An increase in albuminuria is associated with a higher incidence of malignancies

Background

A single albuminuria measurement is reported to be an independent predictor of cancer risk. Whether change in albuminuria is also independently associated with cancer is not known.

Methods

We included 64 303 subjects of the Stockholm CREAtinine Measurements (SCREAM) project without a history of cancer and with at least two urine albumin-creatinine ratio (ACR) tests up to 2 years apart. Albuminuria changes were quantified by the fold-change in ACR over 2 years, and stratified into the absence of clinically elevated albuminuria (i.e. never), albuminuria that remained constant, and albuminuria that increased or decreased. The primary outcome was overall cancer incidence. Secondary outcomes were site-specific cancer incidences.

Results

During a median follow-up of 3.7 (interquartile range 3.6-3.7) years, 5126 subjects developed de novo cancer. After multivariable adjustment including baseline estimated glomerular filtration rate and baseline ACR, subjects with increasing ACR over 2 years had a 19% (hazard ratio 1.19; 95% confidence interval 1.08-1.31) higher risk of overall cancer compared with those who never had clinically elevated ACR. No association with cancer risk was seen in the groups with decreasing or constant ACR. Regarding site-specific cancer risks, subjects with increasing ACR or constant ACR had a higher risk of developing urinary tract and lung cancer. No other associations between 2-year ACR changes and site-specific cancers were found.

Conclusions

Increases in albuminuria over a 2-year period are associated with a higher risk of developing overall, urinary tract and lung cancer, independent of baseline kidney function and albuminuria. These data add important weight to the link that exists between albuminuria and cancer incidence.

Evaluation of the introduction of novel potassium binders in routine care; the Stockholm CREAtinine measurements (SCREAM) project

BACKGROUND

The pharmacological management of hyperkalemia traditionally considered calcium or sodium polystyrene sulfonate and, since recently, the novel binders patiromer and sodium zirconium cyclosilicate. We evaluated their patterns of use, duration of treatment and relative effectiveness/safety in Swedish routine care.

METHODS

Observational study of adults initiating therapy with sodium polystyrene sulfonate or a novel binder (sodium zirconium cyclosilicate or patiromer) in Stockholm 2019-2021. We quantified treatment duration by repeated dispensations, compared mean achieved potassium concentration within 60 days, and potential adverse events between treatments.

RESULTS

A total of 1879 adults started treatment with sodium polystyrene sulfonate, and 147 with novel binders (n = 41 patiromer and n = 106 sodium zirconium cyclosilicate). Potassium at baseline for all treatments was 5.7 mmol/L. Sodium polystyrene sulfonate patients stayed on treatment a mean of 61 days (14% filled ≥3 consecutive prescriptions) compared to 109 days on treatment (49% filled ≥3 prescriptions) for novel binders. After 15 days of treatment, potassium similarly decreased to 4.6 (SD 0.6) and 4.8 (SD 0.6) mmol/L in the sodium polystyrene sulfonate and novel binder groups, respectively, and was maintained over the 60 days post-treatment. In multivariable regression, the odds ratio for novel binders (vs sodium polystyrene sulfonate) in reaching potassium ≤ 5.0 mmol/L after 15 days was 0.65 (95% CI 0.38-1.10) and after 60 days 0.89 (95% CI 0.45-1.76). Hypocalcemia, hypokalemia, and initiation of anti-diarrheal/constipation medications were the most-commonly detected adverse events. In multivariable analyses, the OR for these events did not differ between groups.

CONCLUSION

We observed similar short-term effectiveness and safety for all potassium binders. However, treatment duration was longer for novel binders than for sodium polystyrene sulfonate.

Albuminuria and the risk of cancer: the Stockholm CREAtinine Measurements (SCREAM) project

Background

Studies investigating the association of chronic kidney disease and cancer have focused on estimated glomerular filtration (eGFR) rather than on albuminuria. This study aimed to examine whether albuminuria is associated with cancer incidence, and whether this association is independent of eGFR.

Methods

We included subjects of the Stockholm Creatinine Measurements (SCREAM) project without a history of cancer-250 768 subjects with at least one urine albumin-creatinine ratio (ACR) test (primary cohort) and 433 850 subjects with at least one dipstick albuminuria test (secondary cohort). Albuminuria was quantified as KDIGO albuminuria stages. The primary outcome was overall cancer incidence. Secondary outcomes were site-specific cancer incidence rates. Multivariable Cox proportional hazards regression models adjusted for confounders including eGFR to calculate hazard ratios and 95% confidence intervals (HRs, 95% CIs).

