Predialysis Stage Research Articles

Relationship Between Renal Function and Quality of Life in Patients with CKD at the Pre-Dialysis Stage

Relationship Between Renal Function and Quality of Life in Patients with CKD at the Pre-Dialysis Stage

Validating vascular access data in the Swedish Renal Registry SRR.

All Swedish dialysis units register data on vascular access in the Swedish Renal Registry (SRR). This study assessed external and internal validity of vascular access data in the SRR and its use as a tool in clinical practice. For external validation, all procedures for placed fistulas, open and endovascular reinterventions registered in the SRR in 2011 to 2017 were cross-matched with data from the Swedish National Patient Registry. A two-stage sampling selected 12/60 dialysis units for internal validation. Data on current vascular access for 10 randomly selected patients at each unit were compared with medical record data. SRR data on placed fistulas from 2017 were cross-checked with data from local surgical units. Registrations of central venous catheters (CVCs) as temporary or permanent were used as a proxy for clinical utilization of the registry and analyzed separately. External validity increased from 74% to 83% during the observation period. In all, 1037 datapoints were used in internal validation, with a 95% match between SRR registrations and medical records. Registrations of CVCs, fistulas, and interventions were reliable, with few missing data or mismatches. Vascular access type initiating hemodialysis was missing or incorrect in either the SRR or medical records for 14/120 patients. Registrations of placed fistulas in 2017 matched in all but four (pre-dialysis stage) of 135 cases. Some 35% of the CVCs validated (n = 49) at 7/12 units were not categorized as temporary or permanent. The SRR provides a reliable resource on current vascular access care.

Outcome of Febuxostat treatment in hyperuricemic pre-dialysis chronic kidney disease patients

Introduction: Hyperuricemia is a cause and effect of chronic kidney disease (CKD), accelerates its progression and predisposes to acute kidney injury. Present study aimed to find out the outcome of Febuxostat treatment in hyperuricemic pre-dialysis CKD patients.
 Method: This was a cross sectional study conducted in Nephrology department, Bir hospital, Nepal, during from February 2019 to January 2020, among pre-dialysis CKD stage 3-5 non dialysis (ND) patients with serum uric acid (SUA) >7 mg/d L who were treated with Febuxostat 40 mg once a day and followed up at one, two and three months. The baseline SUA, creatinine, estimated glomerular filtration rate (eGFR) calculated by the modification of diet in renal disease (MDRD) equation compared with values at follow up and according to CKD stages. The adverse effects and liver enzymes were recorded.
 Result: There were total 50 patients, mean age 54.2±16.5 years, male 31 (62%).There were significant reductions of SUA from baseline of 8.9±1.4to 7.1±1.2 vs 5.9±0.9 vs 4.7±1.0) at one, two and three month respectively, p=0.000 and increment of eGFR (ml/min/1.73m2) from 29.6±15.0 to 31.6±16.0, 33.6±16.6, 34.1±17.1, p=0.000.And 41 (82%) patients achieved uric acid < 6 mg/dl at three month. Significant reduction of uric acid in all CKD stages and increment of eGFR in CKD stage 3 and 4 were observed. Adverse effects were epigastralgia in 5 (10%) and joint pain in 13 (26%).
 Conclusion: Febuxostat is an effective serum uric acid lowering drug in pre-dialysis chronic kidney disease patients with improvement of kidney function.

Nutritional support for patients with chronic kidney disease at pre-dialysis stages

Chronic kidney disease (CKD) is characterized by poor outcomes, an increasing frequency of new cases, the need for expensive method of renal replacement therapy at the terminal stage. The main task facing the doctor is slowing the progression of CKD and delay the start of dialysis by applying the nephroprotective strategy, of which diet therapy is an essential part. The key components of the diet for CKD patients are reducing sodium intake to 2.3 g per day in order to improve control of blood pressure (BP), dietary protein restriction adequate to renal function from 0.8 to 0.3 g/kg of body weight per day combined with the prescribing of ketoanalogues of essential amino acids, hyperglycemia control. With the progression of CKD, the main objectives of the diet therapy are the prevention/correction of complications: protein-energy waisting, metabolic acidosis, ensuring sufficient calories, corresponding to the bodys energy expenditures (3035 kcal/kg of body weight per day), limiting phosphate intake to 0.81 g a day, restriction of food potassium. Low-protein diet in combination with ketoanalogues of amino acids, regular monitoring and correction of the nutritional status of patients at the pre-dialysis stages of CKD is an effective and safe method of nephroprotection, which allows delaying the start of dialysis.

