Lower eGFR Levels Research Articles

EGFR Expression in HER2-Driven Breast Cancer Cells.

The epidermal growth factor receptor HER2 is overexpressed in 20% of breast cancer cases. HER2 is an orphan receptor that is activated ligand-independently by homodimerization. In addition, HER2 is able to heterodimerize with EGFR, HER3, and HER4. Heterodimerization has been proposed as a mechanism of resistance to therapy for HER2 overexpressing breast cancer. Here, a method is presented for the simultaneous detection of individual EGFR and HER2 receptors in the plasma membrane of breast cancer cells via specific labeling with quantum dot nanoparticles (QDs). Correlative fluorescence microscopy and liquid phase electron microscopy were used to analyze the plasma membrane expression levels of both receptors in individual intact cells. Fluorescent single-cell analysis of SKBR3 breast cancer cells dual-labeled for EGFR and HER2 revealed a heterogeneous expression for receptors within both the cell population as well as within individual cells. Subsequent electron microscopy of individual cells allowed the determination of individual receptors label distributions. QD-labeled EGFR was observed with a surface density of (0.5–5) × 101 QDs/µm2, whereas labeled HER2 expression was higher ranging from (2–10) × 102 QDs/µm2. Although most SKBR3 cells expressed low levels of EGFR, an enrichment was observed at large plasma membrane protrusions, and amongst a newly discovered cellular subpopulation termed EGFR-enriched cells.

Vancomycin in ICU Patients with Gram-Positive Infections: Initial Trough Levels and Mortality.

BackgroundVancomycin is one of the most common therapeutic agents for treating gram-positive infections, particularly in critically ill patients. The aim of this study was to identify factors associated with initial therapeutic vancomycin trough levels and mortality in a tertiary-care intensive care unit (ICU).MethodsThis retrospective study evaluated 301 adult ICU patients admitted to King Abdulaziz Medical City in Riyadh between October 1, 2017 and December 31, 2018 with confirmed gram-positive infections and received intravenous vancomycin. Vancomycin trough levels of 15–20 mg/L for severe infections and 10–15 mg/L for less severe infections were considered therapeutic.ResultsThe patients were relatively older with a mean age of 60 (SD ±20) years. Initial vancomycin trough levels were therapeutic in 168 (55.8%). Factors associated with initial therapeutic vancomycin trough levels were female gender (adjusted odds ratio [aOR]=2.575), older age (aOR=1.024), receiving a loading dose (aOR=2.445), having bacteremia (aOR=2.061), and high platelet count (aOR=1.003). On the other hand, the increase of estimated glomerular filtration rate (eGFR) (aOR=0.993) and albumin levels (aOR=0.944) were associated with lower odds of initial therapeutic vancomycin trough levels. Factors associated with higher mortality were female gender (adjusted hazard ratio [aHR]=2.630), increased body weight (aHR=1.021), cancer (aHR=3.451), and high APACHE II score (aHR=1.068).ConclusionThe study identified several factors associated with achieving initial therapeutic vancomycin trough levels (i.e. older age, female gender, receiving a loading dose, bacteremia, high platelets count, low eGFR and albumin level). These factors should be considered in the dosing of vancomycin in critically ill patients with gram-positive infections.

A detailed appraisal of renal manifestations in primary hyperparathyroidism from Indian PHPT registry: Before and after curative parathyroidectomy.

Primary hyperparathyroidism (PHPT) is a systemic disorder characterized by hypercalcaemia and inappropriately elevated parathyroid hormone (PTH). Renal manifestations are one of the main presenting features both in symptomatic and asymptomatic PHPT patients. We aimed to compare demographic, clinical and biochemical parameters of PHPT patients with and without renal manifestations and also analysed the influence of curative parathyroidectomy on renal functions. We retrospectively analysed the data of PHPT patients from the last 25years (1995- March 2019) and compared the demographic and clinical presentation and biochemical measurements between patients with and without renal manifestations and evaluated the changes in renal functions after 1year of curative parathyroidectomy. Of the total 544 PHPT patients, 299 (55%) including 91 out of 141 (65%) males had renal manifestations. Among renal manifestations, nephrolithiasis and nephrocalcinosis were found in 41.7% and 27.6% PHPT patients, respectively. PHPT patients with renal manifestations had significantly higher creatinine (109.7 vs 79.6µmol/L; P<.0001) and lower eGFR level (78.8 vs 93.9mL/min/1.73m2 ; P<.0001) compared to patients without renal manifestations. Parathyroidectomy resolved the clinical symptoms with biochemical cure in the patients from both the groups. Patients with renal manifestations showed improvement in creatinine and eGFR levels after 1year of curative parathyroidectomy; however, patients without renal manifestations showed no change in creatinine and eGFR levels. Young age and male gender are predictors of renal manifestations in PHPT. Curative parathyroidectomy improves renal functions in PHPT patients with renal manifestations compared to PHPT patients without renal manifestation.

