Poor Renal Function Research Articles

An open label, single arm, pilot study to evaluate the safety, tolerability, and efficacy of daily fluconazole 150 mg in subjects suffering from Tinea cruris and Tinea corporis

Background Dermatophytes are the most common superficial fungal infections worldwide and are treated with prescribed regimens of terbinafine and itraconazole, or with weekly doses of fluconazole. Dermatologists are increasingly encountering treatment failures, and experts suggest that standard treatment regimens are not applicable anymore. We planned an open-label study to evaluate the results of fluconazole 150 mg daily for 8 weeks in patients with tinea cruris and tinea corporis. Methods Patients were enrolled from the La’Mer Clinic, Mumbai, India. We included adult subjects with uncomplicated dermatophytosis confirmed by microscopic examination of skin scrapings. Pregnancy, poor renal function, and recent exposure to anti-fungal therapy were exclusion criteria. Patients were reviewed on days 14, 28 and 56. The treating doctor scored the severity of erythema, scaling, and pruritus on a four-point scale: absent, mild, moderate, and severe. Of 107 subjects screened, 100 were finally included in the study. Eleven were lost to follow up and one subject withdrew consent. Results The site of disease was body alone in 29, groin alone in 7, and both body and groin in 64 cases. At 5 weeks, 98%, 100%, and 97% of patients had no scaling, erythema, and pruritus, respectively. Skin scrapings showed 100% mycological cure. In one patient the alanine transaminase level rose from 54.9 to 100.2 U/L, and qualified as a grade 1 adverse event not requiring intervention. No other significant adverse events were noted. Conclusions Our results suggest that fluconazole 150 mg daily for eight weeks effectively treats dermatophytosis. This regimen is safe and well-tolerated even in patients with co-morbidities. Fluconazole is about eight times less expensive than itraconazole or terbinafine and may be the preferred therapy. Registration The trial was registered with Clinical Trials Registry, India (Registration number CTRI/2020/06/026110) on 24 June 2020. FDC Company, India, provided financial support for the study.

Management of Chronic Kidney Disease through Ayurvedic Shodhana and Shamana Chikitsa: A Case Report

Chronic Kidney Disease (CKD) has become a major public health issue affecting both younger and older individuals. The prevalence of CKD is on the rise, primarily driven by conditions such as hypertension and type 2 diabetes mellitus. CKD is characterised by progressive and irreversible damage to the kidneys, often presenting asymptomatically in its early stages. As the disease advances, patients may experience symptoms such as pedal oedema, decreased appetite, nausea, reduced urine output, frothy urine and fatigue. Laboratory tests typically show increased levels of creatinine and serum urea, indicating poor renal function. Traditional treatments, including dialysis and renal transplantation, remain mainstream approaches for managing CKD. However, these interventions are often financially prohibitive for many individuals in India, underscoring the urgent need for more affordable and accessible alternatives. In response to these challenges, Ayurvedic medicine offers promising alternative treatments. Hereby, the authors present a case of a 30-year-old male suffering from CKD; despite being recommended for dialysis, the patient opted for Ayurvedic treatment. Ayurvedic Shodhana chikitsa (purification and rejuvenating therapy) through Basti (therapeutic enema) combined with oral herbomineral formulations has demonstrated renoprotective effects and potential benefits in improving haematological parameters in CKD cases. The present case report highlights the importance of traditional Ayurvedic approaches as alternatives to prevent dialysis for CKD patients, particularly in low-income populations.

Factors Predicting Renal Outcomes in Hypertensive Emergencies With Severe Renal Impairment: A Single-Center Retrospective Study.

Hypertensive emergencies, characterized by elevated blood pressure (BP) and multiple organ damage, have poor prognosis. Patients occasionally show gradual improvement in renal function with appropriate antihypertensive treatment despite renal impairment. However, reports analyzing factors predicting prognosis in patients with hypertensive emergencies and severe renal impairment are limited. This retrospective study aimed to investigate clinical features and predictors of renal outcomes in such patients. Patients admitted to our hospital diagnosed with hypertensive emergency with severe renal impairment (serum creatinine [Cr] level > 2.5 mg/dL) between 2007 and 2021, were enrolled and divided into two groups: those who received renal replacement therapy (RRT) after 3 years (RRT group) and those who did not (non-RRT group); clinical characteristics and laboratory data were compared. Fifteen patients were enrolled, with a median age and serum Cr level of 48 years and 5.97 mg/dL, respectively. No significant between-group difference was observed in serum Cr levels or kidney size. However, the non-RRT group exhibited significantly higher levels of serum lactate dehydrogenase (LDH) levels and significantly lower platelet counts (PLT), suggesting development of microangiopathic hemolysis due to severe endothelial damage. Furthermore, the non-RRT group exhibited lower serum potassium levels than the RRT group, accompanied by high plasma renin activity and serum aldosterone levels, suggesting activation of the renin-angiotensin system (RAS). In the non-RRT group, serum Cr, LDH, potassium levels, and PLT improved significantly after treatment. Serum LDH, potassium levels, and PLT are useful predictors of renal prognosis in hypertensive emergencies with extremely poor renal function. In some cases, severe renal damage can be ameliorated by appropriate antihypertensive therapy. A positive response to treatment often signifies a favorable prognosis. Furthermore, early initiation of RAS inhibitors may be beneficial for lowering BP and providing renal protection.