Results

During a median follow-up of 4.3 (interquartile range 2.0-8.2) years, 21 901 subjects of the ACR cohort developed de novo cancer. In multivariable analyses, adjusting among others for eGFR, subjects with an ACR of 30-299 mg/g or ≥300 mg/g had a 23% (HR 1.23; 95% CI 1.19-1.28) and 40% (HR 1.40; 95% CI 1.31-1.50) higher risk of developing cancer, respectively, when compared with subjects with an ACR <30 mg/g. This graded, independent association was also observed for urinary tract, gastrointestinal tract, lung and hematological cancer incidence (all P < .05). Results were similar in the dipstick albuminuria cohort.

Conclusions

Albuminuria was associated with the risk of cancer independent of eGFR. This association was primarily driven by a higher risk of urinary tract, gastrointestinal tract, lung and hematological cancers.

Androgen use in bone marrow failures and myeloid neoplasms: Mechanisms of action and a systematic review of clinical data

Despite recent advancements, treatment of cytopenia due to bone marrow failures (BMF) and myeloid neoplasms remains challenging. Androgens promote renewal and maturation of blood cells and may be beneficial in these forms. Here we report a systematic review of androgens use as single agent in hematologic conditions. Forty-six studies, mainly retrospective with various androgen types and doses, were included: 12 on acquired aplastic anemia (AA), 11 on inherited BMF, 17 on myelodysplastic syndromes (MDS), and 7 on myelofibrosis. Responses ranged from 50 to 70% in inherited BMF, 40-50% in acquired AA and MDS, while very limited evidence emerged for myelofibrosis. In acquired AA, response was associated with presence of non-severe disease; in MDS androgens were more effective on thrombocytopenia or mild to moderate anemia, whilst limited benefit was observed for transfusion dependent anemia. Toxicity profile mainly consisted of virilization and liver enzyme elevation, whilst the risk of leukemic evolution remains controversial.

Quality of laboratory biomarker monitoring during treatment with lithium in patients with bipolar disorder

BACKGROUND

Clinical guidelines recommend monitoring of creatinine and lithium throughout treatment with lithium. We here assessed the extent to which this occurs in healthcare in Sweden.

METHODS

This is an observational study of all adults with bipolar disorder starting lithium therapy in Stockholm, Sweden, during 2007-2018. The main outcome was monitoring of blood lithium and creatinine at therapy initiation and/or once annually. The secondary outcome was monitoring of calcium and thyroid-stimulating hormone (TSH). Patients were followed up until therapy cessation, death, out-migration, or to the end of 2018.

RESULTS

We identified 4428 adults with bipolar disorder who started lithium therapy and were followed up for up to 11 years. Their median age was 39 years, and 63% were women. The median duration on lithium therapy was 4.3 (IQR: 1.9-7.45) years, and the majority who discontinued therapy started another mood stabilizer soon after. Overall, 21% started lithium therapy without assessing the serum/plasma concentration of creatinine. The proportion of people who did not have both lithium and creatinine measured increased from 21% in the first year to 33% in the eleventh year. The proportion with annual testing for TSH or calcium was slightly lower. As few as 16% of patients had both lithium and creatinine tested once annually during their complete time on lithium.

CONCLUSIONS

In a Swedish community sample, lithium and creatinine monitoring was inconsistent with guideline recommendations that call for measurement of annual biomarker levels.

Absolute and Relative Risks of Kidney Outcomes Associated With Lithium vs Valproate Use in Sweden

Importance

Among patients with bipolar disorder, discordant findings have been published on the nephrotoxic effects of lithium therapy.

Objective

To quantify absolute and relative risks of chronic kidney disease (CKD) progression and acute kidney injury (AKI) in people who initiated lithium compared with valproate therapy and to investigate the association between cumulative use and elevated lithium levels and kidney outcomes.

Design, Setting, and Participants

This cohort study had a new-user active-comparator design and used inverse probability of treatment weights to minimize confounding. Included patients initiated therapy with lithium or valproate from January 1, 2007, to December 31, 2018, and had a median follow-up of 4.5 years (IQR, 1.9-8.0 years). Data analysis began in September 2021, using routine health care data from the period 2006 to 2019 from the Stockholm Creatinine Measurements project, a recurrent health care use cohort of all adult residents in Stockholm, Sweden.

Exposures

New use of lithium vs new use of valproate and high (>1.0 mmol/L) vs low serum lithium levels.

Main Outcomes and Measures

Progression of CKD (composite of >30% decrease relative to baseline estimated glomerular filtration rate [eGFR] and kidney failure), AKI (by diagnosis or transient creatinine elevations), new albuminuria, and annual eGFR decrease. Outcomes by attained lithium levels were also compared in lithium users.

