Rate Of Renal Replacement Therapy Research Articles

Right anterior mini thoracotomy for redo cardiac surgery: case series from North America and Europe.

Right anterior mini thoracotomy (RAMT) for aortic valve replacement (AVR) is a minimally invasive procedure that avoids sternotomy. Herein, we report the outcomes of patients who underwent redo-cardiac via a RAMT approach for AVR. This case series reports the clinical outcomes of 14 consecutive redo operations, done in Calgary (Canada) and Gdansk (Poland) between 2020 and 2023. Primary outcomes were 30-day mortality and disabling stroke. Secondary outcomes included surgical times, hemodynamics, permanent pacemaker implantation (PPM), length of ICU and hospital stay, new post-operative atrial fibrillation (POAF), post-operative blood transfusion, incidence of acute respiratory distress syndrome (ARDS), rate of continuous renal replacement therapy (CRRT) and/or dialysis, and chest tube output in the first 12-hours after surgery. Nine patients were male, and the mean age was 64.36 years. There were no deaths, while one patient had a disabling stroke postoperatively. Mean cardiopulmonary bypass and cross clamp-times were 136 min and 90 min, respectively. Three patients needed a PPM, 3 patients needed blood transfusions, and 2 developed new onset POAF. Median lengths of ICU and hospital stays were 2 and 12 days, respectively. There was no incidence of paravalvular leak greater than trace and the average transvalvular mean gradient was 12.23 mmHg. The number of patients requiring redo-AVR is increasing. Redo-sternotomy may not be feasible for many patients. This study suggests that the RAMT approach is a safe alternative to redo-sternotomy for patients that require an AVR.

Sivelestat Inhibits Vascular Endothelial Injury Induced by Inflammatory Response and Improves the Prognosis of Hemorrhagic Fever with Renal Syndrome in Children: An Ambispective Cohort Study.

In Asia, Hanta virus (HTNV) results in severe hemorrhagic fever with renal syndrome (HFRS). The efficacy of sivelestat in treating children with HTNV-induced HFRS remains unclear. An ambispective cohort study was performed on children diagnosed with HFRS and hospitalized at the Children's Hospital Affiliated to Xi'an Jiaotong University from August 2018 to 2023. Patients who received neutrophil elastin-inhibitor infusion between August 2019 and August 2023 were assigned to the sivelestat group, while patients who did not were assigned to the control group. The independent sample t test was used for inter-group analysis. The Chi-square test and Fisher's exact probability test were used for categorical variables. Spearman correlation test was used to evaluate the correlation between two sets of continuous variables. Kaplan-Meier survival curve and Log -Rank test was used to evaluate the difference in cumulative probability of survival between the two groups. No significant differences were observed between the two groups in gender, age, contact history, body mass index, HFRS severity, clinical indexes at admission. Compared to the control group, the sivelestat group exhibited a significant decrease in the interleukin-8 level at 48 h (28.5±3 vs 34.5±3.5) and 72 h (21.3±4.5 vs 31.5±5.6) (P<0.05), as well as the ICAM-1 level at 48 h (553±122 vs 784±187) and 72 h (452±130 vs 623±85) (P<0.05). The concentration of VCAM-1 in the sivelestat group exhibited a consistent downward trend. Moreover, the level of VCAM-1 was significantly lower than that in the control group at 24 h (1760±289 vs 2180±445), 48 h (1450±441 vs 1890±267), and 72 h (1149±338 vs 1500±396) (P<0.05). Kaplan-Meier curve analysis revealed a statistically significant difference in the cumulative probability of survival between two groups (P = 0.041). In the secondary outcomes, the sivelestat group demonstrated a decrease in the utilization rate of mechanical ventilation and continuous renal replacement therapy (CRRT). Sivelestat may suppress neutrophil-mediated inflammatory response to reduce endothelial and organ damage, and improve clinical outcomes in children with severe hemorrhagic fever and renal syndrome.

Association of triglyceride glucose index with the risk of acute kidney injury in patients with coronary revascularization: a cohort study

