Nephrologists Research Articles

#3713 NEPHROLOGISTS’ AND PRIMARY CARE PHYSICIANS’ KNOWLEDGE ABOUT NOVEL TREATMENT OPTIONS FOR TYPE 2 DIABETES AND CKD AUGMENTED BY ONLINE MEDICAL EDUCATION

Abstract Background and Aims Diabetes is the number one cause of kidney failure and chronic kidney disease (CKD) associated with type 2 diabetes (T2D) increases the risk for cardiovascular events 2 to 3- fold thus highlighting the crucial need for early detection of CKD and comprehensive vascular risk control. Recently, novel treatment options with clear benefits for the prognosis of patients with T2D and CKD have emerged. The goal of this activity for primary care physicians (PCP) and nephrologists (NEPH) was to improve their understanding of the clinical benefits as well as safety considerations of selective non-steroidal mineralocorticoid antagonists (nsMRA) in the management of their patients with T2D and CKD. Method Two nephrology experts joined a 20-minute online video discussion with synchronized slides. Educational effect was assessed using a repeated-pair design with pre-/post-assessment. 3 multiple choice questions assessed knowledge, 1 question rated on a Likert-type scale assessed confidence. A paired samples t-test was conducted on overall average number of correct responses and for confidence rating, a McNemar's test was conducted at the question level (5% significance level). Cohen's d with correction for paired samples estimated the effect size of the education on number of correct responses. Data collection from 8/2/22 to 10/17/22. Results Conclusion Participation of PCP and NEPH in an online video expert discussion improved their understanding of the clinical benefits and safety aspects of selective nsMRA as well as their confidence in using such novel therapies for their patients with T2D and CKD in clinical practice.

Mixed methods assessment of providers’ needs in the management of advanced renal cell carcinoma.

313 Background: There is a paucity of data regarding the challenges associated with the timely and accurate diagnosis of Renal Cell Carcinoma (RCC) and its effective multidisciplinary management. This study aimed to assess the knowledge and skills of healthcare providers (HCPs) managing and coordinating the care of patients with advanced RCC (aRCC) across multidisciplinary teams. Methods: A sequential mixed methods needs assessment was conducted across the United States with medical oncologists (ONCs), nephrologists (NEPHs), physician assistants (PAs), nurse practitioners (NPs), and registered nurses (RNs). Interviews, transcribed and thematically analyzed, and online surveys, statistically analyzed, were triangulated. Results: A total of 305 HCPs completed an interview (n=40) or the survey (n=265): 78 ONCs, 62 NEPHs, 57 PAs, 55 NPs, 53 RNs. One third (33%) of HCPs reported suboptimal skills in adjusting the dose of a treatment for aRCC in the event of adverse reactions. Interviews underscored a lack of clarity for HCPs on when to reduce the dose or when to discontinue and/or switch to other drugs. Suboptimal knowledge and skills related to toxicities were found (Table). Breakdowns in communication across multidisciplinary teams were identified by 46% of HCPs. Of those, 61% occurred when monitoring side effects and 48% when referring to ONCs. Some NEPHs reported never, rarely, or sometimes being involved with ONCs in the management of nephritis (25%), chronic kidney disease (19%), or acute renal failure (24%). Interviews suggested the role of NEPHs in the care of aRCC is poorly recognized and that NEPHs are perceived to have limited time to spend in the care of cancer patients. Few NEPHs reported gaps in knowledge/skills managing key renal complications such as nephritis (13%/15%), chronic kidney disease (6%/15%), and acute renal failure (9%/9%). Conclusions: This study identified a need to improve HCPs’ knowledge of the signs/symptoms of treatment side effects, skills in identifying/referring patients to appropriate specialists, and skills in managing adverse events. Barriers to involving NEPHs in the co-management of aRCC included a lack of recognition of their role in managing treatment-induced renal complications.These results should inform educational interventions for professionals caring for aRCC patients.[Table: see text]

Синдром Барттера в практиці нефролога (спостереження з практики)

У статті викладено питання патогенезу, клініки та лікування синдрому Барттера на прикладі клінічного випадку.