Assessment of Erythropoietin Efficacy in Treatment of Anemia in Pre-dialysis Chronic Kidney Disease Patients

Background: Anemia is the most frequent condition in patients suffering from chronic renal disease. Iron supplements are commonly prescribed for these patients using oral and intravenous iron with or without erythropoietin therapy. Objectives: This study aimed at comparing the efficacy of IV iron versus oral iron in raising hemoglobin levels in predialysis chronic kidney disease (CKD) patients. Patients and Methods: A prospective cohort study that was conducted in Met-Ghamr Hospital of Nephrology and Urology from February 2019 to July 2019. The study included 50 CKD patients with anemia in the pre-dialysis stage. Group 1 consisted of 25 patients that were given IV iron while the 25 patients of group 2 were given oral iron. Both groups were monitored for 4 months for changes in hemoglobin levels and side effects. After the initial 4 months, patients in both groups who did not have a sufficient hemoglobin response to iron supplementation were prescribed an additional erythropoiesis-stimulating agent (ESA) with monitoring of hemoglobin response for the consequent 2 months. Results: We found a significant difference in the hemoglobin response between the two sets of patients in favor of the IV route after 4 months. We also found the safety profile of both routes to be comparable. After 4 months, the patients that received additional dose of Epoetin alfa (4000 IU/week for 2 months) showed a significant rise in hemoglobin level over the next 2 months compared to patients who did not receive the additional dose. Conclusion: We concluded that intravenous iron supplement is better than oral iron supplement in correction of anemia in pre-dialysis patients.

P0273THE EFFECT OF END STAGE RENAL DISEASE AND RENAL REPLACEMENT THERAPY ON B LYMPHOCYTE SUBPOPULATIONS

Abstract Background and Aims End-stage renal disease (ESRD) is linked to immunodeficiency, which makes a significant contribution to morbidity and mortality. Disturbances in innate and adaptive immunity have been described in patients on dialysis, although their association with the therapy itself is yet to be defined. The present study aimed to assess the impact of dialysis on B cell subpopulations Method B cells (CD19+) and their subsets B1a (CD19+CD5+), naive (CD19+CD27−), memory (CD19+CD27+), (CD19+BAFFR+) and (CD19+IgM+), were quantified using flow-cytometry of in the peripheral blood of ESRD patients, the first day on dialysis (T0), and repeated 6 months later (T6). The results were compared to age-matched healthy control group. Exclusion criteria were age <18 or>75 years, active autoimmune or chronic inflammatory disease, medical history of malignancy, corticosteroids or immunosuppresive treatment for the last 12 months Results Pre dialysis ESRD patients had reduced lymphocyte count (1527±646μ/L vs. 2459±520μ/L, p<0.001) and B cell (CD19+) count (82.7±59.5μ/L vs. 177.6±73.8μ/L, p<0.001) compared to controls, whereas the percentages of B cell subsets were not particularly affected, except for B1a subset which presented a significant increase (4.1±3.6% vs. 0.7±0.7% p<0.001). In 17 patients who had a follow-up sample 6 months later, the percentage of most subsets was reduced (CD19+CD5+: 1.02±0.8% from 3.6±4.6%, p=0.015, Naive: 40±22.3% from 61±17.4%, p=0.001, CD19+BAFF+:75.8±12.6% from 82.1±9.1%, p=0.04,), apart from memory B cells percentage, which was increased (49.4±52.1% from 32,9±35,5%, p=0.01) and CD19+ IgM+ percentage, which was unaffected . Conclusion A significant reduction of almost all subsets of B cells was noticed in patients with ESRD on pre-dialysis stage. Furthermore, the initiation of renal replacement therapy may be linked to further alterations in B cells subpopulations, especially at their early stages.

P0297CHANGES OF CD4CD28NULL AND CD8CD28NULL T CELLS IN CHRONIC KIDNEY DISEASE AND THE IMPACT OF DIFFERENT DIALYSIS MODALITIES

