Hemodialysis vascular access in elderly patients: A comprehensive review

The number of elderly patients initiating hemodialysis (HD) increased considerably over the past decade. Arteriovenous fistulas (AVFs) are the preferred vascular access (VA) type in most HD patients. Choice of VA for older hemodialysis patients presents a challenge. The higher incidence of comorbidities, longer AVF maturation times, risk of primary failure, risk of patency loss, and shorter life expectancy are important factors to consider. In this review we provide a comprehensive analysis on maturation rates, primary failure, patency, and mortality regarding vascular access in patients older than 75 years of age.

C-reactive protein-to-albumin ratio and six-month mortality in incident hemodialysis patients

BACKGROUND

The first few months of hemodialysis (HD) are associated with a higher risk of mortality. Protein-energy malnutrition is a demonstrated major risk factor for mortality in this population. The C-Reactive Protein to Albumin ratio (CAR) has also been associated with increased mortality risk. The aim of this study was to determine the predictive value of CAR for six-month mortality in incident HD patients.

METHODS

Retrospective analysis of incident HD patients between January 2014 and December 2019. CAR was calculated at the start of HD. We analyzed six-month mortality. A Cox regression was performed to predict six-month mortality and the discriminatory ability of CAR was determined using the receiver operating characteristic (ROC) curve.

RESULTS

A total of 787 patients were analyzed (mean age 68.34 ± 15.5 years and 60.6% male). The 6-month mortality was 13.8% (n = 109). Patients who died were significantly older (p < 0.001), had more cardiovascular disease (p = 0.010), had central venous catheter at the start of HD (p < 0.001), lower parathyroid hormone (PTH) level (p = 0.014) and higher CAR (p = 0.015). The AUC for mortality prediction was 0.706 (95% CI (0.65-0.76), p < 0.001). The optimal CAR cutoff was ≥0.5, HR 5.36 (95% CI 3.21-8.96, p < 0.001).

CONCLUSION

We demonstrated that higher CAR was significantly associated with a higher mortality risk in the first six months of HD, highlighting the prognostic importance of malnutrition and inflammation in patients starting chronic HD.

Planning vascular access creation: The promising role of the kidney failure risk equation

BACKGROUND

Planning for vascular access (VA) creation is essential in pre-dialysis patients although optimal timing for VA referral and placement is debatable. Guidelines suggest referral when eGFR is 15-20 mL/min/1.73 m². This study aimed to validate the use of kidney failure risk equation (KFRE) in VA planning.

METHODS

Retrospective analysis of all adult patients with CKD who were referred for first VA placement, namely AVF or AVG, at a tertiary center, between January 2018 and December 2019. The four-variable KFRE was calculated. Start of KRT, mortality, and VA placement were assessed in a 2-year follow-up. We used Cox regression to predict KRT start and calculated the ROC curve.

RESULTS

256 patients were included and 64.5% were male, mean age was 70.4 ± 12.9 years and mean eGFR was 16.09 ± 10.43 mL/min/1.73 m². One hundred fifty-nine patients required KRT (62.1%) and 72 (28.1%) died in the 2-year follow-up. The KFRE accurately predicted KRT start within 2-years (38.3 ± 23.8% vs 17.6 ± 20.9%, p < 0.001; HR 1.05 95% CI (1.06-1.12), p < 0.001), with an auROC of 0.788 (p < 0.001, 95% CI (0.733-0.837)). The optimal KFRE cut-off was >20%, with a HR of 9.2 (95% CI (5.06-16.60), p < 0.001). Patients with KFRE ⩾ 20% had a significant lower mean time from VA consult to KRT initiation (10.8 ± 9.4 vs 15.6 ± 10.3 months, p < 0.001). On a sub-analysis of patients with an eGFR < 20 mL/min/1.73 m², a KFRE ⩾ 20% was also a significant predictor of 2-year start of KRT, with an HR of 6.61 (95% CI (3.49-12.52), p < 0.001).

CONCLUSION

KFRE accurately predicted 2-year KRT start in this cohort of patients. A KFRE ⩾ 20% can help to establish higher priority patients for VA placement. The authors suggest referral for VA creation when eGFR < 20 mL/min/1.73 m² and KFRE ⩾ 20%.

Validation of the kidney failure risk equation in a Portuguese cohort

INTRODUCTION

In chronic kidney disease (CKD) patients, the risk of kidney replacement therapy (KRT) is highly variable. In 2011, Tangri et al. developed the kidney failure risk equations (KFRE) to predict the 2 and 5-year probability of requiring kidney replacement therapy (KRT). The KFRE is an easily calculated 4-variable equation which has been extensively validated in multiple cohorts. The aim of this study was to validate this risk score in a Portuguese cohort.

METHODS

We conducted a retrospective analysis of CKD patients stage 3-5 referred for nephrology consult at Centro Hospitalar Universitário Lisboa Norte during the first 6 months of 2018. Age, gender, estimated glomerular filtration rate (eGFR) and albuminuria were assessed. The 4-variable kidney failure risk equation (KFRE) calibrated to a non-North American population was calculated. Requirement of KRT was assessed in a 2-year follow-up. We assessed the Cox logistic regression method of the KFRE to predict KRT requirement and the discriminatory ability was determined using the receiver operating characteristic (ROC) curve. A cut-off value was defined as that with the highest validity.

RESULTS

360 patients were included and 54.4% were male. Mean age was 74.9±12.2 years, serum creatinine was 1.97±0.84mg/dL, eGFR was 33.4±12.13ml/min/1.73m2 and albuminuria was 571.1±848.3mg/g. Mean calculated risk score was 6.2±11.2%. Twenty-three patients required KRT (6.4%) in the two-year follow-up. The hazard ratio was 1.1 [95% CI (1.06-1.12), p<0.001] for the 2-year risk of KRT. The KFRE predicted progression to KRT requirement with an auROC of 0.903, [95% CI (0.86-0.95), p<0.001], with a sensitivity 91.3% and specificity of 71.8%. The optimal KFRE cut-off was >4.5% for 2-year nephrologist referral, with an hazard ratio of HR 26.7 [95% CI (6.15-116.3), p<0.001] for 2-year risk of KRT requirement.

DISCUSSION

We have independently externally validated the 2-year KFRE and shown that it has excellent discrimination. The KFRE should be incorporated in clinical care of patients with CKD to improve patient-clinician dialogue and provide guidance on timing of referral for nephrology evaluation and planning for dialysis access.

Preoperative assessment for vascular access: Vascular mapping and handgrip strength

BACKGROUND

Reliable vascular access (VA) is required for patients receiving chronic hemodialysis (HD) treatment. Vascular mapping using duplex doppler ultrasonography (DUS) can aid in planning VA construction. Greater handgrip strength (HGS) was found to be associated with more developed distal vessels both in chronic kidney disease (CKD) patients and healthy individuals, and patients with lower HGS had worse morphologic vessel characteristics and were, therefore, less likely to construct distal VA.

OBJECTIVES

This study aims to describe and analyze clinical, anthropometric, and laboratory characteristics of patients who underwent vascular mapping prior to VA creation.

RESEARCH DESIGN

Prospective analysis.

SUBJECTS

Adult patients with CKD referred for vascular mapping, at a tertiary center, between March 2021 and August 2021.

MEASURES

Preoperative DUS by a single experienced nephrologist was carried out. HGS was measured using a hand dynamometer, and PAD was defined as ABI < 0.9. Sub-groups were analyzed according to distal vasculature size (<2 mm).

RESULTS

A total of 80 patients were included, with a mean age of 65.7 ± 14.7 years; 67.5% were male, and 51.3% were on renal replacement therapy (RRT). Twelve (15%) participants had PAD. HGS was higher in the dominant arm (20.5 ± 12.0 vs 18.8 ± 11.2 kg). Fifty-eight (72.5%) patients had vessels smaller than 2 mm in diameter. There were no significant differences between groups concerning demographics or comorbidities (diabetes, HTN, PAD). HGS was significantly higher in patients with distal vasculature greater than or equal to 2 mm in diameter (dominant arm: 26.1 ± 15.5 vs 18.4 ± 9.7 kg, p = 0.010; non-dominant arm: 24.1 ± 15.3 vs 16.8 ± 8.6, p = 0.008).

CONCLUSIONS

Higher HGS was associated with more developed distal cephalic vein and radial artery. Low HGS might be an indirect sign of suboptimal vascular characteristics, which might help predict the outcomes of VA creation and maturation.

One-Year Mortality after Hemodialysis Initiation: The Prognostic Role of the CHA2DS2-VASc Score

BACKGROUND

CKD is a significant cause of morbidity, cardiovascular and all-cause mortality. CHA2DS2-VASc is a score used in patients with atrial fibrillation to predict thromboembolic risk; it also appears to be useful to predict mortality risk. The aim of the study was to evaluate CHA2DS2-VASc scores as a tool for predicting one-year mortality after hemodialysis is started and for identifying factors associated with higher mortality.

METHODS

Retrospective analysis of patients who started hemodialysis between January 2014 and December 2019 in Centro Hospitalar Universitário Lisboa Norte. We evaluated mortality within one year of hemodialysis initiation. The CHA2DS2-VASc score was calculated at the start of hemodialysis.

RESULTS

Of 856 patients analyzed, their mean age was 68.3 ± 15.5 years and the majority were male (61.1%) and Caucasian (84.5%). Mortality within one-year after starting hemodialysis was 17.8% (n = 152). The CHA2DS2-VASc score was significantly higher (4.4 ± 1.7 vs. 3.5 ± 1.8, p < 0.001) in patients who died and satisfactorily predicted the one-year risk of mortality (AUC 0.646, 95% CI 0.6-0.7, p < 0.001), with a sensitivity of 71.7%, a specificity of 49.1%, a positive predictive value of 23.9% and a negative predictive value of 89.2%. In the multivariate analysis, CHA2DS2-VASc ≥3.5 (adjusted HR 2.24 95% CI (1.48-3.37), p < 0.001) and central venous catheter at dialysis initiation (adjusted HR 3.06 95% CI (1.93-4.85)) were significant predictors of one-year mortality.

