M2 In Group Research Articles

P1097INITIATING MAINTENANCE HAEMODIALYSIS USING INCREMENTAL HAEMODIALYSIS REGIME - A SINGLE CENTRE EXPERIENCE

Abstract Background and Aims Most patients with end stage renal disease (ESRD) initiate maintenance dialysis in three times per week regime irrespectively of residual kidney function (RKF). Incremental haemodialysis (IHD) showed benefits of starting and maintaining patients on less than three times per week regime, most importantly preserving urine volume output (UVO) and RKF. The aim of this study was to assess the main differences between a group of patients initiating dialysis once-weekly (1xHD) and twice-weekly (2xHD), to evaluate time to dialysis regime change, UVO and patients volume status at the end of study period. Method Patients with ESRD who started haemodialysis through the planned IHD (once-weekly and twice-weekly) and were undergoing IHD for at least 4 months (M) were enrolled (n=44) in the study. Study was conducted from January 2016 to December 2019 at dialysis department of our hospital. Patients were divided into two groups: 1xHD (20 pts) and 2xHD (24 pts). They were excluded from the study at the end of study period or earlier if they transitioned to thrice-weekly haemodialysis or died. Patients fluid status and body composition was assessed using results derived from bioimpedance measurements performed using Body Composition Monitor device. Results The 1xHD pts were younger (66,8±11,6 versus 67,4±10 years: P>0.05) and weighed less (74,4±14,7 versus 75,5±11,9 kg, p>0,05) with lower BMI. In both groups there were more males (60% versus 62,5%: P>0,05). The most common cause of ESRD in both groups was nephrosclerosis (45% in 1xHD versus 47,1% in 2xHD, p>0,05), followed by diabetic nephropathy (30% versus 20,8%, p>0,05), obstructive nephropathy (10% versus 8,3%, p>0,05), multiple myeloma (10% versus 8,3%, p>0,05), glomerulonephritis (5% versus 8,3%, p>0,05) and others in 2xHD group (12,5%; polycystic kidney disease and chronic interstitial nephritis). The estimated glomerular filtration rate of all patients at the time of HD initiation was 7,5±2,2 ml/min/1.73m2 (8,2±2,8 in 1xHD group versus 6,9±1,48 ml/ min/1.73m2 in 2xHD group, p>0,05). Baseline daily urine output was similar, 1826,6±344,6 ml/day in 1xHD and 1772,2±343,8 ml/day in 2xHD group (p>0,05). Patients in 1xHD concluded the study after mean period of 13,4 M (min 4 M, max 35 M). At the end of study period only three patients (15%) continued receiving dialysis once-weekly (mean 14,5 M, min 7 M, max 19 M), 12 pts (60%) transitioned to twice-weekly dialysis regime after 2 to 6 M (mean 3,1 M) and continued to receive this dialysis regime until the end of study period. Four pts (20%) transitioned to full-dose dialysis (mean 18,2 M, 11-24 M). Most of the patients in 2xHD group (17; 70,8%) concluded study in the same dialysis regime (mean 20,4 M, 4-24 M), 7 pts (29%) transitioned to full-dose dialysis (mean 12,6 M, 5-21 M) and one patient transitioned to once-weekly HD (8M). At the end of study daily urine output was 1463,1±317,5 in 1xHD versus 1321,1±309,1 ml/day in 2xHD group (p>0,05). Results of assessment of fluid status and body composition at the end of study are in Table 1. We evaluated nutritional status at the end of study: total protein 57,4±8,9 g/l in 1xHD versus 62,8±5,3 g/l in 2xHD, albumin 36,9±10,6 versus 37,6±4,4 g/l, total cholesterol 4,1±1,6 versus 4,4±1,3 mmol/l, triglycerides 1,3±0,8 versus 1,7±0,7 mmol/l (p>0,05 for all parameters). At the end of the study 70% of patients treated with IHD maintained renal function that was sufficient to continue IHD regime with overall survival rate 90% in 1xHD group and 87,5% in 2xHD group. Conclusion IHD, in carefully selected patients with good compliance, provides preservation of UVO and RKF, thus delaying transition to full-dose dialysis and avoiding complications of dialysis, such as intradialytic hypotension and vascular access failure. This type of dialysis is individualized treatment that obtains easier adaptation to dialysis and better quality of life.

P0228THE NEFIGARD TRIAL: THE EFFECT OF NEFECON® (BUDESONIDE) IN PATIENTS WITH PRIMARY IGA NEPHROPATHY AT RISK OF DEVELOPING END-STAGE RENAL DISEASE