Abstract Background and Aims Chronic Kidney Disease (CKD) affects both the innate and adaptive immunity, although clinical consequences, and the effect of different renal replacement methods on those alterations remain unclear. The purpose of this prospective observational study was to investigate the alterations of T cell immunity in CKD patients, as well as the effect of different dialysis methods on T lymphocyte subtypes. Method T cell subpopulations namely CD3+CD4+, CD3+CD8+, CD4+CD28- and CD8CD28- cells, were isolated from whole blood samples using flow cytometry in 40 CKD patients at predialysis state (ESRD-T0). The immunological profile was repeated six months later after initiation of renal replacement therapy (hemodialysis (HD) or peritoneal dialysis (CAPD)). Fifteen age and gender matched healthy individuals served as controls. Results Both CD4+ and CD8+ T cells were significantly reduced in ERSD-T0 patients compared to controls, 604(105-3551) vs. 943(584-1867) μ/L, p=0.001, and 352(103-1561) vs. 422.4(263-1453) μ/L, p=0.05. The percentage of both CD4+CD28null and CD8+CD28null cells, 6.4(0.3-30) % vs. 2.7(0.1-7.8) %, p=0.04 and 58.2(12.8-85.4) % vs. 39(7.8-57.1) %, p=0.01 was increased in ERSD-T0 patients comparing to controls. Furthermore the percentage of CD4+CD28null cells correlated with CRP (r=0.4, p=0.04) and serum albumin levels (r=-0.5, p=0.007), while, significant differences were noticed between patients with and without cardiovascular disease, regarding both, CD4+CD28null and CD8+CD28null cells, 8.6(1-30) % vs. 2.1(0.1-19.8) %, p=0.04 and 62.5(12.8-85.4) vs. 45.5(5.7-73.7), p=0.02, respectively. Changes in the population of CD4+CD28null after 6 months on dialysis showed significant differences between HD and CAPD methods, 110.11(-27.1 to 311.4)% vs. -28.1(-100 to 30)%, respectively, p=0.003, as were in CD8+CD28null cells, 55.23(-29.06 to 197.93)% vs. -8.34(-54.99 to 66.72)%, respectively, p=0.05. Conclusion CKD seem to affect specific T cell subtypes, at a pre-dialysis stage, and levels correlate with chronic inflammatory markers and the presence of CVD. These disturbances are further enhanced in HD, while they are alleviated in CAPD.

P0256RESEARCH OF GUT MACROBIOTA IN PATIENTS WITH CHRONIC KIDNEY DISEASE

Abstract Background and Aims Currently, it is estimated that the intestinal microbiota has hundreds of species of bacteria. It is known that intestinal dysbiosis contributes to the development of many diseases, such as obesity, diabetes mellitus, cardiovascular diseases, including CKD. The question of the relationship between bacterial contamination and the process of endogenous inflammation in patients with chronic kidney disease of the pre-dialysis stages is not completely clear. The aim of the study the composition of the intestinal microbiota in fecal samples and the level of inflammatory markers (CRP, IL-6, leukocytes) in patients with pre-dialysis stages of CKD. Method 60 patients with CKD of the pre-dialysis stages (C2-C4) were examined. The diagnosis of CKD was made on the basis of clinical, instrumental, and laboratory data. To study the relationship between the composition of the intestinal microbiota and inflammation in patients with CKD, we studied markers of inflammation such as CRP and IL-6. CRP was determined in blood serum by a highly sensitive method on a Humareader Single analyzer, IL-6 by enzyme-linked immunosorbent assay on a solid-phase analyzer. eGFR was calculated using the formula CKD-EPI-2011. The control group consisted of 30 healthy subjects. Statistical processing was carried out using methods of variation statistics. The results were processed using Microsoft Exel 2002 & Statistica 6.0. Results The average age of patients was 59 years. Of these, 25 women (40%) and 35 (60%) men. The estimated glomerular filtration rate varied from 30 to 60 ml / min / 1.73 m2, which corresponded to the indicators of the pre-dialysis stages of CKD. Analysis of intestinal microbiota showed a deficiency of Bifidobacterium bacteria (<108 CFU), and an increase in the number of Escherichia (> 108 CFU) in patients with CKD of the pre-dialysis stages. According to the results of the study, in the group of patients with CKD, the level of inflammatory markers was higher (CRP-55%, IL-6-60%, leukocytes 62%) than in the control group (CRP-45%, IL-6-40%, leukocytes 38% ) However, in men, the IL-6 index was higher than in women. In patients with CKD with obesity, the titer of pathogenic bacteria and their spectrum showed the worst results, although unreliable. Conclusion All examined patients had dysbiosis of the 2nd degree. At the same time, an imbalance of the intestinal microbiota is combined with an increased level of CRP, IL-6, and white blood cells.