Results

The study included 10 946 people (median [IQR] age, 45 [32-59] years; 6227 female [56.9%]), of whom 5308 initiated lithium therapy and 5638 valproate therapy. During follow-up, 421 CKD progression events and 770 AKI events were identified. Compared with patients who received valproate, those who received lithium did not have increased risk of CKD (hazard ratio [HR], 1.11 [95% CI, 0.86-1.45]) or AKI (HR, 0.88 [95% CI, 0.70-1.10]). Absolute 10-year CKD risks were low and similar: 8.4% in the lithium group and 8.2% in the valproate group. No difference in the risk of developing albuminuria or the annual rate of eGFR decrease was found between groups. Among more than 35 000 routine lithium tests, only 3% of results were in the toxic range (>1.0 mmol/L). Lithium values greater than 1.0 mmol/L, compared with lithium values of 1.0 mmol/L or less, were associated with increased risk of CKD progression (HR, 2.86; 95% CI, 0.97-8.45) and AKI (HR, 3.51; 95% CI, 1.41-8.76).

Conclusions and Relevance

In this cohort study, compared with new use of valproate, new use of lithium was meaningfully associated with adverse kidney outcomes, with low absolute risks that did not differ between therapies. However, elevated serum lithium levels were associated with future kidney risks, particularly AKI, emphasizing the need for close monitoring and lithium dose adjustment.

Novel glucose-lowering drugs and the risk of acute kidney injury in routine care; the Stockholm CREAtinine Measurements (SCREAM) project

INTRODUCTION

Little is known about the comparative effects of sodium glucose cotransporter-2 inhibitors (SGLT2i), glucagon-like peptide-1 receptor agonists (GLP1-RA), or dipeptidyl peptidase-4 inhibitors (DPP-4i) on the risk of acute kidney injury (AKI) in routine care, which may differ from the controlled setting of trials.

METHODS

Observational study comparing risks of AKI among new users of SGLT2i, GLP1-RA or DPP-4i in the region of Stockholm, Sweden, during 2008-2018. AKI was defined by ICD-10 codes and creatinine-based KDIGO criteria. We used inverse probability of treatment weighting (IPTW) to adjust for 60 potential confounders, weighted Kaplan-Meier curves and Cox regression to estimate hazard ratios and absolute risks.

RESULTS

We included 17,407 participants who newly initiated DPP-4i (N = 10,605), GLP1-RA (N = 4448) or SGLT2i (N = 2354). Mean age was 63 years (39% women) and median (IQR) eGFR was 89 (73-100) ml/min/1.73 m2. During a median follow-up of 2.5 years, 1411 participants experienced AKI. SGLT2i users had the lowest incidence rate of AKI, 18.3 [CI 95% 14.1-23.4] per 1000 person years, followed by GLP1-RA (22.5; 19.9-25.3) and DPP-4i (26.6; 25-28.2). The weighted 3-year absolute risk for AKI was 5.79% [3.63-8.52] in the SGLT2i group, compared with 7.03% [5.69-8.69] and 7.00% [6.43-7.58] in the GLP1-RA and DPP-4i groups, respectively. The adjusted hazard ratio was 0.73 [CI 95% 0.45-1.16] for SGLT2i vs. DPP-4i, and 0.98 [CI 95% 0.82-1.18] for GLP1-RA vs. DPP-4i.

CONCLUSION

This study of routine care patients initiating novel glucose-lowering drugs showed similar occurrence of AKI between therapies, and suggests lower risk for SGLT2i.

Real-life monocentric experience of venetoclax-based regimens for acute myeloid leukemia

Introduction

Combination of venetoclax and hypomethylating agents (HMAs) has become a standard of care in acute myeloid leukemia (AML) aged &gt;75 years or who have comorbidities that preclude intensive induction chemotherapy.

Methods

We conducted a monocentric retrospective analysis on adult patients affected by treatment-naïve AML not eligible for standard induction therapy or refractory/relapsed (R/R) AML treated with venetoclax combinations outside clinical trials. Venetoclax was administered at the dose of 400 mg/daily after a short ramp-up and reduced in case of concomitant CYP3A4 inhibitors.

Results

Sixty consecutive AML were identified. Twenty-three patients (38%) were affected by treatment-naïve AML and 37 (62%) by R/R AML. Median age was 70 years. Among R/R AML 30% had received a prior allogeneic stem cell transplantation (allo-HSCT). In combination with venetoclax, 50 patients (83%) received azacitidine. Antifungal prophylaxis was performed in 33 patients (55%).

Overall response rate was 60%, with 53% of complete remission (CR; 78% for treatment-naïve and 49% for R/R, p 0.017). Median overall survival was 130 days for R/R patients and 269 days for treatment-naïve patients; median event free survival was 145 days for R/R cohort and 199 days for treatment-naïve AML.

Measurable residual disease was negative in 26% of evaluable patients in CR/CR with incomplete hematologic recovery after 2 cycles and in 50% after 4 cycles, with no significant association with survival.

