bluuebunny/crossref_metadata_2025 huggingface dataset:
P0789SERUM URIC ACID IS ASSOCIATED WITH CHRONIC KIDNEY DISEASE PROGRESSION AND MORTALITY: INSIGHTS FROM THE CKD-REIN COHORT
Authors: Prezelin-Reydit Mathilde , Combe Christian , Harambat Jerome , Massy Ziad , Metzger Marie , Lange Céline , Lambert Oriane , Stengel Benedicte , Leffondré Karen
Published: June 2020

Background and Aims

The association between hyperuricemia and CKD progression is not well established in Europe and, to our knowledge, has not yet been investigated using longitudinal measurements.

Method

We used data from CKD-REIN, a prospective cohort study conducted in 40 representative French nephrology clinics, which included 3033 patients with CKD stages 3 to 5 between 2013 and 2016. Patients who had no serum uric acid or no creatinine measure at within 6 months of their inclusion date in the CKD-REIN study were excluded. All uric acid measures were taken into account, from inclusion to the occurrence of renal replacement therapy (RRT), death, or end of follow-up, whichever came first. We used a shared random-effect model for the joint analysis of individual trajectories of uric acid and the hazard of the composite outcome (RRT or death before RRT) and each specific event separately. Hazard ratio were adjusted (aHR) for age, sex, primary kidney disease, metabolic syndrome, cardiovascular disease, proteinuria (< 30, 30-300, > 300 mg/day), and the CKD-EPI estimated glomerular filtration rate (eGFR) at baseline. In a sensitivity analysis, we further adjusted for individual eGFR trajectory.

Results

A total of 2781 patients (65.5% men, median age 69 years) were included. At baseline, the median eGFR was 31.8 mL/min/1.73m2 and the median uric acid value was 425 µmol/L. During a median follow-up of 3.2 years, 434 patients received RRT and 264 died before RRT. At any time of follow-up, an increase of 100 µmol/l of the current value of uric acid was associated with a 16% increased hazard of RRT or death before RRT (aHR 1.16, 95% CI 1.07-1.26). The estimated effect of uric acid was similar with RRT (aHR 1.18, 95% CI 1.04-1.34) and death before RRT (aHR 1.16, 95% CI 1.05-1.28). When further adjusted for eGFR trajectory, the estimated effect of uric acid on the composite outcome was much weaker (aHR 1.06, 95% CI 0.98-1.16).

Conclusion

A higher current level of uric acid is associated with a strong increase in the hazard of RRT or death before RRT in European patients with CKD stage 3 to 5. However, the association is much weaker after adjustment for eGFR trajectory. Further analyses are necessary to better understand the dynamic of the association between uric acid and GFR.
P0790RISK OF CARDIOVASCULAR DISEASE AND CHRONIC KIDNEY DISEASE ACCORDING TO BLOOD PRESSURE CATEGORIES IN DIABETIC PATIENTS : A POPULATION-BASED STUDY
Authors: Lee Jun Young , Choi Seung Ok , Kim You Jin , Shin Hanwul , Kim Miryung , Yang Jae Won , Kim Jae Seok , Han Byoung Geun
Published: June 2020

Background and Aims

American College of Cardiology/American Heart Association (ACC/AHA) guidelines and cardiovascular disease (CVD) and chronic kidney disease (CKD) in diabetes patients remain unclear. We aimed to examine the effects of BP categories defined by the 2017 ACC/AHA guidelines in diabetes patients on the risk of CVD and CKD.

Method

In this population-based cohort study we analyzed data from the National Health Information Database in Korea during 2009-2017. The BP categories were defined as per the 2017 ACC/AHA guidelines: level 1 (systolic <120 mmHg and diastolic <80 mmHg), level 2 (systolic 120-129 mmHg and diastolic <80 mmHg), level 3 (systolic 130-139 mmHg or diastolic 80-89 mmHg), and level 4 (systolic ≥140 mmHg or diastolic ≥90 mmHg). We obtained the risk of CVD, CKD, cerebrovascular disease and CVD mortality.

Results

Overall, 490,352 diabetes patients (men 313,752 [64·0%], women 176,599 [36·0%]) were included in the analysis. Over a mean follow-up of 5 years, 6,508 CVD events occurred. Compared to people with BP levels 1, the adjusted hazard ratios (HRs) for CVD in people with BP levels 2, 3, and 4 were 1·07 (95% confidence interval [CI], 0·98-1·16), 1·12 (95% CI, 1·04-1·20) and 1·17 (95% CI, 1·08-1·26), respectively.

There were also increased risks of CKD [1·18 (95% CI, 1·12-1·24) and 1·22 (95% CI, 1·15-1·29)], cerebrovascular disease [1·21 (95% CI, 1·14-1·29) and 1·52 (95% CI, 1·42-1·63)], and CVD mortality [1·31 (95% CI, 1·09-1·56) and 1·91 (95% CI, 1·58-2·32)] among subjects with BP levels 3 and 4 compared with those with BP level 1. Moreover, among people not taking antihypertensive medications, there were higher risks of CVD, CKD, cerebrovascular disease, and CVD mortality in those with BP levels 3 and 4 than in those with BP level 1. The risks of CVD, CKD, cerebrovascular disease, and CVD mortality significantly increased in patients with a systolic BP of 130 mmHg and diastolic BP of 80 mmHg. These findings provide evidence supporting the 2017 ACC/AHA guidelines for BP targets in diabetes patients.

Conclusion

The risks of CVD, CKD, cerebrovascular disease, and CVD mortality significantly increased in patients with a systolic BP of 130 mmHg and diastolic BP of 80 mmHg. These findings provide evidence supporting the 2017 ACC/AHA guidelines for BP targets in diabetes patients.
P0793THE PERFORMANCE OF THE RENAL FUNCTION IN THE STAGE CKD 5: A DESTINY ALREADY WRITTEN?
Authors: Cannarile Daniela Cecilia , De Liberali Matteo , Gaggi Rossella , Schiavone Giulia , Gibertoni Dino , Mancini Elena
Published: June 2020

Background and Aims

There is a large amount of data on the factors and progression of Chronic Kidney Disease (CKD), especially in the early stages. Stages 4 and 5, on the contrary, have always been considered hard to modify in their speed and evolution. Recent observational studies have however shown that, even in these stages, the progression is often non-linear, heterogeneous and with frequent changes of trajectory. We retrospectively evaluated our CKD stage 5 patients (pts) from 1/1/2016 to 12/31/2018, with a view to analyzing their functional evolution.