CONCLUSION

A CHA2DS2-VASc score ≥3.5 and central venous catheter at hemodialysis initiation were predictors of one-year mortality, allowing for risk stratification in hemodialysis patients.

The impact of early versus late initiation of renal replacement therapy in critically ill patients with acute kidney injury on mortality and clinical outcomes: a meta-analysis

Background

Renal replacement therapy (RRT) is essential in the presence of life-threatening complications associated with acute kidney injury (AKI). In the absence of urgent indications, the optimal timing for RRT initiation is still under debate. This meta-analysis aims to compare the benefits between early and late RRT initiation strategies in critically ill patients with AKI.

Methods

Studies were obtained from three databases [Medical Literature Analysis and Retrieval System Online (MEDLINE), Cochrane Central Register of Controlled Trials (CENTRAL) and Scopus], searched from inception to May 2021. The selected primary outcome was 28-day mortality. Secondary outcomes included overall mortality, recovery of renal function (RRF) and RRT-associated adverse events. A random-effects model was used for summary measures. Heterogeneity was assessed through Cochrane I² test statistics. Potential sources of heterogeneity for the primary outcome were sought using sensitivity analyses. Further subgroup analyses were conducted based on RRT modality and study population.

Results

A total of 13 randomized controlled trials including 5193 participants were analysed. No significant differences were found between early and late RRT initiation regarding 28-day mortality [risk ratio (RR) 1.00; 95% confidence interval (CI) 0.89–1.12, I² = 30%], overall mortality (RR 1.00; 95% CI 0.90–1.12, I² = 42%) and RRF (RR 1.02; 95% CI 0.92–1.13, I² = 53%). However, early RRT initiation was associated with a significantly higher incidence of hypotensive (RR 1.34; 95% CI 1.17–1.53, I² = 6%) and infectious events (RR 1.83; 95% CI 1.11–3.02, I² = 0%).

Conclusions

Early RRT initiation does not improve the 28-day and overall mortality, nor the likelihood of RRF, and increases the risk for RRT-associated adverse events, namely hypotension and infection.

Usefulness of the 6-minute walk test vs cardiopulmonary exercise test for exercise prescription in coronary artery disease patients going into a phase III cardiac rehabilitation program

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

Determining the intensity of exercise is a very important component to obtain the dose-benefits associated with exercise, while maitaining the safaty of the patient with coronary artery disease (CAD) in a cardiovascular rehabilitation (CR) programme. The cardiopulmonary exercise test (CPET) is the gols standard for exercise prescription according to the intend intensisty of aerobic workout. However, its availability is not a reality in many CR centres. The 6-minute walk test (6MWT) is a valid and widely used method because it is low-cost and simple to apply. Nevertheless, it is still unknown the corresponding intensity reached on a 6MWT compared to the one reached on a CPET in already physically active patients with CAD starting a CR phase III programme.

Purpose

To use the peak heart rate (HR) of the 6MWT as a method to prescribe the intensity of aerobic exercise in CAD patients starting a phase III CR programme and to compare it with the ventilatory threshold (VT) of the CPET.

Methods

In this retrospective study, a cohort of patients with CAD enrolled in a phase III CR programme. At the beginning of the programme, all patients performed a 6MWT and a CPET in the same week with at least 48-hour difference. The HR on the 6MWT was recorded continuously using a HR polar (H10 Polar) and on CPET using a twelve-lead ECG. Other parameters were assessed such as objective physical activity (accelerometer) and body composition.

Results

Eighty patients (87.5% males, 60.8 ± 9.4 years old) with CAD were included in this study. Patients were, on average, physically active (361 ± 182 minutes/week of moderate to vigorous physical activity) and overweight (body mass index: 27.7 ± 3.5 kg/m2). The VO2 peak reached on the CPET was 20.3 ± 5.4 ml/kg/min and the percentage of predicted maximum HR was 78.3 ± 11.4 %. The first and second VT corresponded to 75.6 ± 7.8% and 91.2 ± 4.5% of the peak HR obtained with CPET, respectively. The 6MWT HR peak was 113 ± 16 bpm (90.0 ± 13.0 HR peak CPET) and did not differ from the HR of the second VT with a mean value of 115 ± 16 bpm (91.2 ± 4.5% HR peak CPET), p&gt;0.05. Although, the 6MWT HR peak was significantly higher than the HR oh the first VT (95 ± 14 bpm, p&lt;0.001). In a subgroup analysis, the patients who, during the 6MWT, reached more the 90% of the HR peak CPET (n=35, 44% oof the sample) were the ones with lower functional capacity (VO2 peak: 18.4 ± 5.4 ml/kg/min vs 21.7 ± 5.0 ml/kg/min, p=0.006) and higher age (64.4 ± 8.7 years old vs 60.8 ± 9.4 years old, p=0.002).

Conclusion(s)

In the absence of a CPET, the use of a 6MWT HR peak in physically active patients with CAD starting a phase III CR programme has shown to be an efficient method to prescribe moderate to vigorous exercise intensity, corresponding to the second VT. Higher intensities on the 6MWT might be reached in active elderly patients with reduced functional capacity.

MO847: C-Reactive Protein to Albumin Ratio and 6-Month Mortality in Incident Haemodialysis Patients

BACKGROUND AND AIMS

The prevalence of chronic kidney disease (CKD) is growing worldwide and ranges from 8% to 16%. Mortality rates are higher in the first few months of haemodialysis (HD). Protein-energy malnutrition has been demonstrated to be a major risk factor for mortality in this population. The C-Reactive Protein to Albumin ratio (CAR) has been associated with increased mortality risk. We aimed to evaluate if CAR could be used to predict 6-month mortality in incident HD patients.

METHOD

Retrospective analysis of CKD patients who initiated chronic HD between January of 2014 and December of 2019 in a tertiary-care hospital in Portugal. CAR was calculated at HD start. We analyzed 6-month mortality. Variables were submitted to univariate and multivariate analysis to determine factors predictive of 6-month mortality after HD start. We assessed the logistic regression method of the CAR to predict 6-month mortality and the discriminatory ability was determined using the receiver operating characteristic (ROC) curve.

RESULTS

A total of 787 patients were analyzed (mean age 68.34 ± 15.5 years and 60.6% male). The 6-month mortality was 13.8% (n = 109). Patients who died were significantly older [76.50 ± 11.39 versus 67.29 ± 15.52 years; P &lt; 0.001, OR: 1.055 (1.035–1.074); P &lt; 0.001, aOR: 1.058 (1.030–1.086); P &lt; 0.001], had more frequently cardiovascular disease [65.1% versus 46.1%; P &lt; 0.001, OR: 2.192 (1.437–3.342); P &lt; 0.001, aOR: 2.210 (1.210–4.037); P = 0.010], central venous catheter at HD start [83.5% versus 58.3%; P &lt; 0.001, OR: 3.622 (2.136–6.142); P &lt; 0.001, aOR: 3.090 (1.584–6.026); P &lt; 0.001], lower PTH [229.44 ± 170.50 versus 365.95 ± 415.80;  P = 0.006, OR: 0.998 (0.996–0.999); P &lt; 0.001, aOR: 0.998 (0.997–1.000); P = 0.014] and higher CAR [2.85 ± 3.85 versus 1.36 ± 2.44;  P &lt; 0.001, OR: 1.159 (1.086–1.236); P &lt; 0.001, aOR: 1.126 (1.023–1.239); P = 0.015]. The AUC for mortality prediction was of 0.706 [95% confidence interval (0.65–0.76); P &lt; 0.001]. The optimal CAR cut-off was &gt;0.5,  with an odds ratio of 5.362 (95% CI 3.208–8.963; P &lt; 0.001).

CONCLUSION

In our study, we demonstrated that higher CAR was independently associated with a higher mortality rate in the first 6 months of starting HD, highlighting the prognostic importance of malnutrition and inflammation in patients starting chronic HD.

MO120: Kidney Biopsy—Safety at Neprology Gold Standard

BACKGROUND AND AIMS

Percutaneous renal biopsy is a fundamental technique for the diagnosis of numerous renal pathologies. However, it is an invasive technique that requires operator experience and is associated with adverse outcomes. Bleeding complications such as haematuria or perirenal hematoma are frequent, but generally self-limiting, and may rarely be severe to the point of culminating in hypovolemic shock or death. The objectives of this study are to identify the rate of adverse outcomes and potential predictors of adverse outcomes related to the procedure.

METHOD

A retrospective analysis of patients undergoing native kidney biopsy at a tertiary centre, between 2015 and 2019 was carried out, based on the demographic and clinical characteristics of the population, analyses (creatinine at admission, pre-procedure and post-procedure blood counts) and control at 24 h after biopsy) and imaging methods (renal ultrasound 24 h after biopsy).

RESULTS

A total of 176 patients were selected, with a mean age of 48.1 ± 17.6 years. They were mostly caucasian (80.1%) and there was a predominance of females (55.7%). Approximately 46.6% had arterial hypertension, although all had their blood pressure controlled at the time of the biopsy. Mean pre-biopsy creatinine value was 2.0 ± 1.7 mg/dL. Mean pre-biopsy haemoglobin value was 12.1 ± 2.0 g/dL and 24 h post-biopsy 11.8 ± 2 .0 g/dL. There was an overall complication rate of 30.1%, corresponding to 5 cases of haematuria, 36 minor hematomas and 8 major hematomas. There were no deaths and there was no need for surgical intervention to control the bleeding. The only predictor of post-biopsy complications was age, with younger patients having fewer complications (43.9 ± 16.2 versus 50.0 ± 17.9, P = .036). There was no correlation between pre-biopsy creatinine or haemoglobin values and the occurrence of complications, nor was there a greater number of complications in hypertensive patients.

