Stage IV-V Chronic Kidney Disease Research Articles

Sugammadex use in pediatric patients with stage IV-V chronic kidney disease in a quaternary referral hospital: a case series

BackgroundSugammadex is a pharmacologic agent that provides rapid reversal of neuromuscular blockade via encapsulation of the neuromuscular blocking agent (NMBA). The sugammadex-NMBA complex is primarily cleared through glomerular filtration from the kidney, raising the possibility that alterations in renal function could affect its elimination. In pediatric patients, the benefits of sugammadex have led to widespread utilization; however, there is limited information on its application in pediatric renal impairment. This study examined sugammadex use and postoperative outcomes in pediatric patients with severe chronic renal impairment at our quaternary pediatric referral hospital.MethodsAfter IRB approval, we performed a retrospective analysis in pediatric patients with stage IV and V chronic kidney disease who received sugammadex from January 2017 to March 2022. Postoperative outcomes studied included new or increased respiratory requirement, unplanned intensive care unit (ICU) admission, postoperative pneumonia, anaphylaxis, and death within 48 h postoperatively, unplanned deferral of intraoperative extubation, and repeat administrations of NMBA reversal after leaving the operating room.ResultsThe final cohort included 17 patients ranging from 8 months to 16 years old. One patient required new postoperative noninvasive ventilation on postoperative day 2, which was credited to hypervolemia. Another patient had bronchospasm intraoperatively resolving with medication, which could not definitively be associated sugammadex administration. There were no instances of deferred extubation, unplanned ICU or need for supplemental oxygen after tracheal extubation identified.ConclusionNo adverse effects directly attributable to sugammadex in pediatric patients with severe renal impairment were detected. There may be a role for utilization of sugammadex for neuromuscular reversal in this population.

#1839 Evaluating the severity of restless legs syndrome in chronic kidney disease patients across different renal replacement therapies

Abstract Background and Aims Restless Legs Syndrome (RLS) is increasingly recognized as a significant comorbidity in chronic kidney disease (CKD) patients. This cross-sectional study evaluates the risk and severity of RLS in CKD patients across various renal replacement therapies (RRT). Method A total of 167 CKD patients were assessed, including those on hemodialysis (HD) (39%), peritoneal dialysis (PD) (22%), with kidney transplants (19%), and those with non-dialyzed CKD stages IV-V (20%)—the International Restless Legs Syndrome Study Group (IRLS) questionnaire measured RLS severity. Severity scales were categorized into mild (0-10), moderate (11-20), severe (21-30), and very severe (31-40). PTH, P, Ca, ALP, and Mg serum concentrations, as well as vascular calcification, were measured as MBD biomarkers. The Adragaos score was applied to graphs of the hands and pelvis to evaluate vascular calcification. Statistical analyses focused on differences in RLS severity across RRT modalities and associated risk factors. Results The cohort comprised 82 males and 85 females, averaging 58 years. Primary disease etiologies included nephroangiosclerosis (24%), diabetic nephropathy (12%), chronic pyelonephritis (24%), chronic glomerulonephritis (24%), and ADPKD (7%). RLS prevalence was 53.8%, with significant differences in IRLS scores across groups (p ≤ 0.001). HD patients showed a mean IRLS score of 21.8 ± 12.3, with 55% reporting severe or severe symptoms. PD patients scored 16.06 ± 13.02; non-dialyzed CKD patients scored 6.41 ± 6.04; and transplant recipients scored 3.1 ± 4.7. No correlation was found between RLS severity and age or time on RRT. However, significant correlations were observed between RLS severity with HD modality, and the high Adragaos score. Multivariate analysis showed high serum phosphorus p=0.018 and markers of inflammation as a risk factor for RLS severity (CRP levels p=0.034; ferritin (p=0.048). Conclusion This study underscores the disproportionately higher severity of RLS in HD patients, necessitating tailored management strategies for this subgroup. The significant association between RLS severity and calcification and inflammation markers in CKD patients, particularly those on HD, suggests that RLS severity should be a key consideration in the clinical management of CKD. Addressing RLS in these patients may improve their quality of life and influence the outcomes of their renal replacement therapy.

Association of FokI polymorphism of vitamin D receptor gene with vitamin D and parathyroid hormone levels in stage IV-V chronic kidney disease patients

Association of FokI polymorphism of vitamin D receptor gene with vitamin D and parathyroid hormone levels in stage IV-V chronic kidney disease patients

Current views on antiplatelet therapy in acute coronary syndrome patients: the place of clopidogrel

