Renal Morbidity Research Articles

Management of supine hypertension in patients with neurogenic orthostatic hypotension: scientific statement of the American Autonomic Society, European Federation of Autonomic Societies, and the European Society of Hypertension.

: Supine hypertension commonly occurs in patients with neurogenic orthostatic hypotension due to autonomic failure. Supine hypertension promotes nocturnal sodium excretion and orthostatic hypotension, thus, interfering with quality of life. Perusal of the literature on essential hypertension and smaller scale investigations in autonomic failure patients also suggest that supine hypertension may predispose to cardiovascular and renal disease. These reasons provide a rationale for treating supine hypertension. Yet, treatment of supine hypertension, be it through nonpharmacological or pharmacological approaches, may exacerbate orthostatic hypotension when patients get up during the night. Fall-related complications may occur. More research is needed to define the magnitude of the deleterious effects of supine hypertension on cardiovascular, cerebrovascular, and renal morbidity and mortality. Integration of more precise cardiovascular risk assessment, efficacy, and safety data, and the prognosis of the underlying condition causing autonomic failure is required for individualized management recommendations.

Dengue-Associated Acute Kidney Infection: An Updated and Comprehensive Qualitative Review of Literature

Dengue is a viral infection transmitted by an Aedes aegypti mosquito bite that poses a major threat to public health worldwide. While acute kidney injury secondary to dengue infection is a potentially lethal complication, it remains one of the least studied complications of dengue fever. The underlying mechanism of dengue-associated acute kidney injury is complex because it involves multiple pathways that could independently lead to its occurrence. Therefore, the cornerstone of dengue-associated acute kidney injury management should involve prompt recognition and identification of the at-risk population and administration of appropriate supportive treatment in a timely manner with the aim of preventing both renal and non-renal morbidity and mortality.

The Incidence of Acute Kidney Injury and Associated Hospital Mortality.

Studies from multiple countries have shown that acute kidney injury (AKI) in hospitalized patients is associated with mortality and morbidity. There are no reliable data at present on the incidence and mortality of AKI episodes among hospitalized patients in Germany. The utility of administrative codings of AKI for the identification of AKI episodes is also unclear. In an exploratory approach, we retrospectively analyzed all episodes of AKI over a period of 3.5 years (2014-2017) on the basis of routinely obtained serum creatinine measurements in 103 161 patients whose creatinine had been measured at least twice and who had been in the hospital for at least two days. We used the "Kidney Disease: Improving Global Outcomes" (KDIGO) criteria for AKI. In parallel, we assessed the administrative coding of discharge diagnoses of the same patients with codes from the International Classification of Diseases (ICD-10-GM). Among 185 760 hospitalizations, stage 1 AKI occurred in 25 417 cases (13.7%), stage 2 in 8503 cases (4.6%), and stage 3 in 5881 cases (3.1%). AKI cases were associated with length of hospital stay, renal morbidity, and overall mortality, and this association was stage-dependent. The in-hospital mortality was 5.1% for patients with stage 1 AKI, 13.7% for patients with stage 2 AKI, and 24.8% for patients with stage 3 AKI. An administrative coding for acute kidney injury (N17) was present in only 28.8% (11 481) of the AKI cases that were identified by creatinine criteria. Like the AKI cases overall, those that were identified by creatinine criteria but were not coded as AKI had significantly higher mortality, and this association was stage-dependent. AKI episodes are common among hospitalized patients and are associated with considerable morbidity and mortality, yet they are inadequately documented and probably often escape the attention of the treating physicians.

Acute kidney injury in the pediatric intensive care unit at a tertiary care hospital of the Armed Forces: a cross-sectional observational study