Method

We included only patients with longer than 6 months follow-up (Table 1) and at least 4 clinical-laboratory controls that included measured Creatinine Clearance (ClCr) and estimated GFR with CKD-EPI (eGFR). For each patient we analyzed: comparability between eGFR and ClCr, progression rate (Table 2); correlation between ClCr, GFR and some clinical-laboratory parameters (diabetes, blood pressure control, use of ACEi / ARB, ischemic myocardiopathy, peripheral obliterant arteriopathy (POA), proteinuria, Hb, uric acid, PTH, phosphorus).

Statistics

Linear correlation test for continuous variable analysis, chi-square test for group comparison.

Results

Average slope of eGFR: -2.98 ± 3.73 ml / min / year, of ClCr: -3.73 ± 5.8 ml / min / year. The slope of the progression rate by eGFR followed a Gaussian distribution (R 16.9%; L 55.9%; S 18.6%; M 8.4%) with a trend not statistically different from the progression assessed with ClCr (R 32.2%, L 45.7%, S 11.8%, M 10.1%) (Figure 1).

Measured CrCl and eGFR proved well correlated (r=0.565, p<0.001), especially for GFR values <12ml / min.

No correlation was found between eGFR and diabetes, ischemic myocardiopathy, Hb, uric acid, PTH, phosphorus, ACEi / ARB therapy, whereas a significant correlation emerged between the rate of progression and the presence of POA (70% of rapid progression POA, p = 0.035) and pressure control (80% of rapid progression patients do not have adequate pressure control, p = 0.031).

Conclusion

This analysis confirms what is transpiring from the literature: even in stage CKD5 careful monitoring and precise therapeutic strategies can still modify and slow down functional progression. Less than one third of the patients have a GFR loss> 5 ml / min / year, and this rapid progression seems to correlate with the presence of AOCP and poor blood pressure control. For the remaining 70% of the patients, however, a slow evolution or even the possibility of stabilization or functional improvement is expected. These data on the slope of the renal function progression in CKD5, despite the limits of the sample size, encourage us not to consider CKD stage 5 as an inexorable short journey towards artificial replacement therapy.
P0795OUTCOME COMPARISON STUDY ACCORDING TO THE CAUSE OF CHRONIC KIDNEY DISEASE: RESULTS FROM KNOW-CKD STUDY
Authors: Ryu Hyunjin , Hong Yeji , Kim Jayoun , Ahn Curie , Oh Yun Kyu , Oh Kook-Hwan
Published: June 2020

Background and Aims

The cause of chronic kidney disease (CKD) is one of important factors for predicting the outcome. However, relative risks for the adverse outcomes according to the specific causes of CKD is unknown.

Method

Using the longitudinal data of prospective cohort of Korean predialysis CKD, KNOW-CKD cohort, the relative risk of end-stage renal disease (ESRD), composite of ESRD development or creatinine doubling, and composite of cardiovascular disease (CVD) and all-cause mortality according to the cause of CKD were compared. The patients were subgrouped in to four categories at the study entry according to the cause of CKD: glomerulonephritis (GN), diabetic nephropathy (DN), hypertensive nephropathy (HTN), and polycystic kidney disease (PKD). Since the baseline characteristics differed according to the causes of CKD, the inverse probability of treatment weighting (IPTW) methods was used to exclude the effects of other variables on the outcomes. The estimated glomerular filtration rate (eGFR) slope during follow-up was calculated for each cause of CKD using linear mixed model

Results

During the median follow-up of 4.1 years (interquartile range 1.12-7.12 years) total 441 (21.5%) of ESRD, 556 (27.1%) of composite of ESRD or creatinine doubling and 190 (9.3%) composite of CVD and all cause death occurred. In the IPTW adjusted cohorts, DN and PKD showed significantly increased hazard ratios of 1.85 and 5.57 for ESRD development and 1.74 and 4.57 for composite of ESRD developement or creatinine doubling, respectively, compared to GN in the fully adjusted model. Regarding compsite of CVD and all-cause death, also DN and PKD showed significantly increased hazard ratios of 1.93 and 2.16 compared to GN. The adjusted eGFR slope for DN, HTN and PKD was -2.32, -0.90, and -2.41 mL/min/1.73m2 per year, respectively, and all differ statistically significantly compared to GN (eGFR slope of -1.49 mL/min/1.73m2 per year). During the follow-up, GN and DN showed linear declining pattern however, HTN and PKD showed convex linear pattern.

Conclusion

The DN and PKD showed relatively higher risks for renal progression and composite of CVD and death compared to GN.
P0801EGFR LEVEL BEFORE HOSPITALIZATION INFLUENCES OUTCOMES AFTER DISCHARGE REGARDLESS OF ADMISSION DIAGNOSIS
Authors: Ravaglia Fiammetta , Profili Francesco , Spatoliatore Giuseppe , Francesconi Paolo , Rosati Alberto
Published: June 2020

Background and Aims

The risk of hospitalization and death is known to be greater among patients with chronic kidney disease. Less known are the risks after hospital discharge.

Our aim is to evaluate the prognosis after hospital discharge according to the presence and the degree o CKD before the hospitalization.

Method

Target population: Tuscany population (patients on RRT excluded) aged 50+ years, discharged from medical setting in 2017, ordinary regimen (excluding long-term stay/ rehabilitation, trauma and hospitalizations of a special nature), without hospitalization episodes in the 28 days before, with at least one creatinine determination in an outpatient setting in 2017, prior to admission. Data were extracted from hospital discharge sheets.

