Non-valvular atrial fibrillation in patients on peritoneal dialysis, prevalence, treatment and professionals involved

Atrial fibrillation is the most frequent chronic arrhythmia in patients with chronic kidney disease. Oral anticoagulation with vitamin K antagonists and now direct oral anticoagulants have been and are the fundamental pillars for the prevention of thromboembolic events. However, there are no randomized clinical trials on the risk-benefit profile of oral anticoagulation in patients with chronic kidney disease stage 5 on peritoneal dialysis and there is little evidence in the literature in this population. The objective of our study was to know the prevalence, treatment and professionals involved in the management of atrial fibrillation in peritoneal dialysis patients. For this purpose, we performed a descriptive analysis through a survey sent to different peritoneal dialysis units in Spain. A total of 1,403 patients on peritoneal dialysis were included in the study, of whom 186 (13.2%) had non-valvular atrial fibrillation. In addition, the assessment of the scores of thromboembolic and bleeding risks for the indication of oral anticoagulation was mainly carried out by the cardiologist (60% of the units), as well as its prescription (cardiologist 47% or in consensus with the nephrologist 43%). In summary, patients on peritoneal dialysis have a remarkable prevalence of non-valvular atrial fibrillation. Patients frequently receive oral anticoagulation with vitamin K antagonists, as well as direct oral anticoagulants. The data obtained regarding the scores used for the assessment of thromboembolic and bleeding risk, treatment and involvement by Nephrology indicates that there is a need for training and involvement of the nephrologist in this pathology.

MO1050: Covid-19 Vaccination Improved Psychological Distress (Anxiety and Depression Scores) in Chronic Kidney Disease Patients: A Prospective Study

BACKGROUND AND AIMS

To our knowledge, the psychological impact of coronavirus disease (COVID-19) vaccination has not yet been evaluated for the general population nor for chronic kidney disease (CKD) patients.

The purpose of the study is to analyse the impact of vaccination against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on anxiety and depression scores in patients with different modalities of CKD.

METHOD

A total of 117 renal patients (50 haemodialysis patients, 13 peritoneal dialysis patients, 32 kidney transplants and 22 advanced CKD patients at pre-dialysis care) were evaluated for depression, anxiety, health-related quality of life (HRQOL) and perceived fears and resources with standardized (The Hospital Anxiety and Depression Scale; HADS) and self-reported questionnaires. The measure points were before vaccination and 15 days after vaccination.

RESULTS

The main finding of the study is that there is a decrease in the global mean of normal scores for anxiety and depression symptoms in CKD patients, post-vaccination. We did not find statistically significant differences in depression or anxiety scores, nor HRQOL differences between the treatment groups. The three main fears reported by the participants at baseline were those of adverse effects, not getting the vaccine and lack of information.

CONCLUSION

These findings highlight the potential interest of assessing psychological variables related to the impact of vaccination against SARS-CoV-2. New studies will be required to assess the impact of comprehensive vaccine coverage and its psychological impact.

MO717: Prevalence and Management of Non-Valvular Atrial Fibrillation in Peritoneal Dialysis. Results of a Multicentric Survey

BACKGROUND AND AIMS

Among patients with chronic kidney disease, the incidence and prevalence of nonvalvular atrial fibrillation (NVAF) increases as renal function decreases, detecting a prevalence of up to 27% in hemodialysis patients. However, its prevalence among patients on peritoneal dialysis (PD) has been less studied.

The aim of the study is to analyse the prevalence of NVAF and characteristics related to its management in PD patients older than 18 years.

METHOD

An observational, cross-sectional, multicenter and retrospective study was carried out through a survey and request for variables sent through a Google questionnaire to PD units in our country. A total of 1403 patients from 30 PD units were included.

RESULTS

The mean prevalence of NVAF in the study was 13.2%, median 11.7% (interquartile range: 6.1–19.4). A total of 60% of the centers had a prevalence >10%.

A total of 57.6% (n = 17) used the CHADS2 or CHAS2-VASC score to calculate the risk of stroke/thromboembolism in their patients with NVAF. A total of 43.3% (n  = 13) do not use it. In these cases, 15.3% (n = 2) do not calculate it because they treat all patients with NVAF and the remaining 84.6% (n = 11) do not use it because the cardiologist uses it and delegates it to them.