Abstract Background and Aims Since the first description of IgA nephropathy (IgAN) over 50 years ago, it has been recognised that the mucosal immune system plays a crucial role in the pathogenesis of this common global cause of kidney failure. Recently, particular attention has focussed on the importance of the gut-associated lymphoid tissue (GALT) as the potential source of the poorly O-galactosylated IgA1 that triggers the formation of nephritogenic immune complexes in IgAN. Pathway analysis based on a large meta-analysis of genome wide association studies identified the intestinal immune network for IgA production as the most enriched KEGG (Kyoto Encyclopedia of Genes and Genomes) pathway in IgAN. Furthermore, separate studies have shown that the IgA in glomerular IgA deposits is indistinguishable from mucosal IgA. The therapeutic potential of selectively targeting GALT was demonstrated in the NEFIGAN trial (NCT01738035), which assessed the safety and efficacy of a novel targeted-release formulation of budesonide (NEFECON®), designed to deliver budesonide to the GALT-rich distal ileum in patients with IgAN. After 9 months’ treatment, urine protein–creatinine ratio (UPCR) was reduced by 29.3% in the NEFECON® 16 mg group compared with the placebo group. Estimated glomerular filtration rate (eGFR) dropped 4.7 ml/min/1.73 m2 in the placebo group with no deterioration seen in the NEFECON® 16 mg group. Incidence of patients reporting adverse events was similar in all groups. These data led to the design of the NefIgArd study which aims to assess the efficacy, safety, and tolerability of NEFECON® 16 mg in patients with IgAN at risk of end-stage renal disease. Method The NefIgArd study is a randomised, double-blind, placebo-controlled Phase 3 trial, with two parts – PART A a 15–35-day screening period, 9-month treatment and 3-month follow-up period; and PART B a 12-month no-treatment follow-up period (Figure). The study is recruiting across 146 nephrology clinics in 19 countries. Patients must be at least 18 years old with biopsy-confirmed primary IgAN and persistent proteinuria >1 g/24 h and eGFR between 35 and 90 ml/min per 1.73 m2 (CKD-EPI) despite optimised renin–angiotensin system blockade. Patients are randomised on a 1:1 ratio to NEFECON® 16 mg/day or placebo. Consistent with the Kidney Health Initiative White Paper “Proteinuria Reduction as a Surrogate End Point in Trials of IgA Nephropathy” published in early 2019, the primary outcome of Part A is to assess the effect of NEFECON® 16 mg on 24 h UPCR at 9 months compared with placebo. The Part B primary outcome is based on data presented at the NKF/FDA/EMA workshop in March 2018 that supported eGFR slope as an endpoint for full approval and will assess the effect of NEFECON® 16 mg on a 2-year eGFR-based endpoint compared with placebo. In comparison with other studies that are recruiting, we believe that the relatively short period required to provide validation of the surrogacy of proteinuria reduction will significantly reduce the risks of non-protocol treatments and loss of patients from the study that could dilute the true treatment effect of NEFECON®. Results As of 1 January 2020, 207 patients have been randomised, and Part A is expected to complete in Q4 2020, with Part B completing in 2022. To ensure the NefIgArd study results are fully translatable to the global IgAN population, NefIgArd will also open in China in 2020. Conclusion The NefIgArd study builds on the experience of the NEFIGAN trial, the largest commercially sponsored study ever completed in IgAN. The design of the NefIgArd study has used state-of-the-art data to evaluate kidney outcomes, using proteinuria as a reasonably likely surrogate of the effect of NEFECON® on long-term kidney outcomes and confirming long-term renoprotection using an NKF/FDA/EMA-suggested eGFR-based endpoint as a basis for full approval.

P1723CLINICAL AND LABORATORY CHARACTERISTICS OF RENAL TRANSPLANT PATIENTS WITH AA AMYLOIDOSIS IN A TERTIARY CENTER IN TURKEY

Abstract Background and Aims Despite improved therapeutic regimens, AA amyloidosis is still associated with higher risk of mortality after renal transplantation (RT). Moreover the clinical, laboratory characteristics and prognostic factors remain poorly understood. We aimed to identify predictive parameters of prognosis, investigate the etiology, clinical and laboratory features of renal transplant patients with biopsy proven AA amyloidosis. Method We conducted a retrospective study using twenty-eight renal transplant patients with AA amyloidosis and twenty-eight renal transplant control patients without amyloidosis matched for age and time after transplantation that were regularly followed in University of Ankara School of Medicine Nephrology Department between October 2018-October 2019. Causes of AA amyloidosis, treatment (colchicine and/ or anti-interleukin (IL) 1 treatment) and number of Familial Mediterranean Fever (FMF) attacks in the last year in case of FMF, biochemical values such as mean CRP, hemoglobin, serum albumin, proteinuria, glomerular filtration rate (GFR), serum creatinine levels were compared between groups. Results In amyloidosis and non-amyloiodosis group, the mean age was 44±13 and 44±12 years; 57% and 54% were males, mean time after transplantation was 95±64 and 93±12 month, respectively. FMF was found as the most common cause of AA amyloidosis (86%). All FMF patients received colchicine and eight (33%) FMF patients with AA amyloidosis with insufficient response to colchicine were treated with anti-IL-1 agents. The mean colchicine dose was 0,92±0,34 mg/day. The mean GFR were 63±24 ml/dk/1,73 m2 in amyloidosis and 71±19 ml/dk/1,73 m2 in non amyloidosis group, (p=0.195). The most important finding of present study was significantly higher CRP levels in patients with AA amyloidosis compared to non-amyloidosis group (15,12±15,16 mg/L vs 6,59±8,20 mg/L, p=0,011, respectively). Conclusion In this study, we found higher CRP levels in renal transplant patients with AA amyloidosis which indicates persistent ongoing chronic inflammation among these patients. Figure Clinical and Laboratory Characteristics of Patient Groups

The Effects of Intensive Versus Routine Treatment in Patients with Acute Kidney Injury.

