Outcome Of End-stage Renal Disease Research Articles

8. Sepsis-Associated Acute Kidney Injury and Acute Kidney Disease: A 15-Year Cohort Study of 4,226 Adult Sepsis Inpatient Survivors at a Tertiary Medical Center in Taiwan

BackgroundSepsis is the most common cause of acute kidney injury (AKI) and about one-third of patients with sepsis-associated AKI (SA-AKI) develop acute kidney diseases (SA-AKD) and may progress to unfavorable outcomes. We aimed to study the characteristics and outcomes associated with SA-AKI and SA-AKD.MethodsThis cohort study included adult inpatients with first-time sepsis who were admitted during 2003-2017, had qualifying serum creatinine (SCr) measurements at baseline (-365 to -3 days), -2 to +7 days, and +8 to +90 days of sepsis index day, and survived the first 90 days (Figure 1). Sepsis was identified using an electronic medical records-based Sepsis-3 criteria. We classified sepsis inpatients into SA-AKI(-), SA-AKD(-), SA-relapsed-AKD, and SA-nonrecovery-AKD (Figure 2). ESRD and mortality were ascertained by linking to the Catastrophic Illness records and to National Death Registry, respectively. Multivariable Cox proportional hazard model was used to evaluate the risk of mortality and end-stage renal disease (ESRD) associated with SA-AKI/AKD subtypes.Figure 1. Flowchart of the selection process of adult sepsis survivors (N = 4226 patients). Figure 2. Definitions of sepsis associated-acute kidney injury (SA-AKI) and sepsis associated-acute kidney disease (SA-AKD). ResultsOf 4,226 eligible sepsis inpatient survivors, 47.1% developed SA-AKI and 10.1% progressed to SA-AKD (5.4% relapsed and 4.7% nonrecovery). Patient with AKI and non-recovered AKD had the worst baseline renal function (SCr, 1.3 mg/dL) (Table 1). The multivariable analyses revealed that SA-relapsed AKD was significantly associated with increased risk of all-cause mortality for 1-year (aHR 1.67; 95% CI 1.25, 2.24), 3-year (aHR 1.38; 95% CI 1.11, 1.71), and overall (aHR 1.35; 95% CI 1.12, 1.61), compared with SA-AKI(-). SA-relapsed AKD and SA-nonrecovery AKD were both significantly associated with 1-year, 3-year, and overall ESRD, with the risk of about 4-fold or higher than SA-AKI(-) (Table 2).Table 1. Baseline characteristics and outcomes among adult sepsis survivors, by different SA-AKI/AKD subtypes. Table 2. Risk of all-cause mortality and end stage renal disease (ESRD) among adult sepsis survivors. ConclusionSepsis survivors who initially had AKI and developed relapsed or nonrecovery AKD tended to have worse outcomes of all-cause and ESRD, compared with those without AKI. Unexpectedly, patients with non-recovered AKD did not have a higher mortality risk, possibly because we have selected those who survived the first 90 days of sepsis. We will develop two-stage prediction models to identify sepsis patients at risk of developing AKI and SA-AKI patients at risk of developing different types of AKD. Disclosures All Authors: No reported disclosures

Impact of Social Determinants of Health on Chronic Kidney Disease: A Review of Disparities in Renal Transplantation

Background: Striking disparity exists in the incidence and treatment of chronic kidney disease (CKD) secondary to individual social determinants of health. Additionally, the uninsured, minority racial-ethnic groups, and Medicaid enrollees receive less nephrology care prior to being diagnosed with end-stage renal disease (ESRD). The most effective treatment for the management of kidney failure is kidney transplantation. This review addresses how social determinants of health impact the workup for patients with ESRD, with emphasis on the kidney transplant process.
 
 Methods: A search was conducted via multiple online databases (MedLine, PubMed, etc.) for articles that addressed the interplay between CKD, ESRD and kidney transplantation with the social determinants of health.
 
 Findings: The impact of the social determinants of health on CKD, ESRD, and the kidney transplantation process can be qualitatively and quantitatively measured using the five categories of education, health care and access, economic stability, neighborhood and built environment, and social and community context.
 
 Conclusion: Social determinants of health impact outcomes in CKD, ESRD, and kidney transplantation. Public and private initiatives aimed at reducing social disparities among patients with kidney disease must include emphasis on education, health care and access, economic stability, neighborhood and built environment, and social and community context. This initiative is necessary to prevent progression to ESRD and to ensure quality care in the kidney transplantation process.

Association between serum uric acid and renal outcome in patients with biopsy-confirmed diabetic nephropathy.

ObjectiveTo investigate the relationship between serum uric acid (SUA) level and renal outcome in patients with type 2 diabetes mellitus (T2DM) and diabetic nephropathy (DN).MethodsA total of 393 Chinese patients with T2DM and biopsy-proven DN and followed at least 1 year were enrolled in this study. Patients were stratified by the quartiles of baseline level of SUA: Q1 group: 286.02 ± 46.66 μmol/L (n = 98); Q2 group: 358.23 ± 14.03 μmol/L (n = 99); Q3 group: 405.50 ± 14.59 μmol/L (n = 98) and Q4 group: 499.14 ± 56.97μmol/L (n = 98). Renal outcome was defined by progression to end-stage renal disease (ESRD). Kaplan–Meier survival analysis and Cox proportional hazards model were used to analyze the association between SUA quartiles and the renal outcomes.ResultsDuring the median 3-year follow-up period, there were 173 ESRD outcome events (44.02%). No significant difference between SUA level and the risk of progression of DN (P = 0.747) was shown in the Kaplan–Meier survival analysis. In multivariable-adjusted model, hazard ratios for developing ESRD were 1.364 (0.621–2.992; P = 0.439), 1.518 (0.768–3.002; P = 0.230) and 1.411 (0.706–2.821; P = 0.330) for the Q2, Q3 and Q4, respectively, in comparison with the Q1 (P = 0.652).ConclusionsNo significant association between SUA level and renal outcome of ESRD in Chinese patients with T2DM and DN was found in our study. Besides, the role of uric acid-lowering therapy in delaying DN progression and improving ESRD outcome had not yet been proven. Further study was needed to clarify the renal benefit of the uric acid-lowering therapy in the treatment of DN.

