National Kidney And Transplant Institute Research Articles

#4379 SURVIVAL RATES AND ANALYSIS OF PREDICTORS OF MORTALITY AMONG INCIDENT HEMODIALYSIS PATIENTS: A SINGLE CENTER FIVE-YEAR COHORT STUDY

Abstract Background and Aims Studies on improving survival rate among maintenance hemodialysis patients have been extensive. However, only a handful of studies have focused on the factors that determine mortality risk among incident hemodialysis patients, considering that the first few months of hemodialysis initiation are the most critical. Survival rates and factors predicting mortality may vary from one geographic area to another. Local data on these factors, however, are quite lacking. Identification of factors that can be optimized during this crucial period can greatly impact survival of Filipino hemodialysis patients. This study was designed primarily to determine 1-year, 3-year and 5-year survival rates of incident hemodialysis patients enrolled at the National Kidney and Transplant Institute (NKTI). Demographic and clinical factors that may influence mortality risk were identified and analyzed. Method This is a retrospective cohort study which evaluated the data of all incident adult patients enrolled at NKTI Outpatient Dialysis Unit, over a period of 5 years (January 2016 to December 2020). Patients were followed, retrospectively, from initiation until censorship (end of study, loss to follow up, transfer, conversion to peritoneal dialysis or kidney transplant) and the following factors were compared between those who remained alive and those who expired: etiology of kidney disease, age, sex, mode and frequency of dialysis, access, socioeconomic class and biochemical parameters. Descriptive statistics was used to describe and summarize the baseline data. Frequency and proportion were used for categorical variables, and median and inter-quartile range (IQR) for non-normally distributed interval/ratio variables. Survival probabilities were estimated using the Kaplan-Meier method. Cox regression was done to determine factors of overall survival. All valid data were included in the analysis. Null hypothesis was rejected at 0.05α-level of significance. Stata 15.0 was used for data analysis. Results A total of 562 incident hemodialysis patients were enrolled, 94 of whom expired. Among those who expired, there were more patients who were aged above 60 years (56.38% vs 29.91%, p <.001) and with low serum phosphorus level (29.21% vs 16.78%, p=.029) in comparison to those who were alive. Computed 1-year, 3-year, and 5-year survival rate among patients were 89.51% (95% CI 86.10% - 92.12%), 73.03 (95% CI 66.46 – 78.52%) and 42.06% (95% CI 29.52% - 54.99%), respectively. Patients who are older than 60 years (HR 2.75, p= 0.013), hepatitis C positive (HR 3.92, p= 0.021) and those with low phosphorus (HR 1.86, p= 0.015) were noted to have increased risk of mortality. Conclusion Survival rate of incident hemodialysis patients at NKTI is at par with survival estimates abroad. Risk factor identification and optimization of modifiable ones are key in improving patient survival.

#2616 DIAGNOSTIC VALUE OF THE HANDGRIP STRENGTH IN DETECTING PROTEIN-ENERGY WASTING AMONG HEMODIALYSIS PATIENTS AT NATIONAL KIDNEY AND TRANSPLANT INSTITUTE