BackgroundThe triglyceride glucose (TyG) index is a novel and reliable alternative marker for insulin resistance. Previous studies have shown that TyG index is closely associated with cardiovascular outcomes in cardiovascular diseases and coronary revascularization. However, the relationship between TyG index and renal outcomes of coronary revascularization is unclear. The purpose of this study was to investigate the correlation between TyG index and the risk of acute kidney injury (AKI) in patients with coronary revascularization.MethodsA retrospective cohort study was conducted to select eligible patients with coronary revascularization admitted to ICU in the medical information mart for intensive care IV (MIMIC-IV). According to the TyG index quartile, these patients were divided into four groups (Q1-Q4). The primary endpoint was the incidence of AKI, and secondary endpoints included 28-day mortality and the rate of renal replacement therapy (RRT) use in the AKI population. Multivariate Cox regression analysis and restricted cubic splines (RCS) were used to analyze TyG index association with AKI risk. Kaplan-Meier survival analysis was performed to assess the incidence of endpoints in the four groups.ResultsIn this study, 790 patients who underwent coronary revascularization surgery were included, and the incidence of AKI was 30.13%. Kaplan-Meier analysis showed that patients with a high TyG index had a significantly increased incidence of AKI (Log-rank P = 0.0045). Multivariate Cox regression analysis showed that whether TyG index was a continuous variable (HR 1.42, 95% CI 1.06–1.92, P = 0.018) or a categorical variable (Q4: HR 1.89, 95% CI 1.12–3.17, P = 0.017), and there was an independent association between TyG index and AKI in patients with coronary revascularization. The RCS curve showed a linear relationship between higher TyG index and AKI in this particular population (P = 0.078). In addition, Kaplan-Meier analysis showed a significantly increased risk of RRT application in a subset of AKI patients based on quartiles of TyG index (P = 0.029).ConclusionTyG index was significantly associated with increased risk of AKI and adverse renal outcomes in patients with coronary revascularization. This finding suggests that the TyG index may be useful in identifying people at high risk for AKI and poor renal outcomes in patients with coronary revascularization.

#1348 Acute kidney injury: evaluation of factors to predict the need of dialysis therapy

Abstract Background and Aims Acute kidney injury (AKI) is a clinical syndrome with heterogeneous pathophysiological mechanisms, associated with higher morbidity and mortality risk. The existing evidence shows that an episode of AKI increases the risk of chronic kidney disease and end-stage kidney disease, with considerable effects on long term outcomes. Current risk prediction scores were mostly calculated in the setting of contrast induced nephropathy and cardiac surgery reporting the patient's risk of AKI immediately before and after the invasive procedure. To date, no scoring models are available to assess the risk of progression and necessity of renal replacement therapy (RRT) for patients in the course of AKI. Method A prospective observational cohort study was conducted enrolling patients with AKI treated within the Nephrology, Dialysis and Kidney Transplant Unit of IRCCS Azienda Ospedaliero-Universitaria di Bologna from January 2022 to July 2023. The inclusion criteria were: 1) age &amp;gt;18 years, 2) stage 3 AKI according to the current KDIGO guidelines or presence of urgent RRT indication (severe hyperkalemia, metabolic acidosis or fluid overload refractory to medical treatment). The indication for RRT was given based on clinical judgement. Type of RRT, dialyzer and ultrafiltration rate were applied according to the clinical features of the patient. The primary endpoint was the association between AKI features and RRT. Secondary endpoints were evaluation of patients treated with RRT for factors associated with renal recovery. Results We studied 56 patients. The mean age ± SD was 69.8 ± 15.3 years (range, 18-94) and 37 (66.1%) were males. 18 patients (32.1%) were treated with conservative therapy and 38 (67.9%) with RRT. The factors correlated with the necessity of RRT were previous cardiovascular disease (p = 0.002), diabetes mellitus (p = 0.017), Charlson score &amp;gt;5 (p = 0.035), volume overload (p = 0.002), urine output level (p = 0.033) and C reactive protein (CRP; p = 0.020). Multivariate analysis found significant association of cardiovascular disease (OR, 5.94; 95% CI, 1.45 to 24.34; p = 0.013) and elevated CRP (OR, 1.08; 95% CI, 1.00 to 1.16; p = 0.049) during AKI episode with the RRT need in the study cohort. Higher ultrafiltration rate during RRT was correlated with non recovery of kidney function (OR, 1.86; 95% CI, 1.09 to 3.14; p = 0.021). Conclusion Cardiovascular disease and higher CRP were associated with necessity of RRT. More intensive fluid removal during RRT resulted as negative predictor of kidney function recovery. Further studies with larger study samples and randomized design are necessary to confirm these findings.

RENAL PROTECTIVE EFFECT AND CLINICAL ANALYSIS OF VITAMIN B 6 IN PATIENTS WITH SEPSIS.