Interleukin 6 (rs1800795) and pentraxin 3 (rs2305619) polymorphisms-association with inflammation and all-cause mortality in end-stage-renal disease patients on dialysis

Chronic inflammation plays an important role in the progression and outcome of chronic kidney disease (CKD). The circulating levels of the inflammatory biomarkers interleukin 6 (IL6) and pentraxin 3 (PTX3) are enhanced in CKD patients, and are associated with the progression of the disease and with higher risk for cardiovascular events, the major cause of death in CKD patients. Our aim was to study how specific polymorphisms of IL6 and PTX3 encoding genes affect the inflammatory response and outcome of end-stage renal disease (ESRD) patients on dialysis. Methodology included the analysis of two single nucleotide polymorphisms (SNP), namely the IL6 (rs1800795) polymorphism in the promoter region (-174G > C), and the PTX3 (rs2305619) polymorphism in the intron 1 (+ 281A > G), which were analyzed in ESRD patients on dialysis and in a group of heathy individuals. The allelic frequencies, genotype distribution and their association with circulating levels of the inflammatory markers C-reactive protein (CRP), IL6, growth differentiation factor 15 (GDF15) and PTX3, were determined in ESRD patients. Events of death were recorded along one year, to assess the association of the studied SNPs with all-cause mortality and the inflammatory biomarkers, in ESRD patients. Results showed that the allelic frequencies and genotype distribution for IL6 and PTX3 SNPs in the control group and ESRD patients were similar and in agreement with other European reports. For the IL6 polymorphism, we found a trend towards higher levels of high-sensitivity (hs) CRP, IL6 and PTX3 in the homozygous genotypes; the CC genotype also showed the highest levels of GDF15. The mortality rate after the 1-year follow-up was 10.4%. The CC genotype (IL6 SNP) was associated to a higher risk of mortality and deceased patients carrying this genotype also showed the highest levels of hsCRP. Regarding the studied PTX3 SNP, the AA genotype was linked to an enhanced inflammatory response, showing the highest values of hsCRP and IL6. Nevertheless, this genotype had no significant impact on the mortality rate. In conclusion, both studied SNPs seem to modulate the inflammatory response in ESRD and may, therefore, be determinant on disease progression and patients’ outcome. Our data also highlights the importance of research on genetic variants that, although less frequent, may have significant biological value.

Association of Monoclonal Gammopathy with Progression to End-Stage Renal Disease Among a National Cohort of US Veterans

Introduction : Testing for monoclonal proteins may be undertaken as part of the diagnostic evaluation for chronic kidney disease. However, the clinical significance of monoclonal gammopathy detected in this context is often uncertain. Here we examined the association of a positive test for monoclonal protein with progression to end-stage renal disease (ESRD) (dialysis or kidney transplant) among United States (US) veterans.Methods : We used national Veterans Health Administration (VA) clinical and administrative data to identify and characterize a national cohort of veterans with at least one serum creatinine measurement within the VA between October 1, 2000 and September 30, 2001. We used a text search algorithm for keywords pertaining to monoclonal protein contained in laboratory test results in the VA Corporate Data Warehouse within a two-year window of serum creatinine measurement to identify cohort members who had at least one test for monoclonal proteins (serum protein or urine electrophoresis or immunofixation), and to score test results as positive, negative, or unclassifiable. The text-search algorithm was validated by manual review of a random selection of 2% of records (training set) by an attending hematologist. A second manual review of a random selection of 737 records provided a validation set for the search algorithm, demonstrating a sensitivity of 0.73 (95% confidence interval (CI)) of 0.66-0.79, and specificity of 0.94 (95% CI 0.91-0.96), excluding unclassifiable tests. Patients were followed from the time of their first serum creatinine measurement during fiscal year 2001 through September 30, 2011 for the outcome of ESRD using linked data from the US Renal Data System, a national registry for ESRD. Cox proportional hazards regression stratified by glomerular filtration rate (eGFR ml/min/1.73 m2) was used to estimate hazard ratios (HR) with 95% CI for ESRD for patients with a positive vs. negative paraprotein test adjusted for age, sex, race, diabetes, congestive heart failure, vascular disease, and Charlson comorbidity index.Results : Among a cohort of over 2.1 million veterans with a serum creatinine test, we identified 19,993 who underwent paraprotein testing. Overall, 96% of the cohort were male, 69% were ≥ 55 years old, and 23% were ≥ 75 years old. Of those tested, 4,112 (20.5%) had a positive test, 14,541 had a negative test (72.7%) and 6.7% were unclassifiable. Among those with an eGFR <60, 2% (n=8,293) underwent paraprotein testing, as compared with 0.7% (N=11,700) of those with an eGFR≥60. For all levels of eGFR, the crude incidence of ESRD was higher among patients who were tested vs. not tested. For patients with eGFR ≥60 who underwent testing for monoclonal gammopathy, there was an increased crude rate of ESRD among those with a positive vs. negative test result (4.9 vs 2.2 per 1,000 person years) with an adjusted HR of 2.01 (95% CI 1.50-2.71). For patients with lower levels of eGFR, in whom the absolute rate of ESRD was much higher, the adjusted HR for ESRD for those with a positive vs negative test result was attenuated and varied little by eGFR (Figure).Conclusions : Among a large national cohort of US veterans, the risk of progression to ESRD in patients with a reduced eGFR who were tested for monoclonal gammopathy was similar regardless of whether the test result was positive or negative. Although there was an increased risk of ESRD among patients with preserved eGFR, the absolute risk of ESRD in these patients was very low. Evaluating different paraprotein sub-types and correlation with quantitative test results, including serum free light chain (kappa/lambda) ratios may further improve assessment of renal prognosis in patients with monoclonal gammopathy. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

