Severity Of Renal Insufficiency Research Articles

Opioid Prescription in Patients With Chronic Kidney Disease: A Systematic Review of Comparing Safety and Efficacy of Opioid Use in Chronic Kidney Disease Patients.

Patients with diminished renal function necessitate special care. In patients with chronic kidney disease (CKD), opioid analgesics should be prescribed based on the severity of renal insufficiency; this will determine treatment options at the beginning and throughout the management of pain in CKD patients. The dosage of hydrophilic drugs and drugs with active metabolites should be adjusted according to the severity of CKD, and the process of treatment should be monitored by modifying drug dosages as necessary for background and breakthrough pain. Patients with CKD may benefit from opioid analgesics that are lipophilic, such as methadone, fentanyl, and buprenorphine, as the first line; however, fentanyl is inappropriate for patients undergoing hemodialysis. Opioid prescription in CKD patients is the subject of this systematic review, which aims to compare their safety and efficacy. This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 recommendations. Using three databases (PubMed, ScienceDirect, and Google Scholar), we collected and reviewed articles, including literature reviews, randomized control trials (RCTs), and systematic reviews published between 1980 and 2022, to enable us to gather enough valuable data on this rare topic. After applying appropriate filters, a total of 109 results were obtained. They were further screened and subjected to quality assessment tools, which finally yielded 11 studies included in this systematic review. This consisted of two RCTs, two systematic reviews, and seven narrative reviews. This review focused on the safety and appropriate use of opioids in patients with CKD. The accumulation of morphine and codeine metabolites may result in neurotoxic side effects. Hydromorphone and oxycodone are considered safe to administer but require careful adjustments in dosage. Common comorbidities among patients with CKD may amplify opioid-related adverse effects.

The state of the intestinal microbial-tissue complex in patients with chronic kidney disease

The gut microbiota plays a fundamental role in maintaining normal organism homeostasis, regulating a wide range of metabolic, biosynthetic, and immune functions. This complex ecosystem, together with cellular, and stromal components of the intestinal wall, forms the intestinal microbial-tissue complex, which pathology is considered a universal mechanism for the development of many diseases, including chronic kidney disease. Accumulation of nitrogen metabolism products in the intestine, specific diet, polypharmacy, sedentary lifestyle, limited fluid intake, and violation of gastrointestinal motility in patients with chronic kidney disease lead to a decrease in the number of bacteria synthesizing short-chain fatty acids with crucial physiological effects, along with an increase in the content of anaerobic proteolytic bacteria expressing uricase, urease, and p-cresol-, and indole-forming enzymes. The features of gut dysbiosis depend on the etiology of chronic kidney disease and severity of renal insufficiency and differ significantly in individuals receiving various renal replacement therapies (hemodialysis, peritoneal dialysis, kidney transplant recipients). Abnormal microbial metabolism enhances the production and accumulation of microbial-derived uremic toxins: p-cresyl sulfate, indoxyl sulfate, and trimethylamine-N-oxide. Renal insufficiency, through mechanisms mainly associated with the hydrolysis of accumulated in the lumen of the intestine urea, leads to inflammation, and swelling of the intestinal wall, which is accompanied by disorders of the immune tolerance of the mucous layer and disorganization of intercellular junctional complexes, which are critical modulators of intestinal intercellular transepithelial transport. Uremia-induced impairment of the gut epithelial barrier integrity induces the systemic translocation of numerous immunogenic substances generated by the aberrant microbiota, followed by the development of oxidative stress and chronic subclinical inflammation that causes the progression of chronic kidney disease and related complications. The most pronounced changes were observed in people with end-stage chronic kidney disease. Further study of the bidirectional relationship between the kidneys and intestinal microbial-tissue complex will contribute to the development of new directions of pathogenetic therapy and prevention of adverse outcomes in patients with chronic kidney disease.

Carfilzomib Is Safe and Effective in Newly Diagnosed Patients with Multiple Myeloma with Renal Involvement