CONCLUSION

Although bleeding complications were relatively frequent in this sample, serious events were rare, as this reinforces the safety of this procedure (which provides valuable information about the prognosis and decision of the therapy to be instituted). The presence of arterial hypertension and the pre-biopsy creatininemia value did not increase the risk of complications related to the procedure.

MO483: Validation of The Kidney Failure Risk Equation in a Portuguese Cohort

BACKGROUND AND AIMS

In chronic kidney disease (CKD) patients, the risk of kidney replacement therapy (KRT) is highly variable. In 2011, Tangri et al. developed the kidney failure risk equations (KFRE) to predict the 2- and 5-year probability of requiring kidney replacement therapy (KRT). The KFRE is an easily calculated 4-variable equation that has been extensively validated in multiple cohorts. The aim of this study was to validate this risk score in a Portuguese cohort.

METHOD

We conducted a retrospective analysis of CKD patients stage 3–5 referred for nephrology consult at Centro Hospitalar Universitário Lisboa Norte during the first 6 months of 2018. Age, gender, estimated glomerular filtration rate (eGFR) and albuminuria were assessed. The four-variable Kidney Failure Risk Equation (KFRE) calibrated for a non-North American population was calculated. Requirement for KRT was assessed in a 2-year follow-up. We assessed the Cox logistic regression method of the KFRE to predict KRT requirement, and the discriminatory ability was determined using the receiver operating characteristic (ROC) curve. A cut-off value was defined as that with the highest validity.

RESULTS

A total of 360 patients were included, and 54.4% were male. The mean age was 74.9 ± 12.2 years, serum creatinine was 1.97 ± 0.84 mg/dL, eGFR was 33.4 ± 12.13 mL/min/1.73 m2 and albuminuria was 571.1 ± 848.3 mg/g. The mean calculated risk score was 6.2 ± 11.2%. A total of 23 patients required KRT (6.4%) in the 2-year follow-up. The hazard ratio was 1.1 [95% confidence interval (95% CI) 1.06–1.12; P &lt; .001] for the 2-year risk of KRT. The KFRE predicted progression to KRT requirement with an auROC of 0.903, (95% CI 0.86–0.95; P &lt; 0.001), with a sensitivity of 91.3% and specificity of 71.8%. The optimal KFRE cut-off was &gt;4.5% for 2-year nephrologist referral, with a hazard ratio of HR 26.7 [95% CI 6.15–116.3; P &lt; .001] for 2-year risk of KRT. requirement.

CONCLUSION

We have independently externally validated the 2-year KFRE and shown that it has excellent discrimination. The KFRE should be incorporated into the clinical care of patients with CKD to improve patient-clinician dialogue and provide guidance on the timing of referral for nephrology evaluation and planning for dialysis access.

MO477: Predicting 1-Year Mortality After Haemodialysis Start: The Role of the Cha₂Ds₂-VASC Score

BACKGROUND AND AIMS

Chronic kidney disease (CKD) is a significant cause of morbidity, cardiovascular and all-cause mortality. CHA2DS2VASc is a score system used in patients with atrial fibrillation to predict thromboembolic risk. However, it also appears to be useful to predict mortality risk. The aim of the study was to evaluate the CHA2D2SVASc score as a tool to predict 1-year mortality after starting haemodialysis and identify factors associated with higher mortality.

METHOD

Retrospective analysis of patients who started haemodialysis between January of 2014 and December of 2019 at Centro Hospitalar Universitário Lisboa Norte. We evaluated mortality within 1 year of starting haemodialysis. The CHA2D2SVASc score was calculated at the start of haemodialysis. Variables were submitted to univariate and multivariate analysis to determine factors predictive of 1-year mortality after HD start. We assessed the logistic regression method of the CHA2DS2VASc to predict 1-year mortality and the discriminatory ability was determined using the receiver operating characteristic curve.

RESULTS

Of 856 patients analyzed, the mean age was 68.3 ± 15.5 years, the majority were male (61.1%) and Caucasian (84.5%). Mortality within 1 year after haemodialysis started was 17.8% (n = 152). The CHA2D2SVASc score was significantly higher (4.4 ± 1.7 versus 3.5 ± 1.8; P &lt; .001) in patients who died and accurately predicted the 1-year risk of mortality {AUC: 0.646, [95% confidence interval (95% CI) 0.6–0.7]; P &lt; .001}, with a sensitivity 71.7% and specificity of 49.1%, a positive predictive value of 23.9% and a negative predictive value of 89.2%. In the multivariate analysis, CHA2D2SVASc ≥3.5 (adjusted OR: 2.24, 95% CI 1.48–3.37; P &lt; .001] and central venous catheter at dialysis start (adjusted HR: 3.06, 95% CI 1.93–4.85) were significant predictors of 1-year mortality.

CONCLUSION

CHA2D2SVASc score ≥ 3.5 and central venous catheter at haemodialysis start were predictors of 1-year mortality, allowing for risk stratification in haemodialysis patients.

MO317: The Impact of Early Versus Late Initiation of Renal Replacement Therapy in Critically ill Patients With Acute Kidney Injury on Mortality and Clinical Outcomes: A Systematic Review With Meta-Analysis

BACKGROUND AND AIMS

Renal replacement therapy (RRT) is consensual in the presence of life-threatening complications associated with acute kidney injury (AKI). In the absence of urgent indications, the optimal timing for RRT initiation is still under debate. This systematic review with meta-analysis aims to compare the benefits between early and late RRT initiation strategies in critically ill patients with AKI.

METHOD

Studies were obtained from three databases (MEDLINE, CENTRAL and SCOPUS), searched from inception to May 2021. The selected primary outcome was 28-day mortality. Secondary outcomes included overall mortality, recovery of renal function (RRF) and RRT-associated adverse events. A random-effects model was used for summary measures. Heterogeneity was assessed through Cochrane I2 test statistics. Potential sources of heterogeneity for the primary outcome were sought using sensitivity analyses. Further subgroup analyses were conducted based on the RRT modality.

RESULTS

A total of 13 randomized controlled trials, including 5193 participants, were analyzed. No significant differences were found between early and late RRT initiation regarding 28-day mortality [risk ratio (RR) 1.00, 95% confidence interval (95% CI) 0.89–1.12; I² = 30%], overall mortality (RR 1.00, 95% CI 0.90–1.12; I² = 42%) and RRF (RR 1.02, 95% CI 0.92–1.13; I² = 53%). However, early RRT initiation was associated with a significantly higher incidence of hypotensive (RR 1.34, 95% CI 1.17–1.53; I² = 6%) and infectious events (RR 1.83, 95% CI 1.11–3.02; I² = 0%).

CONCLUSION

Early RRT initiation does not improve the 28-day or overall mortality, nor the likelihood of RRF and increases the risk for RRT-associated adverse events, namely hypotension and infection.

Endovascular treatment of the stuck hemodialysis catheter: A report of two cases and literature review

A considerable number of patients present with stuck CVC after long-use of CVC, which is thought to result from the adhesion of the fibrous sheath, formed over the CVC, to the vessel or atrial wall. The removal of these catheters is a difficult and risky procedure. Hong reported a minimally invasive technique through endoluminal balloon dilation, which successfully breaks the adhesions and expands the vein, thus allowing for an easy removal of the CVC. The authors present two cases of a variant method of Hong's technique, and provide a literature review on stuck catheters. Our experience is that balloon angioplasty dilation is a safe and practical option. We highlight the role of experienced interventional nephrologists or radiologists in the management of this complication as endovascular treatment is the first line treatment.

Rituximab in glomerular diseases: a case series and narrative review

INTRODUCTION

The use of Rituximab (RTX) in glomerular diseases (GD) has increased in the past years, although it is still only used in a small fraction of patients.

METHODS

A single center retrospective study of adult patients with membranous nephropathy (MN), focal segmental glomerulosclerosis (FSGS), lupus nephritis (LN), and vasculitis treated with RTX as first or second-line therapy was conducted at our center from 2010 to 2020.

RESULTS

We identified 19 patients; 36.8% had MN and 25.0% each had FSGS, LN, and vasculitis. RTX was first-line therapy in 26.3% of patients and in 73.7% it was second-line therapy. Mean follow-up time was 7.7 ± 7.2 years. In MN, 2 patients (28.6%) had complete remission (CR), 2 patients (28.6%) had partial remission (PR), and 3 patients (42.9%) had no response (NR). In FSGS, 2 patients (50.0%) presented CR, 1 patient (25.0%) had no response, and 1 patient had renal deterioration. Two patients (50.0%) had a LN class IV with a CR after RTX, 1 patient with LN class IIIC/V had no response, and 1 patient with LN class II had renal deterioration. In vasculitis, 3 patients (75.0%) presented CR and 1 patient had PR. Infusion reactions were present in 2 patients (10.5%) and one patient had multiple infectious complications.

CONCLUSIONS

The efficacy of RTX in treating different types of immune-mediated GD has been demonstrated with different response rates, but an overall safe profile. In our case series, the results are also encouraging. Longitudinal studies are needed to better understand the effect of RTX in GD.

