Chronic Kidney Disease Stage 3b Research Articles

Anti-Müllerian hormone concentrations in women with chronic kidney disease

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Resistant Hypertension in Chronic Kidney Disease (CKD): Prevalence, Treatment Particularities, and Research Agenda.

To explore the prevalence, treatment particularities, and research agenda in the management of resistant hypertension among patients with chronic kidney disease (CKD). The prevalence of resistant hypertension is reported to be 2-3 times higher in patients with CKD than in the general hypertensive population. Based in part on the results of the PATHWAY-2 trial showing add-on spironolactone to be superior to placebo or active treatment with an α- or β-blocker in reducing BP, international guidelines recommend the use of spironolactone as fourth-line agent in pharmacotherapy of resistant hypertension. Despite the several-fold higher burden of resistant hypertension among patients with stage 3b-4 CKD, the use of spironolactone in this population has been restricted, mainly due to the risk of hyperkalemia. The recently reported AMBER trial showed that among patients with uncontrolled resistant hypertension and an estimated glomerular filtration rate of 25-45ml/min/1.73m2, the newer potassium-binder patiromer prevented the development of hyperkalemia and increased the proportion of participants who remained on add-on spironolactone over 12weeks of follow-up. Administration of spironolactone was associated with a clinically meaningful reduction of 11-12mmHg in unattended automated office systolic blood pressure (BP) over the course of the AMBER trial. Newer potassium-binding therapies overcome the barrier of hyperkalemia and facilitate the persistent use of spironolactone, which is an effective add-on therapy to control BP in patients with resistant hypertension and advanced CKD. Future trials are now warranted to explore whether this strategy confers benefits on "hard" clinical outcomes in this high-risk population.

Vitamin K Supplementation to Improve Vascular Stiffness in CKD: The K4Kidneys Randomized Controlled Trial.

Vascular calcification, a risk factor for cardiovascular disease, is common among patients with CKD and is an independent contributor to increased vascular stiffness and vascular risk in this patient group. Vitamin K is a cofactor for proteins involved in prevention of vascular calcification. Whether or not vitamin K supplementation could improve arterial stiffness in patients with CKD is unknown. To determine if vitamin K supplementation might improve arterial stiffness in patients in CKD, we conducted a parallel-group, double-blind, randomized trial in participants aged 18 or older with CKD stage 3b or 4 (eGFR 15-45 ml/min per 1.73 m2). We randomly assigned participants to receive 400 μg oral vitamin K2 or matching placebo once daily for a year. The primary outcome was the adjusted between-group difference in carotid-femoral pulse wave velocity at 12 months. Secondary outcomes included augmentation index, abdominal aortic calcification, BP, physical function, and blood markers of mineral metabolism and vascular health. We also updated a recently published meta-analysis of trials to include the findings of this study. We included 159 randomized participants in the modified intention-to-treat analysis, with 80 allocated to receive vitamin K and 79 to receive placebo. Mean age was 66 years, 62 (39%) were female, and 87 (55%) had CKD stage 4. We found no differences in pulse wave velocity at 12 months, augmentation index at 12 months, BP, B-type natriuretic peptide, or physical function. The updated meta-analysis showed no effect of vitamin K supplementation on vascular stiffness or vascular calcification measures. Vitamin K2 supplementation did not improve vascular stiffness or other measures of vascular health in this trial involving individuals with CKD. Vitamin K therapy to improve vascular health in patients with chronic kidney disease, ISRCTN21444964 (www.isrctn.com).

The association of muscle size, strength and exercise capacity with all-cause mortality in non-dialysis-dependent CKD patients.

Patients with chronic kidney disease (CKD) are commonly reported to exhibit skeletal muscle wasting, reduced strength and exercise capacity. Evidence from patients with end-stage renal disease (ESRD) demonstrates these factors are associated with mortality, but it is unclear whether this relationship exists earlier in the illness. Our objective was to determine whether muscle size, strength or exercise capacity was associated with all-cause mortality, unscheduled hospital admissions or time to ESRD in patients not requiring dialysis. This is a prospective cohort study of 89 patients with CKD stages 3b-5 not requiring renal replacement therapy with a mean follow-up period of 3.3years in which the contribution of predictors of rectus femoris muscle size, muscle strength, exercise capacity to all-cause mortality rates, progression to ESRD and time to first hospitalization were investigated. Unadjusted analysis suggested each 1cm2 increase in quadriceps muscle size (measured by ultrasonography cross-sectional area) was associated with a 38% reduced risk for death (p=.006), and a 10m improvement on the incremental shuttle walk test was associated with a 3% reduced risk for death (p=.04). However, this relationship was not present in analysis adjusted for age, gender and eGFR. No association was seen between any factor for the development of ESRD or time to first hospitalization. These results suggest that in this small cohort, muscle size and exercise capacity are associated with mortality when considered alone, but this relationship was not present in adjusted analyses. Further investigation in a larger patient group is warranted.

Development of prognostic model for patients at CKD stage 3a and 3b in South Central China using computational intelligence.

