Multidisciplinary approach to patients with heart failure and kidney disease: preliminary experience of an integrated cardiorenal unit

Background

Cardiorenal programs have emerged to improve the management of cardiorenal disease (CRD). Evidence about the benefits of these programs is still scarce. This work aims to evaluate the performance of a novel cardiorenal program and describe the clinical profile and outcomes of patients with CRD.

Methods

We conducted a retrospective observational study of patients with CRD attended in a cardiorenal unit (CRU) from February 2021 to February 2022. Demographics and laboratory tests were collected and events (all-cause death and cardiovascular hospitalizations) were evaluated. Optimization of comorbidities and protective therapies was also assessed.

Results

Eighty-two patients were included, with a mean age of 76.8 years [standard deviation (SD) 8.5] and 72% were men. A total of 58.5% (n = 47) had left ventricular ejection fraction <50%. The mean follow-up was 11 months (SD 4.0). Almost 54% of the patients (n = 44) required hospitalization, 30.5% for heart failure (HF) decompensation. Total hospitalizations significantly decreased after CRU inclusion: 0.70 versus 0.45 admissions/year (P < .02). Global mortality was 17.1% (n = 14). The percentage of patients with HF with reduced ejection fraction on quadruple therapy increased by 20%, and up to 60% of the patients were on three drugs. A total of 39% of the patients with HF and preserved ejection fraction started treatment with sodium-glucose co-transporter inhibitors. Hyperkalaemia required the use of potassium binders in 12.2% of the patients and treatment of secondary hyperparathyroidism was started in 42.7% and renal anaemia in 23.2%. Renal replacement therapy was initiated in 10% of the patients (n = 8).

Conclusion

CRD confers a considerable risk of adverse outcomes. Cardiorenal programs may improve cardiorenal syndrome management by optimizing therapies, treating comorbidities and reducing hospitalizations.

Unresolved aspects in the management of renal anemia, a Delphi consensus of the Anemia Group of the S.E.N

Anemia is a common complication of chronic kidney disease (CKD) and is associated with a decrease in quality of life and an increased risk of transfusions, morbidity and mortality, and progression of CKD. The Anemia Working Group of the Sociedad Española de Nefrología conducted a Delphi study among experts in anemia in CKD to agree on relevant unanswered questions by existing evidence. The RAND/UCLA consensus methodology was used. We defined 15 questions with a PICO structure, followed by a review in scientific literature databases. Statements to each question were developed based on that literature review. Nineteen experts evaluated them using an iterative Two-Round Delphi-like process. Sixteen statements were agreed in response to 8 questions related to iron deficiency and supplementation with Fe (impact and management of iron deficiency with or without anemia, iron deficiency markers, safety of i.v. iron) and 7 related to erythropoiesis stimulating agents (ESAs) and/or hypoxia-inducible factor stabilizers (HIF), reaching consensus on all of them (individualization of the Hb objective, impact and management of resistance to ESA, ESA in the immediate post-transplant period and HIF stabilizers: impact on ferrokinetics, interaction with inflammation and cardiovascular safety). There is a need for clinical studies addressing the effects of correction of iron deficiency independently of anemia and the impact of anemia treatment with various ESA on quality of life, progression of CKD and cardiovascular events.

Management of immunosuppressive therapy in kidney transplant recipients with COVID-19. A multicentre national study derived from the Spanish Society of Nephrology COVID registry

INTRODUCTION

SARS CoV2 infection has had a major impact on renal transplant patients with a high mortality in the first months of the pandemic. Intentional reduction of immunosuppressive therapy has been postulated as one of the cornerstone in the management of the infection in the absence of targeted antiviral treatment. This has been modified according to the patient`s clinical situation and its effect on renal function or anti-HLA antibodies in the medium term has not been evaluated.

OBJECTIVES

Evaluate the management of immunosuppressive therapy made during SARS-CoV2 infection, as well as renal function and anti-HLA antibodies in kidney transplant patients 6 months after COVID19 diagnosis.

MATERIAL AND METHODS

Retrospective, national multicentre, retrospective study (30 centres) of kidney transplant recipients with COVID19 from 01/02/20 to 31/12/20. Clinical variables were collected from medical records and included in an anonymised database. SPSS statistical software was used for data analysis.

RESULTS

renal transplant recipients with COVID19 were included (62.6% male), with a mean age of 57.5 years. The predominant immunosuppressive treatment prior to COVID19 was triple therapy with prednisone, tacrolimus and mycophenolic acid (54.6%) followed by m-TOR inhibitor regimens (18.6%). After diagnosis of infection, mycophenolic acid was discontinued in 73.8% of patients, m-TOR inhibitor in 41.4%, tacrolimus in 10.5% and cyclosporin A in 10%. In turn, 26.9% received dexamethasone and 50.9% were started on or had their baseline prednisone dose increased. Mean creatinine before diagnosis of COVID19, at diagnosis and at 6 months was: 1.7 ± 0.8, 2.1 ± 1.2 and 1.8 ± 1 mg/dl respectively (p < 0.001). 56.9% of the patients (N = 350) were monitored for anti-HLA antibodies. 94% (N = 329) had no anti-HLA changes, while 6% (N = 21) had positive anti-HLA antibodies. Among the patients with donor-specific antibodies post-COVID19 (N = 9), 7 patients (3.1%) had one immunosuppressant discontinued (5 patients had mycophenolic acid and 2 had tacrolimus), 1 patient had both immunosuppressants discontinued (3.4%) and 1 patient had no change in immunosuppression (1.1%), these differences were not significant.

CONCLUSIONS

The management of immunosuppressive therapy after diagnosis of COVID19 was primarily based on discontinuation of mycophenolic acid with very discrete reductions or discontinuations of calcineurin inhibitors. This immunosuppression management did not influence renal function or changes in anti-HLA antibodies 6 months after diagnosis.