The impact of transient and persistent acute kidney injury in hospital mortality in COVID-19 patients

INTRODUCTION

Acute kidney injury (AKI) has been described in Coronavirus Disease 2019 (COVID-19) patients and is considered a marker of disease severity and a negative prognostic factor for survival. In this study, the authors aimed to study the impact of transient and persistent acute kidney injury (pAKI) on in-hospital mortality in COVID-19 patients.

METHODS

This was a retrospective observational study of patients hospitalized with COVID-19 in the Department of Medicine of the Centro Hospitalar Universitario Lisboa Norte, Lisbon, Portugal, between March 2020 and August 2020. A multivariate analysis was performed to predict AKI development and in-hospital mortality.

RESULTS

Of 544 patients with COVID-19, 330 developed AKI: 166 persistent AKI (pAKI), 164 with transient AKI. AKI patients were older, had more previous comorbidities, had higher need to be medicated with RAAS inhibitors, had higher baseline serum creatine (SCr) (1.60 mg/dL vs 0.87 mg/dL), higher NL ratio, and more severe acidemia on hospital admission, and more frequently required admission in intensive care unit, mechanical ventilation, and vasopressor use. Patients with persistent AKI had higher SCr level (1.71 mg/dL vs 1.25 mg/dL) on hospital admission. In-hospital mortality was 14.0% and it was higher in AKI patients (18.5% vs 7.0%). CKD and serum ferritin were independent predictors of AKI. AKI did not predict mortality, but pAKI was an independent predictor of mortality, as was age and lactate level.

CONCLUSION

pAKI was independently associated with in-hospital mortality in COVID-19 patients but its impact on long-term follow-up remains to be determined.

Presentation and outcomes of chronic kidney disease patients with COVID-19

Introduction:

COVID-19 is currently a global health issue and an important cause of mortality. Chronic kidney disease (CKD) is one of the risk factors for infection, morbidity and mortality by SARS-CoV-2. In our study, we aimed to evaluate the clinical presentation and outcomes of CKD patients with COVID-19, as well as identify predictors of mortality.

Methods:

This was a retrospective study of CKD patients admitted in a tertiary-care Portuguese hospital between March and August of 2020. Variables were submitted to univariate and multivariate analysis to determine factors predictive of in-hospital mortality.

Results:

130 CKD patients were analyzed (median age 73.9 years, male 60.0%). Hypertension (81.5%), cardiovascular disease (36.2%), and diabetes (54.6%) were frequent conditions. Cough, dyspnea, fever and respiratory failure were also common. Almost 60% had anemia, 50% hypoalbuminemia, 13.8% hyperlactacidemia and 17% acidemia. Mean serum ferritin was 1531 µg/L, mean CRP 8.3 mg/dL and mean LDH 336.9 U/L. Most patients were treated with lopinavir/ritonavir, hydroxychloroquine or corticosteroids and only 2 with remdesivir. Eighty percent had acute kidney injury and 16.2% required intensive care unit admission. The 34 patients who died were older and more likely to have heart failure. They had higher neutrophils/lymphocytes ratio, ferritin, lactate, and LDH levels. Multivariate analysis identified an association between older age [OR 1.1 (CI 1.01-1.24), p=0.027], higher ferritin [OR 1.0 (CI 1.00-1.00), p=0.009] and higher LDH levels [OR 1.0 (CI 1.00-1.01), p=0.014] and mortality.

Conclusion:

In our cohort of CKD patients with COVID-19, older age, higher ferritin, and higher LDH levels were independent risk factors for mortality.

Acute kidney injury in hospitalized patients with COVID-19: A Portuguese cohort

INTRODUCTION

The incidence of acute kidney injury (AKI) in coronavirus disease 2019 (COVID-19) patients ranges from 0.5% to 35% and has been associated with worse prognosis. The purpose of this study was to evaluate the incidence, severity, duration, risk factors and prognosis of AKI in hospitalized patients with COVID-19.

METHODS

We conducted a retrospective single-center analysis of 192 hospitalized COVID-19 patients from March to May of 2020. AKI was diagnosed using the Kidney Disease Improving Global Outcome (KDIGO) classification based on serum creatinine (SCr) criteria. Persistent and transient AKI were defined according to the Acute Disease Quality Initiative (ADQI) workgroup definitions.

RESULTS

In this cohort of COVID-19 patients, 55.2% developed AKI (n=106). The majority of AKI patients had persistent AKI (n=64, 60.4%). Overall, in-hospital mortality was 18.2% (n=35) and was higher in AKI patients (28.3% vs. 5.9%, p<0.001, unadjusted OR 6.03 (2.22-16.37), p<0.001). In this multivariate analysis, older age (adjusted OR 1.07 (95% CI 1.02-1.11), p=0.004), lower Hb level (adjusted OR 0.78 (95% CI 0.60-0.98), p=0.035), duration of AKI (adjusted OR 7.34 for persistent AKI (95% CI 2.37-22.72), p=0.001) and severity of AKI (adjusted OR 2.65 per increase in KDIGO stage (95% CI 1.32-5.33), p=0.006) were independent predictors of mortality.

CONCLUSION

AKI was frequent in hospitalized patients with COVID-19. Persistent AKI and higher severity of AKI were independent predictors of in-hospital mortality.

Acute Kidney Disease and Mortality in Acute Kidney Injury Patients with COVID-19

Background: The incidence of AKI in coronavirus disease 2019 (COVID-19) patients is variable and has been associated with worse prognosis. A significant number of patients develop persistent kidney damage defined as Acute Kidney Disease (AKD). There is a lack of evidence on the real impact of AKD on COVID-19 patients. We aim to identify risk factors for the development of AKD and its impact on mortality in COVID-19 patients. Methods: Retrospective analysis of COVID-19 patients with AKI admitted at the Centro Hospitalar Universitário Lisboa Norte between March and August of 2020. The Kidney Disease Improving Global Outcomes (KDIGO) classification was used to define AKI. AKD was defined by presenting at least KDIGO Stage 1 criteria for >7 days after an AKI initiating event. Results: In 339 COVID-19 patients with AKI, 25.7% patients developed AKD (n = 87). The mean age was 71.7 ± 17.0 years, baseline SCr was 1.03 ± 0.44 mg/dL, and the majority of patients were classified as KDIGO stage 3 AKI (54.3%). The in-hospital mortality was 18.0% (n = 61). Presence of hypertension (p = 0.006), CKD (p < 0.001), lower hemoglobin (p = 0.034) and lower CRP (p = 0.004) at the hospital admission and nephrotoxin exposure (p < 0.001) were independent risk factors for the development of AKD. Older age (p = 0.003), higher serum ferritin at admission (p = 0.008) and development of AKD (p = 0.029) were independent predictors of in-hospital mortality in COVID-19-AKI patients. Conclusions: AKD was significantly associated with in-hospital mortality in this population of COVID-19-AKI patients. Considering the significant risk of mortality in AKI patients, it is of paramount importance to identify the subset of higher risk patients.

Hypoalbuminaemia and One-Year Mortality in Haemodialysis Patients with Heart Failure: A Cohort Analysis

INTRODUCTION

The prevalence of chronic kidney disease (CKD) and heart failure (HF) has been rising over the past decade, with a prevalence close to 40%. Cardiovascular disease and malnutrition are common comorbidities and known risk factors for mortality in haemodialysis (HD) patients. We aimed to evaluate the one-year mortality rate after dialysis induction, and the impact of serum albumin levels on survival outcomes, in patients with CKD and HF.

METHODS

This was a retrospective analysis of patients with CKD and HF who underwent chronic HD between January 2016 and December 2019 in a tertiary-care Portuguese hospital. Variables were submitted to univariate and multivariate analysis to determine factors predictive of one-mortality after HD start.

RESULTS

In total, 204 patients were analysed (mean age 75.1 ± 10.3 years). Within the first year of HD start, 28.7% of patients died. These patients were significantly older [79.8 ± 7.2 versus 72.9 ± 10.9 years, p < 0.001; OR 1.08 (1.04-1.13), p < 0.001] and had a higher mean Charlson Index [9.0 ± 1.8 versus 8.3 ± 2.0, p = 0.015; OR 1.22 (1.04-1.44), p = 0.017], lower serum creatinine [5.1 ± 1.6 mg/dL versus 5.8 ± 2.0 mg/dL; p = 0.021; OR 0.80 (0.65-0.97), p = 0.022], lower albumin levels [3.1 ± 0.6 g/dL versus 3.4 ± 0.6 g/dL, p < 0.001; OR 0.38 (0.22-0.66), p = 0.001] and started haemodialysis with a central venous catheter more frequently [80.4% versus 66.2%, p = 0.050]. Multivariate analysis identified older age [aOR 1.07 (1.03-1.12), p = 0.002], lower serum creatinine [aOR 0.80 (0.64-0.99), p = 0.049] and lower serum albumin [aOR 0.41 (0.22-0.75), p = 0.004] as predictors of one-year mortality.

CONCLUSION

In our cohort, older age, lower serum creatinine and lower serum albumin were independent risk factors for one-year mortality, highlighting the prognostic importance of malnutrition in patients starting chronic HD.

