Chronic Kidney Disease Stages III-V Research Articles

Evaluation of hepatosteatosis and gallstone disease in patients with chronic kidney disease.

The prevalence rates of hepatosteatosis and gallstones are increasing owing to the multifactorial causes of chronic kidney disease, and the prevalence may change with the availability of different forms of renal replacement therapy. We aimed to determine the incidence or prevalence rates of hepatosteatosis, cholelithiasis, and acute cholecystitis in patients with chronic kidney disease and compare them between renal replacement therapy modalities. A total of 270 patients (90 with chronic kidney disease stages III-V, 90 undergoing peritoneal dialysis, and 90 undergoing hemodialysis) were included and categorized into the pre-dialysis, hemodialysis, and peritoneal dialysis groups. The patients were questioned about previous gallbladder surgeries and chronic diseases. The results of abdominal ultrasonography, tomography, and magnetic resonance imaging were retrospectively evaluated with respect to the findings on the hepatobiliary system. Hepatosteatosis and cholelithiasis were diagnosed by expert radiologists on the basis of abdominal ultrasonography, tomography, and magnetic resonance imaging findings. The prevalence rates of hepatosteatosis, cholelithiasis, and other liver findings were compared between the groups. Hepatosteatosis and cholelithiasis were detected in 16.7% and 21.5% of the 270 cases, respectively. Hepatosteatosis was present in 17.8%, 25.6%, and 6.7% of patients in the pre-dialysis, hemodialysis, and peritoneal dialysis groups, respectively. The prevalence of hepatosteatosis was significantly higher in patients undergoing hemodialysis than in patients undergoing peritoneal dialysis (p = 0.002). However, no statistically significant difference was found between the peritoneal dialysis and pre-dialysis groups or between the hemodialysis and pre-dialysis groups (p >0.05). The prevalence rates of cholelithiasis were 15.6%, 28.9%, and 20.0%, in the pre-dialysis, hemodialysis, and peritoneal dialysis groups, respectively, and there were no statistically significant differences among the groups. The incidence of acute cholecystitis was significantly higher in the hemodialysis group than in the pre-dialysis group (p = 0.006). Our study showed that the hepatobiliary system is frequently affected in chronic kidney disease and that the findings may differ depending on the renal replacement therapy modality.

Association between sarcopenia and frailty in elderly patients with chronic kidney disease.

Frailty and sarcopenia are prevalent in chronic kidney disease (CKD) populations and could increase the risk for adverse health outcomes. Few studies assess the correlation between frailty, sarcopenia and CKD in non-dialysis patients. Therefore, this study aimed to determine frailty-associated factors in elderly CKD stage I-IV patients, expected to early identify and intervene in the frailty of elderly CKD patients. A total of 774 elderly CKD I-IV patients (>60years of age) recruited from 29 clinical centers in China between March 2017 and September 2019 were included in this study. We established a Frailty Index (FI) model to evaluate frailty risk and verified the distributional property of FI in the study population. Sarcopenia was defined according to the criteria of the Asian Working Group for Sarcopenia 2019. Multinomial logistic regression analysis was used to assess the associated factors for frailty. Seven hundred seventy-four patients (median age 67years, 66.0% males) were included in this analysis, with a median estimated glomerular filtration rate of 52.8mL/min/1.73m2 . The prevalence of sarcopenia was 30.6%. The FI exhibited a right-skewed distribution. The age-related slope of FI was 1.4% per year on a logarithmic scale (r2 =0.706, 95% CI 0.9, 1.8, P<0.001). The upper limit of FI was around 0.43. The FI was related to mortality (HR=1.06, 95% CI 1.00, 1.12, P=0.041). Multivariate multinomial logistic regression analysis showed that sarcopenia, advanced age, CKD stage II-IV, low level of serum albumin and increased waist-hip ratio were significantly associated with high FI status, while advanced age and CKD stage III-IV were significantly associated with for median FI status. Moreover, the results from the subgroup were consistent with the leading results. Sarcopenia was independently associated with an increased risk for frailty in elderly CKD I-IV patients. Patients with sarcopenia, advanced age, high CKD stage, high waist-hip ratio and low serum albumin level should be assessed for frailty.

Normal saline versus balanced crystalloids in patients with prerenal acute kidney injury and pre-existing chronic kidney disease.

