Finerenone: From the Mechanism of Action to Clinical Use in Kidney Disease

Diabetic kidney disease is a frequent microvascular complication of diabetes and is currently the leading cause of chronic kidney disease and end-stage kidney disease worldwide. Although the prevalence of other complications of diabetes is falling, the number of diabetic patients with end-stage kidney disease in need of kidney replacement therapy is rising. In addition, these patients have extremely high cardiovascular risk. It is more than evident that there is a high unmet treatment need in patients with diabetic kidney disease. Finerenone is a novel nonsteroidal mineralocorticoid receptor antagonist used for treating diabetic kidney disease. It has predominant anti-fibrotic and anti-inflammatory effects and exhibits several renal and cardiac protective effects. This review article summarizes the current knowledge and future prospects of finerenone in treating patients with kidney disease.

Subclinical atherosclerosis in patients with relapsing-remitting multiple sclerosis

BACKGROUND

Multiple sclerosis is an inflammatory disorder of the central nervous system. Inflammation may create high susceptibility to subclinical atherosclerosis. The purpose of this study was to compare subclinical atherosclerosis and the role of inflammatory cytokines between the group of patients with relapsing-remitting multiple sclerosis (RRMS) and healthy controls matched for age and sex.

METHODS

The study group consisted of 112 non-diabetic and non-hypertensive RRMS patients treated with disease modifying drugs (DMD) and the control group was composed of 51 healthy subjects. The common carotid artery (CCA) intima media thickness (IMT) was investigated. Serum levels of risk factors for atherosclerosis and inflammatory cytokines were also determined.

RESULTS

The mean CCA IMT (0.572 ± 0.131 mm vs. 0.571 ± 0.114 mm) did not differ (p > 0.05) between patients and controls. The RRMS patients' CCA IMT was significantly correlated with serum interleukin 6 (IL-6) (p = 0.027), high-sensitivity C-reactive protein (hs-CRP) (p = 0.027), cystatin C (p < 0.0005), glucose (p = 0.031), cholesterol (p = 0.008), LDL (p = 0.021), erythrocyte sedimentation rate (p = 0.001) and triglyceride (p = 0.018) level. We fitted generalized linear models in order to assess the relationship between CCA IMT and IL‑6 with adjustment for sex and age. The obtained results showed that adjusted for age (p < 0.001) and sex (p = 0.048) IL‑6 serum levels statistically significantly (p = 0.009) predict CCA IMT only in the RRMS group.

CONCLUSION

The findings of the present study suggest that when treated with DMD RRMS might not be an independent risk factor for early atherosclerosis presenting with arterial wall thickening; however, the results suggest a significant association of IL‑6 serum levels with CCA IMT only in the RRMS group.

The Role of Oxidative Stress in Kidney Injury

Acute kidney injury and chronic kidney disease are among the most common non-communicable diseases in the developed world, with increasing prevalence. Patients with acute kidney injury are at an increased risk of developing chronic kidney disease. One of kidney injury's most common clinical sequelae is increased cardiovascular morbidity and mortality. In recent years, new insights into the pathophysiology of renal damage have been made. Oxidative stress is the imbalance favoring the increased generation of ROS and/or reduced body's innate antioxidant defense mechanisms and is of pivotal importance, not only in the development and progression of kidney disease but also in understanding the enhanced cardiovascular risk in these patients. This article summarizes and emphasizes the role of oxidative stress in acute kidney injury, various forms of chronic kidney disease, and also in patients on renal replacement therapy (hemodialysis, peritoneal dialysis, and after kidney transplant). Additionally, the role of oxidative stress in the development of drug-related nephrotoxicity and also in the development after exposure to various environmental and occupational pollutants is presented.

Higher Body Mass Index is associated with increased arterial stiffness prior to target organ damage: a cross-sectional cohort study

BACKGROUND

Obesity is associated with several neurohumoral changes that play an essential role in organ damage. Increased arterial stiffness causes functional vessel wall changes and can therefore lead to accelerated target organ damage as well. Whether obesity causes an independent increase in central arterial stiffness is, however, not yet fully known.