Abstract 6596: High affinity chimeric antigen receptors with cross reactivity to clinically relevant EGFR mutated proteins

Abstract Introduction: Glioblastoma (GBM) is malignant and aggressive brain tumor with a median overall survival of 14.6 months, despite the development of new treatments. Chimeric Antigen Receptor (CAR) modified T cells are powerful new class of immune based therapies that have shown a high rate of long term durable response in CD19 expressing B-cell malignancies. However, this success has yet to be translated to solid tumors, in part due to a lack of surface antigens specifically expressed on tumor cells while not present on normal tissue and an immunosuppressive tumor microenvironment. Approximately 60% of GBMs contain a mutation, rearrangement, splicing alteration, and/or amplification of EGFR. Investigation of 411 GBM patient samples from University of Pennsylvania identified EGFR amplification in 38% of cases and EGFRvIII in 25% of cases and most common oncogenic missense mutations in extracellular domain (ECD) A289D/T/V, R108G/K, and G598V in 12-13% of cases. ECD missense mutations are associated with increased invasiveness aided by ligand independent activation of receptor and decreased patient survival compared to patients that are wild type EGFR at R108, A289 and G59V locus. Methods: We generated two structurally different CARs by fusing the scFv of mAb806 to 4-1BB and Killer immunoglobulin like receptor (KIR) co-stimulatory domains. mAb806 recognizes a conformationally exposed epitope of wild-type EGFR when it is overexpressed on tumor cells or in the presence of oncogenic mutations such as EGFRvIII. We tested in vitro cytolytic activity of 806-EGFR-CART cells against U87-MG (expressing low levels of EGFR) and U87-MG EGFR (U87-MG parental cell line transduced with EGFR wild type for amplified background) cell lines. These lines were engineered to ectopically express targeted EGFR-ECD missense mutations and EGFRvIII. Results: Both 4-1BB and KIR based EGFR806 CAR T cells specifically lysed tumor cells, proliferated, and secreted cytokines when co-cultured with target-expressing cell lines. To test exclusive specificity of EGFR806 CART to targeted mutations, K562 cells were transduced with EGFR-ECD mutations and co-cultured with 4-1BB and KIR CART cells. While the EGFR806 lysed K562 cells expressing wild type EGFR, EGFR-ECD Mutants, and EGFRvIII, it did not demonstrate any activity against K562-Parental cells. Unlike EGFR-specific cetuximab based CAR, EGFR-806CART cells did not kill EGFR wild type expressing fetal brain astrocytes and keratinocytes in vitro. We further evaluated the in vivo efficacy of CARs in NSG mice by injecting U87-MG, U87-MG EGFR and U87-MG EGFR expressing EGFRvIII subcutaneously and assessed tumor burden and mice survival. Though both 4-1BB and KIR based EGFR806 CART cells control tumor growth, KIR based CAR outperformed 4-1BB based CAR in terms of tumor burden and improved mice survival. Conclusion: Though our CART clinical trial for EGFRvIII positive recurrent GBM patients demonstrated CART therapy is safe and CART cells are able to successfully traffic to regions of active GBM, antigen loss and tumor heterogeneity resulted in limited therapeutic success. Broad specificity of EGFR806 CART cells to Amplified EGFR, EGFRvIII and EGFR-ECD mutants gives us the potential to clear various forms of EGFR. The enhanced anti-tumor efficacy by KIR based CAR in vivo setting provides us with additional therapeutic options for GBM. Citation Format: Radhika Thokala, Zev Binder, Yibo Yin, Michael Milone, Donald M. Orourke. High affinity chimeric antigen receptors with cross reactivity to clinically relevant EGFR mutated proteins [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 6596.

The impact of coexisting diabetes mellitus on clinical outcomes in patients with idiopathic membranous nephropathy: a retrospective observational study

BackgroundIdiopathic membranous nephropathy (IMN) is frequently coexisted with diabetes mellitus (DM). Few researches investigate clinical outcomes in IMN patients coexisting diabetes mellitus (DM), including remission rates, renal survival and complications. Concurrent DM also pose therapeutic challenges to IMN patients due to the influence of glucocorticoids and immunosuppressant on metabolic disorders. We performed this study to investigate the impact of DM on clinical outcomes in IMN and the influence of therapeutic regime on metabolic parameters in diabetic IMN patients.MethodsTwo hundred and six adult hospitalized patients diagnosed with biopsy-proven IMN were retrospectively studied, including 42 patients coexisted with DM. Clinical outcomes including remission rates, renal outcome and complications were compared between groups. Impact of cyclophosphamide and ciclosporin on metabolism and complications were analyzed in IMN patients coexisting DM.ResultsIMN patients coexisted with DM were presented with advanced age, lower level of eGFR and hemoglobin. Patients coexisted with DM experienced worse renal function deterioration and higher incidence of infection. COX regression analysis showed that DM was an independent risk factor for renal function deterioration in IMN patients. There was no significant difference in remission rates and incidence of venous thromboembolism between two groups. Further exploration on the impact of therapeutic regimens on complications and metabolism showed that cyclophosphamide and ciclosporin had no significant difference in incidence of complications including infection and venous thromboembolism, and posed comparable influences on blood glucose, uric acid and blood lipids in IMN patients coexisted with DM.ConclusionCoexisting DM was an independent risk factor for renal function deterioration in IMN patients but did not influence the remission of proteinuria. Glucocorticoids in combination with cyclophosphamide or ciclosporine had similar impact on complications and metabolic index including blood glucose, uric acid and blood lipids in IMN patients coexisted with DM.

