab. Seventeen (31%) plasmapheresis were performed with a median of 7 (6-7 sessions). At 6 months, 55% of the patients presented remission (15 patients complete remission and 8 patients partial remission). The median creatinine was 1.9 (1.2-3.1) mg/dl and the proteinuria was 380 (85 -542) mg/day (p&amp;lt;0.0001 compared to the initial data). At that time, 21% (9) of the patients needed dialysis. Associated factors with the absence of remission were diabetes mellitus (p= 0.016), creatinine at diagnosis (p= 0.002) and the need for hemodialysis at admission (p&amp;lt;0.0001). The only independent predictor of remission was initial creatinine (HR 0.5 [0.3-0.9], p= 0.048). During follow up, renal function improved with a median of creatinine at 18 months of 1.6 (1.2 – 2.9) mg/dl and 1.5 (0.8-2.4) mg/dl at the end. Twelve (28%) patients died during follow up. Associated factors with mortality were age (p=0.02), the need for hemodialysis (p=0.015) and the absence of remission at 6 months (p=0.012) (figure 1). An adjusted model using Cox regression demonstrated that the absence of remission was an independent predictor of mortality (HR 0.2 [0.5-0.8], p= 0.032). Conclusion Initial renal function and 6-month remission predicts mortality in the RPGN.

COVID-19 in kidney transplant recipients.

There is minimal information on coronavirus disease 2019 (COVID‐19) in immunocompromised individuals. We have studied 10 patients treated at 12 adult care hospitals. Ten kidney transplant recipients tested positive for severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) by polymerase chain reaction, and 9 were admitted. The median age was 57 (interquartile range [IQR] 47‐67), 60% were male, 40% Caucasian, and 30% Black/African American. Median time from transplant to COVID‐19 testing was 2822 days (IQR 1272‐4592). The most common symptom was fever, followed by cough, myalgia, chills, and fatigue. The most common chest X‐ray and computed tomography abnormality was multifocal patchy opacities. Three patients had no abnormal findings. Leukopenia was seen in 20% of patients, and allograft function was stable in 50% of patients. Nine patients were on tacrolimus and a mycophenolic antimetabolite, and 70% were on prednisone. Hospitalized patients had their antimetabolite agent stopped. All hospitalized patients received hydroxychloroquine and azithromycin. Three patients died (30%), and 5 (50%) developed acute kidney injury. Kidney transplant recipients infected with COVID‐19 should be monitored closely in the setting of lowered immunosuppression. Most individuals required hospitalization and presenting symptoms were similar to those of nontransplant individuals.

Risk of acute kidney injury after contrast-enhanced computed tomography in emergency department

Background: Despite its risks associated with renal injury, intravenous contrast media increases diagnostic efficacy and hence the chance of early diagnosis and treatment, which leaves clinicians in a dilemma regarding its use in emergency settings. Objective: The aim of this study was to determine the risk and predictors of contrast-induced acute kidney injury following intravenous contrast media administration for computed tomography in the emergency department. Methods: All patients aged 18 years and older who had a basal creatinine measurement within the last 8 h before contrast-enhanced computed tomography and a second creatinine measurement within 48–72 h after computed tomography scan between 1 January 2015 and 31 December 2017 were included in the study. Characteristics of patients with and without contrast-induced acute kidney injury development were compared. Multivariate regression analysis was used to assess the predictors for contrast-induced acute kidney injury. Results: A total of 631 patients were included in the final statistical analysis. After contrast media administration, contrast-induced acute kidney injury developed in 4.9% ( n = 31) of the patients. When the characteristics of patients are compared according to the development of contrast-induced acute kidney injury, significant differences were detected for age, initial creatinine, initial estimated glomerular filtration rate, and all acute illness severity indicators (hypotension, anemia, hypoalbuminemia, and need for intensive care unit admission). A multivariate logistic regression analysis was performed. The need for intensive care unit admission (odds ratio: 6.413 (95% confidence interval: 1.709–24.074)) and hypotension (odds ratio: 5.575 (95% confidence interval: 1.624–19.133)) were the main factors for contrast-induced acute kidney injury development. Conclusion: Our study results revealed that hypotension, need for intensive care, and advanced age were associated with acute kidney injury in patients receiving contrast media. Therefore, we believe that to perform contrast-enhanced computed tomography in emergency department should not be decided only by checking for renal function tests and that these predictors should be taken into consideration.