Impact of Chronic RAAS Use in Elderly COVID-19 Patients: A Retrospective Analysis

Corona Virus Disease-19 (COVID-19) recently emerged as a global pandemic. Advanced age is the most important risk factor for increased virus susceptibility and worse outcomes. Many older adults are currently treated with renin–angiotensin–aldosterone system (RAAS) inhibitors and there is concern that these medications might increase the risk of mortality by COVID-19. This is a retrospective cohort of 346 patients older than 65 years with COVID-19, at the Department of Medicine of the Centro Hospitalar Universitário Lisboa Norte, in Portugal, hospitalized between March 2020 and August 2020. Mean age was 80.9 ± 8.7 years old. Most patients had arterial hypertension (n = 279, 80.6%), almost half (n = 161, 46.5%) had cardiovascular disease and approximately one-third of patients had heart failure (n = 127, 36.7%) or diabetes Mellitus (n = 113, 32.7%). Ninety-eight patients (28.3%) had chronic kidney disease and almost half of the patients (49.4%) were chronically under renin–angiotensin–aldosterone system (RAAS) inhibitors. Twenty percent of patients died during hospitalization. In a multivariate analysis, older age (OR 1.11, 95% CI 1.04, 1.18, p = 0.002), absence of baseline medication with RAAS inhibitors (OR 0.27, 95% CI 0.10, 0.75, p = 0.011), higher serum ferritin (OR 1.00, 95% CI 1.00, 1.00, p = 0.003) and higher lactate levels (OR 1.08, 95% CI 1.02, 1.14, p = 0.006) were independent predictors of mortality. Older age, higher serum ferritin and lactate levels at admission were found to be independent predictors of mortality and might act as early predictors of worsening disease in clinical practice. Chronic treatment with RAAS inhibitors appeared to be protective, supporting guidelines in not discontinuing such drugs.

ANCA Vasculitis Recurrence in Hemodialysis Patients: The Role of Rituximab

Antineutrophil cytoplasmic antibodies-associated vasculitis (AAV) is characterized by systemic inflammation and is the most common cause of new-onset glomerulonephritis in adults older than 50 years. Renal disease secondary to AAV can lead to chronic kidney disease (CKD) requiring renal replacement therapy in approximately 20-25% of patients. Relapses are infrequent in the population on dialysis, and treatment guidelines do not specify these patients. Reports regarding the clinical course, survival, or relapse rate after beginning dialysis are scarce. The authors present 3 cases of CKD patients on hemodialysis who presented with AAV relapse, successfully treated with rituximab, and provide a literature review on relapse treatment.

MO316RITUXIMAB IN GLOMERULAR DISEASES: A COHORT ANALYSIS AND A LITERATURE REVIEW

Background and Aims

Glomerular diseases (GD) account for about 20% of chronic kidney disease causes. They are a heterogeneous group of diseases and current treatment is still inadequate. Rituximab (RTX) is a chimeric antibody which binds specifically to the B-cell surface antigen CD20 and has been applied in the treatment of different GD. The authors present the single center experience of the use of RTX for the treatment of GD as well as a literature review.

Method

We performed a retrospective analysis of all patients with biopsy-proven GD treated with RTX as first or second-line therapy between January 2010 and March 2020. The protocol used was RTX 375 mg/m2 once a week for 4 weeks. Infusions were preceded by adequate premedication.

Results

Nineteen patients with biopsy-proven GD received RTX therapy. Seven patients had membranous nephropathy (MN) (36.8%), 4 patients had focal segmental glomerulosclerosis (FSGS), 4 patients had lupus nephritis (LN) and 4 patients had vasculitis (25.0% each). Five patients (26.3%) received RTX as first-line therapy and 14 patients (73.7%) as second-line therapy, namely long-term prednisolone (Pd) (n=15, 78.9%), calcineurin inhibitors (CNI) (n=6, 31.6%), cyclophosphamide (Cp) (n=7, 36.8%), mycophenolate mofetil (MMF) (n=5, 26.3%) and methotrexate (MTX) (n=1, 5.3%). Serum creatinine at diagnosis was 1.5 ± 1.7mg/dL and the 24-h urine protein at diagnosis was 4.9 ± 4.5g. Mean follow-up time was 7.7 ± 7.2 years. In MN, 2 patients (28.6%) had CR, 2 patients (28.6%) had PR and 3 patients (42.9%) had no response. In FSGS, 2 patients (50.0%) presented CR, 1 patient (25.0%) had no response and the other one had renal deterioration. Two patients (50.0%) had a LN class IV with a CR after RTX, 1 patient with LN class IIIC/V had no response and 1 patient with LN class II had renal deterioration. In vasculitis, 3 patients (75.0%) presented CR and 1 patient had PR. Mean serum creatinine after RTX was 1.6 ± 1.4mg/dL and the mean 24-h urine protein was 1.9 ± 3.1g. Two patients (10.5%) presented infusion reactions and one patient had multiple respiratory infections. This patient had received previous immunosuppression with cyclophosphamide.

Conclusions

A total of 19 patients with biopsy-proven GD received RTX therapy and 12 patients (63.2%) presented a complete or partial remission suggesting the efficacy of RTX in different types of GD. In MN, our response rate was similar to studies such as GEMRITUX and MENTOR trial, which have shown remission in 60–70% of patients. In FSGS, 50% of patients had a stable and complete remission with RTX therapy similar with a meta-analysis of five studies with 51 patients with FSGS. Two patients had refractory LN class IV and both had complete remission (50% of patients with LN). This is in line with a systematic review of case reports and case series that reported sustained complete and partial response rates of 67% in LN class IV. In our cohort, patients with vasculitis received RTX as first-line therapy and complete remission was achieved in 75% of cases, which is in line with the results found in RITUXVAS and RAVE trial. Rituximab was safe and effective in achieving remission in different types of immune-mediated glomerular diseases.

Acute kidney injury in hospitalized patients with COVID-19: A Portuguese cohort

INTRODUCTION

The incidence of acute kidney injury (AKI) in coronavirus disease 2019 (COVID-19) patients ranges from 0.5% to 35% and has been associated with worse prognosis. The purpose of this study was to evaluate the incidence, severity, duration, risk factors and prognosis of AKI in hospitalized patients with COVID-19.

METHODS

We conducted a retrospective single-center analysis of 192 hospitalized COVID-19 patients from March to May of 2020. AKI was diagnosed using the Kidney Disease Improving Global Outcome (KDIGO) classification based on serum creatinine (SCr) criteria. Persistent and transient AKI were defined according to the Acute Disease Quality Initiative (ADQI) workgroup definitions.

RESULTS

In this cohort of COVID-19 patients, 55.2% developed AKI (n=106). The majority of AKI patients had persistent AKI (n=64, 60.4%). Overall, in-hospital mortality was 18.2% (n=35) and was higher in AKI patients (28.3% vs. 5.9%, p<0.001, unadjusted OR 6.03 (2.22-16.37), p<0.001). In this multivariate analysis, older age (adjusted OR 1.07 (95% CI 1.02-1.11), p=0.004), lower Hb level (adjusted OR 0.78 (95% CI 0.60-0.98), p=0.035), duration of AKI (adjusted OR 7.34 for persistent AKI (95% CI 2.37-22.72), p=0.001) and severity of AKI (adjusted OR 2.65 per increase in KDIGO stage (95% CI 1.32-5.33), p=0.006) were independent predictors of mortality.

CONCLUSION

AKI was frequent in hospitalized patients with COVID-19. Persistent AKI and higher severity of AKI were independent predictors of in-hospital mortality.

The neutrophil-to-lymphocyte ratio as a marker of vasculitis activity, severe infection and mortality in anca-associated vasculitis: A retrospective study

INTRODUCTION

Anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) is a multisystemic disease. Despite the improvement in mortality rate since the introduction of immunosuppression, long-term prognosis is still uncertain not only because of the disease activity but also due to treatment associated adverse effects. The neutrophil-to-lymphocyte ratio (NLR) has been demonstrated as an inflammatory marker in multiple settings. In this study, we aimed to investigate the prognostic ability of the NLR in AAV patients.

METHODS

We conducted a retrospective analysis of the clinical records of all adult patients with AVV admitted to the Nephrology and Renal Transplantation Department of Centro Hospitalar Universitário Lisboa Norte from January 2006 to December 2019. NLR was calculated at admission. The outcomes measured were severe infection at 3 months and one-year mortality. The prognostic ability of the NLR was determined using the receiver operating characteristic (ROC) curve. A cut-off value was defined as that with the highest validity. All variables underwent univariate analysis to determine statistically significant factors that may have outcomes. Only variables which significantly differed were used in the multivariate analysis using the logistic regression method.

RESULTS

We registered 45 cases of AVV. The mean age at diagnosis was 67.5±12.1 years and 23 patients were male. The mean Birmingham Vasculitis Activity Score (BVAS) at presentation was 26.0±10.4. Twenty-nine patients were ANCA-MPO positive, 7 ANCA-PR3 positive and 9 were considered negative ANCA vasculitis. At admission, mean serum creatinine (SCr) was 4.9±2.5mg/dL, erythrocyte sedimentation rate (ESR) was 76.9±33.8mm/h, hemoglobin was 9.5±1.7g/dL, C-reactive protein was 13.2±5.8mg/dL and NLR was 8.5±6.8. Thirty-five patients were treated with cyclophosphamide, eight patients with rituximab for induction therapy. Twenty patients developed severe infection within the first three months after starting induction immunosuppression. In a multivariate analysis, older age (73.6±10.5 vs. 62.6±11.3, p=0.002, adjusted OR 1.08 [95% CI 1.01-1.16], p=0.035) and higher NLR (11.9±7.4 vs. 5.9±5.0, p=0.002, adjusted OR 1.14 [95% CI 1.01-1.29], p=0.035) were predictors of severe infection at 3 months. NLR ≥4.04 predicted severe infection at 3 months with a sensitivity of 95% and specificity of 52% and the AUROC curve was 0.0794 (95% CI 0.647-0.900). Nine patients died within the first year. Severe infection at 3 months was independently associated with mortality within the first year (OR 6.19 [95% CI 1.12-34.32], p=0.037).

CONCLUSIONS

NLR at diagnosis was an independent predictor of severe infection within the first 3 months after immunosuppression start, and severe infection within the first three months was consequently correlated with one-year mortality. NLR is an easily calculated and low-cost laboratory inflammation biomarker and can prove useful in identifying AAV patients at risk of infection and poorer prognosis.