P0829THE ASSOCIATION BETWEEN URINARY NGAL AND EGFR SLOPE IN PATIENTS WITH CKD

Abstract Background and Aims Urinary neutrophil gelatinase-associated lipocalin (uNGAL) is a new biomarker for renal tubular damage. The association between uNGAL and renal prognosis have been reported in many papers; however, it may often be affected by urinary tract infection (UTI), and its clinical value with consideration of UTI has not been well investigated in patients with chronic kidney disease (CKD). The aims of our study were to investigate the association between uNGAL and eGFR decline in CKD incorporating the effect of UTI. Method This was a retrospective observational cohort study at a single hospital in Japan. We included adult patients with the estimated glomerular filtration rate (eGFR) of 10 to 70 mL/min/1.73m2 from Jan 2017, who had at least one measurement of uNGAL. We used baseline uNGAL adjusted for urinary creatinine (Cr) as an exposure variable and divided the patients into quartiles. UTI was determined by a single evaluation of urinalysis at baseline. The repeated measured eGFRs were obtained from the electrical health record until dialysis initiation, loss to follow-up, or the end of the observation period whichever occurred first. We performed longitudinal analyses for eGFR decline using the mixed effects model and evaluated the longitudinal effect of uNGAL taking into account of UTI. All statistical analyses were done using STATA 13.1. Results In total, 281 patients with CKD were included. Mean age and eGFR at baseline were 70.2 years and 33.9 mL/min/1.73m2, respectively. The median [interquartile range (IQR)] of baseline uNGAL and urinary protein to Cr ratio (uPCR) were 49.6 [19.4 - 171.4] ug/gCr and 0.82 [0.18 - 3.26] g/gCr, respectively. Patients with UTI (15%) showed significantly higher uNGAL at baseline than those without (219 [89 - 425] vs. 39 [16 - 131]). During the mean follow up of 229 days, nine patients developed eGFR &amp;lt; 5 mL/min/1.73m2. Although a higher uNGAL level was significantly associated with lower eGFR levels at baseline (-3.3 [95% confidence interval (CI): -7.6, 0.93], -9.6 [-14.2, -4.9], and -16.3 [-21.4, -11.1] mL/min/1.73m2 in quartiles Q2-4 as compared to Q1); the eGFR trajectory did not differ with or without baseline UTI in the analytic model, while baseline proteinuria was significantly associated with a steeper slope of eGFR. Conclusion A higher uNGAL was significantly associated with lower eGFR levels at baseline; however, it was not associated with a steeper slope of eGFR in the longitudinal analysis, even with the consideration of the effect of UTI.

P0052EMERGING CONCEPTS IN KIDNEY ATTR AMYLOIDOSIS: CHRONIC ADMINISTRATION OF TAFAMIDIS

Abstract Background and Aims Transthyretin (TTR) amyloidosis is a disease characterized by destabilization of the native TTR tetramer. It can be caused by aging or due to pathogenic mutations, and its diagnosis is often missed. Hereditary transthyretin amyloidosis (ATTRv), due to Val50Met mutation, is frequently linked with polyneuropathy but it can cause nephropathy too, causing wide range levels of albuminuria and renal dysfunction. Tafamidis, a TTR tetramer stabilizer, has been associated with significant decrease of albuminuria in ATTRv. However, TTR nephropathy is not an approved indication for its use. Plus, the renal effects of chronic oral administration of this TTR stabilizer are yet to be understood. This study evaluated longitudinal changes of eGFR-EPI within 72 months of therapy with tafamidis and identified factors associated with these changes. Method A retrospective cohort, single centre study was conducted. We have followed consecutive ATTRv Val50Met patients on tafamidis therapy from July 2012 to March 2019. Men and women aged 18-85 years were eligible if they had neuropathy stage I, were anti-amyloid treatment-naïve patients that accomplished at least 60 months of tafamidis therapy and had eGFR over 45 ml/min/1.73m2 with any grade of albuminuria. Exclusion criteria were: pregnancy, malignancies, diabetes and concurrent etiologies for nephropathy. Statistical analyses included Mann-Whitney test and linear mixed models to analyze the longitudinal changes in eGFR of the two groups of patients (albumunuric/ non-albuminuric at baseline), by controlling for variables that could be associated with eGFR EPI Cystatin C course. Results From 366 patients, biopsy-proven ATTR amyloidosis, treated with tafamidis, 122 patients met our criteria (56 males, 66 females) and had a median age of 36 (IQR: 32-46) years old. Twenty-eight had pathological urinary albumin-to-creatinine ratio (ACR), defined by ACR &amp;gt;30 mg/dL, and ACR &amp;gt;300 mg/dL was only found in females. In univariate analysis no significant differences were found between median eGFR decline in albuminuric versus non-albuminuric patients (p=0.330). At all time points, mean eGFR levels were significantly lower in baseline albuminuric patients. According to our estimation, eGFR at baseline was 11.2 mL/min/1.73 m2 lower in baseline albuminuric patients, adjusted for age at the disease onset and time between symptom onset and tafamidis initiation. Baseline albuminuria status (p=0,005), age at the disease onset (p&amp;lt;0,001) and time between initiation of symptoms and initiation of tafamidis (p=0,016) were the only independent factors associated with longitudinal changes of eGFR (higher age at the disease onset and higher time between symptom onset and tafamidis initiation were associated with lower levels of eGFR). Figure 1 shows the predicted eGFR EPI trajectories over time for baseline albuminuric/ non-albuminuric subjects. Conclusion This study represents a real-life experience of oral chronic administration of tafamidis and its effects on ATTR nephropathy, concerning albuminuria reduction and renal function decline. Our analysis had shown similar decline rates in eGFR, irrespectively the degree of albuminuria at baseline, differently from what would be expected, since higher grades of albuminuria are related with more rapidly kidney function deterioration. Besides its capacity of stabilizing TTR tetramers, tafamidis could have an enhancing role in the podocyte regeneration process through potential cofactors for amyloid fibrils toxic effect, that could be present in the glomerular basement membrane and mesangium. This nephroprotector effect should be considered when a switch of therapy is demanded by the neuropathy status and a second line treatment is considered. Presence of renal disease may be an indication for tafamidis maintenance and combined therapy.