Eleven patients (18%) received an allo-HSCT after venetoclax combinations. Most common grade 3/4 adverse events were infectious (51% of the patients), or hematological without infections (25% of the patients). Use of CYP3A4 inhibitors was associated with a trend to shorter cytopenias and with a lower rate of infections. Invasive fungal infections were less frequent among patients receiving azole prophylaxis (6% vs 26%; p 0.0659).

Discussion

Venetoclax-based regimens are a viable option for AML considered not eligible for standard induction therapy and a valid rescue therapy in the R/R setting.

Azole prophylaxis did not significantly affect response and it was associated with a lower rate of invasive fungal infections. Despite a limited number of patients, the association of venetoclax and HMAs proved to be also a feasible bridging therapy to transplantation.

Abstract P430: Role of Cystatin C-based Estimated Glomerular Filtration Rate for Direct Oral Anticoagulant Dosing in Patients With Atrial Fibrillation

Introduction: Renal dose adjustment is imperative to appropriate direct oral anticoagulant (DOAC) prescribing among patients with atrial fibrillation (AF). Serum creatinine is routinely used to estimate GFR (eGFRcr) in clinical practice, but eGFRcr may be less accurate in certain settings. It is unknown whether other kidney function biomarkers, like cystatin C, is helpful to guide DOAC dosing.

Hypothesis: Appropriate DOAC dosing by eGFRcr but supratherapeutic dosing by cystatin C-based eGFR (eGFRcys) is associated with bleeding, compared to appropriate dosing by both eGFRcr and eGFRcys.

Methods: We conducted observational study from the SCREAM project, a healthcare utilization cohort of Stockholm, Sweden, during 2006-2018. We identified patients with AF on DOACs who had creatinine and cystatin C measured on the same day. We calculated eGFRcr with the 2021 Chronic Kidney Disease (CKD)-EPI and eGFRcys with 2012 CKD-EPI cystatin C equations. We estimated defined daily dose consumed per day and considered <0.8 as a reduced dose. We separately classified supratherapeutic, subtherapeutic, and appropriate dosing by eGFRcr and eGFRcys, and examined the bleeding risk using Cox regression.

Results: Among 5427 AF patients on DOACs, mean age (SD) was 76 (9) years and 43% were women. Compared to eGFRcr, eGFRcys identified more patients with CKD (61% for eGFRcys <60 ml/min/1.73 m 2 vs. 35% for eGFRcr <60 ml/min/1.73 m 2 ), as well as more patients with supratherapeutic dosing (7.9 vs. 2.4%). Among 3064 patients who were classified as appropriate dosing by eGFRcr, 312 (10.2%) were reclassified as supratherapeutic dosing by eGFRcys and had a higher risk of bleeding (hazard ratio=1.58, 95% CI: 1.03-2.42), compared with those who were classified as appropriate dosing by both eGFRcr and eGFRcys ( Table ).

Conclusions: Appropriate DOAC dosing by eGFRcr but supratherapeutic dosing by eGFRcys was associated with a higher risk of bleeding. The findings suggest that eGFRcys may inform decisions on DOAC dosing.

FC 128: Novel Glucose-Lowering Drugs and the Risk of Acute Kidney Injury in Routine Care: The Stockholm Creatinine Measurements (SCREAM) Project

BACKGROUND AND AIMS

Little is known about the comparative effects of dipeptidyl peptidase-4 inhibitors (DPP-4i), glucagon-like peptide-1 receptor agonists (GLP-1RAs) or sodium glucose cotransporter-2 inhibitors (SGLT2i) on risk of acute kidney injury (AKI) in routinely care, which may differ from the controlled setting of trials.

METHOD

We performed a population-based retrospective analysis using the Stockholm CREAtinine Measurements (SCREAM) database, with complete information on diagnoses, medication dispensation claims and laboratory test results for all Stockholm citizens accessing healthcare during 2008–2018. We used a new user active comparator design: new initiation of SGLT2i, GLP1-RA or DPP-4i. The outcome AKI was defined by ICD-10 diagnostic codes as well as KDIGO criteria for rapid creatinine elevations. A multinominal propensity score model with inverse probability treatment weights (IPTW) was used to adjust for 59 identified confounders. Weighted Cox regression was used to estimate adjusted hazard ratios and weighted Kaplan-Meier curves for adjusted absolute risks.

RESULTS

We included 17 043 participants who newly initiated DPP-4i (N = 10 345), GLP1-RA (N = 4384) or SGLT2i (N = 2314). Mean age was 63 years (38% women) and median eGFR 89 mL/min/1.73 m2. During a median follow-up of 2.5 years, 1361 participants experienced AKI. SGLT2i users had the lowest incidence rate of AKI, 17.4 per 1000 person years [95% confidence interval (95% CI) 13.3–22.4], followed by GLP1-RA users, 22.2 (95% CI 19.6–25) and DPP-4 users, 26.1 (95% CI 24.6–27.8). The adjusted 3-year absolute risk for AKI was 5.98 (95% CI 3.65–8.38) in the SGLT2i arm, compared with 6.45 (95% CI 5.26–7.62) in the GLP1-RA arm and 7.03 (95% CI 6.45–7.59) in the DPP-4i arm. The adjusted hazard ratio was 0.85 (95% CI 0.58–1.18) for SGLT2i versus DPP-4i, and 0.93 (95% CI 0.78–1.11) for GLP1-RA versus DPP-4i.