BackgroundAcute kidney injury (AKI) is shown to be the commonest complication in critically ill children admitted to the pediatric intensive care unit (PICU). Kidney Disease: Improving Global Outcomes (KDIGO) classification and definition are now used universally. We undertook prospective observational study to study the etiology and maximum stage of AKI as defined by KDIGO and its complications and outcomes. MethodsAll children admitted to the PICU were included in the study. The diagnosis of sepsis and multiorgan dysfunction syndrome (MODS) was made according to the standard international guidelines. The patients were followed up till discharge/death. All children were screened for AKI at admission and subsequently using serum creatinine measured by modified Jaffe's method and urine output measurement. ResultsA total of 197 children were admitted to the PICU. 38 (19.28%) developed AKI, and 6 (15.78%) developed stage III AKI. Malignancies, serious neurological and renal disorders, and postsurgery complications accounted for most of the cases with AKI. Six were admitted with primary renal condition. Sepsis with or without MODS was seen in 12 patients with AKI and in 8 without AKI. Twenty-one children with AKI and 3 children without AKI were exposed to nephrotoxic drugs. Twenty-three children with AKI required inotropic support. The average length of stay (ALOS) of children with AKI in the PICU was 9.86 days, whereas ALOS of children without AKI was 6.23 days. Eighteen children with AKI (47.36%) and 36 (21.38%) with no AKI died. ConclusionsAKI in children in the PICUs of referral hospitals in the armed forces have varied etiologies and presentations. These children require early identification and management with close monitoring to prevent long-term renal morbidity and mortality.

Pulse Pressure and Outcome in Kidney Transplantation: Results From the Collaborative Transplant Study.

Systolic blood pressure (SBP) and diastolic blood pressure (DBP) are important predictors of graft and patient survival in renal transplantation. Pulse pressure (PP), the difference between systolic and diastolic pressure, has been associated with cardiovascular and renal morbidity in nontransplant epidemiological studies and clinical trials. In this large retrospective analysis of prospectively collected data, transplant recipients from 1995 to 2015 were examined for patient and death-censored graft survival. In 43 006 recipients, a higher 1-year PP was significantly associated with inferior 10-year patient and death-censored graft survival. In patients 60 years or older, SBP but not DBP was associated with 10-year survival, an effect that was pronounced in patients with a normal SBP of <140 mm Hg and an increased PP of 60 mm Hg or greater, highlighting the superior impact of PP on survival in elderly recipients. In recipients 60 years or older, higher PP was associated with increased mortality due to circulatory system diseases but not to infection or cancer. The combination of PP 60 mm Hg or greater and high SBP of 140 mm Hg or greater showed the strongest association with death-censored graft survival across all age groups. We found convincing evidence that PP 1-year posttransplant is predictive of patient survival, especially in elderly recipients with normal SBP. Combined analysis of SBP and PP showed that high PP confers additional predictive information for patient survival beyond that derived from analysis of SBP alone. With regard to prediction of death-censored graft survival, the combination of high SBP and high PP showed the best correlation across all age groups.

Abstract 164: Neighborhood Socioeconomic Status is Significantly Associated with Outcomes After Coronary Artery Bypass Grafting

Objective: Area Deprivation Index (ADI) is a geographically-derived measure of socioeconomic status composed of 17 education, employment, housing-quality, and poverty measures derived from census data. Block group level ADI has recently been made widely accessible to clinicians. A block group is the smallest geographical unit from which census data is collected, representing a homogenous group of people living on a single city block or rural equivalent. Previous work analyzing the relationship of socioeconomic status with cardiac surgery outcomes has been limited by the use of zip codes as the geographic unit, which comprise a larger and more diverse population. This study evaluates the association of ADI with outcomes after coronary artery bypass grafting (CABG). Methods: Patients who underwent isolated CABG in the University of Pennsylvania health system between 2002 and 2018 with a valid home address were assigned an ADI based on their corresponding 2010 Census Block Group. The association between ADI and each STS post-operative outcome was assessed with univariable analysis using a Wilcoxon rank sum test with continuity correction. A multivariable logistic regression model was created for each STS post-operative outcome using variables in the 2008 STS risk model for CABG with ADI as an additional variable. Results: The 6,751 patients who met the inclusion criteria were from 19 states with a median predicted STS risk of post-operative major morbidity and mortality of 16.6% (IQR 7.0% to 19.9%) and median ADI of 31 (IQR 17 to 50). ADI was not normally distributed by Wilcoxon signed rank test (p &lt; 0.01). ADI was significantly associated with stroke (p = 0.03), renal failure (p &lt; 0.01), prolonged ventilation (p &lt; 0.01), reoperation (p = 0.05), and composite morbidity and mortality (p &lt; 0.01) in univariable analysis. When included in a multivariable logistic regression model ADI was significantly associated with renal failure (p = 0.02), prolonged ventilation (p &lt; 0.01), and composite morbidity and mortality (p &lt; 0.01). Conclusions: ADI is associated with STS post-operative outcomes. When included in a multivariable model, ADI remains highly associated with outcomes. Inclusion of block group level socioeconomic status in prediction models may significantly improve risk prediction.

