Longer Dialysis Vintage Research Articles

#1956 Effect of hemodialysis modalities on infection-related mortality

Abstract Background and Aims A growing body of evidence have suggested hemodiafiltration (HDF) provide survival benefit for dialysis patients. HDF may improve immune modulation with enhanced clearance of azotemic toxins, compared to high-flux hemodialysis (HD). We therefore assess the effect of dialysis modalities on infection-related mortality in patients treated in real-world settings. Method We conducted a retrospective cohort-study based on 85,117 adult haemodialysis (HD) patients who were treated in EMEA NephroCare Clinics between January 1, 2019 and December 31, 2022. All patients’ data were extracted from the European Clinical Database (EuCliD®), including mortality from any infection, viral infection, and COVID-19 infection. The definition of mortality cause is based on ICD-10 codes. Any infection related mortality includes a broad range of infection disease types, such as viral, bacterial, parasitic, and fungal infections. The associations between dialysis modality and infection-related mortality were analyzed by multivariable Cox regression models, with both dialysis modality and COVID-19 infection as time-dependent covariates. To account for potential impact of difference in patients’ characteristics, we adjusted for multiple confounding factors. Competing risk analyses with death from non-infection as the competing event were performed by cause-specific and Fine-Gray subdistribution hazard models. Results At baseline 45.0% patients were treated with HDF, which changed to 52.6% by the end of follow-up. Of all HDF treatments in post-dilution mode (account for 98.4% HDF treatments) during follow-up, the average convection volume was 25.7 liters (median [interquartile range], 25.8 [23.9–28.0]). Patients treated with HDF at baseline were younger, with less comorbidities and longer dialysis vintage, compared to patients with HD (Table 1). During a median follow-up of 22.6 months, death from any infection occurred among 6.9% patients, of which 40.1% died from COVID-19 infection. Compared to HD, HDF was associated with a reduced risk of dying from any infection (hazard ratio [HR], 0.89 [95% CI, 0.82–0.97]), which however disappeared if excluding death from COVID-19 infection (Table 2). Similar pattern was also observed for death from viral infection. Association of HDF with death from COVID-19 infection persisted after controlling for multiple confounders (HR, 0.81 [95% CI, 0.71–0.93]). Similar results yielded from competing risk analyses. Conclusion In this large, unselected patient population, the beneficial effect of HDF for infection-related mortality was confined to mortality from COVID-19 infection. Further studies are needed to unravel the relation between dialysis modalities and death from different types of infection.

#1692 Prevalence and risk factors for persistent hyperparathyroidism in long-term kidney transplant recipients

Abstract Background and Aims Secondary hyperparathyroidism, associated with fractures and cardiovascular mortality in end-stage kidney disease, often resolves after kidney transplantation (KT). However, limited knowledge exists regarding persistent hyperparathyroidism (persist-PTH) after long-term KT. We aimed to define the prevalence and risk factors of persist-PTH in KT recipients at ≥3 years post-KT. Method A historical cohort study was conducted in adult KT recipients at Srinagarind Hospital, Khon Kaen University, Thailand, from 2015 to 2020. Persist-PTH is defined as serum parathyroid hormone (PTH) exceeding twice the upper limit of normal (>130 pg/mL) after ≥3 years post-KT. Results A total of 281 patients were included, with a median age of 41.4 years (interquartile range (IQR), 32.7-49.1), and 117 patients (41.6%) were female. The median post-KT follow-up was 71 months (IQR, 54-89) with a glomerular filtration rate (GFR) of 61.8 mL/min/1.73 m² (IQR, 48.2-76.9). The respective median pre-KT and post-KT PTH were 403 pg/mL (IQR, 196.3-862) and 96.7 pg/mL (IQR, 67.3-166). Post-KT PTH levels correlated with pre-KT PTH levels (r²=0.18; P<0.001). Persist-PTH occurred in 100 patients, with a prevalence of 35.6% (95% confidence interval (CI), 30.2-41.4%). Multivariate analysis revealed significant associations between persist-PTH and a longer dialysis vintage (odds ratio (OR) 1.13 per 6-month increase; 95% CI, 1.06-1.20; P<0.001), lower GFR (OR, 0.76 per 10 mL/min/1.73 m² increase; 95% CI, 0.63-0.92; P=0.004), and higher pre-KT PTH (HR, 1.06 per 50 pg/mL increase; 95% CI, 1.02-1.10; P=0.001). Furthermore, persist-PTH with hypercalcemia (>10.2 mg/dL) occurred in 44 patients (15.7%; 95% CI, 11.8-20.4%), and with hypophosphatemia (<2.5 mg/dL) in 23 patients (8.2%; 95% CI, 5.5-12.0%). Conclusion Persist-PTH occurred in over one-third of long-term post-KT recipients, particularly in those with extended dialysis vintage, impaired graft function, and elevated pre-KT PTH levels. This underscores the need for optimal pre-KT PTH control and vigilant graft function monitoring to prevent persist-PTH.

Sarcopenia, an overlooked diagnosis inkidney transplant recipients.