Chronic kidney disease (CKD) stage 3 was divided into two subgroups by eGFR (45mL/ min 1.73m2). There is difference in prevalence of CKD, racial differences, economic development, genetic, and environmental backgrounds between China and Western countries. We used a computational intelligence model (CKD stage 3 Modeling, CSM) to distinguish CKD stage 3 with CKD stage 3a/3b by data distribution rules, pearson correlation coefficient (PCC), spearman correlation (SCC) analysis, logistic regression (LR), random forest (RF), support vector machine (SVM), and neural network (Nnet) to develop Prognostic Model for patients with CKD stage 3a/3b in South Central China. Furthermore, we used RF to discover risk factors of progression of CKD stage 3a and 3b to CKD stage 5. 1090 cases of CKD stage 3 patients in Xiangya Hospital were collected. Among them, 455 patients progressed to CKD stage 5 in a median follow-up of 4years (IQR 4.295, 4.489). We found that the common risk factors for progression of CKD stage 3a/3b to CKD stage 5 included albumin, creatinine, total protein, etc. Proteinuria, direct bilirubin, hemoglobin, etc. accounted for the progression from stage CKD stage 3a to stage 5. The risk factors for CKD stage 3b progression to stage 5 included low-density lipoprotein cholesterol, diabetes, eosinophil percentage, etc. CONCLUSIONS: CSM could be used as a point-of-care test to screen patients at high risk for disease progression, might allowing individualized therapeutic management.

A formula predicting the effective dose of febuxostat in chronic kidney disease patients with asymptomatic hyperuricemia based on a retrospective study and a validation cohort .

Febuxostat is initiated in chronic kidney disease (CKD) patients to lower uric acid but without any renal dosing scheme. This study aimed to determine a formula that predicts the effective dose of febuxostat in patients with an estimated glomerular filtration rate (eGFR) < 60mL/min and asymptomatic hyperuricemia. This is a retrospective analysis of 100 CKD patients treated with febuxostat for asymptomatic hyperuricemia in two private Lebanese clinics. Patients with gout were excluded. Collected variables were age, sex, weight, serum creatinine, serum uric acid (sUA) before and after febuxostat, dose of febuxostat used, and diuretic use. Multiple regression analysis was used to derive a formula predicting the dose of febuxostat based on eGFR (2009 Chronic Kidney Disease Epidemiology Collaboration equation), baseline sUA, and sUA reduction ratio. A prospective cohort of 24 patients was then used to validate the derived model. 100 patients were included with a median age of 71.5 years (interquartile range (IQR), 64.2-79.0); 69% were men. Median baseline sUA was 9.1mg/dL (IQR, 8.4-10.1). Mean eGFR was 31.80±12.96 mL/min/1.73m2. Of the included patients, 18% had CKD stage 3a, 36% had CKD stage 3b, 38% had CKD stage 4, and 8% had non-dialysis CKD stage 5. A formula was computed to predict febuxostat dosing. Variables that were predictive of febuxostat dose and used in the final equation were eGFR, diuretic use, baseline sUA, and sUA reduction ratio. The validation cohort showed no significant difference between the expected sUA and the measured one (p = 0.16). With this new formula, physicians can initiate febuxostat in CKD patients at an effective dose for any desired sUA reduction ratio.

Chronic kidney disease impacts health-related quality of life of children in Uganda, East Africa.

Limited data exist about causes of chronic kidney disease (CKD) and impact on health-related quality of life (HRQoL) in African children. We evaluated types of kidney disease in Ugandan children 0-18years and compared HRQoL in children with CKD or with benign or resolving kidney disease (non-CKD) to assess predictors of HRQoL. Demographic, socioeconomic, and clinical data were obtained for this cross-sectional study. Pediatric Quality of Life Core Scale™ (PedsQL) was used to survey 4 domains and overall HRQoL. CKD and non-CKD scores were compared using unpaired t test. HRQoL predictors were evaluated using linear and logistic regression analyses. One hundred forty-nine children (71 CKD, 78 non-CKD; median age 9years; male 63%) had the following primary diseases: nephrotic syndrome (56%), congenital anomalies of the urinary tract (CAKUT) (19%), glomerulonephritis (17%), and other (8%). CAKUT was the predominant etiology (39%) for CKD; 63% had advanced stages 3b-5. Overall HRQoL scores were significantly lower for CKD (57 vs. 86 by child report, p < 0.001; 63 vs. 86 by parent proxy report, p< 0.001). Predictors of lower HRQoL were advanced CKD stages 3b-5, primary caregiver non-parent, vitamin D deficiency, and anemia. Like other parts of the world, CAKUT was the main cause of CKD. Most CKD children presented at late CKD stages 3b-5. Compared with non-CKD, HRQoL in CKD was much lower; only two-thirds attended school. Vitamin D deficiency and anemia were potentially modifiable predictors of low HRQoL. Interventions with vitamin D, iron, and erythropoietin-stimulating agents might lead to improved HRQoL.