In patients with acute kidney injury (AKI), specialized treatment-initiated in response to an early-warning system- may be beneficial compared with routine treatment. To explore effect estimators in a pilot trial (DRKS00010530), patients with AKI on regular wards of a university hospital were treated either in the usual way (control group) or more intensively (intervention group). The subjects were allotted randomly to the two treatment groups. The more intensive treatment consisted of an early warning system for a rise in the serum creatinine concentration, immediate consultation of a specialist, and the issuance of a patient kidney passport. The primary endpoint was recovery of renal function after AKI during the index hospitalization. Renal complications and process indicators were the secondary endpoints. The proportion of patients whose renal function returned to baseline after AKI was 50% in the intervention group (N = 26) and 42% in the control group (N = 26) (odds ratio 1.4, 95% confidence interval [0.5; 4.0], p = 0.58). The calculated glomerular filtration rate went down, from hospital admission to discharge, by 3 mL/min/1.73 m2 (1st-3rd quartile: [6; -20]) in the intervention group and by 13 mL/min/1.73 m2 in the control group (1st-3rd quartile: [0; -25]; p = 0.09). Complications of AKI such as hyperkalemia, pulmonary edema, and renal acidosis were rarer in the intervention group (15% versus 39%; p = 0.03). In the intervention group, compared with the control group, the cause of AKI was identified more frequently (27% versus 4%; p = 0.05); drugs with relevance to the kidney were discontinued more frequently (65% versus 31%; p = 0.01); and the diagnosis of AKI was more frequently documented in the patient's chart (58% versus 37%; p = 0.03). Specialized consultations supported by an early warning system for AKI seem to be beneficial for patients. The findings of this pilot trial should be verified in larger-scale randomized controlled trials.

Partial vs. radical nephrectomy and the risk of all-cause mortality, cardiovascular, and nephrological outcomes.

The study's objective was to examine the effects of renal-preservation surgery on long-term mortality, cardiovascular outcomes, and renal-related outcomes. We performed a retrospective cohort study of all partial (n=575) and radical nephrectomies (n=882) for tumors ≤7 cm in diameter between 2002 and 2010 across three academic centers in Ontario, Canada. We linked records from provincial databases to assess patient characteristics and outcomes (median seven years' followup using retrospective data). A weighted propensity score was used to reduce confounding. The primary outcome was all-cause mortality. Secondary outcomes included hospitalization with major cardiovascular events, non-cancer related mortality, kidney cancer-related mortality, and dialysis. Mean one-year postoperative estimated glomerular filtration rate (eGFR) was 71 mL/min/1.73 m2 in the partial group and 52 mL/min/1.73 m2 in the radical group. Partial nephrectomy was associated with a lower risk of all-cause mortality in the first five years after surgery (hazard ratio [HR] 0.42, 95% confidence interval [CI] 0.27-0.66), which did not extend beyond five years (HR 1.01, 95% CI 0.68-1.49). Kidney cancer-related mortality was lower in the partial compared to the radical group for the first four years after surgery (HR 0.16, 95% CI 0.04-0.72). There were no significant differences between the groups for cardiovascular outcomes or non-cancer related deaths. Overall survival and cancer-specific survival was reduced in radical nephrectomy patients. However, despite reduced renal function in the radical nephrectomy group, non-cancer-related death, cardiovascular events, and dialysis were not significantly different between groups. Long-term benefits of partial nephrectomy may be less than previously believed.

Local orthodontic force initiates widespread remodelling of the maxillary alveolar bone

Abstract Objectives To clarify the effects of a local orthodontic force on alveolar bone by analysing bone remodelling in different regions of the maxilla during orthodontic tooth movement (OTM). Methods An OTM model was established in rats. Histological changes in the maxilla were analysed using TRAP staining, IHC staining for CTSK and haematoxylin and eosin (H and E) staining. The root bifurcation region of the alveolar bone of the first (M1), second (M2) and third (M3) molars were selected as the regions of interest (ROIs), which were further divided into a cervical and an apical level. Sequential fluorochrome labelling was performed to analyse bone deposition rates. Results The maxillary left first molars were moved mesially. TRAP staining and IHC staining for CTSK showed orthodontic force increased osteoclast numbers in all six ROIs at both the cervical and apical levels. H and E staining indicated elevated osteoblast numbers in the OTM group in all induced regions. Sequential fluorochrome labelling exhibited increased bone deposition rates around M1, M2 and M3 in the OTM group. Conclusions An orthodontic force applied to the first molar could initiate widespread remodelling of the maxillary alveolar bone, which was not restricted to the tension and pressure sites. This may revise the orthodontic biomechanical theory and provide new insights for clinical work.

Clinical Study of Standard- vs Reduced-Dose Tacrolimus Combined With Generic Mycophenolate Mofetil in De Novo Kidney Transplantation: A Prospective Randomized Trial

BackgroundThe lowering of calcineurin inhibitor exposure is possibly considered as the proper strategy to prevent calcineurin inhibitor–induced nephrotoxicity in kidney transplant. This clinical study was designed to compare the efficacy and tolerability of reduced-dose tacrolimus with standard-dose mycophenolate mofetil (MMF) vs standard-dose tacrolimus with reduced-dose MMF. MethodsA prospective, multicenter, open-label, randomized, and parallel-group clinical trial was conducted at 4 transplant centers in Korea. A total sample size was 108, and eligible patients were randomly assigned in a 1:1 ratio to either reduced-dose tacrolimus with standard-dose MMF (the study group) or standard-dose tacrolimus with reduced-dose MMF (the control group) for 6 months in de novo kidney transplant recipients. Graft function, the incidence of efficacy failure, and adverse events were compared. ResultsThe mean estimated glomerular filtration rate at 6 months post-transplantation was 69.83 ± 16.68 mL/min/1.73 m2 in the study group and 69.92 ± 17.55 mL/min/1.73 m2 in the control group (P > .05). The overall incidence of biopsy-proven acute rejection was 3.64% (n = 2) in the study group, compared to 3.77% (n = 2) in the control group (P > .05). There was no graft loss, death, or loss of follow-up in either group. ConclusionIn conclusion, the results suggest that tacrolimus minimization with standard-dose MMF provides adequate immunosuppression with proper renal function and similar rate of incidence of acute rejection compared with the regimen including standard-dose tacrolimus with reduced-dose MMF.

Discontinuation of Proton Pump Inhibitors in Patients With Chronic Kidney Disease.