Most studies of sarcopenia in renal transplant recipients (RTRs) have been hampered by a lack of standardization in the definitions of sarcopenia. In this study, we aimed to investigate the prevalence of sarcopenia and the associated factors in RTRs using the recently proposed criteria of the European Working Group on Sarcopenia in Older People 2018 (EWGSOP2), which included a standardized definition of sarcopenia. We examined 93 consecutive adult RTRs, 46 chronic kidney disease patients, and 46 healthy controls. We assessed the muscle strength with a hand grip test using a dynamometer and with a chair stand test. We used bioimpedance analysis to estimate appendicular skeletal mass using the Sergi formula. Finally, we conducted a 2-minute walking test to assess endurance. Sarcopenia and probable sarcopenia were determined according to the revised criteria of the EWGSOP2. Probable sarcopenia was found in 29 RTR patients (31.2%), of them 14 (15.1%) were diagnosed with sarcopenia. Multivariate logistic regression analysis showed that presence of diabetes mellitus, increased uric acid level, and statin use were risk factors for probable sarcopenia. On the other hand, longer dialysis vintage was a risk factor for sarcopenia in RTRs. We found that probable sarcopenia and sarcopenia were highly prevalent in our relatively young RTRs. We recommend active screening for the presence of sarcopenia in RTRs, especially in the cadaveric ones. Furthermore, caution seems warranted regarding the myopathic side effects in RTRs who use statins.

Alkaline Phosphatase and Parathyroid Hormone Levels: International Variation and Associations With Clinical Outcomes in the DOPPS

BackgroundSecondary hyperparathyroidism increases the risk of fractures and cardiovascular (CV) disease in hemodialysis (HD) patients. The relationship between parathyroid hormone (PTH) and outcomes has been inconsistent, possibly due to variable bone responsiveness to PTH. The KDIGO guideline suggests monitoring total alkaline phosphatase (ALP), but the role of ALP versus PTH in the management of mineral and bone disorder is not clear. MethodsThe analysis included 28,888 HD patients in 9 countries in DOPPS phase 3-7 (2005-2021). The primary exposures of interest were normalized ALP and PTH – raw values divided by facility upper normal limit – measured at study enrollment. Cox models were used to estimate hazard ratios of all-cause/CV mortality and any/hip fracture adjusted for potential confounders. Linear mixed models, adjusted for potential confounders, were employed to investigate the relationship between normalized ALP levels and patient characteristics. ResultsNormalized PTH showed a J-shaped association with all-cause/CV mortality, and a weak linear association with fracture. In contrast, normalized ALP showed a strong association with all outcomes. Factors associated with higher ALP levels after controlling for PTH included Black race, longer dialysis vintage, diabetes mellitus, hypocalcemia, hypophosphatemia, elevated C-reactive protein, and the use of cinacalcet. ConclusionsTotal ALP is a more robust exposure of adverse outcomes than PTH in HD patients. PTH responsiveness is affected by race, primary renal disease, comorbidities, and mineral metabolism and therapy. Our results indicate that it may be useful to evaluate target organ response, rather than PTH alone when considering the consequences of secondary hyperparathyroidism.

The association between blood nickel level and handgrip strength in patients undergoing maintenance hemodialysis

BackgroundProgressive loss of peripheral muscle strength is highly pronounced in patients receiving maintenance hemodialysis (MHD), of which the pathological mechanism tends to be multifactorial. Plasma nickel was reportedly correlated with muscular strength in non-dialysis patients. However, scarce is known regarding the association between blood nickel level and handgrip strength among the patients undergoing MHD.MethodsThis cross-sectional study included patients undergoing MHD at our center in October 2021. Blood samples were collected before the hemodialysis sessions. Nickel level was measured using inductively coupled plasma mass spectrometry. Eligible patients were stratified into three groups by the blood nickel level: tertile 1 (≥ 5.2 ug/L); tertile 2 (< 5.2 ug/L and ≥ 4.5 ug/L); and tertile 3 (< 4.5 ug/L). Handgrip strength measurement was used to evaluate the muscle status. Spearman’s analyses and multivariable linear regression analyses were performed to study the relationship between blood nickel level and handgrip strength.ResultsA total of 236 patients were enrolled, with an average age of 55.51 ± 14.27 years and a median dialysis vintage of 83 (IQR: 48–125) months. Patients in group with a higher blood nickel level (tertile 1) tended to be female, had longer dialysis vintage and higher Kt/V, but lower BMI, serum creatinine, hemoglobin, and handgrip strength level (all p < 0.05). After adjustment for confounding factors in multivariable models, for every 1ug/L increase in nickel level, the patient’s handgrip strength decreases by 2.81 kg (β: − 2.810, 95% confidence interval: − 5.036 to − 0.584, p = 0.014). Restricted cubic spline confirmed the relationship was nearly linear.ConclusionsOur study highlighted that blood nickel level was related to handgrip strength in patients undergoing MHD. Prospective studies with larger sample sizes are still needed to confirm the result.

The ability of phase angle and body composition to predict risk of death in maintenance hemodialysis patients

ObjectiveThe objective of this study was to investigate the ability of phase angle and body composition to identify risk factors for mortality among patients receiving maintenance hemodialysis (MHD) treatment.MethodsIn this retrospective study, we examined the causes of death in 43 MHD patients who were treated at our hemodialysis center between January 2016 and December 2021 and compared the patients to 71 patients who survived during the same period. Body composition was measured using direct segmental multi-frequency bioelectrical impedance to obtain phase angle, fat-free mass (FFM), extracellular water/total body water (ECW/TBW), and waist circumference (WC). Laboratory data were also collected. Phase angle cut-off value-associated variables were identified using ROC analysis. The ability of body composition variables to identify risk factors for death in MHD patients was evaluated.ResultsWe found that cardiovascular disease was the most common cause of death among MHD patients. ROC curve analysis revealed that the optimal cut-off value for phase angle as a predictor of death risk in MHD patients was 4.50°. Additionally, lower phase angle, increased age, longer dialysis vintage, lower KT/V, and hypoproteinemia were identified as significant risk factors for death in MHD patients.ConclusionIn conclusion, our findings suggest that cardiovascular disease is the leading cause of death among MHD patients and that lower phase angle, increased age, longer dialysis duration, and hypoproteinemia can be used to predict the risk of mortality in this patient population. The underlying mechanism by which lower phase angle can be used to predict the prognosis of MHD patients warrants further investigation.