Background. Carfilzomib is a proteasome inhibitor, currently approved for use in relapse-refractory Multiple Myeloma (RRMM).1 There is mixed data on safety of Carfilzomib in patients (pts) with renal impairment (RI) and minimal in the upfront setting, partly due to exclusion of these pts from trials. Pooled data from phase 2 studies of single-agent Carfilzomib in RRMM, noted 24.1% acute kidney injury (AKI), including 23.8% of pts with moderate to severe renal dysfunction (CrCl<50 mL/min).2 Interestingly, severity of renal insufficiency did not have an effect on incidence of toxicity nor overall response rate.3 However, in FOCUS (single agent Carfilzomib vs Dexamethasone +/- Cyclophosphamide in RRMM), grouped renal events were three times more common in patients with baseline CrCl<30ml/min than those with CrCl>50 ml/min.4We previously reported on 71 pts receiving induction Carfilzomib, whose baseline RI was associated with incidence of AKI. Of pts with normal renal function, 36% developed AKI, compared to 59% and 62.5% of those with mild and moderate impairment, respectively.5 Current management dictates dose reduction only once CrCl ≥ 15ml/min.6 The aim of this retrospective study is to report on the safety profile and efficacy of induction Carfilzomib in pts with RI of newly diagnosed MM as evidenced by proteinuria.Methods. Patients were selected from the CarBiRd study (induction Carfilzomib and Dexamethasone; with subsequent Clarithromycin, Lenalidomide, and Dexamethasone; with Lenalidomide maintenance) at the Weill Cornell Medicine Myeloma Center. Pts were grouped based on renal involvement of myeloma. Baseline renal function was established by measuring pre-enrollment GFR using the Modification of Diet in Renal Disease (MDRD) equation. Subjects were stratified into 3 sub-groups: normal function (GFR>80 ml/min/1.732), mild impairment (GFR 50-80 ml/min/1.732), and moderate impairment (GFR 30-49 ml/min/1.732). Incidence of AKI was assessed during induction with Carfilzomib and Dexamethasone only. AKI was defined by increased serum creatinine (sCr) according to the National Cancer Institute's Common Terminology Criteria for Adverse Events Version 4.0.6 sCr and m-protein were measured prior to therapy and upon completion of Carfilzomib/dex induction. Overall response and toxicity were also assessed.Results. 75 patients were enrolled in the CarBiRd study. One withdrew for fever and AKI. Of the 61 patients with evaluable urine m-protein, 23 had normal kidney function, 15 mild impairment, and 3 moderate impairment. AKI was seen in 34.8% of patients with normal renal function, 53.3% with mild and 33.3% with moderate impairment. Of the 17 patients who had AKI, 70.6% had a return sCr within 0.15 mg/dl of baseline. Mean number of cycles of Carfilzomib was 5 (range 3-12). The mean fall in m-protein at end Carfilzomib was 87.4%.Of patients without proteinuria, 10 had normal kidney function, 7 had mild impairment, and 3 had moderate impairment. In pts with normal function 40% developed AKI, whereas those with mild and moderate impairment reported 71.4% and 66.6%, respectively. Mean number of cycles of Carfilzomib was 6.2 (range 3-14). Of the 11 patients who developed AKI, 91% had a return to serum creatinine within 0.15 mg/dl of baseline.Discussion. Data on renal toxicity of carfilzomib in patients with renal involvement of myeloma are limited to date, confounded by exclusion of renal impairment from studies, data mainly in the RRMM setting where prior or concurrent drug exposure may play a role. Previous data indicate baseline renal impairment may predict AKI. We report on a cohort of pts with newly diagnosed myeloma who received carfilzomib/dexamethasone induction, where renal involvement did not predict increased toxicity. In addition, most cases of reported AKI resolved prior to next week dosing, and required no intervention beyond hydration. We acknowledge the small cohort and single-arm, single-center nature of the study. As seen previously, response to therapy does not appear to be affected by renal impairment. At this time, myeloma kidney and decreased GFR should not preclude use of carfilzomib in pts with myeloma. [Display omitted] DisclosuresPerry:celgene: Honoraria. Pekle:celgene: Honoraria; BMS: Honoraria. Niesvizky:BMS: Consultancy; Celgene: Consultancy; Janssen: Consultancy; Amgen: Consultancy. Rossi:Thrassos: Consultancy; Celgene: Consultancy.

Systematic Evaluation of Urinary VCAM1 as Novel Biomarker for Prognosis of Lupus Nephritis.

Lupus nephritis was established as the major cause of morbidity and mortality in systemic lupus erythematosus (SLE) patients. This severity could be monitored by laboratory prognosis with accuracy and specificity for the disease. Recently, various SLE laboratory investigations still have had improper prognosis and also possibly causing tissue injury in the patients. The present study thus aimed to systematically explore a novel urinary protein for further development into a prognosis biomarker in patients. Several urinary proteins that previously were reported with abnormal expression in SLE patients between 2014 - 2019 were comprehensively collected. These proteins were also analyzed for functional category and sites of expression using STIRNG, FUNRICH, and Uniport database. Thereafter, the level of altered protein candidate was then validated by western blotting, correlation analysis, and diagnostic performance. Vascular cell adhesion molecule-1 (VCAM1) protein was found in higher levels and also specific in SLE patients with nephritis. Moreover, VCAM1 has a role in immune response, inflammation, is expressed on plasma membrane of renal cells, and has the ability to secret into urine. The level of VCAM1 in urine of SLE patients was significantly higher than in healthy controls. The area under ROC curve (AUC) was also 0.891. Furthermore, the level of VCAM1 was dramatically associated with the severity of renal insufficiency (r = 0.738). VCAM1 may be a novel urinary biomarker for reliable prognosis of nephritis severity in SLE patients.