Clopidogrel is the most studied P2Y12 receptor blocker and still has no alternative in a number of categories of ACS patients in whom ticagrelor or prasugrel have not been studied or their use is associated with an unacceptably high risk of bleeding. The review is devoted to a detailed consideration of these clinical situations, both in the light of the evidence base for the benefits of clopidogrel andthe practical aspects of its use. Clopidogrel remains the drug of choice in ST-segment elevation ACS patients undergoing thrombolysis, pharmacoinvasive strategy is implemented, and reperfusion therapy is not used at all. In patients with ACS without ST-segment elevation, clopidogrel is preferable in high risk of bleeding. The article discusses in more detail some particular cases of high bleeding risk in ACS patients, in which it is advisable to use clopidogrel: concomitant use of oral anticoagulants, active cancer, chronic kidney disease stages IV-V. Relatively new data on the peculiarities of ACS antiplatelet therapy in the mongoloid race are discussed, which is relevantto the Russian Federation. In real clinical practice, clopidogrel is often used because of intolerance, contraindications or unavailability of more powerful P2Y12 receptor blockers. Affordability, good tolerability, greater safety (including in relation to the development of recurrent minor “annoying” bleedings), single dose clopidogrel and availability of fixed combinations with acetylsalicylic acid result in better adherence to treatment with this drug than with more powerful P2Y12 receptor blockers, which in real-world settings may provide a more optimal treatment outcome. The article discusses approaches to forced de-escalation of antiplatelet therapy – switching from a more potent P2Y12 receptor blocker to clopidogrel. Data is also presented on the study of routine de-escalation at the end of the acute ACS period, both empirical and controlled by functional or genetic tests characterizing the efficacy of clopidogrel. Although routine de-escalation is not currently recommended, randomized trials suggest that this treatment strategy is promising for preventing hemorrhagic complications and reducing the cost of managing patients with ACS.

Clinical value of troponin profiles in early post coronary artery bypass grafting acute care in advanced chronic kidney disease patients: An insight into perioperative patient characteristics

Abstract Funding Acknowledgements Type of funding sources: None. Background and Aims Diagnosis of type V myocardial infarction (MI) in patients with advanced chronic kidney disease (CKD) undergoing coronary revascularisation surgery (CAB) presents a clinical challenge. We describe postoperative serum troponin (cTn) trends after CAB in CKD stages IV-V, and assess associations with gender, preoperative dialysis, clinical presentation and CAB method. Methods We analysed 51 patients with CKD stage IV-V who underwent CAB at a single centre between 2016-2021. Data on patient characteristics, CAB surgery, and cTn (T) levels were collected retrospectively, and independently for our Society of Thoracic Surgeons database. Patient characteristics were compared between patients undergoing on-pump vs off-pump CAB using appropriate testing methods. The differences in cTn trends between males vs females, acute coronary syndrome (ACS) vs stable angina, patients undergoing preoperative dialysis vs not, and on-pump vs off-pump CAB at different time points were assessed using repeated measurements, and a p value<0.05 was considered to be statistically significant. Results Among 51 patients with stage IV (47%) and V (53%) CKD, off-pump CAB was conducted in 41% (21) of the patients, while the rest underwent on-pump CAB. Patients in the off-pump group were older (62.2 vs 56.6 years, p=0.03), and there were no other statistically significant differences in patient characteristics between groups (Table). Over time, cTn levels increased from 0.34 [0.08-0.9] ng/mL at 24h preoperatively to achieve a peak of 0.75 [0.44-1.7] ng/mL at 18h postoperatively. When comparing cTn trends according to gender, preoperative dialysis, clinical presentation and CAB method, cTn levels were higher in males, patients presenting with ACS, patients who did not undergo preoperative dialysis, and in the on-pump CAB group (Figure). However, in this small sample size study, between-group differences in cTn trends did not achieve statistical significance (p=0.26, p=0.18, p=0.5, and p=0.28, respectively). Conclusion Serum troponin levels peaked consistently by 18h postoperatively in advanced CKD patients undergoing CAB. In addition, males, ACS, on-pump CAB, and non-preoperatively dialysed patients had higher levels of cTn. Further large scale studies are required to definitively evaluate the diagnostic utility and cTn cut-off in this high-risk population.

The association of preoperative dialysis with troponin trends and short term outcomes among advanced kidney disease patients undergoing coronary artery bypass grafting