#5999 GRADES II-III INTRA-ABDOMINAL HYPERTENSION INCREASE THE RISK OF GRAFT LOSS OR DEATH AFTER KIDNEY TRANSPLANTATION

Abstract Background and Aims Intra-abdominal hypertension (IAH) is common among post-surgical, critically ill and kidney transplant patients, and is associated with acute kidney injury and increased morbidity and mortality. We aimed to describe the medium-term effect of IAH on graft and patient survival after deceased-donor kidney transplantation. Method 192 consecutive patients who received a cadaveric renal allograft transplant at our hospital were included in this study. IAP was measured every 8h for at least the first 72h after surgery using the urinary bladder technique, and an average value was obtained. Patients were followed up for 24 months or until a composite outcome (defined as graft loss or recipient death) occurred. Clinical, anthropometric, and analytical data was extracted from our hospital's database. Statistical analysis was performed using IBM SPSS Statistics 22. The study was approved by the local ethics committee. Results 192 patients were included. Relevant clinical and anthropometric data are summarized in Table 1. Patients with grades II or III IAH were more frequently male, had longer dialysis vintage, received more frequently hemodialysis as renal replacement therapy and suffered delayed graft function, graft loss or death more repeatedly. In Kaplan-Meier analysis, grade II IAH or higher were associated with lower composite-outcome free survival (Log-Rank: 8.053; p = 0.018) (Figure 1). Conclusion Grade II-III IAH appear to be a risk factor for graft loss or recipient death in our sample of deceased donor kidney transplant recipients. Monitoring of intra-abdominal hypertension could provide useful information to identify patients at higher risk of post-transplant complications.

#3770 EBV-NEGATIVE KIDNEY TRANSPLANT RECIPIENTS AND PTLD: THE IMPACT OF INDUCTION THERAPY

Abstract Background and Aims Individuals who are most susceptible to developing PTLD are those who are EBV-negative and receive organs from EBV-positive donors (EBV R-/D+). The evidence regarding the connection between ATG induction therapy and PTLD is inconsistent. No studies have specifically examined the relationship between ATG use and PTLD in subgroups of EBV-negative transplant recipients (EBV R-). Using the UNOS database, we studied the association between the use of induction agents and PTLD in EBV R- patients. Method We analyzed data from 2007 to 2022 of EBV R- patients who underwent their first kidney-only transplant and excluded those who received induction agents other than ATG, basiliximab, or alemtuzumab. We used logistic regression to evaluate the association between induction agents and PTLD. Results Of 20,531 recipients, 50.7% received ATG, 19.13% received basiliximab, 13.42% received alemtuzumab, and 16.75% received no induction. The overall PTLD incidence was 2.14%. ATG recipients had higher rates of deceased donor transplants, higher degree of HLA mismatch, longer dialysis vintage, and were less likely to be white, compared to non-ATG recipients. Multivariate analysis showed ATG recipients had a higher risk of PTLD compared to non-ATG (odds ratio = 1.47, p&amp;lt;0.001). After excluding recipients who did not receive induction, ATG remained a significant independent risk factor for PTLD when compared to recipients who received either basiliximab or alemtuzumab (odds ratio = 1.35, p = 0.007). There was no statistically significant difference in PTLD risk among patients treated with basiliximab, alemtuzumab, or no induction (refer to Table 1). Conclusion The use of ATG induction in EBV-negative kidney transplant recipients is associated with a higher risk of PTLD compared to basiliximab, alemtuzumab, and no induction. The risk of PTLD should be considered when choosing induction therapy for this patient population.

Serological Response to SARS-CoV-2 Vaccine in Hemodialyzed Patients and the Association with Later COVID-19 Positivity

Background: The effectiveness of the COVID-19 vaccine may differ in hemodialysis patients. The aim of this prospective multicenter study was to determine the degree of serological response to the SARS-CoV-2 vaccine in the population of dialysis patients and its association with later SARS-CoV-2 infections. Methods: A blood sample was taken for the determination of COVID-19 serological status (IgG antibodies) in 706 dialysis patients 16 weeks after vaccination with the second dose (Pfizer-BioNTech). Results: Only 314 (44.5%) hemodialyzed patients had a satisfactory response to the COVID-19 vaccine. Eighty-two patients (11.6%) had a borderline response, while 310 patients (43.9%) had an unsatisfactory (negative) post-vaccinal antibody titer. A longer dialysis vintage had an increased odds ratio (OR) of 1.01 for the occurrence of COVID-19 positivity after vaccination. In the group of subsequently positive patients, 28 patients (13.6%) died from complications of COVID-19. We have found differences in mean survival time between patients with and without appropriate responses to vaccination in favor of patients with a satisfactory serological response. Conclusions: The results showed that the dialysis population will not have the same serological response to the vaccine as the general population. The majority of dialysis patients did not develop a severe clinical picture or die at the time of positivity for COVID-19.