Acute and chronic kidney disease and risk of hospital mortality during COVID-19 pandemic waves in the pre-vaccination era

Background

Chronic kidney disease (CKD) is a risk factor for death from coronavirus disease 2019 (COVID-19), and COVID-19 may cause acute kidney injury (AKI) which also influences outcomes. There is little information on the independent contribution of CKD and AKI to the risk of death in COVID-19 on different waves, as CKD is a key risk factor for AKI.

Methods

We have studied the epidemiology of CKD and AKI in 2878 patients hospitalized for COVID-19 and their independent association with in-hospital mortality in the two largest pre-vaccination COVID-19 waves in Madrid, Spain. Hospitalized COVID-19 patients were grouped into four mutually exclusive categories: previous-CKD, community-acquired AKI (CA-AKI), hospital-acquired AKI (HA-AKI) and normal renal function throughout hospitalization.

Results

Pre-existent or acquired kidney involvement was observed in 35.5% and 36.8% of COVID-19 patients in the 1st and 3rd waves, respectively. Overall, 13.9% of patients with normal kidney function on arrival developed HA-AKI. In the 3rd wave, CA-AKI was more common than in the 1st wave. Overall, 9%-20% of CKD cases and 22%-40% of AKI cases remained undiagnosed in the discharge report. CKD, CA-AKI and HA-AKI were independently associated with risk of death in multivariate analysis, with HA-AKI, which was usually mild, being the most relevant independent risk factor for in-hospital mortality. A model including kidney involvement category, age, Charlson index, admission lactate dehydrogenase and lymphocytes predicted death with a receiver operating characteristic area under the curve of 0.898.

Conclusion

In conclusion, CKD and AKI were common in pre-vaccination waves among hospitalized COVID-19 patients and were independent risk factors for death, even when AKI was mild to moderate, and despite improvements in treatment.

[Management of immunosuppressive therapy in kidney transplant recipients with COVID19. A multicentre national study derived form the S.E.N. COVID registry.]

INTRODUCTION

SARS CoV2 infection has had a major impact on renal transplant patients with a high mortality in the first months of the pandemic. Intentional reduction of immunosuppressive therapy has been postulated as one of the cornerstone in the management of the infection in the absence of targeted antiviral treatment. This has been modified according to the patient`s clinical situation and its effect on renal function or anti-HLA antibodies in the medium term has not been evaluated.

OBJECTIVES

Evaluate the management of immunosuppressive therapy made during SARS-CoV2 infection, as well as renal function and anti-HLA antibodies in kidney transplant patients 6 months after COVID19 diagnosis.

MATERIAL AND METHODS

Retrospective, national multicentre, retrospective study (30 centres) of kidney transplant recipients with COVID19 from 01/02/20 to 31/12/20. Clinical variables were collected from medical records and included in an anonymised database. SPSS statistical software was used for data analysis.

RESULTS

615 renal transplant recipients with COVID19 were included (62.6% male), with a mean age of 57.5 years.The predominant immunosuppressive treatment prior to COVID19 was triple therapy with prednisone, tacrolimus and mycophenolic acid (54.6%) followed by m-TOR inhibitor regimens (18.6%). After diagnosis of infection, mycophenolic acid was discontinued in 73.8% of patients, m-TOR inhibitor in 41.4%, tacrolimus in 10.5% and cyclosporin A in 10%. In turn, 26.9% received dexamethasone and 50.9% were started on or had their baseline prednisone dose increased.Mean creatinine before diagnosis of COVID19, at diagnosis and at 6 months was: 1.7±0.8, 2.1±1.2 and 1.8±1 mg/dl respectively (p<0.001).56.9% of the patients (N=350) were monitored for anti-HLA antibodies. 94% (N=329) had no anti-HLA changes, while 6% (N=21) had positive anti-HLA antibodies. Among the patients with donor-specific antibodies post-COVID19 (N=9), 7 patients (3.1%) had one immunosuppressant discontinued (5 patients had mycophenolic acid and 2 had tacrolimus), 1 patient had both immunosuppressants discontinued (3.4%) and 1 patient had no change in immunosuppression (1.1%), these differences were not significant.

CONCLUSIONS

The management of immunosuppressive therapy after diagnosis of COVID19 was primarily based on discontinuation of mycophenolic acid with very discrete reductions or discontinuations of calcineurin inhibitors. This immunosuppression management did not influence renal function or changes in anti-HLA antibodies 6 months after diagnosis.

The hidden diabetic kidney disease in a university hospital-based population: a real-world data analysis

Background

Correct identification of diabetic kidney disease (DKD) in type 2 diabetes mellitus (T2DM) patients is crucial to implement therapeutic interventions that may prevent disease progression.

Methods

We compared the real prevalence of DKD in T2DM patients according to actual serum and urine laboratory data with the presence of the diagnostic terms DKD and/or CKD on the electronic medical records (EMRs) using a natural language processing tool (SAVANA Manager). All patients ˃18 years of age and diagnosed with T2DM were selected. DKD was defined as an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m² or a urinary albumin:creatinine ratio (UACR) >30 mg/g or a urinary protein:creatinine ratio (UPCR) >0.3 g/g after excluding acute kidney injury.

Results

A total of 15 304 T2DM patients identified on EMRs were eligible to enter the study. A total of 4526 (29.6%) T2DM patients had DKD according to lab criteria. However, the terms CKD or DKD were only present in 33.1% and 7.5%, representing a hidden prevalence of CKD and DKD of 66.9% and 92.5%, respectively. Less severe kidney disease (lower UACR or UPCR, higher eGFR values), female sex and lack of insulin prescription were associated with the absence of DKD or CKD terms in the EMRs (P < .001)

Conclusions

The prevalence of DKD among T2DM patients defined by lab data is significantly higher than that reported on hospital EMRs. This could imply underdiagnosis of DKD, especially in patients with the least severe disease who may benefit the most from optimized therapy.

