Chronic Kidney Disease Stage 3b Research Articles

Abstract 104: Mortality Risk Across Chronic Kidney Disease Stages With Fibrate or Niacin Use Compared With No Fibrate or Niacin Therapy in Male US Veterans

Background: Chronic kidney disease (CKD) patients have a higher cardiovascular (CV) disease and mortality risk, elevated triglycerides (TG), and decreased high density lipoproteins (HDL). Post-hoc analysis of trials examining use of fibrate (Fib) or niacin (Nia) therapy in lowering CV outcome risk have failed to show benefit in mild to moderate kidney disease. These analyses were criticized for their study design or small sample size. We sought to examine if Fib or Nia use is associated with lower mortality risk in US veterans across CKD stages. Methods: In a retrospective cohort analysis, we identified male veterans who initiated Fib or Nia, with a high TG ≥150 mg/dL or low HDL ≤40 mg/dL between 2004-2014, and matched them on CKD stage and TG and HDL levels to unexposed men. We examined the association of Fib or Nia use (ref: unexposed) with 12-month all-cause mortality risk across CKD stage strata using an adjusted Cox proportional hazards model. Propensity scores (PS) included baseline demographics, comorbidities and lab measures and high-dimensional propensity scores (HDPS) included over 100 covariates for each drug and stage analysis. PS and HDPS analyses included score adjustment and matching. Results: The cohort had a mean±SD age of 64±12 years, and 30% had CKD stage 3A and higher. There were 69,295 Fib, 87,727 Nia, and 114,411 unexposed patients, respectively. Patient characteristics were similar across drug groups within each CKD stage. With covariate adjustment, both Fib and Nia were associated with a lower death risk compared to unexposed men in lower CKD stages (Figure A and B). Among those with CKD stage 4/5, Fib and Nia were associated with a higher death risk (HR[95%CI]: 1.43[1.15, 1.78] and 1.17[0.97,1.40], respectively). Those on Fib or Nia and in end-stage renal disease had a null association with mortality. Associations were similar for each CKD stage in PS and HDPS analyses, yet Fib and Nia were no longer associated with a lower death risk for CKD stage 3A and 3B patients. Conclusion: Mortality associations of Fib and Nia among male veterans with high TG and low HDL varied across CKD stage, where CKD stage 4/5 patients had a higher mortality risk, even in PS and HDPS analyses. While covariate balance was met, further studies are needed to examine the mechanisms for this higher observed risk in late-stage CKD patients.

Protocol and Baseline Data of a Multicentre Prospective Double-Blinded Randomized Study of Intravenous Iron on Functional Status in Patients with Chronic Kidney Disease

Background: Iron deficiency (ID) is common in patients with chronic kidney disease (CKD) due to an inadequate dietary intake of iron, poor absorption from the gut and increased iron losses. In addition to preventing anaemia, iron is important for normal heart function, being involved in processes that generate a necessary continuous energy supply. Treatment with intravenous (IV) iron has been suggested to lead to improvement in heart function and well-being in people with ID and CKD. In the Iron and the Heart Study, we hypothesized that IV iron treatment will primarily improve exercise capacity and may secondarily impact the feeling of well-being in comparison to placebo over 3 months in non-anaemic CKD patients who have ID. Methods: This was a prospective double-blinded explorative randomized, multi-centre study designed to compare the effects of IV iron supplementation and placebo in iron-deficient but not anaemic patients with established CKD stages 3b-5 on functional status, and in addition cardiac structure and function. The study included 54 adults with serum ferritin (SF) <100 µg/L and/or transferrin saturation <20%, randomized in a 1:1 ratio to 1,000 mg IV ferric derisomaltose or placebo. Following randomization, participants underwent baseline assessments and then received IV iron or placebo infusion. Each participant was followed up at months 1 and 3. At each visit, patients underwent clinical review, measurements of hematinics and haemoglobin (Hb), and assessments of physical function and well-being. The primary outcome was exercise capacity using the 6-minute walk test. Secondary objectives included effects on hematinic profiles and Hb concentration, changes in myocardial parameters assessed with speckle tracking echocardiography and change in patients’ quality of life. Results: Between October 2016 and April 2018, 55 from 326 individuals from 3 UK centres attended screening and were randomized. The mean (SD) age was 59.6 (11.7) years, 26 (48%) patients were male, the majority were Caucasians (42; 78%), and 32 (59%) were non-smokers. The mean (SD) body mass index was 30.3 (6.5); SF was 66.3 (44.1) µg/L, TS was 20.1 (7.4) % and Hb was 128.7 (10.1) g/L at randomization for the whole group. Mean (SD) serum creatinine was 186.7 (58.6) µmol/L, estimated glomerular filtration rate was 31.1 (9.6) mL/min/1.73 m² and urinary albumin and protein/creatinine ratios 60.9 (133.3) and 83.8 (128.4) mg/mmol respectively. The mean (SD) C-reactive protein was 5.0 (4.4) mg/L and the mean (SD) 6-minute walk distance at baseline was 401.2 (120.2) m. Conclusion: The Iron and the Heart Trial will provide important information on the short-term effects of IV iron treatment in CKD patients with ID without anaemia on measures of exercise capacity, quality of life and mechanistic data on myocardial structure and function. Trial Registration: European Clinical Trials Database (No. 2014-004133-6; REC no. 14/YH/1209; Sponsor ref. R1766).