20 year trends in renal disease mortality in Ghana: A review of autopsies.

Data on the changing levels in renal morbidity and mortality are scant globally. We sought to assess trends in renal disease mortality and attributable causes over a 20 year period in Ghana. A retrospective analysis of 20 year autopsy records of the Pathology Departments of leading teaching hospitals in Ghana, (Korle-Bu Teaching Hospital (KBTH) in Accra and Komfo Anokye Teaching Hospital (KATH) in Kumasi) from January 1994 to December 2013. Data comprising autopsies from in-patients, community cases and coroners' cases were used. We defined primary cause of death as death directly due to renal disease and secondary cause of death as death in which renal disease was a comorbid or contributing factor. Over the period, there were a total of 94 309 deaths, of which 5608 were attributed to renal disease (5.9/100). Mortality rate remained fairly the same from 1994 to 2009 (5.0%), but doubled from 2010 to 2013 (10.8%). Similar trends were observed among males and females during the same period. However, males had slightly higher mortality rates (6.6%; 95% CI: 46.1%-6.8%) compared to females (5.6%; 95% CI: 5.4%-5.8%; P = 0.271). The major leading attributable causes of renal disease death include end stage renal disease 45.0% and acute pyelonephritis accounting for 20.9% of the cases. Hypertensive heart disease accounted for 30.0% of all secondary cause of death while congestive heart disease and septicaemia accounted for 13.0% and 12.0%, respectively. We observed marked increase in the renal disease mortality rate during the last few years predominantly driven by chronic and infectious related renal diseases as a main cause, and hypertensive heart disease and congestive heart failure as the main secondary causes. Measures geared towards prevention, treatment and managing such conditions may impact on the reduction of renal disease mortality rate among Ghanaian populations.

Latent tuberculosis infection and renal transplantation – Diagnosis and management

BackgroundTuberculosis (TB) continues to be the commonest infectious disease cause of death worldwide. Tuberculosis is an important infectious disease cause of morbidity and death in renal transplant recipients. Tuberculosis can also cause loss of kidney allograft. ObjectivesThe purpose of this viewpoint is to highlight the issues related to prevention, diagnosis and treatment of tuberculosis in renal transplant recipients. MethodsThe PubMed database was searched for publications and guidelines on diagnosis and management of LTBI in renal transplantation. Publications on renal allograft recipients with LTBI and TB in post-operative period were also analysed. Specialist Society guidelines were also used. FindingsTuberculosis is one of the most important infectious disease-related causes of morbidity and death in transplant recipients. LTBI in allograft recipients continues to be a clinical management problem. It can occur either from donor kidney or from endogenous reactivation of latent tuberculosis infection or from acquiring new Mycobacterium tuberculosis infection. Tuberculosis can also cause loss of kidney allograft. ConclusionsKidney transplantation is now universally performed in high and low Tuberculosis endemic countries. A high index of awareness of the possibility of TB disease or LTBI is required prior to renal transplant aligned to reduce renal allograft damage, morbidity and death due to tuberculosis. WHO Management recommendations for LTBI screening and treatment should be followed.

Rituximab in ANCA-associated vasculitis presenting with severe acute kidney injury; a case report

Anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis presenting with severe acute kidney injury (AKI), consistent with rapidly progressive glomerulonephritis portends significant renal morbidity with up to 20%–25% of patients reaching end stage renal disease within a few years after diagnosis. Nevertheless, a smaller proportion of patients require dialysis at presentation or within the first six months. There is still some debate as to the first line therapy of choice for such patients vis a vis the use of the newer agent rituximab versus the time-tested cyclophosphamide in combination with glucocorticoids. Our recent experience at The Robert Larner, M.D. College of Medicine, University of Vermont, Burlington, VT, USA in June 2018 allowed us to revisit this controversy.

