Long-term follow-up characteristics of patients with anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) receiving chronic hemodialysis at a single center

BACKGROUND

The clinical characteristics and treatment of patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) after initiating chronic hemodialysis remain unknown.

METHODS

We retrospectively enrolled 11 adult patients with AAV receiving chronic hemodialysis in our hospital from 2000-2016. We collected data describing each patient's clinical findings and treatment before and after initiating hemodialysis. Patients with AAV with and without post-hemodialysis AAV relapse were compared statistically.

RESULTS

The average observation period was 6.8 ± 4.1 years, and the interval between diagnosis and initiating chronic hemodialysis was 1.9 ± 2.6 years. Before initiating chronic hemodialysis, five patients (45%) experienced 12 AAV relapses, with diagnoses made serologically or symptomatically. After initiating chronic hemodialysis, four patients experienced nine relapses, with no significant difference between the number of relapses and the number of patients experiencing relapse (p = 0.067 and 0.083, respectively). For patients' entire clinical courses before initiating chronic hemodialysis, the average steroid dose was 11.6 ± 6.9 g/y. Comparing before and after initiating chronic hemodialysis, the steroid dose decreased significantly to 3.3 ± 1.4 g/y after initiating chronic hemodialysis (p = 0.0012). Two of 11 patients died of serious infections after initiating chronic hemodialysis.

CONCLUSIONS

Our results showed that the number of relapses tended to be lower despite a significantly different lower amount of steroid after initiating hemodialysis compared with before initiating hemodialysis, and the burn-out phenomenon specific to uremic patients was inferred. We believe that early tapering of steroids should be considered to avoid death rather than focusing only on relapse.

Ascitic IL-10 Concentration Predicts Prognosis of Patients Undergoing Cell-Free and Concentrated Ascites Reinfusion Therapy

Cell-free and concentrated ascites reinfusion therapy (CART) is now attracting rising attention as one of the strategies against cancer-related malignant ascites in Japan. Several studies report the safety, effectiveness, and complications of CART applied to patients with malignancies. However, its mechanism reflecting these effects still remains unclear. We evaluated concentration of inflammatory cytokines including interleukin (IL)-1β, IL-6, IL-8, IL-12, tumor necrosis factor (TNF)-α, and immunosuppressive cytokine IL-10 in ascites before CART procedures. We investigated their impacts on survival. IL-1β, IL-6, IL-8, TNF-α, and IL-10 were detected in ascites of the patients undergoing CART. Significant body temperature elevation, one potential complication of CART, was observed among the patients although it was not clinically important. There were no significant correlations between changes in body temperature and the concentration of IL-6, IL-8, and IL-10. The presence of IL-10 in ascites significantly related to longer survival after the first session of CART procedures. However, we observed no other clinically important correlation between cytokine concentrations and changes in WBC and CRP. Concentration of inflammatory cytokines in ascites did not relate to body temperature change, the chief complication of CART. Surprisingly, the presence of IL-10 in ascites related to longer survival after CART. Immunological environment of cancer-related ascites may reflect the outcome of CART and improve survival in those with malignancy.

Impact of Transferrin Saturation on All-Cause Mortality in Patients on Maintenance Hemodialysis

BACKGROUND

Transferrin saturation (TSAT) is an index that represents the iron-binding capacity of transferrin, which is the main transport protein for iron, and is widely used to evaluate iron status.

OBJECTIVE

To evaluate the prognostic importance of TSAT in Japanese patients on maintenance hemodialysis (MHD).

METHODS

A total of 398 patients on MHD were recruited and divided into 3 groups on the basis of their baseline TSAT levels (<20, 20-40, and >40%).

RESULTS

There was no difference in the proportion of patients on erythropoiesis-stimulating agents or iron supplements between the 3 groups. During a mean follow-up period of 52.2 ± 1 6.3 months, 130 patients died of cardiovascular causes (n = 63, 15.8%) or infection (n = 47, 11.8%). Compared with the reference group (TSAT 20-40%), patients with a TSAT <20% had a significantly higher all-cause mortality rate (6.44 vs. 9.55 events per 100 patient-years, p = 0.0452). Kaplan-Meier analysis showed that all-cause mortality rate was significantly higher in patients with TSAT <20% than in the other 2 groups (p = 0.0353).

CONCLUSIONS

Low TSAT was a significant independent risk factor for all-cause mortality in a cohort of Japanese patients on MHD. The findings of this study suggest that the adverse clinical outcomes in patients with low TSAT can be partly attributed to infection-related iron deficiency.