The association between renal function and BMD response to bisphosphonate treatment: Real-world cohort study using linked national registers.

Management of osteoporosis given reduced renal function is one of the largest challenges in the bone clinic. Identify the cut-off for renal function below which there would be no overall BMD benefit associated with bisphosphonate use. Track safety outcomes resulting in hospital encounters. Population-based, observational register-linked study of BMD trajectories in adults from the island of Funen (pop 465,000) as a function of estimated creatinine clearance (CKD-epi), treatment and adherence to oBP. One laboratory performed all the biochemical analyses for the area while all DXA scans were in a central facility. For inclusion, patients were required to have both a DXA scan and an eGFR measurement (CKD-EPI) within 1 year prior to their study index date. Medication Possession Ratio (MPR) was calculated from national data. Out of 6176 incident BP users, 1789 had eGFR and DXA measurements at appropriate timepoints for the planned analysis, while this was the case for 3908 of 29,336 non-users. Users of oBPs exhibited progressively smaller gains in BMD with decreasing renal function. However, for CKD stage 3A and better, the annual change in BMD was significantly more positive than in the non-user group at similar levels of renal function. In non-users, the average annual change in BMD was negative but largely unaffected by renal function down to stage 3B. There were no new cases of acute renal injury, glomerulonephritis or dialysis. The rate of new kidney transplantation was zero in non-users and 0.26 per 1000 PY in the BP user population. Hypocalcaemia encounters did not differ significantly from that seen in non-users. The BMD changes observed in real-world users of oBP in this population based single-clinic are consistent with those observed in the original RCTs of alendronate. We noted a gradual decrease in the absolute gains in BMD in oBP users with decreasing renal function though there was no significant interaction - largely explained by low numbers of treated patients with poor renal function - between CKD stage and adherence driven BMD change. There were no cases of acute renal injury resulting in hospital encounters. More data is needed on the efficacy and safety of bisphosphonates in CKD stage 3B to 5 and prescribers should reconsider the low use of DXA in patients with renal function impairment now that a wider range of treatment options are available.

V12-07 SEX-SPARING ROBOT ASSISTED RADICAL CYSTECTOMY WITH INTRACORPOREAL PADUA ILEAL NEOBLADDER IN FEMALE: SURGICAL TECHNIQUE, PERIOPERATIVE, ONCOLOGIC AND FUNCTIONAL OUTCOMES