ASSOCIATION BETWEEN PRE-TRANSPLANT MEDIAL ARTERIAL CALCIFICATION AND EARLY POST-KIDNEY TRANSPLANT HYPERTENSION FROM A PROPENSITY SCORE WEIGHTING ANALYSIS

Objective: Medial arterial calcification (MAC) detected by mammography (MG) is exclusively in the medial layer of the arteries and associated with cardiovascular (CV) outcomes in end-stage renal disease (ESRD) patients. Association between MAC and hypertension (HTN) after successful kidney transplantation (KT) is unclear. Design and method: Female KT patients with pre-KT MG was divided into MAC and non-MAC groups. Baseline characteristics including age, race, and pre-KT diabetes were balanced by propensity score weighting (PSW). Association between MAC and systolic HTN (SBP &lt;130 mmHg) and diastolic HTN (DBP &lt;80 mmHg) at a 24-week post-KT is examined by multiple logistic regression. Results: Of 51 KT candidates, mean age ± SD was 50.08 ± 10.47 years old and 18 patients (35.29%) were Black and the remaining non-Black were 33 (64.71%). Twenty patients (39.23%) had MAC and 21 patients (41.18%) had diabetes. Among 20 patients in MAC group, 14 and 7 patients had SHTN and DHTN at a 24-week post-KT, respectively; whereas, 17 out of 30 patients (missing 1 patient) in non-MAC group had both SHTN and DHTN (MAC vs. non-MAC for SHTN p 0.341 and for DHTN p 0.133). Compared to non-MAC group, MAC group had higher mean SBP (137.45 ± 18.52 vs. 130.70 ± 17.67; p 0.2060); whereas, its mean DBP was lower (74.15 ± 14.17 vs. 78.73 ± 10.55; p 0.2253). By using generalized boosted modeling-based PSW to balance baseline characteristics (Figure 1A&amp;B) and adjusting for potential confounders including age, race, cause of kidney disease, pre-KT diabetes, serum albumin, corrected calcium, phosphorus, dialysis modality, type of KT, donor age, induction immunosuppressive medications, MAC group had 89% lower the odds of having DHTN compared to non-MAC group (OR 0.11; 95%CI 0.02 to 0.84). However, MAC group appeared to have higher, but not significant, risk for SBP (OR 2.24, 95%CI 0.35 to 14.46). Conclusions: KT patients with pre-KT MAC had lower the risk of developing DHTN during early post-KT period. DHTN, which indicates vascular stiffness and increases risk of CV mortality in ESRD, may not explain CV risk in KT recipients. Pathophysiology of DHTN and CV diseases in KT patients after successful KT may be different from ESRD population.

Spectrum of cancer patients receiving renal biopsy

The frontier of onco-nephrology, particularly renal complications of cancer and treatment, remains unexplored. We revisit the fundamental tool of diagnosing kidney disease, renal biopsy, in cancer patients with renal manifestation. Patients who received renal biopsy from July 2015 to July 2019 were analyzed. Primary outcomes included end-stage renal disease (ESRD), mortality, and catastrophic outcome defined as either ESRD or mortality. A Cox proportional hazards model and Kaplan-Meier technique were used to assess the association with outcome measurements and survival analyses. Immunosuppression after renal biopsy and response to the treatment were evaluated. Among the 77 patients, the median age was 66 years (interquartile range [IQR] 59-73 years) and 46 (59.7%) were male. At the time of renal biopsy, 57 patients (74%) had various degrees of renal insufficiency. Tubulointerstitial damage score, quantified by renal pathology, were associated with higher hazards of ESRD (hazard ratio [HR], 1.77; 95% confidence interval [95% CI], 1.20 to 2.61; P=0.004) and catastrophic outcome (HR, 1.30; 95% CI, 0.99 to 1.70; P=0.058). The response rate to immunosuppression was lower in those diagnosed with tubulointerstitial nephritis (1 of 4 patients, 25%) than those with glomerulopathy (10 of 20 patients, 50%). Renal biopsy may improve diagnostic accuracy and assist in treatment guidance of cancer patients with renal manifestation. Renal biopsy should be encouraged with clinical indication. Collaboration between oncologists and nephrologists is of paramount importance to provide more comprehensive care for caner patients.

Outcomes of end-stage renal disease patients in the PROCESS trial.