Clinical outcomes of drug-eluting stent era according to chronic kidney disease and diabetes (IRIS-DES registry)

Abstract Aims Clinical outcomes in patients who underwent percutaneous coronary intervention (PCI) using various generation drug-eluting stent (DES) stratified by the degree of renal dysfunction and diabetes were not fully elucidated. Methods and results This study included 16,741 patients enrolled in the multicenter IRIS-DES registry. Renal insufficiency was graded according to the baseline renal function. The primary endpoint was major adverse cardiocerebrovascular event (MACCE), defined as a composite of all cause death, myocardial infarction, cerebrovascular events, and target vessel revascularization. Among 16,741 patients, 11,274 (67%) had eGFR ≥60 ml min–1 1.73m–2 at baseline, 4,280 (26%) had eGFR of ≥30 and &amp;lt;60, and 1187 (7%) had eGFR &amp;lt;30. At 3.6 years of follow-up (interquartile range, 2.97–4.87 yrs), the cumulative incidence of MACCE substantially increased according to the severity of renal insufficiency (11.3% in eGRF ≥60, 16.0% in eGFR of ≥30 and &amp;lt;60, and 29.7% in eGRF &amp;lt;30, respectively, P&amp;lt;0.001). After multivariable adjustment of clinical covariates, as compared with patients with eGFR ≥60, the hazard ratios for MACCE was significantly higher in patients with eGFR of ≥30 and &amp;lt;60 (hazard ratio [HR] 1.3, 95% confidence interval [CI] 1.1–1.4) and in patients with eGFR &amp;lt;30 (HR 2.0, 95% CI 1.7–2.4). This effect showed better consistent trends in non-diabetes and non- renal insufficiency in subgroup analysis of the primary endpoint (Figure 3). Conclusions Renal insufficiency is significantly associated with worse clinical outcomes in the DES era. Also, the effect on MACCE was consistent, being better in non-diabetes and non- renal insufficiency. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): CVRF

Reduced serum CTRP12 levels in type 2 diabetes are associated with renal dysfunction.

Serum C1q/TNF-related protein-12 (CTRP12) is one of the newly studied families of adipokines, which is believed to be associated with type 2 diabetes. However, the relationship between serum CTRP12 levels and diabetic nephropathy remains unclear. This study aimed to investigate the relationship between serum CTRP12 levels and renal function in patients with type 2 diabetes. A total of 115 type 2 diabetic patients and 54 healthy subjects were enrolled in this study. 52 patients with type 2 diabetes were in the diabetes group (T2DM). The 63 patients with renal dysfunction were diabetic nephropathy group (T2DM-DN) and were divided into microalbuminuria subgroup (31 cases) and macroalbuminuria subgroup (32 cases) according to the 24-h urine protein excretion rate. The concentrations of serum CTRP12 were determined by enzyme-linked immunosorbent assay. Serum CTRP12 level in T2DM and T2DM-DN groups was significantly lower compared with the control group, while CTRP12 level in T2DM-DN group was significantly lower than that in T2DM group, and was associated with the severity of renal insufficiency. After adjusting for gender and age, serum CTRP12 level was negatively correlated with the duration of diabetes, blood urea nitrogen (BUN), uric acid (UA) and 24-h urinary albumin excretion rate (UAE) in T2DM patients. Logistic regression analysis showed that serum CTRP12 level was significantly associated with renal dysfunction in type 2 diabetes mellitus. And the duration of diabetes, total cholesterol (CHOL) and neutrophils/lymphocytes (NLR) are independent risk factors for renal dysfunction in type 2 diabetes mellitus. Serum CTRP12 may be involved in the occurrence and development of diabetic nephropathy. Trial registration number and date of registration ChiCTR2000030794, March 14, 2020.

The impact of sleeve gastrectomy on renal function in patients with chronic kidney disease varies with severity of renal insufficiency.