METHODS

One hundred thirty-three patients (63.2% male) were included. Body Mass Index (BMI) was defined as body weight in kilograms, divided by the square of body height in meters. Chronic Kidney Disease Epidemiology Collaboration creatinine 2009 equation was used to estimate the glomerular filtration rate (eGFR). Non-invasive applanation tonometry was used for arterial stiffness measurements (Sphygmocor Atcor Medical, Sydney, Australia). All patients underwent coronarography.

RESULTS

The mean age of our patients was 65.0 ± 9.2 years. Their mean BMI was 28.5 ± 4.4 kg/m2, eGFR 75.5 ± 17.2 ml/min/1.73 m2 and ankle-brachial index (ABI) 1.0 ± 0.1. Their arterial stiffness measurements showed mean carotid-femoral pulse wave velocity (cfPWV) 10.3 ± 2.7 m/s, subendocardial viability ratio (SEVR) 164.4 ± 35.0%, and pulse pressure (PP) 47.8 ± 14.5 mmHg. Spearman's correlation test revealed a statistically significant correlation between BMI and SEVR (r = -0.193; p = 0.026), BMI and cfPWV (r = 0.417; p < 0.001) and between BMI and PP (r = 0.227; p = 0.009). Multiple regression analysis confirmed an independent connection between BMI and cfPWV (B = 0.303; p < 0.001) and between BMI and SEVR (B = -0.186; p = 0.040). There was no association between BMI and kidney function, ABI, or coronary artery disease.

CONCLUSION

Increased BMI is independently associated with augmented central arterial stiffness and reduced subendocardial perfusion but not with coronary artery disease, kidney function, or ABI.

Atherosclerosis and Epigenetic Modifications in Chronic Kidney Disease

Chronic kidney disease (CKD) is one of the most common chronic diseases worldwide, with prevalence currently projected at 10% and rising. Cardiovascular disease is the leading cause of morbidity and mortality in CKD patients and is integrally linked with atherogenesis and vascular stiffness. Estimated glomerular filtration rate and the level of proteinuria are not only markers of kidney function but of cardiovascular risk, as well. Despite the efforts, CKD patients still experience excessive cardiovascular burden. MicroRNAs (miRNAs) are small (18-24 nucleotides), single-stranded non-coding RNAs that regulate gene expression by blocking messenger RNA (mRNA) translation and initiating degradation of mRNA. Studies have confirmed the imperative role of miRNA dysregulation in the pathophysiology of several diseases, including atherosclerosis and CKD. This article summarizes what is currently known about the role of miRNAs in CKD patients.

Chronic Kidney Disease and Obesity

There is a pandemic of obesity worldwide and in Europe up to 30% of the adult population is already obese. Obesity is strongly related to the risk of CKD, progression of CKD, and end-stage renal disease (ESRD), also after adjustment for age, sex, race, smoking status, comorbidities, and laboratory tests. In the general population, obesity increases the risk of death. In nondialysis-dependent CKD patients, the association between body mass index and weight with mortality is controversial. In ESRD patients, obesity is paradoxically associated with better survival. There are only a few studies investigating changes in weight in these patients and in most weight loss was associated with higher mortality. However, it is not clear if weight change was intentional or unintentional and this is an important limitation of these studies. Management of obesity includes life-style interventions, bariatric surgery, and pharmacotherapy. In the last 2 years, a long-acting glucagon-like peptide-1 (GLP-1) receptor agonist and GLP-1 and glucose-dependent insulinotropic polypeptide receptor agonist were shown to be effective in managing weight loss in non-CKD patients, but we are awaiting results of more definitive studies in CKD patients.