Dialysis vintage is associated with a high prevalence and severity of unpleasant symptoms in patients on hemodialysis

Background The burden of physical and emotional symptoms caused by somatic illness is present in most dialysis patients. However, it’s unclear how symptom burden varies among patients with different dialysis vintages. We sought to examine differences in the prevalence and severity of unpleasant symptoms in hemodialysis patients with diverse dialysis vintage cohorts. Methods This cross-sectional study included patients on maintenance hemodialysis at the Second Hospital of Anhui Medical University. We used the Dialysis Symptom Index (DSI) to determine the associated unpleasant symptoms, which is a validated survey to assess symptom burden/severity (higher scores indicate more severe symptoms), over June 2022 – September 2022. Results We studied 146 patients: 35 (24%) had a dialysis vintage of ≤12 months (group 1) and 111 (76%) had a dialysis vintage of >12 months (group 2). Concerning Group 1 patients, the prevalence and severity of unpleasant symptoms were significantly higher in Group 2, the most common individual symptoms included feeling tired or lack of energy and trouble falling asleep (i.e., 75–85% of patients in each group), with dialysis vintage being an independent influencing factor (adjusted OR, 0.19; 95% CI, 0.16 to 0.23). Lower hemoglobin levels, iron stores, and dialysis adequacy levels are correlated with longer dialysis vintage. Conclusion We observed a high prevalence of unpleasant symptoms and symptom clusters in a diverse dialysis vintages hemodialysis cohort. Further studies are needed to accurately and routinely define the symptom burden of chronic patients with chronic kidney disease (CKD).

Kidney Stone Events after Kidney Transplant in the United States.

Kidney stone disease is common and can lead to complications such as AKI, urinary tract obstruction, and urosepsis. In kidney transplant recipients, complications from kidney stone events can also lead to rejection and allograft failure. There is limited information on the incidence of kidney stone events in transplant recipients. We identified 83,535 patients from the United States Renal Data System who received their first kidney transplant between January 1, 2007, and December 31, 2018. We examined the incidence of kidney stone events and identified risk factors associated with a kidney stone event in the first 3 years after transplantation. We found 1436 patients (1.7%) who were diagnosed with a kidney stone in the 3 years after kidney transplant. The unadjusted incidence rate for a kidney stone event was 7.8 per 1000 person-years. The median time from transplant to a kidney stone diagnosis was 0.61 (25%-75% range 0.19-1.46) years. Patients with a history of kidney stones were at greatest risk of a kidney stone event after transplant (hazard ratio [HR], 4.65; 95% confidence interval [CI], 3.82 to 5.65). Other notable risk factors included a diagnosis of gout (HR, 1.53; 95% CI, 1.31 to 1.80), hypertension (HR, 1.29; 95% CI, 1.00 to 1.66), and a dialysis of vintage of ≥9 years (HR, 1.48; 95% CI, 1.18 to 1.86; ref vintage ≤2.5 years). Approximately 2% of kidney transplant recipients were diagnosed with a kidney stone in the 3 years after kidney transplant. Risk factors of a kidney stone event include a history of kidney stones and longer dialysis vintage.

Association of Hyperkalemia and Hypokalemia with Patient Characteristics and Clinical Outcomes in Japanese Hemodialysis (HD) Patients.

This study aimed to examine the characteristics and clinical outcomes of Japanese hemodialysis patients with dyskalemia. A retrospective study was conducted using a large Japanese hospital group database. Outpatients undergoing thrice-a-week maintenance hemodialysis were stratified into hyperkalemia, hypokalemia, and normokalemia groups based on their pre-dialysis serum potassium (sK) levels during the three-month baseline period. Baseline characteristics of the three groups were described and compared for the following outcomes during follow-up: all-cause mortality, all-cause hospitalization, major adverse cardiovascular events (MACE), cardiac arrest, fatal arrythmia, and death related to arrhythmia. The study included 2846 eligible patients, of which 67% were men with a mean age of 65.65 (SD: 12.63) years. When compared with the normokalemia group (n = 1624, 57.06%), patients in the hypokalemia group (n = 313, 11.00%) were older and suffered from malnutrition, whereas patients in the hyperkalemia group (n = 909, 31.94%) had longer dialysis vintage. The hazard ratios for all-cause mortality and MACE in the hypokalemia group were 1.47 (95% confidence interval [CI], 1.13-1.92) and 1.48 (95% CI, 1.17-1.86), respectively, whereas that of death related to arrhythmia in the hyperkalemia group was 3.11 (95% CI, 1.03-9.33). Thus, dyskalemia in maintenance hemodialysis patients was associated with adverse outcomes, suggesting the importance of optimized sK levels.