P0898VITAMIN C STATUS MODIFIES PARATHYROID HORMONE SECRETION IN NON-DIALYZED CHRONIC KIDNEY DISEASE PATIENTS

Abstract Background and Aims Among patients with chronic kidney disease (CKD) at predialysis stage, there is a high incidence of secondary hyperparathyroidism. Metabolic changes associated with secondary hyperparathyroidism lead to renal osteodystrophy, including osteitis fibrosa, ectopic calcification, cardiovascular disease, and the risk of death, and serum parathyroid hormone levels are influenced by nutritional variables. Non-dialyzed CKD patients are especially prone to vitamin C deficiency because of dietary restrictions and malnutrition. Vitamin C is an important antioxidant and relates to the development and maintenance of bone tissues. However, the contribution of vitamin C deficiency to parathyroid hormone secretion is unknown. Here, we performed a single-center cross-sectional study in order to assess association of serum vitamin C and parathyroid hormone in non-dialyzed CKD patients. Method We had 280 consecutive patients who underwent serum vitamin C and serum intact parathyroid hormone (iPTH) measurement for screening purposes from January 1st, 2013 to November 30th, 2017. We analysed a total of 128 patients (71.3±11.6 year-old, 80 males) who had an estimated glomerular filtration rate (eGFR) that remained less than 60 mL/min/1.73m2 after 152 patients were excluded because of vitamin C or vitamin D supplementation, age <20 years, dialysis, positive serostatus for HIV, hepatitis B or hepatitis C, chronic infection, or cancer. Results Twenty-three percent of the patients (n=29) had vitamin C levels< 2.0 μg/mL (a range seen in very deficient subjects), 53% (n=68) had levels between 2.0 and 5.5 μg/mL, and 31 patients (24%) had vitamin C levels >5.5 μg/mL, which is considered the upper limit of normal for the healthy population. Log(iPTH) significantly correlated with age (r=-0.238, p=0.00672), log(eGFR) (r=-0.625, p<0.0001), serum calcium (r=-0.609, p<0.0001), and serum phosphate (r=0.41, p<0.0001), and had a tendency to correlate with serum albumin (r=-0.146, p=0.101). Low serum vitamin C was associated with higher serum iPTH (P=0.0005, one-way analysis of variance). In a multiple linear regression model with log(iPTH) as the dependent variable, and age, gender, log(eGFR), serum levels of calcium, phosphate, albumin, and vitamin C as independent variables, the inverse relationship of log(iPTH) and serum vitamin C was confirmed (R2 = 0.568, adjusted R2 = 0.543, P<0.0001), along with other parameters influencing iPTH levels, including age, log(eGFR), serum calcium, and serum phosphate. Low vitamin C levels were also associated with increased serum alkaline phosphatase (r=-0.209, p=0.0179), a further indicator of the impact of vitamin C status on bone metabolism. Conclusion Vitamin C deficiency is prevalent in a significant proportion of non-dialyzed CKD patients. Low vitamin C levels contribute to secondary hyperparathyroidism, leading to increased bone turnover. This novel observation may result from effects of vitamin C on vitamin D metabolism, vitamin D binding in target tissues, and cAMP-linked signalling pathways in bone and parathyroid gland. Therapeutic intervention with supplemental vitamin C for secondary hyperparathyroidism might be a good strategy.

P1366THE ROLE OF A NEPHROLOGIST IN THE CREATION OF VASCULAR ACCESS FOR HEMODIALYSIS

Abstract Background and Aims The creation of vascular access: has it anything to do with a nephrologist ? At first glance, the concept of vascular access is the responsibility of surgical specialists. However, a nephrologist has started executing some of the common intensive treatment methods, using the equipment and techniques, specific to the field of dialysis. In this case, a nephrology specialist sets up different kinds of vascular access, namely the AV (arteriovenous) fistula, the AV graft, and the venous catheter; he/she is, therefore, responsible for its assessment and congruent correction. Method the usage of statistical data, gathered by the medical specialists of the dialysis unit of the Regional Chernihiv Hospital; the analysis of the possible nephrologist’s contribution to the creation of vascular access in patients with kidney diseases. Results During 2017-2019, 332 catheterizations were performed, during each of them vascular access was established: Conclusion 1. A nephrologist, in collaboration with a vascular surgeon, is particularly interested in the creation of vascular access in a patient with chronic kidney disease at the pre-dialysis stage; 2. In most cases, a nephrologist can set up temporary or permanent vascular access in patients with chronic kidney disease or acute kidney injury, which improves the quality of hemodialysis by making him an active participant of the treatment process.

P0961PHYSICAL REHABILITATION OF PATIENTS WITH CHRONIC KIDNEY DISEASE OF PRE -DIALYSIS STAGES

Abstract Background and Aims Chronic kidney disease is a global public health problem. Poor physical condition and skeletal muscle depletion are associated with the combined effects of uremic acidosis, protein-energy deficiency and inflammatory depletion, which leads to further exacerbation of a sedentary lifestyle. The aim of the determination of physical performance and the effectiveness of physical training during the 12-week program in patients with CKD of pre-dialysis stages. Method We examined 130 patients with CKD 2-4 stages. Clinical parameters (BP, BMI, mid-thigh circumference, mid-shoulder circumference, mid-calf circumference), laboratory data (serum creatinine, serum cholesterol, serum albumin, serum phosphorus, serum calcium) were evaluated in all patients according to the formula CKD-EPI 2011. Physical performance was determined by the results of cardiopulmonary stress test. In accordance with the initial data of the patients, a 12-week physical rehabilitation program was individually selected, which included morning exercises, physiotherapy exercises and dosed walking . The data obtained were subjected to statistical processing. Results The average age of patients was 54.8 years. Of these, 52 women (40%) and 78 (60%) men. The estimated glomerular filtration rate varied from 30 to 60 ml / min / 1.73 m2, which corresponded to the indicators of the pre-dialysis stages of CKD. After a 12-week rehabilitation program, the maximal oxygen consumption (V O2peak) increased in 70% of regularly engaged patients by 1.2 times (22.31 ml / min / kg and 27.05 ml / min / kg, respectively), and in 30% of those who did not pass the course Exercise therapy, the indicator of maximum oxygen consumption after 12 weeks was 21.7 ml / min / kg (with an initial 23.7 ml / min / kg) The average blood pressure decreased slightly (from 111 ± 5 initially to 106 ± 5 mm Hg after 12 weeks, p<0.05) When measuring anthropometric parameters, it was found that the circle the mid-thigh increased from 46.5 ± 6.0 cm to 0.6 cm, the circumference of the middle of the shoulder increased from 31.1 ± 4.0 cm to 0.4 cm. The circumference of the middle part of the lower leg was initially 356.7 ± 3.8 cm, and after 12 weeks of training it increased 0.3 cm. In 9 patients, these parameters did not change after a 12-week program. Conclusion Regular physical training led to an increase in the maximum oxygen consumption by 1.2 times. It was noted that regular training contributes to a slight increase in muscle mass in patients with CKD. The importance of regularity of physical therapy classes was also revealed.