Adverse Outcomes of Perioperative Red Blood Cell Transfusions in Coronary Artery Bypass Grafting in Hospital Universiti Sains Malaysia.

BackgroundPerioperative red blood cell (RBC) transfusion in coronary artery bypass grafting (CABG) has both benefits and harms. Our aim was to study the association between perioperative RBC transfusion and its adverse outcomes.MethodsThis was a retrospective study of patients who underwent isolated CABG in Hospital Universiti Sains Malaysia, Kelantan, Malaysia, from 1 January 2013 until 31 December 2017. Data were collected from medical records, and comparisons were made between patients who received perioperative RBC transfusions and those who did not have adverse outcomes after CABG.ResultsA total of 108 patients who underwent isolated CABG were included in our study, and 78 patients received perioperative RBC transfusions. Patients who received perioperative RBC transfusions compared to those who did not were significantly more likely to develop prolonged ventilatory support (21.8% versus 0%, P = 0.003), cardiac morbidity (14.1% versus 0%, P = 0.032), renal morbidity (28.2% versus 3.3%, P = 0.005) and serious infection (20.5% versus 3.3%, P = 0.037). With each unit of packed RBC transfusions, there was a significantly increased risk of prolonged ventilatory support (adjusted odds ratio [AOR] = 1.45; 95% confidence interval [CI] = 1.20–1.77; P < 0.001), cardiac morbidity (AOR =1.40; 95%CI = 1.01–1.79; P = 0.007), renal morbidity (AOR = 1.23; 95%CI = 1.03–1.45; P = 0.019) and serious infection (AOR = 1.31; 95%CI = 1.07–1.60; P = 0.009).ConclusionPerioperative RBC transfusion in isolated CABG patients is associated with increased risks of developing adverse events such as prolonged ventilatory support, cardiac morbidity, renal morbidity and serious infection.

A Holistic Approach to Risk for Early Kidney Injury in Indigenous Youth With Type 2 Diabetes: A Proof of Concept Paper From the iCARE Cohort.

Background:Indigenous youth with type 2 diabetes (T2D) are disproportionately affected by early onset albuminuria and are at high risk of kidney failure in early adulthood. Traditional biological approaches have failed to fully explain the renal morbidity seen in this population. The improving renal Complications in Adolescents with type 2 diabetes through REsearch cohort (iCARE) study was therefore designed in collaboration with patients, to more holistically evaluate risk factors for renal morbidity. We hypothesize that both biological factors and mental health influence renal outcomes, mediated via inflammatory pathways.Objective:The objective of this study was to evaluate the iCARE analytic framework which evaluates relationships between biological factors, mental health, inflammation, and albuminuria utilizing a structural equation modeling (SEM) approach.Methods:The first 187 youth with T2D (10-25 years) from the Manitoba iCARE cohort are presented here to evaluate our theoretical and analytic framework. An SEM was chosen to evaluate the statistical significance of proposed associations. The primary outcome was a nonorthostatic urine albumin:creatinine ratio ≥2 mg/mmol. Main exposures (ie, latent factors) included psychological health (distress, perceived stress, positive mental health and resilience), hypertension (24 hour monitored), and inflammatory markers (C-reactive protein [CRP], erythrocyte sedimentation rate [ESR], fibrinogen). Hemoglobin A1c (HbA1c) and duration of diabetes were covariates.Results:Within the initial cohort (median age = 15 years, duration of diabetes = 2.3 years, 66.8% female), 30.5% (n = 57) had nonorthostatic albuminuria (ALB), and the majority of ALB was persistent (confirmed in 2/3 samples over a 6-month period; n = 47). Youth with ALB had higher HbA1c (10.9% vs 8.9%; P < .001), more hypertension (94.2% vs 78·2%; P = .02), longer duration of diabetes (3.4 vs 2.4 years; P = .01), higher distress (9.2 vs 7.3; P = .02), and stress scores (28.7 vs 26.4; P = .03), and elevated inflammatory markers (CRP: 4.9 vs 3.1 mg/L; P = .01, fibrinogen: 3.7 vs 3.3 µmol/L; P = .02). Factors directly associated with ALB in the SEM were hypertension (0.28; P = .001), inflammation (0.41; P < .001), and HbA1c (0.50; P < .001). Psychological health was independently associated with inflammation (−0.20; P < .001) but not directly associated with ALB.Conclusions:Albuminuria is highly prevalent in Indigenous youth with T2D. This preliminary analysis supports a theoretical framework linking glycemic control, hypertension, and inflammation, potentially mediated by psychological factors with albuminuria. These data support the need for more holistic models of evaluation and care for youth with T2D and multifactorial interventions to prevent complications.