Purpose: Proton pump inhibitors (PPIs) are commonly used medications and are historically well tolerated. Recent studies have linked PPI use to the development of chronic kidney disease (CKD) and end-stage renal disease. This study investigated the impact of discontinuing PPIs on renal function in patients with CKD. Methods: We conducted a retrospective chart review of patients with established CKD, defined as 2 eGFR (estimated glomerular filtration rate) measurements of less than 60 mL/min/1.73 m2 at least 90 days apart, who were on a PPI from January 1, 2014 to December 31, 2014, with a medication possession ratio greater than or equal to 70%. We compared baseline eGFR to a final eGFR after at least 6 months of discontinuation or continuation of a PPI. After power analysis, we targeted an enrollment of 200 patients (100 in each group) to achieve a power of 0.80 and an alpha of 0.05. Summary: A total of 97 patients in the PPI discontinuation group and 100 patients in the PPI continuation group met the study inclusion criteria. Baseline eGFR in the PPI continuation group was 47.9 mL/min/1.73 m2 and 50.7 mL/min/1.73 m2 in the discontinuation group. Final eGFR in the PPI continuation group was significantly higher than baseline at 51.1 mL/min/1.73 m2 (+3.25 ± 12.8, P = .01). Final eGFR in the PPI discontinuation group was 51.8 mL/min/1.73 m2 (+1.09 ± 12.8, P = .3). The average time between baseline and final eGFRs was 270 days in the PPI continuation group and 301 days in the discontinuation group. There was no statistically significant difference in the change in eGFRs between groups (95% confidence interval [CI] = -5.48-2.03, P = .37). Conclusions: Proton pump inhibitor discontinuation after prolonged continuous use in patients with CKD was not associated with a significant change in renal function after 1 year.

Microwave Thermal Ablation versus Open Partial Nephrectomy for the Treatment of Small Renal Tumors in Patients Over 70 Years Old.

Background and objectives: Microwave thermal ablation (MWT) is one of the treatment options for kidney cancer. However, for patients over 70 years old the safety and oncological efficacy of this treatment is still controversial. The goal of this study was to compare MWT with open partial nephrectomy (OPN) and to find out whether MWT is preferable in maintaining patient renal function and reducing the risk of postoperative complications. Materials and Methods: Depending on the treatment choice, all patients were divided into two groups: an MWT group and an open kidney resection (OPN) group. Data have been retrospectively collected for 7 years, starting with January 2012 up to January 2019. A total number of 33 patients with exophytic, single small renal masses were treated with either OPN (n = 18) or MWT (n = 15). All patients had histologically proven T1 kidney cancer. MWT was performed for patients who refused to have OPN or in those cases where the collecting system, renal calyx, and great vessels were free from tumor margins of more than 1 cm. Results: In the MWT group a median (IQR) patients’ age was 75 years (71–79) years, in the OPN group—71.5 (70–75) years, p = 0.005. A median (IQR) Charleston comorbidity index in the MWT group was 7.5 (5–10) and in the same way in the OPN group it was 5.22 (5–6), p = 0.005. A median (IQR) estimated glomerular filtration rate (eGFR) before surgery was higher in the MWT group 59.9 (49.5–73.8) mL/min/1.73 m2 vs. 46.2 (42.7–65.8) mL/min/1.73 m2 in the OPN group, p = 0.12. Three days following the surgery a median (IQR) eGFR was 56.45 (46.6–71.9) in MWT group mL/min/1.73 m2 vs. 43.45 (38.3–65) mL/min/1.73 m2) in the OPN group, p = 0.30. A median (IQR) of primary hemoglobin level was lower in the MWT group compared with the OPN group (134.5 (124–140) g/L vs. 125 (108–138) g/L), p = 0.41. However, after the surgery a median (IQR) lower hemoglobin level was detected in the OPN group (123.5 (111–134) g/L vs. 126 (112–135)), p = 0.53. The median (IQR) duration of the procedure in MWT group was shorter compared with the OPN group (26 (25–30) min vs. 67.5 (55–90) min), p < 0.0001. A median (IQR) hospitalization time was shorter in MWT group (3 (2–3) days vs. 89 (7–11.5) days), p < 0.0001. Pain by the visual analogue scale (VAS) scale the first day after surgery was significantly lower—median (IQR) in the MWT group was 2 (1–3) vs. 4 (3–6)), p = 0.008. Treatment failure rate was numerically higher in MWT (1/15 vs. 0/18, p = 0.56). Conclusions: Pain level on the next day after surgery, mean number of hospitalization and operation time were significantly lower in the MWT group than in the OPN group. The blood loss estimated glomerular filtration rate and oncologic data between the two groups was not statistically significant.

Quantifying lead time bias when estimating patient survival in preemptive living kidney donor transplantation.

Preemptive kidney transplantation is the preferred initial renal replacement therapy, by avoiding dialysis and reportedly maximizing patient survival. Lead time bias may account for some or all of the observed survival advantage, but the impact of this has not been quantified. Using the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, we included adult recipients of living donor kidney transplants during 1998-2017. Patients were transplanted preemptively (n=1435) or after receiving up to 6months of dialysis (n=712). We created a matched cohort using propensity scores, and accounted for lead time (dialysis and estimated predialysis) using left-truncated Cox models with the primary outcome of patient survival. The median eGFR at transplantation was 6.9mL/min per 1.73 m2 in the non-pre-emptive, and 9.6mL/min per 1.73 m2 in the preemptive group. In the matched cohort (n=1398), preemptive transplantation was not associated with a survival advantage hazard ratio (HR) for preemptive vs non-pre-emptive 1.12 (95% confidence interval [CI] 0.79-1.61). Accounting for lead time moved the point estimates toward a survival disadvantage for preemptive transplantation (eg, HR assuming 4mL/min per 1.73m2 /year eGFR decline, 1.21 [0.85, 1.73]), but in all cases the 95% CIs crossed 1. The optimal timing of preemptive living donor kidney transplantation requires further study.