Objective: To investigate the protective effect and possible mechanisms of vitamin B 6 against renal injury in patients with sepsis. Methods: A total of 128 patients with sepsis who met the entry criteria in multiple centers were randomly divided into experimental (intravenous vitamin B 6 therapy) and control (intravenous 0.9% sodium chloride therapy) groups based on usual care. Clinical data, the inflammatory response indicators interleukin 6 (IL-6), interleukin 8 (IL-8), tumor necrosis factor (TNF-α), and endothelin-1 (ET-1), the oxidative stress response indicators superoxide dismutase, glutathione and malondialdehyde, and renal function (assessed by blood urea nitrogen, serum creatinine, and renal resistance index monitored by ultrasound) were compared between the two groups. Results: After 7 d of treatment, the IL-6, IL-8, TNF-α, and ET-1 levels in the experimental group were significantly lower than those in the control group, the oxidative stress response indicators were significantly improved in the experimental group and the blood urea nitrogen, serum creatinine, and renal resistance index values in the experimental group were significantly lower than those in the control group ( P < 0.05). There was no statistical difference between the two groups in the rate of renal replacement therapy and 28 d mortality ( P > 0.05). However, the intensive care unit length of stay and the total hospitalization expenses in the experimental group were significantly lower than those in the control group ( P < 0.05). Conclusion: The administration of vitamin B 6 in the treatment of patients with sepsis attenuates renal injury, and the mechanism may be related to pyridoxine decreasing the levels of inflammatory mediators and their regulation by redox stress.

Intraoperative central venous pressure during cardiopulmonary bypass is an alternative indicator for early prediction of acute kidney injury in adult cardiac surgery

BackgroundThe relationship between venous congestion in cardiopulmonary bypass (CPB) and acute kidney injury (AKI) in cardiac surgery has not utterly substantiated. This study aimed at investigate the relationship between CVP in CPB and the occurrence of AKI.MethodsWe retrospectively reviewed 2048 consecutive patients with cardiovascular disease undergoing cardiac procedure with CPB from January 2018 to December 2022. We used the median CVP value obtained during CPB for our analysis and patients were grouped according to this parameter. The primary outcomes were AKI and renal replacement therapy(RRT). Multivariable logistic regression was used to explore the association between CVP and AKI.ResultsA total of 2048 patients were enrolled in our study and divided into high CVP group (CVP ≥ 6.5 mmHg) and low CVP group (CVP < 6.5 mmHg) according to the median CVP value. Patients in high CVP group had the high AKI and RRT rate when compared to the low CVPgroup[(367/912,40.24%)vs.(408/1136,35.92%),P = 0.045;(16/912,1.75%vs.9/1136;0.79%), P = 0.049]. Multivariate logistic regression analysis displayed CVP played an indispensable part in development of renal failure in surgical.ConclusionsElevated CVP(≥ 6.5mmH2OmmHg) in CPB during cardiac operation is associated with an increased risk of AKI in cardiovascular surgery patients. Clinical attention should be paid to the potential role of CVP in predicting the occurrence of AKI.

Abstract 12228: Prognostic Role of Renal Replacement Therapy Among Hospitalized Patients With Heart Failure in the Brazilian National Public Health System

Introduction: Data on survival and prognostic factors of patients hospitalized with HF in Brazil are scarce. Aims: To determine the in-hospital all-cause mortality rate, in-hospital renal replacement therapy (RRT) rate, and its association with in-hospital mortality in a population of patients admitted with HF to hospitals from the Brazilian National Public Health System (SUS). Methods: We included adult patients with a documented diagnosis of HF (ICD-10 I50.X) admitted to any public hospital in the SUS Hospital Information System (SIHSUS) registry from April 2017 to August 2021. RRT included intermittent hemodialysis, continuous hemodialysis, and peritoneal dialysis. Descriptive statistics and univariate and multivariate Cox regression were employed. Results: Of the 910,128 HF hospitalizations identified, 106,383 (11.7%) resulted in in-hospital death (Table 1). RRT (required by 8,179 non-survivors [7.7%] and 11,496 survivors [1.4%, p &lt; 0.001]) was associated with a 56% increase in the risk of death (HR 1.56, 95% CI 1.52 - 1.59) (Fig 1). All forms of RRT were independently associated with in-hospital mortality (Fig 2). Female sex (HR 1.04, 95% CI 1.03-1.06) and COVID-19 (HR 1.41, 95% CI 1.14-1.81) were identified as risk factors for in-hospital mortality, while heart transplantation improved survival (HR 0.37, 95% CI 0.29-0.47). Hospitalizations requiring RRT and hospitalizations resulting in death were both longer and costlier (Fig 3, 4). Conclusion: In this nationwide registry of patients admitted with HF to Brazilian public hospitals, we found an alarming mortality rate double the estimates reported in European and North American countries. RRT was strongly associated with a prolonged hospital stay, higher cost-of-hospitalization, and in-hospital death. Our findings highlight the significance of optimizing medical therapy for patients admitted with HF to prevent the deterioration of their renal function and the need for RRT.

Long-term renal outcomes of patients with COVID-19: a meta-analysis of observational studies.