Exposure measurement: CKD stage, based on glomerular filtration rate estimated by CKD-EPI equation. Laboratory tests were linked with hospital data with a unique anonymous identifier.

Outcome one month and one year after discharge were:

- hospitalization (medical area, ordinary regime, excluding long-term stay / rehabilitation and special hospitalizations). For all causes and by diagnosis-related group.

- Institutionalization or activation of home care, calculated only one year after discharge.

- all-cause mortality.

Statistical analysis: incidence rates (IR) and ratio of incidence rates (IRR), with 95% confidence intervals, were calculated for institutionalization / home care, hospitalization and death (rough and adjusted for covariates at discharge index: comorbidity, age, gender, discharge department, diagnosis-related group of discharge, days of hospitalization) with Poisson regression model.

Results

33,253 discharges met the eligibility criteria in 2017 (28,706 subjects). The discharges of patients with a eGFR > 60 were 18,194 (54.8%), with eGFR <30 were 4,268 (12.8%). The risk of hospitalization or death increases with decreasing eGFR, both at one month and at one year. One-month death IRR for a GFR <30 vs GFR> 60 was 1.59 (CI95%: 1.39-1.83), the hospitalization IRR was 1.61 (CI95%: 1.46-1, 77). One-year death IRR was 1.46 (CI95%: 1.35-1.58), the hospitalization IRR was 1.35 (CI95%: 1.21-1.50). One-year institutionalization IRR was 1.35 (CI95%: 1.21-1.50) As expected, the main causes of hospitalization were cardiovascular, genitourinary or gastrointestinal diseases.

Conclusion

The lower the renal function before the hospital admission, the greater the chances of hospitalization or death, in the short term and at one year, regardless of admission diagnosis. The risk of losing autonomy also increases. For this reason, the patient discharged with known kidney disease can benefit from protected discharge paths and dedicated post-hospital follow-up.
P0803SYNERGISTIC INTERACTION OF ACUTE HYPERGLYCEMIC STRESS AND NON-ALCOHOLIC FATTY LIVER DISEASE ON THE DEVELOPMENT OF ALBUMINURIA IN GENERAL POPULATION
Authors: Lee Chang Hwa , Yu Mi-yeon , Choi Jong Wook , Yi Joo-Hark , Han Sang-Woong , Park Joon-Sung
Published: June 2020

Background and Aims

Both increased glycemic exposure and non-alcoholic fatty liver disease (NFALD) are independent risks of vascular endothelial dysfunction. To find interactive effects of acute hyperglycemia and hepatic necro-inflammation on initiation of albuminuria, we conducted this nation-wide, population-based interaction analysis using acute-to-chronic glycemic ratio (ACGR) as a candidate indicator of acute increased glycemic exposure and ZJU index as an indicator of NFALD.

Method

Eligible as cases were all native Koreans aged 20 years or older without significant medical illness. A total of 9494 participants were divided into quintiles according to their ACGR results and stratified by sex.

Results: Participants in the highest ACGR quintile were more obese and they were more likely to have elevated BP and increased glycemic exposure as compared with other quintiles. Restricted cubic regression analyses revealed that there was non-linear relationship of ACGR and ZJU index with albuminuria. Multiple logistic regression, adjusted for various conventional risk factor of kidney disease, demonstrated that both ACGR (adjusted OR = 5.388, 95% CI = 1.119-25.95) and ZJU index (adjusted OR = 1.057, 95% CI = 1.002-1.114) were independent predictor of albuminuria. Interestingly, our interaction analysis revealed that ACGR had bigger effect on the risk of albuminuria in participant with elevated ZJU index than those without (adjusted RERI = 2.296, 95% CI = 2.277-2.313; adjusted AP = 0.643, 95% CI = 0.472-0.814; adjusted SI = 8.135, 95% CI = 7.267-9.003).

Conclusion

Our findings suggest that the interaction of acute hyperglycemia and abnormal hepatic fat metabolism may exert synergistic biologic effect on the development of albuminuria.
P0804TRENDS IN BODY MASS INDEX IN PATIENTS WITH INCIDENT CHRONIC AND END STAGE KIDNEY DISEASE FROM 2004 - 2019
Authors: Gamio-Izasmendi Diana , Gillis Keith , Mark Patrick , McManus Siobhan , Traynor Jamie
Published: June 2020

Background and Aims

Obesity is increasingly prevalent in the general population. Body mass index (BMI) has a U-shaped relationship with mortality in chronic kidney disease (CKD), but also has implications for service delivery. We analysed the BMI trends in incident patients referred to CKD clinic (CKD), starting haemodialysis (HD), peritoneal dialysis (PD) and receiving a kidney transplant (Tx). Our aim was to establish the trend in BMI across these specified patient groups over the last 15 years.

Method

A single centre retrospective analysis was carried out including adults referred to secondary care nephrology services between 2004 and 2019. Patients were categorised into CKD, HD, PD, or Tx. Those reaching ESKD were grouped according to first method of renal replacement therapy (RRT). Patients with acute kidney injury and with missing BMI data were excluded. As per the World Health Organisation’s definition, BMI was categorised into classes I, II and III (>30, 35, and 40kg/m2 respectively).

Results

Of 10,057 patients, 6,936 patients were included. Of these, 59.96% (n=4,249) were CKD, 7.39% (n=524) were Tx, 4.85% (n=344) were PD, and 27.43% (n=1,944) were HD. BMI was 27.3±7.2kg/m2 in 2004 and 27.8±7.72kg/m2 in 2019 with no significant change in BMI as a whole throughout that time period (p=0.07). In subgroup analysis, there was no change in BMI in the CKD (p=0.52) or PD (0.76) groups. However, there was a significant increase in BMI seen in both the HD (p<0.001) and Tx (p=0.006) groups. An increase in the proportion of patients with class III obesity was also observed in the HD group (p=0.009) but not the CKD, Tx or PD groups.