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Coronary artery disease continues to be the leading cause of death in patients with stage IV-V chronic kidney disease (CKD IV-V). However, the prognosis and early outcomes for advanced CKD patients undergoing coronary artery bypass grafting (CAB) worsen as the estimated glomerular filtration rate (eGFR) deteriorates. Therefore, we compared postoperative clinical outcomes and troponin trends in patients having advanced CKD according to preoperative dialysis status in a single centre experience. Methods A total of 51 patients with CKD IV and V who underwent CAB between 2016-2021 were included in the study. Data on patient characteristics and postoperative outcomes were collected retrospectively, and independently for our Society of Thoracic Surgeons database. Characteristics were compared between patients having CKD IV vs. CKD V. The differences in postoperative cardiac troponin trends and outcomes were evaluated between patients who did vs. did not undergo preoperative dialysis. The statistical analysis was conducted applying appropriate parametric or non-parametric (for skewed variables) testing methods, and a p value < 0.05 was considered to be statistically significant. Results 47% (24) of subjects had CKD IV, while the rest featured CKD V. Patients with CKD IV tended to be older (61.8 ± 9.2 vs. 56.3 ± 11.5 years, p = 0.07), more obese (BMI: 31.4 ± 6.8, 27.4 ± 4.9 kg/m2, p = 0.02) and had significantly higher preoperative GFR (23 ± 4.9 vs. 9 ± 3.3 mL/min, p < 0.001) (Table.1). When comparing patients who underwent preoperative dialysis vs. those who did not, troponin levels were the highest at 18h postoperative in both groups, however, troponin levels were comparable between both groups at all time points (Table.2). Although, there was no difference in hospital length of stay and mortality between these groups, patients who did not undergo preoperative dialysis had longer intensive care unit length of stay (ICU LOS). Conclusion In this single centre experience preoperative dialysis was not associated with a significant difference in trends of postoperative cardiac enzymes. Although preoperative dialysis was associated with shorter ICU LOS, complex pre-procedural surgical risk assessment remains paramount in reducing complications and mortality in this high-risk population. Abstract Figure. Abstract Figure.

Evaluation of the level of natriuretic peptides in the diagnosis and characterization of chronic kidney disease and cardiorenal syndrome in children

BACKGROUND. Natriuretic peptides have cardio- and renoprotective effects, inhibiting inflammatory and proliferative processes. The role of natriuretic peptides in the early diagnosis and characterization of chronic kidney disease (CKD) and cardiovascular complications as the disease development and progresses has not been studied.TNEAIM: to study the level of natriuretic peptides in children depending on the stage of CKD development and to assess the significance of this indicator.PATIENTS AND METHODS. The study involved 93 children with congenital diseases of the urinary system at the age from 3 to 18 years. Three groups were identified: group I - 54 patients with CKD stage I , group II - 29 patients with CKD stage II; Group III - 10 children with CKD stages IV-V (patients with CKD stages IV and V were combined due to their small amount). Control group - 10 clinically healthy children of the corresponding age. The N-terminal propeptide of natriuretic hormone (NT-proBNP) was determined in the blood by the enzyme-linked immunosorbent assay.RESULTS. An increase in the level of NT-proBNP by 28.7% takes place already in the early stages of CKD. With the progression of CKD, an increase in the level of NT-proBNP was noted from 57.4 % in children in the group of patients with stage I CKD to 80 % in children in group III patients. The maximum concentrations of NT-proBNP, many times higher than those in CKD stages I and II, were observed in children with CKD stages IV-V. The degree of increase in the level of NT-proBNP correlated with the severity of CKD.CONCLUSION. In the diagnosis and characterization of CKD and cardiorenal syndrome in children, the determination of the level of natriuretic peptides is of great importance. A high level of natriuretic peptides characterizes the presence of cardiorenal relationships and can be used as an additional criterion for assessing the severity of CKD, including at the early stages of its development.

The Role of Hyperuricemia in the Pathogenesis and Progressivity of Chronic Kidney Disease

In humans, the end product of purine metabolism is uric acid. Over 70% of uric acid is excreted through the kidneys. When renal function is impaired, uric acid secretion is also impaired. This directly correlates the prevalence of hyperuricemia with the severity of chronic kidney disease (CKD). It has been reported that the prevalence of hyperuricemia in patients with Stage I-III CKD is 40–60% and up to 70% in patients with Stage IV-V CKD. Some studies found a link between serum uric acid levels and decreased glomerular filtration rate (GFR), an independent risk factor for CKD development. Because CKD and serum uric acid levels are related, the relationship between the two frequently generates controversy. As such, this review of the literature discusses the role of uric acid in the pathogenesis and progression of CKD.

DOAC versus warfarin in patients with atrial fibrillation and stage IV-V chronic kideny disease including patients on dialysis