Hematological Disorders during Chronic Kidney Disease Stages 3 to 5 Non-Dialysed in Cameroon

Introduction: Haematological disorders are common complications of chronic kidney disease (CKD) leading by anemia which increase with the severity of the disease. Objective: Assess the haematological profile of CKD patients stages 3 to 5 non-dialysed seen at the first nephrology consultation in Cameroon. Patients and Methods: A hospital-based cross-sectional study was conducted from February to July 2018 at the nephrology unit of the Yaounde University Teaching Hospital and Douala General Hospital. All adults’ (≥18 years old) patients who provided a written informed consent and attended their first nephrology consultation with a nephrologist diagnosis of CKD stages 3 to 5 non-dialysed were included. Clinical and paraclinical data (serum creatinine, full blood count, reticulocytes count, iron status, vitamin B12 and folates count, and bleeding time) were collected. Parametric, non-parametric and correlations tests were used to compare variables. Results: We included 105 (59% males) participants with a mean age of 55.2 ± 13.6 years divided into 20 (19%), 36 (34.3%) and 49 (46.7%) respectively in stage G3, G4 and G5 of CKD. The profile of hematological abnormalities was anemia (86.7%), leucopenia (15.2%), hyperleucocytosis (6.7%), thrombopenia (23.8%), thrombocytosis (3.8%) and prolonged bleeding time (13.3%) without any association with the stage of CKD (p > 0.05). The pattern of anemia was mainly normocytic and normochromic (59.3%) and aregenerative (92.3%) with iron deficiency found in 23 (21.9%) participants. There was no case of vitamin B12 and folates deficiency. Prolonged bleeding time was observed in 14 (13.3%) participants with a weak correlation between platelets count and bleeding time (r = 0.122). Conclusion: We observed that aregenerative normocytic normochromic anemia is the leading haematological abnormality during CKD in this setting. None of the full blood count parameters was associated with CKD stages and there was a week correlation between bleeding time and platelet count.

Coronavirus 2019 pandemic and renal diseases: a review of the literature

Objectives Most people with coronavirus 2019 (COVID-19) develop mild illness, but a minority may require active medical care because of the acute respiratory distress syndrome, sepsis and septic shock, and multiorgan failure, including acute kidney injury (AKI) and cardiac injury. The effect of this infection in those with chronic kidney disease (CKD) including kidney transplant recipients has not been evaluated properly. We aimed to highlight the effect of COVID-19 on patients with CKD and the preventive measures to be taken in addition to possible therapeutic modalities till the end of May 2020. Patients and methods We have reviewed most of the literature concerning COVID-19 and focused on the renal implications. Results Patients with CKD (especially dialysis patients and kidney transplant recipients) are at high risk of death because comorbidities increase the risk of dying owing to COVID-19; moreover, COVID-19 infection exaggerates comorbidities and causes possible drug interactions. Patients with COVID-19-induced AKI should be seen regularly by nephrologists, because the risk of these patients to develop CKD is high. In this review, we evaluated the different studies dealing with such topic. Conclusion Kidney involvement seems to be frequent in patients with COVID-19 infection, and AKI is an independent predictor of mortality. Management of patients on dialysis will need special precautions with strict protocols to minimize the risk to other patients and health care personnel taking care of these patients. Immunocompromised patients, such as transplant recipients and those who are maintained on immunosuppressive medications, will need special care.

1749. A Nationwide Survey of Cytomegalovirus Prevention Strategies in Kidney Transplant Recipients in a Resource-Limited Setting