Handgrip Strength Index: A Novel Parameter Which Quantifies Clinical Weakness in People on Haemodialysis

The muscle strength in people on haemodialysis is associated with nutritional status, quality of life, functional independence, and survival. Handgrip Strength (HGS) is simple to measure, but clinical interpretation is limited by the lack of reference ranges for a haemodialysis population. This study aims to define a novel parameter, HGS index, which quantifies degree of clinical weakness specific to a haemodialysis population and to test if this predicts survival. In a cross-sectional single center study HGS was measured in stable participants on haemodialysis. HGS in the well-nourished subgroup, was used to develop a predictive equation for "expected" HGS according to demographic variables. This then was compared to observed HGS resulting in HGS index (%), an individualized parameter indicating weakness due to clinical variables while accounting for demographic contributors to strength. The association between HGS index and survival was explored in all participants. Among 427 well-nourished individuals on haemodialysis, HGS was strongly associated with demographic variables and predicted in males by the equation: HGS (kg)=0.38∗height (cm) - 0.31∗age (years) - 18, and in females by the equation: HGS (kg)=0.25∗height (cm) - 0.11∗age (years) - 16. Among 547 participants (22% with protein energy wasting), lower HGS index was associated with diabetes (P=.004), lower body mass index (BMI) (P=.005), lower albumin (P=.033), and longer dialysis vintage (P=.007). Over a mean observation period of 2.8years, quintile of HGS index was strongly associated with survival (P=.023), and in a Cox proportional hazards model, the independent predictors of mortality were age, albumin, BMI and HGS index. HGS index, defined as observed relative to expected HGS, is an individualized measure of clinical weakness. It is a novel parameter which independently predicts survival. HGS index improves the detection of clinically relevant muscle weakness in people on haemodialysis, opening up the possibility of earlier, individualized interventions, and improving outcomes in this vulnerable group.

242.8: The Impact of Dialysis Vintage on Cardiovascular Risk Factors And the Findings of Cardiovascular Screening Work Up of Renal Transplant Candidates

Methods: In a single center retrospective chart-review study, we reviewed the outcomes renal transplant recipients who underwent renal transplant from January 2017 to May 2020. We divided the group based on their dialysis vintage, less than 3 years versus more than 3 years. We collected the data about the patients’ demographics, cardiovascular risk factor, dialysis modality, pre-transplant work-up images, and the changes in cardiovascular risk factors in the first post-transplantation year. Results: We included 278 patients, 109 patients in the longer vintage group and 169 patients in the shorter vintage group. The mean age 43.8±16.1 and 164 patients (59%) were male. The mean dialysis vintage in the shorter group was 1± 0.1 year, and 5.7± 2.7 years in the longer vintage group, p <0.001. The most common comorbidities were hypertension (76%), followed by diabetes mellitus (41.7%), and were present in similar proportions of both groups. Compared to the shorter dialysis vintage group, those who had longer dialysis vintage were more likely to have a deceased kidney donor (36.7% vs 8.9%, p <0.001), receive hemodialysis (88.1% vs 76%; p=0.006), predominantly through an arteriovenous fistula (55% vs 20.7%; p <0.001). The results of pretransplant work up including cardiac stress test, calcium scoring, coronary angiogram, cardiac ejection fraction, left ventricular hypertrophy, wall motion abnormalities and the degree of calcifications of pelvic arteries on pelvic Ct scan did not differ between the two groups. In the first post-transplantation year, patients in the longer vintage group were more likely to have reduction in their systolic blood pressure (-7.1±20.7 mmHg vs -1.6±17.5; p=0.027) and were at a higher risk of developing persistent hyperparathyroidism, defined as parathyroid hormone (iPTH) greater than 25.5 pmol/l at one year post transplantation, (27% vs 18%, p=0.003). However, patients in the shorter vintage group were more likely to have post-transplant weight gain (6.8±8.8 kg vs 4.7±; p=0.039). Post transplantation diabetes (PTDM) and morbid obesity at one-year post-transplantation were similar between the two groups. Conclusions: Our study showed that patients with dialysis vintage up to 3 years were not different in their baseline traditional risk factors, cardiovascular pre-transplant work up, nor the changes post renal transplant. This suggest that the increase of mortality related to dialysis vintage might be related to other factors such as uremia, electrolytes shifts and/ or infections. Further studies with longer follow up are needed to investigate if dialysis vintage longer than three years would affect the pre-transplant cardiovascular risk factors or the findings of pre-transplant cardiovascular imagings.

Increased level of free-circulating MtDNA in maintenance hemodialysis patients: Possible role in systemic inflammation.

BackgroundMitochondrial DNA (MtDNA) exposed to the extracellular space due to cell death and stress has immunostimulatory properties. However, the clinical significance of circulating MtDNA in maintenance hemodialysis (MHD) patients and the precise mechanism of its emergence have yet to be investigated.MethodsThis cross‐sectional study consisted of 52 MHD patients and 32 age‐ and sex‐matched healthy controls. MHD patients were further categorized into high and low circulating cell‐free MtDNA (ccf‐MtDNA) groups based on the median value. Copy number of MtDNA was quantified using TaqMan‐based qPCR. Plasma cytokines were measured using ELISA kits. Reactive oxygen species (ROS) and mitochondrial membrane potential (Δψm) in peripheral blood mononuclear cells (PBMCs) were detected using DCFH‐DA or JC‐1 staining.ResultsThe copy numbers of ccf‐MtDNA in patients with MHD were higher than those in healthy controls, and these alterations were correlated with changes of cytokines TNF‐α and IL‐6. Adjusted model in multivariate analysis showed that the presence of anuria and longer dialysis vintage were independently associated with higher levels of ccf‐MtDNA. Meanwhile, although not statistically significant, an inverse correlative trend between urinary MtDNA and ccf‐MtDNA was observed in patients with residual urine. Afterward, using PBMCs as surrogates for mitochondria‐rich cells, we found that patients in the high ccf‐MtDNA group exhibited a significantly higher ROS production and lower Δψm in cells.ConclusionsOur data suggested that changes in ccf‐MtDNA correlate with the degree of inflammatory status in MHD patients, and that the excessive MtDNA may be caused by mitochondrial dysfunction and reduced urinary MtDNA excretion.