Kidney involvement is common in hospitalized coronavirus disease 2019 (COVID-19) patients during the acute phase, little is known about the long-term impact of COVID-19 on the kidney. This is a systematic review and meta-analysis on long-term renal outcomes among COVID-19 patients. We carried out a systematic literature search in PUBMED, EMBASE, SCOPUS, and Cochrane COVID-19 study register and performed the random-effects meta-analysis of rates. The search was last updated on November 23, 2022. The study included 12 moderate to high-quality cohort studies involving 6976 patients with COVID-19-associated acute kidney injury and 5223 COVID-19 patients without acute kidney injury. The summarized long-term renal non-recovery rate, dialysis-dependent rate, and complete recovery rate among patients with COVID-19-associated AKI was 22% (12-33%), 6% (2-12%), and 63% (44-81%) during a follow-up of 90-326.5days. Heterogeneity could be explained by differences in the prevalence of chronic kidney disease and proportion of acute kidney injury requiring renal replacement therapy using meta-regression; patients with more comorbidities or higher renal replacement therapy rate had higher non-recovery rates. The summarized long-term kidney function decrease rate among patients without acute kidney injury was 22% (3-51%) in 90-199days, with heterogeneity partially explained by severity of infection. Patients with more comorbidities tend to have a higher renal non recovery rate after COVID-19-associated acute kidney injury; for COVID-19 patients without acute kidney injury, decrease in kidney function may occur during long-term follow-up. Regular evaluation of kidney function during the post-COVID-19 follow-up among high-risk patients may be necessary.

Left ventricular decompression in veno-arterial extracorporeal membrane oxygenation

Objective: Our study investigates the frequency and determines the characteristics and outcomes of patients with venoarterial extracorporeal membrane oxygenation (VA-ECMO) support requiring left ventricular unloading at Ha Noi Heart hospital.&#x0D; Methods: A cross-sectional descriptive study was conducted among 84 patients undergoing VA- ECMO between December 2018 and December 2021 at Ha Noi Heart hospital. Signs of left ventricular distension in VA-ECMO (Inadequate arterial blood pressure pulsatility, “smoke like” effect in left ventricular, reduced aortic valve opening/absent aortic valve closure, pulmonary edema, left ventricular distension) were studied before and at 24 hours, 48 hours and 72 hours after VA-ECMO support.&#x0D; Results: Left ventricular distention requiring decompression occurs in 44,1% of patients supported with VA-ECMO 3.6% (left ventricular distension), inadequate arterial blood pressure pulsatility (77,4%), “smoke like” effect in left ventricular (53,6%), pulmonary edema 47 ,6%; reduced aortic valve opening/absent aortic valve closure in 35,7% of the cases. Left ventricular decompression may improve clinical outcomes from 48 hours onwards (p&lt;0.05). There were no differences in age, left ventricular ejection fraction before VA-ECMO, ECRP rates, continuous renal replacement therapy rates, duration of mechanical ventilation, duration of ECMO, hospital length of stay and diagnosis of patients with and without left ventricular unloading (p&gt;0.05). The proportion of patients using invasive left ventricular decompression who successful weaning from VA- ECMO was significantly higher than in the group without left ventricular unloading (94,5% versus 74,4%; p&lt;0.05).The survival rate of patients using left ventricular unloading tended to be higher than that in the group without left ventricular decompression (72,9% vs 53,2%; p&gt;0.05) ). Complications of invasive left ventricular decompression included 1 patient with occlusion of the junction requires removal of the left atrial drainage.&#x0D; Conclusion: Left heart decompression may contribute to increasing the success rate of VA-ECMO weaning and may help to improve the survival rate of patients with VA ECMO.

Prognostic role of renal replacement therapy among hospitalized patients with heart failure in the Brazilian national public health system.

Data on patients hospitalized with acute heart failure in Brazil scarce. We performed a cross-sectional, retrospective, records-based study using data retrieved from a large public database of heart failure admissions to any hospital from the Brazilian National Public Health System (SUS) (SUS Hospital Information System [SIHSUS] registry) to determine the in-hospital all-cause mortality rate, in-hospital renal replacement therapy rate and its association with outcome. In total, 910,128 hospitalizations due to heart failure were identified in the SIHSUS registry between April 2017 and August 2021, of which 106,383 (11.7%) resulted in in-hospital death. Renal replacement therapy (required by 8,179 non-survivors [7.7%] and 11,496 survivors [1.4%, p < 0.001]) was associated with a 56% increase in the risk of death in the univariate regression model (HR 1.56, 95% CI 1.52 -1.59), a more than threefold increase of the duration of hospitalization, and a 45% or greater increase of cost per day. All forms of renal replacement therapy remained independently associated with in-hospital mortality in multivariable analysis (intermittent hemodialysis: HR 1.64, 95% CI 1.60 -1.69; continuous hemodialysis: HR 1.52, 95% CI 1.42 -1.63; peritoneal dialysis: HR 1.47, 95% CI 1.20 -1.88). The in-hospital mortality rate of 11.7% observed among patients with acute heart failure admitted to Brazilian public hospitals was alarmingly high, exceeding that of patients admitted to North American and European institutions. This is the first report to quantify the rate of renal replacement therapy in patients hospitalized with acute heart failure in Brazil.