ObjectiveIntravenous fluid administration is a main component of sepsis therapy, but physicians are cautious about giving fluids to end‐stage renal disease (ESRD) patients out of concern for causing volume overload. We compared the outcomes of septic shock patients with and without ESRD and evaluated the association between early intravenous fluid administration and outcomes.MethodsWe analyzed patients enrolled in the Protocolized Care for Early Septic Shock (PROCESS) trial, which studied different resuscitation strategies for early septic shock. Stratifying for ESRD, we compared patient characteristics, course of care, and outcomes between ESRD and non‐ESRD. Using multivariable logistic regression, we determined the association between 6‐hour total fluid volume (> = 30 mL/kg vs < 30 mL/kg) from preenrollment and outcomes.ResultsThere were 84 ESRD and 1257 non‐ESRD patients. ESRD patients had a higher median Charlson Comorbidity score (5 vs 2, P < .001), higher median acute physiology and chronic health evaluation (APACHE) II score (26.5 vs 20.0, P < .001), and lower 6‐hour intravenous fluid administration (54.7 vs 68.3 mL/kg, P < .001). Ninety‐day mortality (33.3% vs 29.3%, P = .43) and intubation rate (31.0% vs 33.4%, P = .64) did not differ between groups. Fewer ESRD received > = 30 mL/kg (66.6% vs 86.7% P < .001). For ESRD, receipt of > = 30 mL/kg intravenous fluid did not alter any outcome. For non‐ESRD patients, receiving ≥30 mL/kg of intravenous fluid was associated with increased 90‐day mortality (adjusted odds ratio = 1.64; 95% confidence interval, 1.03‐2.61).ConclusionsIn the PROCESS trial, ESRD patients had similar outcomes to non‐ESRD patients. Although ESRD patients received less intravenous fluid administration, most received over 30 mL/kg in the first 6 hours. In contrast to non‐ESRD patients, receiving ≥30 mL/kg of intravenous fluid was not associated with worse outcomes in ESRD.

Sepsis in end-stage renal disease patients: are they at an increased risk of mortality?

Objectives This study aims to examine the outcome of end-stage renal disease (ESRD) patients admitted with sepsis to the intensive care unit (ICU). Design Single centre, retrospective cohort study Setting The study was conducted in the Intensive Care Department of King Abdulaziz Medical City, Riyadh, Saudi Arabia. Participants Data were extracted from a prospectively collected ICU database from 2002 to 2017. Patients were considered to have sepsis based on the sepsis-3 definition and were stratified into 2 groups based on the presence or absence of ESRD. Primary and secondary outcomes The primary outcome of the study was in-hospital mortality. Secondary outcomes included ICU mortality, ICU and hospital lengths of stay, and mechanical ventilation duration. Results A total of 8803 patients were admitted to the ICU with sepsis during the study period. 730 (8.3%) patients had ESRD. 49.04% of ESRD patients with sepsis died within their hospital stay vs. 31.78% of non-ESRD patients. ESRD septic patients had 1.44 greater odds of dying within their hospital stay as compared to septic non-ESRD patients (OR 1.44, 95% CI 1.03–1.53). Finally, the predictors of hospital mortality in septic ESRD patients were found to be mechanical ventilation (OR 3.36; 95% CI 2.27–5.00), a history of chronic liver disease (OR 2.26; 95% CI 1.26–4.07), and use of vasopressors (OR 1.74; 95% CI 1.19–2.54). Among patients with ESRD, hospital mortality was higher in subgroups of patients with chronic cardiac (OR 1.86 (1.36–2.53) vs. 1.19 (0.96–1.47)) and chronic respiratory illnesses (OR 2.20 (1.52–3.20) vs. 1.21 (0.99–1.48)). Conclusion ESRD patients admitted to the intensive care unit with sepsis are at greater odds of mortality compared to patients with non-ESRD. This risk is particularly increased if these patients have a concomitant history of chronic cardiac and respiratory illnesses. Key Messages Sepsis and bacterial infections are very common in ESRD patients and following cardiovascular disease; sepsis is the second leading cause of death in patients with ESRD. This study aims to examine the outcome of patients with end-stage renal disease (ESRD) patients admitted with sepsis to the intensive care unit (ICU). The results of this study have shown that end-stage renal disease is associated with greater odds of ICU and hospital mortality among septic patients admitted to an intensive care unit. ESRD patients were also more likely to be started on vasopressors and mechanical ventilation.

EVALUATION OF THE RELATIONSHIP BETWEEN NEUTROPHIL TO LYMPHOCYTE RATIO AND RENAL OUTCOMES PATIENTS WITH CHRONIC RENAL DISEASE