Conclusion

In contrast to the general population, the prevalence of obesity has not changed in incident patients with kidney disease over the last 15 years. In subgroup analysis however, there is a trend towards rising BMI in the incident haemodialysis patient group. Limitations of the study include retrospective design, lack of ethnicity data, and inclusion of only a single measure of adiposity.

Although the relationship between BMI and mortality in patients receiving maintenance haemodialysis is non-linear, the increase in the very obese in this patient group will have significant implications for healthcare providers.
P0805SURPRISE QUESTION IN ADVANCED CHRONIC KIDNEY DISEASE
Authors: Cardoso Fernandes Sara , Moreira Fonseca Nuno , Magriço Rita , Mesquita Isabel , Fernandes Vasco , Ferreira Ana Carina , Nolasco Fernando
Published: June 2020

Background and Aims

Nowadays, patients with end-stage chronic renal disease (ESRD) are initiating dialysis at more advanced ages and having multiple comorbidities. Since the initiation of dialysis in the elderly may not result in increased survival or quality of life, it would be useful to define prognostic criteria for those patients. We aim to evaluate the utility of the surprise question (“Would I be surprised if this patient died in the next 12 months?”) as a predictor of survival in elderly patients in advanced stages of chronic kidney disease (CKD).

Method

Retrospective cohort study of patients elder than 70 years with CKD stages 4 to 5 according to the Chronic Kidney Disease Epidemiology Collaboration equation (CKD-EPI) who attended the CKD information consultation between March 2017 and November 2018. The answer to the surprise question was registered during that office visit. Demographic, clinical and laboratory data (including serum albumin) were analyzed and Charlson Comorbidity Index (CCI) was calculated. Continuous variables are presented as means (±SD) or medians (IQ range), according to normality, and categorical variables as frequencies. Comparisons between groups were made using Student’s T-test and Pearson Chi-squared test. Survival analysis was conducted using Kaplan-Meier test and Cox proportional hazard model. STATA software was used and a p<0.05 was considered significant.

Results

Of the 60 patients selected, 22 (36.7%) were female, 59 (98%) were white and the median age was 78.6±6.3 years. Half of these patients had diabetes mellitus with end-organ damage and 57% suffered from congestive heart failure. The response to the surprise question was “yes” in 31 (51.7%) patients and “no” in 29 (48.3%) patients. We did not find clinical or demographic differences among these groups. The patients were followed for 26 (20-31) months, during which 19 deaths occurred, 4 (21%) in the SQ-yes group and 15 (79%) in the SQ-no group. The response to the surprise question was associated with patients’ survival (KM – p=0.0009), with a positive and negative predictive values of 79% and 66%, respectively. The multivariate analysis (age, sex, race, serum albumin and CCI) showed that the answer to the SQ is an independent predictor of mortality (HR 0.27 [IC 0.08-0.86]).

Conclusion

The SQ seems to be a good predictor of survival in elderly patients in advanced stages of CKD and can be used to assess their prognosis in order to help deciding whether the patient is a good candidate to initiate dialysis or not.
P0810DOSAGE REDUCTION OF LOW MOLECULAR WEIGHT HEPARIN IN PATIENTS WITH RENAL DYSFUNCTION: EFFECTS ON ANTI-XA LEVELS AND CLINICAL OUTCOMES
Authors: Hornung Paul , Khairoun Meriem , Dekker Friedo W , Kaasjager Karin A H , Huisman Albert , Jakulj Lily , Bos Willem Jan , Rosendaal Frits , Verhaar Marianne , Ocak Gurbey
Published: June 2020

Background and Aims

To prevent bio-accumulation of low molecular weight heparins (LMWHs) in patients with an impaired kidney function, guidelines recommend dosage reduction and anti-Xa monitoring. The aim of this study was to investigate the effect of pre-emptive dosage reduction of LMWH on anti-Xa levels. Furthermore, we investigated the association between anti-Xa levels and bleeding, thrombotic events and mortality.

Method

In this single center study, we followed 499 patients with an estimated glomerular filtration rate (eGFR) below 60 ml/min/1.73m2 in whom anti-Xa levels were measured. We observed how many patients had anti-Xa levels that fell within the target range (between 1.0 U/ml and 2.0 U/ml with once daily LMWH and between 0.6 U/ml and 1.0 U/ml with twice daily LMWH), with a standard protocol of a pre-emptive dosage reduction of LMWH (25% reduction in patients with an eGFR between 30 and 60 ml/min/1.73m2 and a reduction of 50% in in patients with an eGFR below the 30 ml/min/1.73m2).

Furthermore, Cox proportional hazard analyses were used to estimate hazard ratios with 95% confidence intervals (CIs) to investigate the association between anti-Xa levels and major bleeding, thrombotic events (ischemic stroke or venous thrombosis) and mortality within three months of follow-up. Hazard ratios were adjusted for age, sex, body mass index, type of LMWH, once or twice daily dosing, antiplatelet drug use, indication for anticoagulation, comorbidities, hemoglobin concentration and eGFR.

Results

In a cohort of 499 patients (445 dalteparin and 54 nadroparin users), the median anti-Xa level was 0.44 U/ml (IQR 0.21-0.75) for the total group (n=499). A pre-emptive dosage reduction of LMWH led to adequate levels of anti-Xa in only 19% of the patients (12% for the dalteparin users and 50% for nadroparin users).

Of the 499 patients, 104 patients had a major bleeding, 27 had a thrombotic event and 146 died within three months. We did not find an association between anti-Xa levels and bleeding or mortality (Table 1). An anti-Xa level below the target range was associated with a non-significant increased risk estimate for thrombosis (HR 2.5, 95% CI 0.7-8.8) after adjustment (Table 1).

