Previous Chronic Kidney Disease Research Articles

Periprocedural complications during transvenous lead extraction. Lessons learned from the GermAn Laser Lead Extraction RegistrY (GALLERY)

Abstract Background Transvenous lead extraction (TLE) has become an established therapy for patients with cardiac device-related complications such as infection or lead dysfunction. Although safe and effective, periprocedural complications such as vascular or cardiac lacerations with the need for major surgical intervention occur and lead to morbidity and mortality. Objective & Methods The aim of this study was to conduct a retrospective analysis of the incidence, management and outcome of all major complications suffered by patients undergoing TLE in the GALLERY and to compare patient characteristics, procedural data and outcome against patients who suffered minor or no periprocedural complications. We performed multivariate regression analysis to identify independent predictors for death in patients with major complications. Results We identified 52 patients with major (Group A), 57 patients with minor (Groups B) and 2415 patients with no periprocedural complications (Group C) undergoing TLE in the GALLERY (2.1%, 2.3% and 95.7% of total patients, respectively). There were no differences in age (67.4±14.0 vs. 66.6±13.5 vs. 68.1±13.8 years; p=0.612), body mass index (BMI – 26.5±5.4 vs. 26.1±4.2 vs. 27.1±4.7 kg/m2; p=0.140) or other comorbidities, such as arterial hypertension or chronic kidney disease (CKD), except for more patients with diabetes mellitus (15.4 vs. 42.1 vs. 31.3%; p=0.01) in Group B and a trend towards less patients with previous cardiac surgery (15.4 vs. 35.1 vs. 24.2%; p=0.053) in Group A. Mean number of leads per patient were 2.5±1.1, 2.4±1.0 and 2.4±1.0 (p=0.645). Most common minor complication was pocket hematoma in 82.6% of cases. Laceration of the superior vena cava (SVC – 40.4%) was the most common major complication, followed by perforation of the right atrium (RA – 23.1%). Emergent median sternotomy was necessary in 80.8% of cases in Group A, of which 67.4% required cardiopulmonary bypass. Clinical success for TLE could only be achieved in 63.5% of cases in Group A, whereas Groups B and C achieved 100.0 and 98.5% (p<0.001), respectively. The mortality rate in Group A was 28.9%, in contrast to 5.3% and 3.0% in Groups B and C (p<0.001), which translates into a procedure-related mortality of 0.6% for the entire GALLERY. Septic shock was the most common cause of death in all groups (7.7 vs. 3.5 vs. 1.9%, p=0.013). Multivariate regression analysis revealed CKD (OR:4.7, 95%CI: 1.06-20.7, p=0.04) and previous cardiac surgery (OR:6.3, 95%CI: 1.2-33.6, p=0.03) as independent predictors for death in patients who suffered a major complication during TLE. Conclusion Although rare, TLE remains a procedure with potential for major complications such as lacerations of the SVC or perforation of the RA. Immediate availability of emergent surgical intervention ensures a survival rate of 71,1%. Previous cardiac surgery and CKD seem to be independent predictors for death in such patients.

Ischemia time in partial nephrectomy: to rush really matters?

Aim: The growth in the incidence of small renal masses has led the implementation of laparoscopic partial nephrectomy to become the technique of choice. However, arterial clamping and secondary renal ischemia still mean a controversial issue due to the risk of renal failure. Our objective is to evaluate the existing literature and its relationship to our experience. Methods: We performed a retrospective study of our series over six years. We analyzed different clinical, perioperative and postoperative functional outcome variables and compared the relationship between tumor complexity and the need for ischemia as well as the relation between ischemia time and renal function over a follow-up time of 6 months. For the discussion, we led a review of the literature on the subject and the paradigm shift that has taken place over the years. Results: A total of 148 patients, most of them male (68.2%) with an average age of 62.4 [standard deviation (SD) 1.7] years, had a Charlson index of 3 [interquartile range (IQR) 1-4]. The average R.E.N.A.L. score was 6 (IQR 5-8). Intraoperative complications were observed in 8.1% of the cases, most of which involved bleeding from a major artery or vein (7.4%). Postoperative complications occurred in 23.6% of the patients, the majority being classified as Clavien 2. Arterial clamping was carried out in 52.7% of the interventions, with a median ischemia time of 8 min (IQR 0-18). The average hospital stay was three days (IQR 2-5). Previous median glomerular filtration rate (GFR) was 83 mL/min/1.73 m2 (IQR 66.2-93.6). On the first postoperative day, the median GFR was 78.4 (SD 21.8), and at 6 months, it was 75.2 (SD 22). We found no statistically significant differences between having hypertension or diabetes mellitus and GFR after surgery, but we found differences in the correlation of a Charlson index ≥ 3 and deterioration of renal function, being the P values 0.01, 0.08 and 0.00 for the first postoperative day, after three and 6 months, respectively. No statistically significant differences were found in whether having a previous chronic kidney disease influenced the decision to perform arterial clamping or not, with a P value of 0.104. Statistically significant differences were found in the relationship between R.E.N.A.L. score and ischemia time. Conclusion: Renal tumors with a higher R.E.N.A.L. score involve the need to accomplish a longer arterial clamping, but its relationship with the deterioration of renal function is unclear, since there are other risk factors, such as patient’s comorbidities.

The Prevalence of Obesity and Metabolic Syndrome among Polish Women without Pre-Existing Cardiovascular Conditions and Diabetes: A Multicenter Study in Poland.