Regarding the decision to start anticoagulant treatment in NVAF: in 60% of the centers (n = 18) the cardiologist indicates anticoagulation, in 36.7% (n = 11) the indication is made jointly (cardiologist and nephrologist) and only in 3.3% (n = 1) the indication is made by the nephrologist.

A total of 72.5% of the patients with NVAF (135/186) received anticoagulant treatment. Of these, 28 (20.7%) received direct-acting anticoagulants and 107 (79.3%) received acenocoumarol. Among direct-acting anticoagulants, the most frequent regimens were: apixaban 2.5 mg/12 h (86%), and edoxaban 30 mg/24 h (7%). A total of 5.9% (11/186) of patients with NVAF did not receive anticoagulant or antiplatelet treatment.

A total of 90% of the centers (n = 27) are familiar with the technique of percutaneous appendage closure for the treatment of NVAF, but it is not available in five of them. This technique has been performed in 17 of the patients with NVAF.

CONCLUSION

The prevalence of NVAF in PD patients is high. The management of these patients is carried out mainly by cardiologists with little participation of nephrologists. Most patients receive anticoagulant treatment with coumarin drugs. The data from this analysis, as well as the limited data from the literature, indicate that an adequate format, a consensus document, as well as more data from observational studies (and especially from randomized controlled trials) are needed to adequately address this common complication in patients with DP.

P1025HISTOLOGICAL AND CLINICAL FINDINGS IN ADULT AUTOPSIES OF TYPE 2 DIABETES MELLITUS PATIENTS WITH OR WITHOUT DIABETIC KIDNEY DISEASE

Background and Aims

Few studies have analyzed early lesions of diabetic nephropathy (DN) in those patients who do not have clinical signs of this involvement, since the indication of renal biopsy is usually performed in patients with significant renal manifestations.The aim of the study was to analyze renal histological lesions from autopsies of diabetic patients with or without clinical expression of DN. Thus, we analyze their correlation according to the presence or absence of proteinuria (albumin/creatinine to ratio > 300). Autopsies from non-diabetic patients was used as a control group.

Method

Kidneys from autopsies of 21 patients with type 2 diabetes mellitus (T2DM) and 4 non-diabetic controls were analyzed by two pathologists. The histological lesions score of DN was performed according to the classification of Tervaert et al. (JASN. 2010; 21: 556–63), and a description of histological findings, clinical and analytical data were made.

Results

The mean glomeruli per sample was: 170 ±88. Patient demographics of autopsies: mean age 76 ± 11 years, mean duration of diabetes 6.08 ± 3.2 years (20%> 10 years). Last known eGFR: 51 ± 28, HbA1c: 7.3 ± 1.9%. Albuminuria and cardiovascular disease were present in 42% and 60% of patients with T2DM. Histological and clinical data are shown in Table and Graphics.

Conclusion

A high percentage of diabetics without early clinical lesions of DN (albuminuria) already express moderate to severe histological changes, especially severe mesangial expansion and severe glomerular vascular lesions. The control group showed minimal histological lesions except for mild expansion of the mesangium and inflammation associated with IFTA. Our data suggest renal involvement in T2DM is present in earlier stages (patients without albuminuria). Therefore, early metabolic control is important, as well as other risk factors that may influence in the development of DN. Large sample size studies are pending to confirm these data.

P0200KEEP ON (KEEPING RAAS INHIBITION TREATMENT WITH OPTIMAL POTASSIUM CONTROL). DESIGN OF A CLINICAL TRIAL OF USING SODIUM ZIRCONIUM CYCLOSILICATE FOR KEEPING RAAS INHIBITION AND/OR MRAS IN PATIENTS WITH CKD AND CONGESTIVE HEART FAILURE HISTORY

Background and Aims

Hyperkalemia (HK) is a potentially life-threatening condition, in patients with chronic kidney disease (CKD) and congestive heart failure (CHF).

The majority of patients affected with CKD or CHF, must be treated with inhibitors of renin angiotensin aldosterone system (RAASi) and mineralocorticoid receptor antagonists (MRAs). However, the treatments previously mentioned, increase the risk of HK episodes, which is the main cause of RAASi and MRAs downtitration or discontinuation, representing an undesirable clinical scenario, given that the patients are at high risk of be deprived of their nephroprotective effect and cardio-renal benefits

The aim of the study is: to analyze if, in patients with HK, CKD and CHF treated with RAASi and/or MRA, serum potassium (sK) reduction by Sodium zirconium cyclosilicate (SZC) treatment is non-inferior to RAASi and/or MRAs discontinuation or downtitration.