Conclusion

Pre-emptive dosage reduction of LMWH leads to low anti-Xa levels in a large proportion of patients and may lead to an undertreatment of patients with an impaired kidney function.
P0812LONG-TERM EFFECTS OF AIR POLLUTANTS ON MORTALITY RISK IN PATIENTS WITH END-STAGE RENAL DISEASE
Authors: Park Jae Yoon , Jung Jiyun , Lee Sung Woo , Kim Ho , Lee Jung Pyo
Published: June 2020

Background and Aims

Long-term exposure to air pollutants significantly increases the morbidity and mortality associated with various diseases. However, little is known about the relationship between air pollutants and end-stage renal disease (ESRD)-related mortality.

Method

A total of 5041 patients who started dialysis between 2008 and 2015 were prospectively enrolled in the Clinical Research Center for End-Stage Renal Disease (CRC-ESRD) cohort study. We assigned a daily mean concentration of air pollutants (PM10, NO2, and SO2) to each participant. Time-varying Cox models were used to investigate the relationship between air pollutants and mortality in ESRD patients.

Results

During the follow-up period (mean 4.18 years), 1475 deaths occurred among 5041 participants. We found a significant long-term relationship between mortality risk and PM10 (HR 1.33, CI 1.13–1.58), NO2 (HR 1.46, CI 1.10–1.95), and SO2 (HR 1.07, CI 1.03–1.11). Elderly patients and patients who lived in metropolitan areas had an increased risk associated with PM10. Elderly patients also had increased risks associated NO2 and SO2.

Conclusion

Long-term exposure to air pollutants had negative effects on mortality in ESRD patients. These effects were prominent in elderly patients who lived in metropolitan areas, suggesting that ambient air pollution, in addition to traditional risk factors, is important for the survival of these patients.
P0813FRAILTY MODIFIES THE ASSOCIATION BETWEEN OPIOID USE AND MORTALITY IN CHRONIC KIDNEY DISEASE PATIENTS: A POPULATION-BASED COHORT STUDY
Authors: CHAO CHIA-TER
Published: June 2020

Background and Aims

The prevalence of chronic pain in patients with chronic kidney disease (CKD) is high and is associated with higher frailty risk, but satisfactory pain control frequently fails to be achieved. Opioid remains instrumental regarding optimal pain management, but its influence on outcomes can be of concern in CKD patients. We examined whether opioid use affected patient outcome and whether such relationship was modified by frailty.

Method

From the longitudinal cohort of diabetic patients (n = 840,000), a well-maintained population-based cohort, we identified those with CKD who were opioid user (at least 7 days within any month; n = 26,029), followed by propensity score-matched to opioid never-users from the same cohort in a 1:1 ratio, based on demographic features, comorbidities, and other medications. We analysed the associations between opioid use and survival in these patients according to their baseline frailty status, defined by the modified FRAIL (Fatigue, Resistance, Ambulation, Illness, and Loss of weight) scale.

Results

Among the enrolled CKD participants (mean age 62.9 ± 13.5 years, 48.2% female), 20.3% did not have any FRAIL item satisfied, while 57.2%, 20.6%, and 1.9% had 1, 2, and at least 3 positive FRAIL items at baseline, respectively. After a median of 4.2 years, 16.4% participants died. Univariate analysis showed that opioid users had an elevated risk of morality compared to non-users (hazard ratio [HR] 1.124, 95% confidence interval [CI] 1.08 – 1.17) (Figure). Cox proportional hazard regression showed that opioid users exhibited an 18.3% higher risk of mortality compared to non-users (HR 1.183, 95% CI 1.13-1.24) among patients with CKD; furthermore, the mortality risk associated with opioid use was observed in CKD participants without frailty only (HR 1.18, 95% CI 1.13-1.24) but not in those with frailty (HR 1.08, 95% CI 0.83 – 1.4).

Conclusion

Opioid use might lead to a higher risk of mortality among CKD patients, but this relationship was observed among those without frailty only. Interestingly, frail CKD patients who were opioid users were not at an elevated risk of mortality compared to non-users.
P0817SMOKING WAS ASSOCIATED WITH LOWER SERUM LEVEL OF SOLUBLE ALPHA KLOTHO IN PATIENTS WITH NON-DIALYSIS CHRONIC KIDNEY DISEASE:RESULTS FROM THE KOREAN COHORT STUDY FOR OUTCOMES IN PATIENTS WITH CHRONIC KIDNEY DISEASE (KNOW-CKD)
Authors: CHAE DONG-WAN , Yi Yong Jin , Cheong Jong Chul
Published: June 2020

Background and Aims

Soluble αklotho (sklotho) in systemic circulation, which is mainly derived from renal tubule, has been reported to play important roles in mineral bone disorders, cardiovascular complications and renal progression in CKD. Although decreased renal parenchymal mass is thought to be a main cause of decreased serum level of sklotho in CKD, various factors causing renal tubular injury such as hypoxia, oxidative stress, proinflammatory cytokines and uremic toxins are also known to decrease the renal tubular expression of αklotho. Because smoking contributes to hypoxia and oxidative damage, we hypothesized that smoking might be related to decreased sklotho in patients with non-dialysis CKD.

Method

To test this hypothesis, we analysed data of 2,101 subjects with non-dialysis CKD from a currently on-going Korean multi-centers prospective cohort study of CKD (KNOW-CKD, NCT01630486 at www.clinicaltrials.gov) in whom serum klotho was measured using an enzyme-linked immunosorbent assay kit (Immuno-Biological Laboratories Co, Gunma, Japan). The intra-assay and inter-assay coefficients of variations were 0.57-1.78% and 3.01-6.12% respectively.