1104-P: Many Benefits of Empagliflozin Persist in Those with Reduced Renal Function: Updated Data from the Association of British Clinical Diabetologists (ABCD) Audit Programme

Background: Sodium-glucose linked transporter 2 inhibitors (SGLT2s) are currently favoured for their tolerability, cardiovascular benefit and renal protective effects. However, due to their mechanism of action, they are only licensed for use in those with preserved renal function at baseline. Previous analyses with other drugs in the class showed potential benefits even when used in those with estimated glomerular filtration rate (eGFR) below licensed level. Methods: Data was extracted from the ABCD nationwide empagliflozin audit and then stratified into groups, as follows, based on baseline eGFR (mL/min/1.73m2): CKD1 (n=2900, eGFR≥90), CKD2 (n=2753, eGFR&amp;lt;90, eGFR≥60), CKD3a (n=210, eGFR&amp;lt;60, eGFR≥45) and CKD3b+ (n=17, eGFR&amp;lt;45). Data was analysed using paired t-tests and ANOVA in Stata 16. Results: 5880 datasets were included with mean (±SD) age 59.5yrs (±10.4), 61.1% male, 86% Caucasian (where known), BMI 33.1kg/m2 (±6.6), HbA1c 9.17% (±1.61) and median duration diabetes 7.3 years (2.2-12.1 IQR) and were broadly similar across groups apart from age: those with more impaired renal function being generally older (CKD1 55.4yrs±9.5 v CKD3b+ 69.6yrs±8.5) with a longer duration diabetes with median (IQR) in CKD1 6.6yrs (1.8-10.9) v CKD3b+ 14.5yrs (8.9-17.3). Reductions in HbA1c, weight and BMI occurred in all groups (P&amp;lt;0.005); reductions in HbA1c were of a smaller magnitude as eGFR declined (ANOVA P&amp;lt;0.01). Changes in systolic (SBP) and diastolic blood pressure (DBP) were significant in those in CKD1- CKD3a but not in CKD3b+ (SBP +2.6mmHg, 95% CI +14.9, -9.6). eGFR was observed to decrease in CKD1 and CKD2 (CKD1 eGFR -2.1mL/min/1.73m2, CI 95% -1.8, -2.3). Conclusion: The use of empagliflozin at eGFR&amp;lt;45mL/min/1.73m2 may still confer HbA1c improvement (although perhaps of lower magnitude) and weight loss, though SBP and DBP reduction may be limited. More evidence is needed regarding its use at lower levels of eGFR. Disclosure T.S.J. Crabtree: None. K. Adamson: None. A. Bickerton: None. S.M. Phillips: None. A. Evans: Other Relationship; Self; AstraZeneca. A.M. Robinson: None. M. Atkin: Speaker’s Bureau; Self; AstraZeneca, Napp Pharmaceuticals. D.S. Morris: None. D.M. Williams: None. J.W. Stephens: Speaker’s Bureau; Self; AstraZeneca, Boehringer Ingelheim Pharmaceuticals, Inc., Napp Pharmaceuticals, Novo Nordisk A/S. D.K. Sennik: Speaker’s Bureau; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Novo Nordisk Inc., Sanofi. A. Rohilla: None. M.L. Cull: None. R.P. Raghavan: Research Support; Self; Allergan plc. Speaker’s Bureau; Self; Abbott, AstraZeneca, Boehringer Ingelheim Pharmaceuticals, Inc., Lilly Diabetes, Napp Pharmaceuticals, Takeda UK. Other Relationship; Self; Napp Pharmaceuticals. M. Yadagiri: None. I.W. Gallen: None. R.E. Ryder: Consultant; Self; GI Dynamics Inc. Other Relationship; Self; Novo Nordisk A/S.

P391Estimated glomerular filtration rate levels and risk of stroke in individuals with diabetes mellitus and atrial fibrillation

Abstract Funding Acknowledgements pfizer Background Diabetes mellitus (DM) is associated with increased risk of embolic complications in non-valvular atrial fibrillation (NVAF). Chronic kidney disease (CKD) has been shown in some studies to increase the risk of stroke. This finding is not consistent among all studies. Therefore the relationship between kidney function, diabetes and stroke risk is complex and warrants further investigation. Purpose To assess the incidence rates and risk of ischemic stroke and mortality by baseline Estimated Glomerular Filtration Rate (eGFR) levels among individuals with AF and DM. Methods A prospective, historical cohort study using our electronic medical records database. The study population included all members 21 years old, with a first diagnosis of NVAF between January 1, 2010 to December 31, 2016 and a minimal follow-up period of 1 year. Among those patients identified as diabetics, we compared three groups of patients according to eGFR levels at the time of AF diagnosis: eGFR ≥ 60, between 30-60 and ≤ 30 or chronic dialysis or kidney transplant. Results A total of 17,567 cases were included in the final analysis, of them, 11013 (62.7%) had eGFR ≥ 60, 4930 (28%) with eGFR between 30-60 and 1624 (9.24%) with eGFR ≤30 . The median age was 75 years (IQR 65-83) with a majority of females in all groups, 52.5%, 51.2% and 55.5% respectively. The incidence of stroke per 100 person-years in the three study groups was: 1.88 in patients with eGFR ≥ 60, 2.69 in patients with eGFR between 30-60 and 3.34 in those with eGFR ≤ 30 . Impaired renal function was associated with increased risk of stroke in univariate analysis, but not found in the adjusted model (Adjusted Hazard Ratio (AHR) = 1.04 {95% 0.89-1.23} for eGFR 30-60 and 1.16 {95% CI 0.88-1.51} for eGFR ≤ 30 compared to GFR ≥ 60). incidence of mortality per 100 person-years was 10.78 in patients with eGFR ≥ 60, 21.49 in patients with eGFR 30-60 and 41.55 in those with eGFR ≤ 30. In both univariate and multivariate analyses, decreased levels of eGFR were associated with increased mortality risk compared to subjects with normal renal function (AHR 1.22 {95%CI 1.14-1.27} and AHR 2.09 {95%CI 1.95-2.24} for eGFR between 30-60 and for eGFR ≤ 30, respectively). Conclusion In this observational prospective cohort of patients with newly diagnosed NVAF, impaired renal function was not found to be associated with increased risk of stroke. Lower eGFR levels were associated with an increased mortality risk.