Associations between serum mineral concentrations and mortality by renal function in the Ludwigshafen Risk and Cardiovascular Health Study

The association of serum concentrations of minerals and phosphate with overall and cardiovascular mortality based on renal function is poorly understood. 3307 patients (average age 62.7 ± 10.6 years) in the Ludwigshafen Risk and Cardiovascular Health (LURIC) study were grouped by estimated glomerular filtration rate (eGFR) into three categories: < 60, 60–89, and ≥ 90 mL/min per 1.73 m2, per KDIGO 2022 guidelines and were analysed using Cox regression. Low serum sodium and iron concentrations were associated with poor renal function and increased overall mortality risk, whereas higher serum zinc concentrations were associated with reduced overall and cardiovascular mortality risk. Elevated serum copper concentrations were associated with increased mortality risk across all eGFR categories. Comparing low and normal eGFR, we observed a fourfold increase in all-cause mortality risk for eGFR < 60 mL/min per 1.73 m2 and a twofold increase for eGFR 60–89 mL/min per 1.73 m2, accompanied by changes in serum mineral concentrations. The optimal range of mineral and phosphate concentrations in serum was strongly related to renal function. To reduce mortality risk, it’s important to regularly monitor serum mineral and phosphate concentrations as well as renal function, especially in cardiovascular patients with compromised renal function.

Association between renal function and the Treatment of Diabetic Macular Edema in Long-Term Cohort Study

To determine the correlation between the severity of chronic kidney disease (CKD) and treatment of diabetic macular edema (DME). The retrospective 2-year cohort study included eyes with DME confirmed using spectral-domain optical coherence tomography in Taipei Veterans General Hospital, Taiwan, between 2010 and 2020. All the eyes were treated with an intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF) during regular follow-up around 2 years. They were categorized into 3 different groups: an estimated glomerular filtration rate ≥ 60 (mL/min per 1.73 m2) (group A), < 60 (group B), and patients undergoing hemodialysis (group C). The main outcome measures were (1) visual improvement, (2) structural improvement, and (3) the injection frequency of anti-VEGF in the different groups. In this study, 167 eyes from 120 patients were enrolled. Compared with groups B and C, the eyes in group A experienced the only significant visual improvement at month 3, month 6, and month 12 (P = 0.0001, 0.0002, 0.0013, respectively). The presence of subretinal fluid and intraretinal cysts was significantly decreased in groups A and B. In the treatment frequency analysis, the number of injections was the highest in group A and lowest in group C during the study period (P = 0.04). The severity of CKD had an impact on the DME treatment. The less severe CKD was, the greater the visual improvement that could be achieved. In addition, relatively poor renal function required a lower anti-VEGF injection frequency. The active prevention of the progression of CKD may play a key role in DME treatment.

Physician Perspectives on the Management of Patients with Resected High-Risk Locally Advanced Squamous Cell Carcinoma of the Head and Neck Who Are Ineligible to Receive Cisplatin: A Podcast.

For the past two decades, cisplatin-based adjuvant chemoradiotherapy (CRT) has remained the standard of care for patients with resected, locally advanced squamous cell carcinoma of the head and neck (LA SCCHN) who are at high risk of disease recurrence. However, many patients are deemed ineligible for cisplatin-based CRT because of poor performance status, advanced age, poor renal function, or hearing loss. Outcomes with radiotherapy alone remain poor, so patients at high risk of disease recurrence who are ineligible to receive cisplatin represent a population with a significant unmet medical need. Although clinical guidelines and consensus documents have provided definitions for cisplatin ineligibility, there are still areas of debate, including thresholds for age and renal impairment as well as criteria for hearing loss. Treatment selection for patients with resected, high-risk LA SCCHN who are deemed ineligible to receive cisplatin is often based on clinical judgment, as treatment options are not clearly specified in international guidelines. Therefore, there is an urgent need to develop alternative systemic treatments to be used in combination with radiotherapy. In this podcast, we share our clinical experience and provide our perspectives related to cisplatin ineligibility in patients with LA SCCHN, discuss the limited clinical evidence for adjuvant treatment of patients with resected, high-risk disease, and highlight ongoing clinical trials that have the potential to provide new treatment options in this setting.