The Significance of Renal Function in Response to Cardiac Resynchronisation Therapy - A Piece of a Much Larger Puzzle.

Although cardiac resynchronisation therapy (CRT) is an important player in the treatment of patients with heart failure (HF), the proportion of CRT patients with no improvement in either echocardiographic or clinical parameters remains consistently high and accounts for about 30% despite meeting CRT implantation criteria. Furthermore, in patients suffering from HF, renal dysfunction accounts for as many as 30-60%. Accordingly, CRT may improve renal function inducing a systemic haemodynamic benefit leading to increased renal blood flow. The aim of the present study was to evaluate the importance of renal function in response to resynchronisation therapy during a 12-month follow-up period. The study consisted of 46 HF patients qualified for implantation of cardiac resynchronisation therapy defibrillator (CRT-D). A CRT responder is defined as a person without chronic HF exacerbations during observation whose physical efficiency has improved owing to the New York Heart Association (NYHA) class improvement ≥1. A statistically significant difference was noted between responders and non-responders regarding creatinine level at the 3rd month (p=0.04) and, particularly, at the 12th month (p=0.02) of follow-up (100±23 vs 139±78 μmol/l). Moreover, there was a remarkable difference between both study groups with regard to GFR CKD-EPI (glomerular filtration rate (GFR) assessed using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula) at the 6th (p=0.03) and 12th month (p=0.01) of follow-up. The reference values for initial creatinine concentrations (101 μmol/l) as well as GFR CKDEPI (63 ml/min/1.73m2) were empirically evaluated to predict favourable therapeutic CRT response. Predictive value of GFR CKD-EPI and creatinine concentration for a positive response to CRT was found relevant.

P30 A ‘cat’-astrophic case of Bartonella infective endocarditis causing a secondary cryoglobulinemia

Abstract Background A 17-year-old college student presented with a year long history of weight loss and poor appetite. She had a background of pulmonary atresia with a ventricular septal defect, treated with a contegra conduit in childhood. She was initially treated for depression. Subsequently she developed a vasculitic rash on her legs with urinalysis demonstrating haemoproteinuria (urine PCR=116) resulting in renal referral and hospital admission. On examination, the patient had a BMI of 15 and was found to have massive splenomegaly. Methods Her initial creatinine was 128 (eGFR 58), although cystatin C (which accounts for low muscle mass) estimated her eGFR at 16. Renal biopsy showed focal necrotizing glomerulonephritis with no acute tubular necrosis or chronic change. Haematological work up was normal with bone marrow revealing reactive changes. Bloods revealed a weakly positive PR3 antibody and a provisional diagnosis of ANCA associated vasculitis was made for which prednisolone was commenced. A rheumatology review was sought. Review of systems was relevant for intermittent joint pains and ocular dryness. Additional bloods showed a low C4, positive RhF, negative anti-CCP, elevated immunoglobulins (IgG 45) and normal ENA profile. Results The provisional diagnosis was altered to cryoglobulinaemic vasculitis which was confirmed as a Type 3 cryoglobulin. Initial investigations for an infectious cause were negative however an echocardiogram showed vegetations on her conduit and treatment was commenced for endocarditis. Blood cultures were negative. Inflammatory markers failed to settle following two weeks of intravenous antibiotics and accordingly the patient was referred for surgical revision of her conduit. Tissue samples ultimately grew Bartonella and aspergillus species. Antibiotic therapy was altered to doxycycline and anti-fungal therapy whilst steroids were continued. Following completion of antibiotic treatment, she has had resolution of her cryoglobulinaemia, normalization of RhF/C4, creatinine is 58 with no proteinuria and IgG is 13. The diagnosis was therefore confirmed as a Type 3 Cryoglobulinaemia secondary to Bartonella endocarditis +/- fungal infection of conduit. The patient’s mother revealed she had adopted several stray cats in the preceding year which was identified as the likely cause of the Bartonella infection. Conclusion In summary, this is a case of Bartonella endocarditis causing a secondary cryoglobulinemia; the exact mechanisms of this is not fully understood but is thought to be due to B cell hyperactivity. Culture-negative infective endocarditis constitutes approximately 10% of the total number of cases of infective endocarditis. Bartonella endocarditis is one of the most common causes of culture-negative endocarditis and is associated with a high mortality rate. Contact with animals, particularly cats, is a key risk factor. It is, therefore, important to enquire about such exposure especially when culture-negative endocarditis is suspected. Disclosures A. Vivekanantham None. E. McCarthy None.