P0873GLA-RICH PROTEIN (GRP) AS AN EARLY AND NOVEL MARKER ASSOCIATED WITH VASCULAR CALCIFICATION AND CKD-MINERAL AND BONE DISORDER (MBD) IN DIABETIC PATIENTS WITH CKD: A PILOT COHORT STUDY

Abstract Background and Aims Cardiovascular disease (CVD) is the most life-threatening complication in chronic kidney disease (CKD) patients. In addition to traditional risk factors, most patients with CKD display abnormal mineral metabolism with underlying hormonal dysregulation, defined as chronic kidney disease-mineral and bone disorder (CKD-MBD). CKD-MBD involves changes in mineral ion homeostasis, bone quality and turnover, cardiovascular and soft tissue calcifications, which highly contribute for cardiovascular complications. Vascular calcification (VC) is associated with significant morbidity and mortality and a strong predictor of cardiovascular risk in CKD patients. Early preventive measures, including new diagnostic/prognostic tools, are required to reduce the development and progression of VC, left ventricular hypertrophy and arterial stiffness, which are crucial for the prevention of CVD outcomes in CKD patients. Gla-rich protein (GRP) is a vitamin K-dependent protein with a dual capacity to function as an inhibitor of pathological calcification and anti-inflammatory agent in the cardiovascular system, whose clinical utility is unknown. Our aim with this study was to evaluate the potential of GRP as a new marker for CKD-MBD and vascular calcification, in type 2 diabetic patients with chronic kidney disease (CKD) stages 2-4. Method In an observational prospective study including all eligible type 2 diabetic patients with CKD stages 2-4 (n=80) followed in outpatient nephrology consultation from 2010 to 2017, we explored correlations between levels of GRP in serum with mineral metabolism and inflammation markers, CKD developmental stage, vascular calcification and pulse pressure (PP). Vascular calcification score (VCS) was evaluated using the plain x-ray of the hands and pelvis (Adragão score), and increased cardiovascular risk was considered for VCS≥3. Measurements of GRP in serum were performed using a recently developed sandwich ELISA assay. Descriptive statistics, ANOVA and post hoc analysis with Scheffe test were used for analysis. Forward stepwise logistic regression (likelihood ratio) analysis was applied to identify predictive factors for VCS and PP, and ROC curves were used to assess the sensitivity and specificity of GRP in relation to these exposure factors. Results Spearman’s correlation analysis revealed the strong positive correlation between levels of serum GRP and eGFR (r=0.863, p&amp;lt;0.0001) and α klotho (r=0.647, p&amp;lt;0.0001), while a negative correlation with phosphate (P) (r=-0.715, &amp;lt;0.0001), FGF23 (r=-0.676, &amp;lt;0.0001), VCS (r=-0.822, p&amp;lt;0.0001), PP (r=-0.533, p&amp;lt;0.0001), calcium x phosphate (CaxP) (r=-0.302, p=0.006) and IL-6 (r=-0.349, p=0.002). Serum GRP levels were found to progressively decreased from stage 2 to stage 4 CKD. Multivariate analysis identified low levels of eGFR and GRP, and high levels of FGF-23 as independent risk factors for both the VCS and PP. The area under the ROC curves for GRP was 0.865±0.046, 95% CI (0.776-0.955), p&amp;lt;0.0001 for VCS and 0.782±0.054, 95% CI (0.677-0.887), p&amp;lt;0.0001 for PP. Conclusion Reduced levels of GRP were associated with higher levels of vascular calcification promoters such as P, FGF-23 and CaxP, and with lower levels of the VC inhibitor α-Klotho, indicating a correlation between GRP and the dysregulation of phosphate metabolism characteristic of CKD-MBD. In addition, this pilot cohort study indicates that GRP levels might be a significant clinical predictor of vascular calcifications in diabetic patients with CKD. Funding This research was funded by the Portuguese Society of Nephrology (SPN) through project funding 2016, by the Portuguese national funds from FCT - Foundation for Science and Technology through the transitional provision DL57/2016/CP1361/CT0006 and project UID/Multi/04326/2019. Acknowledgments To SPN by the attribution of the Jacinto Simões award (2018) financed by Fresenius medical care.

Renal resistive index in chronic kidney disease patients: Possible determinants and risk profile.