Rapid decline of anti-SARS-CoV-2 antibodies in patients on haemodialysis: the COVID-FRIAT study

BACKGROUND

Coronavirus disease 2019 (COVID-19) patients on haemodialysis (HD) have high mortality. We investigated the value of reverse transcription polymerase chain reaction (RT-PCR) and the dynamic changes of antibodies (enzyme-linked immunosorbent assay immunoglobulin M (IgM) + IgA and/or IgG) in a large HD cohort.

METHODS

We conducted a prospective observational study in 10 Madrid HD centres. Infection rate, anti-SARS-CoV-2 antibody dynamics and the incidence of asymptomatic SARS-CoV-2 infection (defined by positive RT-PCR, IgM + IgA and/or IgG) were assessed.

RESULTS

From 1 March to 15 April 2020, 136 of 808 (16.8%) HD patients were diagnosed with symptomatic COVID-19 by RT-PCR of nasopharyngeal swabs and 42/136 (31%) died. In the second fortnight of April, RT-PCR and anti-SARS-CoV-2 antibodies were assessed in 763 of the surviving patients. At this point, 69/91 (75.8%) symptomatic COVID-19 patients had anti-SARS-CoV-2 antibodies. Four weeks later, 15.4% (10/65) of initially antibody-positive patients had become negative. Among patients without prior symptomatic COVID-19, 9/672 (1.3%) were RT-PCR positive and 101/672 patients (15.0%) were antibody positive. Four weeks later, 62/86 (72.1%) of initially antibody-positive patients had become negative. Considering only IgG titres, serology remained positive after 4 weeks in 90% (54/60) of patients with symptomatic COVID-19 and in 52.5% (21/40) of asymptomatic patients. The probability of an adequate serologic response (defined as the development of anti-SARS-CoV-2 antibodies that persisted at 4 weeks) was higher in patients who had symptomatic COVID-19 than in asymptomatic SARS-CoV-2 infection {odds ratio [OR) 4.04 [95% confidence interval (CI) 2.04-7.99]} corrected for age, Charlson comorbidity index score and time on HD. Living in a nursing home [OR 5.9 (95% CI 2.3-15.1)] was the main risk factor for SARS-CoV-2 infection.

CONCLUSIONS

The anti-SARS-CoV-2 antibody immune response in HD patients depends on clinical presentation. The antibody titres decay earlier than previously reported for the general population. This inadequate immune response raises questions about the efficacy of future vaccines.

Iron replacement therapy in the management of anaemia in non-dialysis Chronic kidney disease patients: Perspective of the Spanish Nephrology Society Anaemia Group

This work presents an update on the management of iron deficiency in patients with chronic kidney disease (CKD), either with or without anaemia. A review is made of the recommendations of the guidelines for the treatment of iron deficiency in CKD. It also presents new studies on iron deficiency in patients with CKD, as well as new findings about iron therapy and its impact on clinical outcomes. Anaemia is a common complication of CRF, and is associated with a decrease in the quality of life of the patients, as well as an increase in morbidity and mortality. Iron deficiency (absolute or functional) is common in non-dialysis chronic kidney disease patients, and may cause anaemia or a low response to erythropoiesis-stimulating agents. For this reason, the clinical guidelines for the treatment of the anaemia in Nephrology indicate the correction of the deficiency in the presence of anaemia. Iron replacement therapy is indicated in patients with CKD and anaemia (Hb < 12 g/dl) in accordance with the guidelines. There is no unanimity in the indication of iron replacement therapy in patients with Hb > 12 g/dl, regardless of whether they have an absolute or functional iron deficiency. Intravenous iron replacement therapy is safe, more efficient and rapid than oral therapy for achieving an increase haemoglobin lels and reducing the dose of erythropoiesis-stimulating agents. For the administration of intravenous iron in non-dialysis chronic renal failure patients a strategy of high doses and low frequency would be preferred on being more convenient for the patient, preserves better the venous capital, and is safe and cost-effective. Iron plays an essential role in energy metabolism and other body functions beyond the synthesis of haemoglobin, for which the iron deficiency, even in the absence of anaemia, could have harmful effects in patients with CKD. The correction of the iron deficiency, in the absence of anaemia is associated with functional improvement in patients with heart failure, and in muscle function or fatigue in patients without CKD. Despite the evidence of benefits in the correction of iron deficiency in patients with CKD, more studies are required to evaluate the impact of the correction of the iron deficiency in the absence of anaemia on morbidity and mortality, quality of life and physical capacity, as well as the long-term effect of oral and intravenous iron replacement therapy in this population.

Microvesicles from indoxyl sulfate-treated endothelial cells induce vascular calcification in vitro

Vascular calcification (VC), an unpredictable pathophysiological process and critical event in patients with cardiovascular diseases (CVDs), is the leading cause of morbi-mortality and disability in chronic kidney disease (CKD) patients worldwide. Currently, no diagnostic method is available for identifying patients at risk of VC development; the pathology is detected when the process is irreversible. Extracellular vesicles (EVs) from endothelial cells might promote VC. Therefore, their evaluation and characterization could be useful for designing new diagnostic tools. The aim of the present study is to investigate whether microvesicles (MVs) from endothelial cells damaged by uremic toxin and indoxyl sulfate (IS) could induce calcification in human vascular smooth muscle cells (VMSCs). Besides, we have also analyzed the molecular mechanisms by which these endothelial MVs can promote VC development. Endothelial damage has been evaluated according to the percentage of senescence in endothelial cells, differential microRNAs in endothelial cells, and the amount of MVs released per cell. To identify the role of MVs in VC, VSMCs were treated with MVs from IS-treated endothelial cells. Calcium, inflammatory gene expression, and procalcification mediator levels in VSMCs were determined. IS-treated endothelial cells underwent senescence and exhibited modulated microRNA expression and an increase in the release of MVs. VSMCs exposed to these MVs modulated the expression of pro-inflammatory genes and some mediators involved in calcification progression. MVs produced by IS-treated endothelial cells promoted calcification in VSMCs.