Background: A very prevalent problem worldwide is not only the high prevalence of chronic conditions but also the high frequency of their underdiagnosis and unhealthy lifestyles, both resulting in the development and inadequate treatment of civilization diseases. Therefore, the aim of this study was to assess the prevalence of abnormal metabolic parameters among Polish women aged >35 years who have not yet been diagnosed with cardiovascular diseases, diabetes or chronic kidney disease, as well as evaluate their lifestyles and look for relationships between individual lifestyle parameters and metabolic abnormalities. Methods: This was a multicenter, cross-sectional, observational study conducted on a group of women aged ≥ 35 years without previous cardiovascular disease, diabetes or chronic kidney disease. As part of the study, patients had anthropometric measurements and laboratory tests performed (serum glucose, total cholesterol, LDL, HDL, non-HDL cholesterol and triglycerides) and completed the HLPCQ (the Healthy Lifestyle and Personal Control Questionnaire). Obesity was defined as BMI ≥ 30 kg/m2. Abdominal obesity was defined as a waist circumference ≥ 88 cm. Results: The study included 672 women considered healthy. In the analyzed group of women, 20.6% met the criteria for a diagnosis of obesity based on BMI, and 36.8% were diagnosed with abdominal obesity. In addition, 16.8% of the women had an abnormal fasting blood glucose result. Moreover, 46.4% of the women's blood pressure measurements were above the normal range, and as many as 57.7% of the women had abnormal non-HDL levels. In addition, 150 women met the criteria for a diagnosis of metabolic syndrome. These conditions were far more common in women diagnosed with obesity. Physical activity was associated with a reduced risk of developing obesity and metabolic syndrome. Conclusions: The underdiagnosis of chronic conditions in the study population is high. More than 20% of women met the criteria for a diagnosis of metabolic syndrome, the prevalence of which was significantly higher in patients with obesity. A healthy lifestyle was associated with a reduced risk of developing metabolic syndrome and its individual components. It is necessary to actively search for chronic conditions in patients, which requires the involvement of not only healthcare system employees but also government representatives.

Major Adverse Limb Events in Patients Undergoing Revascularisation for Lower Limb Peripheral Arterial Disease: A Nationwide Observational Study

Major adverse limb events (MALEs) are frequent in patients with lower extremity peripheral arterial disease (PAD). However, routine care MALE rate estimations after revascularisation are scarce. This study aimed to determine post-procedural MALE rates in revascularised patients with PAD and identify predictors for post-procedural MALEs. This was a population based observational study on merged national registry data. Patients with PAD undergoing lower limb revascularisation between 2008 and 2016 were retrieved from the Swedish National Registry for Vascular Surgery. Information on comorbidities, medications, and post-procedural MALE endpoints were identified in national healthcare registries. Primary outcomes of interest were categorised as 2 - 4 point MALE composites that included limb amputation, acute lower limb ischaemia, progression to or relapse of chronic limb threatening ischaemia (CLTI), and ipsilateral re-interventions regardless of indication. Patients with intermittent claudication (IC) and CLTI were analysed separately using Kaplan-Meier estimates. Stepwise Cox proportional hazard models were used for predictor candidate analysis. Overall, 28 021 revascularised patients with PAD were analysed (IC, n = 10 506, 37.5%; CLTI, n = 17 515, 62.5%). During a mean follow up ± standard deviation of 3.2 ± 2.4 years, 5 226 (18.7%), 9 423 (33.6%), and 12 696 (45.3%) patients experienced a 2, 3, and 4 point MALE, respectively. The estimated one year 4 point MALE rates were 21.4% (95% confidence interval [CI] 20.6 - 22.2%) in IC and 46.9% (95% CI 46.1 - 47.7%) in CLTI. Adjusted predictors for experiencing a 4 point MALE in IC were chronic kidney disease (CKD) (hazard ratio [HR] 1.33, 95% CI 1.12 - 1.59) and previous lower limb revascularisation (HR 1.29, 95% CI 1.19 - 1.40). In CLTI, previous contralateral lower limb amputation (HR 1.60, 95% CI 1.47 - 1.73) and CKD (HR 1.25, 95% CI 1.17 - 1.34) were adjusted predictors. This study emphasises the very high MALE rates in revascularised patients with lower limb PAD, especially in CLTI. Prior lower limb revascularisation correlated with increased MALE rates in IC patients, while prior lower limb amputation was linked to subsequent MALEs in CLTI. In both IC and CLTI, CKD was associated with poorer outcomes, regardless of applied MALE definition.

Selection for transcatheter versus surgical aortic valve replacement and mid-term survival: results of the AUTHEARTVISIT study.

Limited data are available from randomized trials comparing outcomes between transcatheter aortic valve replacement (TAVR) and surgery in patients with different risks and with follow-up of at least 4 years or longer. In this large, population-based cohort study, long-term mortality and morbidity were investigated in patients undergoing aortic valve replacement (AVR) for severe aortic stenosis using a surgically implanted bioprosthesis (surgical/biological aortic valve replacement; sB-AVR) or TAVR. Individual data from the Austrian Insurance Funds from 2010 through 2020 were analysed. The primary outcome was all-cause mortality, assessed in the overall and propensity score-matched populations. Secondary outcomes included reoperation and cardiovascular events. From January 2010 through December 2020, a total of 18882 patients underwent sB-AVR (n = 11749; 62.2%) or TAVR (n = 7133; 37.8%); median follow-up was 5.8 (95% CI 5.7-5.9) years (maximum 12.3 years). The risk of all-cause mortality was higher with TAVR compared with sB-AVR: hazard ratio 1.552, 95% confidence interval (CI) 1.469-1.640, P < 0.001; propensity score-matched hazard ratio 1.510, 1.403-1.625, P < 0.001. Estimated median survival was 8.8 years (95% CI 8.6-9.1) with sB-AVR versus 5 years (4.9-5.2) with TAVR. Estimated 5-year survival probability was 0.664 (0.664-0.686) with sB-AVR versus 0.409 (0.378-0.444) with TAVR overall, and 0.690 (0.674-0.707) and 0.560 (0.540-0.582), respectively, with propensity score matching. Separate subgroup analyses for patients aged 65-75 years and >75 years indicated a significant survival benefit in patients selected for sB-AVR in both groups. Other predictors of mortality were age, sex, previous heart failure, diabetes and chronic kidney disease. In this retrospective national population-based study, selection for TAVR was significantly associated with higher all-cause mortality compared with sB-AVR in patients ≥65 years with severe, symptomatic aortic stenosis in the >2-year follow-up.