Effect of dietary sodium intake on residual renal function in patients undergoing peritoneal dialysis: a prospective study of 33 cases

To explore the impact of dietary sodium-intake on residual renal function in patients undergoing peritoneal dialysis (PD). Thirty-three patients on PD with stable dialysis were regularly followed up for 12 months. The daily sodium intake of the patients was calculated based on the 3-day dietary record. Based on the mean daily sodium intake, the patients enrolled were divided into low-salt group (sodium intake≤3.0 g/day, 19 patients) and high-salt group (sodium intake&gt;3.0 g/day, 14 patients). The baseline data of the patients were recorded, and the indicators of residual renal function and peritoneal function were regularly tested. The patients were followed-up at 3-month intervals, and their urine volume, peritoneal ultrafiltration volume and other clinical indicators were recorded and the biochemical indexes were detected to evaluate the changes in the residual renal function and peritoneal function. There was a positive correlation between the total sodium excretion and dietary sodium intake in these patients (r=0.536, P=0.0013), and sodium excretion by dialysis was positively correlated with their sodium intake (r=0.901, P=0.000). Regression analysis suggested that the total sodium excretion was correlated with dietary sodium intake (β=0.416, 95% CI: 0.170-0.666; P &lt; 0.0018); sodium excretion by dialysis was associated with dietary sodium intake (β=0.489, 95% CI: 0.395-0.582; P &lt; 0.001). The residual renal function was reduced by 17.48±11.22 L /(w·1.73 m2) in the low-salt group, as compared to 30.20±18.30 L /(w·1.73 m2) in the high-salt group (P=0.032). The reduction in the residual renal function was correlated with sodium intake in the PD patients (r=0.409, P=0.018). Multivariate regression analysis showed that sodium intake was an independent factor contributing to the reduction of residual renal function (β=14.646, 95% CI 7.426-21.866, P &lt; 0.001). Sodium excretion by PD in patients with continuous ambulatory PD is positively correlated with their dietary sodium intake, which contribute to the decrease of residual renal function. A high dietary sodium intake may accelerate the reduction of residual renal function in these patients.

How to estimate renal function in patients with liver disease: choosing the most suitable equation.

Hepatitis B virus (HBV) infection is a public health challenge, especially in China. In clinical practice, HBV infection is associated with nephropathy. Impaired renal function is frequently observed in compensated Chronic Hepatitis B (CHB) and cirrhosis (LC). Thus, renal function must be monitored to avoid nephrotoxic effects before and during nucleoside analog treatment. Investigating the predictive markers of early renal dysfunction is essential. New GFR-predicting equations, based on Pcr and/or CystC, have been recently recommended in the general population, but their performance in liver disease patients has been rarely studied. In this study, we will discuss how to detect renal dysfunction in patients with HBV infection. A total of 16 LC patients and 23 CHB patients were enrolled in this study, and we collected and compared the clinical data of the two groups. The estimated glomerular filtration rates (eGFRs) were also calculated by several equations. All patients received 99mTc-DTPA dynamic radionuclide imaging examinations to obtain mGFRs as the reference standard. To evaluate the performance of any equation in the CHB and LC groups, paired t test, Pearson's correlation, Kappa analysis and Bland-Altman plots were utilized. Moreover, all 39 subjects were divided into two groups (according to GFR > 90mL/min/1.73m2). We compared the serum and urinary markers of kidney injury between the two groups and selected the indicators of renal injury by univariate analysis. The mGFR was 72.26 ± 20.69mL/min/1.73m2 in the LC group, and 87.49 ± 25.91mL/min/1.73m2 in the CHB group. The paired t test results of eGFR and mGFR showed no difference between eGFR (estimated by the CHINAcr-cys equation) and mGFR (p > 0.05) in the compensated LC and CHB groups. The difference between mGFR and eGFR estimated by other methods was obvious (p < 0.05). Comparing the eGFRs (estimated by 5 different equations) with mGFR in the compensated LC and CHB groups, Pearson's correlation showed that only eGFR (estimated by the CHINAcr-cys equation) had a significant correlation coefficient in CHB (r = 0.678, p = 0.000) and had the highest R2 (R2 = 0.459) among all other measures. The kappa consistency test showed that eGFR from CHINAscr-cys had poor consistency with mGFR in the compensated LC group but moderate consistency in the CHB group. Bland-Altman consistency analysis showed that in the CHB group, the CHINAcr-cys and CKD-EPIcr equations presented narrower acceptable limits than did the aMDRD, c-aMDRD, and CKD-EPIcr-cys equations (62.8, 56.1 vs .85.7, 102.9, 93.6mL/min per 1.73m2). In the compensated LC group, the CHINAcr-cys and CKD-EPIcr equations presented narrower acceptable limits than did the aMDRD, c-aMDRD, and CKD-EPIcr-cys equations (83.6, 81.3 vs. 98, 113.5, 106.3mL/min per 1.73m2). Serum or urinary markers were compared with renal function (GFR > 90mL/min/1.73m2) and showed International normalized ratio (INR) (p = 0.009), creatinine (p = 0.006), urine N-acetyl-β-glucosaminidase (NAG) (p = 0.001) and serum cystatin C (CysC) (p = 0.044). The CHINAcr-cys equation may be more suitable for the estimation of GFR in Chinese patients with CHB or compensated cirrhosis. INR, creatinine, NAG, and CysC are proper biomarkers for screening renal dysfunction in Chinese patients with CHB or compensated LC.