Although laparoscopic sleeve gastrectomy is known, in general, to improve renal function in patients with obesity and chronic kidney disease (CKD), its effect on estimated glomerular filtration rate (eGFR) stratified by the stage of CKD is less clear. We aimed to evaluate the impact of sleeve gastrectomy on renal function in a stratified cohort of patients with CKD. University Hospital. We performed a retrospective review of 1932 patients who met National Institutes of Health's guidelines for metabolic surgery and underwent laparoscopic sleeve gastrectomy performed by 1 of 3 surgeons. One hundred sixty-four patients with CKD stages 1 through 4 were identified. Mean follow-up period was 1.57 ± 1.0 years. Mean age was 56.4 ± 9.9 years with a preoperative body mass index of 47 ± 9 kg/m2, which decreased to 38.9 ± 8.7 kg/m2 at most recent follow-up (P < .001). In the cohort of patients with diabetes, significant decreases were observed in mean glycated hemoglobin level, daily number of oral hypoglycemics, and daily long acting insulin use (P < .001 each). Of 67 patients with diabetes, 34.3% (n = 24) achieved complete remission. In patients with hypertension, average daily number of antihypertensives decreased (P < .001) and 22.3% (n = 31) of 133 patients with hypertension discontinued all antihypertensives. Patients with CKD stages 2, 3a, and 3b showed significant improvement in eGFR. Reinforcing this evidence of improvement, patients with CKD 3a and 3b were more likely to downstage disease compared with those with CKD 4 (58.1% versus 73.1% versus 22.7%, respectively) (P < .001). Renal function, as measured by eGFR, in patients with stages 1 and 4 CKD did not improve after laparoscopic sleeve gastrectomy; in contrast, eGFR in patients with CKD stages 2and 3 significantly improved. Early surgical referral and intervention may be important in achieving the greatest improvement in eGFR and possibly delaying or reversing progression to end-stage renaldisease.

Free Immunoglobulin Light Chains as Criteria of Extracorporeal Hemocorrection in Patients with Monoclonal Gammopathies.

Elimination of free immunoglobulin light chains with the use of EMic2 selective filters was carried out in 12 patients with monoclonal gammopathies and high production of free immunoglobulin light chains. We showed that extracorporeal detoxification for direct removal of excessive free immunoglobulin light chains from the circulation is advisable for these patients, irrespective of the presence and severity of renal insufficiency. Rapid reduction or elimination of free light chains of immunoglobulins in the course of selective extracorporeal elimination helps to prevent the development of irreversible renal failure and to perform adequate antitumor therapy.

A Rare Clinical Entity: Staphylococcus-Related Glomerulonephritis.

Staphylococcus aureus is a rare cause of postinfectious glomerulonephritis, and Staphylococcus-related glomerulonephritis primarily occurs in middle-aged or elderly patients. Patients with Staphylococcus-related glomerulonephritis also present with hematuria, proteinuria of varying degrees, rising serum creatinine levels, and/or edema. The severity of renal insufficiency is proportional to the degree of proliferation and crescent formation. Here, we present a diabetic patient admitted with a history of 1 week of left elbow pain. Laboratory results revealed that erythrocyte sedimentation rate was 110 mm/hour, serum creatinine level was 1 mg/dL, C-reactive protein level was 150 mg/L, and magnetic resonance imaging showed signal changes in favor of osteomyelitis at the olecranon level, with diffuse edematous appearance in the elbow skin tissue and increased intra-articular effusion. After diagnosis of osteomyelitis, ampicillin/sulbactam and teicoplanin were administered. After day 7 of admission, the patient developed acute kidney injury requiring hemodialysis under antibiotic treatment. Kidney biopsy was performed to determine the underlying cause, which showed Staphylococcus-related glomerulonephritis. Recovery of renal functions was observed after antibiotic and supportive treatment.

Arterial hypertension treated with angiotensin converting enzyme inhibitors and glucocorticoids are independent risk factors associated with decreased glomerular filtration rate in systemic sclerosis.