Determination of Microalbuminuraia and Its Relation to HTN in Type 2 Diabetic Patients and General People

Background: Microalbuminuria is a clinical marker of glomerular injury and identified as a risk of progressive renal damage, cardiovascular disease and morbidity. Hypertension (HTN) is a worldwide public health problem andcommonly coexists with Diabetes Mellitus (DM). Objective: The aim of the study was todetermine the prevalence of microalbuminuriain type 2diabetic patients and general people and the relationship between microalbuminuria withHTN and other clinical parametersin these twogroups of people. Methodology: A cross-sectional study was carried out using a pretested structured questionnaire amongrandomly selected107 participants aged from 35-70 years. Out of 107 participants 64 persons were type 2 diabetic patients and 43 were healthy individuals. Biochemical analysis of blood and urine samples was performed. Result: The prevalence of microalbuminuria was 17.2% in diabetic patients and 25.6% ingeneral people whereas the prevalence of HTN was 48.4% among diabetic patients and 51.6% in normal healthy persons. Regardless of the group considered, when microalbuminuria was analyzed according to the different clinical parameters, microalbuminuricpatients had significantly highersystolic (p=0.03) diastolic (p=0.02) blood pressure, urine creatinine (p=0.000), serum creatinine (p=0.012), urine albumin (p=0.019) and GFR (p=0.000). Microalbuminuria was found to be associated with HTN (odds ratio [OR] 3.5, 95% confidence interval [CI] 1.2-9.7). Conclusion: The study concluded thatmicroalbuminuria prevalence is high among general people and HTN has a significant relationship with microalbuminuria. These findings suggest early screening of microalbuminuria and the proper management of other clinical parameters to halt and prevent end stage renal disease and cardiovascular risk in future.

Glomerular filtration rate: when to measure and in which patients?

Of the glomerular, tubular and endocrine functions of the kidney, nephrologists have mostly focused their attention on the glomerular functions-albuminuria and glomerular filtration rate (GFR)-to grade the severity of chronic kidney disease (CKD). Although both albuminuria and GFR are associated with renal and cardiovascular morbidity and mortality, the utility of measured GFR (mGFR) has been questioned. GFR when measured adequately is the most precise measure of glomerular function and can be useful to individualize therapy among patients with CKD. In situations where estimated GFR is known to provide imprecise estimates of glomerular function, for example, sarcopenia and advanced cirrhosis, the measurement of GFR may be especially important. We discuss several clinical situations where mGFR can potentially influence the quality of life or complications of therapy because of interventions based on imperfect knowledge of GFR. We reason that although large databases may not detect the benefits of mGFR at the population level, precision medicine requires that therapy be individualized based on the best estimate of GFR that can be obtained particularly when the risk of harm is increased. The recent standardization of mGFRs is a step in the right direction and may help in treating the individual patient with CKD with a lower risk of complications and a better quality of life. We call for research in these subgroups of patients where it is clinically felt that mGFR is useful for clinical decision-making.