BackgroundHigh ultrasound renal resistive index (RI) predicts poor cardiorenal outcomes in chronic kidney disease (CKD) and has recently emerged as a marker of nephroprotective drugs response. Thus, having a risk profile of CKD patients with abnormal RI may be relevant for the clinicians.MethodsConsecutive patients referred to our non-dialysis CKD clinic from 01/01/2016 to 01/12/2016, were evaluated by clinical and ultrasound analysis. Inclusion criteria were age >18 years and presence of CKD defined as estimated glomerular filtration rate (eGFR)<60 mL/min/1.73m2 and/or proteinuria>0.150g/24h. Renal artery stenosis, solitary kidney, acute kidney injury were the main exclusion criteria. RI value was the mean of three measures in segmental arteries in each kidney. Univariate analysis was performed to evaluate associations between continuous RI and clinical variables. Multivariate linear regression analysis, based on stepwise method with an elimination criterion of p<0.10, was used to assess the independent correlates of RI as continuous variable.ResultsWe studied 73 patients (69.9% men). Mean RI was 0.67±0.09. Frequencies of diabetes and cardiovascular disease (CVD) were 19.2% and 20.6% and median eGFR 54.1 [30.0–84.6] mL/min/1.73m2. From low (<0.65) to intermediate (0.65–0.70) to high (>0.70) RI categories, eGFR and haemoglobin levels were decreased while diabetes, cardiovascular disease (CVD), phosphate and smokers were higher. At univariate analysis, RI was significantly associated with age, presence of diabetes, CVD, serum phosphorus, eGFR, Urea and haemoglobin. Multi-adjusted stepwise regression analysis showed that lower eGFR levels (p<0.001), diabetes (p = 0.042), CVD (p = 0.009), smoking habit (p = 0.021) and higher serum phosphorus levels (p = 0.001) were associated with higher continuous RI. Serum phosphorus showed Area Under the Curves (AUC) values of 0.714 and 0.664 for discriminating RI cut-offs of 0.70 and 0.65.ConclusionsThis analysis suggests that RI is higher in CKD patients with CVD, diabetes, smoking habit and higher serum phosphorus, regardless of eGFR. Further studies are needed to verify whether higher RI indicates more complex pathway of intrarenal damage, besides and beyond kidney function.

PNPLA3 I148M gene variant and chronic kidney disease in type 2 diabetic patients with NAFLD: Clinical and experimental findings.

Emerging evidence suggests an association between patatin-like phospholipase domain-containing protein-3 (PNPLA3) rs738409 (I148M protein variant) and risk of chronic kidney disease (CKD), but the mechanisms underpinning this association are poorly understood. We studied 157 patients with type 2 diabetes (T2DM) who underwent ultrasonography and vibration-controlled transient elastography for diagnosing nonalcoholic fatty liver disease (NAFLD). CKD was defined as estimated glomerular filtration rate (e-GFR) <60mL/min/1.73m2 and/or abnormal albuminuria. We surveyed PNPLA3 mRNA expression in human tissues, using the liver as a positive control, and also measured PNPLA3 mRNA and protein expression levels in human cell lines represented in the kidney and the liver. In all, 112 patients had NAFLD and 43 had CKD. Patients homozygous for the I148M variant (n=11) had lower e-GFR levels (60.6±11.7 vs 77.8±15.9 vs 83.5±16.5mL/min/1.73m2 , P=.0001) and higher prevalence of CKD (63.6% vs 24.2% vs 25.0%, P=.028), compared to those with I/M (n=66) and I/I (n=80) PNPLA3 genotype. The association of I148M homozygosity with lower e-GFR levels (P<.0001) and higher risk of CKD (adjusted-odds ratio 6.65; 95% CI 1.65-26.8, P=.008) was independent of liver disease severity (as detected by liver stiffness ≥7kPa) and other risk factors. PNPLA3 mRNA expression was greatest in liver and renal cortex, and podocytes showed high PNPLA3 mRNA and protein levels, comparable to that of hepatocytes and hepatic stellate cells respectively. The PNPLA3 I148M variant was associated with CKD, independently of common renal risk factors and severity of NAFLD PNPLA3 expression levels were particularly high in renal podocytes.

Abstract P274: Kidney Filtration Markers and the Risk of Clinical Outcomes in Individuals With Type 2 Diabetes in the Advance Trial

Introduction: Creatinine-based estimated glomerular filtration rate (eGFR) is biased in the setting of obesity and other conditions. Alternative kidney filtration markers may be particularly useful in adults with diabetes, but few studies examined the risk of clinical outcomes associated with filtration markers in adults with type 2 diabetes. Objective: We evaluated whether baseline levels and change in eGFR based on creatinine (Cr), cystatin C (Cys), and B 2 -microglobulin (B2M) were associated with the risk of clinical outcomes among individuals with type 2 diabetes. Methods: In the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) trial, Cr, Cys, and B2M were measured in 7,217 participants at baseline and a random sample of 640 participants at the 1 year visit. We categorized baseline eGFR Cr , eGFR Cys , eGFR B2M , and the average across the 3 eGFR estimates (eGFR avg ) into quarters, and examined associations with major macrovascular and microvascular events together, and separately, and all-cause mortality using Cox regression models, adjusting for established risk factors. We also examined associations with continuous eGFR decline and increase (per 30%). Results: Over a median follow-up of 5 years, 1,313 combined major macrovascular (n=748) and microvascular events (n=637), and 743 deaths occurred. Lower levels of eGFR based on all three filtration markers individually and combined were associated with 1.5 to 2.2 times higher risk of combined major macrovascular and microvascular events, with similar patterns for other outcomes ( Table ). Per 30% decline in eGFR Cys and eGFR avg were associated with a &gt;2-fold higher risk of all clinical outcomes, after additional adjustment of baseline eGFR. Conclusions: In adults with type 2 diabetes, baseline levels of eGFR based on alternative filtration markers and per 30% decline in eGFR Cys and eGFR avg were consistently associated with all clinical outcomes.

Gla-Rich Protein (GRP) as an Early and Novel Marker of Vascular Calcification and Kidney Dysfunction in Diabetic Patients with CKD: A Pilot Cross-Sectional Study.