The aim of this study was to estimate prevalence and severity of renal insufficiency in systemic sclerosis (SSc) and to assess risk factors associated with reduced glomerular filtration rate (GFR) in SSc patients. Seventy-three consecutive patients with SSc (67 women and 6 men), mean age 56.2years, mean disease duration 6.7years, were included in this cross-sectional study. GFR was measured by creatinine clearance (CCr) in all patients, as well as 24-h proteinuria. We assessed frequency and severity of renal insufficiency in our patients with SSc and estimated the association of renal insufficiency with age, disease duration, subtype of the disease, earlier diagnosed arterial hypertension, and medications for which we assumed to affect renal function-cytostatics, nonsteroidal anti-inflammatory drugs, glucocorticoids, ACE inhibitors, diuretics, and calcium channel blockers (CCB). Fifty-six out of 73 patients with SSc (76.7%) had reduced GFR (CCr lower than 90ml/min), compared to 17/73 (23.3%) of patients with normal renal function. Mild renal insufficiency was noticed in 28/73 (38.4%), moderate in 21/73 (28.8%) and severe renal insufficiency in 5/73 (6.8%). End-stage renal disease (CCr<15ml/min) was found in 2/73 (2.7%) of patients. Using the univariate general linear statistical model, we have found that previously diagnosed arterial hypertension and treatment with glucocorticoids are independent risk factors for reduced GFR. On the other hand, age, disease duration, disease form, as well as antibodies (anticentromere antibodies-ACA and anti-topoisomerase I antibodies-ATA) were excluded as independent risk factors. Patients with SSc and arterial hypertension treated with CCB had significantly higher mean CCr than patients treated with diuretics (90.4 vs 53.5ml/min, p=0.03), or patients treated with ACE inhibitors (90.4 vs 41.7ml/min, p=0.001). Decreased GFR is common in SSc. Most of patients have mild or moderate renal insufficiency. Previously diagnosed arterial hypertension, especially when treated with ACE inhibitors or diuretics, and glucocorticoids are independent risk factors associated with reduced GFR in SSc. These medications should be therefore used with caution in SSc patients.

Inappropriateness of medication prescriptions about chronic kidney disease patients without dialysis therapy in a Chinese tertiary teaching hospital.

BackgroundWith the increasing incidence rate of chronic kidney disease (CKD), inappropriate use of medicine in CKD patients is an important issue, as it may cause adverse effects in patients and progression to chronic renal failure.ObjectiveThe aim of this study is to assess the frequency of inappropriate medicine use among CKD patients.MethodsA cross-sectional study was conducted from November 1 to December 1, 2014 in a Chinese teaching tertiary hospital. All medication prescriptions for CKD patients with serum creatinine level above normal value were enrolled. The prescriptions, including unreasonable dosage, contraindicated, and cautiously used medicines in CKD patients, were evaluated and the related medications were also analyzed and classified.ResultsTwo hundred and two patients were included, and a total of 1,733 lines of medication prescriptions were evaluated. The prevalence of inappropriate medication prescriptions in CKD patients was 15.18%, of which, unreasonable dosage (n=56), contraindicated (n=46), and cautiously used medicines (n=161) accounted for 3.23%, 2.65%, and 9.29%, respectively. Spearman’s rank correlation coefficient implied that there was a significant correlation between the severity of renal insufficiency and frequency of inappropriate medication prescriptions (P=0.02, r=0.056). Among the inappropriate medication prescriptions, nutraceutical and electrolytes (n=65, 24.71%), cardiovascular drugs (n=61, 23.19%), and antimicrobial drugs (n=55, 20.91%) represented the top three medicine categories in CKD patients.ConclusionThe study confirmed that inappropriate medication prescriptions were prevalent in CKD patients. Improving the quality of medication prescriptions in CKD patients is necessary.

Renal Resistive İndeks’in Hafif Orta Böbrek Yetersizliği Olan Koroner Arter Hastalarında Hastalık Şiddetini Belirlemedeki Yeri

Objectives: The aim of this study was to determine the renal resistive index (RRI) in patients with mild to moderate renal insufficiency, and to investigate the relationship between RRI and the severity of coronary artery disease (CAD) and renal function. Materials and Methods: The study included 76 patients diagnosed with CAD on coronary angiography. The patients comprised 41 males and 35 females. Renal resistive index was determined using renal Doppler ultrasonography (RDU). Renal length, width, and parenchymal thickness was measured. The severity of CAD was graded according to Gensini score, and the patients were divided into two groups: mild atherosclerosis (Gensini score <20 points) and severe atherosclerosis (Gensini score ≥20 points). The estimated glomerular filtration rate (eGFR) was calculated for each patient. Based on GFR stage, the patients were divided into three groups, and the relationship between RRI and GFR stage was investigated. Results: Gensini scores indicated that the RRI was significantly higher in the patients with severe CAD compared to those with mild CAD [0.62 (0.58-0.71)] vs. [0.71 (0.63-0.78)], p <0.001). No significant differences were observed in renal length, width, and parenchymal thickness. The eGFR was significantly lower in the patients with severe CAD compared to those with mild CAD ( p =0.02). Grading of the patients based on GFR values indicated a significant correlation between GFR and RRI. RRI was [0.63(0.59-0.68)] in patients with stage 1 (GFR ≥ 90), was [0.77(0.71-0.84)]in patients with stage 2 (GFR 60–89) and was [0.81(0.73-0.85)]in patients with stage 3 (GFR 30–59) ( p <0.001). The sensitivity and specificity of RRI in the diagnosis of CAD severity were 80.60% and 66.70%, respectively. Conclusion: RRI shows a parallel increase with the severity of CAD and with the severity of renal insufficiency. RRI, as determined with non-invasive RDU, may provide additional information on the severity of CAD, kidney function and microcirculation.