International Icodextrin Use and Association with Peritoneal Membrane Function, Fluid Removal, Patient and Technique Survival.

Icodextrin has been shown in randomized controlled trials to benefit fluid management in peritoneal dialysis (PD). We describe international icodextrin prescription practices and their relationship to clinical outcomes. We analyzed data from the prospective, international PDOPPS, from Australia/New Zealand, Canada, Japan, the United Kingdom, and the United States. Membrane function and 24-hour ultrafiltration according to icodextrin and glucose prescription was determined at baseline. Using an instrumental variable approach, Cox regression, stratified by country, was used to determine any association of icodextrin use to death and permanent transfer to hemodialysis (HDT), adjusted for demographics, comorbidities, serum albumin, urine volume, transplant waitlist status, PD modality, center size, and study phase. Icodextrin was prescribed in 1986 (35%) of 5617 patients, >43% of patients in all countries, except in the United States, where it was only used in 17% and associated with a far greater use of hypertonic glucose. Patients on icodextrin had more coronary artery disease and diabetes, longer dialysis vintage, lower residual kidney function, faster peritoneal solute transfer rates, and lower ultrafiltration capacity. Prescriptions with or without icodextrin achieved equivalent ultrafiltration (median 750 ml/d [interquartile range 300-1345 ml/d] versus 765 ml/d [251-1345 ml/d]). Icodextrin use was not associated with mortality (HR=1.03; 95% CI, 0.72 to 1.48) or HDT (HR 1.2; 95% CI, 0.92 to 1.57). There are large national and center differences in icodextrin prescription, with the United States using significantly less. Icodextrin was associated with hypertonic glucose avoidance but equivalent ultrafiltration, which may affect any potential survival advantage or HDT.

MO961: Mineral Metabolism Parameters and Bone Density During The First Year of Kidney Transplantation

Abstract BACKGROUND AND AIMS We evaluated retrospectively in a cohort of kidney-transplanted patients (KTxp), the variations of mineral metabolism (MM) parameters, femoral and vertebral bone density during the first year of kidney transplantation (KTx). METHOD 383 KTxp (M = 232), up to the 650 transplanted in our Department (2004–2017) were studied. At 1st(T1) and 12th(T2) mth of KTx biochemical, femoral and vertebral dual-energy X-ray absorption (DEXA) data were recorded. T-score (Ts) -1 &amp;gt;Ts &amp;gt; -2.5 was considered Osteopenia (F-OPN/V-OPN) and Ts &amp;lt; -2.5 osteoporosis (F-OPS/V-OPS). RESULTS The KTxp age and dialysis vintage (DV) were 48 ± 12 years and 53 ± 25 months; 67% of KTxp had a history of hemodialysis. In 82.5% of cases, a donor deceased KTx (DD) was performed and in 40% of KTxp had a previous history of steroid therapy. During the first year of KTx 91% and 93% of KTxp received respectively calcineurin inhibitors and mycophenolate, and the steroids cumulative dose (SCD) was 2683 ± 926 mg. At T1, cholecalciferol and calcifediol were supplemented in 5% and 8% of KTxp, and AT T12 in 12% and 15% of KTxp. An increase in BMI (23 ± 3 versus 24 ± 3 kg/m2 P &amp;lt; 0.0001), Ca (9.82 ± 0.83 versus 9.9 ± 0.73 mg/dL, P &amp;lt; 0.0001), P (2.4 ± 0.96 versus 3.1 ± 0.61 mg/dL, P &amp;lt; 0.0001), 25OH-D (14.4 ± 6.81 versus 18.8 ± 9.7 ng/mL, P &amp;lt; 0.0001), Hb (11.0 ± 1.4 versus 12.8 ± 1.5 g/dL, P &amp;lt; 0.0001), albumin (4.2 ± 0.38 versus 4.46 ± 0.35 g/dL, P &amp;lt; 0.0001) was observed. Serum creatinine (1.41 ± 0.4 versus 1.37 ± 0.3 mg/dL, P = 0.03), PTH (87 ± 73 versus 79 ± 86 pg/mL, P = 0.06 and ALP (107 ± 92 versus 93 ± 58 U/L, P &amp;lt; 0.0001) had a reduction. Femoral bone mineral density (F-BMD) at T1 and F-Ts-T1 were 0.749 ± 0.17 g/cm2 and -1.55 ± 1.06. F-OPS-T1 was present in 17.5% and F-OPN-T1 in 53% of KTxp. F-BMD-T1 correlated directly with BMI-T1 (P &amp;lt; 0.0001) and inversely with 25OH-D-T1 (P &amp;lt; 0.004). F-Ts-T1 was inversely correlated with DV (P = 0.04), BMI-T1 (P &amp;lt;0.0001) and PTH-T1 (P = 0.02). KTxp with F-OPS-T1 had longer DV and lower BMI (P = 0.02). At T12, F-BMD-T12 and F-Ts-T12 were 0.77 ± 0.67 g/cm2 (P = 0.17 versus F-BMD-T1) and −1.4 ± 0.9 (P = 0.002 versus F-Ts-T1).F-OPS-T12 was present in 13.2% of patients and F-OPN-T1 in 55.2%. F-BMD-T12 correlated directly with BMI-T12 (P &amp;lt; 0.04). F-Ts-T12 correlated inversely with DV (P = 0.004), Ca at T1 (P = 0.001) and T12 (P = 0.0005) and with [SCD at T12 (P = 0.02)]. Patients with F-OPS-T1 had longer DV (P = 0.004) and higher PTH at T1 and T12 (P = 0.04 and P = 0.08). F-DEXA category worsened in 3.5% of KTxp. At T1, V-BMD-T1 and V-Ts-T1 were 0.92 ± 0.19 g/cm2 and −1.5 ± 1.58. V-OPS-T1 was present in 30% of KTxp and V-OPN-T1 in 34.5%. V-BMD-T1 correlated directly with BMI-T1 (P &amp;lt; 0.0001) and Ca-T1 (P = 0.04). V-Ts-T1 was inversely correlated with DV (P = 0.04), PTH-T1 (P = 0.02), Ca-T1 (P = 0.03), ALP-T1 (P = 0.01). A direct correlation between V-Ts-T1 and BMI-T1 (P &amp;lt; 0.0001) and 25OHD-T1 (P = 0.02) was present. V-OPS-T1 was more prevalent in males (P = 0.01).They had lower BMI (P &amp;lt; 0.0001), albumin (P = 0.02) and higher Ca-T1 (P = 0.008) and ALP-T1 (P = 0.03). At T12, V-BMD-T12 and V-Ts-T12 were 0.90 ± 0.22 g/cm2 and −1.5 ± 1 .33 (both NS versus T1). V-OPS-T12 was present in 27.7% of KTxp and V-OPN-T12 in 37.2%. V-BMD-T12 correlated directly with BMI-T1 and T12 (P &amp;lt; 0.0001 and P = 0.005) and inversely with Ca-T12 (P = 0.03) and SCD-T12 (P = 0.04). V-Ts-T12 was inversely correlated with DV (P = 0.004), SCD-T12 (P = 0.02) and with Ca at T1 (P = 0.001) and T12 (P = 0.0005). A direct correlation was found with BMI-T1 and T12 (P = 0.0002 and P = 0.001). V-OPS-T12 was more prevalent in DD (P = 0.001). They were older (P = 0.01), had longer DV (P = 0.01). BMI-T1 and T12 were lower in V-OPS-T12 (P = 0.002 and P = 0.03) and Ca-T12 higher (P = 0.01). SCD-T12 was higher in V-OPN-T12 and V-OPS-T12 (P = 0.05). V-DEXA category worsened in 32% of KTxp. CONCLUSION In the first year of KTx several modifications of MM are present. Both femoral and vertebral DEXA seem to be strongly related to the pre-KTx status, in particular, nutritional status and dialysis vintage are related to bone status at T1. Strong importance on T12 evaluation is taken by the SCD.