P1331OPTIMAL PLANNING OF VASCULAR ACCESS IS CALLED FOR IN WOMEN. AVF ARE MORE INTERVENED AND ABANDONED DESPITE LESS CO-MORBIDITY

Abstract Background and Aims Central venous catheter (CVC) increase the risk of infection, central stenosis, hospitalizations, morbidity, mortality and later arterio-venous (AV) access failure. Vascular access planning begins in the predialysis stage of Chronic Kidney Disease (CKD). An optimal timely referral to vascular surgeon is possible since 80 % of patients are known to kidney units before initiating hemodialysis (HD). Despite this, some 71 % (75% women and 68 % men respectively) of incident patients had a CVC as vascular access when starting HD in Sweden during 2017. Some reports have shown increased risk of AVF failure in women which has been contradicted by others. The aim of this study was to determine factors of importance for achieving a functioning fistula for women and men. Method Data from the national Swedish Renal Registry (SRR), that covers the disease progression from CKD phase to renal replacement therapy, was used as well as mandatory national registries. Data was extracted from 2011 to 2017 for, sex, age, primary renal diagnosis, number of CVC, patient phase, co-morbidity, socio-economic factors as well as interventions and complications. A Royston-Palmer model was used for hazard ratio (HR). Cumulative incidence plots were used for fistula patency. P value < .005 was considered significant Results The study included 5040 patients at baseline (33% women). The mean age, the time in dialysis before fistula placement and numbers of CVC did not differ between the sexes. Prevalence of polycystic kidney disease was the only primary diagnosis that differed between the sexes (10.7% among women versus 6.5% among men respectively p<.01). Cancer, hypertension and ischemic heart disease, was more prevalent among men (24.0 vs 19.1 p<.001, 80,9% vs 75.7, p<.001 and 25.3 vs 18.0 p<001). Education level were similar between the sexes whereas more men were married and born in Sweden as compared women (49.3 vs 41.6 p<.001 and 78.9 vs 73.0 p<.001). Age, diabetes and peripheral arterial disease increased the risk for reinterventions by 6% and 28% and 36% (HR 1.06 [1.03,1.15], 1.28[1.18,1.40], and 1.36[1.19,1.56] respectively. The risk for reintervention and abandonment was higher for women (HR 1.19 [95% CI: 1,09,1,56, and 1.42[1,26,1.60)]. Figure 1. shows cumulative incidence for primary patency in lower arm fistula for men and women. Incidence of secondary patency abandonment is higher for women with lower and upper arm AVF while no differences between men and women were observed for AV grafts. Conclusion When receiving the first fistulas, men present a higher co-morbidity as compared to women while age and time of dialysis with a CVC is similar between the sexes. Only 42% will receive an AVF in CKD phase with detriment for men. The consequence of placement in CKD phase could matter and needs to be further analysed. AVF confers a higher risk for reintervention and abandonment, particularly among women which may explain the higher use of CVC. This higher risk must be taken into account when planning for vascular access and follow up.