CONCLUSION

This study of routinely cared patients initiating novel glucose-lowering drugs observed similar occurrence of AKI between therapies.

MO502: Use of Lithium, Valproate and the Risk of Acute or Chronic Kidney Disease: An Observational Study From Routine Care Data

BACKGROUND AND AIMS

Lithium is an established treatment for bipolar disorder and treatment-resistant depression. Despite awareness of potential kidney damage, there is a lack of research evidence to inform on the existence and magnitude of the risk. Observational studies to date show conflicting findings, possibly explained by inadequate control populations, prevalent user bias and a lack of information on kidney function or serum lithium levels.

METHOD

We conducted a cohort study to compare kidney outcomes in adults who started lithium or valproate therapy in Stockholm, Sweden, during 2007–18. Within lithium users, we also compared outcomes by average serum lithium concentrations during the first year of therapy. Kidney outcomes were CKD progression (composite of &gt;30% eGFR decline and kidney failure) and AKI (by diagnosis or KDIGO transient creatinine elevations). Propensity score weighted Cox regression was used to estimate hazard ratios with [95% confidence intervals (95% CI)] and balance 46 identified confounders. Complete collection of repeated dispensations at Swedish pharmacies allowed modelling of the time-dependent risk associated with cumulative lithium exposure. Sensitivity analyses included restricting to patients with a diagnosis of bipolar disorder, apply a 1-year lag, use of alternative weighting methods and evaluation of eGFR monitoring rates to ascertain surveillance bias between groups.

RESULTS

We included 16 645 individuals, of whom 5308 initiated lithium and 5638 valproate therapy. Their median age was 45 years (57% women) and median eGFR was 99 mL/min/1.73 m2. A total of 179 CKD progression events and 234 AKI were identified during a median of follow-up of 4.3 and 4.2 years, respectively. After propensity score weighting, the adjusted hazard ratio for the risk of CKD progression was 1.12 (95% CI 0.86–1.47) and for AKI 0.88 (95% CI 0.7–1.09). There was a weak, non-statistically significant association between cumulative exposure to lithium and the risk of CKD progression that was not observed for cumulative use of valproate. Results were consistent among patients with a bipolar disorder diagnosis and robust to 1-year lag or alternative weighing methods. A total of 3913 lithium users were on therapy for at least one year and underwent routine serum lithium monitoring. Compared with patients with average serum lithium levels &lt;1.0 mEq/L, those with serum lithium ≥1.0 mEq/L (n = 270) were at a higher risk of both CKD progression (HR: 2.18; 1.28–3.71) and AKI (HR: 1.37; 0.81–2.34).

CONCLUSION

In this analysis of patients from routine clinical practice, the risk of kidney outcomes associated with lithium therapy did not differ from that of valproate. Modest risk magnitudes need to be offset with the effectiveness and anti-suicidal benefits of lithium. However, elevated serum lithium levels strongly predicting kidney risk, emphasizing the need for close monitoring and lithium dose-adjustment.

Use of nephrotoxic medications in adults with chronic kidney disease in Swedish and US routine care

Background

To characterize the use of nephrotoxic medications in patients with chronic kidney disease (CKD) Stages G3–5 in routine care.

Methods

We studied cohorts of adults with confirmed CKD G3–5 undergoing routine care from 1 January 2016 through 31 December 2018 in two health systems [Stockholm CREAtinine Measurements (SCREAM), Stockholm, Sweden (N = 57 880) and Geisinger, PA, USA (N = 16 255)]. We evaluated the proportion of patients receiving nephrotoxic medications within 1 year overall and by baseline kidney function, ranked main contributors and examined the association between receipt of nephrotoxic medication and age, sex, CKD G-stages comorbidities and provider awareness of the patient's CKD using multivariable logistic regression.

Results

During a 1-year period, 20% (SCREAM) and 17% (Geisinger) of patients with CKD received at least one nephrotoxic medication. Among the top nephrotoxic medications identified in both cohorts were non-steroidal anti-inflammatory drugs (given to 11% and 9% of patients in SCREAM and Geisinger, respectively), antivirals (2.5% and 2.0%) and immunosuppressants (2.7% and 1.5%). Bisphosphonate use was common in SCREAM (3.3%) and fenofibrates in Geisinger (3.6%). Patients <65 years of age, women and those with CKD G3 were at higher risk of receiving nephrotoxic medications in both cohorts. Notably, provider awareness of a patient's CKD was associated with lower odds of nephrotoxic medication use {odds ratios [OR] 0.85[95% confidence interval (CI) 0.80–0.90] in SCREAM and OR 0.80 [95% CI 0.72–0.89] in Geisinger}.