You have accessJournal of UrologyBladder Cancer & Urinary Diversion (V12)1 Apr 2020V12-07 SEX-SPARING ROBOT ASSISTED RADICAL CYSTECTOMY WITH INTRACORPOREAL PADUA ILEAL NEOBLADDER IN FEMALE: SURGICAL TECHNIQUE, PERIOPERATIVE, ONCOLOGIC AND FUNCTIONAL OUTCOMES Gabriele Tuderti*, Riccardo Mastroianni, Rocco Simone Flammia, Mariaconsiglia Ferriero, Costantino Leonardo, Umberto Anceschi, Aldo Brassetti, Salvatore Guaglianone, Michele Gallucci, and Giuseppe Simone Gabriele Tuderti*Gabriele Tuderti* More articles by this author , Riccardo MastroianniRiccardo Mastroianni More articles by this author , Rocco Simone FlammiaRocco Simone Flammia More articles by this author , Mariaconsiglia FerrieroMariaconsiglia Ferriero More articles by this author , Costantino LeonardoCostantino Leonardo More articles by this author , Umberto AnceschiUmberto Anceschi More articles by this author , Aldo BrassettiAldo Brassetti More articles by this author , Salvatore GuaglianoneSalvatore Guaglianone More articles by this author , Michele GallucciMichele Gallucci More articles by this author , and Giuseppe SimoneGiuseppe Simone More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000957.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Despite the widespread use of robot assisted radical cystectomy (RARC), there is paucity of data concerning outcomes of sex-sparing (SS) RARC with intracorporeal ileal neobladder (iN) in female patients. In this video we described surgical steps of SS- RARC in female patients, and we reported perioperative, pathologic and functional outcomes. METHODS: From January 2013 to June 2018, 11 female patients underwent sex-RARC-iN at a single tertiary referral centre. Inclusion criteria were cT≤2 N0 M0 bladder tumour at baseline imaging (CT or MRI), and absence of tumour in bladder neck, trigone and urethra at TURB. Exclusion criteria included any contraindication to iN. Key surgical steps are: isolation of the ureters; preparation of umbilical, uterine and superior vesical arteries. In Sex-sparing approach development of vesico-uterine plane is performed, and uterine feeding arteries are preserved, while in standard procedure uterine and vesical pedicle are transected close to their origins from iliac internal artery. Notably, sex-sparing RARC allows to preserve utero-vaginal component of hypogastric plexus that is almost sacrificed during standard RARC. Baseline, perioperative and 1-yr outcomes were reported. RESULTS: Median operative time was 255 minutes. Median hospital stay was 7 days. Low grade Clavien complications occurred in 4 patients (36.3%), while high grade complications were not observed. Seven patients (63.7%) had an organ confined disease at the pathologic specimen; nodal involvement and positive surgical margins were not detected in any case. At a median follow-up of 28 months, no patient developed new onset of chronic kidney disease stage 3b; one patient developed ureteroileal anastomotic stricture requiring robotic reimplantation 18 months following surgery. One-yr day-time and night-time continence rates were 90.9% and 86.4%, respectively. Quality of life, physical and emotional functioning improved significantly over time (all p≤0.04), while urinary symptoms and sexual function worsened at 3-mo with a significant recovery at 1-yr (all p≤0.04). Overall, 8 out 11 patients (72.7%) were sexually active at 12-mo evaluation. CONCLUSIONS: In select populations, SS-RARC with iN can be offered to female patients motivated to preserve sexual function as an oncologically safe procedure, associated with favourable functional outcomes. The anatomical preservation of utero-vaginal components of inferior hypogastric plexus represents the cornerstone for a quick and effective recovery in terms of urinary continence and sexual activity. Source of Funding: none © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e1112-e1112 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Gabriele Tuderti* More articles by this author Riccardo Mastroianni More articles by this author Rocco Simone Flammia More articles by this author Mariaconsiglia Ferriero More articles by this author Costantino Leonardo More articles by this author Umberto Anceschi More articles by this author Aldo Brassetti More articles by this author Salvatore Guaglianone More articles by this author Michele Gallucci More articles by this author Giuseppe Simone More articles by this author Expand All Advertisement PDF downloadLoading ...

Reverse epidemiology and the obesity paradox for patients with chronic kidney disease: a Markov decision model.

Obesity has been associated with both increased progression of chronic kidney disease (CKD) as well as with a paradoxical improvement in survival among end-stage renal disease patients undergoing hemodialysis. As such, the optimal weight management strategy for obese CKD patients remains unclear. To estimate the outcomes of obese, CKD stage 3b patients after 3 weight loss interventions, including medical weight management, sleeve gastrectomy (SG), and Roux-en-Y gastric bypass (RYGB), were followed to determine which strategy optimizes long-term survival. University hospital, Aurora, Colorado. A decision analytic Markov state transition model was created to simulate the life of 30,000 obese patients with CKD stage 3b, as they progressed to end-stage renal disease, transplantation, and death. Life expectancy after conservative medical weight management, RYGB, and SG were estimated. Base case patients were defined as being 50 years old and having a preintervention BMI of 40 kg/m2. Sensitivity analysis of initial BMI was performed. All Markov parameters were extracted from literature review. RYGB and SG were associated with improved survival for patients with preintervention body mass index of >38 kg/m2. Compared with conservative weight management, base case patients who underwent RYGB gained 10.6 months of life, and gained 8.3 months of life after SG. Balancing progression of CKD with improved survival on end-stage renal disease for obese patients requires selective use of weight management strategies. RYGB and SG improved survival for CKD patients with Class II and III obesity, but not for patients with Class I obesity. As such, aggressive weight loss interventions should be reserved for patients with Class II and III obesity, while more conservative methods should be offered to those with Class I obesity.

PUVs are more common in boys with hypospadias

The association between posterior urethral valves (PUVs) and hypospadias has previously been reported in case reports. After the identification of this twin pathology in a number of patients, a national retrospective review of all patients with this dual diagnosis was performed. All patients were identified in each centre from surgical databases of prospectively collated information on all surgical procedures. The medical notes were reviewed to ascertain demographics, the type of hypospadias, the mode of presentation of the valves and the outcome. Twenty-eight patients who had the dual diagnosis of hypospadias and PUV between 2002 and 2017 in the four tertiary paediatric centres where specialist paediatric urology is undertaken in our country were identified. Most patients (n=24) had the valves diagnosed after hypospadias surgery. The median age at the time of hypospadias surgery was 1.4 years (range 1-4 years). There were 12 proximal and 16 mid or distal hypospadias. The commonest presentation was with problems voiding after surgery in 14 cases with a further seven boys who had urinary tract infections. Four patients had a urethro-cutaneous fistula after repair that initiated further assessment. Two boys had distal dehiscence of their repair. There was one boy presented with new onset daytime incontinence. The median time of follow-up after valve incision surgery was 4.9 years (range 0.1-12.3 years). Twenty-two patients (three pre toilet training) had no ongoing urinary symptoms. Twenty-one boys have normal renal function with one patient in stage 3b chronic kidney disease. The incidence of this dual diagnosis in Scotland is estimated at one in 100 cases of hypospadias in the paediatric population. The incidence of PUV in boys with hypospadias is estimated at 1%patients.