V028 - Sex-sparing robot-assisted radical cystectomy with intracorporeal Padua ileal neobladder in female: Surgical technique, perioperative, oncologic and functional outcomes

Our aim was to illustrate our technique of sex-sparing (SS)-robot-assisted radical cystectomy (RARC) in female patients receiving an intracorporeal neobladder (iN). From January 2013 to June 2018, 11 female patients underwent SS-RARC-iN at a single tertiary referral center. Inclusion criteria were a cT ≤ 2 N0 M0 bladder tumor at baseline imaging (CT or MRI) and an absence of tumors in the bladder neck, trigone and urethra at TURB. Baseline, perioperative, and outcomes at one year were reported. The median operative time was 255 min and the median hospital stay was seven days. Low-grade Clavien complications occurred in four patients (36.3%), while high-grade complications were not observed in any. Seven patients (63.7%) had an organ-confined disease at the pathologic specimen; nodal involvement and positive surgical margins were not detected in any of the cases. At a median follow-up of 28 months (IQR 14-51), no patients developed new onset of chronic kidney disease stage 3b. After one year, daytime and nighttime continence rates were 90.9% and 86.4% respectively. Quality of life as well as physical and emotional functioning improved significantly over time (all p ≤ 0.04), while urinary symptoms and sexual function worsened at three months with a significant recovery taking place at one year (all p ≤ 0.04). Overall, 8 out of 11 patients (72.7%) were sexually active at the 12-month evaluation. In select female patients, SS-RARC-iN is an oncologically sound procedure associated with favorable perioperative and functional outcomes.

P0645EDARAVONE MAY DECREASE THE INCIDENCE OF CONTRAST INDUCED ACUTE KIDNEY INJURY (CI-AKI)

Abstract Background and Aims Edaravone is a low-molecular-weight antioxidant drug targeting peroxyl radicals of reactive oxygen species and has shown clinical efficacy in patients with acute ischemic stroke. We have conducted a multicenter open prospective randomized controlled study to evaluate the efficacy of edaravone in preventing AKI in patients with CKD 3b-4 stages. Method The study included 2 groups of patients aged 46 to 68 (55 ± 3): group A (n=16) with CKD stage 3b or 4 (eGFR EPI 32 ± 4 ml/min) that received intravenous edaravone 30 mg bid on 0,1,2 day of contrast media infusion and control group B (n=20) with CKD stage 3b or 4 (eGFR EPI 33 ± 3 ml/min) with no edaravone intervention during CT coronarography. Patients of both groups received intravenous hydration with 0.9% sodium before CT. Primary endpoint: CIN onset in 48 hours after contrast media infusion and need for RRT. Secondary endpoint: serum potassium level above 5.5 mmol/l. Results CIN onset was obtained in 4 patients of group A and 12 patients of group B (p&amp;gt;0,05, RR 0.417, RRR 0.583, RD 0.350, NNT 2.857). Other results are presented in table

P0787THE IMPORTANCE AND BENEFITS OF THE REGISTRY OF PREDIALYSIS PATIENTS - ROMANIAN EXPERIENCE

Abstract Background and Aims Registries provide an organized and standardized method to systematically collect observational data about specific groups of patients managed in routine clinical practice for a predetermined objective. Data collected by patient registries may help researchers develop hypotheses about disease mechanisms or treatment approaches and inform health care policy thereby potentially improving quality. It is known that chronic kidney disease (CKD) represents the 6th cause of mortality worldwide and it has an increased prevalence. Therefore, the aim of our Registry is to collect epidemiological and medical data regarding the CKD patients from our country in order to drive improvements in health care quality. Method Starting from January 2019, all Romanian nephrologist have been collecting demographic and medical data CKD-related from patients diagnosed with CKD stages 1-5. These data are introduced in a special designed software program – ReNal – that is easy to be accessed. The demographic and medical information include: ID, gender, age, region, body mass index, CKD etiology, comorbidities, chronic treatment, CKD stage, laboratory test, such as serum creatinine, urea, uric acid, calcium, phosphates, iPTH, albuminuria, proteinuria, glomerular filtration rate, hemoglobin etc. (results collected from each medical assessment). Results During almost 1-year, over 10000 patients with CKD stages 1-5 were introduced in our Registry, with mean age of 69.2 ± 3.5, 51.22% female patients, 48.78% male patients. From our preliminary results, hypertension and diabetes mellitus represent the main cause of CKD in Romania, according with the international data. In addition, CKD stages 3b and 4 were highly represented. These are part of the preliminary results, future data will be available. Conclusion Analyzing the assessed data from our Registry, in future several key points could be achieved: the importance of a correct financial appraisal sustained by health system, adequate and active assessment of CKD patients including the complications, highlighting the disease progression rate depending on the recommended treatment, designing an efficient prevention program.