Normal saline (N/S) and Ringer's-Lactate (L/R), are administered in everyday clinical practice. Despite that, N/S increases the risk of sodium overload and hyperchloremic metabolic acidosis. In contrast, L/R has lower sodium content, significantly less chloride and contains lactates. In this study we compare the efficacy of L/R versus N/S administration in patients with prerenal acute kidney injury (AKI) and pre-established chronic kidney disease (CKD). In this prospective open-label study we included patients with prerenal AKI and previously known CKD stage III-V without need for dialysis. Patients with other forms of AKI, hypervolemia or hyperkalemia were excluded. Patients received either N/S or L/R intravenously at a dose of 20 ml/kg body-weight/day. We studied kidney function at discharge and at 30 days, duration of hospitalization, acid-base balance and the need for dialysis. We studied 38 patients and 20 were treated with N/S. Kidney function improvement during hospitalization and at 30 days after discharge, was similar between the two groups. Duration of hospitalization was also similar. Anion-gap improvement as expressed with Δanion-gap between discharge and admission day was higher in those patients that received L/R in comparison to those that received N/S and pH increase (ΔpH) was slightly higher in the L/R group. No patient required dialysis. Administration of L/R or N/S to patients with prerenal AKI and pre-established CKD had no significant difference in short or long term kidney function but L/R showed a better profile in acid-base balance improvement and Cl- overload in comparison to N/S.

Voiding and renal function 10 years after radical cystectomy and orthotopic neobladder in women.

To assess long-term voiding and renal function (RF) changes after radical cystectomy (RC) and orthotopic neobladder (ONB) surgery in women without disease recurrence. Women who underwent RC and ONB reconstruction between 1995 and 2011 were included in this study. Patients who developed disease failure or were lost to follow-up were excluded. The study outcomes were long-term voiding function and the incidence and predictors of RF deterioration (defined as >20% decline of baseline). Analysis was performed using the log-rank test and Cox regression analysis. The study included 195 patients with a median (interquartile range) follow-up of 98 (53-151) months, of whom 95 had >10 years of follow-up. Daytime continence, night-time continence and chronic urine retention (CUR) were identified in 170 (87%), 134 (69%) and 52 patients (27%), respectively. Among patients with >10 years of follow-up, 82 (86%), 66 (70%) and 31 (33%) had daytime continence, night-time continence and CUR at the last follow-up visit, respectively. RF deterioration events occurred in 74 patients throughout the follow-up and chronic kidney disease (CKD) stage III-V developed in 80 patients. Patients' age (hazard ratio [HR] 1.41, 95% confidence interval [CI]1.06-1.89; P = 0.02) and serous-lined extramural tunnel diversion (HR 0.43, 95% CI 0.19-0.86; P = 0.02) were the independent predictors of RF deterioration. Among patients with >10 years of follow-up, RF deteriorated in 46 patients (49%) and CKD stage III-V developed in 40 (42%). Women surviving more than 10 years after RC and ONB maintained acceptable continence status, apart from having a higher CUR rate, compared to those followed for <10 years. However, RF deterioration developed in nearly half of them.

Home-based exercise programs in patients with chronic kidney disease: A systematic review and META-analysis.

Intradialysis exercise programs in renal patients result in improved functional capacity, muscle strength, symptoms of depression, and health-related quality of life. Home-based exercise programs are an alternative to overcome logistical and human resource problems. However, the implementation of these programs is not an easy task and there is a lack of knowledge regarding the benefits associated with home-based exercise programs. To determine whether home-based exercise programs improve functional capacity, health-related quality of life, muscle strength, and symptoms of depression among patients with stage III-V chronic kidney disease. A systematic review and meta-analyses following PRISMA guidelines were utilized. Relevant articles were collected and independently assessed for their inclusion eligibility. Effects of home-based exercise were summarized by the standardized mean differences and represented by forest plots (Review Manager 5.4). Eight studies were included, none of which reported any adverse effects. The intervention was usually aerobic, 76% of these programs lasted 3-6months, and exercise adherence was 60-87.5%. Four studies measured health-related quality of life and found significant improvements in several subscales. Regarding functional capacity, five studies used the six-minute walking test (44.9 meters; 95% CI [30.45, 59.30]; p ≤ .001), three studies used the sit-to-stand-to-sit test (-0.45 seconds; 95% CI [-0.46, -0.26]; p ≤ .001), and two studies used the timed up-and-go test (-0.76 seconds; 95% CI [-1.38, -0.15]; p ≤ .001) and the handgrip strength test (1.16 kg; 95% CI [-2.88, 5.20]; p ≤ .001). Home-based exercise programs are beneficial to renal patients. These interventions are safe and effective to improve health-related quality of life and functional capacity and reduce symptoms of depression among patients with chronic kidney disease.

Epicardial adiposity as a predictor of COVID-19 severity in overweight and obese patients