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.

Aortic Calcification and Arterial Stiffness Burden in a Chronic Kidney Disease Cohort with High Cardiovascular Risk: Baseline Characteristics of the Impact of Phosphate Reduction On Vascular End-Points in Chronic Kidney Disease Trial

Chronic kidney disease (CKD) is associated with excess cardiovascular morbidity and mortality compared to the general population. Hyperphosphataemia, associated with vascular calcification and arterial stiffness, may play a key role in the pathogenesis of cardiovascular disease (CVD) associated with CKD, although phosphate reduction strategies have not consistently proven to beneficially affect clinically relevant outcomes. The IMpact of Phosphate Reduction On Vascular End-points in CKD (IMPROVE-CKD) study is an international, multi-centre, randomized, placebo-controlled trial investigating the effect of the phosphate binder lanthanum carbonate on intermediate cardiovascular markers in patients with stage 3b–4 CKD. The primary end-point is change in carotid-femoral pulse wave velocity (PWV, SphygmoCor) after 96 weeks. Secondary outcomes include change in abdominal aortic calcification (AAC, computed tomography), serum phosphate and fibroblast growth factor 23 (FGF-23). In total, 278 participants were recruited and randomized, mean age 63 ± 13 years, 69% male, 45% diabetes, 32% CVD, 33% stage 3b CKD and 67% stage 4 CKD. Mean estimated glomerular filtration rate and serum phosphate were 26.6 ± 8.3 mL/min/1.72 m² and 1.25 ± 0.20 mmol/L, respectively. Median (interquartile range) intact and c-terminal FGF-23 levels were 133.0 (89.1–202) pg/mL and 221.1 (154.3–334.1) RU/mL, respectively. Mean PWV was 10.8 ± 3.6 m/s and 81% had AAC (median Agatston score 1,535 [63–5,744] Hounsfield units). PWV ≥10 m/s was associated with older age, diabetes, CVD, presence of AAC, higher systolic blood pressure (BP), larger waist circumference and higher alkaline phosphatase. AAC was associated with older age, male sex, diabetes, CVD, higher diastolic BP, dyslipidaemia (and use of statins), smoking, larger waist circumference and increased PWV. In conclusion, IMPROVE-CKD participants had high baseline risk for cardiovascular events, as suggested by high baseline PWV and AAC values.

Impact of Continuous Flow Left Ventricular Assist Device Therapy on Chronic Kidney Disease: A Longitudinal Multicenter Study

BackgroundMany patients undergoing durable left ventricular assist device (LVAD) implantation suffer from chronic kidney disease (CKD). Therefore, we investigated the effect of LVAD support on CKD. MethodsA retrospective multicenter cohort study, including all patients undergoing LVAD (HeartMate II (n = 330), HeartMate 3 (n = 22) and HeartWare (n = 48) implantation. In total, 227 (56.8%) patients were implanted as bridge-to-transplantation; 154 (38.5%) as destination therapy; and 19 (4.7%) as bridge-to-decision. Serum creatinine measurements were collected over a 2-year follow-up period. Patients were stratified based on CKD stage. ResultsOverall, 400 patients (mean age 53 ± 14 years, 75% male) were included: 186 (46.5%) patients had CKD stage 1 or 2; 93 (23.3%) had CKD stage 3a; 82 (20.5%) had CKD stage 3b; and 39 (9.8%) had CKD stage 4 or 5 prior to LVAD implantation. During a median follow-up of 179 days (IQR 28–627), 32,629 creatinine measurements were available. Improvement of kidney function was noticed in every preoperative CKD-stage group. Following this improvement, estimated glomerular filtration rates regressed to baseline values for all CKD stages. Patients showing early renal function improvement were younger and in worse preoperative condition. Moreover, survival rates were higher in patients showing early improvement (69% vs 56%, log-rank P = 0 .013). ConclusionsRenal function following LVAD implantation is characterized by improvement, steady state and subsequent deterioration. Patients who showed early renal function improvement were in worse preoperative condition, however, and had higher survival rates at 2 years of follow-up.