The Majority of Myeloma Patients Are Vitamin D Deficient, Unrelated to Survival or Cytogenetics

▪Introduction: Since a link between solar radiation, vitamin D production, and decreased colon cancer mortality was established in 1980, there has been increasing interest in vitamin D and cancer, suggesting that higher vitamin D levels improve overall survival, specifically in breast and colorectal cancer (Maalmi H et al, Eur J Canc, May-2014, PMID 24582912), but also in follicular lymphoma (Kelly JL, J Clin Onc, 1-May-2015, PMID 25823738). In myeloma, largest published series is from the Mayo Clinic reporting on 148 newly diagnosed MM patients for which no survival association was found, but there were associations between low 25-OH-Vit D (<20 ng/mL) and higher serum CRP, serum creatinine, and ISS stage (Ng AC, Am J. Heme, Jul-2009, PMID 19415724); we wanted to expand on their trailblazing analysis. Cytogenetically high risk myeloma characterized by the amplification of 1q21 is associated with increased serum levels of soluble IL-6 receptor (sIL-6r) (Stephens OW, Blood, 2012, PMID 22072558) which may be associated with other markers of inflammation, e.g. CRP, creatinine, and b2microglobulin.Methods: The Buckeye Myeloma Registry (OSU 10115) opened in 2011 to enroll any patient with a plasma cell dyscrasia. Serum total 25-OH-Vitamin D was measured at the time of the initial clinic visit to the myeloma group at Ohio State.Results: Of a total of 843 patients, 115 (13.6%), 53 (6.3%) with SMM, and 675 (80.1%) with MM. In the 675 MM patients, the median age was 64 y.o. (range 28-95), 14.5% African-American and the remainder Caucasian, with 28.6% ISS stage 1, 48.7% ISS stage 2, 21.9% ISS stage 3, and 24.5% unknown. At diagnosis for the MM patients, 67% presented with lytic bone disease.Out of 675 MM patients, there were 52 (7.7%) patients with < 10 ng/mL 25-OH-Vit D, 394 (51%) with low vit D (10-30 ng/mL), and 229 (39%) for 25-OH-Vit D 30-100 ng/mL. There was no correlation between 25-OH-Vit D and BMI or creatinine, but there was a strong correlation with race (r=0.18, p<0.000026).Among the MM patients, log-rank [Mantel-Cox] analysis of overall survival with serum 25-OH-Vit D including all groups demonstrated no significant differences (p=0.9725) with only 101 events. There was no correlation between 25-OH-Vit D and the presence on CD138-selected FISH of 1q21 amplification (p=0.196), 17p (p53) deletion (p=0.68), or 13q deletion (p=0.812).Conclusion: The majority of myeloma patients are vitamin D deficient, but this was not associated with worsened overall survival or with high risk cytogenetics. Cox proportional hazards analyses of survival adjusted for significant univariate covariates will be presented at the meeting. Correlations with presence or absence of diffuse lytic bone disease, severity of renal insufficiency, and race will also be presented at the meeting. DisclosuresNo relevant conflicts of interest to declare.

AB0638 Corticosteroid Use and Arterial Hypertension Are Independent Risk Factors Associated with Low Glomerular Filtration Rate in Systemic Sclerosis

BackgroundApart from scleroderma renal crisis, which is a rare but life-threatening condition in systemic sclerosis (SSc), many patients demonstrate less severe renal complications, probably associated with reduced renal blood flow...