Aim. To evaluate epicardial adiposity (EA), verified on the basis of epicardial adipose tissue (EAT) thickness according to echocardiography, as a possible predictor of the severity of coronavirus disease 2019 (COVID-19) course in overweight and obese patients in a retrospective analysis of data.Material and methods. We analyzed data on 165 patients (age, 45,2±4,7 years; men, 67,9%; body mass index, 31,4±3,5 kg/m2) who received outpatient or inpatient treatment for symptomatic COVID-19 in period from March 2020 to November 2021. Patients with diabetes, stage III-V chronic kidney disease and/ or cardiovascular disease were excluded from the analysis, with the exception of hypertension. EA was verified in the case of EAT thickness ≥4,8 mm for persons aged 35-45 years and ≥5,8 mm for persons 46-55 years old.Results. Patients with EA were characterized by higher hospitalization rates (52,2% vs 9,0%, p&lt;0,01), moderate (56,5% vs 19,7%, p&lt;0,01), high and very high severity (17,4% vs 3,3%, p&lt;0,01) of disease course, lung injury of CT-1, CT-2 and CT-3 (32,6% vs 9,8% (p&lt;0,01), 21,7% vs 7,4% (p&lt;0,05), and 15,2% vs 2,5% (p&lt;0,01), respectively), invasive ventilation (8,7% vs 0,8%, p&lt;0,05) and C-reactive protein &gt;10 mg/l (69,6% vs 21,3%, p&lt;0,01). Predictors of hospitalization for symptomatic COVID-19 according to multivariate logistic regression analysis were age, fasting glycemia, systolic blood pressure, EAT thickness, which was characterized by the highest standardized regression coefficient among other predictors (0,384, p&lt;0,001).Conclusion. EAT thickness may be one of the predictors of COVID-19 severity in overweight and obese patients. Persons with EA in the case of COVID-19 need more careful monitoring and measures to prevent severe course and complications.

Childhood nephrolithiasis and nephrocalcinosis caused by metabolic diseases and renal tubulopathy: A retrospective study from 2 tertiary centers.

Objectives:To study childhood nephrolithiasis and nephrocalcinosis caused by metabolic disorders, distal renal tubular acidosis (dRTA), and familial hypomagnesemia, hypercalciuria, and nephrocalcinosis (FHHNC).Methods:We retrospectively evaluated 86 children presented over 10 years (2011-2021), with nephrolithiasis (89%) and nephrocalcinosis (11%) caused by metabolic disorders (62%), FHHNC (21%), and dRTA (17%).Results:The mean age at discovery was 72.7 months. The underlying metabolic etiologies included hyperoxaluria (38%), cystinuria (32%), hypercalciuria (24%), and hyperuricosuria (6%). Genetic testing was carried out for 23 patients. Hyperoxaluria was typically treated medically (75%). However, the majority progressed to end-stage kidney disease (ESKD). Most children with cystinuria, hypercalciuria, and hyperuricosuria required medical and surgical intervention. Patients with FHHNC typically presented with nephrocalcinosis. Genetic testing revealed Claudin-16 mutations in 7 children. Patients often progressed to stage II-IV chronic kidney disease (61%) and ESKD (6%). Patients with dRTA typically presented with nephrocalcinosis (80%), as well as poor weight gain and failure to thrive (86%), and medical treatment included sodium bicarbonate and potassium replacement. Despite nephrocalcinosis progression, most patients had normal renal function (53%), although the remaining 47% progressed to chronic kidney disease (none reached ESKD).Conclusion:Childhood nephrolithiasis is mainly related to metabolic disorders and is associated with poor renal outcomes. Nephrocalcinosis and nephrolithiasis have poor outcomes when associated with FHHNC, while nephrocalcinosis associated with dRTA has relatively good renal outcomes.

Oral Anticoagulants for Nonvalvular Atrial Fibrillation in Patients With High Risk of Gastrointestinal Bleeding

Many patients with nonvalvular atrial fibrillation (NVAF) are at a high risk of gastrointestinal (GI) bleeding due to conditions including older age; stage III to V chronic kidney disease (CKD); HAS-BLED (hypertension, kidney or liver disease, stroke history, prior bleeding, unstable international normalized ratio, age >65, drug or alcohol use) score of 3 or greater; corticosteroid, antiplatelet or nonsteroidal anti-inflammatory drug (NSAID) use; or GI conditions. To compare the risk of stroke and/or systemic embolism (SE) and major bleeding (MB) among patients with NVAF and high risk of GI bleeding who received non-vitamin K antagonist oral anticoagulants (NOACs) vs those who received warfarin. This retrospective cohort study included patients with NVAF who were 75 years and older; had stage III to V CKD; had an HAS-BLED score of 3 or greater; used corticosteroids, antiplatelets, or NSAIDs; or had GI conditions. Data were collected from the Centers for Medicare & Medicaid Services and 4 commercial insurance databases between January 1, 2012, and September 30, 2015. Data analysis was conducted from January 2012 to September 2015. New prescription for apixaban, dabigatran, rivaroxaban, or warfarin between January 1, 2013, and September 30, 2015 (identification period). Six propensity score-matched cohorts were created to compare between study drugs. For the primary objective, Cox models were used to estimate stroke and/or SE and MB hazard ratios (HRs). A total of 381 054 patients (187 489 [49.2%] women) with NVAF and at least 1 high-risk GI bleeding factor were identified (HAS-BLED score ≥3: 284 527 [74.7%]; aged ≥75 years: 252 835 [66.4%]; corticosteroid, antiplatelet, or NSAID therapy: 107 675 [28.3%]; prior GI bleeding conditions: 74 818 [19.6%]; and stage III-V CKD: 56 892 [14.9%]). All NOACs were associated with a lower risk of stroke and/or SE vs warfarin (apixaban: HR, 0.60; 95% CI, 0.52-0.68; dabigatran: HR, 0.75; 95% CI, 0.64-0.88; rivaroxaban: HR, 0.79; 95% CI, 0.73-0.86). Compared with warfarin, apixaban and dabigatran were associated with a lower risk of MB (apixaban: HR, 0.59; 95% CI, 0.56-0.63; dabigatran: HR, 0.78; 95% CI, 0.70-0.86), while rivaroxaban was associated with a higher risk (HR, 1.11; 95% CI, 1.05-1.16). In this study of patients with NVAF and high risk of GI bleed, NOACs were associated with lower rates of stroke and/or SE, but NOACs had varying risks of MB compared with warfarin. These results may help inform treatment options in this patient population.