Abstract Background and Aims Protein energy wasting (PEW) is a syndrome of adverse nutritional and catabolic changes common among chronic kidney disease (CKD) patients. Handgrip strength (HGS) was one of the methods of screening PEW mentioned in Kidney Disease Outcomes Quality Initiative guidelines. However, only few studies determined the validity of HGS in detecting PEW among maintenance hemodialysis (MHD) patients. The study aimed to determine the diagnostic validity of HGS in detecting PEW among MHD patients in a tertiary government hospital, with the following specific objectives: to determine the prevalence of PEW among MHD patients, to compare the demographic and clinical profile by PEW status, to identify the optimal cut-off point of HGS pre- and post-HD sessions in detecting PEW by sex, and to determine the following diagnostic value parameters of HGS pre- and post-HD sessions in detecting PEW by sex in terms of discriminative ability, accuracy, sensitivity, specificity, positive predictive value and negative predictive value. Method Participants included in this cross-sectional study are randomly selected patients undergoing MHD in National Kidney and Transplant Institute (NKTI) from September to October, 2022. Diagnosis of PEW was based on the Malnutrition Inflammation Score (MIS) ≥5. HGS was measured using a dynamometer pre- and post-dialysis sessions. Results A total of 143 patients were included in the study, and 53% were diagnosed with PEW. Pre-HD and post-HD HGS have acceptable discriminative ability based on Area Under the Curve >0.70 in detecting PEW regardless of patient sex. In males, a post-hemodialysis cut-off of <17.9 showed 72% sensitivity and 71% specificity in detecting PEW. Meanwhile, a pre-hemodialysis cut-off of <18.6 in females showed 83% sensitivity and 65% specificity in detecting PEW. Conclusion PEW is common among MHD patients in NKTI. The diagnostic performance of HGS in detecting PEW was found to be acceptable in both males and females. While both pre- and post-HD measures can be used in males, only the pre-HD measures are recommended for females. HGS can, therefore, be used as a non-expensive, accurate and objective screening assessment tool in detecting PEW for MHD patients. External validation of the proposed HGS cut-off values is still recommended.

P8.141: Prevalence and Outcome of Kidney Transplant Recipients Infected With BK Polyoma Virus at National Kidney And Transplant Institute From 2016 to 2021

Background: BK polyoma virus (BKV) infection is an evolving challenge in kidney transplant recipients as untreated infections often lead to allograft dysfunction or graft loss. The virus is ubiquitous with viruria and viremia being detected in 30% and >10% of patients, respectively. Decreasing the immunosuppression has been established as the mainstay of treatment, however, screening protocols vary between institutions. Objective: This study aims to describe the prevalence and outcomes of kidney transplant recipients with BKV at the National Kidney and Transplant Institute (NKTI) for the last 5 years. Methods: This is a retrospective study conducted at the NKTI wherein chart review was performed. Age, gender, native kidney disease, viral loads (urine and blood), graft biopsy results were reviewed. Clinical outcomes such as graft failure, early complications, and readmission were also determined. Results: There were 1057 kidney transplants and 12 BKV cases from 2016-2021 with a prevalence of 1.1%. The mean age of recipients was 39 (range 17-66) years, majority of which were males (58%) (Table 1). Half of the recipients had chronic glomerulonephritis with anti-thymocyte globulin being the most common induction agent (67%). Majority (88%) did not have urinary stents. Of the identified cases, viruria (41%) and viremia (33%) were present with 50% having biopsy-proven BKV nephropathy. Most cases presented >6 months from transplant (66%) and viral loads were above 500 copies/ml in 83% of cases. One patient was highly sensitized (8%) and two patients had graft loss (17%). No graft loss and retransplants were done for BKV. Conclusion: The low prevalence of BKV infection in our center reflects the varying practice of clinicians in the management of transplant recipients. Reduction of immunosuppression remains to be the treatment of choice. Early detection may prevent morbidity and graft loss. Routine screening for BKV has been recommended however, it has yet to gain acceptance among our transplant physicians.

A Scoring Tool to Predict Pulmonary Complications in Severe Leptospirosis with Kidney Failure.