8270 A Rare Case Of PTHrP Induced Severe Hypercalcemia Secondary To Squamous Cell Carcinoma Of Tongue

Abstract Disclosure: N. Vennelaganti: None. S. Vennelaganti: None. K. McCowen: None. Background: PTHrP-mediated hypercalcemia is often associated with solid organ malignancies and indicates a poor prognosis. The occurrence of this condition due to SCC of the head and neck, particularly of the tongue, is uncommon. This case report aims to shed light on this rare clinical presentation. Clinical Case: A 70-year-old woman with a history of tobacco use disorder, alcoholic liver cirrhosis, and a chronic fungal prosthetic joint infection presented with altered mental status and acute kidney injury. Laboratory tests revealed a corrected calcium level of 15.4 mg/dL and suppressed PTH of 3 pg/mL, indicating non-PTH-dependent hypercalcemia. Differentials considered included malignancy, multiple myeloma, 1,25 OH Vit D mediated hypercalcemia via fungal granuloma formation, and immobilization. Diagnostic evaluation revealed normal levels of 25 hydroxy Vitamin D ie: 54 ng/mL, normal kappa to lambda ratio suggestive of negative myeloma screen, normal TSH of 2.81 uIU/mL, and a low 1,25 OH Vit D level ie: 11.4 pg/mL (Ref range: 19.9-79.3 pg/mL). An elevated PTHrP concentration of 9.7 pmol/L (ref range 0-3.4 pmol/L) was noted. CT angiography performed for stroke evaluation incidentally discovered a base of tongue mass, which was difficult to appreciate on exam due to obtundation. A biopsy confirmed SCC of the tongue, and she was determined to be Stage IVA. The patient's hypercalcemia was determined to be secondary to PTHrP production from the tongue SCC compounded by immobilization. She was treated with IV fluids and subcutaneous calcitonin, normalizing her calcium levels over 20 days. IV Bisphosphonates were held inpatient due to poor renal function. She was seen by oncology and determined to not be fit for surgical management or chemotherapy. Radiation therapy was advised for management and patient was discharged. While awaiting her outpatient radiation treatment, the patient had another episode of altered mental status and was found to have a serum calcium of 16.4 mg/dL. She was managed with IV fluids, calcitonin and IV Zoledronate which improved her serum calcium. She has since been receiving monthly IV Zometa with oncology for hypercalcemia of malignancy. She was recently readmitted with severe oropharyngeal and pharyngeal dysphagia and has received a PEG tube for feeding. She is still pending radiation therapy for SCC tongue. Conclusion: Initially, during the workup of this case, we believed her hypercalcemia was likely immobilization-induced, but thorough investigation and the elevated PTHrP levels steered us towards malignancy as a potential etiology. This case is an example of an occult malignancy which lead to severe hypercalcemia. It also contributes to the understanding of hypercalcemia in cancer patients and highlights the rare association of SCC of the tongue with PTHrP-mediated hypercalcemia . PTHrP secreting SCC of head and neck are typically associated with a poor prognosis. Presentation: 6/2/2024

Clinical implications of admission and follow-up urea-to-creatinine ratio in patients with acute decompensated heart failure

PurposeAcute decompensated heart failure (ADHF) patients with a poor renal function have a worse prognosis. The urea-to-creatinine ratio (UCR) may be a valuable tool for assessing kidney function and stratifying patients with ADHF. We evaluated the value of an admission and follow-up UCR in predicting AKI, 28-day mortality, and rehospitalization in patients with ADHF.MethodsThis prospective research comprised sixty patients with ADHF. Based on the mean admission UCR, patients are classified into two groups: the high UCR group (UCR ≥ 42.33) and the low UCR group (UCR < 42.33). On the third day, they are categorized into high UCR and low UCR groups according to the same mean of UCR (42.33). A 28-day follow-up was implemented.ResultsThirty patients (50%) developed AKI, and nine (15%) died during follow-up. In the high UCR group, the development of AKI was considerably more significant than in the low UCR group on the 3rd day (69.2% vs. 35.2%, respectively, p = 0.010). Furthermore, the high UCR group experienced a higher death rate than the low UCR group on the 3rd day (26.9% vs. 5.8%, respectively, p = 0.024). A considerable statistical correlation was reported between UCR and eGFR on the 3rd day (p = 0.025). According to ROC, UCR on the 3rd day was a significant predictor of AKI and 28-day mortality in these patients ((AUC = 0.736 and 0.718, respectively). In contrast, UCR on admission was not a predictor of AKI or 28-day mortality (p = 0.578 and 0.305, respectively). Also, neither admission nor 3rd day UCR could predict HF readmission (p = 0.108 and 0.298, respectively). By the Kaplan–Meier curve, survival rates were highest when UCR ≤ 34.85 and reduced when UCR > 34.85 (p < 0.001).ConclusionThe follow-up UCR is a good predictor of AKI development and elevated 28-day mortality in ADHF patients. Considering its simplicity, this biomarker should be used more systematically in clinical practice.