Abstract Introduction Patients with atrial fibrillation (AF) and severe chronic kidney disease (CKD) were excluded from most phase III randomized controlled trials (RCTs) of direct oral anticoagulants (DOACs). Evidence of warfarin versus DOAC in the AF population with stage IV-V CKD is therefore limited. Aim To evaluate the effectiveness and safety of DOAC compared with warfarin on this population including dialysis patients. Methods A systematic review and meta-analysis of RCTs and observational studies involving AF patients with stage IV-V CKD treated with warfarin versus DOACs were conducted to evaluate the following outcomes: stroke (ischemic and hemorrhagic) or systemic embolism (SE), all-cause mortality, major bleeding, gastrointestinal (GI) bleeding, and intracranial bleeding. If the heterogeneity between studies was moderate to high calculated as the I2 ≥50%, a meta regression was undertaken between baseline characteristics and the study outcomes. We conducted a literature search using key words related to AF, severe CKD, DOAC and warfarin in PubMed, Embase and Cochrane Library. Results Nine studies were included in the meta-analysis. Compared to warfarin, DOAC was significantly associated with a reduced risk of stroke or systemic embolism (SE) (risk ratio [RR] = 0.69; 95% confidence interval [CI] 0.50–0.95) (Figure 1), intracranial bleeding (RR=0.54; 95% CI 0.35–0.84) and hemorrhagic stroke (RR=0.39; 95% CI 0.16–0.95). There was no significant difference between DOACs and warfarin in the risk of all-cause mortality (RR=0.80; 95% CI 0.57–1.13), major bleeding (RR = 0.70; 95% CI 0.44–1.11) (Figure 2) and GI bleeding (RR=0.76; 95% CI 0.56–1.02). For the outcome stroke or SE, dabigatran (compared with apixaban) significantly eliminated the net effect of DOAC as compared with warfarin (coefficient, 0.8; P=0.003). Regarding major bleeding, rivaroxaban and dabigatran both eliminated the DOAC effect from the meta-analysis as compared to apixaban (P=0.01 & P<0.0001). Dabigatran significantly increased the risk of GI bleeding in comparison to apixaban (coefficient, 0.48; P=0.002) in comparison with the overall similar effect of warfarin in the meta-analysis. Conclusion Among patients with AF and stage IV or V CKD including dialysis patients, DOAC appears to have similar or better effectiveness and safety compared to warfarin. Funding Acknowledgement Type of funding sources: None. Stroke or systemic embolism

Impact-of-medication-reconciliation-by-clinical-pharmacist-during-hospital-admission-of-patients-with-chronic-kidney-disease-ckd-stage-iv-v-in-hospital-raub-pahang

Medication errors are more likely to occur during patient’s transition of care. There was very little information about impact of medication reconciliation activities done for patients with chronic kidney disease (CKD) Stage IV-V during admission stage in Malaysian Primary Hospitals. The objective of this study is to evaluate the impact of clinical pharmacist’s medication reconciliation activities during hospital admission of patients with CKD stage IV-V. This cross-sectional study was carried out in two multidisciplinary wards (male & female ward) in Hospital Raub, Pahang over 12 months with ethical approval. A clinical pharmacist was assigned to enroll potential study subjects in both wards. Patients over 18 years old who had previous history of CKD Stage IV-V were included in the study after obtaining informed consent. Medication reconciliation was carried out by the clinical pharmacist within 24 working hours during the admission of study subjects. All detected medication discrepancies were further classified as “intended” or “unintended” after discussion with the prescribing medical officer. The Severity Level of each unintended medication discrepancy was rated by a visiting medical specialist. Twelve patients with CKD stage V were recruited to the study. A total of 49 medication discrepancies were identified and most (89.8%) were found to be unintended. The most common unintended medication discrepancy identified was omission error. Most of the unintended medication discrepancies (59.1%) was rated as “No potential harm”, while 40.9% were rated as “Potential for monitoring and/or Intervention to preclude harm”. None of the unintended medication discrepancy was rated as “Potential harm”. In conclusion, medication discrepancies were common during admission of patients with late-stage chronic kidney disease in a primary hospital. Medication reconciliation performed by clinical pharmacist during admission has a potential role in preventing potential harms that may arise from unintentional medication discrepancies.

P0915PROTEIN ENERGY WASTING IS ASSOCIATED WITH A DECLINE IN MUSCLE PROTEIN SYNTHESIS IN CKD PATIENTS

Abstract Background and Aims Skeletal muscle is a highly adaptive tissue, however even small imbalances between protein synthesis and degradation can lead to substantial protein loss. Althought proteolysis plays a major role in the development of cachexia in CKD (chronic kidney disease), the responses of muscle protein metabolism to malnutrition had not been completely elucidated. We evaluated retrospectively the results of kinetic studies of protein turnover estimated by the forearm perfusion method associated with H2phenylalanine kinetic, obtained in CKD patients and controls in the last 25 years. Method We analyzed 59 forearm H2phenylalanine kinetic studies obtained in 14 controls (C) (M 11, F 3) and 45 patients with CKD, of whom 15 (M 10, F 5) were on conservative treatment (CKD stage IV-V), 16 (M 14, F 2) under maintenance hemodialysis (HD), 14 (M 12, F 2) in peritoneal dialysis (DP); all subjects were on non-restricted protein/calorie (0.8-1.1 g/kg and 28-32 kcal/kg, respectively) diets. Ten (M 9, F 1) HD patients had Protein Energy Wasting. Acidosis was corrected in all patients (HCO3 24.2±1.9 mmol/L) and studies were performed in the post-absorptive overnight fasted state at rest. Results Overall, Muscle protein synthesis and degradation were similar (p=NS) in patients and controls. Protein net balance was reduced in patients with PD and those with CKD Stage IV-V (p <0.003 - p <0.014) indicating a reduced catabolic state and nitrogen conservation. However PEW HD patients showed reduced rates of protein synthesis and degradation (p <0.048 and p <0.04 respectively). In addition the efficiency of muscle protein turnover, a parameter expressing muscle's ability to reuse amino acids derived from degradation into protein synthesis, was significantly reduced in HD PEW patients vs. controls (55.5 vs. 61.2 %, p <0.018, respectively) and vs. not malnourished patients in conservative treatment (70.1 % p <0.0025) or in PD (74.6 % p <0.005). Conclusion In CKD patients, in absence of acidosis, muscle is able to increase the efficiency of protein metabolism for the maintenance of nitrogen balance. However, in PEW patients, combined alterations of protein synthesis and degradation proceed together to a reduced efficiency of amino acids recycled into protein synthesis and contribute to maintaining wasting. These data also suggest that calorie/protein requirements of CKD patients with PEW may be higher than currently theorized.