Disorders of Serum Polyunsaturated Fatty Acids in Renal Transplant Patients

BackgroundDisturbances in polyunsaturated fatty acids (PUFA) could predispose renal transplant (RTx) patients to cardiovascular risk. The purpose of this study was to evaluate serum content of ω-3 and ω-6 PUFA in RTx subjects, in comparison to nontransplanted chronic kidney disease (CKD) patients in predialysis stages and to healthy controls. In the second part of the study, PUFA were analyzed in subcutaneous adipose tissue of CKD subjects at the time of kidney transplantation. MethodsThe first part of the study was conducted in a cohort (n = 134) of 3 groups: patients after renal transplantation (RTx group, n = 24), patients with CKD in stages 2-5, not on dialysis (CKD-ND group, n = 67), and controls without CKD (control group, n = 43). The fatty acids (FA) assessed by gas chromatography-mass spectrometry (GC-MS) were alpha-linolenic acid (ALA), eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), linoleic acid (LA), and arachidonic acid (AA). Diet was assessed by food frequency questionnaire FFQ-6. In the second part of the study, the same FA were evaluated in samples of adipose tissue taken during the kidney transplantation procedure and compared with FA of controls from the adipose tissue collected during hernia surgeries. ResultsThe first part of the study showed that RTx patients presented significantly lower serum content of all the examined PUFA, in comparison to the CKD-ND group and controls. For instance, EPA in RTx equaled 0.65 ± 0.32%, in CKD-ND 0.82 ± 0.43%, and in controls 1.06 ± 0.68% (P = .005). No significant correlations were found between serum PUFA and diet in RTx patients. The second part of the study revealed no significant difference in the adipose tissue PUFA between CKD patients at the time of kidney transplantation and controls. ConclusionsRTx patients present with low serum content of potentially beneficial PUFA. This finding does not seem to be solely due to an altered diet. Observed disorders might result from immunosuppressive drugs or other, yet undetermined, causes.

The relationship between oral diseases and infectious complications in patients under dialysis.

Association was investigated between oral health before dialysis and the incidence of systemic infections during dialysis. We hypothesized that low-grade systemic inflammation caused by poor oral health associates with infectious episodes in patients on dialysis, despite earlier eradication of oral infection foci. A total of 117 patients (46 with peritoneal and 71 with hemodialysis) were examined and treated at predialysis stage and followed up during dialysis. Number of infection episodes and microorganisms cultured from blood and peritoneal fluid were analyzed. Number of teeth, periodontal inflammatory burden, and total dental index scores were assessed, and salivary matrix metalloproteinase 8, triggering receptor on myeloid cells 1, peptidoglycan recognition protein 1 (PGLYRP1), and interleukin-1β were measured. In hemodialysis, 134 infection episodes were recorded, while peritoneal dialysis group had 77 peritonitis episodes. Culture-negative samples were 69% in hemodialysis and 23% in peritoneal dialysis group. Staphylococci were the most frequently associated microorganisms. Infections during dialysis did neither associate with oral health parameters nor associate with salivary inflammatory biomarkers, except for PGLYRP1, which associated with number of infection episodes during hemodialysis (p=.046). A number of infection episodes during hemodialysis were associated with salivary PGLYRP1 but not the other salivary markers or oral infection markers.

Refractory Hypertension in Infantile-Onset Denys-Drash Syndrome.

Denys-Drash syndrome is characterized by progressive nephropathy, gonadal dysgenesis, and Wilms tumor caused by a WT1 gene mutation. Infants with Denys-Drash syndrome frequently experience severe hypertension, but detailed clinical manifestations have yet to be clarified. Cases of infantile-onset Denys-Drash syndrome with severe hypertension at our hospital were retrospectively analyzed and the pathogenesis of hypertension was investigated. Six infants who received the diagnosis of Denys-Drash syndrome at the median age of 10 days (range: 2-182 days) were enrolled. Five infants had the complication of severe hypertension within a few days of diagnosis. All the patients showed rapid progression to end-stage renal disease and urgently required dialysis due to anuria/oliguria and hypervolemia with a median duration of 7.5 days (range: 0-17 days) on the day after diagnosis. Even under dialysis, all the patients continued to need antihypertensive treatment. Five patients underwent a preventive nephrectomy for Wilms tumor, and one patient underwent a nephrectomy due to progression to Wilms tumor. Two patients developed hypotension after a nephrectomy. The main causes of hypertension were hypervolemia in the predialysis stage, renin-associated hypertension in the dialysis stage, and multiple factors, including increased plasma catecholamine-associated hypertension in the postnephrectomy dialysis stage. At last the follow-up after bilateral nephrectomy, four of the five patients required antihypertensive treatment. Not all the patients showed target organ complications caused by hypertension. Severe hypertension is a common complication of infantile-onset Denys-Drash syndrome. The possibility of hypotension after nephrectomy should be considered in patients with Denys-Drash syndrome.