ABSTRACT Aim: Regardless of the cause of renal disease, there is strong evidence that an acute and chronic proinflammatory condition exists in adults with chronic renal disease (CRD) and End Stage Renal Disease (ESRD) and that inflammation contributes to morbidity and mortality. In this study, we aimed to investigate whether neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) are associated with poor renal outcome (ESRD + Death) in patients with CRD. Materials and Methods: 194 Turkish CRD (stage 3-5) patients who were regularly came to the nephrology outpatient clinic were enrolled to study. patients records were evaluated and groupped according to the renal status and mortality at the end of four years follow up time. Results: During the follow-up period, 15 out of 194 patients died, renal replacement treatment began to 89 patients and remaning 90 patients were still followed as non-ESRD patients. When compared the patients with ESRD and who were still followed up as non-ESRD patients there was a statistically significant difference in male gender, follow-up time, BMI, SBP, DBP, baseline eGFR, albumin, Hb, Ca, P, NLR, PLR and spot urine creatine ratio.NLR was as an independent risk factor in CRD patients for the progression of the disease and the poor renal outcome. Conclusion: In conclusion, we demonstrated that NLR is an independent predictor of ESRD and poor renal outcome in CRD patients. Therefore, NLR measurement may be useful in predicting the progression of kidney disease in CRD patients. Keywords: Neutrophil to lymphocyte ratio, platelet to lymphocyte ratio, chronic renal disease, progression ÖZET Amaç: Böbrek hastalığının nedenine bakılmaksızın, kronik böbrek hastalığı (KBH) ve Son Evre Böbrek Hastalığı (SDBY) olan yetişkinlerde akut ve kronik proinflamatuar bir durumun var olduğuna ve inflamasyonun morbidite ve mortaliteye katkıda bulunduğuna dair güçlü kanıtlar vardır. Bu çalışmada, CRD hastalarında nötrofil / lenfosit oranının (NLR) ve trombosit / lenfosit oranının (PLR) kötü böbrek sonucu (ESRD + Ölüm) ile ilişkili olup olmadığını araştırmayı amaçladık. Gereç ve yöntem: Nefroloji polikliniğine düzenli olarak başvuran 194 Türk CRD (evre 3-5) çalışmaya alındı. Dört yıllık izlem süresi sonunda hasta kayıtları böbrek durumuna ve mortaliteye göre değerlendirildi. Bulgular: Takip süresi boyunca 194 hastadan 15'i öldü, 89 hastaya renal replasman tedavisi başlandı ve 90 hasta halen ESRD olmayan hastalar olarak takip edilmektedir. ESRD olan hastalar ESRD olmayan hastalar ile karşılaştırıldığında erkek cinsiyet, takip süresi, BMI, SBP, DBP, başlangıç eGFR, albümin, Hb, Ca, P, NLR, PLR ve spot idrar kreatin oranı arasında istatistiksel olarak anlamlı bir fark vardı. NLR, CRD hastalarında hastalığın ilerlemesi ve kötü böbrek sonucu için bağımsız bir risk faktörü olarak bulundu. Sonuç: Sonuç olarak, NLR'nin CRD hastalarında bağımsız bir ESRD ve kötü böbrek sonucu öngörücüsü olduğunu gösterdik. Bu nedenle NLR ölçümü, CRD hastalarında böbrek hastalığının ilerlemesini tahmin etmede yararlı olabilir. Anahtar Kelimeler: Nötrofil / lenfosit oranı, trombosit / lenfosit oranı, kronik böbrek hastalığı, progresyon

P1399SPARING EFFECT OF PERITONEAL DIALYSIS VS HEMODIALYSIS ON CHANGE OF BONE MINERAL DENSITY EVALUATED BY WHOLE-BODY DXA AFTER INITIATION OF DIALYSIS THERAPY AND ITS IMPACT ON CLINICAL OUTCOME

Abstract Background and Aims Bone loss is associated with progression of cardiac calcification and increased mortality in end stage renal disease (ESRD) patients but the relations and underlying causes are unclear. We investigated factors associated with changes of bone mineral density (BMD) during the first year after initiation of dialysis and the association between BMD changes and subsequent mortality in ESRD patients. Method In a prospective study of 242 ESRD patients (median age 55 years, 61% men) starting dialysis, total BMD and BMD at specific bone sites (including seven subregions: head, arms, legs, trunk, hip, pelvis and spine) was assessed by whole body dual-energy X-ray absorptiometry (DXA) at baseline and one year after dialysis start. Framingham cardiovascular disease (CVD) risk score, body composition, nutritional status, handgrip strength, various biochemical biomarkers (white blood cell, hemoglobin, albumin, creatinine, calcium, phosphate, intact parathyroid hormone, triglyceride, cholesterol, HDL cholesterol and high-sensitivity C-reactive protein) were recorded. We used multivariate linear regression analysis for BMD change analysis. We followed patients from 12 months after initiating of dialysis until renal transplantation, death or end of 60 months follow-up. During follow-up, 59 patients (24%) died due to CVD (n=33) or other causes (n=26) and 95 patients (39%) underwent renal transplantation. Fine and Gray competing risk analysis was used to ascertain associations of BMD changes with all-cause and CVD-related mortality. Results From baseline to one year after initiation of dialysis, there was a significant decrease of BMDtotal and BMDleg, trunk, rib, pelvis and spine in hemodialysis (HD) patients, whereas no difference was seen in peritoneal dialysis (PD) patients. In multivariate linear regression analysis adjusting for several confounders, HD therapy - compared to PD therapy - was significantly associated with negative changes in BMDtotal (β=-0.15), BMDhead (β=-0.14), BMDleg (β=-0.18) and BMDtrunk (β=-0.16). The direction and extent of changes in BMD, i.e. increase of BMD, associated with statistically significant lower all-cause mortality risk for BMDtotal (sHR, 0.91), BMDhead (sHR 0.91) and BMDleg (sHR 0.92), while for CVD-mortality a significant association with BMD changes was found only for changes in BMDhead (sHR 0.92). Conclusion In patients starting on dialysis, PD therapy appeared to have a beneficial effect on BMD changes as compared to HD during the first year of dialysis therapy. This difference may have implications for clinical outcomes as the degree of bone loss was associated with subsequent mortality. Changes towards increased BMDtotal, BMDhead and BMDleg associated with lower all-cause mortality. For head region – which is known as a cortical bone rich site – positive BMD change associated also with lower CVD mortality suggesting that increase or maintenance of BMD of cortical bone rich sites may have stronger association with clinical outcome in ESRD than BMD of trabecular bone.