Impact of the Diverting Stoma on Renal Function.

Although loop ileostomy as a diverting stoma has been considered to affect renal dysfunction, few reports have compared loop colostomy with loop ileostomy regarding renal function. This is an important issue in the current setting of increased opportunities to perform surgery on patients with poor renal function. This study aims to reveal the effect of ileostomy on renal dysfunction compared to colostomy following sphincter-preserving rectal surgery. This study was a retrospective analysis. We compared preoperative and postoperative blood urea nitrogen, serum creatinine and estimated glomerular filtration rate values. The study was conducted at a single academic institution in Osaka, Japan. From October 2013 to November 2021, 135 consecutive patients underwent rectal surgery with diverting stoma are included. Differences in pre- and postoperative renal function values by stoma creation site in patients with preoperative chronic kidney disease. Risk factors for patients with newly kidney disease after stoma creation. In the preoperative chronic kidney disease (+) patients, the differences between the pre- and post-values in the blood urea nitrogen (p = 0.047) and the serum creatinine (P = 0.028) values were higher than in the preoperative chronic kidney disease (-) patients. In the preoperative chronic kidney disease (+) patients, ileostomy was significantly associated with an elevation of the serum creatinine value (p = 0.025) and a decrease in estimated glomerular filtration rate value (p = 0.041) from the pre-operative one compared with that of colostomy. In multivariate analysis, ileostomy (odds ratio; 7.443, p = 0.011) and hypertension (4.226, p = 0.008) were independent risk factors of newly kidney disease postoperatively. Limitations to our study includes its retrospective nature and bias due to the stoma site being determined by each surgeon. We should take care to choose diverting stoma especially in patients with a risk of kidney disfunction. See Video Abstract.

Thrombocytopenia after transcatheter aortic valve implantation

Introduction and objectivesThrombocytopenia frequently occurs after transcatheter aortic valve implantation (TAVI) but its impact is poorly understood. We aimed to analyze the incidence, clinical impact, and predictors of acquired thrombocytopenia after TAVI. MethodsThis retrospective multicenter registry included 3913 patients undergoing TAVI with a baseline platelet count of ≥ 100 *109/L. Acquired thrombocytopenia was defined as a decrease in baseline platelet count of ≥ 50% (early nadir ≤ 3 days and late nadir ≥ 4 days) post-TAVI. The primary endpoint was 30-day all-cause mortality and secondary endpoints were procedural safety and 2-year all-cause mortality. ResultsThe incidence of acquired thrombocytopenia was 14.8% (early nadir: 61.5%, late nadir: 38.5%). Thirty-day mortality occurred in 112 (3.0%) patients and was significantly higher in those with thrombocytopenia (8.5% vs 2.0%, adjusted OR, 2.3; 95%CI, 1.3-4.2). Procedural safety was lower and 2-year mortality was higher in patients with thrombocytopenia vs those without (52.1 vs 77.0%; P <.001, and 30.2% vs 16.8%; HR, 2.2, 95%IC, 1.3-2.7) and especially in those with late nadir thrombocytopenia (45.8% vs 54.5%; P=.056, and 38.6% vs 23.8%, HR, 2.1; 95%CI, 1.5-2.9). Independent predictors of thrombocytopenia comprised baseline and procedural factors such as body surface area, absence of diabetes, poorer renal function, peripheral vascular disease, nontransfemoral access, vascular complications, type of transcatheter heart valve, and earlier TAVI procedures. ConclusionsAcquired thrombocytopenia was common (15%) after TAVI and was associated with increased short- and mid-term mortality and decreased procedural safety. Moreover, late thrombocytopenia compared with early thrombocytopenia was associated with significantly worse clinical outcomes. Further investigations are needed to elucidate the etiologic mechanisms behind these findings.