Towards efficient use of noble metals via exsolution exemplified for CO oxidation

Many catalysts and in particular automotive exhaust catalysts usually consist of noble metal nanoparticles dispersed on metal oxide supports. While highly active, such catalysts are expensive and prone to deactivation by sintering and thus alternative methods for their production are being sought to ensure more efficient use of noble metals. Exsolution has been shown to be an approach to produce confined nanoparticles, which in turn are more stable against agglomeration, and, at the same time strained, displaying enhanced activity. While exsolution has been extensively investigated for relatively high metal loadings, it has yet to be explored for dilute loadings which is expected to be more challenging but more suitable for application of noble metals. Here we explore the substitution of Rh into an A-site deficient perovskite titante aiming to investigate the possibility of exsolving from dilute amounts of noble metal substituted perovskites. We show that this is possible and in spite of certain limitations, they still compete well against conventionally prepared samples with higher apparent surface loading when applied for CO oxidation.

Eculizumab in secondary atypical haemolytic uraemic syndrome

Background. Complement dysregulation occurs in thrombotic microangiopathies (TMAs) other than primary atypical haemolytic uraemic syndrome (aHUS). A few of these patients have been reported previously to be successfully treated with eculizumab.

Methods. We identified 29 patients with so-called secondary aHUS who had received eculizumab at 11 Spanish nephrology centres. Primary outcome was TMA resolution, defined by a normalization of platelet count (>150 × 10⁹/L) and haemoglobin, disappearance of all the markers of microangiopathic haemolytic anaemia (MAHA), and improvement of renal function, with a ≥25% reduction of serum creatinine from the onset of eculizumab administration.

Results. Twenty-nine patients with secondary aHUS (15 drug-induced, 8 associated with systemic diseases, 2 with postpartum, 2 with cancer-related, 1 associated with acute humoral rejection and 1 with intestinal lymphangiectasia) were included in this study. The reason to initiate eculizumab treatment was worsening of renal function and persistence of TMA despite treatment of the TMA cause and plasmapheresis. All patients showed severe MAHA and renal function impairment (14 requiring dialysis) prior to eculizumab treatment and 11 presented severe extrarenal manifestations. A rapid resolution of the TMA was observed in 20 patients (68%), 15 of them showing a ≥50% serum creatinine reduction at the last follow-up. Comprehensive genetic and molecular studies in 22 patients identified complement pathogenic variants in only 2 patients. With these two exceptions, eculizumab was discontinued, after a median of 8 weeks of treatment, without the occurrence of aHUS relapses.

Conclusion. Short treatment with eculizumab can result in a rapid improvement of patients with secondary aHUS in whom TMA has persisted and renal function worsened despite treatment of the TMA-inducing condition.

Risk Factors for Clostridium Difficile Diarrhea in Patients With Solid Organ Transplantation

BACKGROUND

There is limited knowledge about specific risk factors for Clostridium difficile infection (CDI).

METHOD

A retrospective study comparing cases of CDI in solid organ transplant (SOT) recipients with controls (SOT recipients who did not present CDI).

RESULTS

Thirty patients with SOT from 1340 transplantation recipients had at least 1 episode of CDI (2.23%). The accumulated incidence was 3.06% in liver transplantation, 2.78% in lung transplantation, 2.36% in kidney transplantation, and 0.33% in heart transplantation. Seven (23%) cases occurred during the first 2 months. Fifteen (50%) cases were community acquired. Colonoscopy was performed in 6 (20%) cases, but pseudomembranes were observed in only 1 (16%) case. Independent variables found to be related to CDI were previous treatment with proton pump inhibitors (PPIs; odds ratio [OR] 5.5; 95% confidence interval [CI] 1.2-32.0), immunosuppressive regimen including mycophenolate (OR 5.2; 95%CI 1.1-18), hospitalization during the previous 3 months (OR 5.1; 95%CI 1.1-17), and antibiotic treatment during the previous month (OR 6.7; 95%CI 1.4-23). Five (16.7%) patients did not respond to the initial treatment. Recurrences were noted in 6 (20%) patients.

CONCLUSIONS

Liver transplant recipients presented the highest incidence. Risk factors for CDI were previous treatment with PPIs, immunosuppressive regimen containing mycophenolate, prior hospitalization, and prior antibiotic treatment.

Use of radioactive iodine I-131 and monitoring of radioactivity in patients with chronic kidney disease on haemodialysis

Thyroid carcinoma is a neoplasia with a higher incidence in patients with chronic kidney disease. In recent years advances have been made in diagnostic and therapeutic trials. Dialysis patients are a particular group, their cancer being detected indirectly in the study of secondary hyperparathyroidism and during the study prior to renal transplantation. Thyroidectomy is the definitive treatment, but in patients with risk of recurrence, ablative therapy is required using radioactive iodine I-131, which is predominantly eliminated by renal excretion, therefore its use in patients on dialysis poses a problem in terms of dosage. Two cases are presented of patients on haemodialysis undergoing radioablation with radioactive iodine I-131, which with multidisciplinary treatment had the expected results in the patients.

The development of anemia is associated to poor prognosis in NKF/KDOQI stage 3 chronic kidney disease

Background

Anemia is a common condition in CKD that has been identified as a cardiovascular (CV) risk factor in end-stage renal disease, constituting a predictor of low survival. The aim of this study was to define the onset of anemia of renal origin and its association with the evolution of kidney disease and clinical outcomes in stage 3 CKD (CKD-3).

Methods

This epidemiological, prospective, multicenter, 3-year study included 439 CKD-3 patients. The origin of nephropathy and comorbidity (Charlson score: 3.2) were recorded. The clinical characteristics of patients that developed anemia according to EBPG guidelines were compared with those that did not, followed by multivariate logistic regression, Kaplan-Meier curves and ROC curves to investigate factors associated with the development of renal anemia.