Multidisciplinary education and lifestyle camps for CKD patients and their closest family members: effects on disease progression, self-management and psychosocial condition-a retrospective cohort study.

Multidisciplinary education including psychosocial care (MDE) may alleviate high burden of chronic kidney disease (CKD). Family support also has utmost importance, yet, MDE has rarely been provided jointly for patients and their relatives. We organized intensive, 1-week-long boarding MDE and lifestyle camps for CKD stage III-V patients and their relatives and assessed the rate of CKD progression, proportion of participants' home-based dialysis choice, transplant activity, and improvement of their coping and attitude evaluated by written narratives. Outcome was compared to 40 controls with similarly advanced CKD, under standard of care on our outpatient clinic. In 60 predialysis patients, serum creatinine 12months before participation was 281 [IQR 122] µmol/l, right before MDE 356 [IQR 141] µmol/l, 12months after MDE 388 [IQR 284] µmol/l, eGFR decreased from 18.5 [IQR 10] ml/min to 14.0 [IQR 7] ml/min and 13.0 [IQR 8] ml/min, respectively. Twelve months' changes before and after MDE differed significantly (p = 0.005 for creatinine; p = 0.003 for eGFR). Decreased progression was found in comparison to controls (p = 0.004; 0.016, respectively) as well. During follow-up, MDE patients compared to controls chose PD as dialysis modality more often (p = 0.004), and were more active in renal transplantation (p = 0.026). Based on narratives, MDE enhanced participants' disease-specific knowledge and ability for coping. It also improved sympathy, helpfulness, and the mutual responsibilities of family members. Our unique MDE programme with participation of the closest relatives enhanced the effectiveness of education and strengthened family support, which contributed to favorable CKD outcome, increased activity in home-based dialysis selection and transplant activity.

Effect of serum potassium level on renal function progression in stage Ⅲ-Ⅴ chronic kidney disease patients without dialysis

Objective: To investigate the effect of serum potassium level and hyperkalemia on the renal function decline in chronic kidney disease (CKD) patients. Methods: The clinical data at baseline and follow-up in stage Ⅲ-Ⅴ CKD patients without dialysis who were followed up for more than one year in Tianjin First Central Hospital from May 2015 to June 2019 and Teikyo University School of Medicine from January 2008 to July 2013 were retrospectively collected. All patients were divided into stable group (337 cases), slow progression group (337 cases) and rapid progression group (338 cases) according to the tertile of estimated glomerular filtration rate (eGFR) slope (the annual average percentage of eGFR decline). Multivariate logistic regression analysis models were used to evaluate the correlations of baseline serum potassium or time-averaged serum potassium level with CKD rapid progression. Results: Three hundred and forty-three cases from Tianjin First Central Hospital and 669 cases from Teikyo University School of Medicine were included in the study, and 635 cases (62.7%) were male. The average age was (61±14) years old and the average eGFR decline slope was 4.0%/year. The levels of baseline serum potassium and time-averaged serum potassium of patients in the slow progression group [(4.47±0.52) and (4.51±0.43) mmo/L] and rapid progression group [(4.62±0.62) and (4.76±0.48) mmo/L] were higher than those in the stable group [(4.37±0.49) and (4.38±0.37) mmo/L] (both P<0.05). Meanwhile, 24.6% (83/338) of the patients in the rapid progression group had hyperkalemia at baseline (serum potassium ≥5.0 mmol/L) and 34.9% (118/338) of the patients had time-averaged serum potassium ≥5.0 mmol/L, which were higher than those in the stable group [10.7% (36/337) and 6.5% (22/337)] (both P<0.001). Multivariate logistic regression analysis showed that compared with the stable group, baseline serum potassium (OR=1.843, 95%CI: 1.051-3.234) and time-averaged serum potassium (OR=2.495, 95%CI: 1.040-5.987) were correlated with the rapid progression of CKD. Time-averaged serum potassium ≥5.0 mmol/L was the independent influencing factor for rapid progression of CKD. Conclusions: During the follow-up period, the average level of serum potassium in stage Ⅲ-Ⅴ CKD patients should be controlled under 5.0 mmol/L, which may reduce the risk of rapid decline of renal function.