Epidural block with lidocaine ameliorates kidney function deterioration and fibrosis of chronic kidney disease in rats

BackgroundAccording to evidences from clinical practices and experiments, renal denervation achieved by removing both the afferent and sympathetic nerves has therapeutic impacts on poor renal function and hypertension in chronic kidney disease (CKD). Epidural anesthesia is presumed to function on the target spine segments with a complete sympathetic block. Based on this perspective, we hypothesized that epidural block with lidocaine could ameliorate renal injury in CKD rats. Method and ResultsMale Sprague-Dawley rats weighing 250–300 g were randomized into four groups: control, CKD, CKD + sham, and CKD + epidural block with lidocaine groups. CKD was induced by resection of the lower and upper thirds of the left kidney followed by right nephrectomy one week later. Significant differences in renal function, sympathetic activation as well as renal fibrosis parameters were observed between CKD and control rats. These parameters corresponded with typical phenotypes of CKD rats. Epidural block with lidocaine improved renal function as well as renal fibrosis, and reversed the abnormalities of the renal function and cardiovascular parameters either fully or partially. ConclusionEpidural block with lidocaine confers renal protection, which is presumably mediated by decreasing sympathetic nerve activities in the renal region and other target organs in CKD.

Joint effects of sleep disturbance and renal function impairment on incident new-onset severe metabolic dysfunction-associated steatotic liver disease.

To elucidate the effects of sleep parameters and renal function on the risk of developing new-onset severe metabolic dysfunction-associated steatotic liver disease (MASLD). The primary analysis involved a cohort of 305 257 participants. Multivariable Cox models were employed to calculate hazard ratios and 95% confidence intervals. Traditional mediation and two-step Mendelian randomization (MR) analyses were conducted to assess the associations and mediating roles of renal function indicators between sleep and new-onset severe MASLD. Poor sleep score and renal function biomarker score (RFS) were associated with an increased risk of new-onset severe MASLD (all ptrend <0.001). Participants with poor sleep patterns and the highest RFS had a 5.45-fold higher risk of new-onset severe MASLD, compared to those with healthy sleep patterns and the lowest RFS (p < 0.001). The RFS could explain 10.08% of the correlations between poor sleep score and risk of new-onset severe MASLD. Additionally, MR analyses supported a causal link between insomnia and new-onset severe MASLD and revealed a mediating role of chronic kidney disease in the connection between insomnia and new-onset severe MASLD risk. This study highlights the independent and combined associations of sleep parameters and renal function indicators with new-onset severe MASLD, underscoring the bidirectional communication of the liver-kidney axis and providing modifiable strategies for preventing MASLD.

Hematocrit and Renal Failure in Aortic Arch Surgery: A Society of Thoracic Surgeons Database Study

BackgroundThis study examined the association between cardiopulmonary bypass (CPB) hematocrit and postoperative acute renal failure (ARF) in patients undergoing aortic arch surgery with hypothermic circulatory arrest. MethodsThe Society of Thoracic Surgeons Adult Cardiac Surgery Database was queried from 2011 to 2019 for patients undergoing aortic arch surgery with hypothermic circulatory arrest. A multivariable logistic regression model estimated the adjusted odds of postoperative ARF on the basis of CPB hematocrit. Effects were stratified by preoperative kidney function and the duration of hypothermic circulatory arrest by using interaction terms. The study also investigated the association between postoperative ARF and major postoperative outcomes by using multivariable regression models. ResultsOn adjusted analysis, higher CPB hematocrit (>20%-25%, >25%-30%, >30%) was associated with lower odds of ARF as compared with lower CPB hematocrit (≤20%) (>20-25%, aOR, 0.78; 95% CI, 0.65-0.93; P = .006; >25%-30%, aOR, 0.65; 95% CI, 0.50-0.84; P = .0007; >30%, aOR, 0.45; 95% CI, 0.28-0.72; P = .0008). The predicted probability of postoperative ARF by CPB hematocrit was higher in patients with lower preoperative renal function (estimated glomerular filtration rate, <60 mL/min/1.73 m2) (interaction P = .03). The association between hematocrit and postoperative ARF was not significantly modified by hypothermic circulatory arrest time (interaction P = .74). All postoperative outcomes were significantly worse in patients with postoperative ARF (all P < .0001). ConclusionsAmong patients undergoing aortic arch surgery, a higher CPB hematocrit level is associated with reduced likelihood of postoperative ARF. Preoperative renal function, but not hypothermic circulatory arrest duration, significantly modified this association. The maintenance of higher CPB hematocrit may reduce the incidence of postoperative ARF, especially for patients with poor preoperative renal function.

Sex-disaggregated analysis of acute kidney injury in hospitalized children with sickle cell anemia in Uganda.