P1012NAIL CAPILLARY DENSITY DURING POSTOCCLUSIVE REACTIVE HYPEREMIA AND VENOUS CONGESTION IS MORE IMPAIRED IN DIABETIC COMPARED TO NON-DIABETIC CKD PATIENTS

Abstract Background and Aims Αlterations in endothelial function and capillary circulation have been associated with increased cardiovascular events and overall mortality. Both diabetes mellitus (DM) and chronic kidney disease (CKD) have been associated with microcirculatory damage. Nailfold video-capillaroscory can provide a thorough assessment of capillary density and microcirculation changes. This is the first study examining in comparison microcirculatory function parameters in diabetic and non-diabetic patients with CKD. Method We included 48 diabetic and 48 non-diabetic adult patients (&amp;gt;18 years) with CKD (eGFR: &amp;lt;90 and ≥15mL/min/1.73m2), matched in a 1:1 ratio for age, sex and eGFR within each CKD stage (2, 3a, 3b and 4). All participants underwent nailfold video-capillaroscopy, during which capillary density was measured at normal conditions (baseline), after a 4-minute arterial occlusion (postocclusive reactive hyperemia) and at the end of a 2-minute venous occlusion (congestion phase). Results Baseline demographic, anthropometric and laboratory characteristics were similar between patients with and without diabetes in total and in CKD stages. Overall, no significant differences at baseline capillary density were observed between groups; however diabetic patients presented significantly lower capillary density during reactive hyperemia (36.3±3.8 vs 38.3±4.3 capillaries/mm2, p=0.022) and at venous congestion (37.8±4.0 vs 39.8±4.2 capillaries/mm2, p=0.015). When stratified according to CKD stages, the between-group differences in parameters of interest were not significant in stages 2, 3a and 4. In stage 3b, capillary density was significantly lower in diabetic compared to non-diabetic subjects at baseline (31.1±2.8 vs 33.4±3.4 capillaries/mm2, p=0.044), during postocclusive hyperemia (36.8±2.7 vs 40.0±4.3 capillaries/mm2, p=0.037) and venous congestion (38.3±2.8 vs 41.5±3.5 capillaries/mm2, p=0.022). Conclusion Capillary density during postocclusive reactive hyperemia and after venous congestion is lower in diabetic compared to non-diabetic CKD patients, a finding indicative that diabetes is an additional factor contributing to microcirculatory functional impairment in CKD. These differences are more prominent in CKD stage 3b, and less prominent in earlier and later stages.

P0156SHORT-TERM BLOOD PRESSURE VARIABILITY IN DIABETIC AND NON-DIABETIC PATIENTS WITH CKD STAGE 2, 3A, 3B AND 4

Abstract Background and Aims Blood pressure variability (BPV) is an important risk factor for cardiovascular events and mortality in patients with chronic kidney disease (CKD). Previous evidence suggests that BPV is gradually increasing across CKD stages. Whether type 2 diabetes mellitus (DM) is an additional risk factor for increased BPV has never been studied. The aim of this study is to examine in comparison BPV in diabetic and non-diabetic patients with CKD. Method We included 48 diabetic and 48 non-diabetic adult patients (&amp;gt;18 years) with CKD (eGFR: &amp;lt;90 και ≥15mL/min/1.73m2), matched in a 1:1 ratio for age, sex and eGFR within each CKD stage (2, 3a, 3b and 4). All patients underwent 24-hour ambulatory blood pressure (BP) measurement with the Mobil-O-Graph device. Brachial BP variability was calculated with validated formulas. We calculated standard deviation (SD), weighted SD (wSD), coefficient of variation (CV), and average real variability (ARV) of BP during the 24-hour, day- and night-time periods with validated formulas. Results In total population, ambulatory systolic BP (SBP) levels were significantly higher in diabetics compared to non-diabetic counterparts in all studied periods. No significant differences were evidence for ambulatory diastolic BP (DBP) in total or across CKD stages. In total, 24-hour SBP SD (15.43±4.34 vs 13.38±3.35, p=0.011), wSD (14.41±4.11 vs 12.53±3.19, p=0.014) and ARV (10.94±2.75 vs 9.46±2.10, p=0.004) were higher in patients with DM compared to those without DM. In addition, 24hour DBP SD (11.04±2.39 vs 9.80±2.28, p=0.010), wSD (10.30±2.52vs 9.05±1.99, p=0.008), CV (14.77±3.05 vs 13.14±2.96, p=0.009) and ARV (8.23±2.10 vs 7.10±1.33, p=0.002) were again different between groups. Across CKD stages 2 and 3a, BPV indices were insignificantly higher in patients with DM. In CKD Stage 3b, 24-hour SBP-SD (16.30±4.52 vs 11.35±2.62, p=0.003), wSD (15.42±4.54 vs 10.77±2.30, p=0.004), ARV (12.46±3.19 vs 8.34±2.07, p=0.001) and 24-hour DBP-CV (14.84±3.63 vs 12.18±1.91, p=0.035) were higher in diabetic compared to non-diabetic patients. In contrast, no difference between groups existed in CKD Stage 4. Conclusion Patients with DM present increased BPV in CKD Stages 2, 3a and 3b (moderately impaired renal function). This difference is not apparent in patients with advanced CKD at Stage 4.