Eligibility for lipid-lowering therapy when applying systemic coronary risk estimation 2 according to guidelines on apparently healthy middle-aged individuals.

To estimate the proportion eligible for lipid-lowering therapy (LLT) when using the systemic coronary risk estimation 2 (SCORE2) on apparently healthy individuals. Individuals aged 50-64 years were randomly invited to The Swedish Cardiopulmonary Bioimage Study (n = 30 154). Participants with previous atherosclerotic cardiovascular disease (CVD), diabetes mellitus, or chronic kidney disease were excluded. The 10-year risk of CVD was estimated using the SCORE2 equation and the multicell chart. Eligibility for LLT was estimated according to the 2021 European Society of Cardiology CVD prevention guidelines. Presence of coronary atherosclerosis was determined using coronary computed tomography angiography (CCTA). Among 26 570 apparently healthy individuals, 32% had high and 4% had very high 10-year CVD risk, according to the SCORE2 equation. Among high- and very-high-risk individuals, 99% had low-density lipoprotein cholesterol levels above guideline goals making 35% of the total population eligible for LLT. Of those eligible, undergoing imaging, 38% had no signs of coronary atherosclerosis according to CCTA. Using the SCORE2 chart, 52% of the population were eligible for LLT, of which 44% had no signs of coronary atherosclerosis. In those with high or very high risk, ongoing LLT was reported in 7% and another 11% received LLT within 6 months after study participation. Nearly all apparently healthy individuals with high and very high CVD risk, or 35% of the total population, were eligible for LLT according to guidelines, and a large proportion had no signs of atherosclerosis. Compared with the SCORE2 equation, the SCORE2 chart resulted in more individuals being eligible for LLT.

#1689 Urosepsis and hypovolemia—the main causes of AKI in nursing home residents

Abstract Background and Aims Nursing home residents are at high risk for acute kidney injury (AKI) due to increased prevalence of comorbidities, prolonged immobilization in bed and altered cognitive function. As our nephrology department is confronted with high addressability of institutionalized adults with kidney impairment, we considered describing the epidemiology of AKI and risk factors for AKI-related mortality in this population. Method All adult patients admitted with AKI (KDIGO creatinine-based diagnostic criteria) in our nephrology department during a 6 months period (1st January-30th June 2023) were included in this study. Patients’ data (age, gender, comorbidities) and AKI-related data (causes, need for dialysis recovery of renal function, death) were compared between institutionalized and non-institutionalized patients. Factors associated with increased risk of death in AKI in nursing home residents were also analyzed. All the data was analyzed using IBM SPSS Statistics 25 (IBM, Corp.); the results were considered significant at P &amp;lt; 0.05. Results During the mentioned period a total of 297 patients with AKI were hospitalized: 57 nursing home residents (19.19%) and 240 patients with community-acquired AKI. The nursing-home residents were significantly older, female gender prevailed and history of stroke was significantly higher than in patients with community-acquired AKI (Table 1); no significant differences were found regarding prevalence of diabetes, chronic heart failure or previous chronic kidney disease. Chronic immobilization in bed was present in all institutionalized patients and in 21 patients with community acquired-AKI (8.75%). Multifactorial AKI, dehydration with hypovolemia and urosepsis were significantly more frequent in nursing-home residents, but there were no differences regarding other causes of AKI (Table 1). Increased prevalence of urosepsis in institutionalized patients was not associated with higher frequency of obstruction of urinary tract. Compared with community-acquired AKI, ICU admission and evolution with multiple organ failure were significantly more frequent in institutionalized patients with AKI, but there were no significant differences regarding the need for hemodialysis/hemodiafiltration, nor regarding the recovery of renal function in survivors. Analyzing factors associated with death in nursing home residents, we found that prolonged hospital stay, ICU admission, sepsis and multiorgan failure were associated with increased risk of in-hospital death (Table 2). Conclusion AKI in chronic institutionalized patients is mainly caused by dehydration and/or non-obstructive urosepsis, is often multifactorial and it is associated with increased risk of multiorgan failure, ICU admission and death. An early recognition and a better awareness of these risk factors in nursing homes can improve the epidemiology and the outcome of this severe disease.