Physicians' responsibility toward environmental degradation and climate change: A position paper of the European Federation of Internal Medicine

The current data on climate change and environmental degradation are dramatic. The consequences of these changes are already having a significant impact on people's health. Physicians - as advocates of the patients, but also as citizens - have an ethical obligation to be involved in efforts to stop these changes. The European Federation of Internal Medicine (EFIM) strongly encourages the Internal Medicine societies and internists across Europe to play an active role in matters related to climate change and environmental degradation. At a national level, this includes advocating the adoption of measures that reduce greenhouse gas (GHG) emissions and environmental degradation and contributing to policy decisions related to these issues. At a hospital level and in clinical practice, supporting actions by the health sector to reduce its ecological footprint is vital. At the level of EFIM and its associated internal societies, promoting educational activities and developing a toolkit to prepare internists to better care for citizens who suffer from the consequences of climate change. In addition to advocating and implementing effective actions to reduce the ecological footprint of the health industry, recommending the introduction of these themes in scientific programs of Internal Medicine meetings and congresses and the pre- and postgraduate medical training. At a personal level, internists must be active agents in advocating sustainable practices for the environment, increasing the awareness of the community about the health risks of climate change and environmental degradation, and being role models in the adoption of environmentally friendly behaviour.

MO728: Association of Interleukin-6 with Subendocardial Viability Ratio in Hemodialysis Patients

BACKGROUND AND AIMS

Inflammation is an important process in the pathogenesis of atherosclerosis, and chronic kidney disease (CKD) is recognized as a proinflammatory state. Interleukin-6 (IL-6) is associated with cardiovascular events and also predicts mortality in individuals with CKD patients.

The subendocardial viability ratio (SEVR) is one of the pulse wave analysis parameters and represents a non-invasive measure of coronary perfusion. In a non-dialysis CKD population, we previously reported about the prognostic value of SEVR for cardiovascular outcome in these patients.

The aim of this study was to investigate the association between inflammatory markers IL-6, tumour necrosis factor-α (TNF-α), high-sensitive C-reactive protein (hsCRP) and SEVR in CKD patients undergoing maintenance hemodialysis (HD).

METHOD

In a cross-sectional study, we enrolled only HD patients. SEVR was assessed using a generalized transfer function applied to the radial artery pressure wave form (Sphygmocor, Atcor Medical, Sydney, Australia). Plasma IL-6, TNF-α and hsCRP were measured by an enzyme-linked immunosorbent assay.

RESULTS

A total of 40 HD patients (mean age 65.2 ± 11.8 years, 72.5% male) were included. Other descriptive parameters are presented in Table 1. A statistically significant correlation was found between SEVR and IL-6 (r = 0.379; P = 0.016), but not between SEVR and TNF-α (P = 0.195), nor between SEVR and hsCRP (P = 0.686).

In a multivariate adjusted model with SEVR as dependent variable and IL-6, TNF-α and hsCRP as independent variables we found a statistically significant association only between SEVR and IL-6 (β = 0.393; P = 0.017).

CONCLUSION

This study suggests an association between IL-6 and SEVR in HD patients.

MO931: Serum Uric AcidA Marker of Malnutrition and Mortality in Patients Undergoing Maintenance Haemodialysis

BACKGROUND AND AIMS

Malnutrition in patients on maintenance haemodialysis (HD) develops along different pathways, and factors contributing to the development of malnutrition may be categorized as of iatrogenic and non-iatrogenic origins. Iatrogenic factors are an inadvertent consequence of dialysis for HD patients (e.g. removal of uremic solutes), whereas non-iatrogenic factors develop spontaneously from different factors accompanying the progression of kidney disease but are not related to the primary treatment (e.g. low dietary energy and protein intake). Malnutrition is prevalent in 28%–54% HD patients and is an important risk factor for mortality. The aim of our study was to investigate the impact of serum uric acid (SUA) and other non-invasive markers of malnutrition on the survival of maintenance HD patients.

METHOD

We performed a study on 77 HD patients without malignant disease who were observed from January 2016 until their death or January 2021. Their median age was 63.0 (IQR 19) years, and their dialysis vintage was 1449 (IQR 1848) days. We recorded past medical history, laboratory tests and basic demographic data and performed bioelectrical impedance analysis with BodyStat (BodyStat Ltd). