Mortality In HD Patients Research Articles

#4818 IMPACT OF COMBINED PHYSICAL FRAILTY AND DEPRESSIVE SYMPTOMS ON MORTALITY IN PATIENTS ON HEMODIALYSIS

Abstract Background and Aims Patients receiving hemodialysis [HD] are getting older, with 38.8% of patients in Japan being 75 years or older. HD patients also have multiple comorbidities, which are known to be associated with poor clinical outcomes, especially in the older patients. Moreover, physical frailty and depressive symptoms are common in HD patients and these are known to be risk factors for poor prognosis. However, it is unclear whether the coexistence of physical frailty and depressive symptoms contributes to an increased risk of mortality in older patients with multiple comorbidities. As a result, the goal of this study was to look at the relationship between physical frailty and depressive symptoms and mortality in HD patients of different ages. Method This study included 409 Japanese outpatients with HD (mean age 65.9 years, 62.6% male, and 2.0 years of hemodialysis history). Slow walking speed and/or weak hand grip strength were used to define physical frailty. The Center for Epidemiological Studies-Depression scale was used to assess depressive symptoms. Patients were divided into four groups: (1) no depressive symptoms, no physical frailty; (2) depressive symptoms, no physical frailty; (3) no depressive symptoms, physical frailty; and (4) depressive symptoms, physical frailty. All-cause mortality was the outcome; Cox regression analysis was performed, with analysis stratified by age group (<75 years, ≥75 years) to examine differences by age. Results Physical frailty and depressive symptoms were prevalent in 268 (65.5%) and 143 (35.0%) of the population, respectively. Physical frailty and depressive were present in 103 people (25.2%). 129 (31.5%) people died during the follow-up period (median 49 months). In all patients, Cox regression analysis revealed that physical frailty and no depressive symptoms (hazard ratio [HR], 1.86, 95% confidence interval [CI], 1.01–3.44) and coexistence of physical frailty and depressive symptoms (HR, 2.30, 95% CI, 1.23–4.28) were significantly associated with an increased risk of death. In the <75-year-old group, a combination of physical frailty and depressive symptoms was significantly associated with an increased risk of death (HR, 2.45; 95% CI, 1.23–4.88). In the ≥75-year-old group, however combined physical frailty and depressive symptoms were not significantly associated with mortality (HR, 2.06; 95% CI, 0.34–12.55), whereas C-reactive protein was (HR, 1.59; 95% CI, 1.10–2.28). Conclusion Physical frailty and depressive symptoms were common in HD patients. In terms of prognosis, the coexistence of physical frailty and depressive symptoms were linked to mortality in the <75-year-old group, whereas in the <75-year-old group, the coexistence of physical frailty and depressive symptoms was not associated with death, but higher inflammation was associated.

#6287 EFFECT OF REMOTE ISCHEMIC PRECONDITIONING ON NUTRITIONAL STATUS, COGNITIVE FUNCTION, AND BONE IN HEMODIALYSIS PATIENTS: A RANDOMIZED CONTROLLED TRIAL

Abstract Background and Aims Remote ischemic preconditioning (RIPC) is a process in which a brief period of ischemia is induced in one part of the body to protect another part from damage due to subsequent periods of more severe ischemia. Hemodialysis sessions are considered an ischemic process because it involves reducing blood flow to certain parts of the body, which can lead to tissue damage .Malnutrition, deterioration of cognitive function, bone disorders, cardiovascular disease, and hemodynamic instability can result from ischemia induced by hemodialysis sessions. These adverse effects increase mortality in HD patients. RIPC has been studied as a potential therapeutic strategy to reduce the risk of cardiovascular events in hemodialysis patients; however, the effect of RIPC on cognitive function, nutritional status, and bone disorder among hemodialysis patients has not been enough studied. Aim: to assess the effect of remote ischemic preconditioning on nutritional status, bone disorders, and cognitive function in hemodialysis patients at the urology and nephrology center, Mansoura University. Method Fifty patients who received regular hemodialysis for more than one year in our dialysis unit were included. The patients were randomized (single-blind) into two groups a control group (20 patients) and an intervention group (30 patients). Before each HD session, sphygmomanometer cuffs was placed around the non-vascular access arm. Three cycles of ischemia for five minutes were performed followed by reperfusion for five minutes. Ischemia was induced by inflating the sphygmomanometer cuffs to 200 mmHg. This maneuver was done before each HD session for 12 weeks. The Montreal Cognitive Assessment (MOCA) was used to assess cognitive function. The nutritional state was assessed by anthropometric measurement (body weight, BMI), laboratory (serum albumin and serum cholesterol), and Subjective Global Assessment Form (SGA). Serum calcium (s.Ca) and serum phosphorus (s.po), serum alkaline phosphate (s. ALP) and intact parathyroid hormone (iPTH) were used as indices for bone profile. Results The intervention group include 30 patient with mean age (36+/-10), 19 male (63.3%) and 11 females (36.7%). The control group include 20 patient with mean age (46+/-9), 12 male (60%) and eight female (40%). None of these patients’ demographic data (age, sex, original kidney disease, and duration of dialysis) were significantly different between the study groups (P>0.05). MOCA test score at baseline was (24.5 +/-2.6) at intervention group and (24.4+/-3.2) at control group, and after 12 weeks intervention was (24.8 +/-2.2) at intervention group and (24.4+/-2.8) at control group. there were no statistical significance regarding cognitive function between the two group over time (p = 0.4). NO significant Statistical changes in anthropometric measurements (Body weight (p = 0.3) and BMI (P = 0.6) were found between the two groups. Additionally, no significant changes (serum albumin and cholesterol) were detected. SGA score at baseline was at intervention group (1.2+/-0.4) and control group (1.1 +/- 0.3), and after 12 week was at the intervention group (1.4 +/-0.5) and control group (1.6 +/-0.5). SGA showed no statistical significance between the two groups over time (p = 0.2). No significant statistical changes regarding bone profile (s.ca (p = 0.5), s.PO (p = 0.2), s.ALP (p = 0.7) and iPTH (p = 0.5)). Conclusion Although some studies showed a beneficial effect of RIBC on reduction of cardiovascular risk, our study found no significant effect on cognitive function, nutritional status, and bone disorders among hemodialysis patients.

Peripheral arterial disease in hemodialysis patients 10 years later

Background and objectivePatients with chronic kidney disease (CKD) on hemodialysis present high cardiovascular comorbidity. Peripheral arterial disease (PAD) is associated with higher mortality and the interest in its early detection and treatment is increasing. The objective of this study is to determine the frequency and severity of symptomatic PAD, and to establish its relationship with mortality in HD patients that have received treated early and compare them with a cohort of our center already reported. Material and methodsRetrospective study on a cohort of incident patients since 2014 and followed up until December 2019. Demographic data, cardiovascular risk, the presence of symptomatic PAD at baseline and during follow-up were collected. Trophic lesions were graded using the Rutherford scale. ResultsInitially, there were 91 patients and 7 cases that were not included in the study were lost to follow-up. Age 64 ± 16 years, men 51.6% (47/91). The percentage of baseline PAD was 10.7% (9/84). During a median follow-up of 35 months (20−57), the diagnosis of PAD increased to 25% (21/84). Half of the patients with PAD 52.38% (11/21) obtained a score greater than 3 in the Rutherford Clinical Classification, which corresponds to severe disease. 13/21 patients required reoperation due to recurrence of symptoms (61.9% of cases with PAD).The development of PAD was significantly associated with: an elevated index of Charlson (3.9±2.1 vs. 7.7 ± 3.5; P = 0.001),being male (19 vs. 2; P = 0.001), diabetic (no: 7; yes: 15; P = 0.001) and with a history of chronic ischemic heart disease (no: 13; yes: 8; P = 0.001), 38.1% (8/21) had ischemic heart disease in patients who developed PAD, while in the absence of PAD the presence of ischemic heart disease was 9.5% (6/63). Furthermore, more than half (66.7% [14/21]) of those who developed PAD were diabetic.Univariate analysis showed that age, C reactive protein, albumin, and number of surgical interventions, but not PAD, were associated with mortality. In the multivariate analysis adjusted for other factors, only C reactive protein was related to overall survival Exp β: 2.17; P = 0.011; CI (1.19–3.97). Regarding cardiovascular mortality, in the multivariate Cox analysis, only PAD was related to mortality of cardiovascular origin Exp β: 1.73; P = 0.006; CI (1.17–2.56). ConclusionsA significant number of patients on hemodialysis develop PAD requiring peripheral vascular surgery. PAD was not associated with overall mortality in our cohort, but it did show an association with cardiovascular mortality. Prospective studies with a larger sample size are necessary. New surgical treatments and Follow-up by vascular surgeons could improve the severity of PAD and the long-term prognosis.

Prognostic value of the combination of neutrophil-to-lymphocyte ratio, monocyte-to-lymphocyte ratio and platelet-to-lymphocyte ratio on mortality in patients on maintenance hemodialysis.

Hemodialysis (HD) is the most important renal replacement therapy for patients with end-stage kidney disease (ESKD). Systemic inflammation is a risk factor of mortality in HD patients. Neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), and platelet-to-lymphocyte ratio (PLR) are new inflammatory markers. However, previous studies have inconsistent conclusions about the predictive value of NLR, MLR and PLR on mortality of HD patients. The aim of this study was to establish an inflammation scoring system by including NLR, MLR and PLR, and evaluate the association between the inflammation score and all-cause and cardiovascular mortality in HD patients. In this single center retrospective cohort study, 213 incident HD patients from January 1, 2015 to December 31, 2020 were included. Baseline demographic and clinical data and laboratory measurements were collected. According to the optimal cut-off values, NLR, MLR and PLR were assigned 0 or 1 point, respectively. Then, the inflammation score was obtained by adding the NLR, MLR and PLR scores. All patients were followed until July 31, 2021. The associations of the inflammation score with all-cause and cardiovascular mortality were assessed by multivariable-adjusted Cox models. Of 213 patients, the mean (± SD) age was 56.8 ± 14.4 years, 66.2% were men, and 32.9% with diabetes. The primary cause of ESKD was mainly chronic glomerulonephritis (46.5%) and diabetic nephropathy (28.6%). The median inflammation score was 2 (interquartile range = 1-3). During a median 30 months (interquartile range = 17-50 months) follow-up period, 53 patients had died, of which 33 deaths were caused by cardiovascular disease. After adjusting for demographics, primary diseases and other confounders in multivariable model, the inflammation score = 3 was associated with a hazard ratio for all-cause mortality of 4.562 (95% confidence interval, 1.342-15.504, P = 0.015) and a hazard ratio for cardiovascular mortality of 4.027 (95% confidence interval, 0.882-18.384, P = 0.072). In conclusion, an inflammation scoring system was established by including NLR, MLR and PLR, and the higher inflammation score was independently associated with all-cause mortality in HD patients.

COVID-19 clinical outcomes and risk factors in fully vaccinated hemodialysis patients: A single-center prospective cohort study

Hemodialysis patients (HD) are at high risk for coronavirus infection (COVID-19) and associated adverse outcomes compared with the general population. Although vaccination against SARS-CoV-2 has played an important role in stemming the spread of COVID-19 in the general population, the characterization of vaccine efficacy in dialysis patients is based primarily on humoral responses, whereas clinical data are generally not available. The aim of this study was to determine the incidence of COVID-19, clinical outcomes, and risk factors for SARS-CoV-2 infection in fully vaccinated HD patients.
 Methods. Of 186 HD patients treated at Link-Medital LLC Medical Center (Odesa, Ukraine) between March 2020 and March 2022, 170 patients aged 53.5 (44-63.5) years were enrolled in this prospective observational cohort study and followed up one year after completion of vaccination. Among them were 67 (39.4%) HD patients who were fully vaccinated against COVID-19 with BNT162b2 (Pfizer-BioNTech) or Moderna-mRNA-1273 mRNA vaccines and 103 (60.6%) unvaccinated HD patients. The outcomes assessed were COVID-19 morbidity and severity, hospitalization, and death associated with COVID-19.
 Results. During the 12-month follow-up, nearly half of 83/170 (48.8%) patients became infected with SARS-CoV-2, including 18/67 (26.7%) vaccinated patients and 65/103 (63.1%) unvaccinated patients (χ2 = 10.8; p = 0.001). The incidence rate of COVID-19 was 27 (95% CI 16, 42) in vaccinated patients at our center and 63 (95% CI 49, 80) per 100 patient-years (p = 0.001) in unvaccinated patients.
 Cox proportional hazards regression analysis showed that vaccinated HD patients had a statistically significant lower risk of hospitalization [HR = 0.2 (95%CI 0.1;0.4)] and need for oxygen support [HR = 0.19 (95%CI 0.09; 0.38)] compared with unvaccinated patients. Kaplan-Meyer analysis of COVID-19-associated mortality demonstrated a significantly higher survival of vaccinated HD patients compared with unvaccinated (χ2 = 4.6, log-rank p = 0.03).
 Further multivariate logistic analysis showed that age over 65 years, obesity, low adequacy of HD and duration of more than 5 years, anemia, low levels of parathyroid hormone (PTH) and high-density lipoprotein cholesterol (HDL-C), elevated CRP, arterial hypertension, and other cardiovascular diseases (CVD) significantly increased the risk of SARS-CoV-2 infection in fully vaccinated HD patients.
 Conclusions. Vaccination against COVID-19 is associated with a reduction in morbidity, hospitalization rates, and mortality in HD patients. Age over 65 years, obesity, low adequacy of HD and its duration of more than 5 years, anemia, low PTH and HDL-C levels, elevated CRP, arterial hypertension, and other CVDs significantly increased the risk of SARS-CoV-2 infection in fully vaccinated HD patients.

MO905: Calcification of Branches is Superior to Abdominal Aortic Calcification in Predicting Mortality of Hemodialysis Patients

Abstract BACKGROUND AND AIMS Vascular calcification (VC) is considered to be an important initiating risk factor of cardiovascular events, which contributes to the leading cause of death in maintenance hemodialysis (MHD) patients. VC has a high incidence and has been reported to predict the mortality of MHD patients. Inspired by an extreme example of VC in dialysis patients, calciphylaxis (which involves extensive calcification of small- and medium- arteries with poor prognosis), we hypothesized that VC of branches was a better predictor of mortality than abdominal aortic calcification. Therefore, a cohort study based on MHD patients was constructed to investigate the distribution characteristics of VC, compare the predictive value of VC on mortality among different arteries, and explore a comprehensive model predicting mortality. METHOD A total of 1583 patients in our Blood Purification Center from January 2015 to September 2017 were screened, and 237 eligible patients were finally included. Abdominal-pelvic computed tomography images were collected and an open-source software 3D Slicer (version 4.11) was used to calculate the calcification volume in abdominal aorta, celiac trunk, superior and inferior mesenteric artery, renal artery, common iliac artery and internal iliac artery. Demographic and clinical data including medical history and some laboratory indexes were collected. Patients were followed-up until all-cause death or September 2020. Cause of death and survival time were recorded in detail. The area under the curve (AUC) of Time-dependent receiver operating curves (ROC) was calculated to evaluate the predictive value of arterial calcification. 80% of cases were randomly assigned to the training dataset and the remaining were assigned to the validation dataset. Lasso regression was performed to screen variables. Cox proportional hazards regression was performed to construct the predicting model and nomogram. C-index, calibration and decision curve analysis were used to evaluate the comprehensive model. SPSS software (version 26.0) and R software (version 4.1.2) perform statistical analysis. RESULTS The prevalence of total VC is 95.36%. Among the abdominal arteries, abdominal aortic calcification is the most prevalent (88.61%), followed by calcification of internal iliac artery (85.65%) and common iliac artery (80.17%). Median survival time was 37.00 (1.00–70.00) months. The 1-year survival rate, 3-year survival rate and 5-year survival rate were 73.42%, 50.01% and 35.43%, respectively. Cardiovascular disease accounts for 54.01% of the death cause. AUC of Time-dependent ROC by internal iliac artery and mesenteric artery calcification for predicting mortality is significantly higher than that of other arterial calcification. Internal iliac artery calcification (IIAC) was screened out as the most representative predictor for all-cause death among the calcification of arterial calcification by lasso regression. When analyzing IIAC and other clinical data, age (hazard ratio 1.03, P < 0.001), serum albumin level (hazard ratio 0.919, P < 0.001) and IIAC (hazard ratio 1.36, P = 0.003) were independent factor of mortality in HD patients. The nomogram based on Cox proportional hazards model is shown in Figure 1. C-index of the model was 74.09%. Decision curves of Cox proportional hazards model from training dataset and validation dataset showed the reliable predictive value of Cox model (Figure 2). CONCLUSION This is the first study evaluating the calcification volume of abdominal aortic branches and comparing their predictive values. In conclusion, calcification of abdominal aortic branches, especially internal iliac artery, is a better predictor for mortality of HD patients than abdominal aortic calcification. Our concern with calcification of large arteries in MHD patients needs to be shifted to smaller branch arteries.

POS-614 AORTIC ARCH CALCIFICATIONS AND MORTALITY IN HEMODIALYSIS PATIENTS

Vascular calcification has now been recognized as a major complication in dialysis patients because of its strong influence on the prognosis. Several reports have shown the strong relationship between vascular calcification and clinical outcomes including cardiovascular events and mortality in HD patients.

Clinical significance of a novel reticulocyte-based erythropoietin resistance index in HD patients: A retrospective study.

The erythropoietin resistance index (ERI) is an indicator of erythropoiesis-stimulating agent (ESA) responsiveness and is typically calculated using Hb. However, Hb does not directly reflect ESA-induced erythropoiesis because of its long-term nature. We thus designed a novel ERI calculated with reticulocyte Hb (RetHb), a real-time index, and investigated its association with mortality in HD patients. We calculated the ERI using the change in RetHb before and after ESA administration (ERIΔRetHb ) and retrospectively analyzed its association with 3-year all-cause mortality using Kaplan-Meier survival curves and Cox regression analyses. A total of 102 patients were included. Patients with the highest ERIΔRetHb had the worst prognosis according to the Kaplan-Meier survival curves (Log-rank p=0.02). Multivariate Cox regression analysis showed that the ERIΔRetHb was significantly and independently associated with all-cause mortality (hazard ratio: 9.82, 95% CI [1.50, 64.41], p=0.02). The ERIΔRetHb was significantly and independently associated with all-cause mortality in HD patients.

Low serum prealbumin concentration predicts long-term mortality in maintenance hemodialysis patients with hepatitis B and/or C virus infections.

Background and AimA low serum prealbumin concentration is common in maintenance hemodialysis patients with hepatitis B and C and may be associated with mortality. In this study, we assessed Department of Nephrology and Hemodialysis predictive value of a low serum prealbumin concentration on mortality in HD patients using reused low‐flux dialyzers who were infected with hepatitis B and/or C virus.MethodsWe used serum prealbumin levels to predict the long‐term mortality of 326 hemodialysis patients. The patients were divided into two groups: group 1 (n = 140, with hepatitis B and/or C virus infections), and group 2 (n = 186, without hepatitis virus infections).ResultsDuring a 5‐year follow‐up, there were 75 deaths due to all‐cause mortality (23.0%). Mortality was significantly higher (P < 0.001) in patients with hepatitis B and/or C infection (44%) than in those without hepatitis infection (8%). Serum prealbumin was lower in the hepatitis infected group and mortality group than in non‐infected group and survival group. Multivariate Cox regression analysis showed that long duration of HD and lower serum prealbumin and albumin were related to mortality in patients undergoing maintenance HD. Receiver operating characteristic curves showed that serum prealbumin had a good prognostic value in predicting mortality in both groups with hepatitis B and/or C virus infection and without hepatitis infection (AUC = 0.792 [95% confidence interval: 0.714–0.87], P < 0.001; cut‐off value = 24.5 mg/dl, sensitivity = 62.3%, and specificity = 88.6%).ConclusionIn HD patients, serum prealbumin was a good prognostic biomarker of mortality in both groups of patients with hepatitis B and/or C virus infections and without hepatitis infections.

Association of soluble ST2 and right ventricular dysfunction with mortality in chronic hemodialysis patients

Abstract Background End stage kidney disease (ESKD), is a triggering and facilitating factor for cardiac remodelling (i.e., morphologic hypertrophy and/or dilatation associated with deterioration of systolic and/or diastolic function) that contribute to heart failure (HF). RV dysfunction (RVD) has been demonstrated to predict mortality in ESKD patients. Purpose The present study aimed to investigate the potential associations between RVD and circulating biomarkers of myocardial inflammation and fibrosis with all-cause mortality in HD patients. Method We performed a retrospective single-centre cohort study of prevalent patients admitted in a chronic HD program for more than 3 months. Clinical characteristics and echocardiographic parameters were assessed in all patients. Pre-dialysis blood samples for measurement of inflammatory (e.g., C reactive protein, interleukin-1, interleukin-18) and fibrotic (e.g., soluble suppression of tumorigenesis-2 [sST2], galectin-3, C-terminal pro-peptide of procollagen type I and N-terminal pro-peptide of procollagen type III) biomarkers were collected. RVD was defined using tricuspid annular plane systolic excursion (TAPSE) &amp;lt;1.7 cm or pulsed Doppler peak annular velocity (S') &amp;lt;9.5 cm/s. The ability of sST2 to discriminate between mortality was assessed using AuROC curve. Results We enrolled forty-eight patients, mean patients age was 74 (64 – 79)years, and 62.5% were males. 95.8% of the patients had high blood pressure, and at least 70.8% had HF criteria. About 52.1% of the patients were on OnLine HDF. Regarding the echocardiogram parameters, 56.3% had no functional heart disease, 10.4% had LVD (LVEF ≤45% and diastolic dysfunction ≥ grade 2), and 33.3% had RVD (TAPSE &amp;lt;17mm and/or S'&amp;lt;9.5cm/s), with or without LVD. Mortality was higher 45.5% (log-rank, p=0.003) in patients with RVD as diagnosed by S' than in patients without RVD. No difference in mortality was observed for RVD defined by TAPSE. There were no differences in the morphology and function parameters of the left ventricle between patients with and without RVD. From all biomarkers measured only sST2 was associated with RVD. Indeed, an age- and sex-adjusted analyses showed that doubling of sST2 was inversely associated with a decreased in S' (estimate = −2.03, 95% CI [−3.04 to −1.00] cm/s; P=0.002). Mortality was increased in patients with sST2 ≥40.45 ng/mL compared to patients with sST2 &amp;lt;40.45 ng/mL (66.7% vs. 18.9%, log-rank; p=0.004). Conclusion This preliminary data would suggest that patients on chronic HD, circulating levels of sST2 were independently associated with RVD. In addition, elevated sST2 levels and RVD were associated with increased all-cause mortality. The myocardial pro-remodelling effect of sST2 in HD patients with RVD warrants further investigation. Funding Acknowledgement Type of funding sources: None.

Premature aging of circulating T cells predicts all-cause mortality in hemodialysis patients

BackgroundPatients with end-stage renal disease (ESRD) exhibit a premature aging phenotype of immune system, which is recently concerned as a significant factor for increased risk of various morbidities. Nevertheless, there are few dates explicating the relevancy of T cell senescence to mortality. In this study, we prospectively studied the predictive value of T cell senescence for mortality in hemodialysis patients.MethodsPatients who had been on hemodialysis treatment for at least 6 months were enrolled. T cell senescence determined by differentiation status was evaluated by flow cytometry. Survival outcomes were estimated using the Kaplan-Meier method. Univariate and multivariate analyses were performed to evaluate the prognostic impact of T cell premature aging and other clinical factors on all-cause mortality.ResultsA total of 466 patients (277 man and 169 women) were enrolled in this study. Decreased number of naïve T cell, as the most prominent feature of T cell senescence, did not change in parallel with age in these patients. Decreased absolute count of T cell, naïve T cell, CD4+ naïve T cell were independently associated with all-cause mortality. Decreased percentage of T cell and increased percentage of CD8+central-memory T cell were also independently associated with all-cause mortality. After including all the T cell parameters in one regression model, only decreased count of naïve T cell was significantly associated with increased mortality in these patients.ConclusionsAging-associated T cell changes are aggravated in ESRD patients. For the first time, our study demonstrates that naïve T cell depletion is a strong predictor of all-cause mortality in HD patients.

Cognitive impairment, endothelial biomarkers and mortality in maintenance haemodialysis patients: a prospective cohort study

Haemodialysis (HD) patients have a high prevalence of cardiovascular disease risk factors as well as cognitive impairment. The objective of the present study was to evaluate the interrelationship between cognitive impairment, endothelium-related biomarkers and cardiovascular/non-cardiovascular mortality. A total of 216 outpatients were recruited from three centres in a dialysis network in Brazil between June 2016 and June 2019. Sociodemographic and clinical data were obtained by applying a patient questionnaire, reviewing medical records data and conducting patient interviews. Cognitive function was assessed using the Cambridge Cognitive Examination. Plasma endothelium-related biomarkers [syndecan-1, intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion protein-1 (VCAM-1) and angiopoietin-2 (AGPT2)] were measured. Patients were followed for 30 months. Cox proportional hazards regression models were used to assess the associations of the cognitive function scores and each endothelium-related biomarker with cardiovascular/non-cardiovascular mortality. Cognitive function was associated with cardiovascular mortality {each standard deviation [SD] better cognitive score was associated with a 69% lower risk for cardiovascular mortality [hazard ratio (HR) 0.31 [95% confidence interval (CI) 0.17-0.58]} but not with non-cardiovascular mortality. Moreover, cognitive function was also correlated with all endothelial-related biomarkers, except VCAM-1. ICAM-1, AGPT2 and syndecan-1 were also associated with cardiovascular mortality. The association between cognitive function and cardiovascular mortality remained significant with no HR value attenuation [fully adjusted HR 0.32 (95% CI 0.16-0.59)] after individually including each endothelial-related biomarker in the Cox model. In conclusion, cognitive impairment was associated with several endothelium-related biomarkers. Moreover, cognitive impairment was associated with cardiovascular mortality but not with non-cardiovascular mortality, and the association between cognitive impairment and cardiovascular mortality in HD patients was not explained by any of the endothelial-related biomarkers.

Evaluation of serum sclerostin level and its correlation with valvular calcification in haemodialysis patients

Abstract Background The majority of hemodialysis patients are affected by the cardiovascular calcification. Vascular/valvular calcification contributes to an extremely high cardiovascular morbidity and mortality in HD patients. Objective To asses circulating levels of Scl in ESRD patients receiving HD and their relation to aortic and mitral valve calcification detected by echocardiography as well. Patients and Methods The study included 80 ESRD patients undergoing HD in Al-Sahel Nephrology and Dialysis unit. Routine chemical investigations, serum sclerostin by ELISA were done to all patients, as well a trans-thoracic Echocardiography. Results serum Scl level ranged from 0.41 ng\ml to 1.65 ng\ml. calcification was documented in 53/80 (66.2%) of our HD patients: 26/80 had aortic valve calcification only(32.5%), 6/80 patients (7.5%) had mitral valve calcification alone, while 21/80 of patients had both aortic and mitral valves calcification (26.25%). 27/80 (33.75%) patients had no calcification. We didn’t find any significant correlation between serum Scl level and valvular calcification nor age, sex or HD duration. Conclusion valvular calcification are prevalent in HD population. Serum Scl was not associated with valvular calcification.

Long-term effects of citric acid-based bicarbonate haemodialysis on patient outcomes: a survival propensity score-matched study in western France.

Citric acid-based bicarbonate haemodialysis (CIT-HD) has gained more clinical acceptance over the last few years in France and is a substitute for other acidifiers [e.g. acetic acid (CH3COOH) and hydrochloric acid (HCl)]. This trend was justified by several clinical benefits compared with CH3COOH as well as the desire to avoid the consequences of the corrosive action of HCl, but a nationwide clinical report raised concerns about the long-term safety of CIT-HD. The aim of this study was to assess the long-term effects of CIT-HD exposure on patient outcomes in western France. This is a population-based retrospective multicentre observational study performed in 1132 incident end-stage kidney disease patients in five sanitary territories in western France who started their renal replacement therapy after 1 January 2008 and followed up through 15 October 2018. Relevant data, collected prospectively with the same medical software, were anonymously aggregated for the purposes of the study. The primary goal of this study was to investigate the effects of citrate exposure on all-cause mortality. To provide a control group to CIT-HD one, propensity score matching (PSM) at 2:1 was performed in two steps: the first analysis was intended to be exploratory, comparing patients who received citrate ≤80% of the time (CIT-HD ≤80) versus those who received citrate >80% of the time (CIT-HD >80), while the second analysis was intended to be explanatory in comparing patients with 0% (CIT-HD0) versus 100% citrate time exposure (CIT-HD100). After PSM, in the exploratory part of the analysis, 432 CIT-HD ≤80 patients were compared with 216 CIT-HD >80 patients and no difference was found for all-cause mortality using the Kaplan-Meier model (log-rank 0.97), univariate Cox regression analysis {hazard ratio [HR] 1.01 [95% confidence interval (CI) 0.71-1.40]} and multivariate Cox regression analysis [HR 1.11 (95% CI 0.76-1.61)] when adjusted for nine variables with clinical pertinence and high statistical relevance in the univariate analysis. In the explanatory part of the analysis, 316 CIT-HD0 patients were then compared with 158 CIT-HD100 patients and no difference was found using the Kaplan-Meier model (log-rank 0.06), univariate Cox regression analysis [HR 0.69 (95% CI 0.47-1.03)] and multivariate Cox regression analysis [HR 0.87 (95% CI 0.57-1.33)] when adjusted for seven variables with clinical pertinence and high statistical relevance in the univariate analysis. Findings of this study support the notion that CIT-HD exposure ≤6 years has no significant effect on all-cause mortality in HD patients. This finding remains true for patients receiving high-volume online haemodiafiltration, a modality most frequently prescribed in this cohort.

Low serum uric acid levels increase the risk of all-cause death and cardiovascular death in hemodialysis patients

Background Elevated serum uric acid (SUA) is associated with increased cardiovascular (CV) and all-cause mortality risk in the general population, but the impact of UA on mortality in hemodialysis patients is still controversial. The aim of the study was to explore the relationship between SUA and all-cause mortality and CV mortality in hemodialysis patients. Methods This retrospective, observational cohort study included 210 HD patients with a mean age of 56.6 ± 16.6 years. All demographic and laboratory data were recorded at baseline. The Kaplan–Meier method and Cox proportional hazard regression model were used to examine the association between SUA and all-cause mortality and CV mortality in HD patients. Results With 420 µmol/L (20th percentile) and 644 µmol/L (80th percentile) as the boundary points, the patients were divided into three groups. After a median follow-up of 49.8 months, 68 (32.4%) all-cause deaths and 34 (16.2%) CV deaths were recorded. The Kaplan–Meier method showed that with a decrease in SUA, all-cause mortality (log rank χ 2 = 15.61, p = .000), and CV mortality (log rank χ 2=14.28, p = .000) increased. Each 100 µmol/L increase in SUA was associated with lower all-cause mortality with an hazard ratio (HR) of 0.792 (0.645–0.972) and lower CV mortality with an HR of 0.683 (0.505–0.924) after adjusting for age, sex, and complications. Compared to the lowest quartile, all-cause mortality [HR 0.351(0.132–0.934), p = .036] and CV mortality [HR 0.112 (0.014–0.925), p = .042] were lower in the highest SUA quartile. Conclusion A lower SUA level in HD patients was associated with a higher risk of all-cause mortality and CV mortality. Moreover, higher SUA concentrations may be cardioprotective in HD patients.

Long-term cardiovascular prognosis after rotational atherectomy in hemodialysis patients: Data from the J2T multicenter registry

BackgroundHemodialysis (HD) patients have heavy calcium deposits in their stenotic coronary arteries and worse post-percutaneous coronary intervention (PCI) prognoses than those who do not undergo HD. Rotational atherectomy (RA) facilitates PCI success in severely calcified lesions. We aimed to identify clinical and procedural characteristics that predict HD patients' long-term prognoses after PCI that included RA in the drug-eluting stent (DES) era. MethodsThis study included 302 patients who underwent regular HD from J2T Multicenter Registry database of 1090 consecutive patients who underwent RA to treat de novo calcified lesions at three university hospitals between 2004 and 2015. The primary endpoint was cardiovascular (CV) death. ResultsDuring the 5-year observation period, 59 CV deaths (19.5%) occurred. The CV death group and non-CV death group had comparable profiles except significantly lower left ventricular ejection fraction, higher brain natriuretic peptide (BNP), lower rate of RA burr upsizing, and lower rate of final thrombolysis in myocardial infarction (TIMI) 3 flow achievement in the CV death group. Cox regression analysis revealed that increasing ablation burr size (hazard ratio [HR]: 0.33; 95% confidence interval [CI]: 0.13–0.81), final TIMI 3 flow (HR: 0.07; 95% CI: 0.02–0.28), lower BNP level, and optimal medication were independently associated with better CV mortality in HD patients. ConclusionIn the DES era, oral medications at the time of PCI and stepwise calcium ablation were associated with improved long-term CV mortality in HD patients who are scheduled to undergo RA to treat severely calcified coronary artery stenoses, as therapeutic strategies.

Individualized prediction of mortality using multiple inflammatory markers in patients on dialysis.