#327 Impact of outpatient medication on community-acquired acute kidney injury

Abstract Background and Aims Medications are a relatively common cause of acute kidney injury (AKI) in hospitalized patients and those in the intensive care unit (ICU). However, we know less about the influence of outpatient medication in patients admitted from the emergency room who already have a community-acquired AKI (CA-AKI) The purpose of this study is to analyze the impact of outpatient medication in a cohort of patients with CA-AKI admitted to the nephrology service of a tertiary level hospital. Method This is a single-center, observational, longitudinal, and retrospective study based on a cohort of patients with CA-AKI admitted to the Nephology Service of a third level hospital from January 2010 to December 2018. We analyzed the characteristics of outpatient medication in these patients and their clinical consequences during admission and follow-up after hospital discharge. Results A total of 639 patients were included in the final analyses. The mean age was 72.93 ± 13.38 years. 61.7% were men. Charlson comorbidity index (CCI) was 5.87 ± 2.4 points. The length of stay was 11.63 ± 10.14 days. In view of the Etiology of AKI, 72.1% had prerenal AKI and 27.9% non-prerenal. 436 patients had a history of previous chronic kidney disease (CKD) (68.23%). AKI KDIGO stages were: stage I, 105 cases (16.4%); stage II, 67 cases (10.5%); stage III 467 cases (63.1%). Hemodialysis (HD) was required in 114 patients (17.8%). 62 patients (9.7%) died during hospital stay. The average number of drugs ingested prior to admission was 8.45 ± 4.11 with no differences by sex. Percentage of patients taking drug groups: diuretics 62.8%; Angiotensin-converting enzyme inhibitors (ACEI) or Angiotensin receptor Blockers (ARB) 68.4%; combination of diuretics with ACEI/ARB 50.9%; Proton-pump inhibitors (PPI) 64.1%; Statins 43.5%; Beta blockers 30.7%; allopurinol 25.8%; Anticoagulants 20.2%; Metformin 13.8%; Spironolactone 13.5%. There was a significant positive correlation between age (r=0.189; p&amp;lt;0.001), baseline creatinine (r=0.258; p&amp;lt;0.001), and CCI (r=0.43; p&amp;lt;0.001), with the number of drugs. There was a significant inverse correlation between peak creatinine during admission (r=−0.170; p&amp;lt;0.001), length of stay (r=−0.109; p 0 0.006), and number of drugs. Patients with prerenal etiology consumed significantly more drugs than those with parenchymal or obstructive etiology (9.09 ± 3.9 vs 6.77 ± 4.1 and 6.92 ± 4.3 respectively) The number of drugs did not influence the AKI stage, mortality during admission, nor the need for dialysis or ICU admission. Patients taking non-potassium sparing diuretics had significantly lower sodium (137.1 ± 5.73 vs 135.75 ± 5.9 mmol/L; p=0.005) and chloride levels (99.94 ± 9 vs 98.42 ± 8.1 mmol/L; p=0.029) compared to those who did not take them. Patients taking potassium-sparing diuretics (6.49 ± 1.55 vs 5.14 ± 1.32 mmol/L; p&amp;lt;0.001), ACEI/ARBs (5.42 ± 1.44 vs 5.12 ± 1.4 mmol/L; p=0.014) or beta-blockers (5.51 ± 1.38 vs 5.24 ± 1.44 mmol/L; p=0.030) presented significantly hyperkalemia compared to those who did not take them. After performing a multivariate linear regression analysis, the only drugs that was associated with hyperkalemia were potassium-sparing diuretics (B 1.35; 95% CI 1.05-1.66; p&amp;lt;0.001). In the follow-up after discharge, patients taking 6 or fewer drugs had better survival than those taking 7 to 12, and the latter better than those taking more than 12 drugs (log rank test: Chi square 24.47; p&amp;lt;0.0001) In the univariate cox regression, the number of drugs significantly influenced survival (Exp(B) 1.069; 95% CI 1.043-1.096; p&amp;lt;0.0001). Conclusion The patients in our series with CA-AKI were polymedicated, mainly those of prerenal etiology, with a clear correlation with age, baseline creatinine and previous comorbidity and with a prominence of ACEIs/ARBs, diuretics, and PPIs. Certain drugs had a significant impact on ionic alterations, adding morbidity to the condition. The number of drugs ingested is a marker of survival after hospital discharge. It is necessary to optimize outpatient drug management to prevent the development of CA-AKI and their consequences.

#1786 Correlation of electrolyte disturbances in community-acquired acute kidney injury

Abstract Background and Aims Acute renal injury can cause electrolyte disorders that increase patient morbidity and mortality. There are few data in the literature describing these alterations and the possible correlation between them in patients with community-acquired AKI (CA-AKI). The purpose of this study is to analyze the correlation between electrolyte disorders in a cohort of patients with CA-AKI admitted to the nephrology service of a tertiary level hospital. Method This is a single-center, observational, longitudinal, and retrospective study based on a cohort of patients with CA-AKI admitted to the Nephology Service of a third level hospital from January 2010 to December 2018. We analyzed the incidence of changes in sodium, potassium, chloride, bicarbonate, calcium, and phosphorus in these patients and their correlations. Results A total of 639 patients were included in the final analyses. The mean age was 72.93 ± 13.38 years. 61.7% were men. Charlson comorbidity index was 5.87 ± 2.4 points. The length of stay was 11.63 ± 10.14 days. In view of the Etiology of AKI, 72.1% had prerenal AKI and 27.9% non-prerenal. 436 patients had a history of previous chronic kidney disease (CKD) (68.23%). AKI KDIGO stages were: stage I, 105 cases (16.4%); stage II, 67 cases (10.5%); stage III 467 cases (63.1%). Hemodialysis (HD) was required in 114 patients (17.8%). 62 patients (9.7%) died during hospital stay. The most frequent ionic alterations at a global level were low bicarbonate (78.3%), hyperkalemia (53.05%), hypocalcemia (49.6%) and hyponatremia (41.5%). When analyzing whether electrolyte alterations occurred simultaneously: 2.2% of cases did not present any, 6.3% only one, 18.2% two, 26.4% three, 26.1% four, 14.9% five and 5.9% six simultaneous alterations. There were no statistically significant differences between groups on mortality during admission. Higher mortality at discharge has been found in patients with a greater number of ionic alterations (p = 0.046). In our sample, positive correlations were found between sodium-bicarbonate (r = 0.184; p &amp;lt; 0.001), peak creatinine-potassium (r = 0.182; p &amp;lt; 0.001), potassium-chloride (r = 0.167 p &amp;lt; 0.001), sodium-chloride (r = 0.614; p &amp;lt; 0.001), phosphorus-peak creatinine (r = 0.394; p &amp;lt; 0.001), pH-bicarbonate (r = 0.747, p &amp;lt; 0.001) and phosphorus–PTH (r = 0.330; p &amp;lt; 0.001). Negative correlations were found between sodium–potassium (r = −0,123; p = 0.002), bicarbonate-potassium (r = −0.354; p &amp;lt; 0.001), potassium-pH (r = −0.390; p &amp;lt; 0.001), peak creatinine–chlorine (r = −0.013; p = 0.004), bicarbonate–chlorine (r = −0.236; p &amp;lt; 0.001), calcium–phosphorus (r = −0.174; p &amp;lt; 0.001), calcium–peak creatinine (r = −0.138; p = 0.001) and bicarbonate–peak creatinine (r = −0.274; p &amp;lt; 0.001). Conclusion In our series of patients with CA-AKI, many statistically significant correlations were found between altered electrolytes in acute renal failure. Most of these associations can be explained by the pathophysiology of acute kidney injury. However, it should be noted that not all cases have such a clear explanation. It is important to consider that all patients in our study had already developed acute renal failure upon admission. Therefore, these results should be interpreted with caution and confirmed through further evaluations. We suggest that additional research in this area is necessary to improve the management and prognosis of this condition.