Trastornos del sueño en el paciente con enfermedad renal crónica avanzada

Objetivo: Conocer las alteraciones y/o trastornos del sueño en los pacientes con Enfermedad Renal Crónica Avanzada. Método: Se realizó una búsqueda en las bases de datos Google Académico, Scielo, Science Direct, PubMed y Scopus. Se incluyeron artículos científicos en español e inglés y texto completo disponible. Se analizaron aquellos artículos que trataban sobre alteraciones del sueño en los pacientes en prediálisis, y en tratamiento renal sustitutivo: Hemodiálisis, Diálisis Peritoneal y Trasplante Renal. Resultados: Se han incluido 30 artículos publicados entre los años 2013 y 2018. Los pacientes con Enfermedad Renal Crónica Avanzada presentan una alta prevalencia de alteraciones del sueño, llegando a alcanzar una prevalencia de casi el 90% en pacientes en hemodiálisis y diálisis peritoneal, y 62% en pacientes con trasplante renal; y entre el 44% y el 77% en la etapa prediálisis. Las alteraciones del sueño más frecuentes encontradas, fueron: insomnio, síndrome de piernas inquietas, apnea del sueño y somnolencia diurna excesiva. Como principales medidas y tratamientos utilizados para las alteraciones del sueño en estos pacientes se han encontrado terapias tanto farmacológicas, como no farmacológicas y la combinación de ambas. Conclusiones: Las alteraciones del sueño tienen una alta prevalencia en los pacientes con Enfermedad Renal Crónica Avanzada, tanto en prediálisis como en tratamiento renal sustitutivo; siendo las más frecuentes el insomnio, el síndrome de piernas inquietas, la apnea obstructiva del sueño y la somnolencia diurna excesiva. Entre los factores de riesgo más influyentes destacan: ansiedad y depresión, Diabetes Mellitus, hipertensión arterial, problemas respiratorios y tiempo en diálisis.

Cardio-ankle vascular index is linked to deranged metabolic status, especially high HbA1c and monocyte-chemoattractant-1 protein, in predialysis chronic kidney disease.

Arterial stiffness is an independent predictor of cardiovascular disease in chronic kidney disease (CKD). Cardio-ankle vascular index (CAVI) is a newly developed method used to assess arterial stiffness, independent of changes in blood pressure. CAVI reflects stiffness and atherosclerosis at the thoracic, abdominal, common iliac, femoral, and tibial artery levels. In predialysis stage 3-5 diabetic and nondiabetic CKD patients, CAVI levels and its relation to atherosclerosis-associated risk factors including monocyte-chemoattractant protein-1 (MCP-1), sclerostin, fibroblast growth factor-23 (FGF-23), Klotho, and 25-OH vitamin D were determined. The study was performed on three age-matched and gender-matched groups. Group 1 included 46 stage 3-5 nondiabetic CKD patients, group 2 included 44 stage 3-5 diabetic CKD patients, and group 3 included 44 non-uremic controls. All subjects underwent CAVI measurement. Serum glycated hemoglobin (HbA1c), total calcium, phosphorus, parathormone, FGF-23, Klotho, MCP-1, sclerostin, and 25-OH vitamin D were determined using standard methods. CAVI level was 8.22 ± 0.18m/s in diabetic CKD patients and significantly higher than in nondiabetic CKD (7.61 ± 0.18m/s) and control (7.59 ± 0.17m/s) patients. FGF-23 level was higher in the CKD groups than controls but not statistically significant. MCP-1 level was significantly higher in diabetic CKD patients. Klotho and sclerostin levels were significantly lower in diabetic CKD patients. In the whole cohort, CAVI showed positive correlations with age (r = 0.447, p < 0.0001), smoking (r = 0.331, p = 0.035), mean arterial blood pressure (MABP; r = 0.327, p < 0.0001), fasting blood glucose (r = 0.185, p = 0.033), and HbA1c (r = 0.258, p = 0.003). Stepwise regression analysis revealed that age (p = 0.0001, B = 0.461), MABP (p < 0.0001, B = 0.365), HbA1c (p = 0.003, B = 0.251), and MCP-1 (p = 0.013, B = 0.214) independently predicted CAVI levels. Our results indicate higher CAVI levels, therefore, resulting in increased arterial stiffness in the setting of diabetic CKD. Apart from age and MABP, deranged metabolic status, especially increased HbA1c and MCP-1 levels, is also independently associated with increasing CAVI levels in CKD patients. These results emphasize the importance of metabolic control in the development of arterial stiffness in CKD patients, which is an early predictor of developing cardiovascular complications.

HBV vaccination with Fendrix is effective and safe in pre-dialysis CKD population