A growing body of research is categorizing sex differences in both sickle cell anemia (SCA) and acute kidney injury (AKI); however, most of this work is being conducted in high-resource settings. Here, we evaluated risk factors and clinical parameters associated with AKI and AKI severity, stratified by sex, in a cohort of children hospitalized with SCA and vaso-occlusive pain crisis (VOC). The purpose of this study was to explore sex disparities in a high-risk, vulnerable population. This study was a secondary analysis of data collected from a cohort of Ugandan children between 2 and 18 yr of age prospectively enrolled. A total of 185 children were enrolled in the primary study; 41.6% were female and 58.4% were male, with a median age of 8.9 yr. Incident or worsening AKI (P = 0.026) occurred more frequently in female compared with male children, despite no differences in AKI on admission. Female children also had altered markers of renal function including higher creatinine levels at admission (P = 0.03), higher peak creatinine (P = 0.006), and higher urine neutrophil gelatinase-associated lipocalin (NGAL) at admission (P = 0.003) compared with male children. Female children had elevated total (P = 0.045) and conjugated bilirubin at admission (P = 0.02) compared with male children and higher rates of hematuria at admission (P = 0.004). Here, we report sex differences in AKI in children with SCA and VOC, including increased incidence and worsening of AKI in female pediatric patients, in association with an increase in biological indicators of poor renal function including creatinine, estimated glomerular filtration rate, and NGAL.NEW & NOTEWORTHY In this study, we report an increased risk of developing acute kidney injury (AKI) during hospitalization, worsening AKI, and death among females with sickle cell anemia (SCA) hospitalized with an acute pain crisis compared with males. The sex differences in AKI were not explained by socioeconomic differences, severity of pain, or disease severity among females compared with males. Together, these data suggest that female children with SCA may be at increased risk of AKI.

Goal-Directed Use of Prothrombin Complex Concentrates in Liver Transplantation: Is a Plasma-Free Procedure Feasible?

Background: Fresh frozen plasma (FFP) transfusions have been the mainstay of hemostatic intervention for the treatment of bleeding and coagulation abnormalities arising during liver transplantation (LT) for decades. However, numerous clinical studies showed that FFP has many side effects, including the risk of pathogen transmission, transfusion-associated circulatory overload (TACO), transfusion-related immunomodulation (TRIM), and transfusion-related acute lung injury (TRALI). These adverse events are particularly challenging in patients undergoing LT, who often suffer from severe portal hypertension, poor renal function and coexisting cardiac disease.The aims of this review are to summarize the pharmacological properties of currently available PCCs, to represent the theoretical benefits and the possible risks related to the use of these drugs in patients undergoing LT, and, finally, to review the current literature on the topic in order to highlight the evidence that currently supports PCC use in LT patients. Methods: The current literature on the topic was reviewed in order to highlight the evidence that currently supports PCC use in LT patients. Results: Prothrombin complex concentrates (PCCs) may offer several advantages when compared to FFP. Indeed, PCCs have been shown to reduce the risk of TACO, which during liver transplantation may deteriorate portal hypertension, increase intraoperative bleeding, and possibly reduce survival rates. One of the major concerns for PCC use is thrombogenicity. However, currently available PCCs are much safer as they contain inactivated forms of the vitamin K-dependent coagulation factors and protein C, protein S, antithrombin and/or heparin. Nowadays, the use of PCCs to correct coagulation abnormalities that occur during LT is an increasingly widespread practice. However, it is not yet clear what level of evidence supports this practice, and what the risks associated with it are. Conclusions: Administration of PCC in LT patients to correct haemostatic abnormalities seems to be well-tolerated, but the relationship between PCC use and thromboembolic events in the postoperative period remains unclear. Adequately powered, methodologically sound trials are urgently required for more definitive conclusions about the efficacy and safety of PCCs in a broad phenotype of LT recipients.

Age and other criteria influencing nontreatment of patients (pts) with locally advanced or metastatic urothelial carcinoma (la/mUC): Results of a physician survey in five European countries (Eu5).