#2271 Cardiovascular event prediction in kidney transplant recipients: a new risk score derivation and internal validation

Abstract Background and Aims Kidney transplant recipients (KTRs) have a cardiovascular (CV) risk 3 to 5-fold higher than that of the general population.CV disease represents the main cause of death in KTRs, both due to the presence of traditional risk factors and factors strictly related to transplant. The main CV risk calculators proved to be poorly predictive in the KTR population. We, therefore, aimed to compare the performance of CV risk scores already in use and to develop and validate a CV risk score in our KTRs population. Method Our analysis included 371 adult KTRs in follow-up at the outpatient clinic from 1 January 2015 to 31 December 2016. The composite outcome was the occurrence of MACE. We compared the performance of three main CV risk calculators (Framingham Risk Score-FRS-, INDANA score and PORT score). Thereafter, we built a predictive model selecting study variables by backward stepwise Cox regression. The risk score for each variable was weighted according to the HR of the final multivariable model. Internal and external validation of the prediction score and its discriminative capacity was assessed via area under the curve (AUC) curve, and the calibration via the Hosmer–Lemeshow test. Results After a mean follow-up of 68 months, CV events occurred in 71 (19%) KTRs. FRS, INDANA and PORT were demonstrated to have low predictive power in our population (Fig. 1). The accuracy did not improve after adjustment for immunological and transplant-related variables. Therefore, we derived a model including significative variables at multivariate analysis: age, dialysis vintage, systolic blood pressure, eGFR and 24-hour proteinuria (Akaike information criteria 713). The model discrimination was good (Harrel's c: 0.73). According to the hazard ratio, 3 points have been attributed to age higher than 60 years and 24 h proteinuria higher than 1 g/d, 2 points to dialysis vintage longer than 5 years, systolic blood pressure higher than 140 mmHg and eGFR less than 30 ml/min/1.73 m2. The new score demonstrated good discrimination (AUC 0.70, Fig. 2) and calibration (Hosmer-Lemeshow test 11.34, P = 0.12). The new score was internally validated by 10-fold cross-validation (mean AUC 0.70, 95% CI 0.60-0.77). For each point of the new score, the risk of the event increased by 40% and a score higher than three was associated with a 4-fold increased risk of composite endpoint. Conclusion We confirmed the poor predictive power of the known CV risk assessment tools in our real-world KTRs population. Moreover, their discriminatory power was not improved by adjustment for the occurrence of biopsy-proven rejection, HLA compatibility and donor-specific antibody. A new score for CV event prediction including traditional risk factors, such as age and systolic blood pressure, and variables related to renal function and the effects of previous chronic kidney disease, was developed and internally validated.

Impact of Indocyanine Green Angiography on Postoperative Parathyroid Function: A Propensity Score Matching Study.

Background: Thyroidectomy constitutes an important portion of endocrine surgery procedures and is associated with various complications such as bleeding, recurrent laryngeal nerve injury, and postoperative hypoparathyroidsm. Effective parathyroid preservation during thyroid surgery is crucial for patient well-being, with current strategies heavily reliant on surgeon experience. Among various methods, Indocyanine Green Angiography (ICGA) offers a promising method for intraoperative assessment of parathyroid gland perfusion. Methods: In a retrospective study, patients undergoing bilateral thyroidectomy from January 2021 to January 2023 were analyzed, excluding those with previous thyroidectomy, parathyroid disease, or chronic kidney disease. The study compared a control group (n = 175) with an ICGA group (n = 120), using propensity score matching for statistical analysis. Matched cohorts included 120 patients in each group. The primary outcome of this study was identified as temporary postoperative hypoparathyroidism, with secondary outcomes including the rate of parathyroid reimplantation and the incidence of permanent postoperative hypoparathyroidism. Results: The ICGA group showed significantly more parathyroid autotransplantations (p < 0.01). While not statistically significant, the control group had a higher incidence of temporary postoperative hypoparathyroidism (p < 0.09). Rates of hypocalcemia on postoperative day 1 and permanent hypocalcemia were similar. Subgroup analysis indicated more postoperative day 1 hypoparathyroidism in the control group during central neck dissections (p < 0.049). Conclusions: Intraoperative ICGA use correlated with higher parathyroid autotransplantation and suggested reduced postoperative hypoparathyroidism. Changes in fluorescence intensity following a second ICG injection may provide an objective method to assess parathyroid perfusion. Further large-scale studies are needed to fully understand ICGA's impact on parathyroid preservation.