BackgroundCytomegalovirus (CMV) causes morbidity in kidney transplant (KT) recipients. Strategies to prevent this infection in resource-limited settings have been unreliably implemented and under-explored. We investigated CMV prevention strategies utilized among transplant centers in Thailand.MethodsA questionnaire on CMV prevention strategies for KT recipients was developed using a web-based electronic survey website (www.surveymonkey.com). The survey was delivered to 31 transplant centers in Thailand. One infectious disease physician (ID) and one nephrologist (NP) from each center were included.ResultsThere were 43 respondents from 26 (84%) transplant centers including 26 (60%) IDs and 17 (40%) NPs. The majority worked in a public hospital setting (63%) and had encountered KT recipients for at least 2 years (74%). Forty-one (98%) physicians agreed on the necessity of CMV prevention. Of these, 34 (81%) physicians implemented prevention strategies for their patients. Interventions included preemptive approaches (47%), prophylaxis (44%), hybrid approaches (3%); surveillance after prophylaxis (3%), and CMV-specific immunity-guided approaches (3%). For CMV-seropositive KT recipients, use of preemption (84%) exceeded prophylaxis (12%). However, 81% of the former preferred targeted prophylaxis in patients receiving anti-thymocyte globulin therapy. Sixty-five and 93% of physicians started preemptive therapy when plasma CMV DNA loads reached 2,000 and 3,000 copies/mL (1,820 and 2,730 IU/mL), respectively. A significantly greater percentage of NPs initiated preemptive therapy at a plasma CMV level of 1,820 IU/mL compared with IDs (88% vs. 50%, [P = 0.02]). The most common barrier to prevention strategy implementation was financial inaccessibility of oral valganciclovir (67%) and quantitative CMV DNA testing (12%). The majority (81%) felt that a guideline would allow physicians to implement CMV prevention strategies for their patients.ConclusionMost physicians agreed on a need for preemptive approaches, although prophylaxis was targeted in those receiving intense immunosuppression. Guidelines and financial accessibility could improve CMV prevention strategy implementation in Thai KT recipients.Disclosures All authors: No reported disclosures.

Regional Professionals Network to Support the Renal Epidemiology and Information Registry in Ile-de-France.

We present the regional professional network to support the Renal Epidemiology Information Network (REIN) registry in maintaining high quality data production and information analyses in Ile-De-France region. The network is based on a long term partnership between the nephrologists and a regional methodology support unit. It integrates clinical research assistants for data quality control. We also present organizational methods on maintaining the registry and enhancing information analyses and automating analyses reports.

A Nationwide Survey of Cytomegalovirus Prevention Strategies in Kidney Transplant Recipients in a Resource-Limited Setting.

ObjectiveStrategies to prevent cytomegalovirus (CMV) infection in resource-limited settings have been under-explored. We investigated CMV prevention strategies utilized among transplant centers in Thailand.MethodA questionnaire on CMV prevention strategies for kidney transplant (KT) recipients was developed using a web-based electronic survey website (www.surveymonkey.com). The survey was delivered to 31 transplant centers in Thailand. One infectious disease physician (ID) and 1 nephrologist (NP) from each center were included.ResultsThere were 43 respondents from 26 of the 31 transplant centers (84%), including 26 (60%) IDs and 17 (40%) NPs. Forty-one 95% (41/43) physicians agreed on the necessity of CMV prevention. Of these, 77% (33/43) physicians implemented prevention strategies for their patients. Interventions included preemptive approaches (48%), prophylaxis (45%), hybrid approaches; surveillance after prophylaxis (3%), and CMV-specific immunity-guided approaches (3%). For CMV-seropositive KT recipients, use of preemptive approaches (84%) exceeded prophylaxis (12%). However, 81% of the former preferred targeted prophylaxis in patients receiving antithymocyte globulin therapy. Sixty-five percent and 93% of physicians started preemptive therapy when plasma CMV DNA loads reached 2000 and 3000 copies/mL (1820 and 2730 IU/mL), respectively. A significantly greater percentage of NPs initiated preemptive therapy at a plasma CMV DNA load of 1820 IU/mL compared with IDs (88% vs 50%; P = .02). The most common barrier to prevention strategy implementation was financial inaccessibility of oral valganciclovir (67%) and quantitative CMV DNA testing (12%).ConclusionsMost physicians agreed on a need for preemptive approaches, although prophylaxis was targeted in those receiving intense immunosuppression. The financial implication is the main barrier for CMV prevention in Thailand.

Point of care renal ultrasonography for the busy nephrologist: A pictorial review.