4570 Background: Real-world studies have shown that a majority of pts with la/mUC do not receive first-line (1L) systemic therapy (tx), despite guideline recommendations. This cross-sectional study assessed the criteria that Eu5 physicians consider when making decisions about 1L tx for pts with la/mUC. Methods: A quantitative online survey of Eu5 physicians was performed in Aug-Sep 2022. Respondents answered questions related to demographics, practice patterns, and criteria considered in 1L decision-making. Descriptive statistics were used to analyze demographics and responses. Logistic regression was used to analyze physician characteristics associated with reporting no age threshold vs any age threshold when defining platinum ineligibility. Results: 503 physicians (69% oncologists and 31% urologists) completed the quota-based survey. Most respondents had been in practice for &gt;10 years (69%) and treated 5-19 pts with la/mUC per month (58%) in public teaching hospitals (40%), public nonteaching hospitals (24%), and private hospitals (20%). Physicians estimated that they do not prescribe 1L tx for ≈25% of their pts. The majority of physicians selected advanced age (62.0%) and poor performance status (PS; 54.7%) as their top reasons for not prescribing 1L tx, followed by pt refusal (45.9%) and poor renal function (43.1%). Most physicians (78.1%) reported having an age threshold above which they recommend against 1L systemic tx (mean, 74.7 years old [Table]). After adjusting for baseline characteristics, physicians were more likely to have an age threshold if they were from Italy vs Germany (odds ratio [OR] 0.22 [95% CI 0.06-0.73]), practiced in a public nonteaching hospital (OR 0.28 [95% CI 0.10-0.73]) or public/private office settings (OR 0.14 [95% CI 0.03-0.57]) vs private hospital, and if they treated &lt;20 pts/month (2-10 pts: OR 0.36 [95% CI, 0.17-0.74]; 11-19 pts: OR 0.25 [95% CI 0.09-0.62]). Conclusions: 1L systemic tx rates self-reported by Eu5 physicians were higher than those previously published. Many physicians reported having an age threshold for not offering systemic tx, which was relatively low compared with the senior age profile of the la/mUC population. Physicians who reported an explicit age threshold may be inappropriately excluding pts from tx; this could be a driver for systemic tx underutilization in la/mUC. [Table: see text]

#1505 Late-onset lupus nephritis: clinical-epidemiological, histological, prognostic and therapeutical implications: a single center experience

Abstract Background and Aims Systemic lupus erythematosus (SLE), a chronic autoimmune disease, and lupus nephritis (LN), are typically diagnosed in women in fertile age. Late-onset SLE is defined as a disease onset over 50 years. Our main objective was to analyze the clinical, histological, prognostic and therapeutical features related to LN in our late-onset SLE population. Method A single center and retrospective study was performed comparing clinical-demographic, histological, prognostic and therapeutical data of 45 LN biopsied patients from 1994 to 2023. We divided the study population according to the age of onset of LN into classic-onset (&amp;lt; 45 years) and late-onset (&amp;gt; 45 years). Results Late-onset LN patients showed a higher association with Sjögren's and antiphospholipid syndrome, more cardiovascular comorbidities at presentation, poorer renal function at diagnosis and higher SDI score. On histology they showed more non-proliferative LN classes (II followed by V). Late-onset LN responders needed more time to achieve response but had fewer relapses. Non responsive patients had more incidence of acute kidney injury (AKI) and more glomerulosclerosis and interstitial fibrosis-tubular atrophy (IFTA) at presentation, as well as more need for renal replacement therapy (RRT) at diagnosis and at follow-up. The principal independent variables associated with relapse were the younger age at SLE diagnosis and an initial partial renal response (PRR). Patients of both groups who experienced relapse received higher doses of intravenous cyclophosphamide and less mycophenolic acid (MFA) analogues. Patients who received induction with MFA analogues were more likely to achieve complete renal response (CRR) or non-renal response (NRR). Conclusion late-onset LN is often accompanied by poor renal function at presentation. It seems imperative to establish a tailored approach in this fragile population in order to avoid unnecessary immunosuppression.

High ADMA Is Associated with Worse Health Profile in Heart Failure Patients Hospitalized for Episodes of Acute Decompensation

Background and Objectives: episodes of acute decompensation in chronic heart failure (ADHF), a common health problem for the growing elderly population, pose a significant socio-economic burden on the public health systems. Limited knowledge is available on both the endothelial function in and the cardio-metabolic health profile of old adults hospitalized due to ADHF. This study aimed to investigate the connection between asymmetric dimethylarginine (ADMA)—a potent inhibitor of nitric oxide—and key health biomarkers in this category of high-risk patients. Materials and Methods: this pilot study included 83 individuals with a known ADHF history who were admitted to the ICU due to acute cardiac decompensation. Selected cardiovascular, metabolic, haemogram, renal, and liver parameters were measured at admission to the ICU. Key renal function indicators (serum creatinine, sodium, and potassium) were determined again at discharge. These parameters were compared between patients stratified by median ADMA (114 ng/mL). Results: high ADMA patients showed a significantly higher incidence of ischemic cardiomyopathy and longer length of hospital stay compared to those with low ADMA subjects. These individuals exhibited significantly higher urea at admission and creatinine at discharge, indicating poorer renal function. Moreover, their lipid profile was less favorable, with significantly elevated levels of total cholesterol and HDL. However, no significant inter-group differences were observed for the other parameters measured. Conclusions: the present findings disclose multidimensional, adverse ADMA-related changes in the health risk profile of patients with chronic heart failure hospitalized due to recurrent decompensation episodes.