Results

During the 36-month follow-up period, 50% reached CKD-4 or 5, and approximately 35% were diagnosed with anemia (85% of renal origin). The probability of developing renal anemia was 0.12, 0.20 and 0.25 at 1, 2 and 3 years, respectively. Patients that developed anemia were mainly men (72% anemic vs. 69% non-anemic). The mean age was 68 vs. 65.5 years and baseline proteinuria was 0.94 vs. 0.62 g/24h (anemic vs. non anemic, respectively). Baseline MDRD values were 36 vs. 40 mL/min and albumin 4.1 vs. 4.3 g/dL; reduction in MDRD was greater in those that developed anemia (6.8 vs. 1.6 mL/min/1.73 m²/3 years). These patients progressed earlier to CKD-4 or 5 (18 vs. 28 months), with a higher proportion of hospitalizations (31 vs. 16%), major CV events (16 vs. 7%), and higher mortality (10 vs. 6.6%) than those without anemia. Multivariate logistic regression indicated a significant association between baseline hemoglobin (OR=0.35; 95% CI: 0.24-0.28), glomerular filtration rate (OR=0.96; 95% CI: 0.93-0.99), female (OR=0.19; 95% CI: 0.10-0.40) and the development of renal anemia.

Conclusions

Renal anemia is associated with a more rapid evolution to CKD-4, and a higher risk of CV events and hospitalization in non-dialysis-dependent CKD patients. This suggests that special attention should be paid to anemic CKD-3 patients.

Anemia development and cardiovascular risk management in nonanemic stage 3 chronic kidney disease

BACKGROUND/AIM

There is little information on the development of anemia in the early stages of chronic kidney disease. The aim of this study was to analyze the onset of renal anemia in a cohort of initially nonanemic chronic kidney disease patients followed up in nephrology clinics.

METHODS

This epidemiological, prospective, three-year, multicenter study enrolled patients aged 18-78 years with stage 3 chronic kidney disease without anemia. Interim analysis was performed on the data collected during the first 12 months.

RESULTS

The study included 432 patients, average age 63.6 years (range 22-78 years, 70% male). The main etiologies of chronic kidney disease were glomerular (11.6%), interstitial (10.4%), vascular (29.4%), and diabetic (16.9%). The percentages of patients with comorbidities were 33.8% diabetes (2.5% type 1), 69% dyslipidemia, and 93% hypertension. During the first year, 12.4% of patients developed anemia. The chronic kidney disease progression rate was low: proteinuria was 0.46 +/- 0.8 g/24 h at one year versus 0.67 +/- 1.0 g/24 h at baseline. Diabetic patients showed a greater prevalence of previous cardiovascular events (50.0% vs. 24.5%) and worse control of some modifiable cardiovascular risk factors: smoking (13.4% vs. 8.6%), obesity (BMI > 30 kg/m(2), 33.6% vs. 25.3%), target blood pressure (<130/80 mmHg, 21.0% vs. 27.9%), and proteinuria (0.8 +/- 1.1 vs. 0.6 +/- 0.9 g/day).

CONCLUSIONS

After one year, 12.4% of patients developed anemia. Diabetic patients had a higher cardiovascular risk and limited blood pressure control. The overall control of cardiovascular risk was unsatisfactory.

Effect of different dialysis modalities on microinflammatory status and endothelial damage

BACKGROUND AND OBJECTIVES

We studied the relationship between microinflammation and endothelial damage in chronic kidney disease (CKD) patients on different dialysis modalities.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Four groups of CKD stage 5 patients were studied: 1) 14 nondialysis CKD patients (CKD-NonD); 2) 15 hemodialysis patients (HD); 3) 12 peritoneal dialysis patients with residual renal function >1 ml/min (PD-RRF >1); and 4) 13 peritoneal dialysis patients with residual renal function <or=1 ml/min (PD-RRF <or=1). Ten healthy subjects served as controls. CD14(+)CD16(+) cells and apoptotic endothelial microparticles (EMPs) were measured by flow cytometry. Serum vascular endothelial growth factor (VEGF) was measured by ELISA.

RESULTS

CKD-NonD and HD patients had a higher percentage of CD14(+)CD16(+) monocytes than PD groups and controls. CD14(+)CD16(+) was similar in the PD groups, regardless of their RRF, and controls. The four uremic groups displayed a marked increase in apoptotic EMPs and VEGF compared with controls. Apoptotic EMPs and VEGF were significantly higher in HD patients than in CKD-NonD and both PD groups. However, there were no significant differences between CKD-NonD and the two PD groups. There was a correlation between CD14(+)CD16(+) and endothelial damage in CKD-NonD and HD patients, but not in PD and controls.

CONCLUSIONS

There was an increase in CD14(+)CD16(+) only in CKD-NonD and HD patients. In these patients, there was a relationship between increased CD14(+)CD16(+) and endothelial damage. These results strongly suggest that other factors unrelated to the microinflammatory status mediated by CD14(+)CD16(+) are promoting the endothelial damage in PD, regardless of their RRF.

Previous comorbidity and lack of patient free choice of technique predict early mortality in peritoneal dialysis

OBJECTIVE

To study the prognostic factors for mortality and hospital admission for patients on peritoneal dialysis (PD).

METHOD

Biannual data on individual characteristics, clinical and analytical progress, treatment, and events were studied for a cohort of incident patients undergoing PD (2003-2006) in a reference area of 8.8 million people.