A Body Mass Index-Based Cross-Classification Approach for the Assessment of Prognostic Factors in Chronic Kidney Disease Progression

Background/Aims: Cross-classification analyses are rarely reported. We investigated the prognostic factors for chronic kidney disease (CKD) progression using a body mass index (BMI)-based cross-classification approach. Methods: Patients’ renal outcome (≥50% decline in the estimated glomerular filtration rate or end-stage renal disease) in each subcohort was examined. Results: The number of prognostic factors identified in the multivariate Cox analysis was smaller in the “BMI ≥25, female” and CKD stage 3 subcohorts than in other subcohorts. Prognostic factors identified in the “BMI ≥25, CKD stage 3” subcohort only comprised albuminuria and male sex, and those in the “BMI ≥25, female” subcohort only comprised albuminuria, hyperphosphatemia, and anemia. Albuminuria, kidney impairment, male sex, hyperphosphatemia, anemia, and increased pulse pressure × heart rate product (PP × HR; pulsatile stress) were stable renal prognostic factors in almost all subcohorts. On the other hand, the prognostic value of increased BMI, younger age, hypoalbuminemia, increased intact parathyroid hormone, and decreased estimated 24-h urinary potassium excretion (e24hUK) differed according to subcohort. BMI was positively associated with CKD progression in the “BMI ≥25, age ≥65 years” and “BMI ≥25, CKD stages 4–5” subcohorts, whereas it was negatively associated with CKD progression in the “BMI <25, diabetes mellitus” subcohort. PP × HR was independently associated with CKD progression in the “BMI <25, CKD stage 3” subcohort, which had relatively few identified renal prognostic factors. Decreased e24hUK was a renal prognostic factor for CKD progression in the “BMI <25, CKD stages 4–5” subcohort, while no significant factors were observed in the “BMI ≥25, CKD stages 4–5” subcohort. Conclusion: A BMI-based cross-classification approach, which provides more comprehensive findings than that in previous approaches, is expected to be an effective method for evaluating renal prognostic factors in patients with CKD who are affected by multiple risk factors.

Recent Advances in the Management of Vascular Calcification in Patients with End-Stage Renal Disease

BACKGROUND

Vascular calcification (VC) is common in patients with chronic kidney disease (CKD) including end-stage renal disease (ESRD). The pathogenesis of VC is complex, resulting in increased arterial stiffening, which is associated with cardiovascular mortality. In addition to traditional cardiovascular risk factors, CKD patients also have a number of non-traditional cardiovascular risk factors that may play an important role in the pathogenesis of VC.

SUMMARY

Management of CKD-mineral bone disorder using conventional therapeutic approaches, which include restricting dietary phosphate, administering phosphate binders, and using active vitamin D and calcimimetics, may inhibit the progression of VC, but these approaches remain controversial because recommended biochemical targets are difficult to achieve. Current treatment strategies focus on correcting abnormal calcium, phosphate, parathyroid hormone, and vitamin D levels in ESRD patients. Novel therapies for addressing VC include magnesium and vitamin K supplementation, which are currently being investigated in randomized controlled trials. This review summarizes current treatment strategies and therapeutic targets for the management of VC in patients with ESRD. Key Messages: A better understanding of the potential therapeutic approaches to VC may lead to improved mortality rates among patients with CKD including those on dialysis. Fetuin-A inhibits VC by binding to the nanoparticles of calcium and phosphate, preventing mineral accretion. These particles are known as calciprotein particles and may provide an important pathway for mineral transport and clearance. This review article summarizes the current management of VC in patients with ESRD.

Aortic Arch Calcification and Bone-Associated Molecules in Peritoneal Dialysis Patients

BACKGROUND/AIMS

Aortic arch calcification (AoAC) is a fatal complication in dialysis. AoAC progression-related molecules in continuous ambulatory peritoneal dialysis (CAPD) remain unclear.

METHODS

AoAC was estimated using plain chest radiography scoring (AoACS) in 30 CAPD patients (age 49.3 ± 13.4 years). AoAC progression was defined as increased AoACS on follow-up chest X-ray at the end of the study (progressors). Fibroblast growth factor-23 and osteoprotegerin (OPG) were measured.

RESULTS

Median follow-up was 38.5 months. Progressors were older, had shorter PD vintage, higher body mass index, and higher serum OPG levels (255.6 ± 109.2 pg/mL) than nonprogressors (183.4 ± 68.2 pg/mL; p = 0.0400). Progressors also showed higher pulse pressure (62.4 ± 20.0 mm Hg) and pulse wave velocity (1,909.9 ± 310.6 cm/s) than nonprogressors (48.5 ± 13.6 mm Hg; p = 0.0030 and 1,390.1 ± 252.8 cm/s; p = 0.0005, respectively).

CONCLUSION

AoAC progression was associated with increased aortic stiffness. OPG may be associated with AoAC progression in CAPD.

Strategies for the Super-Aged Dialysis Population: Survival Benefits or Alternative Goals?