Steroid pretreatment of organ donors does not impact on early rejection and long-term kidney allograft survival: Results from a multicenter randomized, controlled trial.

Steroid pretreatment of deceased donors reduces inflammation in allografts and is recommended by organ procurement guidelines. The impact on long‐term graft outcome, however, remains elusive. In this multicenter randomized controlled trial, 306 deceased donors providing organs for 455 renal transplant recipients were randomized to 1000 mg of methylprednisolone or placebo prior to organ procurement (ISRCTN78828338). The incidence of biopsy‐confirmed rejection (Banff>1) at 3 months was 23 (10%) in the steroid group and 26 (12%) in the placebo group (P = .468). Five‐year functional graft survival was 84% and 82% for the steroid group and placebo group, respectively (P‐value = .941). The hazard ratio of functional graft loss was 0.90 (95% confidence interval 0.57‐1.42, P = .638) for steroid vs placebo in a multivariate Cox model. We did not observe effect modification by any of the predictors of graft survival and treatment modality. A robust sandwich estimate was used to account for paired grafts of some donors. The mean estimated GFR at 5 years was 47 mL/min per 1.73 m2 in the steroid group and 48 mL/min per 1.73 m2 in the placebo group (P = .756). We conclude that steroid pretreatment does not impact on long‐term graft survival. In a donor population with higher risk of delayed graft function, however, repetitive and higher doses of steroid treatment may result in different findings.

Effect of midazolam, propofol, and dexmedetomidine on postoperative cognitive dysfunction after cardiac surgery in the elderly

Background Postoperative cognitive dysfunction (POCD) is among the most prevalent and serious life-threatening postoperative complications. Aim The primary outcome was to compare the efficacy of dexmedetomidine, propofol, and midazolam on prevention of POCD during cardiac surgery in the elderly. The secondary outcome is to determine possible complications during the first postoperative day. Patients and methods Ninety elderly patients undergoing cardiac surgery were randomly divided during the cardiopulmonary bypass period into three equal groups. group M: received midazolam 0.1 mg/kg/h, group P: received propofol 1 mg/kg/h, and group D: received dexmedetomidine 0.5 µg/kg/h. Mini-Mental State Examination (MMSE), incidence of POCD, and interleukin 6 (IL-6) were recorded on the day before surgery (M0, F0, L0, respectively), 1 h after extubation (M1, F1, L1, respectively), and 1 week postoperatively (M2, F2, L2, respectively). POCD was diagnosed when the MMSE score decreased two points or more from the preoperative value. Adverse effects (hypotension, bradycardia, laryngospasm, postoperative nausea and vomiting, and hypertension) were recorded. Results As regards MMSE, there were no significant differences among groups except at M1 where it was higher in group D than the other two groups. In groups M and P only, MMSE was significantly higher at M1 than M0 and returned to near preoperative value at M2 in the same group. There were no significant differences regarding the incidence of POCD at F0, F1, and F2. There were no significant differences with respect to blood IL-6, among groups except at L1 where it was significantly higher in both group M and group P than group D. In groups M and P only, IL-6 was significantly higher at L1 than L0 and then returned to near preoperative value at L2 in the same group. Conclusion Dexmedetomidine was a good choice for reducing POCD in cardiac surgery in elderly patients with less side effects.

Clinicopathological characteristics and renal outcomes of childhood-onset lupus nephritis with acute kidney injury: A multicenter study

Objectives: Acute kidney injury (AKI) at onset of adult systemic lupus erythematosus (SLE) is a risk factor for end stage kidney disease (ESKD). However, data on childhood-onset lupus nephritis (LN) with AKI are scarce.Methods: We retrospectively reviewed the complete files of pediatric SLE patients from 1995 to 2010. All patients underwent kidney biopsy promptly after diagnosis.Results: Thirty-six patients (10 males and 26 females) were enrolled. Mean age at diagnosis and observation period were 11.6 ± 2.4 and 8.1 ± 4.4 years, respectively. Seven patients had AKI at onset of SLE. Compared with those without AKI, patients with AKI had significantly higher proportions of pathologically proliferative LN. Only one patient with AKI progressed to ESKD without complete recovery of renal function. Overall and renal survival rates were 100and 97.2%, respectively. There was no significant difference in estimated glomerular filtration rate at the final visit (85ml/min/1.73 m2 in the AKI group vs. 103.2 ml/min/1.73 m2 in the non-AKI group; p = .11).Conclusion: Our study demonstrated favorable renal outcomes in childhood-onset LN with AKI in the near to midterm period. Inducing complete remission may be important for preserving renal function.

Pengaruh Edukasi Pola Makan dan Senam terhadap Kadar Gula Darah Pada Penderita DM Tipe 2

The high prevalence of diabetes mellitus (DM) type 2 one risk factor is an unhealthy lifestyle, especially an unhealthy diet and lack of physical activity. Education followed by physical activity required to provide benefits to the body as a way of exercise can lower blood sugar. The recommended physical activity such as gymnastics, Gymnastics is aerobic physical exercise with a series of movements in a way to follow the rhythm of the music. The study aims to determine the effect of diet and exercise education on blood sugar levels in people with type 2 dm in Bengkulu City Puskesmas Lingkar Timur years 2018. This quasi-experimental research design.consists of 30 intervention and 30 control group. Gymnastics held 3 times a week for 1 week and education 1 time for 1 week, with an examination of the blood sugar levels of pretest and posttest. Data collection equipment consists of glucometers and bathroom scales and microtoice. The used statistical test Chi-Square test, t-dependent, and t-independent. The results of the study the characteristics of most women, age range 40-70 years intervention group and a control group 32-79 years, the average BMI in the intervention group is 24.21 m2 and 24.33 m2 in the control group, the intervention group showed that the levels of blood sugar before an average of 271.90 mg/dl, while the results of the blood sugar level after an average of 225.93 mg/dl. in the control group blood sugar levels before an average of 278.27 mg/dl whereas the blood sugar level results after an average of 285.67 mg/dl. Based on the statistical test that no educational influence diet and exercise on blood sugar levels in patients with type 2 dm p-value of 0.002. Expected to Type 2 diabetic patient's diet, increasing exercise and increased activity at home.