Evaluation of the relationship between the mean platelet volume and the neutrophil/lymphocyte ratio with progression of chronic kidney disease in patients with autosomal dominant polycystic kidney disease.

OBJECTIVEIncreased inflammation is known to cause higher mortality and morbidity in autosomal dominant polycystic kidney disease (ADPKD). At the same time, inflammation has been shown to contribute in chronic kidney disease (CKD) progression pathogenesis. Neutrophil-lymphocyte ratio (NLR) and mean platelet volume (MPV) have been lately found to be related with systemic inflammation. Therefore, in this study, it was intended to evaluate any correlation between the NLR and MPV degree and poor prognosis in ADPKD patients.METHODSThe study sample comprised 86 adult patients (male: 80.2%, mean age: 35.35 years) screened in the Nephrology Outpatient Clinic with the diagnosis of ADPKD. Data were obtained from the electronic database of the hospital. Two groups were made from the patients: Group I included ADPKD patients with CKD Stages I–II and Group II included ADPKD patients with CKD Stages III–V. The relationships between CKD stage and laboratory parameters were analyzed.RESULTSSignificantly higher NLR (2.64±1.43 vs. 2.02±0.89, p=0.024), MPV (9.84±1.65 vs. 9.08±1.17, p=0.045), and hs-CRP (10.7±2.2 vs. 22.4±8.3, p=0.001) values were determined in Group II than in those with Group I. Positive correlations were statistically significative observed between hs-CRP and MPV and NLR in the patients with ADPKD.CONCLUSIONThe study results demonstrated that significantly NLR and MPV are increased in ADPKD patients with progression of CKD. Therefore, lowering the NLR and MPV level could be new, therapeutic, and preventive alternatives for patients with ADPKD.

Risk factors and knowledge assessment of general public for chronic kidney disease in Taif Region, Saudi Arabia

Introduction: Chronic kidney disease (CKD) is a worldwide public health problem since the rapid increasing prevalence of relevant risk factors, like diabetes, hypertension, unhealthy diet, low to no physical activity and metabolic syndrome. The current study aimed at assessing the risk factors and the general public awareness of CKD in Taif region, Saudi Arabia. Method: We conducted a cross-sectional study during the period of September 2019 to March 2020. For risk factors assessment data regarding CKD cases were collected from the department of nephrology at AL-Hada Military hospital in Taif. An online-based questionnaire was distributed to the general public for knowledge assessment of CKD. 6th year pharmacy student at Taif University and nephrologists from the hospital were also invited to answer the questionnaire. Results: The data of 456 CKD patients with 600 non-CKD individuals were compared for assessment of the most common risk factors. 99% of participants were CKD stage III-V patients. The majority, n=371(81.57%), of the participants were &gt;50 years old. N=328(71.93%) had type 2 diabetes mellitus (Risk ratio= 2.32, CI= 2.03-2.65; Odd ratio=5.7, CI= 4.36-7.45), n=396(86.84%) had hypertension (Risk ratio =9.65,CI-7.46-12.48; Odd ratio: 66.73, CI=45.19-98.54) and n=264(57.89%) had a history of heart diseases (Risk ratio= 3.62, CI=2.96-4.42; Odd ratio= 7.22, CI= 5.42-9.62). In CKD groups, 28.07% of them had low physical activity. In contrast with the control group, only 4% had low physical activity level in their daily routine (p&lt;0.00001). In the general public (n=1419), 919 (64.7%) had poor knowledge, 273 (19.22%) had fair knowledge, and 227 respondents (16.01%) had good knowledge of CKD. Conclusion: The finding suggests that age &gt;50 years, low educational attainment, family history of CKD, diabetes, hypertension, history of kidney stone, CVD and high BMI were significantly associated with CKD progression. We also found that the majority of the general public had poor knowledge of CKD compared to pharmacy graduates and nephrologists. These findings warrant the need for the development of awareness initiatives and programs designed to increase the level of knowledge of the general public of CKD.

Efecto regulador de paricalcitol sobre parámetros inflamatorios, fibróticos y anticalcificantes en el paciente con enfermedad renal crónica. Más allá de la regulación de la enfermedad óseo-mineral