Rapid identification of patients likely to develop pulmonary complications in severe leptospirosis is crucial to prompt aggressive management and improve survival. The following article is a cohort study of leptospirosis patients admitted at the National Kidney and Transplant Institute (NKTI). Logistic regression was used to predict pulmonary complications and obtain a scoring tool. The Kaplan–Meir method was used to describe survival rates. Among 380 patients with severe leptospirosis and kidney failure, the overall mortality was 14%, with pulmonary hemorrhage as the most common cause. In total, there were 85 (22.4%) individuals who developed pulmonary complications, the majority (95.3%) were observed within three days of admission. Among the patients with pulmonary complications, 56.5% died. Patients placed on mechanical ventilation had an 82.1% mortality rate. Multivariate analyses showed that dyspnea (OR = 28.76, p < 0.0001), hemoptysis (OR = 20.73, p < 0.0001), diabetes (OR = 10.21, p < 0.0001), renal replacement therapy (RRT) requirement (OR = 6.25, p < 0.0001), thrombocytopenia (OR = 3.54, p < 0.0029), and oliguria/anuria (OR = 3.15, p < 0.0108) were significantly associated with pulmonary complications. A scoring index was developed termed THe-RADS score (Thrombocytopenia, Hemoptysis, RRT, Anuria, Diabetes, Shortness of breath). The odds of developing pulmonary complications were 13.90 times higher among patients with a score >2 (63% sensitivity, 88% specificity). Pulmonary complications in severe leptospirosis with kidney failure have high mortality and warrant timely and aggressive management.

Comparison of Outcomes among Chronic Kidney Disease V Patients with COVID-19 at the National Kidney and Transplant Institute: A Retrospective Cohort Study.

Background There is very little published data on outcomes of COVID-19 among chronic kidney disease (CKD) patients. We compared the outcomes of COVID-19 in a tertiary care renal hospital among CKD V patients on hemodialysis (HD), peritoneal dialysis (PD), and dialysis initiation, in terms of duration of hospitalization, in-patient mortality, and 30-day mortality. Methods A total of 436 CKD V patients, on either HD, PD, or dialysis initiation, with COVID-19 who were admitted at the National Kidney and Transplant Institute (NKTI) from March 13, 2020, to August 31, 2020, were included. Kaplan–Meier survival analysis was performed. Comparison of probability of mortality by group was performed using Log-Rank test. p values ≤0.05 were considered statistically significant. Results Among 436 CKD V patients, 298 (68%) were on HD, 103 (24%) were on PD, and 35 (8%) required dialysis initiation. Overall in-hospital mortality was 34%; 38% were on HD, 20% on PD, and 37% on dialysis initiation. Total 30-day mortality was 27%; 32% were on HD, 26% on PD, and 16% on dialysis initiation. Median follow-up was 24 days. Among the 137 deaths recorded, total median time to death was 10 days; 8.5 days, 15.5 days, and 9 days for HD, PD, and dialysis initiation groups, respectively. Probability of mortality was significantly higher in HD patients versus PD patients (p < 0.00001) and in the dialysis initiation group compared to PD patients (p=0.0234). Mortality probability, however, was not significantly different in HD patients versus the dialysis initiation group (p=0.63). Conclusion Among CKD V patients diagnosed with COVID-19 at the NKTI, those on HD and on dialysis initiation had significantly higher in-hospital and 30-day mortality, compared to patients on PD.

Direct medical costs of type 2 diabetes mellitus in the Philippines: findings from two hospital databases and physician surveys

ObjectiveTo estimate the annual direct medical cost of type 2 diabetes mellitus (T2DM) in hospitals and outpatient care clinics from a healthcare payer perspective in the Philippines.Design and participants(1) A...

A Scoring Tool to Predict Pulmonary Complications in Severe Leptospirosis with Kidney Failure

Background: Pulmonary hemorrhage is the most common cause of mortality in severe leptospirosis. Rapid identification of patients likely to develop pulmonary complications will prompt aggressive management and improve survival. Objectives: To identify predictors of pulmonary complications in severe leptospirosis patients with kidney failure. Materials and Methods: A retrospective cohort of leptospirosis patients admitted at the National Kidney and Transplant Institute (NKTI) from January to December 2018 was reviewed. Logistic regression was used to predict pulmonary complications and to obtain a scoring tool. Kaplan-Meir was used to describe survival rates. Results: Among 380 patients with severe leptospirosis and kidney failure, over-all mortality was 14% with pulmonary hemorrhage as the most common cause. There were 85 (22.4%) who developed pulmonary complications, majority (95.3%) observed within three days of admission. Among patients with pulmonary complications, 56.5% died. Patients on mechanical ventilation had an 82.1% mortality. Multivariate analyses showed dyspnea (OR=28.76, p 2 (63% sensitivity, 88% specificity). Conclusion: Pulmonary complications in severe leptospirosis with kidney failure has high mortality and warrants timely and aggressive management. A simple scoring system will aid in early identification and management. Funding Statement: The authors received no financial support for the research, authorship, and/or publication of this article. Declaration of Interests: There are no financial conflicts of interest to disclose. Ethics Approval Statement: Upon approval of the Technical Review Board, the protocol was submitted to the Research Ethics Committee of NKTI and was issued ethics clearance. Only the investigators and data collectors had access to the patient charts. A unique code number was assigned to each chart abstracted.