Quality of Care and Outcomes Among Patients With Acute Myocardial Infarction by Level of Kidney Function at Admission: Report From the Get With The Guidelines Coronary Artery Disease Program

Many patients admitted for acute myocardial infarction (AMI) have chronic renal insufficiency. We studied the impact of chronic renal insufficiency on mortality and quality of inpatient care for AMI from the American Heart Association's Get With The Guidelines-Coronary Artery Disease Program. We hypothesized that mortality and quality of inpatient care would not vary with renal function. We examined in-hospital AMI performance measures by renal function based on glomerular filtration rate (GFR). Severity of renal insufficiency was categorized as normal (GFR ≥ 90 mL/min/1.73 m(2)), mild (GFR 60-90 mL/min/1.73 m(2)), moderate (GFR 30-60 mL/min/1.73 m(2)), severe (GFR 15-30 mL/min/1.73 m(2)), and kidney failure (GFR ≤ 15 mL/min/1.73 m(2) or dialysis). A total of 21721 patients from 291 sites were studied, with most data collected in 2008 to 2009. Multivariable regression analysis after adjusting for patient characteristics was performed and generalized estimating equations were used to account for within-hospital clustering. In-hospital mortality and quality of inpatient care were assessed. Renal insufficiency was present in 82.0 percent of AMI patients. The adjusted odds ratio vs normal renal function for mortality increased with worsening renal function: 1.45 for mild renal insufficiency (95% confidence interval [CI]: 1.03-2.05, P = 0.03); 3.36 for moderate renal insufficiency (95% CI: 2.31-4.89, P < 0.0001); 5.43 for severe renal insufficiency (95% CI: 3.70-7.95, P < 0.0001); and 6.35 for kidney failure (95% CI: 4.48-9.01, P < 0.0001). Patients with renal insufficiency received less inpatient and discharge guideline-recommended therapy for AMI. Among AMI patients, mortality and guideline-recommended inpatient therapy correlated inversely with renal function. Adjusted mortality was equally poor among patients with severe renal dysfunction and on dialysis.

Baseline incidence and severity of renal insufficiency evaluated by estimated glomerular filtration rates in patients scheduled for contrast-enhanced CT

Although pre-existing renal insufficiency (RI) is the most important risk factor for contrast-induced nephropathy (CIN), the background distribution of baseline renal function has not been investigated thoroughly in patients scheduled for contrast-enhanced CT. To investigate the incidence and severity of baseline RI evaluated by estimated glomerular filtration rates (eGFR) in patients who underwent contrast-enhanced CT at an academic center. A total of 6586 patients (3630 men and 2956 women; mean age 57.0 ± 11.9 years) who underwent contrast-enhanced CT between January and December 2008 were retrospectively studied. Of these, 829 had cardiovascular diseases (CVD), 5116 had oncologic diseases, 178 had diabetes mellitus (DM), and 1572 had chronic liver disease (CLD). The eGFR (mL/min/1.73 m(2)) was calculated from their serum creatinine level. Mild, moderate-a, moderate-b, and severe RI were recorded at 60 < =eGFR < 90, 45 < =eGFR < 60, 30 < =eGFR < 45 and eGFR < 30, respectively. Of the 6586 patients, 1.6%, 3.7%, 13.7%, and 54.2% were judged to present with severe, moderate-b, moderate-a, and mild RI, respectively. While moderate-b-to-severe RI was recorded in 133 (3.2%) of 4161 patients aged 70 years or less, it was observed in 218 (9.0%) of the 2425 patients who were 71 years or older. Among the 829 CVD patients, 9.9% manifested moderate-b-to-severe- and 73.0% mild-to-moderate-a RI. The corresponding rates were 4.4% and 68.9% for oncologic disease, 16.9% and 61.2% for DM, and 4.8% and 71.5% for CLD patients. By univariate analysis, there was a significant association between moderate-b-to-severe RI and the advanced age, CVD, DM, and non-oncologic disease. Multivariate analysis showed that the advanced age, DM, and non-oncologic disease were statistically associated with moderate-b-to-severe RI. The incidence of RI of eGFR < 45mL/min/1.73 m(2) at baseline was high in patients with advanced age, CVD and DM and in patients without oncologic disease.

Chronic Renal Disease in Pregnancy

The purpose of this review was to examine the impact of varying degrees of renal insufficiency on pregnancy outcome in women with chronic renal disease. Our search of the literature did not reveal any randomized clinical trials or meta-analyses. The available information is derived from opinion, reviews, retrospective series, and limited observational series. It appears that chronic renal disease in pregnancy is uncommon, occurring in 0.03-0.12% of all pregnancies from two U.S. population-based and registry studies. Maternal complications associated with chronic renal disease include preeclampsia, worsening renal function, preterm delivery, anemia, chronic hypertension, and cesarean delivery. The live birth rate in women with chronic renal disease ranges between 64% and 98% depending on the severity of renal insufficiency and presence of hypertension. Significant proteinuria may be an indicator of underlying renal insufficiency. Management of pregnant women with underlying renal disease should ideally entail a multidisciplinary approach at a tertiary center and include a maternal-fetal medicine specialist and a nephrologist. Such women should receive counseling regarding the pregnancy outcomes in association with maternal chronic renal disease and the effect of pregnancy on renal function, especially within the ensuing 5 years postpartum. These women will require frequent visits and monitoring of renal function during pregnancy. Women whose renal disease is further complicated by hypertension should be counseled regarding the increased risk of adverse outcome and need for blood pressure control. Some antihypertensives, especially angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers, should be avoided during pregnancy, if possible, because of the potential for both teratogenic (hypocalvaria) and fetal effects (renal failure, oliguria, and demise).