Hipertensão resistente: abordagem clínica

Hipertensão arterial resistente é definida como a pressão arterial de consultório não controlada, apesar do uso de três ou mais anti-hipertensivos, incluindo, preferencialmente, um diurético. Indivíduos em uso de quatro ou mais medicamentos com controle pressórico também são considerados hipertensos resistentes. Por sua vez, hipertensão refratária é a pressão arterial não controlada, apesar do uso de cinco ou mais drogas, incluindo um tiazídico de ação prolongada e um antagonista da aldosterona. Sua prevalência vem crescendo com o envelhecimento da população e o avanço da obesidade, estando relacionada às altas taxas de morbidade e mortalidade de origem cardiovascular e renal. A abordagem diagnóstica se baseia em quatro pontos: afastar pseudorresistência, identificar o fenômeno do jaleco branco, investigar causas secundárias e identificar lesões subclínicas para estratificação do risco cardiovascular. O objetivo terapêutico é o controle da pressão arterial de 24 horas. Mudanças de estilo de vida devem ser implementadas e as três primeiras drogas devem incluir um diurético adequado, um inibidor do sistema renina-angiotensina-aldosterona e um bloqueador de canais de cálcio. Persistindo o descontrole pressórico, adicionamos a quarta droga: espironolactona. Quanto aos hipertensos refratários, novas modalidades terapêuticas vêm sendo desenvolvidas, como a denervação renal e a estimulação do barorreflexo.

Successful treatment of severe arterial hypotension and anuria in a preterm infant with renal tubular dysgenesis\u2013 a case report

BackgroundOligohydramnios sequence can be caused by renal tubular dysgenesis (RTD), a rare condition resulting in pulmonary and renal morbidity. Besides typical features of Potter-sequence, the infants present with severe arterial hypotension and anuria as main symptoms. Establishing an adequate arterial blood pressure and sufficient renal perfusion is crucial for the survival of these infants.Case presentationWe describe a male preterm infant of 34 + 0 weeks of gestation. Prenatally oligohydramnios of unknown cause was detected. After uneventful delivery and good adaptation the infant developed respiratory distress due to a spontaneous right-sided pneumothorax and required thoracocentesis and placement of a chest tube; he showed no major respiratory concerns thereafter and needed only minimal ventilatory support. Echocardiography revealed no abnormalities, especially no pulmonary hypertension. However, he suffered from severe arterial hypotension and anuria refractory to catecholamine therapy (dobutamine, epinephrine and noradrenaline). After 36 h of life, vasopressin therapy was initiated resulting in an almost immediate stabilization of arterial blood pressure and subsequent onset of diuresis. Therapy with vasopressin was necessary for three weeks to maintain adequate arterial blood pressure levels and diuresis. Sepsis and adrenal insufficiency were ruled out as inflammation markers, microbiological tests and cortisol level were normal. At two weeks of age, our patient developed electrolyte disturbances which were successfully treated with fludrocortisone. He did not need renal replacement therapy. Genetic analyses revealed a novel compound hyterozygous mutation of RTD. Now 17 months of age, the patient is in clinically stable condition with treatment of fludrocortisone and sodium bicarbonate. He suffers from stage 2 chronic kidney disease; blood pressure, motor and cognitive development are normal.ConclusionsRTD is a rare cause of oligohydramnios sequence. Next to pulmonary hypoplasia, severe arterial hypotension is responsible for poor survival. We present the only second surviving infant with RTD, who did not require renal replacement therapy during the neonatal period. It can be speculated whether the use of vasopressin prevents renal replacement therapy as vasopressin increases urinary output by improving renal blood flow.