Rivaroxaban versus warfarin in patients with nonvalvular atrial fibrillation and stage IV-V chronic kidney disease

There is limited evidence on the effectiveness and safety of direct-acting oral anticoagulants in patients with nonvalvular atrial fibrillation (NVAF) and advanced chronic kidney disease (CKD). This study compared the risks of ischemic stroke/systemic embolism (ISSE) and major bleeding in patients with NVAF and stage IV-V CKD treated with rivaroxaban or warfarin. Patients with NVAF and stage IV-V CKD who initiated rivaroxaban or warfarin treatment between November 2011 and June 2018 were selected from the Optum® Deidentified Electronic Health Record Database. Propensity score matching was used to balance rivaroxaban and warfarin patients on 112 measured baseline covariates. ISSE and major bleeding events over 2 years following treatment initiation were ascertained with validated end point definitions. Outcomes were analyzed as time-to-event data using Kaplan-Meier survival estimators and Cox regression. A total of 781 eligible rivaroxaban-treated patients were propensity score-matched to 1,536 warfarin-treated patients; baseline covariates were well balanced after matching (absolute standardized differences <0.1). The average patient age was 80 years; 60.5% were female; 81.3% and 18.7% had CKD stage IV and V, respectively. Hazard ratios for rivaroxaban compared to warfarin were 0.93 (95% CI 0.46-1.90, P = .85) for the risk of ISSE and 0.91 (95% CI 0.65-1.28, P = .60) for major bleeding. No statistically significant difference in the risk of ISSE or major bleeding was found between rivaroxaban- and warfarin-treated patients. Although further study is needed, rivaroxaban appears to be a reasonable alternative to warfarin for ISSE prevention in the setting of NVAF and stage IV-V CKD.

A018 Acute Coronary Syndrome in Severe Chronic Kidney Disease – Analysis of Management and Outcome

The choice of medical therapy alone or invasive revascularisation in patients with severe chronic kidney disease (CKD) presenting with acute coronary syndrome (ACS) is difficult. Clinical trials frequently excludes patients with severe CKD. In the absence of evidence, optimal management is controversial. We aim to assess management and outcome in the Auckland region. Patients with CKD stage IV-V or end stage kidney disease (ESKD) on dialysis who presented to hospital between 2012-2019 with ACS were identified from the national ANZACS-QI registry. Clinical details, management and combined endpoint of major adverse cardiovascular and cerebrovascular events (MACCE) of all-cause mortality, stroke, rehospitalisation and heart failure were analysed with a mean follow-up of 2.2±1.8 years. 229 patients were identified. Mean age 65±11y. STEMI comprised 18% and NSTEACS 82%. 99 (43%) were dialysis dependent. Patients on dialysis were more likely to undergo invasive coronary angiography (ICA) (83% vs 65%, p=0.002). Overall rate of ICA is 73%, similar in both STEMI and NSTEACS. Stent revascularisation comprise 30% and coronary artery bypass grafting is 17%. Peri-procedural complications were low (significant bleed 1%, stroke 1%, contrast nephropathy 3.6%, death 1.8%). Patients who underwent ICA had reduced all-cause-mortality (OR 0.55, 95%CI 0.38-0.79, p=0.001) and MACCE rates (OR 0.61, 95%CI 0.43-0.84, p=0.003) compared to medical therapy alone. In the Auckland region, over half of patients with severe CKD presenting with ACS undergo ICA which appears to reduce mortality and MACCE rates compared to medical therapy alone.

"At-risk" kidney: How surgical factors influence renal functional preservation after partial nephrectomy.