BACKGROUND/AIMS

Japan's aging population has prominent epidemiological and patient characteristics. The number of hemodialysis patients aged ≥70 years is increasing. Age-adjusted mortality is improving, but some cause-specific mortalities remain unchanged, including infectious disease and malignancy, requiring combative strategies. However, survival trends for patients aged 90 years or older are not known.

METHODS

We examined annual data reported by the -Japanese Society for Dialysis Therapy Renal Data Registry for the period 1987-2014 to determine survival trends.

RESULTS

Survival in the super-aged group (≥90 years) is still mostly unimproved. In terms of cause-specific survival, especially death due to heart failure differs distinctly between this group and the remaining elderly patients, indicating that improving their survival is difficult. Alternative dialysis goals could therefore be considered. The major dialysis objective in this population could be to maintain quality of life and limit functional impairment.

CONCLUSION

Survival of the super-aged population has not improved in the last 2 decades. Thus, withholding or withdrawing dialysis and providing conservative management without dialysis treatment could be an important option for patients aged 90 years or older.

Effects of tolvaptan on renal function in chronic kidney disease patients with volume overload

Background

Fluid overload in chronic kidney disease (CKD) is generally controlled by diuretics, with potentially harmful effects on renal function. The efficacy of tolvaptan, a vasopressin V2-receptor antagonist and aquaretic, has not been evaluated for fluid control in CKD with reduced renal function.

Methods

Each patient from a group of 24 CKD patients on tolvaptan 15 mg/d plus conventional diuretics (T group) was matched by age and sex with a patient from a group of 24 CKD patients on conventional nonaquaretic diuretics alone not associated to tolvaptan other than tolvaptan (C group). Changes in renal function were compared between the groups for 1 year.

Results

There were no significant differences in blood pressure, hemoglobin levels, cardiac function, urine specific gravity, and urinary sodium concentration between the 2 groups at the beginning of the follow-up period and 1 year after. The estimated glomerular filtration rate (eGFR) by the formula developed by Japanese Society of Nephrology (in mL/min/1.73 m²) decreased: C group (from 28.3±13.6 to 23.0±12.3, p=0.09), T group (from 22.7±12.4 to 19.4±12.2, p=0.18), but both did not reach significance. A 50% reduction in eGFR was observed in 4 patients in the C group and 1 in the T group (p<0.05). A subgroup analysis performed on the patients with stage 3-4 CKD demonstrated a significant reduction in eGFR in the C group (n=17, p=0.04), but not in T group (n=17, p=0.07).

Conclusion

These results suggest that tolvaptan may have less effects on CKD progression among stage 3-4 CKD patients who are on conventional diuretics.

A Prospective Cohort Study Showing No Association Between Serum Sclerostin Level and Mortality in Maintenance Hemodialysis Patients

BACKGROUND/AIMS

Potential relationships between serum sclerostin levels and the levels of bone metabolic markers in maintenance hemodialysis (MHD) patients have yet to be evaluated. This study sought to determine whether serum sclerostin levels are associated with mortality in MHD patients.

METHODS

We measured serum sclerostin levels in a Japanese MHD cohort, classified the patients into tertiles according to these levels, and followed their course for a 42-month period.

RESULTS

The cohort consisted of 389 MHD patients and there were 75 deaths. Kaplan-Meier analyses showed that the tertile of serum sclerostin was not associated with mortality risk. Cox analyses showed that there were no significant associations between serum sclerostin level and mortality.

CONCLUSION

Serum sclerostin level was not an independent predictor of mortality in MHD patients after adjustment for several confounders. However, whether clinical interventions to modulate serum sclerostin levels in MHD patients would improve their survival remains to be determined.

Role of Frailty on Outcomes of Dialysis Patients

Frailty is a clinical state in which there is an increase in the individual's vulnerability to developing increased dependency and/or mortality when exposed to a stressor. Since the mean age of dialysis patients is increasing worldwide, frailty has recently come to be considered one of the risk factors for mortality in the older dialysis population. The prevalence of frailty among dialysis patients has ranged from 3.0- to 10-fold higher than in community-dwelling elderly, depending on the method of assessing frailty and patient characteristics. Since frailty has been found to be associated with higher mortality, independent of clinical characteristics and comorbidity, interventions to improve frailty have the potential to contribute to better quality of life and lower mortality among dialysis patients. In addition, greater attention should be focused on the possibility that early rehabilitation of dialysis patients might improve poor outcomes. Clinical research should aim at devising an adequate strategy to address frailty, including identifying the optimal timing for intervention.