The application of bedside ultrasonography in routine clinical practice has dramatically evolved over the last few decades and will likely continue to grow as technological advances lead to enhanced portability and affordability of the equipment. Despite mounting interest, most nephrology fellowship training programs do not offer formal training in renal ultrasonography and there is inertia among practicing nephrologists to adopt this skill as a practice-changing advancement. Lack of familiarity with the topic is considered a key reason for this inertia. Understanding of basic ultrasound physics, instrumentation, principles of optimal image acquisition and interpretation is critical for enhanced efficiency and patient safety while using this tool. Herein, we provide a brief overview of the basic principles of diagnostic renal ultrasonography as well as introduction to common sonographic pathologies encountered in day-to-day nephrology practice with illustrative images.

Professor Dr. HL Trivedi pioneering nephrologist and patriot who cared for his country (31-08-1932 TO 2-10-2019)

Professor Dr. HL Trivedi pioneering nephrologist and patriot who cared for his country (31-08-1932 TO 2-10-2019)

Bioimpedance Spectroscopy-Guided Ultrafiltration Normalizes Hydration and Reduces Intradialytic Adverse Events in Hemodialysis Patients.

Chronic fluid overload as well as excessive fluid removal are associated with increased morbidity and mortality in hemodialysis (HD) patients. The clinical method to probe the dry weight is often inaccurate and the bioimpedance spectroscopy (BIS) is shown to improve the accuracy. We compared the impact of BIS and clinical methods to guide ultrafiltration (UF) in a randomized controlled study on the intradialytic complications and blood pressure control in prevalent HD patients. Fifty patients on maintenance HD were randomized to BIS method (BIS-group) and clinical method (CL-group) to guide UF. The body composition monitor (BCM) was done post-HD in all patients at baseline and 2-weeks interval during the study period of 6 months to determine the hydration status, but the result was revealed only to the nephrologist managing the patients in BIS-group to probe the dry weight. The endpoints of the study were blood pressure control, intradialytic complications and anti-hypertensive drug burden. The mean age was 56.0 ± 12.0 years and 70% were male. There was significant increase in patients with normal hydration in BIS-group (20% vs. 88%, p = 0.0001), but remained similar to baseline in CL-group (40% vs. 48%, p = 0.3) at 6 months. The incidence of intradialytic hypotension was significantly reduced in BIS-group (4.84 ± 3.0 vs. 2.8 ± 3.13 events/patient/6 months, p = 0.003). There was 35% reduction in hypertensive pill burden in BIS-group with similar blood pressure, compared to CL-group. Post-dialysis underhydration was more common than over or normal hydration at baseline in our population, indicating that clinical method to probe dry weight often resulted in hypovolemia. BIS method to determine dry weight resulted in normalization in volume status and consequently resulted in significant reduction in intradialytic hypotension and anti-hypertensive pill burden over 6-month period.

Early failure of arteriovenous fistula and its related factors and nursing

Objective The aim of the study was to investigate the early failure of newly created arteriovenous fistula(AVF) in patients on maintenance hemodialysis and the factors responsible for the failure. Methods The clinical data were retrospectively reviewed, preoperative examination and laboratory biochemical indicators of 88 patients with newly created AVF for maintenance hemodialysis in our hospital through Hospital Management Information System and telephone follow-ups. Binary Logistic regression was used to analyze the protective factors for early failure. Results In 88 patients, early failure of the AVF was found in 15 patients. Twenty-three factors, including gender, were involved in statistical analysis. There were statistical differences between the two groups in hypertension (χ2=7.689, P=0.006) and whether they had early referral to nephrologists (χ2=5.334, P=0.021). Further regression analysis showed hypertension (OR=0.192, 95% CI=0.0538-0.692, P=0.012) was protective factor and without early referral (OR=3.651, 95% CI=1.068-18.302, P=0.039) was the risk factor of early failure. Conclusion This study shows that no early referral and combined hypertension is an important factor affecting the early failure, emphasizing the clinical work, for the diagnosis of patients with chronic kidney disease, early nephrological referral should be established, and blood pressure monitoring should be done to help reduce the incidence of complications. Key words: Renal dialysis; Autogenous arteriovenous fistula; Fistula dysfunction