RESULTS

489 patients (age 53.58 years, 61.6% male) with 3-year follow-up were included. They presented at inclusion with Charlson Comorbidity Index (CCI) of 5.25; previous cardiovascular (CV) event, 23.7%; diabetes mellitus (DM), 19.1%; and hypertension (HT), 89.9%. Annual hospitalization rate per patient-year at risk was 0.6. The variables that predicted admission were CCI [odds ratio (OR) 1.14 per point], DM (OR 1.66), and previous CV event (OR 1.90). Anemia maintained significance when corrected for CCI: hemoglobin, 0.79 per 1 g/dL Hb; CCI, 1.15 per point. Annual mortality rate was 5.4%. Those that died were older (67.47 vs 52.78 years) and had a higher CCI (8.35 vs 5.0), a lower initial Hb (11.5 vs 12.2 g/dL), a higher hospital admission rate, a higher annual rate of peritonitis, more previous CV events (50.0% vs 22.1%), and higher prevalence of DM (38.5% vs 17.9%). Survival analysis identified the following prognostic factors: CCI [hazard ratio (HR) 1.51 per point], CV event (HR 2.85), DM (HR 2.52), age (HR 1.06 per year), and mandatory referral to PD (HR 6.54). The effect of CV events and DM persisted after correction for age, and that of choice of technique after correcting for CCI and/or age.

CONCLUSIONS

The CCI is useful for risk estimation in PD patients. Previous CV event, DM, and age are the most relevant risk factors. Control of anemia has prognostic value for hospital admissions. Mandatory referral to PD is associated with higher mortality. The prognosis in PD depends on predialysis patient management.

Previous Comorbidity and Lack of Patient Free Choice of Technique Predict Early Mortality in Peritoneal Dialysis

Objective

To study the prognostic factors for mortality and hospital admission for patients on peritoneal dialysis (PD).

Method

Biannual data on individual characteristics, clinical and analytical progress, treatment, and events were studied for a cohort of incident patients undergoing PD (2003-2006) in a reference area of 8.8 million people.

Results

489 patients (age 53.58 years, 61.6% male) with 3-year follow-up were included. They presented at inclusion with Charlson Comorbidity Index (CCI) of 5.25; previous cardiovascular (CV) event, 23.7%; diabetes mellitus (DM), 19.1%; and hypertension (HT), 89.9%. Annual hospitalization rate per patient-year at risk was 0.6. The variables that predicted admission were CCI [odds ratio (OR) 1.14 per point], DM (OR 1.66), and previous CV event (OR 1.90). Anemia maintained significance when corrected for CCI: hemoglobin, 0.79 per 1 g/dL Hb; CCI, 1.15 per point. Annual mortality rate was 5.4%. Those that died were older (67.47 vs 52.78 years) and had a higher CCI (8.35 vs 5.0), a lower initial Hb (11.5 vs 12.2 g/dL), a higher hospital admission rate, a higher annual rate of peritonitis, more previous CV events (50.0% vs 22.1%), and higher prevalence of DM (38.5% vs 17.9%). Survival analysis identified the following prognostic factors: CCI [hazard ratio (HR) 1.51 per point], CV event (HR 2.85), DM (HR 2.52), age (HR 1.06 per year), and mandatory referral to PD (HR 6.54). The effect of CV events and DM persisted after correction for age, and that of choice of technique after correcting for CCI and/or age.

Conclusions

The CCI is useful for risk estimation in PD patients. Previous CV event, DM, and age are the most relevant risk factors. Control of anemia has prognostic value for hospital admissions. Mandatory referral to PD is associated with higher mortality. The prognosis in PD depends on predialysis patient management.

[Cinacalcet in patients on peritoneal dialysis with moderate to severe hyperparathyroidism resistant to conventional treatment, a one-year, prospective study]

BACKGROUND

Cinacalcet has improved the management of hyperparathiroidism (HPTH) in hemodialysis. To our knowledge there are no specific studies on peritoneal dialysis (PD).

AIM

The aim of the present study was to evaluate the efficacy of Cinacalcet on the achievement of optimal and suboptimal targets on treatment of hyperparathiroidism (HPTH) in PD patients. As secondary objectives we have studied the safety of treatment and estimate the mean time to reach these targets, and evaluate economic cost.

METHODS

Eighteen patients undergoing more than 4 months on PD with a severe HPTH (PTH > 500 pg/ml) resistant to conventional treatment with diet, chelants and vitamin D were included in this prospective open-label study. We have used the targets of K/DOQITM-clinical guidelines as optimal target. We have selected as suboptimal targets: PTH < 350 pg/ml, phosphorus < 6 mg/dl and calcium < 10.4 mg/dl (only when simultaneous CaxP was under 55 mg2/dl2). Oral Cinacalcet was given with main meal in a single daily start dose of 30 mg and titrated thereafter monthly. We considered the first value on target as an event and used a Kaplan-Meyer survival analysis to estimate mean time to reach target.

RESULTS

On inclusion all patients have at least two previous PTH values over 500 pg/ml, PTH mean 695,3 (SD 96) and they were on PD with an appropriate efficacy during a mean of 15.56 months (SD 0.78). Mean follow-up time under Cinacalcet treatment was 12 months. The percentage of patients with a PTH under 350 pg/ml was 66,7% on month 3, 60% on month 6 and 100% after 1 year. The percentage of patients that reach an aggregate of all suboptimal targets (PTH< 350 pg/ml and calcium < 10.4 mg/dl and phosphorus< 6 mg/dl and CaxP < 55 mg2/dl2) was 33.3% on month 6 and 66.7% after 1 year. The mean time to reach PTH target was 2.33 months with a 95% confident interval [1.35-3.32] and to reach the aggregate of all target was 16.94 months [11.38-22.5]. Cinacalcet has been well tolerated, we reduced the dose in a single patient due to secondary effects, but treatment was not discontinued in any case.

CONCLUSION

In summary the addition of Cinacalcet to conventional treatment in PD patients with resistant HPTH has improved the achievement of targets, and has been reasonably safe in our patients.

Definición de procesos e indicadores para la gestión de accesos vasculares para hemodiálisis

INTRODUCTION

The prevalence of renal replacement therapy has increased, affecting 885 patients per million inhabitants. More than 50% of these patients require hemodialysis with permanent vascular access. In our center a multidisciplinary group was organized to manage processes related to vascular access for hemodialysis.