MO741: Poor Agreement between Physical Examination and Bioimpedance Spectroscopy in the Detection of Hypervolemia in Haemodialysis Patients

Abstract BACKGROUND AND AIMS Assessment of dry-weight among patients on haemodialysis is challenging in the absence of reliable markers to define overhydration (OH) [1, 2]. This study aimed to explore the value of two simple clinical signs, the presence of pedal oedema and crackles at pulmonary auscultation, in diagnosing hypervolemia, using the bioimpendence spectroscopy as a more objective method. METHOD In a cohort of 107 asymptomatic dialysis patients, the volume status was assessed with physical examination and bioimpedance spectroscopy shortly before the mid-week dialysis session [3]. Patients were also asked to perform home blood pressure (BP) monitoring with a validated, automatic device (HEM-705, Omron, Healthcare) [4] for 1 week in order to determine their BP control status. RESULTS Patients within the high tertile of pre-dialysis OH had longer dialysis vintage, lower serum albumin and higher home systolic BP, despite the more aggressive treatment with a higher average number of antihypertensives daily. In receiver-operating-characteristic (ROC) curve analysis, pedal oedema [area under curve (AUC): 0.534, 95% confidence interval (95% CI) 0.416–0.651] and pulmonary crackles (AUC: 0.551; 95% CI 0.432–0.671) had limited accuracy in the diagnosis of pre-dialysis OH &amp;gt; 2.2 L. The agreement of pedal oedema (Cohen's k-coefficient: 0.065) and pulmonary crackles (Cohen's k-coefficient: 0.122) with bioimpedance spectroscopy in the detection of hypervolemia was poor. In multivariate linear regression analysis, longer dialysis vintage (β: 0.306; P&amp;lt;0.001) and higher home systolic BP (β: 0.287; P&amp;lt;0.01) were the two factors that were independently associated with pre-dialysis OH. CONCLUSION This diagnostic-test study showed that among asymptomatic hemodialysis patients, pedal oedema and pulmonary crackles in physical examination had limited discriminatory power in the detection of hypevolemia, as assessed more objectively with the method of bioimpedance spectroscopy.