Efficacy and safety of granulocyte adsorption apheresis in elderly patients with ulcerative colitis

BACKGROUND

Elderly ulcerative colitis (UC) is increasing. Elderly UC differ from younger UC with respect to the course of their disease. Granulocyte adsorption apheresis (CAP) is often used to treat elderly UC. We retrospectively analyzed the cases of elderly UC who underwent CAP for remission induction therapy in a comparison with younger UC.

METHODS

96 patients with UC underwent CAP. Patients who concurrently received tacrolimus, biological agents, or high-dose steroid therapy were excluded. The remaining 80 patients were evaluated. We divided them into an elderly group (aged ≥65 years) and a younger group, and then we compared the groups' (1) clinical characteristics, (2) the efficacy and adverse effects of CAP, and (3) the complications of PSL.

RESULTS

The remission rate was 70.8% in the elderly group and 87.5% in the younger group. There were significant differences between the two groups with respect to the age at the onset of UC, the estimated glomerular filtration rate on admission, underlying diseases, and complications of PSL therapy. Adverse effects of CAP included headache, complications of blood reinfusion, heparin allergy, hypotension, and failure of blood removal. There were significant differences between the two groups with respect to the complications of PSL therapy (all P < .05).

CONCLUSIONS

Although the elderly group had longer durations of UC, a higher prevalence of underlying diseases, and a higher frequency of adverse events due to PSL therapy. No serious adverse effects of CAP occurred in either group. Thus, CAP was safe and effective in both younger and elderly UC.

Association of dialysis with in-hospital disability progression and mortality in community-onset stroke

AIM

End-stage renal disease is associated with increased risk of cerebrovascular disease, but the effect on post-stroke clinical outcomes has not been thoroughly investigated.

METHODS

Using the Japanese Diagnosis Procedure Combination database, which includes administrative claims and discharge abstract data, we examined the association between risk factors including dialysis therapy and in-hospital disability progression or mortality in patients with community-onset stroke. We extracted data of patients aged ≥ 20 years old who were admitted to the hospital within 3 days after onset of stroke between July 2010 and March 2013. The disability level was divided into modified Rankin Scale (mRS) 0-1, 2-3, 4-5, and 6 (death). Disability progression was defined as an increase in disability level. Odds ratios for in-hospital disability progression and mortality were calculated using logistic regression models.

RESULTS

Of 435 403 patients, 7562 (1.7%) received dialysis therapy. The median length of stay was 21 and 20 days for patients with and without dialysis, respectively. During the hospital stay, disability progressed in 100 402 (23.1%) patients and 45 919 (10.5%) died. Patients on dialysis had a higher prevalence of disability progression (26.8%) and mortality (13.1%) compared to those without dialysis (23.0% and 10.5%, respectively). Dialysis was associated with an increased risk of in-hospital disability progression (odds ratio, 1.56; 95% confidence interval, 1.47-1.66) and mortality (odds ratio 1.70; 95% confidence interval, 1.57-1.84). These risks were comparable among subtypes of stroke.

CONCLUSIONS

Dialysis was associated with an increased risk of in-hospital disability progression and mortality among patients with community-onset stroke, regardless of stroke subtype.

[Fragility Fractures in Hemodialysis Patients. Frailty and fragility fractures among dialysis patients.]

According to the current status of chronic dialysis therapy in Japan 2016, the average age at the time of dialysis initiation is 68.57 years for males and 71.19 years for females, which has been rising continuously. Frailty is a geriatric syndrome that is frequently seen in the elderly. It is known that frailty among dialysis patients are more common than the general population of the same age, and that frailty is associated with life prognosis. As eGFR decreases, BMD decreases and fracture risk increase, and dialysis patients are at the highest risk of fracture in CKD patients. Various factors such as frailty, sarcopenia, PEW(protein-energy wasting), dynapenia, uremic osteoporosis, diabetes, AGEs(advanced glycation end products), oxidative stress, falls are involved in the increased risk of fracture in dialysis patients, and consequently, fragile fractures occur frequently in dialysis patients. Fragile fracture is a common complication in dialysis patients, and it is reported that the hospitalization for fracture, and the subsequent course is associated with poor prognosis. In diabetes, bone quality declines without loss of BMD, so the conventional DXA method may be insufficient in predicting fracture risk among dialysis patients, and the evaluation method using HR-pQCT or FRAXR may be useful. It has been reported that bisphosphonate is an established therapy in patients with primary osteoporosis, but many bisphosphonates cannot be used at eGFR of less than 30 mL/min per 1.73 m2. Bisphosphonate-related adverse effects such as accumulation, ossification, osteomalacia, ADB(adynamic bone), and jaw bone necrosis were reported, there are few reports of usefulness in CKD patients. Denosumab administration trial results for women with osteoporosis in dialysis patients have been waited(NCT 01464931). In this article, we outline the relation, diagnosis, and treatment of fragile fractures and frailty in dialysis patients.