Restrictive Versus Liberal Red Blood Cell Transfusion for Cardiac Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Introduction:Patients undergoing cardiac surgery are among the most common recipients of allogenic red blood cell (RBC) transfusions. However, whether restrictive RBC transfusion strategies for cardiac surgery achieve a similar clinical outcome in comparison with liberal strategies remains unclear.Methods:We searched PubMed, Embase, the Cochrane Collaboration Central Register of Controlled Trials, and conference proceedings from inception to December 2017 for all randomized trials (RCTs). The primary outcome was mortality. Secondary outcomes were stroke, respiratory morbidity, renal morbidity, infections, myocardial infarction (MI), cardiac arrhythmia, gut morbidity, reoperation, intensive care unit (ICU) length of stay (hours), and hospital length of stay (days). We calculated the risk ratios (RR) and weighted mean difference (MD) for the clinical outcomes using a random-effects model.Results:We included 9 RCTs with a total of 9,005 patients. There was no significant difference in mortality between groups (RR 1.03; 95% CI 0.74-1.45; P=0.86). In addition, there were no significant differences between groups in the clinical outcomes of infections (RR 1.09; 95% CI 0.94-1.26; P=0.26), stroke (RR 0.98; 95% CI 0.72-1.35; P=0.91), respiratory morbidity (RR 1.05; 95% CI 0.89-1.24; P=0.58), renal morbidity (RR 1.02; 95% CI 0.94-1.09; P=0.68), myocardial infarction (RR 1.00; 95% CI 0.80-1.24; P=0.99), cardiac arrhythmia (RR 1.05; 95% CI 0.88-1.26; P=0.56), gastrointestinal morbidity (RR 1.93; 95% CI 0.81-4.63; P=0.14), or reoperation (RR 0.90; 95% CI 0.67-1.20; P=0.46). There was a significant difference in the intensive care unit length of stay (hours) (MD 4.29; 95% CI: 2.19-6.39, P<0.01) favoring the liberal group. However, there was no significant difference in the hospital length of stay (days) (MD 0.15; 95% CI -0.18-0.48; P=0.38).Conclusion:This meta-analysis showed that restrictive strategies for RBC transfusion are as safe as liberal strategies in patients undergoing cardiac surgery.Key points:•Restrictive strategies for red blood cell transfusion are as safe as liberal approaches in patients undergoing cardiac surgery.•Longer duration of stay in the intensive care unit is more common in patients managed with a restrictive transfusion approach. However, the overall hospital length of stay appeared to be similar between both groups.•Further studies are needed to ascertain threshold triggers for RBC transfusion. [Display omitted] DisclosuresHassan:abott: Other: grant. Bhatt:American Heart Association Quality Oversight Committee: Other: chair; Boston VA Research Institute, Society of Cardiovascular Patient Care, TobeSof: Membership on an entity's Board of Directors or advisory committees; Medscape Cardiology: Consultancy; Regado Biosciences: Consultancy; Elsevier Practice Update Cardiology: Consultancy, trustee; cardax: Consultancy; Abbott, Amarin, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Chiesi, Eisai, Ethicon, Forest Laboratories, Idorsia, Ironwood, Ischemix, Lilly, Medtronic, PhaseBio, Pfizer, Regeneron, Roche, Sanofi Aventis, Synaptic, The Medicines: Research Funding; Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute, for the PORTICO trial, funded by St. Jude Medical, now Abbott), Cleveland Clinic, Duke Clinical Research Institute, Mayo Clinic, Mount Sinai School of Medicine, Population: Other: Data monitoring committee; American College of Cardiology; Unfunded Research: FlowCo, Merck, PLx Pharma, Takeda.: Other: trustee; ACC Accreditation Committee), Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute; RE-DUAL PCI clinical trial steering committee funded by Boehringer Ingelheim), Belvoir Publications (Editor in Chief, Harvard Heart Letter),: Other: board member; American College of Cardiology (Senior Associate Editor, Clinical Trials and News, ACC.org: Honoraria.

Natural history and risk factors for diabetic kidney disease in patients with T2D: lessons from the AMD-annals.

The Associazione Medici Diabetologi (AMD) annals initiative is an ongoing observational survey promoted by AMD. It is based on a public network of about 700 Italian diabetes clinics, run by specialists who provide diagnostic confirmation and prevention and treatment of diabetes and its complications. Over the last few years, analysis of the AMD annals dataset has contributed several important insights on the clinical features of type-2 diabetes kidney disease and their prognostic and therapeutic implications. First, non-albuminuric renal impairment is the predominant clinical phenotype. Even though associated to a lower risk of progression compared to overt albuminuria, it contributes significantly to the burden of end-stage renal disease morbidity. Second, optimal blood pressure control provides significant but incomplete renal protection. It reduces albuminuria but there may be a J curve phenomenon with eGFR at very low blood pressure values. Third, hyperuricemia and diabetic hyperlipidemia, namely elevated triglycerides and low HDL cholesterol, are strong independent predictors of chronic kidney disease (CKD) onset in diabetes, although the pathogenetic mechanisms underlying these associations remain uncertain. Fourth, the long-term intra-individual variability in HbA1c, lipid parameters, uric acid and blood pressure plays a greater role in the appearance and progression of CKD than the absolute value of each single variable. These data help clarify the natural history of CKD in patients with type 2 diabetes and provide important clues for designing future interventional studies.