Patients with chronic kidney disease have a poor response to hepatitis B vaccine due to the immunodeficiency conferred from chronic uremia. A recombinant HB vaccine containing an improved adjuvant system AS04 (HBV-AS04) has been manufactured but scarce evidence exists on HBV-AS04 use among patients with CKD. To assess efficacy and safety of an adjuvanted recombinant vaccine (HBV-AS04) in a large cohort of CKD patients at pre-dialysis stage (with susceptibility to HBV infection). Patients were prospectively enrolled to receive four 20-mcg doses of HBV-AS04 by intramuscular route (deltoid muscle) at months 1, 2, 3, and 4. Anti-HBs surface antibody concentrations were tested at intervals of 1, 2, 3, 4, and 12months. Multivariate analyses were performed to assess the parameters, which predicted immunologic response to HBV-AS04 vaccine. One hundred and seven patients were included and 102 completed the study. At completion of vaccine schedule, the frequency of responders (anti-HBs titers≥10mIU/mL) was 95% (97/102) (mean anti-HBs antibody titers, 688.9±385mIU/mL), according to per-protocol analysis. Serum haemoglobin levels were greater in responder than non- or low-responder patients to HBV-AS04 (P=0.04) and this was confirmed by multivariate analysis. The seroprotection rate at month 50 was 88% (30/34) with lower anti-HBs antibody titers (218.5±269.6mIU/mL, P=0.001). No major side effects were observed. Our prospective study performed in a real-world setting showed a high immunogenicity and safety of HBV-AS04 vaccine in patients with CKD not yet on maintenance dialysis. Studies provided with longer follow-ups are under way to assess the durability of seroprotection in responders.

MON-262 Kidney Transplant Awareness in HD patients and factors influencing this; a single centre satellite unit experience

Aim: To evaluate kidney transplantation awareness in satellite haemodialysis patients (SHP) and investigate influencing factors. Haemodialysis patients in a satellite dialysis unit were asked to complete a standardised questionnaire: exploring patient views and knowledge about kidney transplant. Patient demographics (age, gender, ethnicity, diabetic status, employment status, transplant status/scoring) were also recorded. 25 of 28 questionnaires were returned; responders declined anonymity and identified themselves. Demographics: mean age 58±14.9 years, males 64%, ethnicity ratio (NZ European: Maori: Pacifica) 14:9:2, diabetes 32%, employed 24%. 80% of respondents had treatment options discussed with them at the pre dialysis stage including kidney transplant. Despite this knowledge of the transplant list varied, 40% - no knowledge, 16% - were ineligible, 44% - some knowledge. 32% of respondents felt they were listed for transplant, 68% stated they were not listed. 92% were aware of live donor donation, 70% knew of a transplant recipient, 60% felt people lived longer with a transplant. Many patients thought they were either being worked up or listed when actually they were not. 14 patients calculated transplant survival score was >80%, 9 patients scored <80% (7 scored <70%). 2 patients not scored (80+ years). Those scoring >80%, 5 are currently listed, 4 are being workup up, 6 have not begun work up (including 3 deemed medically unfit). 3 patients listed had a prior failed transplant and were relisted within 12 months. Ethnicity of those scoring >80%: 6 NZ European, 7 Maori, 1 Pasifika. Ethnicity of those scoring <80%: 6 NZ European, 2 Maori, and 1 Pacifica. Many discrepancies in transplant knowledge were highlighted, including eligibility criteria and clarity regarding being ‘worked up’ and being ‘listed’. Patients were aware of the ability to receive a transplant, but lacked awareness of their own transplant eligibility situation/status. Patients listed were generally younger, had the ability to work and took an active role in their healthcare and demonstrated a good understanding of the transplant process. Reasons for this could include prior knowledge of the workup process or shorter dialysis vintage resulting in less dialysis related complications.

Validity and internal consistency of EQ-5D-3L quality of life tool among pre-dialysis patients with chronic kidney disease in Sri Lanka, a lower middle-income country.

ObjectiveEQ-5D-3L is a generic QOL tool used mainly in economic evaluations. Burden of Chronic Kidney Disease (CKD) is rising in Sri Lanka. Assessing the validity of generic QOL tools creates new opportunities of their utilization among patients with CKD.MethodsA cross-sectional study was conducted among 1036 CKD patients, selected using the simple random sampling technique. The validity was tested with six a-priori hypotheses. These included construct validity assessments, evaluating convergent validity and performing known group comparisons. EQ-5D-3L, Short Form-36 (SF-36) were used to assess QOL. Center for Epidemiological Studies Depression Scale (CES-D-20) and General Health Questionnaire-12 (GHQ-12) were used to assess the presence of depression and psychological distress respectively. Internal consistency of the whole tool and when each item is removed was assessed by Cronbach alpha.ResultsThe response rate was 99.2%. Majority of participants were males (n = 646,62.4%) in the age category of 41–60 (n = 530; 51.2%). Most were in either stage 4 or 5 of CKD (n = 646,75.1%). The summary measures of SF-36, positively and significantly correlated with the EQ-5D-3L index and VAS scores (p<0.001). EQ-5D-3L QOL scores were significantly different between the group with depression and without as measured by CES-D-20 (p<0.001). Assessed using GHQ-12, similar significance was detected between the group with psychological distress and without (p<0.001). The Cronbach alpha was 0.834 and when each item was removed, ranged from 0.782 to 0.832.ConclusionEQ-5D-3L is a valid generic QOL tool with satisfactory internal consistency to be used among CKD patients in the pre-dialysis stage.