P0184RISK PREDICTION FOR DEATH AND END-STAGE RENAL DISEASE DOES NOT PARALLEL REAL-LIFE TRAJECTORY OF OLDER PATIENTS WITH ADVANCED CHRONIC KIDNEY DISEASE - A ROMANIAN CENTER EXPERIENCE

Abstract Background and Aims In Europe, the share of the elderly (≥65 years of age) in the total population is estimated to increase from 19.2% in 2016 to 29.1% by 2080. In 2016, European Renal Best Practice (ERBP) group published a clinical practice guideline on management of older patients with CKD stage3b or higher (eGFR&amp;lt;45ml/min/1.73 m2). Two risk stratifications scores were emphasized: Bansal score for prognosticating risk of death in medium term, and Kidney Failure Risk Equation (KFRE) for estimating progression of CKD stage 3b or 4 to ESRD. Our group, as part of the ERBP team, aimed to evaluate and apply the framework proposed by the guideline, consisting of risk prediction for both mortality and progression to ESRD in a cohort of elderly patients with advanced CKD. After dividing the population in groups of risk, we described their real-life trajectory in terms of either reaching ESRD/death. Method In this retrospective cohort study we included patients aged ≥65 years with CKD stage 3b-4, evaluated at the Outpatient Nephrology Department of Dr. C. I. Parhon Hospital from Iași, Romania, between October 2016 – October 2018. Individual risk for mortality was predicted using Bansal score, a nine-variable equation model. A total score of 7 (associated with a mortality risk of 53.82%) was established as cut-off value to differentiate between 2 groups: high risk of mortality (Bansal ≥ 7) and low risk of mortality (Bansal &amp;lt; 7), given the fact that the ERBP guidelines don’t define a threshold for high risk in respect to mortality outcome. According to the algorithm proposed by the guideline, individual risk for progression to ESRD at 5 years was calculated in the low mortality risk group, using the 4-variable Kidney Failure Risk Equation (KFRE). Results The final cohort included 958 patients, with a mean age of 74 years (SD: 7), and with similar gender distribution (50.6% female vs. 49.4% male). Predicted trajectory in terms of reaching ESRD / death: When we applied Bansal score for mortality, the total study population (N=958) was divided in two groups: N1 with high risk of mortality, which comprised more than half of the cohort (548 patients, 57.2%) and N2 with low risk of mortality (410 patients, 42.8%). Individual risk of progression to ESRD was then estimated in N2 group, using 4-variable KFRE. Nearly ¾ of this group (75.4%, 309 subjects) presented a low-risk of progression and ¼ (24.6%, 101 subjects) had high-risk. Real-life trajectory in terms of reaching ESRD / death: From the entire cohort, 31 patients started renal replacement therapy (RRT) and 164 patients died as their first clinical event. The RRT initiation rate was 3.6% of N1 group (20 subjects) versus 2.7% of N2 group (11 subjects). The mortality rate was 15.5% of N1 group (85 deaths) versus 19.3% of N2 group (79 deaths). Figure 1 depicts the real-life trajectory of the population groups in terms of reaching ESRD / death. Conclusion In a large population from Eastern Europe, the application of the algorithm from the Clinical Practice Guideline on management of older patients with advanced CKD showed that risk prediction for death and end-stage renal disease does not parallel the real-life trajectory of the population. More than half of the subjects had a high risk of mortality, however we found similar death rates in the 2 groups (high versus low risk of mortality). Also, the RRT initiation rates were similar, irrespective of predicted mortality risk or kidney failure risk, suggesting that implementing the guideline in real-life settings is still a challenge.

P0763A COMPARATIVE STUDY OF ARTERIAL STIFFNESS AND WAVE REFLECTIONS IN DIABETIC AND NON-DIABETIC PATIENTS WITH CKD

Abstract Background and Aims Arterial stiffness is associated with increased risk for target-organ damage, cardiovascular events and overall mortality in the general population, patients with diabetes mellitus and patients with chronic kidney disease (CKD) of all stages. This is the first study to evaluate in comparison arterial stiffness and arterial wave reflections in diabetic and non-diabetic patients with CKD. Method This study included 48 diabetic and 48 non-diabetic adult patients (&amp;gt;18 years) with CKD (eGFR: &amp;lt;90 και ≥15mL/min/1.73m2), matched in a 1:1 ratio for age, sex and eGFR within each CKD stage (2, 3a, 3b and 4). All patients underwent carotid-femoral pulse wave velocity (PWV), central blood pressure (BP), and wave reflections measurement with applanation tonometry (Sphygmocor, Atcor Medical, Australia). Results Office systolic and diastolic blood pressure was similar between diabetic and non-diabetic subjects with CKD in total and across CKD stages. Office brachial pulse pressure (PP) was significantly lower in non-diabetics (49.00±8.0 vs 52.67±8.7 mmHg, p= 0.034). Office PWV was marginally higher in diabetics compared with non-diabetics (10.89±2.0 vs 10.06±2.2 m/sec, p=0.056). In CKD stages 2 and 4, no significant difference in PWV between the two groups was noted, but PWV was higher for diabetics in CKD stages 3a (11.28±1.4 vs 9.83±1.5 m/sec, p=0.023) and 3b (11.13±1.9 vs 9.46±1.2 m/sec, p=0.016). Heart-rate-adjusted augmentation index [AIx(HR75)] was higher in diabetic compared with non-diabetic subjects only in CKD stage 4 (32.08±4.2 vs 25.92±6.6%, p=0.013). Conclusion Diabetic CKD patients present higher arterial stiffness than non-diabetic counterparts. The additional contribution of diabetes towards increased arterial stiffness is more prominent in patients with moderately impaired renal function (CKD stage 3a and 3b), whereas at stage 4, PWV was increased independent of diabetes presence.