Acute kidney disease and long-term outcomes in critically ill acute kidney injury patients with sepsis: a cohort analysis

BACKGROUND

Acute kidney injury (AKI) is frequent during hospitalization and may contribute to adverse short- and long-term consequences. Acute kidney disease (AKD) reflects the continuing pathological processes and adverse events developing after AKI. We aimed to evaluate the association of AKD, long-term adverse renal function and mortality in a cohort of patients with sepsis.

METHODS

We performed a retrospective analysis of adult patients with septic AKI admitted to the Division of Intensive Medicine of the Centro Hospitalar Lisboa Norte (Lisbon, Portugal) between January 2008 and December 2014. Patients were categorized according to the development of AKI using the Kidney Disease: Improving Global Outcomes (KDIGO) classification. AKI was defined as an increase in absolute serum creatinine (SCr) ≥0.3 mg/dL or by a percentage increase in SCr ≥50% and/or by a decrease in urine output to <0.5 mL/kg/h for >6 h. AKD was defined as presenting at least KDIGO Stage 1 criteria for >7 days after an AKI initiating event. Adverse renal outcomes (need for long-term dialysis and/or a 25% decrease in estimated glomerular filtration rate after hospital discharge) and mortality after discharge were evaluated.

RESULTS

From 256 selected patients with septic AKI, 53.9% developed AKD. The 30-day mortality rate was 24.5% (n = 55). The mean long-term follow-up was 45.9 ± 43.3 months. The majority of patients experience an adverse renal outcome [n = 158 (61.7%)] and 44.1% (n = 113) of patients died during follow-up. Adverse renal outcomes, 30-day mortality and long-term mortality after hospital discharge were more frequent among AKD patients [77.5 versus 43.2% (P < 0.001), 34.1 versus 6.8% (P < 0.001) and 64.8 versus 49.1% (P = 0.025), respectively]. The 5-year cumulative probability of survival was 23.2% for AKD patients, while it was 47.5% for patients with no AKD (log-rank test, P < 0.0001). In multivariate analysis, AKD was independently associated with adverse renal outcomes {adjusted hazard ratio [HR] 2.87 [95% confidence interval (CI) 2.0-4.1]; P < 0.001} and long-term mortality [adjusted HR 1.51 (95% CI 1.0-2.2); P = 0.040].

CONCLUSIONS

AKD after septic AKI was independently associated with the risk of long-term need for dialysis and/or renal function decline and with the risk of death after hospital discharge.

Long-term consequences of acute kidney injury: a narrative review

The incidence of acute kidney injury (AKI) has increased in the past decades. AKI complicates up to 15% of hospitalizations and can reach up to 50-60% in critically ill patients. Besides the short-term impact of AKI in patient outcomes, several studies report the association between AKI and adverse long-term outcomes, such as recurrent AKI episodes in 25-30% of cases, hospital re-admissions in up to 40% of patients, an increased risk of cardiovascular events, an increased risk of progression of chronic kidney disease (CKD) after AKI and a significantly increased long-term mortality. Despite the long-term impact of AKI, there are neither established guidelines on the follow-up care of AKI patients, nor treatment strategies to reduce the incidence of sequelae after AKI. Only a minority of patients have been referred to nephrology post-discharge care, despite the evidence of improved outcomes associated with nephrology referral by addressing cardiovascular risk and risk of progression to CKD. Indeed, AKI survivors should have specialized nephrology follow-up to assess kidney function after AKI, perform medication reconciliation, educate patients on nephrotoxic avoidance and implement strategies to prevent CKD progression. The authors provide a comprehensive review of the transition from AKI to CKD, analyse the current evidence on the long-term outcomes of AKI and describe predisposing risk factors, highlight the importance of follow-up care in these patients and describe the current therapeutic strategies which are being investigated on their impact in improving patient outcomes.

Intraoperative oliguria does not predict postoperative acute kidney injury in major abdominal surgery: a cohort analysis

BACKGROUND

Acute kidney injury (AKI) is a common complication in patients undergoing major abdominal surgery and is associated with considerable morbidity and mortality. Several studies investigating the association between intraoperative urine output and postoperative AKI have shown conflicting results. Here, we investigated the association of intraoperative oliguria with postoperative AKI in a cohort of patients submitted to elective major abdominal surgery.

METHODS

This was a single-center retrospective analysis of adult patients who underwent elective major abdominal surgery from January 2016 to December 2018. AKI was defined according to the serum creatinine criteria of the KDIGO classification. Intraoperative oliguria was defined as urine output of less than 0.5 mL/kg/h. Risk factors were evaluated using multivariate logistic regression analysis.

RESULTS

A total of 165 patients were analyzed. In the first 48 h after surgery the incidence of AKI was 19.4%. Postoperative AKI was associated with hospital mortality (p=0.011). Twenty percent of patients developed intraoperative oliguria. There was no association between preexisting comorbidities and development of intraoperative oliguria. There was no correlation between the type of anesthesia used and occurrence of intraoperative oliguria, but longer anesthesia time was associated with intraoperative oliguria (p=0.007). Higher baseline SCr (p=0.001), need of vasoactive drugs (p=0.007), and NSAIDs use (p=0.022) were associated with development of intraoperative oliguria. Intraoperative oliguria was not associated with development of postoperative AKI (p=0.772), prolonged hospital stays (p=0.176) or in-hospital mortality (p=0.820).

CONCLUSION

In this cohort of patients we demonstrated that intraoperative oliguria does not predict postoperative AKI in major abdominal surgery.

The neutrophil-to-lymphocyte ratio as a marker of vasculitis activity, severe infection and mortality in anca-associated vasculitis: A retrospective study

INTRODUCTION

Anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) is a multisystemic disease. Despite the improvement in mortality rate since the introduction of immunosuppression, long-term prognosis is still uncertain not only because of the disease activity but also due to treatment associated adverse effects. The neutrophil-to-lymphocyte ratio (NLR) has been demonstrated as an inflammatory marker in multiple settings. In this study, we aimed to investigate the prognostic ability of the NLR in AAV patients.

METHODS

We conducted a retrospective analysis of the clinical records of all adult patients with AVV admitted to the Nephrology and Renal Transplantation Department of Centro Hospitalar Universitário Lisboa Norte from January 2006 to December 2019. NLR was calculated at admission. The outcomes measured were severe infection at 3 months and one-year mortality. The prognostic ability of the NLR was determined using the receiver operating characteristic (ROC) curve. A cut-off value was defined as that with the highest validity. All variables underwent univariate analysis to determine statistically significant factors that may have outcomes. Only variables which significantly differed were used in the multivariate analysis using the logistic regression method.

RESULTS

We registered 45 cases of AVV. The mean age at diagnosis was 67.5±12.1 years and 23 patients were male. The mean Birmingham Vasculitis Activity Score (BVAS) at presentation was 26.0±10.4. Twenty-nine patients were ANCA-MPO positive, 7 ANCA-PR3 positive and 9 were considered negative ANCA vasculitis. At admission, mean serum creatinine (SCr) was 4.9±2.5mg/dL, erythrocyte sedimentation rate (ESR) was 76.9±33.8mm/h, hemoglobin was 9.5±1.7g/dL, C-reactive protein was 13.2±5.8mg/dL and NLR was 8.5±6.8. Thirty-five patients were treated with cyclophosphamide, eight patients with rituximab for induction therapy. Twenty patients developed severe infection within the first three months after starting induction immunosuppression. In a multivariate analysis, older age (73.6±10.5 vs. 62.6±11.3, p=0.002, adjusted OR 1.08 [95% CI 1.01-1.16], p=0.035) and higher NLR (11.9±7.4 vs. 5.9±5.0, p=0.002, adjusted OR 1.14 [95% CI 1.01-1.29], p=0.035) were predictors of severe infection at 3 months. NLR ≥4.04 predicted severe infection at 3 months with a sensitivity of 95% and specificity of 52% and the AUROC curve was 0.0794 (95% CI 0.647-0.900). Nine patients died within the first year. Severe infection at 3 months was independently associated with mortality within the first year (OR 6.19 [95% CI 1.12-34.32], p=0.037).

CONCLUSIONS

NLR at diagnosis was an independent predictor of severe infection within the first 3 months after immunosuppression start, and severe infection within the first three months was consequently correlated with one-year mortality. NLR is an easily calculated and low-cost laboratory inflammation biomarker and can prove useful in identifying AAV patients at risk of infection and poorer prognosis.

Atypical Hemolytic Uremic Syndrome and Nephrotic Syndrome Associated with Cytomegalovirus Infection

Atypical hemolytic uremic syndrome (aHUS) is a rare disease. It results from the dysregulation of the alternative complement pathway on the cell surface which causes endothelial damage. Increasing evidence links, these abnormalities to mutations in genes of complement regulators or with autoantibodies against complement factors. These mutations have an incomplete penetrance and variable phenotype. Cytomegalovirus (CMV) is endemic throughout the world, and the incidence of severe CMV disease in immunocompetent adults appears to be greater than previously thought. aHUS and nephrotic syndromes associated with CMV infection are rare. Identification of triggers for aHUS manifestation in a genetically susceptible patient is extremely important since this permits a faster initiation of treatment and clinical improvement. We report a case of a man with a homozygotic deletion of CFHR3-1 whose initial presentation was aHUS and nephrotic syndromes associated with CMV infection.