This study aimed to evaluate whether the combination of inflammatory markers could provide predictive powers for mortality in individual patients on dialysis and develop a predictive model for mortality according to dialysis modality. Data for inflammatory markers were obtained at the time of enrollment from 3,309 patients on dialysis from a prospective multicenter cohort. Net reclassification index (NRI) and integrated discrimination improvement (IDI) were calculated. Cox proportional hazards regression analysis was used to derive a prediction model of mortality and the integrated area under the curve (iAUC) was calculated to compare the predictive accuracy of the models. The incremental additions of albumin, high-sensitive C-reactive protein (hsCRP), white blood count (WBC), and ferritin to the conventional risk factors showed the highest predictive powers for all-cause mortality in the entire population (NRI, 21.0; IDI, 0.045) and patients on peritoneal dialysis (NRI, 25.7; IDI, 0.061). The addition of albumin and hsCRP to the conventional risk factors markedly increased predictive powers for all-cause mortality in HD patients (NRI, 19.0; IDI, 0.035). The prediction model for all-cause mortality using conventional risk factors and combination of inflammatory markers with highest NRI value (iAUC, 0.741; 95% CI, 0.722–0.761) was the most accurate in the entire population compared with a model including conventional risk factors alone (iAUC, 0.719; 95% CI, 0.700–0.738) or model including only significant conventional risk factors and inflammatory markers (iAUC, 0.734; 95% CI, 0.714–0.754). Using multiple inflammatory markers practically available in a clinic can provide higher predictive power for all-cause mortality in patients on dialysis. The predictive model for mortality based on combinations of inflammatory markers enables a stratified risk assessment. However, the optimal combination for the predictive model was different in each dialysis modality.

The Calcium-Sensing Receptor Gene Polymorphism rs1801725 and Calcium-Related Phenotypes in Hemodialysis Patients

Background/Aims: The calcium-sensing receptor gene (CASR) rs1801725 variant is responsible for a non-conservative amino-acid change (A986S) in the calcium-sensing receptor cytoplasmic tail. We hypothesized that rs1801725 polymorphism might be helpful in understanding Ca-related abnormalities in HD patients. Methods: In 1215 subjects (245 on cinacalcet), we determined the associations of rs1801725 with secondary hyperparathyroidism (sHPT)-related laboratory parameters, PTH-decreasing effect of cinacalcet hydrochloride, coronary artery disease (CAD), myocardial infarction (MI), nephrolithiasis-related ESRD, and mortality. CASR rs7652589(A<G)_rs1801725(G>T) haplotypes and rs1801725 epistatic interactions with vitamin D signaling pathway genes were examined for associations with selected phenotypes. Results: The rs1801725 variant allele showed an increasing independent effect on plasma PTH (P_corrected = 0.009). CASR rs7652589_rs1801725 AT haplotype was associated with 1.7-fold higher frequency of PTH levels over 437 pg/mL than the reference haplotype GG (P = 0.001). CASR rs7652589_rs1801725 AG haplotype was 1.5-fold more frequent in nephrolithiasis-related ESRD than the GG haplotype (P = 0.004). There were no significant associations between rs1801725, CAD, MI, and response to cinacalcet. Variant homozygosity of rs1801725 correlated independently with higher infection-related mortality compared with heterozygosity (HR 7.95, 95%CI 2.15 – 29.37, P = 0.003) and major homozygosity (HR 5.89, 95%CI 1.69 – 20.55, P = 0.040). CASR rs1801725 did not show epistatic interactions with vitamin D signaling pathway genes concerning tested associations. Conclusion: The variant allele of CASR rs1801725 solely and together with the variant allele of rs7652589 increases risk of more advanced sHPT. Homozygosity of the rs1801725 variant allele contributes to infection-related mortality in HD patients.

Worsening calcification propensity precedes all-cause and cardiovascular mortality in haemodialyzed patients

A novel in-vitro test (T50-test) assesses ex-vivo serum calcification propensity which predicts mortality in HD patients. The association of longitudinal changes of T50 with all-cause and cardiovascular mortality has not been investigated. We assessed T50 in paired sera collected at baseline and at 24 months in 188 prevalent European HD patients from the ISAR cohort, most of whom were Caucasians. Patients were followed for another 19 [interquartile range: 11–37] months. Serum T50 exhibited a significant decline between baseline and 24 months (246 ± 64 to 190 ± 68 minutes; p < 0.001). With serum Δ-phosphate showing the strongest independent association with declining T50 (r = −0.39; p < 0.001) in multivariable linear regression. The rate of decline of T50 over 24 months was a significant predictor of all-cause (HR = 1.51 per 1SD decline, 95% CI: 1.04 to 2.2; p = 0.03) and cardiovascular mortality (HR = 2.15; 95% CI: 1.15 to 3.97; p = 0.02) in Kaplan Meier and multivariable Cox-regression analysis, while cross-sectional T50 at inclusion and 24 months were not. Worsening serum calcification propensity was an independent predictor of mortality in this small cohort of prevalent HD patients. Prospective larger scaled studies are needed to assess the value of calcification propensity as a longitudinal parameter for risk stratification and monitoring of therapeutic interventions.

Increasing skin autofluorescene advance glucosylation end products (ages) predict mortality in HD patients

Increasing skin autofluorescene advance glucosylation end products (ages) predict mortality in HD patients