P0912THE SERUM CREATININE TO CYSTATIN C RATIO AND CLINICAL OUTCOMES IN PATIENTS WITH NON-DIALYSIS CHRONIC KIDNEY DISEASE: THE KNOW-CKD COHORT

Abstract Background and Aims Muscle wasting leads to poor outcomes in patient with chronic kidney disease (CKD). The serum creatinine to cystatin C (Cr/CysC) ratio has been reported as marker for muscle mass and may predict outcomes in chronic diseases. We hypothesized that the Cr/CysC ratio would be a predictor of outcomes in CKD. Method We investigated a total of 2142 patients (male 61%, aged 54±12 year) with CKD followed for a median of 3.74 years. We assessed the factors associated with Cr/CysC ratio and the relationship between Cr/CysC ratio and outcomes of end-stage renal disease (ESRD), cardiovascular event (CVE), and mortality. Results The Cr/CysC ratio significantly correlated with age (r=-0.18), estimated glomerular filtration rate (eGFR) (r=-0.21), serum albumin (r=0.11), 24-hour urine creatinine (r=0.38), and moderate to vigorous physical activity time (r=0.07). After adjusting for age, sex, eGFR, and log urine albumin creatinine ratio (model 1), the hazard ratios for ESRD, CVE, and mortality were 0.96 (95% CI, 0.86-1.07), 0.78 (95% CI, 0.61-0.99), and 0.72 (95% CI, 0.53-0.97) per 1 standard deviation Cr/CysC increase (0.21), respectively. After full adjustment for model 1 variables plus lifestyle factors, laboratory factors, and comorbidities (model 2), the hazard ratios for ESRD, CVE, and mortality were 0.99 (95% CI, 0.88-1.10), 0.84 (95% CI, 0.65-1.07), and 0.75 (95% CI, 0.55-0.99) per 1 standard deviation Cr/CysC increase (0.24), respectively. In subgroup of the elderly (age&amp;gt;65 year) and early stage CKD (eGFR&amp;gt;60 ml/min/1.73m2), the hazard ratios for CVE were significantly lower in patients with high Cr/CysC ratio. Conclusion Cr/CysC ratio correlates with muscle biomarkers and physical activity. A higher Cr/CysC ratio is associated with low CVE and mortality, but not ESRD in CKD.

P0784RAPID WEIGHT CHANGE OVER TIME IS A RISK FACTOR FOR ADVERSE OUTCOMES IN PREDIALYSIS CHRONIC KIDNEY DISEASE: RESULTS FORM KNOW-CKD STUDY

Abstract Background and Aims Both obesity and underweight are related to the adverse outcomes in the chronic kidney disease (CKD). However, the effects of longitudinal weight changes on predialysis CKD population has not been studies so far. In this study, we analysed the effects of longitudinal body weight changes on the adverse outcomes in the predialysis CKD population, using the multicentre prospective cohort study in Korean pre-dialysis CKD cohort, so called KNOW-CKD. Method In this longitudinal analysis, total 2,022 patients were included. Longitudinal weight changes of study population were calculated into the percent change per year using regression analysis and classified into five groups: group 1; ≤ -5%/year (74 subjects), group 2; -5&amp;lt; to ≤-2.5 %/year (122 subjects), group 3; -2.5&amp;lt; to &amp;lt;2.5%/year (1642 subjects), group 4; 2.5≤ &amp;lt;5 %/year (123 subjects), and group 5; ≥ 5 %/year (61 subjects). The risk of end-stage renal disease (ESRD) development and composite outcome of cardiovascular disease (CVD) and all-cause death were compared according to the longitudinal weight changes. Results During the median 4.4 years of follow-up, total 414 and 188 events of ESRD and composite outcome of CVD and death occurred. When cause-specific regression analysis was conducted before and after adjusting age, sex, body mass index, mean blood pressure, estimated glomerular filtration rate, urine albumin-to-creatinine ratio, diabetics, cardiovascular disease, and modified Charlson Comorbidity Index score, all groups showed significant increased HR compared to group 3 for the ESRD. There was U-shape correlation between the degree of longitudinal body weight changes and the renal outcome (HR 3.89, 2.00, 1.89 and 3.34, P &amp;lt;0.001, &amp;lt;0.001, =0.001 and &amp;lt;0.001 for group 1, 2, 4 and 5, respectively). Also similar U-shape relationship was seen with composite outcome, (HR 3.14, 2.05, 1.65 and 2.68, P &amp;lt;0.001, 0.007, 0.123 and 0.007 for group 1, 2, 4 and 5, respectively) when compared to the reference group 3 When spline curve was drawn between the longitudinal body weight changes and adjusted HR for ESRD and composite of CVD and death, clear U-shape relationship was observed (Figure). The U-shape correlation was highlighted in the subgroup of estimated glomerular filtration rate &amp;lt;45 mL/min/1.73m2. Conclusion Both rapid weight reduction and gain are independent risk factor for the ESRD development and composite outcome of CVD and death in predialysis CKD patients, especially in advanced CKD stages. Therefore, monitoring bodyweight changes are important and more studies are needed to give safe guideline to the predialysis CKD for maintaining optimal nutritional status.

Effect of a bicarbonate-buffered peritoneal dialysis solution on clinical and laboratory indices of dialysis adequacy

Background Biocompatible fluids for peritoneal dialysis (PD) have been introduced to improve the dialysis adequacyand patient outcomes in end-stage renal disease. However, being buffered with lactate, these fluids may insufficiently correct metabolic acidosis and lead to changes in peritoneal structure. Bicarbonate buffered fluids might mitigatethese complications. The aim of the study was to evaluate the influence of a bicarbonate dialysis fluid on clinical andlaboratory indices of dialysis adequacy.