OBJECTIVES

To define processes for the management of vascular access for hemodialysis and to evaluate these processes.

MATERIAL AND METHOD

Setting. Level III hospital in the autonomous community of Madrid serving 485,000 inhabitants.

STUDY PERIOD

2002-2004.

METHODOLOGY

A multidisciplinary working group was set up. The three most frequent processes were defined and described. Flow charts were used for graphical representation. Quality criteria and indicators were defined with prospective monitoring of electronic medical records, design of a specific surgical protocol, and retrospective analysis.

RESULTS

Comparison of the results with the literature. First vascular access. The percentage of patients with arteriovenous fistulas on starting hemodialysis. Percentage of prevalent patients with venous access (autologous fistula, prosthetic device, catheter). Maintenance of access: Rate of thrombosis in autologous-prosthetic arteriovenous fistulas. Percentage of rescued arteriovenous fistulas after thrombosis. Rate of temporary catheters. Resource management. Percentage of ambulatory interventions. Rate of admissions related to arteriovenous fistulas.

CONCLUSIONS

Arteriovenous fistulas are the main source of morbidity and hospital admission in patients with chronic renal failure in hemodialysis programs. Multidisciplinary management achieves results above the standards described in the literature. There do not appear to be other determining factors for these results, since the technical procedures performed do not differ from those described in the literature.

A prospective multicentre study of the role of anaemia as a risk factor in haemodialysis patients: the MAR Study

BACKGROUND

Retrospective studies have shown hospitalization and mortality rates during haemodialysis (HD) to be associated with anaemia.

METHODS

The prospective, multicentre Morbidity-and-mortality Anaemia Renal (MAR) study was designed to establish the burden of anaemia by controlling for other risk factors. Charlson index was used for comorbid adjustment. Finally, 1428 patients from 119 centres (60% men, aged 64.4 years, time on HD 15.3 months, Charlson comorbidity index 6.5 +/- 2.3) completed follow-up. They had hypertension (75.8%), diabetes mellitus (25.9%), heart failure (13.9%) and coronary disease (16.7%). Of the total patients, 94.8% were receiving erythropoietin (111.6 +/- 70.6 U/kg/week) and 76.7% i.v. iron, and haemoglobin (Hb) at inclusion was 11.7 +/- 1.5 g/dl.

RESULTS

Hospitalization rate was 1.1 admissions/patient/year. Yearly mortality was 12% [35% cardiovascular (CV)]. The relative risk and confidence interval (CI) for hospitalization and death were 0.86 (0.81-0.91) and 0.82 (0.73-0.91), respectively, per 1 g/dl increase in initial Hb after adjustment for comorbidity, vintage, aetiology, access type, albumin and Kt/V. The probability of remaining free from hospitalization (CI) was 0.34 (0.27-0.41) for initial Hb <10 g/dl, 0.47 (0.41-0.53) for Hb 10-11 g/dl, 0.54 (0.49-0.59) for Hb 11-12 g/dl, and 0.63 (0.59-0.67) for Hb >12 g/dl. Same analysis for patient survival was 0.77 (0.71-0.83) for Hb <10 g/dl vs 0.82 (0.77-0.87) for Hb 10-11 vs 0.89 (0.86-0.92) for Hb 11-12 vs 0.92 (0.90-0.94) for Hb > 12 g/dl, P < 0.001. The Cox regression model for hospitalization-free survival included the risk factors initial Hb (relative risk 0.86 per 1 g/dl increase, P < 0.001) Charlson, albumin and prior CV event.

CONCLUSION

Hb level predicted 1-year-survival and hospitalization. This effect persisted after adjustment for comorbidity and other prognostic factors.

[Prospective monitoring of vascular access in hemodialysis by means of a multidisciplinary team]

PURPOSE

Nowadays, expert guidelines recommend the monitoring programs of the vascular access (VA) by a multidisciplinary team.

MATERIAL AND METHOD

We present the experience over the last five years, of a prospective VA surveillance by a multidisciplinary team. The quality indicators reached are described as the associated factors for survival of the new VA.

RESULTS

Three hundred seventeen VA have been studied, 73% were arteriovenous fistulas(AVF) and the rest were polytetrafluoroethylene (PTFE) grafts at 282 patients. The main causes of dysfunctions were elevated dynamic venous pressure (42.5%) and the decreased blood flow (36.4%) with a 88% of positive predictive value. Over the 5 years there was 88 thrombosis (24 AVF and 64 PTFE grafts), that means a hazard thrombosis global rate of 0.15 access/year, which were distributed in 0.06 for AVF and 0.38 in PTFE grafts. Two hundred and one repairs of VA were done: 66.6% were elective repair after a proper review by the multidisciplinary team and the rest of them were done after the AV thrombosis happened. Urgent rescue surgeries were done in 76% of the thrombosis. 62.5% of the patients did not need a catheter after vascular access thrombosis. The complication relation with AVF and PTFE were 11.4% of the total patients hemodialysis hospitalizations. 65.2% of the VA were new access. 57% of patients were properly reviewed in the pre-dialysis unit at least once and 80% of them start haemodialysis with a mature access. The average survival (Kaplan Meier) of the new AVF was 1,575+/-55 days vs 1,087+/-102 of the PTFE grafts (p < 0.008). The survival after 1, 2 and 3 years for the AVF was 89%, 85% and 83% and for the PTFE graft 3% 67% and 51% respectively. The Cox regression has proved that the type of vascular access is the strongest factor associated to VA survival. The survival added of VA repaired due to dysfunction was 1,062 +/- 97 days vs 707 +/- 132 due to thrombosis, log rank 5.17 (p < 0,02). The increasing risk of those repaired after a thrombosis vs dysfunction is 4.2 p < 0,01.