Management of Acute Kidney Injury Following Major Abdominal Surgery: A Contemporary Review

Acute kidney injury (AKI) is a frequent occurrence following major abdominal surgery and is independently associated with both in-hospital and long-term mortality, as well as with a higher risk of progressing to chronic kidney disease (CKD) and cardiovascular events. Postoperative AKI can account for up to 40% of in-hospital AKI cases. Given the differences in patient characteristics and the pathophysiology of postoperative AKI, it is inappropriate to assume that the management after noncardiac and nonvascular surgery are the same as those after cardiac and vascular surgery. This article provides a comprehensive review on the available evidence on the management of postoperative AKI in the setting of major abdominal surgery.

Acute Kidney Injury: From Diagnosis to Prevention and Treatment Strategies

Acute kidney injury (AKI) is characterized by an acute decrease in renal function that can be multifactorial in its origin and is associated with complex pathophysiological mechanisms. In the short term, AKI is associated with an increased length of hospital stay, health care costs, and in-hospital mortality, and its impact extends into the long term, with AKI being associated with increased risks of cardiovascular events, progression to chronic kidney disease (CKD), and long-term mortality. Given the impact of the prognosis of AKI, it is important to recognize at-risk patients and improve preventive, diagnostic, and therapy strategies. The authors provide a comprehensive review on available diagnostic, preventive, and treatment strategies for AKI.

P0446OUTCOMES OF CYCLOPHOSPHAMIDE FOR ANTI-NEUTROPHIL CYTOPLASMIC ANTIBODIES-ASSOCIATED VASCULITIS: DIFFERENT PROTOCOLS, SINGLE-CENTER EXPERIENCE AND LITERATURE REVIEW

Background and Aims

Cyclophosphamide (CYC), associated with corticosteroids has been considered the mainstay of treatment for severe antineutrophil cytoplasmic antibody−associated vasculitis (AAV) for decades. This protocol is effective in 70-90% of patients resulting in drastic improvement in both renal and patient survival. Nevertheless, cyclophosphamide is associated with significant rates of adverse events, namely severe infections and malignancies. The authors present the single-center experience of the use of CYC for AAV treatment regarding clinical presentation, immunosuppression protocol, outcomes and adverse events, as well as a comparison with the main RCTs and studies using CYC for induction of remission of AAV.

Method

Retrospective analysis of clinical records of patients with AAV diagnosis (de novo or relapse) treated with CYC in the ward of the Nephrology Department of Centro Hospitalar Universitário Lisboa Norte between January 2006 and December 2019.

Results

Thirty patients with AAV diagnosis treated with CYC for induction of remission were identified. Average age was 69.4 ± 11.5 years. On admission, serum creatinine (SCr) was 5.03 mg/dL ± 2.24 mg/dL (eGFR 13.3 mL/min/1.73 m2 ± 11.1 mL/min/1.73 m2). Twenty patients (67%) required renal replacement therapy at admission and 12 (40%) had alveolar hemorrhage. The average Birmingham Vasculitis Activity Score (BVAS) was 27.5 ± 11.5. Immunosuppressive regimens varied considerably, as they were left to the clinician's consideration. Intravenous methylprednisolone pulses were performed in 29 (96.7%) patients, with total dose ranging from 1000 mg to 5000 mg. Cyclophosphamide was also prescribed at clinician’s choice, with only one patient receiving oral CYC and 29 patients receiving from 1 to 11 pulses in different doses. Plasma exchange was performed in 12 (40%) patients due to alveolar hemorrhage and/or rapidly progressive renal insufficiency. After induction of remission, twenty patients received maintenance therapy.

On a 12-month follow-up, 9 (30%) patients were on renal replacement therapy and, in the remaining patients, mean SCr was 2.23 ± 0.98 mg/dL (eGFR 33.4 mL/min/1.73 m2 ± 19.8 mL/min/1.73m2). Fifteen (50%) patients experienced severe infection at 6 months, 3 (10.7%) patients developed malignancies and 7 (23.3%) patients died on a 12-month follow-up.

Conclusion

Our cohort of patients treated with CYC is unlike the population that underwent clinical trials. In our cohort, SCr at presentation was considerably higher, being only comparable to MEPEX and the control arm of RITUXVAS. The BVAS score of our patients was also significantly superior than all other studies. Furthermore, most clinical trials do not include patients with alveolar hemorrhage, present in 40% of the patients in our study, nor RRT requirement, present in 67% of our patients. The higher rate of severe infections and mortality registered in our cohort reflects the severity of the disease at presentation, but also highlights the importance of modifying immunosuppression to the population and the need for future regimens which can reduce the rate of adverse effects.

P0217NEUTROPHIL TO LYMPHOCYTE RATIO AT ADMISSION CAN ESTIMATE VASCULITIS ACTIVITY AND POOR PROGNOSIS IN PATIENTS WITH ANCA-ASSOCIATED VASCULITIS: A RETROSPECTIVE STUDY

Background and Aims

Anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) is a multisystemic disease. Despite the improvement in mortality rate since the introduction of immunosuppression, long-term prognosis is still uncertain not only because of the disease activity but also due to treatment associated adverse effects. The neutrophil-to-lymphocyte ratio (NLR) has been demonstrated as an inflammatory marker in multiple settings. In this study, we aimed to investigate the prognostic ability of the NLR in AAV patients.

Method

We conducted a retrospective analysis of the clinical records of all adult patients with AVV admitted to the Service of Nephrology and Renal Transplantation of Centro Hospitalar Universitário Lisboa Norte from January 2006 to December 2019. NLR was calculated at admission. The outcomes measured were severe infection at 3 months and one-year mortality.

The prognostic ability of the NLR was determined using the receiver operating characteristic (ROC) curve. A cut-off value was defined as that with the highest validity. All variables underwent univariate analysis to determine statistically significant factors that may have outcomes. Only variables which significantly differed were used in the multivariate analysis using the logistic regression method.

Results

We registered 45 cases of AVV. The mean age at diagnosis was 67.5±12.1 years and 23 patients were male. The mean BVAS at presentation was 26.0±10.4. Twenty-nine patients were ANCA-MPO positive, 7 ANCA-PR3 positive and 9 were considered negative ANCA vasculitis. At admission, mean SCr was 6.7 ± 2.9mg/dL, ESR was 76.9 ± 33.8, hemoglobin was 9.5 ± 1.7g/dL, C-reactive protein was 13.2 ± 5.8mg/dL and NLR was 8.5 ± 6.8. Thirty-five patients were treated with cyclophosphamide, eight patients with rituximab for induction therapy.

Twenty patients developed severe infection within the first three months after starting induction immunosuppression. In a multivariate analysis, older age (73.6±10.5 vs 62.6±11.3, p=0.002, adjusted OR 1.08 [95% CI 1.01 – 1.16], p= 0.035) and higher NLR (11.9±7.4 vs 5.9±5.0, p=0.002, adjusted OR 1.14 [95% CI 1.01 – 1.29], p= 0.035) were predictors of severe infection at 3 months. NLR ≥ 4.04 predicted severe infection at 3 months with a sensitivity of 95% and specificity of 52% and the AUROC curve was 0.0794 (95% CI 0.647 – 0.900).

Nine patients died within the first year. Severe infection at 3 months was independently associated with mortality within the first year (OR 6.19 [95% CI 1.12 – 34.32], p= 0.037).

Conclusion

NLR at diagnosis was an independent predictor of severe sepsis within the first 3 months after immunosuppression start, and severe sepsis within the first three months was consequently correlated with one-year mortality. NLR is an easily calculated and low-cost laboratory inflammation biomarker and can prove useful in identifying AAV patients at risk of infection and poorer prognosis.

Timing of Initiation of Renal Replacement Therapy in Sepsis-Associated Acute Kidney Injury

Sepsis-associated acute kidney injury (SA-AKI) is a major issue in medical, surgical and intensive care settings and is an independent risk factor for increased mortality, as well as hospital length of stay and cost. SA-AKI encompasses a proper pathophysiology where renal and systemic inflammation play an essential role, surpassing the classic concept of acute tubular necrosis. No specific treatment has been defined yet, and renal replacement therapy (RRT) remains the cornerstone supportive therapy for the most severe cases. The timing to start RRT, however, remains controversial, with early and late strategies providing conflicting results. This article provides a comprehensive review on the available evidence on the timing to start RRT in patients with SA-AKI.

In-hospital mortality in elderly patients with acute kidney injury requiring dialysis: a cohort analysis

OBJECTIVE

To determine risk factors for in-hospital mortality in elderly patients with acute kidney injury (AKI) requiring dialysis.

INTRODUCTION

AKI requiring dialysis is frequent in elderly and is associated with an increased intra-hospital mortality. With the growing number of older individuals among hospitalized patients with AKI demands a thorough investigation of the factors that contribute to their mortality to improve outcomes.

METHODS

We performed a retrospective analysis of patients older than 80 years, admitted due to AKI requiring dialysis between January 2016 and December 2017. Patients who need intensive-care units (ICU) admission were excluded. The primary outcome was all-cause in-hospital mortality.

RESULTS

A total of 154 patients were evaluated. The mean age was 85.3 ± 4.0 years and 76 patients (49.4%) were male. The overall mortality rate was 26.6%. On the multivariate analysis, serum albumin (OR 0.42 [95% CI 0.21-0.85], p 0.016), C reactive protein/albumin ratio (OR 1.04 [95% CI 0.99-1.09], and renal function recovery (OR 018 [95% CI 0.49-0.65], p 0.009) were the factors associated with higher in-hospital mortality.

CONCLUSIONS

Lower albumin level, higher C reactive protein/albumin ratio at admission, and absence of renal function recovery are associated with increased in-hospital mortality's risk in elderly with acute kidney injury requiring dialysis.