Chronic Kidney Disease Impacts Health-Related Quality of Life of Children in Uganda, East Africa

Background: 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 renal disease in Ugandan children 0-18 years and compared HRQoL in children with CKD or with benign or resolving renal disease (non-CKD) to assess predictors of HRQoL. Methods: Demographic, socioeconomic and clinical data were obtained for this cross-sectional study. Pediatric Quality of Life Core ScaleTM (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. Findings: 149 children (71 CKD, 78 non-CKD; median age 9 years; 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<0.0001; 63 vs. 86 by parent proxy report, p<0.0001). Predictors of lower HRQoL were advanced CKD stages 3b-5, primary caregiver non-parent, vitamin D deficiency and anemia. Interpretation: Like other parts of the world, CAKUT was the main cause of CKD. Most CKD children presented at late CKD stages 3b-5. Compared to 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. Funding Statement: Early Career Program Award (Grant 12754) of the Thrasher Research Fund. Declaration of Interests: The authors of this manuscript have no conflicts of interest to disclose. Ethics Approval Statement: At enrollment after explanation of the study objectives, relevance, risks and benefits, informed consent was obtained from all parents or caregivers, and assent obtained from children who were eight years or older. This study was approved by the Baylor College of Medicine Institutional Review Board, the Makerere University Faculty of Medicine and Mulago Hospital Research and Ethics Committees, and the Uganda National Council of Science and Technology.

Initial Acute Decline in Estimated Glomerular Filtration Rate After Sodium-Glucose Cotransporter-2 Inhibitor in Patients With Chronic Kidney Disease.

BackgroundRenal function deterioration accompanied by an acute decrease in estimated glomerular filtration rate (eGFR) was observed early after starting sodium-glucose cotransporter-2 inhibitor (SGLT2i) therapy. It is unclear how much and how frequently the initial acute decline in eGFR (IAD-eGFR) would occur after SGLT2i administration, and the effects of IAD-eGFR on subsequent renal function are unknown in type 2 diabetes mellitus (T2DM) patients with chronic kidney disease (CKD).MethodsWe retrospectively recruited T2DM patients with CKD (stage 3b; 30 ≤ eGFR < 45 mL/min/1.73 m2) and who were newly treated with add-on SGLT2i. We further investigated the effects of SGLT2i therapy on eGFR early after starting treatment (1 - 3 months) and after 6 months of treatment. We examined the factors associated with a large IAD-eGFR (≥ 10%) using logistic regression analyses.ResultsEighty-seven patients (male, 74.7%; mean age, 69.8 years; median hemoglobin A1c, 7.3%; mean eGFR, 37.8 mL/min/1.73 m2) were analyzed. The mean minimum eGFR early after SGLT2i administration was 34.9 mL/min/1.73 m2, which was significantly lower than before treatment (mean, -7.7%). Seventy patients (80.5%) had IAD-eGFR, and 36 patients (41.4%) had a large IAD-eGFR (≥ 10%). Overall, the mean eGFR was 38.2 at 6 months after starting SGLT2i administration. In patients with a large IAD-eGFR (≥ 10%), the eGFR decreased by 72.2% at 6 months to 35.5 mL/min/1.73 m2, showing a significant decline from the pretreatment value. In patients without a large IAD-eGFR, eGFR increased by 66.7% at 6 months to 40.0 mL/min/1.73 m2. Multiple logistic regression analysis showed that patients with a large IAD-eGFR had a significant association with a high estimated daily salt intake.ConclusionsSGLT2i treatment frequently induced a significant decrease in eGFR early after starting therapy, but eGFR tended to recover after 6 months in T2DM patients with CKD stage 3b. A large IAD-eGFR (≥ 10%) caused by SGLT2i may lead to subsequent deterioration in renal function, and it was significantly associated with a higher estimated daily salt intake. These results suggest that a more effective renoprotective therapeutic strategy using SGLT2i may be implemented by avoiding the occurrence of a large IAD-eGFR. Further prospective studies are warranted.

Polypharmacy Is Associated With Accelerated Deterioration of Renal Function in Cardiovascular Outpatients

BackgroundPolypharmacy is associated with poor prognosis of patients with various diseases. However, it has not been precisely addressed how polypharmacy affects the clinical characteristics of the cardiovascular outpatients. The aim of this study is to search for the clinical characteristics related to the number of prescribed drugs in the cardiovascular outpatients. Also, we examine whether the number of the prescribed drugs affects the worsening of renal function.MethodsThis retrospective study was conducted using the data of 259 continuous cardiovascular outpatients who were examined complete blood count (CBC) and serum creatinine.ResultsIn the univariate analysis, the number of prescribed drugs were associated with the number of cardiovascular diseases or their risk factors, age, white blood cells, platelet, body mass index, anemia, and chronic kidney disease stage 3b or higher. In the multivariable analysis, independent variables that significantly correlated with the number of prescribed drugs were the number of cardiovascular diseases or their risk factors, anemia, and chronic kidney disease stage 3b or higher. Among 259 patients, 208 patients received follow-up examination of serum creatinine. The number of prescribed drugs was the only factor that was associated with accelerated deterioration of renal function.ConclusionsPolypharmacy is associated not only with poor renal function but with accelerated deterioration of renal function. Polypharmacy may be causally related with renal dysfunction.