MO731: Predictors of Early and 1-Year Mortality After an Acute Coronary Event in Haemodialysis Patients

Abstract BACKGROUND AND AIMS Cardiovascular disease (CVD) is the leading cause of mortality in haemodialysis (HD) patients (40%), mainly secondary to a coronary event (17%). According to the European Society of Cardiology (ESC), beta-blockers (BBs), anti-platelets, angiotensin-converting enzyme inhibitors (ACEis)/angiotensin receptor blockers (ARBs) and statins are the cornerstones of CVD prevention. However, a great percentage of dialysis patients remain undermedicated. Our aim is to identify the predictors of mortality in HD patients after an acute myocardial infarction (AMI) during hospitalization and 1 year after the cardiac event. Methods We performed an observational retrospective study of all HD patients admitted to the coronary intensive care unit between January 2017 and December 2020 due to a myocardial infarction. Our variables of interest were collected before and after hospital discharge and 1 year after. We assessed patients’ frailty using the clinical frailty scale (CFS) and baseline cardiovascular (CV) risk using ESC’s classification; as we focused in HD patients (very-high risk of CVD), we classified CV risk regardless of the kidney disease. IBM SPSS 23.0 was used to perform statistical analysis; the confidence interval (CI) was set at 95%. RESULTS We collected 70 patients (males: n = 51, 73.2%), with a mean age of 70.9 ± 12.2 years and a median time in HD of 73.2 ± 60 months. Identifiable CV risk factors were: dyslipidaemia (98.6%), arterial hypertension (95.7%), heart failure (74.3%), diabetes (57.1%) and obesity (55.7%); mean total cholesterol and low-density lipoprotein cholesterol (LDL) levels were 151 ± 39.6 and 97.5 ± 34.1 mg/dL, respectively. As a result, 81.4% of our sample was classified as having a very high baseline CV risk. Before admission, most patients were on statin therapy (87.1%), but only 34.2% were taking the proper statin class/dosage adjusted to their CV risk. In fact, only 7.1% were previously medicated with all prognosis-modifying drugs (ACEis/ARBs, statins, anti-platelets and BBs). The mean hospitalization stay was 10.3 ± 9 days, and the early mortality rate (30 days post-admission) was 18.6%. Mortality was higher in older patients (72.5 ± 10.3 versus 69.1 ± 10.9 years; P = .3), males (21.6 versus 10.5%), with longer HD vintage (82.8 ± 46.8 versus 70.8 ± 48 months; P = 0.41) and higher CV risk (very-high CV risk, 84.6 versus 80%; P = .7); hypoalbuminemia (serum albumin &amp;lt; 3.0 g/dL) (OR 5.4, 95% CI 1.2–25.1; P = .028) and higher frailty score (CFS ≥ 4) (OR 6.1, 95% CI 1.2–30.0; P = .002) prompt a worse short-term prognosis. The mortality rate after 1 year was 30%, with a median time of 5.6 ± 2.4 months since the cardiac event. Mortality was also higher in older patients (71.5 ± 10 versus 69 ± 10 years; P = .34), males (31.3 versus 26.3%; P = 0.70), with longer dialysis vintage (85.2 ± 45.6 versus 67.2 ± 48; P = .14) and longer hospitalizations (12.8 ± 9.9 versus 9.3 ± 8.3; P = .12). After discharge, patients prescribed with at least three prognosis-modifying drugs had a lower 1-year mortality rate (3.2 versus 26.9%; OR 11, 95% CI 1.2–97.0; P = .003). Hypoalbuminemia (OR 9.4, 95% CI 2.3–4.3’; P = .002) and higher frailty scores (CFS ≥ 4) (OR 4.1, 95% CI 1.2–14.0; P = .025) were associated with worse outcomes. CONCLUSION We concluded that most HD patients were undermedicated prior to a coronary event given their baseline CV risk. Despite most studies in HD patients did not find a beneficial long-term effect of starting statin therapy after HD initiation, one must always individualize therapy according to the patient's CV risk. In our series, better-nourished patients with at least three prognosis-modifying drugs had a lower mortality rate, which highlights the importance of these drugs on survival together with optimal nutritional care.

MO1003: Role of Tacrolimus Trough Levels on Intra-Abdominal Pressure After Kidney Transplantation

Abstract BACKGROUND AND AIMS Increased intra-abdominal pressure (IAP) is common after kidney transplantation (KT). However, the role of potential transplant-specific predictors of this complication, such as tacrolimus-associated endothelial dysfunction, remains unclear. We aimed to describe the relationship between tacrolimus trough levels and IAP in a sample of incident KT patients. METHOD Single-centre prospective cohort of deceased-donor KTs. Anesthesia, surgical technique and immunosuppression induction therapy were the same in all cases. IAP monitoring was performed according to WSACS guidelines using the urinary bladder technique (UnoMeter Abdo-Pressure kit). IAP values were registered every 8h during the first 72 h after surgery or until reoperation. Mean IAP values during the first 7 2h (72 h-IAP) were used in this analysis. The first measured tacrolimus trough levels after transplantation were included as a potential predictor of IAP. Patients without recorded tacrolimus trough levels during the first 7 days after surgery were excluded. The study was approved by the local ethics committee. RESULTS A total of 192 patients were enrolled in the study. Table 1A summarizes relevant patient and haemodynamic variables. Subjects with more severe intra-abdominal hypertension were more commonly males, with longer dialysis vintage, higher BMI and suffered diabetes more frequently. Multivariate linear regression analysis was used to examine potential predictors of 72 h-IAP, including male sex, months on dialysis, body mass index (BMI) (Table 1B), 72 h-fluid balance and tacrolimus trough levels. Recipient age, months on dialysis, BMI and tacrolimus trough levels were independent predictors of 72 h-IAP. CONCLUSION Tacrolimus-associated endothelial dysfunction may play a role in the increase of IAP after transplantation. In contrast, accumulated fluid balance, one of the strongest predictors of IAP in the ICU setting, failed to predict IAP values in our sample. These results offer new insight both into the pathophysiology of increased IAP and into the complex mechanisms of tacrolimus-associated nephrotoxicity in the early post-transplant period.