A single center study of cancer patients with chronic kidney disease

Purpose: It is clinically understood that chronic kidney disease (CKD) and cancer are interrelated. Yet, few studies measure how renal outcomes vary according to common malignancies and common therapeutic agents. We report the incidence and the nature of CKD among cancer patients from a single institution. Methods: A retrospective chart review of cancer patients managed in the onconephrology clinic at the Moffitt Cancer Center from 05/01/2015 to 07/31/2016 was conducted. Patients with kidney injury were included in this study. Renal function was recorded at three-month follow-up intervals for 15-month duration. Results: Out of the total 88 patients with median age of 68 years, 63 patients (~ 72%) were diagnosed with chronic kidney disease (CKD), whereas the remaining had acute kidney injury. Kidney cancer and multiple myeloma represented the single malignancies with the largest proportion of CKD with 12 patients each (~14% each). Patients with kidney cancer had a mean creatinine of (2.35, 1.74 SD) mg/dl compared to patients without kidney cancer with creatinine (1.97, 1.07 SD) mg/dl. Abdominal cancers represented the highest frequency category of malignancies in this sample (n = 38), and about 32 (84%) of these patients had CKD. About 80% of patients with genitourinary cancers (n = 27) had CKD. In terms of prescribed chemotherapeutic agents, patients treated with tyrosine kinase inhibitors had a lower average estimated glomerular filtration rate (28.37, 9.86 SD) mL/min/1.73 m 2 compared to other chemotherapeutic agents, though this was weakly significant (p-value = 0.07). Similar renal outcomes per malignancy and chemotherapy are reported. Conclusion: This group of patients demonstrated the frequency of chronic kidney disease differs depending on the type of malignancy or chemotherapy. A multidisciplinary approach involving oncologists and nephrologists should be adopted to prevent further renal damage from cancer and its therapies.

Nephrologists' Views on Dialyzing Older Patients

While attending on an inpatient medical service recently, I cared for an older man with end-stage renal disease, dementia, severe aortic stenosis, and

Assessment of Kidney Function Tests in Diabetes Mellitus Patients under Insulin Doses in Arar Region, Kingdom of Saudi Arabia

Objectives: The aim of this work was to assess the kidney function tests in Diabetes Mellitus patients under insulin doses in Arar regionIntroduction: Diabetes Mellitus (D.M) is a prevalent endocrinal disorder in Kingdom of Saudi Arabia. Present study is to highlight the effect of long lasting cases of controlled D.M on Kidney Functions in a local region. Diabetic renal disease in human often requires the better part of two decades to develop the signs and symptoms of advanced/clinical diabetic nephropathy with underlying extensive damage to the various segments of the nephron, thereby causing albuminuria, rising blood pressure, and a progressive decline of glomerular filtration.Materials and Methods: The serum biochemistry investigation for Glucose, Urea and Creatinine.1-Glucose: The fasting serum glucose level was obtained from the laboratory of Clinical Biochemistry using department Autoanalyser (Dimension model RXL MAX) of the Arar Central Hospital, Arar.2-Urea: Urea Kit (Randox) and a spectrophotometer were used to determine the serum urea concentration in the samples.3-Creatinine: Serum creatinine was measured by a Kit (Randox), using the compensated kinetic Jaffe assay.Results & Discussions: It is clear from the result that in almost all patients blood glucose is within normal range but their kidney function test i.e. urea and creatinine lies in high range. Measurements of Blood pressure (SBP &DBP) also found to be in normal range for all patients. So obtained results could be interpreted as: The patients are controlled diabetics under insulin therapy but with very high serum creatinine level indicating severely affected glomerular filtration rate.Conclusion: Based on this study it could be concluded that long duration of diabetes mellitus can affect renal function through destructive effects on vascular bed of renal tissues as a part of general vascular and nervous pathological effects of diabetes mellitus. These patients are advised to go for dialysis regularly and should be under observation of well qualified Nephrologists.