P0330RENAL INVOLVEMENT IN OBSTETRIC CATASTROPHIC ANTIPHOSPHOLIPID SYNDROME

Abstract Background and Aims Catastrophic antiphospholipid syndrome (CAPS) is an uncommon, often fatal, variant of the antiphospholipid syndrome (APS) that defined as multiorgan thrombosis affecting three and more organs confirmed by histopathology of small vessel occlusions in at least one organ or tissue. The development of CAPS in pregnancy poses many diagnostic challenges as a result of its overlap with other obstetric TMA syndromes. Because of the high associated mortality rate, prompt recognition and treatment are paramount. Some studies have shown that complement activation contributes in antiphospholipid antibodies (aPL) mediated thrombosis in CAPS. Short treatment with eculizumab can result in a rapid improvement of pts with TMAs other than aHUS with persisted hematological and renal symptoms worsened despite treatment of the TMA-inducing condition. Aims: Analysis of renal involvement, course and outcomes of obstetric CAPS Method From 2016 to 2019 we observed 11 pts aged 19 - 38 years with CAPS, occurred during pregnancy (from 16 to 40 weeks) or postpartum period. Only 1 patient had a diagnosis of APS with SLE before pregnancy. 5 out of 11 pts had the first pregnancy, 6 pts already had a history of pregnancy, but all previous pregnancies were failed: miscarriage or antenatal death of the fetus. Results Preeclampsia (PE) and/or HELLP syndrome, surgical intervention in combination with obstetric complications (bleeding, manual separation of the placenta, Сaesarean delivery, etc.) preceded CAPS manifestation in all pts. Moreover, in 1 patient with SLE, secondary APS and triple aPL positivity, HELLP syndrome developed very early stage of 16 weeks. In all cases, aPL circulation was detected (anti-cardiolipin antibodies and/or anti-beta-2-glycoprotein-1, lupus anticoagulant). All pts (100%) had complete MAHA (microangiopathic hemolysis): hemoglobin level 73,0 ± 19,2 g/l, LDH level 1066,7 ± 1056,7 U/l, schizocytosis), thrombocytopenia (122,0±157,9х10µL) and multi-organ failure (MOF): kidney damage (81%, 9 of 11), liver (63%, 7 of 18), gastrointestinal tract, heart, lungs, central nervous system - 55% (6 of 11), skin (gangrene 1-9%). A feature of kidney involvement was the development of AKI (mean creatinine level 207,6 ±140,3 mg/dl, oliguria or anuria) not all pts (9 of 11), in 2 case was observed only minimnal urinary syndrome without increasing sCr. All pts underwent traditional treatment, including plasma exchange and/or plasma infusions+corticosteroids+anticoagulants, which was effective in 6 out of 11 pts. In the 2 most severe plasma-resistant cases complement-blocking treatment with eculizumab was prescribed, with rapid positive dynamics was observed: the relief of MOF, hematological parameters normalization after the first infusion and recovery of kidney function by the end of the induction course. Favorable outcome with complete normalization of lab parameters and clinical improvement with kidney function normalization was achieved in 8 of 11 women. In 1 patient chronic kidney disease (CKD) stages 3B has occurred as outcome of AKI. 2 pts died despite ongoing therapy with PT + ST+IG+AC from progressive multiple organ failure. Conclusion 1. Сomplicated obstetric history in patients with acute obstetric TMA requires mandatory exception of CAPS 2. Proven role of complement system involvement in the pathogenesis of CAPS gives a reason for the complement-blocking therapy appointment in severe postpartum TMA, which increases the patients' chance of recovery.

Alendronate use and bone mineral density gains in women with moderate-severe (stages 3B\u20135) chronic kidney disease: an open cohort multivariable and propensity score analysis from Funen, Denmark