POS-180 EXTERNAL VALIDATION OF A CLINICAL SCORING SYSTEM TO PREDICT MORTALITY IN LEPTOSPIROSIS PATIENTS: A SINGLE-CENTRE RETROSPECTIVE STUDY

Leptospirosis is a widespread and prevalent zoonotic disease with an incidence 10 times higher in tropical countries, such as the Philippines. It spreads through contact of the Leptospires via ingestion of contaminated water or soil. It may progress from a mild fever to severe multi-organ damage leading to mortality in 5-20%. Although it is a potentially fatal disease, it remains underreported with no reliable global incidence figures. Based on the Philippines’ Department of Health disease surveillance, there were 3,011 cases reported nationwide in 2019 with the majority (38%) located in the National Capital Region (NCR). This study aims to externally validate a clinical prognostication tool for risk of progression to mortality in symptomatic leptospirosis patients, thereby helping in the triaging of patients. The initial 2018 derivation cohort was composed of 383 patients seen from January to October 2018 at the National Kidney and Transplant Institute (NKTI). It then combined potential predictive factors based on history, initial physical examination and baseline laboratory results at the emergency room level. Logistic regression was performed to identify the independent predictors that resulted in mortality. By univariate comparison,13 risk factors (all with p <0.05) were then selected for the final scoring system model and assigned a score with a minimum of 0 to maximum of 18 points.This retrospective validation study of the clinical scoring system included 169 subjects admitted at NKTI from January to December 2019. All patients with complete medical records, aged over 18 years with a clinical diagnosis of leptospirosis based on NKTI guidelines were included. Receiver operating characteristic (ROC) analysis was used to assess the predictive ability of the scoring system for mortality progression. Sensitivity, specificity, predictive values, and likelihood ratios and its 95% confidence intervals were then computed via STATA 15.0. Model calibration in the external validation cohort was evaluated using the Hosmer–Lemeshow goodness-of-fit test. In this validation study, majority of the patients were male, in both the survivors (n=122) and non survivors (n=21). The mean age of included patients is 37 years old (range 19-79). The following factors based on p-value were shown to be significant predictors of mortality: hemorrhage (54.5%), tachypnea (63.6%), thrombocytopenia (77.2%), and acidosis (54.5%). The cutoff score of 4 points, based on Youden’s J-index, showed an 86.36% sensitivity and 62.59% specificity in predicting mortality. The highest mortality rate is seen for risk scores >9, where there is a 25.8% chance of mortality. The scoring system's ability to discriminate between subjects in different risk categories was assessed by C-statistic, and is equivalent to the area under the receiver operating characteristic curve (AUC). Based on the ROC curve analysis, the validation cohort achieved a good discriminatory AUC of 0.77. The clinical scoring system has moderate accuracy, is well calibrated, and has a sensitivity of 86% and specificity of 63% in predicting progression to mortality. The risk scoring system can be useful for immediate triaging for leptospirosis patients at the emergency room level.