Influence of timing of Levosimendan administration on outcomes in cardiac surgery.

Though a subgroup analysis has shown improved survival for patients suffering severely reduced ventricular function undergoing coronary artery bypass grafting, RCTs were not able to demonstrate overall beneficial effects of perioperative Levosimendan in cardiac surgery. This might be due to Levosimendan's pharmacokinetics reaching a steady-state concentration only 4-8 h after administration. Thus, this study now analysed the influence of timing of Levosimendan administration on perioperative outcome in cardiac surgery patients preoperatively presenting with severely reduced ventricular function and therefore considered at high-risk for intra- or postoperative low cardiac output syndrome. We hypothesized that prolonged preoperative Levosimendan administration ("preconditioning") would reduce mortality. All adult patients undergoing cardiac surgery between 2006 and 2018 perioperatively receiving Levosimendan were included in this retrospective, observational cohort study (n = 498). Patients were stratified into 3 groups: Levosimendan started on the day prior to surgery ("preop"), Levosimendan started on the day of surgery ("intraop") or post ICU admission ("postop"). After propensity score matching (PSM) was performed, outcomes defined according to proposed standard definitions for perioperative outcome research were compared between groups. After PSM, there were no significant differences in patients' characteristics, comorbidities and type/priority of surgery between groups. Compared to intraop or postop Levosimendan treatment, preop treated patients had significantly lower in-hospital-mortality (preop vs. intraop. vs. postop = 16,7% vs. 33,3% vs. 42,3%), duration of mechanical ventilation and rate of continuous renal replacement therapy. Prolonged preoperative treatment with Levosimendan of cardiac surgery patients preoperatively presenting with severely reduced left ventricular function might be beneficial in terms of postoperative outcome. Our results are in line with recent experts' recommendations concerning the prolonged perioperative use of Levosimendan. We strongly recommend that future randomized trials include this "preconditioning" treatment as an experimental arm.

Increased Drop in Activity of Alkaline Phosphatase in Plasma from Patients with Endocarditis.

(1) Infective endocarditis is a severe inflammatory disease associated with substantial mortality and morbidity. Alkaline phosphatase (AP) levels have been shown to change significantly during sepsis. Additionally, we previously found that a higher initial AP drop after cardiac surgery is associated with unfavorable outcomes. Therefore, the course of AP after surgery for endocarditis is of special interest. (2) A total of 314 patients with active isolated left-sided infective endocarditis at the Department of Cardiac Surgery (Medical University of Vienna, Vienna, Austria) between 2009 and 2018 were enrolled in this retrospective analysis. Blood samples were analyzed at different time points (baseline, postoperative days 1-7, postoperative days 14 and 30). Patients were categorized according to relative alkaline phosphatase drop (≥30% vs. <30%). (3) A higher rate of postoperative renal replacement therapy with or without prior renal replacement therapy (7.4 vs. 21.8%; p = 0.001 and 6.7 vs. 15.6%; p = 0.015, respectively) and extracorporeal membrane oxygenation (2.2 vs. 19.0%; p = 0.000) was observed after a higher initial alkaline phosphatase drop. Short-term (30-day mortality 3.0 vs. 10.6%; p = 0.010) and long-term mortality (p = 0.008) were significantly impaired after a higher initial alkaline phosphatase drop. (4) The higher initial alkaline phosphatase drop was accompanied by impaired short- and long-term outcomes after cardiac surgery for endocarditis. Future risk assessment scores for cardiac surgery should consider alkaline phosphatase.