Results

Mean age was 53.6±12.2 years and 1282 (61.0%) were men. The number of current, former and never smokers were 338 (16.1%), 642 (30.6%), and 1118 (53.2%) respectively. The median pack-year was 20.0 (interquartile range: 10.0-35.0). Mean eGFR by CKD-EPICr equation was 53.0±30.7 ml/min/1.73m2 and mean UACR was 903.9±1423.8 mg/g. Median serum sklotho was 536.0 (IQR: 419.5 – 667.0) pg/ml. In multivariable linear regression with backward stepwise adjustment by all significant factors for sklotho in univariate linear regression, smoking pack-year was independent variable for sklotho. (β= -0.786, p=0.032 95% CI for β: -1.504 to -0.069). Age and serum uric acid were also negatively associated with sklotho, while eGFR, serum alkaline phosphatase, and serum hemoglobin were positively associated with sklotho in the same analysis. Median sklotho of never, former, and current smokers were 551.0 (IQR:430 – 689.3) pg/ml, 509.5 (IQR: 407.8 – 645.3) pg/ml, and 521. (IQR: 397.8 – 645.0) pg/ml respectively. Linear mixed model adjusted by sex, age, eGFR, hemoglobin, alkaline phosphatase, and uric acid demonstrated that sklotho in never smokers was significantly higher than former (p=0.004) and current smokers (p=0.001). But there was no difference in sklotho between former and current smokers.

Conclusion

Smoking was associated with lower serum sklotho in non-dialysis CKD. But no difference in sklotho between former and current smoker casted doubt on causal relationship between smoking and serum sklotho
P0818IMPROVING MORTALITY TRENDS FOR PATIENTS WITH CHRONIC KIDNEY DISEASE IN THE IRISH HEALTH SYSTEM: THE IRISH KIDNEY DISEASE SURVEILLANCE SYSTEM (IKDSS)
Authors: Laird Matthew , Alheyali Raihan , Browne Leonard , Plant Liam , Walsh Cathal , Austin Stack
Published: June 2020

Background and Aims

It is unclear whether targeted efforts for the treatment of chronic kidney disease (CKD) has led to a sustained reduction in mortality rates. We examined annual trends in mortality for patients with and without CKD in the Irish health system.

Method

We utilised data from the Irish Kidney Disease Surveillance System (IKDSS) to explore 1-year mortality rates among patients with and without CKD in the health system. The principal data sources included; regional laboratory information systems; dialysis registers; and mortality data files from the national Central Statistics Office (CSO). We created multi-annual cohorts of patients, age > 18 years with one or more serum creatinine values who received healthcare within the Irish health system from 2008 to 2012. Serum creatinine values (first test in fiscal year) were used to calculate glomerular filtration rate (eGFR) and CKD was defined as GFR < 60ml/min/1.73m. Mortality data were available from the national mortality files with vital status up to December 31st 2013. Age standardised death rates were determined for the Irish population (IRE) and the European Standard Population (ESP) (standardised to the age distribution of a standard European population in 2012. Comparisons were conducted using segmented linear regression.

Results

We included 351,223 adult individuals between 2008 and 2012. Age standardised mortality rates (EU) were more than 2-fold higher for patients with CKD than without, P<0.001. From 2008-2012, age-standardised mortality rates decreased significantly in patients with CKD from a peak of 47.7 to 31 per 1000 person-years, P for trend=p=0.012, and from a peak of 17.8 to 15.5 per 1000 person-years in patients without CKD, P=0.006. Mortality rates for men were significantly higher than for women in patients with and without CKD, but the pattern of improvement was similar for both sexes. These patterns were replicated when comparisons were made using Irish standard age distribution.

Conclusion

Mortality rates among CKD patients have declined in the Irish population from 2008 to 2012 in both men and women. The processes and interventions that have led to these reductions need further exploration.

Figure 1. (a) Crude and age standardised mortality rates (b-c) of those with and without CKD in the Irish Health System between 2008-2012 .
P0820EMERGENCY DEPARTMENT UTILIZATION BY PATIENTS WITH ADVANCED CHRONIC KIDNEY DISEASE AND DIALYSIS: A POPULATION BASED STUDY
Authors: Chhibba Ruchi , Leon-Mantilla Silvia , Ferguson Thomas , Komenda Paul , Tangri Navdeep , Rigatto Claudio
Published: June 2020

Background and Aims

Chronic Kidney Disease (CKD) is a potent risk factor for kidney failure, cardiovascular events and all cause hospitalizations. In addition to higher outpatient resource use, patients with CKD may present more frequently to the emergency department (ED) and may be more likely to be admitted for hospitalization. In Manitoba, we previously demonstrated an 8-fold increase in the frequency of ED presentations by patients on dialysis as compared to a non-dialysis population. Comparable data on ED visits remain sparse for patients with CKD G3-G5, not on dialysis. Here, we aim to describe the frequency of ED visits and highlight differences in reasons for visit in patients with CKD stages G3-G5 and Those on dialysis when compared to a non-renal population.

Method

We performed a retrospective cohort study using administrative health data from the Winnipeg Regional Health Authority, Canada. We included all adults (≥ 18 years) with CKD stages G3-G5 and patients undergoing dialysis between January 1st, 2010 and December 31, 2014. Secular trends in the in the rates of ED visits were calculated for those with CKD, those on dialysis and in the non-renal population.

Results

Over the study period, patients undergoing dialysis had the highest incidence of ED visits, followed by patients with CKD and those with normal kidney function (150 vs 106 vs 34 per 100 persons per year respectively). These rates were stable over the period studied. Among the non-renal population, the most common reasons for an ED visit were musculoskeletal complaints (25.6%), followed by gastrointestinal (11.04%) and cardiovascular complaints (10.26%). In the CKD and dialysis cohort, ED visits were more commonly secondary to cardiovascular complaints (21.54% and 18.99% respectively), followed by respiratory and gastrointestinal complaints. Admission to hospital was higher in CKD and dialysis populations than in the non-renal population (29.56%, 26.07% vs 10.61%, respectively).

Conclusion

Patients with CKD present frequently to the ED, and are often admitted after presentation. Cardiovascular and respiratory complaints are more common in the CKD population.
P0822ESTIMATED GFR DECLINE OF PKD PATIENTS IN CKD G3B-5 WAS AS FAST AS THAT OF DKD PATIENTS: A RESULT FROM A JAPANESE COHORT STUDY FOR PATIENTS WITH ADVANCED CKD, THE REACH-J STUDY
Authors: Hoshino Junichi , Saito Chie , Tsunoda Ryoya , Nagai Kei , Kai Hirayasu , Okubo Reiko , Kondo Masahide , Okada Hirokazu , Narita Ichiei , Wada Takashi , Kashihara Naoki , Robinson Bruce , Yamagata Kunihiro
Published: June 2020

Background and Aims

CKD progression in Japanese patients with advanced chronic kidney disease (CKD)—an estimated glomerular filtration rate (eGFR) <45 ml/min/1.73m2—has remained largely unexamined.