BackwardCardiovascular events are the major cause of morbidity and mortality in patients with chronic kidney disease (CKD). Inflammation and mineral-bone disorder are pathological conditions that have been associated with an increased cardiovascular risk. ObjectiveShow paricalcitol regulation overinflammatory, fibrotic and mineral disorder parameters in CKD. Material and methodsProspective Study in 46 CKD stages III-V patients without dialysis patients whith elevated parathormone in which we introduced paricalcitol. We evaluated classic and newest mineral and bone metabolism serum parameters (calcium, phosphorus, parathormone, fibroblast growth factor-23 [FGF-23], Klotho, calcidiol), inflammatory-fibrosis and anticalcifying parameters (interleukin-6 and 10, tumor necrosis factor-a [TNF- α], transforming growth factor-b [TGF-β],bone morphogenic protein-7 [BMP-7] and fetuin-A) for four months. ResultsAt the end of study soluble Klotho increased (p=.001), FGF-23 remained stable, calcium and phosphorus levels were not increased, calcidiol increased (p=.010) and PTH decreased (p=.002). Inflammation-fibrosis and calcification parameters showed positive regulation after paricalcitol treatment: interleukin-6 decreased significantly (p=.001) and also TNF-α did (p=.005), on the contrary, interleukin-10 and fetuin-A increased (p=.001 for both). Anti-fibrosis marker BMP-7 increased (p=.001) and TGF-b decreased (p=.001). We did not find significant changes in renal function. ConclusionsParicalcitol treatment might be profitable in regulating inflammatory and anticalcificant parameters, unmodified calcium or phosphorus seric levels and preserving kidney function in renal patients with no dialysis. Our selected parameters could indicate paricalcitol effects in mineral and endothelial disorder related to renal disease.

Isolated nocturnal and isolated daytime hypertension associate with altered cardiovascular morphology and function in children with chronic kidney disease: findings from the Cardiovascular Comorbidity in Children with Chronic Kidney Disease study.

Prevalence of isolated nocturnal hypertension (INH) and isolated daytime hypertension (IDH) is around 10% in adults. Data in children, especially in chronic kidney disease (CKD), are lacking. The aim of this cross-sectional multicenter cohort study was to define the prevalence of INH and IDH and its association with cardiovascular morphology and function, that is, pulse wave velocity (PWV), carotid intima-media thickness (cIMT), or left ventricular mass index (LVMI) in children with CKD. Ambulatory blood pressure (BP) monitoring profiles were analyzed in 456 children with CKD stages III-V participating in the Cardiovascular Comorbidity in Children with Chronic Kidney Disease Study (64.3% males, 71.3% congenital anomaly of the kidney and urinary tract, age 12.5 ± 3.2 years, estimated glomerular filtration rate 29 ± 12 ml/min per 1.73 m). Baseline PWV, cIMT, and LVMI were compared in normotension, INH, IDH, or sustained 24-h hypertension. Prevalence of sustained hypertension was 18.4%, of INH 13.4%, and of IDH 3.7%. PWV SDS (SD score) and cIMT SDS were significantly higher in sustained hypertension and INH, and PWV SDS was significantly higher in IDH, compared with normotension. LVMI was significantly increased in sustained hypertension, but not in INH or IDH. Determinants of INH were smallness for gestational age, older age, higher height SDS and parathyroid hormone, and shorter duration of CKD. In logistic regression analysis, day/night-time hypertension or ambulatory BP monitoring pattern (normal, INH, IDH, sustained hypertension) were independently associated with cardiovascular outcome measures: elevated night-time BP was associated with increased cIMT, PWV, and left ventricular hypertrophy; INH was associated with cIMT. INH is present in almost one out of seven children with predialysis CKD; INH and nocturnal hypertension in general are associated with alterations of arterial morphology and function.

P956Management of coronary artery disease in elderly patients with ischemic heart failure and reduced ejection fraction - insights from the COMMIT-HF study

Abstract Background Heart failure (HF) is one of the most important global health problems in developed and ageing societies. Coronary artery disease (CAD) is the most common etiologic factor, related to poor outcomes. Data on CAD management in HF is scarce, especially when addressing subpopulations often omitted in randomized trials, such as the elderly. Purpose With a large cohort of HF patients (n=2730) we have decided to assess the clinical profile, treatment modalities and outcomes in elderly patients undergoing percutaneous coronary intervention (PCI). Methods We analyzed a large single-center all-comer registry of HF patients (left ventricular ejection fraction LVEF≤35%) treated in a large-volume cardiovascular center (2009–2015). Acute coronary syndromes on admission were excluded. Patients with ischemic etiology were selected for further analysis (n=1703) and subsequently divided into the elderly (≥75 y.o., n=346) and young (&lt;75 y.o., n=1357) subgroups. Results The elderly group had understandably a worse clinical profile (mean age 79,1±3,5 vs 61,2±8,2, p&lt;0,001; male 75,2 vs 85,4%, p&lt;0,001; NYHA III &amp; IV 60,3 vs 49,6%, p=0,07; diabetes 50,3 vs 44,9%, p=0,07; AF 35,8 vs 22,0%; p≤0,001; anemia 52,6 vs 36,7%, p&lt;0,001; chronic kidney disease stage III-V 54,1 vs 28,9%, p&lt;0,001; severe mitral insufficiency 13,3 vs 8,7%, p=0,01; history of myocardial infarction 68,8 vs 67,4%, p=0,62).ICD or CRT-D were implanted less frequently in the elderly (56,1 vs 68,5%; p&lt;0,001). Echo analysis revealed significantly better LVEF (27,95,3± vs 25,9±6,0%, p&lt;0,001) and less ventricular dilation (LVEDV 159±61 vs 205±82 ml, p&lt;0,001). Coronary angiography was performed frequently in both groups (78,6 vs 74,9%, p=0,15). Significant lesions were observed in 73,5 and 65,0% of cases respectively (p=0,008). The elderly were insignificantly less frequently qualified for CABG (9,0 vs 12,5%, p=0,17). Proportion of patients qualified for medical management of CAD was similar (23,5 vs 20,7%, p=0,40). PCI was performed frequently in both groups (59,5 vs 57,9%, p=0,69), often as multi-vessel procedures (34,4 vs 32,4%, p=0,67). There was a trend towards more complete revascularization in the younger patients (50,0 vs 59,5%, p=0,06). 12-month all-cause mortality was significantly higher in the elderly (20,3 vs 7,8%, p&lt;0,001). Periprocedural compilications were very low and comparable (bleeding and/or need for transfusion, stroke and myocardial infarction). PCI itself was not a factor influencing long term outcomes (HR 0,75, 95% CI 0,51–1,1, p=0,15). Cox regression analysis revealed that prior stroke, ejection fraction, ICD and beta-blockers were the factors influencing survival (figure 1). Conclusions The analysis shows that PCI is a viable treatment option in the elderly population and when indicated can be performed safely, with good short and long term results. Interventions such as ICD implantation or optimal medical therapy of HF should always be considered. Acknowledgement/Funding None