To investigate the influence of surgical modifiable factors on chronic kidney disease upstaging in a contemporary cohort of patients with normal and "at-risk" kidneys undergoing partial nephrectomy. We reviewed 778 consecutive patients with (n=634)/without (n=144) chronic kidney disease or risk factors for chronic kidney disease in our institutional partial nephrectomy database. Chronic kidney disease upstaging was assessed using glomerular filtration rate measurements preoperatively and at 3-12months postoperatively. Using a multivariate logistic regression, baseline clinicodemographic factors, and the operative measurements of excisional volume loss and warm and cold ischemia time on rates of chronic kidney disease upstaging were determined. Marginal effects were used to analyze the impact of ischemia time and generate interaction curves. Chronic kidney disease/risk factors for chronic kidney disease had equivalent rates of chronic kidney disease upstaging as the healthy kidney cohort (31.5% vs 38.2%, P=0.15). Of the entire cohort, 2.8% were upstaged to stageIV-V chronic kidney disease. Multivariate analysis found a significant association between chronic kidney disease upstaging and excisional volume loss in both cohorts (no chronic kidney disease/risk factors for chronic kidney disease: odds ratio 1.63, P=0.04; chronic kidney disease/risk factors for chronic kidney disease: odds ratio 1.42, P=0.001). Only in the chronic kidney disease/risk factors for chronic kidney disease cohort, there was an association between ischemia type/duration and chronic kidney disease upstaging (odds ratio 1.04, P=0.04). Warm ischemia began to predict an increased risk of chronic kidney disease upstaging at 17.6min, which became statistically significant at 49min. Chronic kidney disease upstaging is common after partial nephrectomy. Although volume loss unequivocally affects rates of upstaging irrespective of baseline renal function, warm ischemia time disproportionately influences "at-risk" kidneys. Therefore, strong consideration should be given to minimizing volume loss and using cold ischemia when extended clamp times are anticipated in "at-risk" kidneys.

Predictors of acute kidney injury after infrarenal abdominal aortic aneurysm repair in octogenarians

ObjectiveAcute kidney injury (AKI) is a common postoperative complication after abdominal aortic aneurysm (AAA) repair and is associated with significant morbidity and mortality. However, limited studies have investigated this complication in elderly patients. This study aims to evaluate AKI in octogenarians after open endovascular AAA repair (OAR) and endovascular AAA repair (EVAR). MethodsData were obtained from the Vascular Quality Initiative database on all patients who underwent elective infrarenal AAA repair between January 2003 and April 2017. Univariate analysis was used to compare AKI rates as well as failure to rescue after AKI between octogenarians and nonoctogenarians in OAR and EVAR. Stepwise multivariable logistic regression analysis was implemented to identify independent predictors and develop a risk calculator of AKI in octogenarians undergoing AAA repair. ResultsA total of 27,993 patients (12% OAR and 88% EVAR) were included, of which 6708 (24%) were octogenarians (OAR, 332; EVAR, 6376). Postoperative AKI was more common in octogenarians as compared with nonoctogenarians in OAR (15.1% vs 10.1%; P = .01) and EVAR (4.2% vs 2.7%; P < .001). Similarly, failure to rescue, defined as 30-day mortality after postoperative AKI, was higher in octogenarians whether undergoing OAR (28.0% vs 8.8%; P < .001) or EVAR (14.1% vs 7.5%; P < .01). On multivariable analysis, octogenarians undergoing OAR had a 3.5 times higher odds of AKI compared with those undergoing EVAR (odds ratio [OR], 3.52; 95% confidence interval [CI], 2.36-5.23; P < .001). Other independent risk factors for postoperative AKI in octogenarians included chronic obstructive pulmonary disease (OR, 1.48; 95% CI, 1.14-1.93), chronic kidney disease stage III (OR, 2.17; 95% CI, 1.26-3.76) and chronic kidney disease stage IV-V (OR, 5.7; 95% CI, 3.0-10.9), peripheral artery disease (OR, 1.99; 95% CI, 1.34-2.94), preoperative β-blocker use (OR, 1.85; 95% CI, 1.45-2.38), and aneurysm diameter (OR, 1.25; 95% CI, 1.11-1.41). These predictors were incorporated in an interactive risk calculator of AKI after AAA repair in octogenarians (C-statistic = 0.728). ConclusionsAKI is a serious complication after AAA repair, especially in octogenarians, and is associated with high failure to rescue rates. A careful assessment of risk factors for AKI in elderly patients should be performed to inform clinical decision making.

Renal Function as a Predictor of Reamputation After Initial Transmetatarsal Amputation in the Perioperative Period