Method

We conducted a nationwide cohort study of Japanese patients with advanced CKD. We recruited 2,249 advanced CKD patients (eGFR<45/ml/min/1.73m2) receiving nephrologist care from a national sample of 31 facilities throughout Japan, randomly selected with stratification by region and facility size, aligned with the international CKD Outcomes and Practice Patterns Study (CKDopps). From baseline data, we calculated annual eGFR decline by CKD stage and causes of CKD over 4 years before enrollment. Variability of eGFR decline was calculated from standard error of the regression.

Results

The reported causes of CKD were 552(25%) had diabetic kidney diseases (DKD), 131(6%) had PKD, 591(26%) had nephrosclerosis, 299(13%) had glomerulonephritis, and 676(30%) had other renal diseases. Of 1939 eligible patients with eGFR data more than two years, median (IQR) annual eGFR declines (ml/min/1.73m2/year) in PKD and DKD patients were 2.30 (1.16, 3.38) and 1.18 (0.23, 3.69) in G3b, 2.60 (1.81, 3.40) and 1.97 (0.20, 4.75) in G4, and 4.00 (2.00, 5.60) and 3.94 (2.05, 7.05) in G5, respectively. These eGFR declines were significantly faster than those of other kidney diseases. On the other hand, the variability of the decline in PKD patients was significantly smaller than that of DKD patients (0.43 vs 0.71, p<0.001). This trend was consistent in all CKD stages.

Conclusion

Our study clarified that, similar to DKD patients, annual eGFR decline of PKD patients was significantly faster than those of other kidney diseases throughout all stages. Furthermore, the variability of the decline in PKD patients was smaller than those of others. These data suggest that comprehensive nephrology care should be needed especially for these patients.
P0829THE ASSOCIATION BETWEEN URINARY NGAL AND EGFR SLOPE IN PATIENTS WITH CKD
Authors: Fukuda Shungo , Fujii Naohiko , Matsushita Taisuke , Yonemoto Sayoko , Hayashi Daisuke , Okuno Ayako , Saeki Mizuho
Published: June 2020

Background and Aims

Urinary neutrophil gelatinase-associated lipocalin (uNGAL) is a new biomarker for renal tubular damage. The association between uNGAL and renal prognosis have been reported in many papers; however, it may often be affected by urinary tract infection (UTI), and its clinical value with consideration of UTI has not been well investigated in patients with chronic kidney disease (CKD). The aims of our study were to investigate the association between uNGAL and eGFR decline in CKD incorporating the effect of UTI.

Method

This was a retrospective observational cohort study at a single hospital in Japan. We included adult patients with the estimated glomerular filtration rate (eGFR) of 10 to 70 mL/min/1.73m2 from Jan 2017, who had at least one measurement of uNGAL. We used baseline uNGAL adjusted for urinary creatinine (Cr) as an exposure variable and divided the patients into quartiles. UTI was determined by a single evaluation of urinalysis at baseline. The repeated measured eGFRs were obtained from the electrical health record until dialysis initiation, loss to follow-up, or the end of the observation period whichever occurred first. We performed longitudinal analyses for eGFR decline using the mixed effects model and evaluated the longitudinal effect of uNGAL taking into account of UTI. All statistical analyses were done using STATA 13.1.

Results

In total, 281 patients with CKD were included. Mean age and eGFR at baseline were 70.2 years and 33.9 mL/min/1.73m2, respectively. The median [interquartile range (IQR)] of baseline uNGAL and urinary protein to Cr ratio (uPCR) were 49.6 [19.4 - 171.4] ug/gCr and 0.82 [0.18 - 3.26] g/gCr, respectively. Patients with UTI (15%) showed significantly higher uNGAL at baseline than those without (219 [89 - 425] vs. 39 [16 - 131]). During the mean follow up of 229 days, nine patients developed eGFR < 5 mL/min/1.73m2. Although a higher uNGAL level was significantly associated with lower eGFR levels at baseline (-3.3 [95% confidence interval (CI): -7.6, 0.93], -9.6 [-14.2, -4.9], and -16.3 [-21.4, -11.1] mL/min/1.73m2 in quartiles Q2-4 as compared to Q1); the eGFR trajectory did not differ with or without baseline UTI in the analytic model, while baseline proteinuria was significantly associated with a steeper slope of eGFR.

Conclusion

A higher uNGAL was significantly associated with lower eGFR levels at baseline; however, it was not associated with a steeper slope of eGFR in the longitudinal analysis, even with the consideration of the effect of UTI.
P0836ROLE OF THE NEPHROLOGIST AS A CONSULTANT FOR VASCULAR SURGERY SERVICE IN A UNIVERSITY HOSPITAL
Authors: Siverio Morales Orlando , Martin Edduin , Dominguez Virginia , Marin Carlos , Aragao Ana , Luis Rodríguez Desirée , Jarque Ana , Garcia Patricia , Reguera Maria Jose , Macia Manuel
Published: June 2020

Background and Aims

The clinical profile and complexity of hospitalised patients from Vascular Surgery are similar to those from Nephrology. Also, the majority of patients with peripheral vascular disease has some degree of chronic kidney disease. Therefore, the collaboration of nephrologist as consultants could have a significant impact on the adequate attention of these patients.

Our aim was to analyze the epidemiological and clinical characteristics of the vascular surgery patients admitted in a public university hospital of 1000 beds that were attended by a nephrologist during their hospitalization.

Method

Observational study of a retrospective cohort of 138 patients in a 1 year period (January 1st to December 31st 2018). The following data were considered: nature of the consultation (“Urgent” LESS THAN 24 H TO BE ATTENDER OR “Standar”), reason for consultation/nephrological diagnosis, cause of admission, follow-up period, age, sex, presence of : Diabetes Mellitus (DM), Hypertension (HT) and/or Chronic Kidney Disease (CKD) presence.