The Plasma Soluble Urokinase Plasminogen Activator Receptor Is Related to Disease Activity of Patients with ANCA-Associated Vasculitis

Objective The soluble urokinase plasminogen activator receptor (suPAR) is associated with kidney diseases and is used as a prognostic factor of renal function progression. The aim of this study was to explore whether circulating suPAR was associated with antineutrophil cytoplasmic autoantibody- (ANCA-) associated vasculitis (AAV) disease activity. Methods We evaluated 90 AAV patients with follow-up data and 35 normal controls; their plasma suPAR and C-reactive protein (CRP) levels were measured by ELISA. Associations between these levels, clinical parameters, and prognosis were analyzed. Results Plasma suPAR levels in AAV patients were significantly higher than in healthy controls (5,920.08 ± 3,447.17 vs. 1,441.97 ± 835.04 pg/mL, P < 0.001). Furthermore, suPAR was significantly elevated in AAV patients in active stage compared to those in partial remissions (6,492.19 ± 3,689.48 vs. 5,031.86 ± 2,489.01 pg/mL, P = 0.039). Correlation analyses demonstrated that suPAR levels positively correlated with initial serum creatinine, BVAS, CRP, and procalcitonin concentration, and negatively correlated with eGFR and C3 circulating levels. In a Kaplan-Meier survival analysis, patients with plasma suPAR levels >5683.3 pg/mL showed poorer survival than patients with lower levels (log-rank, P = 0.001). Besides, multivariate analyses confirmed that plasma suPAR levels were an independent adverse prognostic factor for a composite outcome of end-stage renal disease (ESRD) or death, after adjusting for age and gender (HR 1.05, 95% CI = 1.01 − 1.11, P = 0.043). Receiver operating characteristic curves showed a suPAR cutoff value >6662.2 pg/mL for composite outcome with 68% sensitivity and 88% specificity, with an AUC = 0.82, (95% CI = 0.68 − 0.96, P < 0.001). Conclusion Circulating suPAR levels might be a marker of activity correlated with disease activity in AAV patients, and, to some extent, could be a factor of poor prognosis.

Serum Prealbumin and Echocardiography Parameters Predict Mortality in Peritoneal Dialysis Patients

Aim: Protein-energy malnutrition and cardiovascular (CV) disease predisposes patients with end-stage renal disease (ESRD) on dialysis to a high risk of early death, but the prognostic value of prealbumin (PAB) and echocardiographic indices in ESRD patients treated with maintenance peritoneal dialysis (PD) remains unclear. Methods: A total of 211 PD patients (mean age 49.2 ± 15.4 years, 51.7% male) were prospectively studied. PAB and echocardiography parameters were recorded at baseline. Follow-up (mean ± SD: 33.7 ± 17.3 months) was conducted based on hospital records, clinic visits, and telephone reviews, to record death events and their causes. Results: In the Cox proportional hazards model, PAB and the echocardiographic parameters listed below were found to be optimal predictors of all-cause mortality: PAB (p = 0.003), aortic root diameter (ARD) (p = 0.004), interventricular septum end-diastolic thickness (IVSd) (p = 0.046), and left ventricular end-diastolic diameter index (LVEDDI) (p = 0.029). Of the above-mentioned factors, PAB (p = 0.018), ARD (p = 0.031), and IVSd (p = 0.037) were independent predictors of CV mortality in PD patients. Of note, malnutrition, degradation of the aorta, and myocardial hypertrophy are also known death risk factors in the general population. The all-cause mortality and CV death rate significantly increased as the number of risk factors increased, reaching values as high as 40 and 22% in patients who had all of the risk factors, i.e., abnormal PAB, ARD, and IVSd (p < 0.001 and p = 0.011). Conclusion: In PD patients, low serum PAB and abnormal echocardiographic parameters together were significantly associated with all-cause mortality and CV death, independently of other risk factors. These risk factors for death in PD are similar to those in the general population. Noticeably, the combination of echocardiographic parameters and PAB could provide additional predictive value for mortality in PD patients. In light of these findings, more studies in an optimal model containing PAB and echocardiographic parameters for the prediction of outcomes in ESRD are required.

The effect of renal transplantation on left ventricular function, electrocardiography, and mechanical synchrony by gated myocardial perfusion imaging

BackgroundDepressed left ventricular ejection fraction (LVEF), LV mechanical dyssynchrony (LVMD), and prolonged QTc interval predict poor outcomes in end-stage renal disease (ESRD). Renal transplantation improves mortality in ESRD patients but the effects of transplantation on these indices remain undefined. MethodsWe identified patients with myocardial perfusion imaging (MPI) before and after renal transplantation. A control group consisted of ESRD patients who underwent 2 MPIs but did not receive a transplant. Changes in LVEF, LVMD indices [phase standard deviation (SD) and bandwidth (BW)] by MPI, and electrocardiogram (ECG) indices were determined. ResultsThe study population consisted of 32 ESRD patients (53% male, 50 ± 11 years, 59% African American, 65% diabetic). The second MPI was performed 31 months (13-59 months) after renal transplantation. LVEF (72 ± 10% vs. 67 ± 10%, P < 0.001) but not SD (22 ± 15° vs. 22 ± 11°, P = 0.9) or BW (58 ± 35° vs. 57 ± 29°, P = 0.9) improved after transplantation. There were no changes in these indices in the control group. QTc (425 ± 30 ms vs. 447 ± 32 ms, P = <0.001) but not QRS (90 ± 21 ms vs. 90 ± 21 ms, P = 0.9) improved significantly after renal transplantation. ConclusionsLVEF and QTc improved after renal transplantation but LVMD indices and QRS did not change, which suggests that LVMD and electrical dyssynchrony may be irreversible in ESRD.