Vascular calcification (VC) is one of the strongest predictors of cardiovascular risk in chronic kidney disease (CKD) patients. New diagnostic/prognostic tools are required for early detection of VC allowing interventional strategies. Gla-rich protein (GRP) is a cardiovascular calcification inhibitor, whose clinical utility is here highlighted. The present study explores, for the first time, correlations between levels of GRP in serum with CKD developmental stage, mineral metabolism markers, VC and pulse pressure (PP), in a cohort of 80 diabetic patients with mild to moderate CKD (stages 2–4). Spearman’s correlation analysis revealed a positive association of GRP serum levels with estimated glomerular filtration rate (eGFR) and α-Klotho, while a negative correlation with phosphate (P), fibroblast growth factor 23 (FGF-23), vascular calcification score (VCS), PP, calcium (x) phosphate (CaxP) and interleukin 6 (IL-6). Serum GRP levels were found to progressively decrease from stage 2 to stage 4 CKD. Multivariate analysis identified low levels of eGFR and GRP, and high levels of FGF-23 associated with both the VCS and PP. These results indicate an association between GRP, renal dysfunction and CKD-mineral and bone disorder. The relationship between low levels of GRP and vascular calcifications suggests a future, potential utility for GRP as an early marker of vascular damage in CKD.

Lower eGFR is associated with increased probability of liver fibrosis in Chinese diabetic patients.

Kidney dysfunction is linked to nonalcoholic fatty liver disease (NAFLD) progression including fibrosis, steatosis, or inflammation. We aimed to explore whether lower levels of estimated glomerular filtration rate (eGFR) was associated with increased probability of liver fibrosis. Two thousand six hundred eighty-nine subjects enrolled from Shanghai, China, were included in this study. NAFLD fibrosis score (NFS) was used to risk stratify NAFLD patients for fibrosis. eGFR was used to assess kidney function. The association of eGFR level with elevated NFS, and thus high risk of fibrosis, was analysed by linear regression and multinomial logistic regression. The predictive power of eGFR was evaluated via receiver operating characteristic (ROC) curve. A negative association was found between eGFR and NFS (B = -0.21, 95% CI, -0.37 to -0.04, P = .016). As eGFR quartiles decreased, the prevalence of probable fibrosis increased after adjusting for age, sex, current smoking, waist circumference, duration of diabetes, HbA1c , hypertension, dyslipidaemia, and homeostasis model assessment index of insulin resistance (HOMA-IR) (Q4: reference; Q3: 1.49, 95% CI, 0.82-2.71; Q2: 1.88, 95% CI, 0.97-3.67; Q1: 2.70, 95% CI, 1.36-5.37, Pfor trend = .002, 1SD increment: 0.73, 95% CI, 0.58-0.92). The eGFR level can be an effective indicator in differentiating patients with probable presence of fibrosis from those without (AUROC: 0.71, cut-off point: 92.78 mL/min/1.73 m2 , P < .001). Lower levels of eGFR were associated with higher NFS and thus greater risk of presence of fibrosis in patients with NAFLD and T2DM. Individuals with NAFLD and diabetes should carefully monitor eGFR and receive regular urinalysis, especially when advanced fibrosis is suspected.

A Polymorphism in the Gene Encoding the Insulin Receptor Binding Protein ENPP-1 Is Associated with Decreased Glomerular Filtration Rate in an Under-Investigated Indigenous African Population

Introduction: The C allele of the ectonucleotide pyrophosphatase/phosphodiesterase 1 (ENPP-1) rs1044498 polymorphism has previously been associated with increased binding of ENPP-1 to the insulin receptor (IR), resulting in decreased IR signalling and enhanced insulin resistance. It has also been associated with reduced kidney function in participants with diabetes of predominantly European and Asian descent. The association of this polymorphism with kidney disease in healthy Black South African participants has yet to be ascertained. Objective: This study, therefore, aimed to determine whether the K121Q polymorphism is associated with estimated glomerular filtration rate (eGFR) in a Black South African cohort. Methods: Black South African participants (n = 348) from an existing cohort with known eGFR levels were genotyped for the K121Q polymorphism using PCR-RFLP and assessed for any statistical association between genotype and kidney function. Results: Individuals with the A allele had significantly lower eGFR levels than individuals with the CC genotype (86.52 ± 18.95 vs. 93.29 ± 23.55 mL/min; p = 0.022). The association of the A allele with lower eGFR levels remained after controlling for sex, blood pressure, insulin resistance, age, smoking, thyroid-stimulating hormone, insulin-like growth factor-1, and BMI (R² = 0.030, p < 0.001). Conclusion: The rs1044498 A allele was significantly associated with lower eGFR levels in a cohort of apparently healthy Black South Africans, through an unknown mechanism that was independent of insulin resistance. It is possible that the rs1044498 polymorphism affects kidney function by altering the role of ENPP-1 in endothelial wound healing, podocyte signalling, or oxidative stress. Thus, the presence of this polymorphism may predispose individuals to a greater risk of CKD even in the absence of diabetes.

Sodium-glucose cotransporter 2 inhibitors: extending the indication to non-diabetic kidney disease?

This year the medical community was pleasantly surprised by the results of the first large outcome trial that primarily examined the renal effects of the sodium-glucose cotransporter 2 (SGLT2) inhibitor canagliflozin (CANA) in subjects with diabetes and impaired kidney function. The Evaluation of the Effects of Canagliflozin on Renal and Cardiovascular Outcomes in Participants With Diabetic Nephropathy (CREDENCE) trial showed that CANA, relative to placebo, reduces the risk for end-stage renal disease, doubling of creatinine or renal death by 34% [hazard ratio 0.66 (95% confidence interval 0.53–0.81]. These effects were consistent across baseline estimated glomerular filtration rate (eGFR) and haemoglobin A1c subgroups. In this review we combine the results of the CREDENCE trial with those of several cardiovascular outcome trials with SGLT2 inhibitors and show that, unexpectedly, patients with lower eGFR levels may have greater benefit with respect to cardiovascular outcome than patients with normal kidney function. The cardio- and renoprotective effects of SGLT2 inhibitors seem to be independent of their glucose-lowering effects, as shown in several post hoc analyses. In this review we discuss the alleged mechanisms of action that explain the beneficial effects of this novel class of drugs. Moreover, we discuss whether these findings indicate that this class of drugs may also be beneficial in non-diabetic chronic kidney diseases.