SummaryBisphosphonates are contraindicated in moderate-to-severe chronic kidney disease patients. However, they are used to prevent fragility fractures in patients with impaired kidney function, despite a lack of evidence on their effects on bone density in these patients. We demonstrated that Alendronate had a positive effect on bone in these patients.PurposeThis study aimed to assess the association between alendronate use and bone mineral density (BMD) change in subjects with moderate-severe chronic kidney disease (CKD).MethodsWe created a cohort of CKD stage 3B–5 patients by linking all DXA-based measurements in the Funen area, Denmark, to biochemistry, national health registries and filled prescriptions. Exposure was dispensation of alendronate and the outcome was annualized percentage change in BMD at the femoral neck, total hip and lumbar spine. Individuals were followed from first BMD to the latest of subsequent DXA measurements. Alendronate non-users were identified using incidence density sampling and matched groups were created using propensity scores. Linear regression was used to estimate average differences in the annualized BMD.ResultsUse of alendronate was rare in this group of patients: propensity score matching (PSM) resulted in 71 alendronate users and 142 non-users with stage 3B–5 CKD (as in the 1 year before DXA). Whilst alendronate users gained an average 1.07% femoral neck BMD per year, non-users lost an average of 1.59% per annum. The PSM mean differences in annualized BMD were + 2.65% (1.32%, 3.99%), + 3.01% (1.74%, 4.28%) and + 2.12% (0.98%, 3.25%) at the femoral neck, total hip and spine BMD, respectively, all in favour of alendronate users.ConclusionIn a real-world cohort of women with stage 3B–5 CKD, use of alendronate appears associated with a significant improvement of 2–3% per year in the femoral neck, total hip and spine BMD. More data are needed on the anti-fracture effectiveness and safety of bisphosphonate therapy in moderate-severe CKD.

Dietary Phosphate Consumption in Australians With Stages 3b and 4 Chronic Kidney Disease

Dietary phosphate modification is a common therapy to treat hyperphosphatemia in individuals with chronic kidney disease (CKD). However, current dietary intake and common food sources of phosphate typically consumed by individuals with CKD are not well characterized. This study examined a cohort of CKD patients to determine total dietary intake and common food sources of phosphate, including phosphate additives. Participants with CKD stages 3b and 4 recruited to a substudy of the "IMPROVE-CKD (IMpact of Phosphate Reduction On Vascular End-points in Chronic Kidney Disease) Study" completed a 7-day self-administered diet record at baseline. Diet histories were analyzed and daily phosphate intakes determined using FoodWorks V.9 (Xyris). The proportion of phosphate contributed by each food group was determined using the AUSNUT 2011-2013 Food Classification System. Ingredient lists of packaged food items consumed were reviewed to determine frequency of phosphate-based additives. Ninety participants (mean eGFR 26.5mL/min/1.73m2) completed this substudy. Mean phosphate intake of participants was 1544±347mg/day, with 96% of individuals exceeding the recommended daily intake of phosphate (1000mg/day). The highest sources of dietary phosphate were milk-based products (25%) and meat and poultry products/dishes (25%). Phosphate-based food additives were identified in 39% (n=331/845) of packaged foods consumed by participants. Dietary phosphate intakes of Australians with CKD are high and come from a variety of sources. Managing dietary phosphate intake requires a patient-centered, tailored approach with an emphasis on maintaining nutritional adequacy and awareness of phosphate additives.

Chronic kidney disease in Russia: the Ural eye and medical study

BackgroundTo examine the prevalence of chronic kidney disease (CKD) and its associations in a Russian population.MethodsOut of 7328 eligible individuals, the population-based cross-sectional Ural Eye and Medical Study included 5899 (80.5%) individuals aged 40+ years and undergoing a detailed medical examination. The estimated glomerular filtration rate (eGFR) was calculated using the Chronic-Kidney-Disease-Epidemiology-Collaboration (CKD-EPI) equation.ResultsThe mean eGFR was 72.3 ± 19.1 mL/min/1.73m2 (median:70.3 mL/min/1.73m2). Prevalence of CKD stage 3a (eGFR< 60 mL/min/1.73m2 and > 45 mL/min/1.73m2), CKD stage 3b (eGFR< 45 mL/min/1.73m2 and > 30 mL/min/1.73m2) and CKD stage 4+ (eGFR< 30 mL/min/1.73m2) were 1351/5841 (23.1%;95% confidence interval (CI):22.1,24.2), 294/5841 (5.0%;95%CI:4.5,5.6), and 29/5841 (0.5%;95%CI:0.3,0.7), respectively. The CKD stage 3+ prevalence increased (P < 0.001) from 11.1% (95%CI:8.4,13.9) in 40–44-year-olds to 56.8% (95%CI:52.8,60.8) in 75 + year-olds. In univariate analysis, CKD stage 3a + prevalence increased with higher systolic blood pressure (P < 0.001). In multivariable analysis, higher prevalence of CKD stage 3a + was associated with older age (P < 0.001;odds ratio (OR):1.06;95%CI:1.05,1.07), female sex (P < 0.001;OR:2.29;95%CI:1.94,2.69), rural region of habitation (P = 0.001;OR:1.29;95%CI:1.11,1.50), higher body mass index (P = 0.03;OR:1.02;95%CI:1.002,1.03), lower prevalence of house ownership (P = 0.02;OR:0.57;95%CI:0.35,0.92), higher prevalence of mostly sitting or standing during work (P < 0.001;OR:1.40;95%CI:1.20,1.64), higher serum concentration of triglycerides (P < 0.001;OR:1.23;95%CI:1.12,1.35) and blood urea nitrogen (P < 0.001;OR:1.33;95%CI:1.27,1.40), lower serum concentration of hemoglobin (P = 0.03;OR:0.99;95%CI:0.99,0.999), and lower prevalence of chronic obstructive pulmonary disease (P < 0.001;OR:0.57;95%CI:0.42,0.78).ConclusionsIn this population from Russia aged 40+ years, prevalence of CKD stage 3+ (28.7%;95%CI:27.5,29.8) was relatively high as compared to populations from other countries. Associated factors were older age, female sex, rural region, higher body mass index, a sedentary lifestyle, and lower socioeconomic background.