Effect of Methylprednisolone and Cyclophosphamide on the Survival of Patients with Leptospirosis, Renal Failure and Pulmonary Hemorrhage

Objectives: To determine the efficacy of three day methylprednisolone plus single dose intravenous cyclophosphamide on the survival of patients with leptospirosis, renal failure and pulmonary hemorrhage. Methods: A retrospective review of 138 patients diagnosed with leptospirosis at the National Kidney and Transplant Institute (NKTI) from August 1, 2009 to August 31, 2013 were included in the study. Patients were grouped according to those who received standard therapy with a 3-day course of Hydrocortisone (HC group) compared to a 3-day course of Methylprednisolone-Cyclophosphamide (MP-C). Patient survival, length of hospital stay and time to becoming dialysis independent were compared. Results: There were 65 patients in the HC group and 73 patients in the MP-C group. Mean age was 35.9 years, with male predominance. The most common clinical manifestation was fever. Thrombocytopenia was the major indication to steroid therapy. Survival of patients given MP-C was significantly higher than those given HC (88% and 74% respectively; p=0.035). The post treatment activated Plasma Thromboplastin Time (aPTT) was significantly lower in the MP-C group. There was no significant difference in the length of hospital stay and time to becoming dialysis independent. Conclusion: Three day MP-C pulsing significantly improves survival of patients with leptospirosis, renal failure and pulmonary hemorrhage.

AOS2 Prevalence of symptomatic deep vein thrombosis in patients with cancer admitted to the National Kidney and Transplant Institute in the Philippines

Background Prevention of cancer-associated thrombosis is important for reducing the burden of disease, yet it has received little attention from clinicians. In this study we aimed to assess the prevalence of deep venous thrombosis (DVT) in patients with solid and haematological malignancies who were admitted to the National Kidney and Transplant Institute (NKTI) and to define the profile of patients with cancer who developed DVT. Methods In this retrospective study, charts of inpatients with cancer who developed DVT from January 2005 to December 2010, were reviewed. ICD-10 codes for DVT and pulmonary embolism were used to search for patients. The total number of patients with cancer was obtained from the medical records section of the electronic database. Findings Ten thousand two hundred and ninety-nine patients with cancer were admitted to NKTI from 2005 to 2010. Forty-six developed DVT (prevalence 0.45%). Prevalence in solid and haematological malignancies was 0.44% and 0.43%, respectively. DVT commonly occurred within 6 months of cancer diagnosis, and in patients with stage IV malignancies and those who were obese. Lung cancer was the most common malignancy that presented with DVT. Leg oedema was the most common initial manifestation. Doppler venous ultrasonography frequently showed proximal DVT with or without distal involvement. Twnety-one deaths were known to have occurred after diagnosis of DVT. Most patients died within 1–3 months of the onset of DVT. Septic shock was the most common cause of death. Interpretation The results suggest that DVT in patients admitted to NKTI occur in those with late-stage cancer and that the thrombosis is usually extensive, symptomatic, and arises early after the initial diagnosis of cancer. Also, after the onset of DVT, most patients died within 1–3 months, which is lower than the median survival cited in previous studies. The authors declared no conflicts of interest.

Incidence of Infusion-related Reaction to Monoclonal Antibody Rituximab: A National Kidney and Transplant Institute Experience