Conclusions

One in five patients with CKD received nephrotoxic medications in two distinct health systems. Strategies to increase physician's awareness of patients’ CKD and knowledge of drug nephrotoxicity may reduce prescribing nephrotoxic medications and prevent iatrogenic kidney injury.

Mobility of solid and porous hollow SiO2 nanoparticles in saturated porous media: Impacts of surface and particle structure

Silica nanoparticles (SiO₂ NPs) are of increasing interest in nano-enabled agriculture, particularly as nanocarriers for the targeted delivery of agrochemicals. Their direct application in agricultural soils may lead to the release of SiO₂ NPs in the environment. Although some studies have investigated transport of solid SiO₂ NPs in porous media, there is a knowledge gap on how different SiO₂ NP structures incorporating significant porosities can affect the mobility of such particles under different conditions. Herein, we investigated the effect of pH and ionic strength (IS) on the transport of two distinct structures of SiO₂ NPs, namely solid SiO₂ NPs (SSNs) and porous hollow SiO₂ NPs (PHSNs), of comparable sizes (~200 nm). Decreasing pH and increasing ionic strength reduced the mobility of PHSNs in sand-packed columns more significantly than for SSNs. The deposition of PHSNs was approximately 3 times greater than that of SSNs at pH 4.5 and IS 100 mM. The results are non-intuitive given that PHSNs have a lower density and the same chemical composition of SSNs but can be explained by the greater surface roughness and ten-fold greater specific surface area of PHSNs, and their impacts on van der Waals and electrostatic interaction energies.

FC 070USE OF POTENTIALLY NEPHROTOXIC MEDICATIONS IN PERSONS WITH CHRONIC KIDNEY DISEASE: PARALLEL COHORT STUDIES IN SWEDISH AND U.S ROUTINE CARE

Background and Aims

Many adverse drug events are preventable, such as those potentially resulting from the prescription of nephrotoxic drugs to persons with chronic kidney disease (CKD). We here quantify the extent of contemporary nephrotoxic medication use in patients with CKD.

Method

In two observational cohorts of Swedish (Stockholm CREAtinine Measurements [SCREAM] project, Stockholm, Sweden) and U.S. (Geisinger Health System, Pennsylvania) adults with confirmed CKD stages G3-G5 undergoing routine care during 2016-2018, we explored the prescription (in U.S.) and dispensation (in Sweden) of 115 different ambulatory drugs with proven or purported nephrotoxicity during the 12 months following study inclusion. We evaluated the proportion of participants receiving nephrotoxic drugs, ranked main contributors and identified clinical predictors.

Results

In the Swedish cohort, there were 57880 patients (54.6% women) with median age of 80.00 (inter-quartile range [IQR]: 73.0-86.0) years and eGFR 48.9 ([IQR]: 39.9-55.0) mL/min/1.73 m2. In the U.S. cohort, there were 16255 patients (59% women) with median age of 76 years and eGFR 44 mL/min/1.73 m2. During observation, 20% (Sweden) and 17% (U.S.) of patients received at least one nephrotoxic drug. The top 3 potentially inappropriate nephrotoxic drugs identified were NSAIDs (9% and 11% of participants in U.S. and Sweden received it), antivirals (2.0% and 2.5%) and immunosuppressants (1.5% and 2.7%). Bisphosphonate use was common in Sweden (3.3% of participants), but not in U.S. (0.5%). Conversely, fenofibrates were common in U.S. (3.6%), but not in Sweden (0.13%). In adjusted analyses, patients with young age (&lt;65 years old), women, or with CKD G3 were at higher risk of receiving nephrotoxic medications in both cohorts (P&gt;0.05 for all). Notably, patients aware of their CKD (identified either by issued diagnosis or recent visit to a nephrologist), were at lower risk of nephrotoxic drug use (OR 0.87, 95% CI 0.82-0.92 in Sweden and 0.89, 95% CI 0.81-1.01 in U.S.).

Conclusion

In two geographically distinct health systems, one in five patients with CKD received potentially inappropriate nephrotoxic medications, mainly NSAIDs. Strategies to increase CKD awareness and physician’s knowledge of drug nephrotoxicity may reduce inappropriate ambulatory prescriptions and prevent iatrogenic kidney injury.