Role of Vascular Function in the Prognosis of Heart Failure Patients.

Background: Blood vessels have the Windkessel effect and are involved in blood circulation. The breakdown of this mechanism is also involved in the pathogenesis of heart failure (HF); however, the relationship between vascular dysfunction and HF prognosis is not fully understood. Methods: We evaluated 214 patients hospitalized for HF at our institution who underwent a cardio-ankle vascular index (CAVI), which evaluates vascular function, between January 2012 and July 2018. To investigate factors (including CAVI) associated with major adverse cardiac events (MACE) during 1 year after patients with HF were discharged, we evaluated clinical profiles, blood tests, chest X-P, 12-lead electrocardiography, and transthoracic echocardiographic findings. MACE was defined as cardiovascular death or readmission for HF. Results: The severity of HF between the MACE and non-MACE was not significantly different. Previous HF and chronic kidney disease were significantly more common in the MACE group. CAVI and % mean atrial pressure in the MACE group were statistically higher than those in the non-MACE group. The cardiac shadow as shown by chest X-P and left ventricular size in the MACE group were significantly bigger, and HF preserved ejection fraction (EF) (EF > 50%) was significantly more common in the MACE group. In multivariate analysis, CAVI was an independent predictive factor for the occurrence of MACE (model 1; hazard ratio (HR): 1.33, 95% confidence interval (CI): 1.05-1.68, p = 0.018; model 2; HR: 1.31, 95% CI: 1.07-1.60, p = 0.009). Conclusions: Because high CAVI is associated with poor prognosis of HF, these patients require more careful treatment.

Impact of dexamethasone in severe COVID-19-induced acute kidney injury: a multicenter cohort study

BackgroundAcute kidney injury (AKI) in intensive care unit (ICU) patients with severe COVID-19 is common (> 50%). A specific inflammatory process has been suggested in the pathogenesis of AKI, which could be improved by dexamethasone (DXM). In a small monocenter study (n = 100 patients), we reported a potential protective effect of DXM on the risk of AKI. This study aimed to investigate the preventive impact of DXM on AKI in a multicenter study of patients with severe COVID-19.MethodsWe conducted a multicenter study in three French ICUs from March 2020 to August 2021. All patients admitted to ICU for severe COVID-19 were included. Individuals with preexistent AKI or DXM administration before admission to ICU were excluded. While never used during the first wave, DXM was used subsequently at ICU entry, providing two treatment groups. Multivariate Cause-specific Cox models taking into account changes in ICU practices over time, were utilized to determine the association between DXM and occurrence of AKI.ResultsSeven hundred and ninety-eight patients were included. Mean age was 62.6 ± 12.1 years, 402/798 (50%) patients had hypertension, and 46/798 (6%) had previous chronic kidney disease. Median SOFA was 4 [3–6] and 420/798 (53%) required invasive mechanical ventilation. ICU mortality was 208/798 (26%). AKI was present in 598/798 (75%) patients: 266/598 (38%), 163/598 (27%), and 210/598 (35%) had, respectively, AKI KDIGO 1, 2, 3, and 61/598 (10%) patients required renal replacement therapy. Patients receiving DXM had a significantly decreased hazard of AKI occurrence compared to patients without DXM (HR 0.67; 95CI 0.55–0.81). These results were consistent in analyses that (1) excluded patients with DXM administration to AKI onset delay of less than 12 h, (2) incorporating the different ‘waves’ of the COVID-19 pandemic.ConclusionsDXM was associated with a decrease in the risk of AKI in severe COVID-19 patients admitted to ICU. This supports the hypothesis that the inflammatory injury of AKI may be preventable.

Effect of Intravitreal Anti-Endothelial Growth Factor Agents on Renal Function in Patients With Diabetes Mellitus

BackgroundIntravitreal administration of vascular endothelial growth factor inhibitors (anti-VEGF) is the treatment of choice in retinal pathology associated with type 2 diabetes mellitus (DM2). We aimed to analyze the effect on renal function in patients with DM2 after intravitreal anti-VEGF administration. MethodsSingle-center retrospective and observational study of patients with DM2 with and without chronic kidney disease (CKD). We analyzed the evolution of renal function after anti-VEGF onset, compared with a control group. ResultsWe included 45 patients (55.6% male) who received anti-VEGF therapy. Mean age was 74.4±11.5 (50-91) years. These were compared with 45 patients with similar characteristics. After 12-months, 76.3% had CKD with a mean reduction in estimate glomerular filtration rate (eGFR) of 19.4%. Nine patients (20%) had a >25% reduction in eGFR, and three patients (6.7%) had a >50% reduction in GFR. At 24-months, 80% of patients had CKD with a mean eGFR drop of 28%. The mean eGRF slope of patients who had received anti-VEGF treatment was 10 ml/min/year compared to 1,5 ml/min/year in the control group (p<0.05). After the first administration, five patients (17.2%) in the CKD group required renal replacement therapy during follow-up (mean time 22±12 months). Main risk factors for need of dialysis were age, presence of previous CKD, and baseline proteinuria. ConclusionIntravitreal anti-VEGF administration is a risk factor for CKD and rapid progression to end-stage kidney disease in patients with previous CKD. Knowing these drugs' implications is crucial to avoid CKD progression and opportunely limit their use in certain patients.

Post-discharge all-cause mortality in COVID-19 recovered patients hospitalized in 2020: the impact of chronic kidney disease.