SP776RELATIVELY UNKNOWN "NEPHROLOGISTS" BETWEEN 1st-14th CENTURY

SP776RELATIVELY UNKNOWN "NEPHROLOGISTS" BETWEEN 1st-14th CENTURY

Successful AV fistula creation does not lead to higher catheter use: the experience by the Northwest Renal Network 16 Vascular Access Quality Improvement Program. Four years follow-up.

In 2002, the Center for Medicare and Medicaid Services (CMS) required all 18 Renal Networks to participate in a Vascular Access Quality Improvement Program (QIP). The Northwest Renal Network (NWRN 16) chose to increase arteriovenous fistula (AVF) use. NWRN 16 hypothesized that strategies which targeted the improvement of AVF rate and the reduction of catheter use were the same. In December 2001, 44.2% of hemodialysis (HD) patients in the NWRN 16 received HD using an AVF which met the Dialysis Outcome Quality Initiative (K/DOQI) 40% AVF guideline for prevalent patients. However, 43% of HD facilities (2869 patients) had less than 40% of AVF and higher HD catheter rates than the average Network catheter rates (25.0 vs. 20.3%). To address the needs of underperforming facilities, NWRN 16 provided education and tools for their vascular access decision makers to promote AVF creation and catheter reduction. In 2002, NWRN 16 sponsored four regional workshops targeted at nephrologists, vascular surgeons, HD nurses, and interventional radiologists. Percentage of AVFs in use in invited facilities increased from 31.3% pre-intervention to 56.2% at 4 yrs: 78% increase (99% confidence interval: 77.8% to 81.5%). Percentage of catheters increased from 25% to 25.8%: 3.2% change over 4 yrs (99% confidence interval: 2.5% to 4%). The success of Network 16's AVF interventions demonstrates the effectiveness of Network education promoting multidisciplinary teamwork, and innovative strategies to increase dramatically AVF use without substantial increase in catheter use.

Evaluating and Treating Patients with Mineral and Bone Disorders Associated with Chronic Kidney Disease

Sponsoring Organization: Kidney Disease: Improving Global Outcomes (KDIGO)Target Audience: Nephrologists, primary care physicians, and others caring

Foregoing or Withdrawing Dialysis: Perspectives of Nephrologists

Weighing the benefits and burdens of dialysis in frail elders with chronic kidney disease (CKD) — and deciding whether to withhold this intervention —

Effectiveness of bioelectrical impedance analysis interventions on volume status in hemodialysis patient:a systematic review

Objective To evaluate the effectiveness of bioelectrical impedance analysis(BIA) interventions on volume status in hemodialysis patient. Methods Searched The Cochrane Library, PubMed, EMbase, EBsco, Wanfang Data, China Biology Medicine, China National Knowledge Infrastructure to collect clinical trials. The retrieval time was from database to July 15, 2016. The studies were selected according to the inclusion and exclusion criteria and were critically appraised by two reviewers. Then the data of included studies were extracted. Meta-analysis was conducted by using RevMan 5.3 software and descriptive analysis. Results Ten clinical trials were included six random control trial, one controlled clinical trail, three longitudinal study, involving 2 009 patients. The results of Meta-analysis showed that the effectiveness of BIA interventions on volume management could improve blood pressure (P=0.001), protect the heart function(left ventricular mass index,P=0.002), compared with the clinical evaluation method, the BIA assessment of dry weight of hemodialysis patients could reduce hospitalization rate 14%. Descriptive analysis showed that BIA intervention volume management had certain advantages for the survival benefit of patients, but the current research was still few, had not yet come to a certain conclusion. Conclusions BIA can improve the management of the volume status and dry weight of hemodialysis patients, so as to it can improve the clinical benefit and survival benefit of patients.Better methods and guidelines for assessing DW and using BIA need to be developed.We propose that experienced HD nursing staff be trained in the use of the BIA to help monitor patient over hydration and approximate dry weight in consultation with the nephrologists responsible for the care of these patients so as to obviate excessive residual over hydration between nephrology reviews. Key words: Renal Dialysis; Electric impedance; Meta-analysis; Volume management