Impact of Chronic Kidney Disease in Older Adults Undergoing Hip or Knee Arthroplasty: A Large Database Study

BackgroundHip and knee arthroplasties are among the most commonly performed surgical procedures in the elderly. In this age group, uncertainty exists regarding the importance of mild to moderate chronic kidney disease (CKD), which is prevalent but often unrecognized in the perioperative setting. This study evaluates the association between mild to moderate CKD and adverse postoperative outcomes in patients 65 years or older MethodsThis retrospective study selected patients 65 years or older undergoing hip or knee arthroplasty between 2006 and 2016 from the National Surgical Quality Improvement Program database. We created logistic regression models to analyze the relationship between CKD stage and each of our coprimary outcomes. The primary outcomes were major complication and mortality occurring within 30 days of surgery. ResultsOf the 193,747 included patients, 68,424 (35.3%) underwent hip and 125,323 (64.7%) knee arthroplasty. Within 30 days of surgery, 12,767 patients (6.6%) experienced a major complication and 352 (0.2%) died. Compared to patients with no kidney disease, patients with CKD stages 3b and 4 were at higher risk for both major complication (adjusted odds ratio [aOR] 1.28 [1.08-1.52], aOR 1.5 [1.13-1.98], respectively) and mortality (aOR 3.17 [1.23-8.14], aOR 3.93 [1.26-12.21], respectively) after hip arthroplasty, and for major complication (aOR 1.42 [1.23-1.63], aOR 1.52 [1.19-1.93], respectively) after knee arthroplasty. ConclusionAmong elderly patients, stage 3b and stage 4 CKD were associated with 30-day postoperative major complication after hip or knee arthroplasty, and with 30-day postoperative mortality after hip, but not knee, arthroplasty. Further research will be required to inform perioperative management decisions.

Chronic Kidney Disease Has a Graded Association with Death and Cardiovascular Outcomes in Stable Coronary Artery Disease: An Analysis of 21,911 Patients from the CLARIFY Registry.

Chronic kidney disease (CKD) is associated with an increased cardiovascular risk in a broad spectrum of populations. However, the risk associated with a reduced estimated glomerular filtration rate (eGFR) in patients with stable coronary artery disease receiving standard care in the modern era, independently of baseline cardiovascular disease, risk factors, and comorbidities, remains unclear. We analyzed data from 21,911 patients with stable coronary artery disease, enrolled in 45 countries between November 2009 and July 2010 in the CLARIFY registry. Patients with abnormal renal function were older, with more comorbidities, and received slightly lower—although overall high—rates of evidence-based secondary prevention therapies than patients with normal renal function. The event rate of patients with CKD stage 3b or more (eGFR <45 mL/min/1.73 m2) was much higher than that associated with any comorbid condition. In a multivariable adjusted Cox proportional hazards model, lower eGFR was independently associated with a graded increased risk of cardiovascular mortality, with adjusted HRs (95% CI) of 0.98 (0.81–1.18), 1.31 (1.05–1.63), 1.77 (1.38–2.27), and 3.12 (2.25–4.33) for eGFR 60–89, 45–59, 30–44, and <30 mL/min/1.73 m2, compared with eGFR ≥90 mL/min/1.73 m2. A strong graded independent relationship exists between the degree of CKD and cardiovascular mortality in this large cohort of patients with chronic coronary artery disease, despite high rates of secondary prevention therapies. Among clinical risk factors and comorbid conditions, CKD stage 3b or more is associated with the highest cardiovascular mortality.

Anti-Müllerian hormone concentrations in women with chronic kidney disease.

BackgroundSerum anti-Müllerian hormone (AMH) is a biomarker of ovarian reserve. There are limited data to guide the clinical interpretation of AMH in women with chronic kidney disease (CKD). The purpose of this study was to examine AMH concentrations in women with CKD compared with women without CKD.MethodsWe conducted a prospective cohort study of serum AMH concentrations in 163 non-pregnant women with CKD. Serum AMH concentrations were compared with age-specific AMH centiles from 887 healthy female controls.ResultsParticipants included 30 women with Stage 1 CKD, 37 women with Stage 2 CKD, 26 women with Stage 3a CKD, 31 women with Stage 3b CKD and 39 women with Stages 4 and 5 CKD. The median estimated glomerular filtration rate (eGFR) was 51 (interquartile range 31–80) mL/min/1.73 m2. Serum AMH concentrations were lower in all CKD stages compared with women without CKD. Women ages 20–24 years with CKD had comparable serum AMH concentrations (median 1.959 ng/mL) to women ages 35–39 years without CKD (median 1.995 ng/mL). There was no evidence that eGFR was an independent modifier of serum AMH concentrations. More than half of women with CKD (58%) were predicted to have a low response to gonadotrophin stimulation.ConclusionsWomen with CKD have a lower ovarian reserve and are predicted to have a lower ovarian response to gonadotrophin stimulation compared with women without CKD of a similar age. Women with CKD who fail to conceive within 6 months of regular unprotected intercourse should be considered for fertility assessment and intervention.