Phenotypic and Ultrastructural Profile of M5 Leukemia Cells in Peripheral Blood and Skin Infiltrate

The leukemic cells circulating in the peripheral blood and invading the skin of a patient with type M5 myelomonocytic leukemia were compared using ultrastructural, cytochemical and immunological criteria. Neoplastic cells exhibited more differentiated morphologic features in the skin than in peripheral blood, resembling tissue macrophages. The cytochemical pattern did not show any appreciable difference, whereas the surface antigenic profile was dissimilar. Most circulating leukemic cells were Leu M1+ and Leu M3+, and the percentage of OKM1+ and OKIa-1+ cells varied in two different blood samples examined. Conversely, OKIa-1 monoclonal antibody stained viritually all the leukemic cells infiltrating the skin in the absence of any appreciable reactivity with the other monoclonal antibodies. The phenotype of the malignant cells in the skin did not vary during the clinical course of the disease. These observations suggest that the cutaneous microenvironment is able to induce leukemic cells to mutate their phenotypic features towards a more mature state, or that only relatively differentiated circulating leukemic cells are able to leave the bloodstream and colonize the skin.

Ophthalmological Aspects in Allogenic Bone Marrow Transplantation: Sjögren-Like Syndrome in Graft-Versus-Host Disease

PURPOSE

A major complication of allogenic bone marrow transplantation (BMT) is graft-versus-host disease (GVHD), characterized principally by involvement of the eyes, producing a Sjögren-like syndrome (SLS). This study assessed the predictive role of the eye involvement in the onset of GVHD.

METHODS

Thirty-five patients transplanted for hematological malignancies were routinely examined for ocular manifestation of dry eye. Examination includes the Schirmer I test, break-up time, Lissamine Green staining, fluorescein test, lactoferrin test and impression cytology. A threshold was established for quantitative analysis of SLS.

RESULTS

Fifteen of 35 patients (40%) developed SLS during long-term follow-up. Ten of these (77%) developed acute or chronic GVHD.

CONCLUSIONS

The possible etiology of SLS includes three factors: total body irradiation, ocular toxicity of chemotherapy and GVHD. A correlation was found between poor-prognosis GVHD and the occurrence of SLS.

Occurrence of graft-versus-host disease increases mortality after umbilical cord blood transplantation for acute myeloid leukaemia: a report from Eurocord and the ALWP of the EBMT

BACKGROUND

The efficacy of umbilical cord blood transplantation (UCBT) as treatment for acute myeloid leukaemia (AML) relies on immune-mediated graft-versus-leukaemia effects. Previous studies have suggested a strong association between graft-versus-host disease (GVHD) occurrence and graft-versus-leukaemia effects after allogeneic hematopoietic cell transplantation.

METHODS

Here, we evaluated the kinetics of relapse rate in correlation with GVHD occurrence after UCBT. The kinetics of relapse rate over time in correlation to GVHD occurrence were assessed by calculating the relapse rate per patient-year within sequential 90-day intervals. The impact of GVHD on relapse and mortality was further studied in multivariate Cox models handling GVHD as a time-dependent covariate.

RESULTS

The study included data from 1068 patients given single (n = 567) or double (n = 501) UCBT. The proportion of patients with grade II, III and IV acute GVHD was 20%, 7% and 4%, respectively. At 2 years, the cumulative incidence of chronic GVHD was 42%, the cumulative incidence of relapse was 32%, and overall survival was 32% as well. Relapse rates declined gradually over time during the first 30 months after transplantation. There was a possible suggestion that grade II-IV acute (HR = 0.8, P = 0.1) and chronic (HR = 0.65, P = 0.1) GVHD decreased relapse risk. However, grade II-IV acute GVHD significantly increased early (the first 18 months after UCBT) mortality (HR = 1.3, P = 0.02), whilst chronic GVHD increased each early (HR = 2.7, P < 0.001) and late (HR = 4.9, P < 0.001) mortality after UCBT.

CONCLUSIONS

The occurrence of grade II-IV acute or chronic GVHD each increases overall mortality after UCBT for AML mitigating the possible graft-versus-leukemia effect of GVHD.

Comparison of outcomes after unrelated cord blood and unmanipulated haploidentical stem cell transplantation in adults with acute leukemia

Outcomes after unmanipulated haploidentical stem cell transplantation (Haplo) and after unrelated cord blood transplantation (UCBT) are encouraging and have become alternative options to treat patients with high-risk acute leukemia without human leukocyte antigen (HLA) matched donor. We compared outcomes after UCBT and Haplo in adults with de novo acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL). Median follow-up was 24 months. Analysis was performed separately for patients with AML, n=918 (Haplo=360, UCBT=558) and ALL, n=528 (Haplo=158 and UCBT=370). UCBT was associated with delayed engraftment and higher graft failure in both AML and ALL recipients. In multivariate analysis, UCBT was associated with lower incidence of chronic graft-vs-host disease both in the AML group (hazard ratio (HR)=0.63, P=0.008) and in the ALL group (HR=0.58, P=0.01). Not statistically significant differences were observed between Haplo and UCBT for relapse incidence (HR=0.95, P=0.76 for AML and HR=0.82, P=0.31 for ALL), non-relapse mortality (HR=1.16, P=0.47 for AML and HR=1.23, P=0.23 for ALL) and leukemia-free survival (HR 0.78, P=0.78 for AML and HR=1.00, P=0.84 for ALL). There were no statistically differences on main outcomes after unmanipulated Haplo and UCBT, and both approaches are valid for acute leukemia patients lacking a HLA matched donor. Both strategies expand the donor pool for patients in need.