Category: Midfoot/Forefoot Introduction/Purpose: With increasing rates of patients being newly diagnosed with diabetes mellitus, foot complications are becoming more common, which often lead to amputation. Compared to major lower extremity amputations, transmetatarsal amputations (TMA) are associated with lower cost, better function, and more aesthetically satisfactory results for patients. Renal failure has been shown to be a significant predictor of morbidity and mortality in lower extremity amputations at various levels. However, previous reports examining the effect of renal function on reamputation rates after TMA have been mixed. As a result, the purpose of this study was to evaluate renal dysfunction as a risk factor for reamputation after initial TMA during the 30-day perioperative period in a large population database. Methods: Patients under 90 years of age who underwent a TMA between 2012 and 2015 were retrospectively identified in the prospectively collected American College of Surgeons-National Surgical Quality Improvement Program® (ACS-NSQIP®) database using the Current Procedure Terminology (CPT) code 28805. Failure of the initial TMA was defined as reamputation in the 30-day perioperative period through corresponding CPT codes. From these criteria, a total of 1,775 patients were identified. More than 150 unique patient factors were included in the study, but glycated hemoglobin (HbA1C) was not reported by the ACS-NSQIP® database. Diabetes status was categorized into four groups: “Insulin” dependent, “Non-Insulin” dependent, or “None.” Filtration rate was estimated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation, and patients were categorized into stages of chronic kidney disease (CKD). Results: Over the 30-day perioperative period, the rate of reamputation after TMA was 6.5%. No statistical differences in age, gender, race, body-mass index, or level of pre-operative functional status were found between groups. Reamputation rates after TMA was significantly correlated with higher white blood cell counts (p&lt;.00001), greater serum creatinine (p=.021), higher blood urea nitrogen (p=.021), type of glycemic control (p=.002), stage of CKD (p=.003), dialysis (p=.001), and pre-operative blood transfusion (p=.042). Stage IV-V CKD was associated with 75% increased odds of reamputation (OR=1.75, 95% CI=1.12-2.73), and higher stage of CKD was associated with greater reamputation rates (p=.003) where stage II CKD had the lowest reamputation rate (3.6%) and stage V with the highest reamputation rate (10.9%). A similar trend was seen with 30-day mortality (p&lt;.00001). Conclusion: In the current study, CKD was significantly correlated with reamputation rates after TMA as well as 30-day mortality. In contrast to a previous report, dialysis was also associated with TMA failure and need for reamputation. Our findings corroborate previous findings correlating dialysis-dependent renal failure and mortality. Whether patients in certain stages of CKD would achieve better outcomes with higher-level amputation rather than a TMA should be investigated in future studies.

Editor's Choice – Comparison of Renal Outcomes in Patients Treated by Zenith® Fenestrated and Zenith® Abdominal Aortic Aneurysm Stent grafts in US Prospective Pivotal Trials

Fenestrated endovascular repair (FEVAR) has been used to treat complex abdominal aortic aneurysms (AAAs). The risk of renal function deterioration compared with infrarenal endovascular aortic repair (EVAR) has not been determined. Patients with preserved renal function (estimated glomerular filtration rate [eGFR]>45 mL/minute) enrolled in two prospective, non-randomised studies evaluating Zenith fenestrated and AAA stent grafts were matched (1:2) by propensity scores for age, sex, hypertension, diabetes, and pre-operative eGFR. Sixty-seven patients were treated by FEVAR and 134 matched controls treated by EVAR. Mean follow-up was 30±20 months. Outcomes included acute kidney injury (AKI) defined by RIFLE and changes in serum creatinine (sCr), eGFR, and chronic kidney disease (CKD) staging up to 5 years. AKI at 1 month was similar between groups, with > 25% decline in eGFR observed in 5% of FEVAR and 9% of EVAR patients (p=.39). There were no significant differences in > 25% decline in eGFR at 2 years (FEVAR 20% vs. EVAR 20%; p>.99) or 5 years (FEVAR 27% vs. EVAR 50%; p=.50). Progression to stage IV-V CKD was similar at 2 years (FEVAR 2% vs. EVAR 3%; p>.99) and 5 years (FEVAR 7% vs. EVAR 8%; p>.99), with similar sCrand eGFR up to 5 years. During follow-up, there were more renal artery stenosis/occlusions (15/67 [22%] vs. 3/134 [2%]; p<.001) and renal related re-interventions (12/67 [18%] vs. 4/134 [3%]; p<.001) in patients treated by FEVAR. Rate of progression to renal failure requiring dialysis was low and identical in both groups (1.5% vs. 1.5%; p>.99). Aortic repair with FEVAR and EVAR was associated with similar rates of renal function deterioration in patients with preserved pre-operative renal function. Renal related re-interventions were higher following FEVAR, although net changes in renal function were similar in both groups.

PP.19.08] SERUM URIC ACID CHANGE AND MODIFICATION OF BLOOD PRESSURE AND FASTING PLASMA GLUCOSE IN A PHARMACOLOGICALLY UNTREATED POPOLATION SAMPLE