DYNAMICS OF FUNCTIONAL STATE OF KIDNEYS IN PATIENTS WITH RESISTANT HYPERTENSION AND CHRONIC KIDNEY DISEASE ACCORDING TO LONG-TERM FOLLOW-UP

Resistant hypertension and chronic kidney disease are closely related from a pathogenetic and clinical point of view. To study the dynamics of functional state of kidneys and as well as to identify the predictors of its improvement, 117 patients with resistant hypertension were examined. Dynamic follow−up of patients included monitoring of antihypertensive therapy, blood pressure, biochemical and humoral parameters during 3, 6 and 36 months of treatment. The findings have shown that a significant long−term improvement in blood pressure control in the patients with chronic kidney disease improves their function and also has a nephroprotective effect in patients without any signs of renal damage. The established prognostic value of the higher initial creatinine content for the improvement of renal function in patients with resistant hypertension is stipulated with a positive effect of antihypertensive therapy on the glomerular filtration rate dynamics. The close association between improved renal function and lower baseline levels of interleukin 6 as well as an active renin in the blood may indicate a role for systemic inflammation and renin−angiotensin−aldosterone system activity in the renal dysfunction development. Prolonged improvement in blood pressure control in the patients with resistant hypertension without diabetes is associated with a stable level of urinary albumin excretion, whereas in patients with diabetes, an albuminuria increases over time. The study concluded that independent predictors of improved renal function in patients with resistant hypertension are higher baseline creatinine and lower glomerular filtration rate, lower concentrations of interleukin 6, active renin and plasma potassium. Key words: resistant arterial hypertension, chronic kidney disease, functional state of kidneys, antihypertensive therapy.

Association of Longitudinal Values of Glycated Hemoglobin With Cardiovascular Events in Patients With Type 2 Diabetes and Multivessel Coronary Artery Disease

Glycated hemoglobin (HbA1c) values are used to guide glycemic control, but in patients with type 2 diabetes and multivessel coronary artery disease (CAD), the association of the longitudinal values of HbA1c with cardiovascular outcomes is unclear. To assess whether longitudinal variation of HbA1c is associated with cardiovascular events in long-term follow-up among patients with diabetes and multivessel CAD. This cohort study included 888 patients with type 2 diabetes and multivessel CAD in the Medicine, Angioplasty, or Surgery Study (MASS) Registry of the Heart Institute of the University of São Paulo from January 2003 to December 2007. Data were analyzed from January 15, 2018, to October 15, 2019. Longitudinal HbA1c values. The combined outcome of all-cause mortality, myocardial infarction, and ischemic stroke. Of 888 patients with type 2 diabetes and multivessel CAD, 725 (81.6%; median [range] age, 62.4 [55.7-68.0] years; 467 [64.4%] men) had complete clinical and HbA1c information during a median (interquartile range) follow-up period of 10.0 (8.0-12.3) years, with a mean (SD) of 9.5 (3.8) HbA1c values for each patient. The composite end point of death, myocardial infarction, or ischemic stroke occurred in 262 patients (36.1%). A 1-point increase in the longitudinal value of HbA1c was significantly associated with a 14% higher risk of the combined end point of all-cause mortality, myocardial infarction, and ischemic stroke (hazard ratio, 1.14; 95% CI, 1.04-1.24; P = .002) in the unadjusted analysis. After adjusting for baseline factors (ie, age, sex, 2-vessel or 3-vessel CAD, initial CAD treatments, ejection fraction, and creatinine and low-density lipoprotein cholesterol levels), a 1-point increase in the longitudinal value of HbA1c was associated with a 22% higher risk of the combined end point (hazard ratio, 1.22; 95% CI, 1.12-1.35; P < .001). Longitudinal increase of HbA1c was independently associated with higher rates of cardiovascular events in patients with type 2 diabetes and multivessel CAD.