Results

138 patients, Mean age was 67,8 y (range 35-92 y). 76,81% were men and 23,19% were women. Most frequent cause for consultations were: 1. Patients on Hemodialysis treatment (66 = 47,83%); 2. Exhacerbations of CKD (29 = 21,01%); 3. Acute Kidney Failure (18 = 13,04%); 4. Kidney transplantation (11 = 7,97%); 5. Ionic alterations (7 = 5,07%); 6. Advanced CKD (6=4,35%).

Cause of admission: 1. Chronic lower limb ischemia (68=49,27%); 2. Problems related to arteriovenous fistula (Creation of vascular access: 10=7,25% and complications of vascular access: 16=11,59%); 3. Aneurysmatic complications (14=10,14%); 4. Diabetic foot (11=7,97%); 5. Infections (7=5,07%); 6. Deep venous thrombosis (6=4,35%).

About 75.35% had DM, 91.30% were hypertensive and 62.32% had both clinical conditions.

The average follow-up time was 72 days (range 1-223 days) and 92,03 % need to be follow-up more than 24 hours.

About 49,27% of the consultation were urgent.

Conclusion

The number of patients admitted to vascular surgery department requiring nephrology attention are high and represents an important percentage of the clinical activities and resources demanding to the nephrology service.

Exhacerbations of CKD, Diabetes Mellitus and Hypertension are constant clinical conditions in patients admitted to vascular surgery requiring nephrology assessment.

Based on these data is important to improve the coordination between both departments and to stablish a specific training program for nephrologist and vascular surgeons in order to optimize the management of this patients.
P0841SPECTRUM OF RENAL DISORDERS AT A TERTIARY CARE HOSPITAL IN KARACHI, PAKISTAN: RESULTS FROM AN OUTPATIENTS DATABASE IN A DEVELOPING COUNTRY
Authors: Yaqub Sonia , Awan Safia
Published: June 2020

Background and Aims

The burden of renal diseases in developing countries is rising. However, little is known about the epidemiology and clinical pattern of various disorders in our part of the world. The objective of this study was to understand the burden of disease faced by nephrologists in a tertiary care setting.

Method

It was a prospective observational study of all presentations to nephrology clinics at Aga Khan University Hospital Karachi over a period of one year.

Results

A total of 1589 out-patients with renal diseases were seen during the study period. The mean age of the study participants were 49.9 years and 629 (53%) were male. 88.6% of patients belonged to Karachi and Hyderabad areas of Sind province. CKD was the most common diagnosis (93.5%). Diabetic kidney disease and hypertension and related disorders were causes of CKD in 29.5% and 29.1% cases respectively. In 13.1% patients, the etiology of CKD could not be determined. Among glomerulonephritis (6.67%), membranous nephropathy was the commonest disorder (32.1%) followed by FSGS (29.2%), Minimal change disease (15.1%) and IgA nephropathy (10.4%). SLE and lupus nephritis was seen in 48 patients (4.0%). Around 10% patients were suffering from various tubulointerstitial diseases (renal stones, UTIs, Acute and chronic tubulointerstitial nephritis).

Conclusion

It’s a first study of its kind reporting frequency of various renal disorders from an outpatient registry at a tertiary care hospital in Pakistan. Diabetes and hypertension account for almost 60% of cases with CKD. Membranous nephropathy is the commonest glomerular disease in an urban population cohort. We need more studies on spectrum of renal diseases for better planning and available resource management.
P0842MANAGEMENT OF RENAL RISK PATIENTS AND THERAPEUTIC CHANGES AFTER DIAGNOSIS OF KIDNEY DISEASE IN PRIMARY CARE
Authors: Zitt Emanuel , Sprenger-Mähr Hannelore , Lhotta Karl
Published: June 2020

Background and Aims

Screening for chronic kidney disease (CKD) is proposed in high risk groups. Whether a new CKD diagnosis in general practice leads to improved patient management, is largely unknown.

Method

To answer this question and evaluate the kidney disease specific pharmacological care in renal risk patients, a screening study in patients at high risk for kidney disease was performed in the primary care setting in ten general practices in the state of Vorarlberg, Austria. General practitioners were provided with guidelines for the management of CKD with a focus on blood pressure control, RAS inhibition and use of statins.

Results

In total, 434 patients between age 35 and 77 were included (61% males, mean age 56±7 years, eGFR 86±15 ml/min, body mass index 31±6 kg/m, blood pressure 135±16/83±10 mmHg), of whom 80% had hypertension, 43% had diabetes and 42% were obese. RAS-blockers were already taken by 64% of patients, statins by 39%. A diagnosis of CKD (stage ≥G3 and/or ≥A2) was established in 73 patients (17%), 60% of them had diabetes. Compared to patients without CKD, CKD patients were already treated more often with RAS-blockers (78% vs 61%, p=0.005), whereas statin usage was comparable (44% vs 38%, p=0.3347). After CKD diagnosis, medical therapy was changed in 13 patients (18%). A RAS-blocker was initiated in two out of the 16 patients without a preexisting RAS-blocker (12.5%), the dosage was increased in one patient. Antihypertensive therapy was intensified adding amlodipine in seven patients (10%), and a statin was begun in six (15%) out of 41 statin-naive patients. In those without CKD after the screening, therapy was changed in 40 patients (11%). Compared to patients with CKD, fewer patients started a statin therapy (5% vs 15%, p=0.012) and were additionally treated with amlodipine (3% vs 10%, p=0.021) to optimize blood pressure control.

Conclusion

This study shows that in the primary care setting a great proportion of CKD patients are already on RAS-blockers, whereas the prescription rate for statins is low. A diagnosis of CKD led to a moderate increase in statin therapy, which leaves further opportunity for improvement. The reasons for this rather low use of statins in CKD patients need to be determined.