Efficacy of entecavir in treating hepatitis B virus-associated membranous nephropathy.

hepatitis B virus-associated membranous nephropathy (HBV-MN) is the most common pathological type of hepatitis B virus-associated glomerulonephritis. This study evaluated the efficacy of entecavir antiviral therapy for HBV-MN patients due to the intolerable side effects of interferon-alpha and high incidence rate of drug-resistance in lamivudine therapy. thirty-two patients with HBV-MN were identified by biopsy and treated with entecavir for 52 weeks. These patients were followed up to evaluate outcomes of entecavir-treatment. Descriptive statistics were used to summarize patient demographics and treatment outcomes. entecavir treatment reduced 24-h urinary protein excretion. The total probability of partial proteinuria and complete remission at 24 and 52 weeks was 53.1 and 78.1 %, respectively. A decrease of circulating HBV-DNA was observed in all patients with active HBV replication. The significant decrease of 24-h urinary protein began at 12 weeks, as early as the decrease of serum HBV-DNA level. The serum HBV DNA titers at baseline and after 52 weeks of treatment were 4.3 ± 2.8 log10 and 2.3 ± 1.7 log10, respectively. Meanwhile, eGFR increased from 100.3 ± 20.5 ml/min/1.73 m2 at baseline to 107.7 ± 15.9 ml/min/1.73 m2 after 52 weeks of treatment. The serum alanine aminotransferase level (ALT) gradually decreased to normal during entecavir antiviral treatment. entecavir treatment in HBV-MN patients was carefully described. Complete remission and HBV replication suppression were induced by entecavir treatment in HBV-MN patients. Patients with high serum creatinine (Scr), ALT and low eGFR levels benefit more from entecavir treatment. Entecavir therapy is well tolerated by patients and no adverse reactions were observed.

Comparison of glomerular filtration rate estimation using Jaffé and enzymatic creatinine assays in diabetic patients.

Diabetic kidney disease (DKD) develops an end-stage renal failure and is a major cause of death in diabetic patients. A GFR below 60ml/min per 1.73m2 is one of the main markers of DKD. Therefore, the development of an accurate test for diagnosis and monitoring of the mentioned disease would be essential. Here, we examined the impacts of two different kits with different methods for creatinine measurement on the GFR values. Blood samples were collected from 80 diabetic patients referring to the clinical laboratory. The levels of serum creatinine were assessed using Jaffé and enzymatic assays by kits from two different manufacturers. Then to assess the eGFR levels, the MDRD equation was used. Further descriptive parameters of both methods and correlation of methods were also calculated. Descriptive analysis of the data demonstrates a slight increase in the serum creatinine measured by Jaffé assay which leads to a substantial decrease in the levels of eGFR compared to the eGFR calculated by the enzymatic assay. Moreover, eGFR over 60mL/min/1.73 m 2 in enzymatic assay was observed in 27.5% of participants while eGFR of the same participants was below 60mL/min/1.73m 2 when it was measured by Jaffé method. Consequently, 27.5% positive discordant cases were reported by Jaffé assay followed by misclassifying them as DKD patients compared with the enzymatic assay. While using Jaffé assay, a low level of eGFR is observed which generates more misclassification into the DKD group and demands to an inclusive consideration by physicians in order to diagnose and monitor the DKD patients.

Corneal nerve fiber loss in diabetes with chronic kidney disease

AimsPatients with chronic kidney disease (CKD) in type 2 diabetes typically manifest with severe peripheral neuropathy. Corneal confocal microscopy is a novel technique that may serve as a marker of nerve injury in peripheral neuropathy. This study examines the changes that occur in corneal nerve morphology as a result of peripheral neuropathy due to renal dysfunction in people with type 2 diabetes. MethodsSixty-two participants (mean age, 62 ± 12 years) with type 2 diabetes and 25 age-matched healthy controls underwent a comprehensive assessment of neuropathy using the total neuropathy score (TNS). The corneal sub-basal nerve plexus was imaged using corneal confocal microscopy. Corneal nerve fiber length, fiber density, branch density, total branch density, nerve fractal dimension, inferior whorl length and inferior whorl nerve fractal dimension were quantified. Based on the eGFR, participants were classified into those with diabetic CKD (eGFR < 60; n = 22) and those without CKD (eGFR ≥ 60; n = 40). ResultsParticipants with diabetic CKD had significantly lower corneal nerve fiber density (P = 0.037), length (P = 0.036) and nerve fractal dimension (P = 0.036) compared to those without CKD. Multiple linear regression analysis revealed that reduced corneal nerve fiber density (ß coefficient = 0.098, P = 0.017), length (ß coefficient = 0.006, P = 0.008) and nerve fractal dimension (ß coefficient = 0.001, P = 0.007) was associated with low eGFR levels when adjusted for age, duration of diabetes and severity of neuropathy. ConclusionCorneal confocal microscopy detects corneal nerve loss in patients with diabetic CKD and reduction in corneal nerve parameters is associated with the decline of kidney function.