P4510Impact of secondary tricuspid regurgitation on survival in heart failure - insights from COMMIT-HF registry

Abstract Background Functional tricuspid regurgitation (fTR) is common in left sided heart disease, especially in patients with concomitant left-sided valvular diseases and can lead to functional impairment and reduced survival. However, the impact of fTR on survival in chronic heart failure with reduced left ventricular ejection fraction (HFrEF) without severe left valvular diseases (LVD) is not fully established. The aim of the present study was to observe if moderate to severe fTR may influence the survival in patients with HFrEF without severe LVD. Methods We have analyzed a large single-center registry (n=2731) of HFrEF patients treated in a large-volume cardiovascular center between 2009–2015. After exclusion of patients with severe aortic and mitral valve disease we have included 2435 patients with HFrEF (left ventricular ejection fraction (LVEF) ≤35%). Functional moderate to severe tricuspid regurgitation without severe left valvular diseases was present in 465 patients. Twelve -month vital status was available for the whole patient population. Univariate and multivariate Cox proportional hazard regression models were performed to evaluate the relationship between moderate to severe fTR and mortality in the study group. Results Comparison of clinical data of fTR and non-fTR in HFrEF patients revealed some significant differences (age 63.3±12.9 vs 61.3±12.4, p=0.002; female sex 25.8% vs 17,9%, p&lt;0.001; chronic kidney disease stage III-V 45.3 vs 26.6%, p=0.001; atrial fibrillation 52.4% vs 28.5%, p&lt;0.001). Twelve-month all-cause mortality was over 2-fold higher in the fTR group (21.2% vs 8.1%, p&lt;0.001). There were no significant differences with regard to the medical treatment, implantable defibrillator or cardiac resynchronization therapy. The presence of fTR was identified as an independent echocardiographic factor impaired 12-month all-cause survival (HR 1.59, CI 1.2- 2.09, p&lt;0.001, figure 1) Conclusion Apart from the LVEF, the presence of moderate to severe fTR may predict 12-month all-cause mortality in patients with HFrEF. Acknowledgement/Funding None

Impact of allopurinol on metabolic acidosis in patients with chronic kidney disease; a randomized controlledtrial

Introduction: Chronic kidney disease (CKD) is a disabling disease with multiple complications, like, increased serum levels of uric acid due to glomerular filtration rate (GFR) impairment. Objectives: This study was designed to evaluate the effect of allopurinol on metabolic acidosis in patients with renal failure. Patients and Methods: This is a randomized controlled-trial study on 50 patients with CKD stage II-IV, who referred to Qaem and Montaserieh hospitals in Mashhad. Patients were selected and randomly divided into two equal groups of 25 subjects. In addition to standard treatments, the intervention group received 100 mg allopurinol tablet for three months and the control group received placebo. Demographic data were obtained from each individual. Serum uric acid level, creatinine, blood pH and bicarbonate levels were assessed at the initiation of treatment and at the end of the third month. Results: The mean age of patients was 54.04±12.62 years. Allopurinol administration resulted in a significant increase of serum bicarbonate levels and pH (P&lt;0.001 for each) compared to the control group. A significant reduction in uric acid (P&lt;0.05) and an increase in GFR (P&lt;0.05) was observed in both groups. Conclusion: Allopurinol could ameliorate metabolic acidosis, glomerular filtration and uric acid in patients with CKD.

Prevalence of chronic kidney disease among patients undergoing transradial percutaneous coronary interventions.