Association between elevated lactate and clinical outcomes in adults with diabetic ketoacidosis

PurposeTo assess the occurrence of hyperlactatemia among patients admitted to the intensive care unit (ICU) with diabetic ketoacidosis (DKA), and effect on in-hospital mortality. Materials and methodsA retrospective, multicentre, cohort study of adult patients admitted to ICU with a primary diagnosis of DKA in Australia and New Zealand, utilising a pre-existing dataset. The primary exposure variable was lactate, dichotomised into normolactatemia (lactate <2.0 mmol/L) and hyperlactatemia (lactate ≥ 2.0 mmol/L) groups. The primary outcome was in-hospital mortality. Secondary outcomes included ICU and hospital length of stay (LOS), requirement for ventilation, renal replacement therapy (RRT) and inotropes. ResultsThe final dataset included 9061 patients. Hyperlactatemia was associated with in-hospital mortality (Odds Ratio [OR] 1.785 (95% CI 1.122–2.841, p = 0.014), hospital LOS (Geometric mean ratio [GMR] 1.063, 95% CI 1.025–1.103, p = 0.001), ICU LOS (GMR 1.057, 95% CI 1.026–1.09. p < 0.001), RRT (OR 2.198, 95% CI 1.449–3.334, p < 0.001) and inotropes (OR 1.578, 95% CI 1.311–1.899, p < 0.001). These associations persisted in Type 2 but not Type 1 diabetics. ConclusionsHyperlactatemia in patients admitted to ICU with DKA is associated with higher mortality, longer hospital and ICU LOS, and higher rates of mechanical ventilation, RRT and inotropes.

Understanding the Burden of Kidney Failure in Trinidad and Tobago: A Review of the Epidemiological Data From a Regional Center.

Objective The aim of this study was to determine the incidence of new patients requiring renal replacement therapy and to gather data on sex, age, ethnicity, mortality, and causes of kidney failure in Trinidad and Tobago in comparison with the rest of the world. Method Electronic data were gathered for new patients initiating dialysis between January 1, 2016, and December 31, 2017, including the date of dialysis initiation, age, gender, ethnicity, diagnosis, dialysis access and modality, and outcome at three months and the end of the year. The data were analyzed using simple descriptive statistics via Microsoft Excel (Microsoft Corporation, Redmond, Washington, United States). Results Over a two-year period, 265 new patients underwent renal replacement therapy, of which 51.7% were 50-69 years of age, 53.9% were male, 46% were female, 67.9% were Afro-Trinidadian, and 38.1% had a combination of diabetes mellitus and hypertension as the cause of kidney failure. The incidence rates of treated end-stage renal disease (ESRD) globally in 2016 and 2017 were 306 and 224 per million population, respectively, and mortality for both years was 32% and 32.1%, respectively. Conclusion Our study showed that Trinidad and Tobago has one of the highest incidences of patients initiating renal replacement therapy and mortality rates.

#5943 THE VALUE OF THE HISTOLOGICAL CLASSIFICATIONS OF ANCA ASSOCIATED VASCULITIS IN PREDICTING LONG TERM KIDNEY SURVIVAL

Abstract Background and Aims Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) are a group of multisystemic autoimmune diseases characterized by necrotizing inflammation of small vessels, with a predilection for the kidney. The prognostic value of histological classification of ANCA-glomerulonephritis (ANCA-GN) is discussed. In 2010, Berden and colleagues proposed a prognostic classification based on glomerular involvement; in 2018, Brix et al. introduced the ANCA Renal Risk Score, which includes histological features and glomerular filtration rate; in 2017 the Mayo Clinic Chronicity Score, that considers chronic histological lesions, was designed and assessed in ANCA-GN. We aimed to identify which score is the best tool to predict end-stage kidney disease or death in a cohort of ANCA-GN patients. Method Patients who underwent kidney biopsy in two Italian centers within 32 years were retrospectively collected. Inclusion criteria: age &amp;gt;18 years, and at least one year of follow-up. A minimum of 10 glomeruli was considered adequate for a biopsy. Renal biopsies were classified according to Berden's classification, Renal Risk Score and Mayo Clinic Chronicity Score. The primary end point of the study was the development of end-stage kidney disease (ESKD) at 5 years, defined as the chronic need of renal replacement therapy (RRT) or glomerular filtration rate (GFR) &amp;lt;15 ml/min. The secondary endpoint was a composite endpoint of ESKD or death for all causes. Results Of the 152 patients 84 were male, the median age was 63.8 years (Figure 1). Mean eGFR at diagnosis was 21.32 ml/min/1.73 m2. 32.2% of patients were PR-3 positive, 50.6% were MPO positive, 17.2% were ANCA-negative. After a mean follow-up of 71.7 ± 66.7 months, 59 patients (38.8%) were on chronic dialysis or with a GFR &amp;lt;15 ml/min; among them, 20 patients died. The pure kidney survival rate (without ESKD or GFR&amp;lt;15 ml/min) was 79% at 1 year, 65% at 5 years, 59.8% at 10 years. Figure 2 reported the pure kidney survival rates of the patients assigned to every class of the three scores that we considered in this study. Fig. 3, Fig. 4, Fig. 5 show Kaplan-Meyer curves for the secondary outcome (ESKD+death); patients are classified according to the Berden's score (Fig. 2), the Renal Risk Score (Fig. 3) and Mayo Clinic Chronicity Score (Fig. 4). Conclusion Berden histopathological classification and Renal Risk Score are predictive of renal prognosis when we consider the primary outcome (ESKD or eGFR&amp;lt;15 ml/min) and when we consider the composite outcome (ESKD + death). The Mayo Clinic Chronicity Score allows a reliable stratification of the patients only when we consider the composite outcome (ESKD and death).