CONCLUSIONS

The monitoring of the vascular access by a multidisciplinary team has reached:low rate of thrombosis, high elective number of repairs of the VA, high urgent rescue surgery after a thrombosis and a few number catheter needed and hospitalizations. AVF are associated with greater survival than PTFE. The VA repair due to dysfunction vs thrombosis had a greater survival as well.

[Cardiovascular risk in hemodialysis in Spain: prevalence, management and target results (MAR study)]

Cardiovacular disease is the main cause of morbidity and mortality in hemodialysis (HD) patients. However, there are no reliable data neither on the prevalence of cardiovacular disease nor its risk factors in Spain. The Morbidity and mortality Anemia Renal study (MAR) is a two-year multicenter, open-label, prospective cohorts study. Its main objective is to assess the general morbidity and mortality, particularly of a cardiovascular cause, and its relationship with the degree of anemia. Secondary objectives are: a/ the description of current clinical practices in anemia, dialysis, vascular access, and CV risk factor management; and b/ the description of hospitalization and mortality causes. This paper describes the prevalence of cardiovascular disease and risk factors of the HD population in Spain. A total of 1.710 patients were included (60% male, aged 64.4 years, 16.2 months on HD). The mean co-morbidity Charlson index was 6.5 +/- 2.3. Cardiovascular disease was the most prevalent comorbidity, 16.7% had a coronary disease, and 13.9% had different degrees of heart failure, while 11.6% had arrhythmia, 1.7% stroke and 5.5% peripheral artery disease. The prevalence of hypertension was 75.8%, 74.4% of patients received antihypertensive drugs, and still 40% of patients had an inadequate blood pressure control. The investigators considered as dyslipidemic 34.1% of patients, and prescribed treatment to 69.5% of them, while the remaining 30.5% (10.4% of the total) had hyperlipidemia with no drug therapy. Eleven percent was active smoker, and 26.6% former smoker. There was 47.4% of patients with a corporal mass index above 25. Secondary hyperparathyroidism with PTH above of 300 pg/ml was present in 22.2% of patients. Despite the EBPG and K-DOQI recommendations, only 68.8% of prevalent hemodialysis patients attained a hemoglobin (Hb) above 11 g/dl, 89.4% ferritin levels above 100 ng/ml, 66.5 degrees/a a transferrin saturation index (TSI) above 20%, and 61.1% met all three objectives. In summary, this first cross-sectional analysis has allowed us to know in detail the standard practice in multiple aspects of management of HD population in Spain. It has also established clear differences in the prevalence of cardiovascular disease and risk factors from the US registries. Last but not least we have identified therapeutic opportunities to improve the course and prognosis of our patients.

The beneficial effects of intervention in early renal disease

In renal disease, anaemia is a risk factor for cardiovascular disease (CVD), such as left ventricular hypertrophy (LVH), in both dialysis patients and patients with early renal disease. During the past decade, many studies have showed that partial correction of anaemia leads to partial regression of LVH in hypertensive and normotensive dialysis patients. Several reports support the pre-dialysis use of epoetin. Evidence of cardiovascular risk reduction with epoetin treatment in pre-dialysis patients is growing. For example, in an open, prospective study of epoetin in pre-dialysis patients, an increase in mean haemoglobin of 2.7 g/dl was accompanied by a decrease in left ventricular mass index in almost all patients. This regression, obtained in the absence of improved blood pressure (BP) control, confirms the role of anaemia in the genesis of LVH. These results have been confirmed in two recent studies. Risk reduction strategies (i.e. BP control, lipid lowering, smoking cessation, anaemia correction) from the earliest stages of renal disease may facilitate the prevention of cardiovascular conditions such as LVH in chronic renal failure (CRF) patients. Indeed, if all the well recognized risk factors (including anaemia) are aggressively identified and treated, then long-term reductions in cardiovascular morbidity and mortality should be achieved. In conclusion, preliminary studies show reversal of hypertrophy after correction of renal anaemia with epoetin. Extrapolation of results from studies in CRF suggests the use of earlier treatment of anaemia to maximize cardiovascular benefits. Further studies of the cardiovascular benefits of earlier epoetin intervention in early renal disease are indicated.

Cardiovascular effects of recombinant human erythropoietin in predialysis patients

Treatment with recombinant human erythropoietin (rHuEPO) has solved the problem of anemia in patients on dialysis. However, its application to predialysis patients has raised some doubts about its effects on the progression of renal disease and on blood pressure (BP) and hemodynamic regulation. We have prospectively studied over at least 6 months a group of 11 predialysis patients receiving rHuEPO treatment (initial dose, 1,000 U subcutaneously three times a week). Clinical assessment and biochemical and hematologic measurements were made once every 2 weeks. Twenty-four-hour ambulatory BP monitoring, echocardiography, and determination of neurohumoral mediators of hemodynamics were performed once every 3 months. An adequate hematologic response was found (hemoglobin, 11.7 +/- 0.4 g/dL v 9 +/- 0.3 g/dL) without changes in the progression of renal disease. A decrease in cardiac output and an increase in total peripheral resistance was seen as anemia improved. A trend toward decreased left ventricular (LV) thickness and a significant decrease in LV mass index (from 178.2 +/- 20.6 g/m2 to 147.3 +/- 20.6 g/m2) were observed. Blood pressure control did not improve; moreover, in some patients an increase in systolic values was detected by ambulatory BP. Casual BP remained seemingly stable. Sequential determinations of neurohumoral mediators of hemodynamic substances (endothelin, renin, norepinephrine, epinephrine, dopamine) failed to explain these results. Ambulatory BP reveals a worse control in some patients who were previously hypertensive and confirms the utility of this technique in the assessment of patients under erythropoietin treatment. The trend toward LV hypertrophy regression without improved BP control confirms the role of anemia among the multiple factors leading to LV hypertrophy in end-stage renal disease (ESRD), and opens therapeutic possibilities. Better control of BP may avoid a potential offsetting of beneficial effects that correcting anemia would have on the cardiovascular system.