Acute coronary syndromes in patients with renal disease: What are the issues?

Patients with chronic kidney disease and acute coronary syndromes are at high risk for both bleeding and ischemic events. This risk increases with the severity of renal insufficiency. Management for acute coronary syndromes in the setting of kidney disease is a paradox; as the benefit of current treatment is high, so is the risk for complications. Patients with chronic renal disease are frequently excluded from randomized clinical trials, and therefore, the optimal treatment strategies are often speculative in this high-risk patient population. Additional research is needed to further refine the optimal management of patients with chronic kidney disease in the setting of acute coronary syndromes.

Mitral valve prolapse and mitral regurgitation are common in patients with polycystic kidney disease type 1

Patients with autosomal dominant polycystic kidney disease (ADPKD) have an increased occurrence of cardiac valve abnormalities. However, the prevalence of cardiac abnormalities in patients with a uniform genotype of ADPKD has not been previously reported. We performed M-mode and color Doppler echocardiography on 109 patients from 16 families with polycystic kidney disease type 1 (PKD1). Findings were compared with those of 73 unaffected family members and 73 healthy controls. Mitral valve prolapse was found in 26% of patients with PKD1, 14% of unaffected relatives, and 10% of control subjects. The prevalence of hemodynamically significant mitral regurgitation (grade 2 or 3) was 13%, 4%, and 3%, respectively. Prevalences of grade 2 or 3 aortic regurgitation (8%, 4%, and 3%, respectively) and tricuspid regurgitation (4%, 6%, and 7%, respectively) were not significantly different among the three groups. Left ventricular hypertrophy (LVH) was found in 19% of subjects with PKD1, 6% of unaffected relatives, and 4% of control subjects. Systolic blood pressure and severity of renal insufficiency were related to mitral regurgitation and LVH in subjects with PKD1. The prevalence of cardiac valve abnormalities did not differ between unaffected relatives and control subjects. Mitral valve prolapse is a characteristic finding in patients with PKD1. Conversely, mitral regurgitation and LVH are likely to be secondary to elevated blood pressure in these patients. © 2001 by the National Kidney Foundation, Inc.

ACE inhibitors to prevent end-stage renal disease: when to start and why possibly never to stop: a post hoc analysis of the REIN trial results. Ramipril Efficacy in Nephropathy.

In this post hoc, secondary analysis of the Ramipril Efficacy In Nephropathy (REIN) trial, an angiotensin-converting enzyme (ACE) inhibition risk/benefit profile was assessed in 322 patients with nondiabetic, proteinuric chronic nephropathies and different degrees of renal insufficiency. The rate of GFR decline (Delta GFR) and the incidence of end-stage renal disease (ESRD) during ramipril or non-ACE inhibitor treatment were compared within three tertiles of basal GFR. Delta GFR was comparable in the three tertiles, whereas the incidence of ESRD was higher in the lowest tertile than in the middle and highest tertiles. Ramipril decreased Delta GFR by 22%, 22%, and 35% and the incidence of ESRD by 33% (P < 0.05), 37%, and 100% (P < 0.01) in the lowest, middle, and highest tertiles, respectively. Delta GFR reduction was predicted by basal systolic (P < 0.0001), diastolic (P = 0.02), and mean (P < 0.001) BP and proteinuria (P < 0.0001) but not by basal GFR (P = 0.12). ESRD risk reduction was predicted by basal proteinuria (P < 0.01) and GFR (P < 0.0001) and was strongly dependent on treatment duration (P < 0.0001). Adverse events were comparable among the three tertiles and within each tertile in the two treatment groups. Thus, disease progression and response to ACE inhibition do not depend on severity of renal insufficiency. The risk of ESRD and the absolute number of events saved by ACE inhibition is highest in patients with the lowest GFR. However, renoprotection is maximized when ACE inhibition is started earlier and when long-lasting treatment may result in GFR stabilization and definitive prevention of ESRD.