Our Experience of Patients with Juvenile Nephronophthisis After Renal Transplantation

Introduction Juvenile nephronophthisis (NPHP), an autosomal recessive tubulointerstitial nephropathy, accounts for 10%–20% of renal failure cases in childhood. Treatment of patients with NPHP is symptomatic. Kidney transplantation is the treatment of choice when ESRD is established. We report herein our center's experience with kidney transplantation for children with juvenile NPHP. Materials and Methods We retrospectively analyzed medical records of 142 renal transplant patients. We compared donor types, dialysis modality and duration, immunosuppressive treatment, acute rejection rate and outcomes of the patients with (group 1) and without (group 2) juvenile nephronophthisis. Results Seventeen (11.9%) had primary juvenile nephronophthisis diagnosis. Of the 17 NPHP patients (group 1), 5 (31.2%) received a cadaveric donor and 12 (68.7%) received a living related donor transplantation. Of the 125 without NPHP patients (group 2), 23 (17.6%) received a cadaveric donor and 102 (82.3%) received a living related donor. The mean age of the patients in group 1 was 149.56±50.33 months and 154.36±58.59 months in group 2 (P=.75). The mean follow-up period was 60.18±35.86 months in group 1, 46.35±30.51 months in group 2 (P=.09). There was no significant difference between groups in terms of dialysis modality and duration of dialysis and immunosuppressive treatment. Although the rate of acute rejection (11% vs 28.4%) and graft loss (5.25% vs 10.2%) were found lower in patients with NPHP, the difference was not statistically significant. Both groups had similar glomerular filtration rates post-transplant at 1 and 5 years (95.95±21.10 and 83.79±28.98 mL/min/1.73 m2 in group 1; 89.79±30.55 and 84.83±29.38 mL/min/1.73 m2 in group 2, respectively). Conclusions We observed preserved graft functions for long periods and we can say that post-transplant prognosis is good among renal transplant recipients with juvenile NPHP.

CSF3R Mutations are frequently associated with abnormalities of RUNX1, CBFB, CEBPA, and NPM1 genes in acute myeloid leukemia

Mutations in the colony-stimulating factor 3 receptor (CSF3R) gene occur frequently in chronic neutrophilic leukemia and are rare in de novo acute leukemia. The objective of this study was to assess the incidence of CSF3R mutations in acute leukemia and their association with other genetic abnormalities. Amplicon-targeted, next-generation sequencing of 58 genes was performed retrospectively on 1152 patients (acute myeloid leukemia [AML], n = 587; acute lymphoid leukemia [ALL], n = 565). Reverse transcriptase-polymerase chain reaction analysis was used to detect 35 leukemia-specific gene fusions. CSF3R mutations (26 patients) were detected in 3.6% (13 of 364 patients), 4.6% (8 of 175 patients), and 8.3% (4 of 48 patients) of those with de novo, relapsed, and secondary AML, respectively, and in 0.2% (1 of 565 patients) of those with ALL. In total, 9 distinct CSF3R mutations were detected. Membrane-proximal missense mutations and cytoplasmic truncations were identified as mutually exclusive. The proportion of patients who had French-American-British subtypes M2 and M4 in the CSF3R-mutated group was significantly greater than that in the CSF3R wild-type group for both the de novo AML cohort (P = .001) and the relapsed AML cohort (P = .024). All de novo and relapsed AMLs with CSF3R mutations were associated with genetic alterations in transcription factors, including RUNX1-RUNX1T1, CBFB-MYH11, double-mutated CCAAT/enhancer binding protein α (CEBPAdm), and NPM1 mutations; and core-binding factor gene abnormalities and CEBPAdm accounted for 90.5% (19 of 21 patients). CSF3R mutations are uncommon in AML; however, when they occur, they are often associated with core-binding factor gene abnormalities and CEBPAdm. An in-depth understanding of the interaction between these genetic alterations could facilitate a clearer understanding of the role of CSF3R mutations in AML development and may be used for disease classification, prognosis, and the development of targeted therapy.

Effect of Coaching to Increase Water Intake on Kidney Function Decline in Adults With Chronic Kidney Disease