Genome-Wide Study Updates in the International Genetics and Translational Research in Transplantation Network (iGeneTRAiN).

The prevalence of end-stage renal disease (ESRD) and the number of kidney transplants performed continues to rise every year, straining the procurement of deceased and living kidney allografts and health systems. Genome-wide genotyping and sequencing of diseased populations have uncovered genetic contributors in substantial proportions of ESRD patients. A number of these discoveries are beginning to be utilized in risk stratification and clinical management of patients. Specifically, genetics can provide insight into the primary cause of chronic kidney disease (CKD), the risk of progression to ESRD, and post-transplant outcomes, including various forms of allograft rejection. The International Genetics & Translational Research in Transplantation Network (iGeneTRAiN), is a multi-site consortium that encompasses >45 genetic studies with genome-wide genotyping from over 51,000 transplant samples, including genome-wide data from >30 kidney transplant cohorts (n = 28,015). iGeneTRAiN is statistically powered to capture both rare and common genetic contributions to ESRD and post-transplant outcomes. The primary cause of ESRD is often difficult to ascertain, especially where formal biopsy diagnosis is not performed, and is unavailable in ∼2% to >20% of kidney transplant recipients in iGeneTRAiN studies. We overview our current copy number variant (CNV) screening approaches from genome-wide genotyping datasets in iGeneTRAiN, in attempts to discover and validate genetic contributors to CKD and ESRD. Greater aggregation and analyses of well phenotyped patients with genome-wide datasets will undoubtedly yield insights into the underlying pathophysiological mechanisms of CKD, leading the way to improved diagnostic precision in nephrology.

Improving Patient Experience and Treatment Adherence in the Adult, Outpatient Hemodialysis Population.

The commonly employed medication reconciliation process leaves room for mismanagement of medications in the complex end-stage renal disease patient population. The purpose of this quality improvement project was to implement and evaluate a multidisciplinary education and feedback intervention designed to improve self-management for adults with end-stage renal disease. A pre-post, same subject repeated measures design was used to evaluate the intervention. Laboratory values, vital signs, interdialytic weight gains, dialysis attendance, and questionnaires were used to assess regimen adherence. We observed improvements in patient outcomes including laboratory values, vital signs, and interdialytic weight gains. Significant improvements in process outcomes were also seen, including accuracy of medication lists, dialysis attendance, and use of remote pharmacy services. A comprehensive medication review, with concurrent pharmacist access, represents a time-effective approach to improved self-management and end-stage renal disease outcomes.

233-OR: Chronic Kidney Disease (CKD) Outcomes with Dulaglutide (DU) vs. Insulin Glargine (IG) in Type 2 Diabetes (T2D) and Moderate-to-Severe CKD by Albuminuria Status: AWARD-7

In the AWARD-7 study, conducted in T2D and moderate-to-severe CKD, DU treatment was associated with slower decline in estimated glomerular filtration rate (eGFR) compared to IG. One-year treatment with DU 1.5 mg weekly was associated with a lower rate of CKD outcomes, including eGFR decline ≥40% or end-stage renal disease (ESRD), compared to IG at similar levels of glycemic control and blood pressure. The aim of this post hoc analysis was to determine risk of these CKD outcomes between treatments in albuminuria subgroups. Participants with T2D and CKD stages 3-4 were randomized (1:1:1) to DU 0.75 mg or 1.5 mg weekly versus titrated IG daily, added-on to titrated insulin lispro, for one year. The occurrence of the composite outcome of eGFR decline ≥40% or ESRD was compared between treatments using a Cox proportional hazards model time-to-first event analysis. At baseline, treatment groups had similar eGFR by albuminuria subgroups (Table). The majority of events occurred in patients with macroalbuminuria (Table). Compared to IG, the incidence rate of the composite endpoint was significantly lower for DU 1.5 mg in the overall study population and in those with macroalbuminuria. In conclusion, the risk of ≥40% eGFR decline or ESRD outcomes was reduced by more than half for DU 1.5 mg compared to IG, particularly in the macroalbuminuric subgroup. Disclosure K.R. Tuttle: Consultant; Self; AstraZeneca, Boehringer Ingelheim International GmbH, Gilead Sciences, Inc., Goldfinch Bio. Research Support; Self; Eli Lilly and Company. B.L. Rayner: Advisory Panel; Self; AstraZeneca, Servier. Other Relationship; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Cipla Medpro, Novartis AG. M. Lakshmanan: Employee; Self; Eli Lilly and Company. Stock/Shareholder; Self; Eli Lilly and Company. B. Woodward: Employee; Self; Eli Lilly and Company. Stock/Shareholder; Self; Eli Lilly and Company. A. Kwan: Employee; Self; Eli Lilly and Company. Employee; Spouse/Partner; Eli Lilly and Company. M. Konig: Employee; Self; Eli Lilly and Company, Eli Lilly and Company. F.T. Botros: Employee; Self; Eli Lilly and Company. Stock/Shareholder; Self; Eli Lilly and Company. Funding Eli Lilly and Company