Calreticulin mutation-specific immunostaining in myeloproliferative neoplasms: pathogenetic insight and diagnostic value

Mutations in the gene calreticulin (CALR) occur in the majority of JAK2- and MPL-unmutated patients with essential thrombocythemia (ET) and primary myelofibrosis (PMF); identifying CALR mutations contributes to the diagnostic pathway of ET and PMF. CALR mutations are heterogeneous spanning over the exon 9, but all result in a novel common protein C terminus. We developed a polyclonal antibody against a 17-amino-acid peptide derived from mutated calreticulin that was used for immunostaining of bone marrow biopsies. We show that this antibody specifically recognized patients harboring different types of CALR mutation with no staining in healthy controls and JAK2- or MPL-mutated ET and PMF. The labeling was mostly localized in megakaryocytes, whereas myeloid and erythroid cells showed faint staining, suggesting a preferential expression of calreticulin in megakaryocytes. Megakaryocytic-restricted expression of calreticulin was also demonstrated using an antibody against wild-type calreticulin and by measuring the levels of calreticulin RNA by gene expression analysis. Immunostaining using an antibody specific for mutated calreticulin may become a rapid, simple and cost-effective method for identifying CALR-mutated patients complementing molecular analysis; furthermore, the labeling pattern supports the preferential expansion of megakaryocytic cell lineage as a result of CALR mutation in an immature hematopoietic stem cell.

Treatment of experimental esophagogastric myotomy with bone marrow mesenchymal stem cells in a rat model

BACKGROUND

Over the last 15 years, many studies demonstrated the myogenic regenerative potential of bone marrow mesenchymal stem cells (BM-MSC), making them an attractive tool for the regeneration of damaged tissues. In this study, we have developed an animal model of esophagogastric myotomy (MY) aimed at determining the role of autologous MSC in the regeneration of the lower esophageal sphincter (LES) after surgery.

METHODS

Syngeneic BM-MSC were locally injected at the site of MY. Histological and functional analysis were performed to evaluate muscle regeneration, contractive capacity, and the presence of green fluorescent protein-positive BM-MSC (BM-MSC-GFP(+) ) in the damaged area at different time points from implantation.

KEY RESULTS

Treatment with syngeneic BM-MSC improved muscle regeneration and increased contractile function of damaged LES. Transplanted BM-MSC-GFP(+) remained on site up to 30 days post injection. Immunohistochemical analysis demonstrated that MSC maintain their phenotype and no differentiation toward smooth or striated muscle was shown at any time point.

CONCLUSIONS & INFERENCES

Our data support the use of autologous BM-MSC to both improve sphincter regeneration of LES and to control the gastro-esophageal reflux after MY.

Chronic Relapsing Thrombotic Thrombocytopenic Purpura Successfully Treated with Rituximab: Case Report

Plasma therapy is a cornerstone in the treatment of idiopathic Thrombotic Thrombocytopenic Purpura (TTP); however about one-third of patients relapse. In this subset of patients different immunosuppressive approaches have been reported with variable efficacy. We describe the case of an 11-year-long chronic relapsing TTP, requiring frequent plasma exchange procedures and treated unsuccessfully with several immunosuppressive agents. On the occasion of a further relapse, the patient was treated with rituximab, and achieved normalization of hematological values and clinical status for about one year. Upon further relapse, rituximab therapy was started again successfully. A monthly administration was performed with the aim of maintaining the clinical and hematological response stable. In conclusion, rituximab is a safe and effective alternative to other immunosuppressive therapies for chronic relapsing TTP patients.

Fatal Acute Hepatitis C Virus Infection in Patients with Hematological Malignancies

Patients in hematology units are at risk of hepatitis C virus infection. In these patients acute infection is reportedly mild, presents only moderately increased ALT levels, is characterized by a significant delay in anti-HCV seroconversion and does not influence the course of the underlying disease. We describe two fatal cases of acute HCV infection occurring in patients with hematologic malignancies and we hypothesize that, in a subset of immunocompromised patients, acute HCV infection may play a still unrecognized but not marginal role in contributing to death. Prospective studies are needed to define the frequency of fatal acute HCV infection among hematologic patients undergoing chemotherapy.