In observational studies, increased water intake is associated with better kidney function. To determine the effect of coaching to increase water intake on kidney function in adults with chronic kidney disease. The CKD WIT (Chronic Kidney Disease Water Intake Trial) randomized clinical trial was conducted in 9 centers in Ontario, Canada, from 2013 until 2017 (last day of follow-up, May 25, 2017). Patients had stage 3 chronic kidney disease (estimated glomerular filtration rate [eGFR] 30-60 mL/min/1.73 m2 and microalbuminuria or macroalbuminuria) and a 24-hour urine volume of less than 3.0 L. Patients in the hydration group (n = 316) were coached to drink more water, and those in the control group (n = 315) were coached to maintain usual intake. The primary outcome was change in kidney function (eGFR from baseline to 12 months). Secondary outcomes included 1-year change in plasma copeptin concentration, creatinine clearance, 24-hour urine albumin, and patient-reported overall quality of health (0 [worst possible] to 10 [best possible]). Of 631 randomized patients (mean age, 65.0 years; men, 63.4%; mean eGFR, 43 mL/min/1.73 m2; median urine albumin, 123 mg/d), 12 died (hydration group [n = 5]; control group [n = 7]). Among 590 survivors with 1-year follow-up measurements (95% of 619), the mean change in 24-hour urine volume was 0.6 L per day higher in the hydration group (95% CI, 0.5 to 0.7; P < .001). The mean change in eGFR was -2.2 mL/min/1.73 m2 in the hydration group and -1.9 mL/min/1.73 m2 in the control group (adjusted between-group difference, -0.3 mL/min/1.73 m2 [95% CI, -1.8 to 1.2; P = .74]). The mean between-group differences (hydration vs control) in secondary outcomes were as follows: plasma copeptin, -2.2 pmol/L (95% CI, -3.9 to -0.5; P = .01); creatinine clearance, 3.6 mL/min/1.73 m2 (95% CI, 0.8 to 6.4; P = .01); urine albumin, 7 mg per day (95% CI, -4 to 51; P = .11); and quality of health, 0.2 points (95% CI, -0.3 to 0.3; P = .22). Among adults with chronic kidney disease, coaching to increase water intake compared with coaching to maintain the same water intake did not significantly slow the decline in kidney function after 1 year. However, the study may have been underpowered to detect a clinically important difference. clinicaltrials.gov Identifier: NCT01766687.

MP59-03 A MULTICENTRE ANALYSIS OF THE ROLE OF THE G8 SCREENING TOOL IN THE ASSESSMENT OF PERI-OPERATIVE AND FUNCTIONAL OUTCOME IN ELDERLY PATIENTS WITH KIDNEY TUMOURS

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy VI1 Apr 2018MP59-03 A MULTICENTRE ANALYSIS OF THE ROLE OF THE G8 SCREENING TOOL IN THE ASSESSMENT OF PERI-OPERATIVE AND FUNCTIONAL OUTCOME IN ELDERLY PATIENTS WITH KIDNEY TUMOURS Tommaso Silvestri, Nicola Pavan, Riccardo Boschian, Giacomo Di Cosmo, Bernardino De Concilio, Antonio Celia, Giovanni Liguori, and Carlo Trombetta Tommaso SilvestriTommaso Silvestri More articles by this author , Nicola PavanNicola Pavan More articles by this author , Riccardo BoschianRiccardo Boschian More articles by this author , Giacomo Di CosmoGiacomo Di Cosmo More articles by this author , Bernardino De ConcilioBernardino De Concilio More articles by this author , Antonio CeliaAntonio Celia More articles by this author , Giovanni LiguoriGiovanni Liguori More articles by this author , and Carlo TrombettaCarlo Trombetta More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1855AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Increasing life expectancy in the general population and the fact that a disproportional burden of cancer occurs in people age ≥ 65 years old have generated great interest in delivering better cancer care for older adults. EORTC and NCCN recommend that all patients with cancer age ≥ 70 years old should undergo some form of geriatric assessment. G8 Screening Tool is a robust geriatric tool to identify a geriatric risk profile and for prediction of functional decline and prognostic information for overall survival. We evaluated the role of G8 Screening Tool in the assessment of outcome of elderly patients (≥ 70 y.o.) underwent surgery for kidney tumours. METHODS We prospectively enrolled 162 patients (≥ 70 years old at surgery date) from January 2012 to January 2016 underwent surgery at two urological institution.G8 Screening Tool was applied to each patient before surgery. We divided population into two groups (frail group vs. not-frail group) in relation to the geriatric risk profile based on G8 score (≤14 vs. > 14 respectively). The aim was to identify the role of G8 Score in predicting intraoperative, postoperative complications and functional outcomes. RESULTS A total of 70 females (34%) and 92 (46%) males were included in the analysis. 69 patients (42,6%) underwent PN, while 93 patients (57,4%) underwent RN. Mean age at surgery was 76.57 (SD±6,37). Comorbidity factors were included: mean CCI was 3.06 (SD±1,99) with CCI > 5 points in 18 patients (15,65%), mean BMI was 25,15 (SD±2,87), 55 patients (34%) with DM, 98 patients (60%) with HTN. CKD stage III was present in 73 patients (45,1%) underwent surgery. Mean ECOG PS was 1,53 (SD±0,66) with score ≥ 3 in 7 patients (6,1%). Mean ASA Score was 2,84 (SD±0,73). According to the G8 Score, 91 patients (60%) were included in the frail group and 71 (40%) in the not-frail group. 41 patients of frail group vs. 2 patients of not-frail group developed intraoperative complications (p<0,0001). 51 patients of frail group vs. 4 patients of not-frail group developed postoperative complications (p<0,0001). After a mean follow-up of 40,56 months, mean eGFR was 43,72 ml/min/1.73m2 (SD±21,49) in frail group vs. 47,53 ml/min/1.73m2 (SD±13,36) in not-frail group (p=0,015). CONCLUSIONS G8 Screening Tool seems to be an effective and useful instrument to predict the risk of complications and functional outcomes in elderly patients candidate for kidney surgery. However, further investigations should be necessary to confirm the good potential of this tool. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e782 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Tommaso Silvestri More articles by this author Nicola Pavan More articles by this author Riccardo Boschian More articles by this author Giacomo Di Cosmo More articles by this author Bernardino De Concilio More articles by this author Antonio Celia More articles by this author Giovanni Liguori More articles by this author Carlo Trombetta More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...