Objective: Serum uric acid (SUA) is an emerging risk factor for incident hypertension and type 2 diabetes. Our ais is to clarify if changes in SUA are associated to different incidence in these main cardiovascular risk factors in a general population sample.Design and method: For the purpose of this study, from the historical cohort of the Brisighella Heart Study, a longitudinal epidemiological study, we selected non diabetic subjects that in 2008 were untreated with uric acid lowering drugs nor antihypertensive ones, and that in the following 4 years did not suffer from gout, stage IV-V chronic kidney disease, neoplasms or used in non continuous way uric acid lowering drugs. Then we divided the subjects in four main groups: the ones that mantained their SUA level unchanged during the next 4 years, the ones that increased it >1 mg/dL without treatment, the ones that reduced it >1 mg/dL without drug treatment and the ones that reduced it >1 mg/dL with the continuous use of allopurinol (150–300 mg/day). Results: As expected, in the whole population, BMI, BP, FPG, Glucose, total and LDL-cholesterol, and TG had the tendence to increase with the increase of age between the two consecutive population surveys. However, evaluating the trend in the various studied parameters among the different identified subgroups, we observed specific differences only as it regards SBP and FPG. Infact, no significant changes have been registered as it regards anthropometric measurement, lipid pattern, liver and renal function in the different considered population subgroups. Compared to 2008, SBP significantly increased in subjects with worsened (and untreated) SUA level, while improved in subjects treated with allopurinol. In 2012, subjects with worsened (and untreated) SUA level had a significantly higher SBP compared with subjects with unchanged SUA and those with SUA improved after allopurinol treatment (p < 0.05). An identical trend has been observed as it regards FPG. Conclusions: Based on our data, obtained from a cohort of overall healthy subjects, it seems that the SUA control could positively influence the age-related worsening of SBP and FPG in general population.

Risk of Acute Kidney Injury, Dialysis, and Mortality in Patients With Chronic Kidney Disease After Intravenous Contrast Material Exposure

ObjectiveTo examine the effect of intravenous iodinated contrast material administration on the subsequent development of acute kidney injury (AKI), emergent dialysis, and short-term mortality using a propensity score–adjusted analysis of computed tomographic scan recipients with chronic kidney disease (CKD). Patients and MethodsIn this institutional review board–approved retrospective study, all patients with CKD who received a contrast-enhanced (contrast group) or unenhanced (noncontrast group) computed tomographic scan from January 1, 2000, to August 1, 2013 were identified. Patients were subdivided into CKD stage III (baseline estimated glomerular filtration rate, 30-59 mL/min per 1.73 m2) and CKD stage IV-V (baseline estimated glomerular filtration rate, <30 mL/min per 1.73 m2) subgroups and separately underwent propensity score generation, stratification, and 1:1 matching. Rates of AKI, 30-day emergent dialysis, and mortality were compared between contrast and noncontrast groups. Sensitivity analyses examining only patients with stable prescan serum creatinine levels and incorporating intravenous fluid administration at the time of the CT scan into the model were also performed. ResultsA total of 6902 patients (4496 CKD stage III, matched: 1220 contrast and 1220 noncontrast; 2086 CKD stage IV-V, matched: 491 contrast and 491 noncontrast) were included in the study. After propensity score adjustment, rates of AKI, emergent dialysis, and mortality were not significantly higher in the contrast group than in the noncontrast group in either CKD subgroup (CKD stage III: OR, 0.65-1.00; P<.001-.99 and CKD stage IV-V: OR, 0.93-2.33; P=.22-.99). Both sensitivity analyses revealed similar results. ConclusionIntravenous contrast material administration was not associated with an increased risk of AKI, emergent dialysis, and short-term mortality in a cohort of patients with diminished renal function.

The effect of lanthanum carbonate on metabolic acidosis in patients with chronic kidney disease stage IV, V and V-D.

Hyperphosphatemia and metabolic acidosis are frequently encountered in advanced chronic kidney disease (CKD) patients. Correction of metabolic acidosis in patients with advanced CKD leads to a decrease in the progression of renal impairment and improves nutritional outcomes. Lanthanum carbonate is used for control of hyperphosphatemia. This study evaluated the effect of lanthanum carbonate on metabolic acidosis in CKD IV-V patients and in patients on dialysis. Retrospective data of patients in whom lanthanum carbonate therapy was initiated were collected from 2009 to 2013 in a single dialysis center. Of the 79 patients in whom lanthanum carbonate was introduced, 51 patients were included in the analysis. Of the 51 patients, 39 patients received chronic hemodialysis, two patients received peritoneal dialysis therapy, and 10 patients had stage IV-V CKD not on dialysis. The primary outcome was the serum bicarbonate change after the introduction of lanthanum carbonate. There was a significant increase in mean serum bicarbonate concentration of 2.79 mmol/L (p ≤ 0.001) compared to baseline. The increase remained in the CKD IV-V patients (2.50 mmol/L, p = 0.005) and in the patients on dialysis (2.81 mmol/L, p < 0.001). Serum bicarbonate remained higher (p > 0.05) than baseline up to 6 months after lanthanum carbonate introduction. In this study, lanthanum carbonate introduction increased serum bicarbonate concentration in a small sample of CKD IV-V patients and in patients on dialysis. Further studies are needed to confirm this effect and investigate whether the correction of metabolic acidosis by using lanthanum carbonate in CKD IV-V patients can improve clinical outcomes.