In Brazil, the COVID-19 burden was substantial, and risk factors associated with higher in-hospital mortality rates have been extensively studied. However, information on short-term all-cause mortality and the factors associated with death in patients who survived the hospitalization period of acute SARS-CoV-2 infection is limited. We analyzed the six-month post-hospitalization mortality rate and possible risk factors of COVID-19 patients in a single center in Brazil. This is a retrospective cohort study focused on a six-month follow-up. The exclusion criteria were death during hospitalization, transference to another hospital, and age under 18. We collected data from the charts of all hospitalized patients from March 2020 to December 2020 with a positive RT-PCR test for SARS-CoV-2, resulting in a sample size of 106 patients. The main outcome was death after hospitalization, whereas comorbidities and demographics were evaluated as risk factors. The crude post-hospitalization death rate was 16%. The first 30 days of follow-up had the highest mortality rate. In a Cox regression model for post-hospitalization mortality, previous chronic kidney disease (HR, 4.06, 95%CI 1.46 - 11.30) and longer hospital stay (HR 1.01, 95%CI 1.00 - 1.02) were the only factors statistically associated with death. In conclusion, a high six-month all-cause mortality was observed. Within the six-month follow-up, a higher risk of death was observed for patients who had prior CKD and longer hospital stay. These findings highlight the importance of more intensive medical surveillance during this period.

Impact of Access Site on Periprocedural Bleeding and Cerebral and Coronary Events in High-Bleeding-Risk Percutaneous Coronary Intervention: Findings from the RIVA-PCI Trial.

The preference for using transradial access (TRA) over transfemoral access (TFA) in patients requiring percutaneous coronary intervention (PCI) is based on evidence suggesting that TRA is associated with less bleeding and fewer vascular complications, shorter hospital stays, improved quality of life, and a potential beneficial effect on mortality. We have limited study data comparing the two access routes in a patient population with atrial fibrillation (AF) undergoing PCI, who have a particular increased risk of bleeding, while AF itself is associated with an increased risk of thromboembolism. Using data from the RIVA-PCI registry, which includes patients with AF undergoing PCI, we analyzed a high-bleeding-risk (HBR) cohort. These patients were predominantly on oral anticoagulants (OAC) for AF, and the PCI was performed via radial or femoral access. Endpoints examined were in-hospital bleeding (BARC 2-5), cerebral events (TIA, hemorrhagic or ischemic stroke) and coronary events (stent thrombosis and myocardial infarction). Out of 1636 patients, 854 (52.2%) underwent TFA, while 782 (47.8%) underwent the procedure via TRA, including nine patients with brachial artery puncture. The mean age was 75.5years. Groups were similar in terms of age, sex distribution, AF type, cardiovascular history, risk factors, and comorbidities, except for a higher incidence of previous bypass surgeries, heart failure, hyperlipidemia, and chronic kidney disease (CKD) with a glomerular filtration rate (GFR) < 60ml/min in the TFA group. No clinically relevant differences in antithrombotic therapy and combinations were present at the time of PCI. However, upon discharge, transradial PCI patients had a higher rate of triple therapy, while dual therapy was preferred after transfemoral procedures. Radial access was more frequently chosen for non-ST-segment elevation myocardial infarction (NSTEMI) and unstable angina pectoris (UAP) cases (NSTEMI 26.6% vs. 17.0%, p < 0.0001; UAP 21.5% vs. 14.5%, p < 0.001), while femoral access was more common for elective PCI (60.3% vs. 44.1%, p < 0.0001). No differences were observed for ST-segment elevation myocardial infarction (STEMI). Both groups had similar rates of cerebral events (TFA 0.2% vs. TRA 0.3%, p = 0.93), but the TFA group had a higher incidence of bleeding (BARC 2-5) (4.2% vs. 1.5%, p < 0.01), mainly driven by BARC 3 bleeding (1.5% vs. 0.4%, p < 0.05). No significant differences were found for stent thrombosis and myocardial infarction (TFA 0.2% vs. TRA 0.3%, p = 0.93; TFA 0.4% vs. TRA 0.1%, p = 0.36). In HBR patients with AF undergoing PCI for acute or chronic coronary syndrome, the use of TRA might be associated with a decrease in in-hospital bleeding, while not increasing the risk of embolic or ischemic events compared to femoral access. Further studies are required to confirm these preliminary findings.

Decreased circulating transforming growth factor-beta (TGF-β) and kidney TGF-β immunoreactivity predict renal disease in cats with naturally occurring chronic kidney disease.

The aim of the present study was to compare the circulating transforming growth factor-beta (TGF-β) of clinically normal age-matched and naturally occurring chronic kidney disease (CKD) cats and to determine the correlation between the TGF-β expression and histopathological changes in cats with CKD. A total of 11 clinically normal age-matched and 27 cats with naturally occurring CKD were included in this study. Circulating TGF-β was quantified by immunoassays. Kaplan-Meier analysis was used to calculate the association between survival time and the concentration of circulating TGF-β. A general linear model was used to compare the circulating TGF-β between groups. Immunohistochemical analyses revealed TGF-β expression in renal tissues from cats with CKD that died during the study (n = 7) and in available archived renal tissue specimens taken at necropsy from cats that had previous CKD with renal lesions (n = 10). Correlations of the TGF-β expression and clinical parameters (n = 7) and histopathological changes (n = 17) were analysed using Spearman's rank correlation. The median survival time of cats with a lower concentration of circulating TGF-β was shorter than that of cats with a higher concentration. The area under the curve of circulating TGF-β for predicting CKD was 0.781, indicating good differentiation. The study indicated a significant difference in circulating TGF-β concentrations between clinically normal cats and those with CKD and demonstrated that TGF-β expression is correlated with tubular atrophy. The study findings suggest that decreased serum TGF-β and tubular atrophy with TGF-β immunoreactivity may be significant in cats with CKD.