Application of an interrupted time series analysis (ITS) to evaluate the effect of universal dialysis policy from 2006 to 2016 in a province of northeastern Thailand

Background: An interrupted time series (ITS) analysis is a powerful tool for policy evaluation. In Thailand, chronic kidney disease (CKD) is a public health problem that requires a long recovery time and has a high treatment cost. The universal coverage policy for renal replacement therapy (universal dialysis policy), is used to treat this disease but policy evaluation using ITS analysis has rarely been conducted. This study applied ITS analysis to test the effect of such a policy between 2006 and 2016. Methods: Data were retrieved from the electronic database of the health data center in Roi Et Province for the period between January 1, 2006 and December 31, 2016. 15,681 CKD stage 5 patients were included. The intervention under assessment was the universal health coverage system, which has been implemented since 2008. Results: Results showed that before implementation of the universal dialysis policy, the overall trend of access to renal replacement therapy (RRT) slightly increased (0.74; 95% confidence interval (CI): 0.58, 0.90). After implementation of the policy, access sharply increased (6.10; 95%CI: 3.67, 8.54), while the linear trend after policy implementation also slightly increased (0.29; 95%CI: 0.05, 0.14). The stratified analysis showed the same linear directional trend before and immediately after implementing the universal dialysis policy. Conclusions: Implementation of the universal dialysis policy positively impacted the rate of renal replacement therapy in CKD stage 5 patients, while access to health care services also increased.

Intraoperative hemodialysis during open-heart surgery in patients with severe chronic kidney disease: a retrospective cohort study

BackgroundAcute kidney injury and chronic kidney disease (CKD) after cardiac surgery are associated with poor renal prognosis and increased mortality. The impact of intraoperative hemodialysis (IHD) on postoperative renal function remains unknown. We aimed to evaluate the utility of IHD during open-heart surgery in patients with severe non-dialysis-dependent chronic kidney disease (CKD-NDD) and its association with clinical outcomes.MethodsThis was a single-center retrospective cohort study that employed IHD during non-emergency open-heart surgery in patients with CKD stage G4 or G5. Patients who underwent emergent surgery, chronic dialysis, and/or kidney transplantation were excluded. We retrospectively compared the clinical characteristics and outcomes between patients from the IHD and non-IHD groups. The primary outcomes were 90-day mortality and postoperative initiation of renal replacement therapy (RRT).ResultsTwenty-eight patients were categorized into the IHD group and 33 into the non-IHD group. When comparing the IHD and non-IHD groups, men accounted for 60.7 vs. 50.3% of patients, the mean patient age was 74.5 (standard deviation [SD] 7.0) vs. 72.9 (SD 9.4) years (p = 0.744), and the proportion of patients with CKD G4 was 67.9 vs. 84.9% (p = 0.138). Regarding clinical outcomes, no significant differences were observed in the 90-day mortality (7.1 vs. 3.0%; p = 0.482) and 30-day RRT (17.9 vs. 30.3%; p = 0.373) rates between the groups. Among the patients with CKD G4, the IHD group had significantly lower 30-day RRT rates than the non-IHD group (0 vs. 25.0%; p = 0.032). RRT initiation was less likely for patients with CKD G4 (odds ratio 0.07, 95% confidence interval [CI] 0.01–0.37; p = 0.002); however, IHD did not significantly decrease the incidence of poor clinical outcomes (odds ratio 0.20, 95% CI 0.04–1.07; p = 0.061).ConclusionsIHD during open-heart surgery in patients with CKD-NDD did not improve their clinical outcomes with regards to postoperative dialysis. However, for patients with CKD G4, IHD may be useful for postoperative cardiac management.

Admission of kidney patients to a closed staff nephrology department results in a better short-term survival.