Method

Results

The study will demonstrate results on serum electrolytes, renal function, albuminuria, KDQoL questionnaire and changes in relative overhydration (multifrequency bioimpedance -BCM Fresenius-)

Conclusion

The KEEP ON study will define the ability of SZC to facilitate the use of RAAS-I and / or MRA in patients with HK and cardiorenal syndrome allowing the maintenance of the medications recommended by international guidelines for the treatment of CHF at different degrees of CKD while maintaining the potential cardio-renal and nephroprotective benefit.

P0322OUR EXPERIENCE IN ELECTRONIC CONSULTATION FOR REDUCING WAITING LIST AND OPTIMIZING NEPHROLOGY HEALTHCARE

Background and Aims

Chronic kidney disease (CKD) is recognized as a health problem in the general population; as a result, there is a growing demand for specialist services. This is especially relevant in the Spanish health system which covers the entire population free of charge.

We describe our experience with new e-consultation software that allows specialists to provide clinical recommendations to primary care providers about non-subsidiary patients referred to our Nephrology Department. This system respects current protocols and is based on patient chart review without face-to-face visits, thus avoiding unnecessary time wastage in the healthcare system.

Method

Our Nephrology department covers the metropolitan area of Valencia with 341,972 citizens attended by 16 primary care centers. The Community IT software system allows all doctors (hospitals and primary care) to access the patient's medical records including laboratory, radiology, anthropometric data and treatments. A mailbox, developed as part of the Hospital General’s IT system, receives all proposed referrals from primary care doctors to our department. A nephrologist then decides if the e-consultation requires an in-person visit or can be answered as a non face-to-face visit. Thus, patient’s appointments are scheduled in less than one week (mean 3.8±4.5 days) and the outpatient visit in less than 14 days.

The main referral criteria were: albumin/creatinine ratio> 300 mg/g, eGFR<30 ml/min/1.73 (<45 in <70 years), renal progression, resistant hypertension in CKD patients, electrolyte abnormalities and renal anemia. Patients with conditions that do not meet referral criteria are attended and given the appropriate recommendations via e-consultation. The patient is not required to present at the hospital. We describe the results of e-consultations from 1St September 2017 to 31st December 2019.

Results

A total of 2641 consultations were submitted between September, 2017 to December, 2019 (807 in 2017, 861 in 2018 and 903 in 2019). Of these, 285 (12%) were answered as non face-to-face visit (6% of the 2017 e-consultations, 11% from 2018 and 24% from 2019).

The characteristics of the 285 non face-to-face e-consultations: mean age: 68.9 ±19.5 years, female: 61.4%, diabetics: 31.2%. The main reasons for referral were: mild/low eGFR (35%), mild albuminuria (10%), administrative questions related to treatments (10%), mild hypertension (4%), mild electrolyte disturbances (2%), subacute renal dysfunction resolved (10%) (mostly NSAIDs), non-nephrology causes (mainly urological) (8%), non-renal pathology (simple renal cysts, other) (10%) and other causes (11%). The re-consult rate was 2% within the first year.

Regarding patients referred with low eGFR, the mean age was 76 ± 14 years (range: 19-98), female sex: 73.9%, eGFR: 39±11 ml/min/1.73m2, serum creatinine 1.4 ± 0.4 mg/dL. Urine alb/creat ratio: 49±127 mg/g. Thirty five percent of them were between 70-79 years and 48% were> 80 years old. For those patients referred with mild albuminuria: mean age was: 57±21 years, male sex: 61%, diabetics: 31%, eGFR: 77±18 ml/min/1.73m2, serum creatinine 0.87±0.27 mg/dL. Urine alb/creat ratio: 83 ± 54 mg/g (range 33-128).

There was a 17 day waiting list to attend an outpatient nephrology clinic in 2016 (previous to the initiation of the e-consultation period). On the contrary, during the study period it was 14 days in 2017 and 4 days each in both 2018 and 2019.

Conclusion

Our experience shows that non-face-to-face e-consultation for patients with mild renal pathology promotes the effective management of patients who do not meet remission criteria according to established protocols. It also prevents the remission of a significant percentage of patients, reduces the waiting list and optimizes the healthcare system’s resources.