While transradial approach to conduct percutaneous coronary interventions offers multiple advantages, the procedure can cause radial artery damage and occlusion. Because radial artery is the preferred site for the creation of an arteriovenous fistula to provide dialysis, patients with chronic kidney disease are particularly dependent on radial artery for their long-term survival. In this retrospective study, we investigated the prevalence of chronic kidney disease in patients undergoing coronary interventions via radial artery. Stage of chronic kidney disease was based on estimated glomerular filtration rate and National Kidney Foundation - Kidney Disease Outcomes Quality Initiative guidelines. A total of 497 patients undergoing transradial percutaneous coronary interventions were included. Over 70.4% (350/497) of the patients had chronic kidney disease. Stage II chronic kidney disease was observed in 243 (69%) patients (estimated glomerular filtration rate = 76.0 ± 8.4 mL/min). Stage III was observed in 93 (27%) patients (estimated glomerular filtration rate = 49 ± 7.5 mL/min). Stage IV chronic kidney disease was observed in 5 (1%) patients (estimated glomerular filtration rate = 25.6 ± 4.3 mL/min) and Stage V chronic kidney disease was observed in 9 (3%) patients (estimated glomerular filtration rate = 9.3 ± 3.5 mL/min). Overall, 107 of 350 patients (30%) had advanced chronic kidney disease, that is, stage III-V chronic kidney disease. Importantly, 14 of the 107 (13%) patients had either stage IV or V chronic kidney disease. This study finds that nearly one-third of the patients undergoing transradial percutaneous coronary interventions have advanced chronic kidney disease. Because many of these patients may require dialysis, the use of radial artery to conduct percutaneous coronary interventions must be carefully considered in chronic kidney disease population.

Effect of Chronic Kidney Disease and Supplemental Polyunsaturated Fatty Acid Use on Exercise Levels During Cardiac Rehabilitation in Patients With Coronary Artery Disease.

The correlation between chronic kidney disease (CKD) and increased cardiovascular disease-related mortality is well established. Cardiac rehabilitation (CR) improves exercise capacity, quality of life, and risk factors in patients with coronary artery disease (CAD). Data on the benefits of CR in patients with CKD are sparse. The purpose of this study was to compare outcomes after CR in patients with CAD but normal renal function, versus those with CAD and CKD. We studied 804 patients with CAD entering an exercise-based CR program. Demographics, risk factors, exercise capacity in metabolic equivalent levels (METs), and estimated glomerular filtration rate (GFR) were recorded before and after the 3-month CR program. Use of polyunsaturated fatty acid (PUFA) was determined by medical records review. Stage III-V CKD (GFR <60 mL/min/1.73 m) was present in 170 patients at baseline. After CR, METs improved in all patients, although increases in patients with a GFR 30 to 59 mL/min/1.73 m (Δ1.6) and a GFR <30 (Δ1.2) were smaller than those in patients with a GFR ≥60 (Δ2.6, P < .05 vs GFR 30-59 and GFR <30). In patients with a GFR ≥60 mL/min/1.73 m, PUFA use was associated with a 20% greater increase in MET levels compared with nonusers (Δ3.0 vs Δ2.5, P = .02); and in patients with a GFR 30 to 59, PUFA use was associated with 30% increase in MET level compared with nonusers (Δ2.0 vs Δ1.4, P = .03). These observations persisted after multivariable adjustment for baseline MET level, demographics, and risk factors. Potential mitigation by PUFA of the smaller improvement in exercise capacity with decreasing GFR requires confirmation in prospective randomized trials.

IgA nephropathy with presentation of nephrotic syndrome at onset in children.

Despite a low incidence, nephrotic syndrome (NS) can present with IgA nephropathy (IgAN). The clinical characteristics and long-term outcomes of pediatric patients with IgAN presenting with NS (NS-IgAN) at onset have not been fully elucidated. We retrospectively analyzed 426 patients, and compared clinical and pathological (Oxford) findings between those with NS-IgAN and those with non-NS-IgAN. Among 426 patients, 30 (7.0%) had NS-IgAN. Logistic analyses showed that male sex (OR: 7.6, p = 0.0002), M1 (OR: 10.3, p = 0.002), and E1 (OR: 15.2, p = 0.0001) were significantly related to NS. The mean observation period was 6.2 ± 3.2years. Although NS-IgAN was associated with significantly lower renal survival than non-NS-IgAN according to Kaplan-Meier analysis (p = 0.02), renal survival of NS-IgAN was good (92.4% at 10years). The most significant prognostic factor for renal survival was remission of proteinuria after treatment, and NS at onset is also a significant prognostic factor for renal survival after adjusting for remission of proteinuria. Twenty children with NS-IgAN were treated with prednisolone alone, or prednisolone and immunosuppressant. Remission of proteinuria occurred in 21 patients. Three cases of NS-IgAN progressed to stage III-V chronic kidney disease at the most recent observation. They all demonstrated heavy proteinuria after the 2-year initial treatment. The significant factor for persistent proteinuria at 5years was S1 in NS-IgAN. The most significant factor for renal survival was responsiveness to treatment, not NS itself. As modifiable acute lesions are the dominant pathological findings in NS-IgAN, histological improvements achieved by appropriate treatments can result in a favorable prognosis.