Use of Potentially Nephrotoxic Medications by U.S. Adults with Chronic Kidney Disease: NHANES, 2011-2016.

People with chronic kidney disease (CKD) are at risk for adverse events and/or CKD progression with use of renally eliminated or nephrotoxic medications. To examine the prevalence of potentially inappropriate medication (PIM) use by U.S. adults by CKD stage and self-reported CKD awareness. Cross-sectional analysis of National Health and Nutrition Examination Surveys, 2011-2016 PARTICIPANTS: Non-pregnant adults with stages 3a (eGFR 45-59 mL/min/1.73 m2), 3b (eGFR 30-44), or 4-5 (eGFR < 30) CKD, stratified as CKD-aware/unaware. PIMs were identified on the basis of KDIGO guidelines, label information, and literature review. We calculated proportions using any and individual PIMs, assessing for differences over CKD awareness within each CKD stage. Analyses were adjusted for age, sex, race/ethnicity, education, comorbidities, and insurance type. Adjusted proportions of U.S. adults taking any PIM(s) exceeded 50% for all CKD stages and awareness categories, and were highest among CKD-unaware patients with stages 4-5 CKD: 66.6% (95% CI, 55.5-77.8). Proton pump inhibitors, opioids, metformin, sulfonylureas, and non-steroidal anti-inflammatory drugs (NSAIDs) were all used frequently across CKD stages. NSAIDs were used less frequently when CKD-aware by patients with stage 3a CKD (2.2% [95% CI, - 0.3 to 4.7] vs. 10.7% [95% CI, 7.6 to 13.8]) and stages 4-5 CKD (0.8% [95% CI, - 0.9 to 2.5] vs. 16.5% [95% CI, 4.0 to 29.0]). Metformin was used less frequently when CKD-aware by patients with stage 3b CKD (8.1% [95% CI, 0.3-15.9] vs. 26.5% [95% CI, 17.4-35.7]) and stages 4-5 CKD (none vs. 20.8% [95% CI, 1.8-39.8]). The impact of CKD awareness was statistically significant after correction for multiple comparisons only for NSAIDs in stage 3a CKD. PIMs are frequently used by people with CKD, with some impact of CKD awareness on NSAID and metformin use. This may lead to adverse outcomes or hasten CKD progression, reinforcing the need for improved medication management among people with CKD.

Features of the structural and functional condition of the myocardium in patients with chronic kidney disease and chronic heart failure

Relevance. The results of the structural and functional condition of the heart in patients with chronic heart failure with mid-range ejection fraction and heart failure with preserved ejection fraction and chronic kidney disease stage 3 were analyzed.&#x0D; Purpose. To study clinical and laboratory parameters, as well as the structural and functional condition of the myocardium in patients with chronic kidney disease stage 3 and chronic heart failure with mid-range ejection fraction and heart failure with preserved ejection fraction.&#x0D; Materials and methods. A total of 41 patients with chronic stage 3 kidney disease and chronic heart failure with mid-range ejection fraction and heart failure with preserved ejection fraction were examined. Structural and functional changes in the myocardium were estimated by means of echocardiography and tissue Doppler imaging.&#x0D; Results and conclusion. In patients with chronic heart failure with mid-range ejection fraction and heart failure with preserved ejection fraction, the presence of chronic kidney disease stage 3b in comparison with stage 3a is characterized by a more significant interatrial conduction abnormality, AV-node and bundle of the His, and also more significant violation of systolic function, not only the left, but also right ventricles. In the patients with chronic heart failure with mid-range ejection fraction and heart failure with preserved ejection fraction and the presence of chronic kidney disease stage 3a, diastolic dysfunction of the left ventricle of the I type prevails significantly more often. In the patients with chronic kidney disease of 3b stage diastolic dysfunction of the left ventricle type II is more common.