The association between preinduction arterial blood pressure and postoperative cardiovascular, renal, and neurologic morbidity, and in-hospital mortality in elective noncardiac surgery: an observational study.

The association between preinduction blood pressure (BP) and postoperative outcomes after noncardiac surgery is poorly understood. Whether this association depends on the presence of risk factors for poor cardiovascular outcomes remains unclear. Accordingly, we evaluated the association between preinduction BP and its different components; isolated systolic hypertension (ISH) and wide pulse pressure (WPP), and postoperative complications in patients with and without revised cardiac risk index (RCRI) components. We analysed consecutive patients undergoing elective noncardiac surgery at Cleveland Clinic. Separate analyses were undertaken for patients with and without any RCRI components. Preinduction BP was assessed both continuously and according to hypertension stages. Logistic regression was used to assess the association between the BP values and composite of in-hospital mortality as well as cardiovascular, renal, and neurologic morbidity. We considered the following potential confounding factors in our analysis; year of surgery, age, sex, race, BMI, and American College of Cardiology/American Heart Association surgical procedure risk classification. Of 58 276 patients, 10 512 had one or more RCRI components. For those with no RCRI, no significant relationship was found between preinduction BP and outcome after adjustment for confounders. For patients with RCRI, the adjusted incidence was the greatest among those with normal preinduction SBP and DBP of less than 70 mmHg. Among patients with preinduction DBP greater than 75 mmHg, risk rose slightly with increasing SBP. However, we found no association between preinduction hypertension stages, ISH, or WPP and the composite outcome in patients with and without RCRI. Preinduction low DBP less than 70 mmHg or SBP greater than 160 mmHg and not ISH, nor WPP were associated with an increased risk of postoperative complications in noncardiac surgery patients with one or more RCRI components.

A1458 Effect of Salt Intake on Plasma and Urinary Uric Acid Levels in Chinese Adults

Objectives: Uric acid (UA) has been proposed as an important risk factor for cardiovascular and renal morbidity. We conducted an interventional trial to assess the effects of altered salt intake on plasma and urine UA levels and the relationship between UA levels and salt sensitivity in humans. Methods: Ninety subjects (18–65 years of age) were selected from a rural community of northern China. All subjects were sequentially maintained on a normal diet for three days at baseline, a low-salt diet for 7 days (3.0 g/day, NaCl), and a high-salt diet for an additional 7 days (18.0 g/day of NaCl). Results: The plasma UA levels were significantly increased from baseline to the low-salt diet and decreased from the low-salt to high-salt diet. In contrast, the daily urinary levels of UA were significantly decreased from baseline to the low-salt diet and increased from the low-salt to high-salt diet. Also, 24-h urinary sodium excretions were inversely correlated with the plasma UA, and positively correlated with the urinary UA excretions. Additionally, salt-sensitive subjects were associated with a significantly higher plasma UA changes in comparison to salt-resistant subjects, and a negative correlation between the degree of salt sensitivity and plasma UA difference was observed. Conclusion: The present study indicates that variations in dietary salt intake affect the plasma and urine, and plasma UA may be involved in the pathophysiological process of salt sensitivity.

Subclinical metabolic and cardiovascular abnormalities in autosomal dominant polycystic kidney disease .

Autosomal dominant polycystic kidney disease (ADPKD) is the most prevalent genetic kidney disease. It carries high lifetime morbidity not only due to chronic kidney disease, but also due to a higher risk of cardiovascular death. Multiple metabolic abnormalities associated with ADPKD including insulin resistance and hyperlipidemia as well as subclinical cardiovascular abnormalities, such as left ventricular hypertrophy (LVH), contribute to this cardiovascular risk. These conditions may manifest before evidence of worsening estimated glomerular filtration rate (eGFR). Renal oxidative stress also occurs early in the disease and is a driver of ADPKD progression. Animal models have shown that calorie restriction may mitigate these inflammatory processes. Further research is required to show whether attenuation of metabolic abnormalities associated with ADPKD may improve renal and cardiovascular morbidity. .