Clinical epidemiology and outcomes of emergency department-acute kidney injury: A systematic review

BackgroundOver half of all community-acquired acute kidney injury (CA-AKI) initially presented to emergency department (ED), but emergency department acute kidney injury (ED-AKI) is poorly characterised, poorly understood with no systematic review, often under-recognized and under-managed. ObjectiveTo review the incidence, risk factors, and outcomes of ED-AKI, and risk factors of post-ED-AKI mortality globally. MethodsWe included published prospective or retrospective observational studies, controlled trials, and systematic reviews reporting AKI in adult ED attendees within 24 h of ED admission. Iatrogenic causes of AKI from medical interventions were excluded. We used PubMed to identify articles from 1996 to August 14, 2021, and adopted the National Heart, Lung, and Blood Institute (NHLBI) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies to assess risk of bias. We used a Forest plot to present pooled ED-AKI incidence rates and I2 statistics. Other parameters were summarized narratively. ResultsUsing 24 h from ED admission as the definition for ED-AKI we identified six articles from 2005 to 2018 in high-income settings and one article with a 48-h timeframe. The pooled incidence of ED-AKI was 20 per 1000 adult ED attendances. Risk factors for ED-AKI included increasing age, nursing home residence, previous hospital admission within 30 days, discharge diagnosis of diabetes, obstructive uropathy, sepsis, gastrointestinal medical conditions, high serum creatinine, bilirubin, C-reactive protein, white blood cell, alanine aminotransferase, low serum sodium or albumin on admission, poor premorbid renal function, antibiotic use, active malignancy, lung disease, hyperlipidaemia, and infection. Crude, all-cause 24-h mortality rate was 4.56 % and the one-year mortality rate was 35.04 %. Increasing age and comorbidities including cardiovascular disease and malignancy were associated with higher mortality rates. ConclusionThe review reveals a paucity of relevant literature which calls for further research, increased vigilance, red flag identification, and standardized management protocols for ED-AKI.

Clinical Outcomes in Acute Decompensated Heart Failure Patients with Reduced Ejection Fraction and Impaired Renal Function–A Study Comparing Levosimendan and Dobutamine

Background Cardiorenal syndrome is a disorder in which renal function is affected by heart failure (HF) or vice versa. It occurs in 20% of HF patients. The most common reason for hospitalization is acute decompensation (ADHF). Diuretics and inodilators are the standard of treatment in the management. Our objective was to demonstrate that levosimendan is more effective than dobutamine in improving the outcome of ADHF patients with a low ejection fraction (EF) and impaired kidney function. Material and methods The study was carried out between January to December 2022. Patients with ADHF, a low EF (&lt;40%) on echocardiography, and decreased renal function (estimated glomerular filtration rate [eGFR] &gt;15 and &lt;60 mL/min/m2) were included. All patients have given consent. The study was approved by the institutional ethical committee. The estimated study sample size was 18 in each group, and as the study continued, we enrolled 60 patients, who were divided into two equal groups (30 in each). The patients were assigned either levosimendan or dobutamine based on preassigned numbers in the software. The clinical characteristics (serum creatinine, eGFR, EF, cardiac output, and cardiac index) were measured on the first, seventh, and at one month (30 days). Results Of the 60 patients, 40 were men and 20 were women. The mean age was (50 ± 8.9 vs 50.8 ± 11.2) years. Of the comorbidities, hypertension was seen in 83.3% followed by diabetes (56.7%). Serum creatinine levels in both groups at admission and 30 days were (2.2 ± 0.3 vs. 2.5 ± 0.7, P = 0.1) and (1.6 ± 0.4 vs. 2.4 ± 0.8, P = 0.05). The eGFR of both groups at admission and 30 days follow up was (32.6 ± 9.1 vs. 28.2 ± 11.4, P = 0.2) and (40 ± 15.5 vs. 29.4 ± 12.6, P = 0.05). At 30 days, the predetermined outcomes in terms of improvement in EF, cardiac output, improved eGFR and cardiac index were better in the levosimendan compared to dobutamine group significantly. Conclusion In ADHF patients with decreased EF and poor renal function, levosimendan improved renal and cardiac indices more than dobutamine at 30 days of follow up.