CHRONIC KIDNEY DISEASE, MUSCLE WEAKNESS, AND MOBILITY LIMITATION

Objectives: Chronic kidney disease (CKD) is associated with increased mobility limitation. Prior research has documented that peripheral nerve abnormalities occur early in CKD and progressively worsen. Loss of balance, impaired muscle strength, and slow gait predispose older adults to falls and frailty. However, the current literature is limited by a lack of nationally representative data that includes objective measures of kidney disease and physical functioning. Thus, this research examines whether CKD is associated with muscle strength, balance, gait, and self-reported mobility limitations. Methods: Data come from the 2016 Health and Retirement Study (HRS). Estimated GFR, a measure of kidney functioning derived from creatinine levels in the blood, was used to classify CKD (i.e, eGFR<45 or Stage 3b CKD). Logistic and linear regression models were generated to examine the association of CKD with physical functioning, net of demographic characteristics (i.e., age, sex, race, and education) and comorbidities (i.e., obesity, pain, and number of diagnosed medical conditions). Results: In unadjusted models, CKD was significantly associated (p<0.05) with more mobility limitations, slower walking speeds, stronger grip strengths, and non-participation in balance tests. After adjusting for covariates, CKD (β=-1.43, p=0.01) was negatively associated with grip strength. In sex-stratified models, CKD was associated with slower walking speeds among men, whereas CKD was associated with more mobility limitations among women. Discussion: In a nationally representative sample of older adults, CKD was associated with poorer physical functioning on multiple measures. After adjusting for demographic characteristics and comorbidities, CKD was associated with increased muscle weakness.

The association between proinflammatory cytokines and kidney function, body composition, and nutritional markers in nondialysis-dependent chronic kidney disease patients with diabetes mellitus type 2

Chronic kidney disease (CKD) is associated with a subclinical inflammatory state, which contributes to increased mortality in CKD patients. The purpose of this study was to examine the association between chosen cytokines, such as IFN-γ, IL-10, IL-2p70, IL-6, and kidney function as well as the body composition and nutritional markers in patients with CKD and diabetes mellitus type 2. 21 patients with diabetes mellitus type 2 and CKD stage 3b-5, with estimated glomerular filtration rate (eGFR) lower than 45 mL/min/1.72m2, not being treated with dialysis were included in the study. Body composition was assessed by bioimpedance spectroscopy (Body Composition Monitor - Fresenius Medical Care). Significant, negative correlations between lean tissue index (LTI) and IFN-γ concentrations (r=-0.52, p=0.021) as well as IL-6 concentrations (r=-0.46, p=0.047) were observed. Only the IL-6 levels significantly correlated with kidney function expressed by eGFR (r=-0.47, p=0.034). We observed a significant positive correlation between IL-6 level and IFN-γ (r=0.51, p=0.019) as well as with high-sensitivity C-reactive protein (hsCRP) levels (r=0.48, p=0.029). The IL-10 level significantly correlated with hsCRP (r=0.53, p=0.015). In CKD patients with diabetes mellitus type 2 during conservative treatment, IL-6 levels were associated with kidney function expressed by eGFR. IL-6 levels and IFN-γ levels negatively correlated with the amount of muscle mass. Cytokines did not show any association with the amount of fat tissue this study.

Retrospective cohort study on the safety and efficacy of docetaxel in Japanese non-small cell lung cancer patients with nondialysis chronic kidney disease stage 3b or higher.

BackgroundIt has been reported that 20% of lung cancer patients have renal impairment caused by chronic kidney disease (CKD). Since docetaxel is predominantly excreted by the hepatobiliary system, it is administered to non‐small cell lung cancer (NSCLC) patients with renal impairment. However, few clinical data are available on the toxicity and efficacy of docetaxel for patients with nondialysis renal impairment. Furthermore, some cases of tubular nephrotoxicity caused by docetaxel in NSCLC patients have been reported. Therefore, a retrospective cohort study was conducted to assess the influence of nondialysis CKD on the toxicity and efficacy of docetaxel in NSCLC patients.MethodsNSCLC patients who received docetaxel were assessed for renal function, occurrence of adverse events and treatment efficacy.ResultsA total of 34 NSCLC patients who received docetaxel were studied. Eight (23.5%) patients had nondialysis CKD stage 3b or higher, with an estimated glomerular filtration rate (eGFR) <45 mL/min/1.73 m2. Although the differences were not statistically significant, the starting dose of docetaxel (mg/m2) was lower (60 mg/m2; 37.5% vs. 69.2%) in patients with an eGFR <45 than that in patients with an eGFR ≥45. No significant association was observed between pretreatment eGFR and hematological and nonhematological toxicities. No significant difference was observed in the disease control rate (62.5% vs. 65.4%, P = 1.000) or in the median overall survival (10.7 vs. 11.7, P = 0.735) between patients with an eGFR <45 and those with an eGFR ≥45.ConclusionDocetaxel is a reasonable option for NSCLC patients with nondialysis CKD stage 3b or higher. Dose reduction of docetaxel is also a possibility for NSCLC patients with CKD stage 3b or higher.