Dear Editor, The advent of rituximab to standard therapy dramatically increased the overall survival of CD20 positive oncologic and haematologic malignancies.1 Incidence of infusionrelated reaction to rituximab is high, as high as 77% for the fi rst infusion.2 Reactions can be mild from simple rashes, to potentially life-threatening anaphylaxis. The objective of this paper is to determine the incidence of infusion reactions to rituximab, premedications used, and management given for these reactions. This is a retrospective study involving chart review of patients admitted at the National Kidney and Transplant Institute (NKTI) for rituximab administration from January 2005 to May 2011. Demographic profi le and premedications used (dexamethasone, acetaminophen, antihistamines) were obtained. Incidence of infusion reactions was determined, as well as the corresponding management. Infusion reactions were graded according to the National Cancer Institute (NCI) Criteria for Toxicity version 3. Research protocol was approved by the review board of the NKTI. Categorical variables were expressed using descriptive statistics (percentages) and continuous variables were expressed as median and range. Fisher’s Exact Test was done to determine whether there exists a difference between those with reactions and those without. Statistical analysis was carried out using SAS version 9 (SAS Institute, NC, USA). P value <0.05 was considered signifi cant. Forty-six patients were included, with a median age of 56 years (range 23 to 83). There were 22 males and 24 females, and the mean performance status was Eastern Co-operative Group (ECOG) 1 (range 0 to 3). Diffuse Large B Cell Lymphoma (DLBCL) was the most common diagnosis with 36 patients (78.27%) followed by Burkitt lymphoma and chronic lymphocytic leukemia (CLL) with 3 patients (6.52%) each. There were 5 patients who developed infusion reactions with rituximab. Infusion events occurred in 5 out of 46 patients (10.86%) during the study period. All reactions occurred in the fi rst infusion of rituximab. Three out of the 5 patients were diagnosed with DLBCL and were given R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone), while the remaining 2 patients were diagnosed with CLL and were given RFC (rituximab, fl udarabine, cyclophosphamide) protocol. Four patients had grade II reaction and one patient had grade I reaction according to the NCI Toxicity criteria. All reactions occurred in the fi rst 30 minutes of infusion. Patients experienced chills, fever, and rashes. All symptoms resolved within 30 minutes. Management included infusion interruption, hydrocortisone, acetaminophen, and diphenhydramine. Rituximab rechallenge was successful, with all the patients able to complete infusion. Table 1 shows the risk profi le and premedications given to the patients. Comparing those who developed reactions to those that did not, only the use of ranitidine showed a statistical signifi cant difference (P = 0.0199).

Prevalence of hepatitis B and hepatitis C in haemodialysis patients

The prevalence of hepatitis B surface antigen (HBsAg), hepatitis B exposure and antibodies against the hepatitis C virus (anti‐HCV) was assessed in 86 haemodialysis patients at the National Kidney and Transplant Institute (NKTI) using the commercial radioimmunoassay and ortho HCV ELISA assay. Of the 86 patients included in the study, 42 were male with a mean age of 44.9 years and a mean duration of dialysis of 2.4 years. Forty‐four were female with a mean age of 48.4 years and a mean duration of dialysis of 2.3 years. Hepatitis B exposure was 57% and 12.8% of haemodialysis patients were positive for HBsAg, whereas 39.8% of patients were positive for anti‐HCV. There was a significant correlation (P=0.00007) between anti‐HCV positivity and the length of time on haemodialysis. However, there was no significant correlation found between the number of blood transfusions received and anti‐HCV positivity. There was also no significant correlation found between HBsAg and antibodies to hepatitis B core antigen (anti‐HBc) positivity and the number of blood transfusions or the length of time on haemodialysis, nor between hepatitis B and C exposure and elevated aminotransferase levels.

Prevalence of hepatitis B and hepatitis C in haemodialysis patients

SUMMARY: The prevalence of hepatitis B surface antigen (HBsAg), hepatitis B exposure and antibodies against the hepatitis C virus (anti‐HCV) was assessed in 86 haemodialysis patients at the National Kidney and Transplant Institute (NKTI) using the commercial radioimmunoassay and ortho HCV ELISA assay. of the 86 patients included in the study, 42 were male with a mean age of 44.9 years and a mean duration of dialysis of 2.4 years. Forty‐four were female with a mean age of 48.4 years and a mean duration of dialysis of 2.3 years. Hepatitis B exposure was 57% and 12.8% of haemodialysis patients were positive for HBsAg, whereas 39.8% of patients were positive for anti‐HCV. There was a significant correlation (P= 0.00007) between anti‐HCV positivity and the length of time on haemodialysis. However, there was no significant correlation found between the number of blood transfusions received and anti‐HCV positivity. There was also no significant correlation found between HBsAg and antibodies to hepatitis B core antigen (anti‐HBc) positivity and the number of blood transfusions or the length of time on haemodialysis, nor between hepatitis B and C exposure and elevated aminotransferase levels.