Extreme events are more likely to affect the breeding success of lesser kestrels than average climate change

Climate change is predicted to severely impact interactions between prey, predators and habitats. In Southern Europe, within the Mediterranean climate, herbaceous vegetation achieves its maximum growth in middle spring followed by a three-month dry summer, limiting prey availability for insectivorous birds. Lesser kestrels (Falco naumanni) breed in a time-window that matches the nestling-rearing period with the peak abundance of grasshoppers and forecasted climate change may impact reproductive success through changes in prey availability and abundance. We used Normalised Difference Vegetation Index (NDVI) as a surrogate of habitat quality and prey availability to investigate the impacts of forecasted climate change and extreme climatic events on lesser kestrel breeding performance. First, using 14 years of data from 15 colonies in Southwestern Iberia, we linked fledging success and climatic variables with NDVI, and secondly, based on these relationships and according to climatic scenarios for 2050 and 2070, forecasted NDVI and fledging success. Finally, we evaluated how fledging success was influenced by drought events since 2004. Despite predicting a decrease in vegetation greenness in lesser kestrel foraging areas during spring, we found no impacts of predicted gradual rise in temperature and decline in precipitation on their fledging success. Notwithstanding, we found a decrease of 12% in offspring survival associated with drought events, suggesting that a higher frequency of droughts might, in the future, jeopardize the recent recovery of the European population. Here, we show that extreme events, such as droughts, can have more significant impacts on species than gradual climatic changes, especially in regions like the Mediterranean Basin, a biodiversity and climate change hotspot.

Transient and Persistent AKI and Outcomes in Patients Undergoing Major Abdominal Surgery

INTRODUCTION

Acute kidney injury (AKI) is a frequent diagnosis in surgical patients which has a detrimental effect on short-term and long-term outcomes. The purpose of this study was to evaluate the incidence and predictive factors of transient and persistent postoperative AKI in patients submitted to major abdominal surgery and to characterize the impact of AKI on in-hospital mortality.

METHODS

This study was a cross-examination of a retrospective analysis of clinical data of 450 patients who underwent major abdominal surgery from January 2010 to February 2011. Only AKI developing in the first 48 h after surgery was considered. AKI was diagnosed using the Kidney Disease: Improving Global Outcome (KDIGO) classification based on both serum creatinine (SCr) and urine output criteria. Persistent and transient AKI were defined according to the Acute Disease Quality Initiative (ADQI) workgroup definitions.

RESULTS

In our study, 22.4% of patients developed AKI in the first 48 h post-surgery (n = 101), and 48% of patients had persistent AKI (n = 49), defined as postoperative AKI, with a duration of more than 48 h. Older age (adjusted odds ratio [OR] 1.06 [1.00-1.11], p = 0.039), hypertension (adjusted OR 4.60 [1.17-18.11], p = 0.029), and higher preoperative SCr (adjusted OR 22.67 [4.00-128.46], p < 0.001) were independent predictors of persistent AKI. The overall in-hospital mortality was 6.4% (n = 29). Persistent AKI was associated with higher mortality than transient AKI (51.9 vs. 20.7%; unadjusted OR 13.03 [5.78-29.36], p < 0.001; adjusted OR 4.20 [1.02-17.27], p = 0.047).

CONCLUSION

In this cohort of patients submitted to major abdominal surgery, persistent AKI was an independent predictor of in-hospital mortality in contrast to transient AKI.

Artificial Intelligence in Acute Kidney Injury Risk Prediction

Acute kidney injury (AKI) is a frequent complication in hospitalized patients, which is associated with worse short and long-term outcomes. It is crucial to develop methods to identify patients at risk for AKI and to diagnose subclinical AKI in order to improve patient outcomes. The advances in clinical informatics and the increasing availability of electronic medical records have allowed for the development of artificial intelligence predictive models of risk estimation in AKI. In this review, we discussed the progress of AKI risk prediction from risk scores to electronic alerts to machine learning methods.

Complete blood count in acute kidney injury prediction: a narrative review

Acute kidney injury (AKI) is a complex syndrome defined by a decrease in renal function. The incidence of AKI has raised in the past decades, and it is associated with negative impact in patient outcomes in the short and long term. Considering the impact of AKI on patient prognosis, research has focused on methods to assess patients at risk for developing AKI, diagnose subclinical AKI, and on prevention and treatment strategies, for which it is crucial an understanding of pathophysiology the of AKI. In this review, we discuss the use of easily available parameters found in a complete blood count to detect patients at risk for developing AKI, to provide an early diagnosis of AKI, and to predict associated patient outcomes.

Factors affecting arteriovenous fistula dysfunction: A narrative review

Vascular access dysfunction is one of the most important causes of morbidity and mortality in haemodialysis patients, contributing to up to one third of hospitalisations and accounting for a significant amount of the health care costs of these patients. In the past decades, significant scientific advances in understanding mechanisms of arteriovenous fistula maturation and failure have contributed to an increase in the amount of research into techniques for creation and strategies for arteriovenous fistula dysfunction prevention and treatment, in order to improve patient care and outcomes. The aim of this review is to describe the pathogenesis of vascular access failure and provide a comprehensive analysis of the associated risk factors and causes of vascular access failure, in order to interpret possible future therapeutic approaches. Arteriovenous fistula failure is a multifactorial process resulting from the combination of upstream and downstream events with consequent venous neo-intimal hyperplasia and/or inadequate outward remodelling. Inflammation appears to be central in the biology of arteriovenous fistula dysfunction but important triggers still need to be revealed. Given the significant association of arteriovenous fistula failure and patient's prognosis, it is therefore imperative to further research in this area in order to improve prevention, surveillance and treatment, and ultimately patient care and outcomes.

High-Urgency Renal Transplantation for Patients With Vascular Access Failure: A Single-Center Experience

In the face of access failure for renal replacement therapy or severe complications despite or due to dialysis, high-urgency renal transplant (HU-RT) allocation is possible. Vascular access failure patients have multiple comorbidities and a higher risk of cardiovascular and thrombotic events. Thus, it is presumed that graft and patient survivals might be worse for these patients. The aim of this paper was to analyze the characteristics and outcomes of HU-RT patients due to access failure for renal replacement therapy when comparing them to a population of deceased-donor renal transplant (DDRT) patients. We analyzed data from our Renal Transplantation Unit from January 2006 to April 2017. In this period, 374 patients had a renal transplant. Of these, 11 patients received a high-urgency deceased-donor renal transplant (HU-DDRT). Compared with patients who had a DDRT, HU-DDRT patients were predominantly female (54.5% vs 43.5%, P = .007) and younger (41.6 ± 7.9 vs 49.4 ± 11.8, P = .031). HU-DDRT patients were not significantly more sensitized than DDRT (14.1 ± 27.4 vs 13.5 ± 24.1, P = .935), and had a comparable number of HLA mismatches (3.4 ± 1.4 vs 3.6 ± 1.2, P = .343). Despite the higher incidence in hypertensive (90.9 vs 73.5%, P = .196) and diabetic patients (27.3% vs 15.7%, P = .305) in the HU-DDRT group, this difference was not statistically significant. The percentage of retransplantation was similar in both groups (9.1% vs 7.2%, P = .808). Donor sex, age, and baseline serum creatinine were similar between the groups. There was an increased proportion of expanded criteria donors in HU-DDRT (54.5% vs 25.1%, P = .028). There were no differences in cold or warm ischemia time nor in serum creatinine at discharge or during the first 2 years of follow-up. In both groups, a similar proportion of patients experienced acute rejection episodes. Comparable to DDRT patients, HU-DDRT patients had a high proportion of graft survival at the 1-year follow-up (90.9% vs 93.1%, P = .777). At a 2-year follow-up, graft survival was lower in the HU-DDRT group (81.8% vs 91.5%, P = .267). Mean follow-up for both groups was comparable (78.5 ± 46.7 vs 68.4 ± 40.8 months, P = .424). Overall, graft loss occurred in approximately 36.4% of HU-DDRT patients and 20.9% of DDRT patients (P = .219). Both groups had an overall mortality rate of around 9%. The differences were not statistically significant due to the limited number of patients. More comorbidities and reportedly worse cardiovascular prognosis of access failure (AF) patients and use of expanded criteria donors did not negatively reflect in worse short-term outcomes in our cohort, which highlights the importance of HU-RT in prolonging the survival of AF patients.

Uremic lion face syndrome

Mineral bone disorder is a common feature of chronic kidney disease. Lion face syndrome is rare complication of severe hyperparathyroidism in end-stage renal disease patients, which has been less commonly reported due to dialysis and medical treatment advances in the last decade. The early recognition of the characteristic facial deformity is crucial to prompt management and prevent severe disfigurement. The authors present a rare case of severe hyperparathyroidism presenting with lion face syndrome and bone fractures.

Refractory Anemia in a Kidney Transplant Recipient

Anemia is a common finding after kidney transplantation (KT). Herein, we present a 34-year-old man who received a deceased-donor KT in 2017. Induction immunosuppression therapy consisted of thymoglobulin, tacrolimus (TAC) and methylprednisolone; the maintenance therapy included mycophenolate (MMF) 500 + 500 mg, TAC 4 + 4 mg and prednisolone (PD) 5 mg. One year after KT, he progressively developed dyspnea and fatigue. Laboratory exams revealed hypochromic microcytic anemia unresponsive to increasing doses of darbepoetin. Upper endoscopy and colonoscopy were normal. Bone marrow examination revealed erythroid hyperplasia with numerous proerythroblasts. Serology and viral load for human parvovirus B19 were both positive. Immunosuppression was reduced; he was treated with immunoglobulin. After one week, anemia improved. After 2 months the patient remained asymptomatic with stable hemoglobin. Although rare, PVB19 infection is a clinically significant infection that often presents as aplastic anemia in the post-transplantation period.