Едаравон у профілактиці контраст-індукованого гострого ураження нирок

Мета роботи – оцінити ефективність едаравону в запобіганні розвитку контраст-індукованого гострого ураження нирок (КІГУН).Матеріали і методи. Проведено багатоцентрове відкрите проспективне рандомізоване контрольоване дослідження для оцінювання ефективності едаравону в профілактиці КІГУН у пацієнтів із хронічною хворобою нирок (ХХН) 3b–4 стадії. Було сформовано дві групи хворих віком 46–68 років (у середньому (55±3) роки) – основну і контрольну. Основну групу становили 16 пацієнтів з ХХН 3b або 4 стадії (розрахункова швидкість клубочкової фільтрації за формулою СКD-EPI (32±4) мл/хв), які отримували едаравон у дозі 30 мг шляхом внутрішньовенного інфузійного введення. До контрольної групи увійшло 20 пацієнтів із ХХН 3b або 4 стадії (розрахункова швидкість клубочкової фільтрації (33±3) мл/хв), у яких едаравон при проведенні коронароангіографії не застосовували. Пацієнти обох груп перед коронароангіографією отримували внутрішньовенну гідратацію 0,9 % натрію. Первинна кінцева точка: розвиток КІГУН протягом 48 год після введення контрастного засобу та необхідність проведення ниркової замісної терапії. Вторинна кінцева точка: рівень калію в сироватці крові понад 5,5 ммоль/л. Результати та обговорення. Розвиток КIГУН документовано у 4 пацієнтів основної групи та 12 пацієнтів контрольної групи (р≤0,05; RR 0,417; RRR 0,583; RD 0,350; NNT 2,857). Виявлено статистично значущу різницю між групами для обох кінцевих точок, що свідчить про перспективні можливості застосування едаравону для профілактики КІГУН у пацієнтів з ХХН 3b–4 стадії. Аналіз індивідуальних даних показує, що едаравон був ефективнішим у хворих із ХХН 3b стадії (три випадки КІГУН з 10) порівняно з ХХН 4 стадії (один із 2).Висновки. Едаравон може бути перспективним рішенням для профілактики КІГУН у пацієнтів із ХХН 3b–4 стадії, яким терміново виконують коронароангіографію.&#x0D;

SAT-185 Primary Adrenal Lymphoma Presenting with Symptomatic Hypercalcaemia

Introduction: Primary adrenal lymphoma (PAL) is a rare cause of adrenal enlargement with approximately 200 cases reported in the literature to date. It tends to affect elderly men and has a high incidence of bilateral involvement at diagnosis. We report the case of a 66 year old man, whose PAL manifested with symptomatic hypercalcaemia.A 66 year old male, originally from the Philippines, was referred to the emergency department with nausea, vomiting, weight loss and right flank pain. His past medical history was significant for hypertension, gout and stage 3b chronic kidney disease. His medications were amlodipine, losartan and febuxostat. His family history was significant for hypertension. On examination he was hypertensive (blood pressure, 160/100 mmHg) and hyperpigmented. His laboratory investigations revealed; corrected calcium of 3.79 mmol/l, undetectable PTH, vitamin D 49 nmol/l. He was treated with intravenous (IV) 0.9% saline and IV zoledronic acid and his calcium levels improved.To investigate causes of non-PTH mediated hypercalcaemia, computerised tomography of the thorax, abdomen and pelvis (CT TAP) as well as a positron emission tomography (PET) scan were performed. These demonstrated bilateral, large, metabolically active adrenal masses with no evidence of extra-adrenal disease. Differential diagnosis at this point included bilateral adrenal hyperplasia, metastases, lymphoma or adrenal TB. There were no radiological features of adrenocortical carcinoma (ACC) or phaeochromocytoma and subsequent biochemical investigations confirmed no evidence of cortisol, androgen or catecholamine excess. Adrenocorticotrophic hormone (ACTH) levels were elevated however, and a synacthen test revealed inadequate adrenal reserve (peak cortisol 214 nmol/l). The patient was commenced on maintenance steroids and with stress dose steroid cover, proceeded to adrenal biopsy. Histology confirmed diffuse large B cell non-Hodgkin’s lymphoma. Haematology became involved in his care and he commenced polychemotherapy in the form of R-CHOP, 1 week post confirmation of the diagnosis. His treatment is ongoing and he has tolerated it well with minimal side effects, except a flare of gout.Learning points: PAL should be considered in the differential diagnosis in patients with bilateral adrenal masses. Image guided adrenal biopsy is the gold standard for diagnosis, though caution must be exercised and an ACC or phaeochromocytoma should be excluded prior to biopsy. The prognosis of PAL is poor and therefore early diagnosis and prompt initiation of treatment are required to improve outcomes.