Machine learning can accurately predict pre-admission baseline hemoglobin and creatinine in intensive care patients

Patients admitted to the intensive care unit frequently have anemia and impaired renal function, but often lack historical blood results to contextualize the acuteness of these findings. Using data available within two hours of ICU admission, we developed machine learning models that accurately (AUC 0.86–0.89) classify an individual patient’s baseline hemoglobin and creatinine levels. Compared to assuming the baseline to be the same as the admission lab value, machine learning performed significantly better at classifying acute kidney injury regardless of initial creatinine value, and significantly better at predicting baseline hemoglobin value in patients with admission hemoglobin of <10 g/dl.

SAT-212 Is Chronic Kidney Disease on the rise in Malaysia? Findings from a nationwide study

CKD represents a significant public health problem because of its associated socio-economic and health consequences. In 2011 the National Health and Morbidity Survey (NHMS) showed a 9.07% prevalence of CKD in West Malaysia. and identified diabetes, hypertension and older age as risk factors. The objective of this population-based study was to determine the trend in prevalence and risk factors of CKD in adults aged >18 years in both East and West Malaysia. A total of 1398 individuals ≥ 18 years old, representative of the adult population in Malaysia was randomly selected using a stratified cluster method. Respondents completed a lifestyle and medical history questionnaire and had blood pressure measured before blood and urine samples were taken. Glomerular filtration rate (eGFR) was estimated from calibrated serum creatinine using the CKD-EPI equation. Urinary albumin and creatinine were tested to assess albuminuria. CKD was defined as eGFR < 60 ml/min/1.73m2 or the presence of persistent albuminuria if eGFR ≥ 60 ml/min/1.73m2. The national CKD prevalence was estimated using complex design analysis where the sampling procedure and the population weight were adjusted for gender and urban/rural residence. Multivariate analysis was used to identify risk factors for CKD. A total of 1,047 individuals (75%) agreed to participate in this study. Of these, 977 respondents had serum creatinine measured. The final analysis set comprised 890 respondents i.e. those with eGFR< 60 ml/min/1.73m2 (N = 65) and those with eGFR ≥ 60 ml/min/1.73m2 who either had an initial negative urine albumin creatinine ratio (ACR) (N = 691) or a repeated sample of urine if the initial urine ACR was positive (N = 134). Mean age of respondents was 48.8 years, 41.1% were males, 19.6% had diabetes and 51% had hypertension. The overall prevalence of CKD was 15.48% (95% CI: 12.30, 19.31). An estimated 3.85% had stage 1 CKD (eGFR > 90 ml/min/1.73m2 and persistent albuminuria), 4.82% had stage 2 (eGFR of 60 – 89 ml/min/1.73m2 and persistent albuminuria), and 6.81% had stage 3 - 5 (eGFR < 60ml/min/1.73 m2). Only 5% of respondents with CKD were aware of their diagnosis. Risk factors for CKD included increasing age (aOR 1.06), Body Mass Index (aOR 1.06), diabetes mellitus (aOR 3.32) and hypertension (aOR 3.72). The prevalence of CKD in Malaysia has increased from 9.07% in 2011 to 15.48% in 2018. The risk factors for CKD are highly prevalent among the Malaysian population and now include Body Mass Index. The National CKD prevention program, adopted into the National Strategic Plan for Non-Communicable Disease in Malaysia in 2018, needs to be successfully implemented to address the rising tide of CKD.