Chronic kidney disease is an independent risk factor of postoperative seizures after burr hole surgery for chronic subdural hematomas

Background: Postoperative seizures are serious neurological complications of chronic subdural hematomas (CSDH). The identification of risk factors of seizures after CSDH is needed to determine which patients require antiepileptic prophylaxis. Methods: We retrospectively collected data on patients diagnosed with CSDH from 2015 to 2018. Postoperative seizures are defined as those occurring within 30 days after surgery. Non-hemorrhagic subdural effusion and acute subdural hemorrhage after craniotomy were precluded in the study. We collected data from 221 patients who had burr hole surgery. We retrospectively recorded patient characteristics, hematoma characteristics, symptoms at admission, comorbid conditions, and other related parameters to evaluate the impact of these parameters on postoperative seizures. Results: Postoperative seizures occurred in 16 patients (7.24%). The univariate analysis showed that previous chronic kidney disease (31.25% vs. 5.37%, p= 0.001), age (60.44 vs. 66.54 y, p = 0.029), low Glasgow Coma Score (GCS) at admission (13.69 vs. 14.46, p = 0.015), and preoperative midline shift (9.79 vs. 8.57 mm, p = 0.021) were significantly correlated with postoperative seizures. The multivariate analysis revealed that previous chronic kidney disease (odds ratio [OR] = 27.103; 95% confidence interval [CI] = 4.887-150.296; p &lt; 0.001), younger age (OR = 0.921; 95% CI = 0.866-0.979; p = 0.009) and preoperative midline shift (OR = 1.782; 95% CI = 1.175-2.702; p = 0.007) were independent risk factors of seizures. However, there was no significant difference in GCS at admission. Conclusions: The independent predictors of postoperative seizures in patients with CSDH were preoperative midline shift, chronic kidney disease, and younger age. For younger patients with chronic kidney disease and preoperative midline displacement, we recommend antiepileptic preventive measures during the perioperative period.

Inflammatory Bowel Disease With Chronic Kidney Disease and Acute Kidney Injury

It remains unclear whether inflammatory bowel disease is associated with long-term risk of chronic kidney disease (CKD) and acute kidney injury (AKI) in the general population. A total of 417,302 participants, including 2,940 patients with ulcerative colitis and 1,261 patients with Crohn's disease, without previous CKD and AKI at baseline (2006-2010) from the UK Biobank were included. The study outcomes included incident CKD and AKI, ascertained by self-report data and data linkage with primary care, hospital admissions, and death registry records. Analysis was conducted in 2022. During a median follow-up of 12.5 years, 13,564 and 14,331 participants developed CKD and AKI, respectively. Compared with the hazard ratio for non-inflammatory bowel diseases, the hazard ratios for CKD and AKI related to inflammatory bowel diseases were 1.57 (95% CI=1.37, 1.79) and 1.96 (95% CI=1.74, 2.20) after adjustments for age, sex, and race and were 1.32 (95% CI=1.15, 1.51) and 1.70 (95% CI=1.51, 1.91) after further adjustments for biological, behavioral, and socioeconomic factors in addition to mental health and self-rated health. Similar results were found for patients with Crohn's disease (adjusted hazard ratio=1.38 (95% CI=1.09, 1.75) for CKD and 1.62 [95% CI=1.30, 2.02] for AKI) and those with ulcerative colitis (adjusted hazard ratio=1.29 (95% CI=1.09, 1.51) for CKD and 1.71 [95% CI=1.49, 1.97] for AKI) in the fully adjusted models. Genetic risks of kidney diseases did not significantly affect the association of inflammatory bowel disease with incident CKD and AKI (both p-interactions>0.05). The association between inflammatory bowel disease and the risk of incident CKD (p-interaction=0.010) and AKI (p-interaction<0.001) were stronger in younger participants than in older participants. Inflammatory bowel disease was associated with higher risks for CKD and AKI, independent of genetic risks of kidney diseases.

Outcomes of Transcatheter Aortic Valve Implant Among Patients With A Previous Coronary Artery Bypass Graft: A Nationwide Analysis

There is a paucity of data regarding the temporal trends and outcomes of transcatheter aortic valve implant (TAVI) among patients with a previous coronary artery bypass graft (CABG) surgery. We queried the Nationwide Readmissions Database (2016 to 2019) for hospitalized patients who underwent TAVI using the appropriate International Classification of Diseases, Tenth Revision procedural codes. A multivariable regression analysis was used to adjust for the patients' and hospitals' characteristics in comparing the study groups. The primary outcome was in-hospital mortality. The final analysis included 237,829 patients who underwent TAVI, of whom 42,671 (17.9%) had a previous CABG. During the study period, there was a decrease in the proportion of patients with previous CABG who underwent TAVI (21.0% in 2016 vs 15.5% in 2019, ptrend=0.01), although there was no change in their in-hospital mortality rate (1.08% in 2016 vs 1.25% in 2019, ptrend=0.43). Patients with a previous CABG were younger and less likely to be women than those without a previous CABG. TAVI among those with a previous CABG was associated with lower in-hospital mortality (adjusted odds ratio [aOR] 0.79, 95% confidence interval [CI] 0.69 to 0.91), similar rate of ischemic stroke (aOR 0.81, 95% CI 0.71 to 0.93) and permanent pacemaker implant (aOR 1.00, 95% CI 0.93 to 1.05). Patients with a previous CABG had a lower all-cause 90-day readmission (odds ratio 0.95, 95% CI 0.94 to 1.06) but higher readmission for transient ischemic attack. Among those with a previous CABG, female gender and chronic kidney disease stage ≥3 were independently associated with a higher in-hospital mortality, whereas obesity was associated with a lower in-hospital mortality. In conclusion, there was a decrease in the proportion of patients with a previous CABG among those who underwent TAVI. TAVI among those with a previous CABG was not associated with increased in-hospital adverse events or 90-day all-cause readmissions.