The outcome of patients with chronic kidney disease (CKD) and acute kidney injury (AKI) is often dismal and measures to ameliorate their course are scarce. When admitted to the hospital, kidney patients are often hospitalized in general Medicine wards rather than in a specialized Nephrology department. In the current study, we compared the outcome of two cohorts of kidney patients (CKD and AKI) admitted either to general open-staff (with rotating physicians) Medicine wards or to a closed-staff (non-rotating Nephrologists) Nephrology ward. In this population-based retrospective cohort study, we enrolled 352 CKD patients and 382 AKI patients admitted to either Nephrology or General Medicine wards. Short-term (< = 90 days) and long-term (>90 days) outcomes were recorded for survival, renal outcomes, cardiovascular outcomes, and dialysis complications. Multivariate analysis was performed using logistic regression and negative binomial regression adjusting to potential sociodemographic confounders as well as to a propensity score based on the association of all medical background variables to the admitted ward, to mitigate the potential admittance bias to each ward. One hundred and seventy-one CKD patients (48.6%) were admitted to the Nephrology ward and 181 (51.4%) were admitted to general Medicine wards. For AKI, 180 (47.1%) and 202 (52.9%) were admitted to Nephrology and general Medicine wards, respectively. Baseline age, comorbidities and the degree of renal dysfunction differed between the groups. Using propensity score analysis, a significantly reduced mortality rate was observed for kidney patients admitted to the Nephrology ward vs. general Medicine in short term mortality (but not long-term mortality) among both CKD patients admitted (OR = 0.28, CI = 0.14-0.58, p = 0.001), and AKI patients (or = 0.25, CI = 0.12-0.48, p< 0.001). Nephrology ward admission resulted in higher rates of renal replacement therapy (RRT), both during the first hospitalization and thereafter. Thus, a simple measure of admission to a specialized Nephrology department may improve kidney patient outcome, thereby potentially affecting future health care planning.

Development and Validation of a Renal Replacement after Trauma Scoring Tool.

Stress on the healthcare system requires careful allocation of resources such as renal replacement therapy (RRT). The COVID-19 pandemic generated difficulty securing access to RRT for trauma patients. We sought to develop a renal replacement after trauma (RAT) scoring tool to help identify trauma patients who may require RRT during their hospitalization. The 2017 to 2020 TQIP database was divided into a derivation (2017 to 2018 data) and validation (2019 to 2020 data) set. A 3-step methodology was used. Adult trauma patients admitted from the emergency department to the operating room or ICU were included. Patients with chronic kidney disease, transfers from another hospital, and emergency department death were excluded. Multiple logistic regression models were created to determine the risk for RRT in trauma patients. The weighted average and relative impact of each independent predictor was used to derive a RAT score, which was validated using area under receiver operating characteristic curve (AUROC). From 398,873 patients in the derivation and 409,037 patients in the validation set, 11 independent predictors of RRT were included in the RAT score derived with scores ranging from 0 to 11. The AUROC for the derivation set was 0.85. The rate of RRT increased to 1.1%, 3.3%, and 20% at scores of 6, 8, and 10, respectively. The validation set AUROC was 0.83. RAT is a novel and validated scoring tool to help predict the need for RRT in trauma patients. With future improvements including baseline renal function and other variables, the RAT tool may help prepare for the allocation of RRT machines/staff during times of limited resources.

Comparing Outcomes Between Surgical and Transcatheter Aortic Valve Replacement in Classical Low-Flow Low-Gradient Aortic Stenosis

Patients with classic low-flow low-gradient (cLFLG) aortic stenosis (AS) have a poor prognosis but still benefit from aortic valve replacement. There is a paucity of evidence to guide the choice between transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR). This study compared procedural and midterm outcomes in patients with cLFLG AS between TAVR and SAVR. Patients with cLFLG AS, defined as an aortic valve area ≤1 cm2, mean gradient <40 mm Hg, and left ventricular ejection fraction <50%, were selected from a single center between 2015 and 2020. Inverse probability weighting and regression were used to adjust for differences in baseline characteristics, the nonrandom assignment of treatment modalities, and procedural differences. The primary end point was all-cause mortality. A total of 322 patients (220 TAVR and 102 SAVR) were included. At a follow-up of 4.4 ± 1.5years, the adjusted hazard ratio (HR) for mortality after inverse probability weighting with SAVR was 0.66, 95% confidence interval (CI) 0.31 to 1.35; p=0.24. Worse renal function at baseline (per 10ml/min/m2 increase HR 0.92, 95% CI 0.84 to 1.00, p=0.04) and multiple valve interventions (HR 5.39, 95% CI 2.62 to 11.12, p <0.001) independently predicted mortality. There was no difference in stroke and permanent pacemaker implantation, but the rates of renal replacement therapy were higher among the SAVR cohort: 13.7% versus 0%; p <0.001. In conclusion, among patients with cLFLG AS, there was no difference in midterm mortality between TAVR and SAVR, supporting the use of either treatment. However, in patients with poor renal function or at risk of renal failure, TAVR may be the preferred option.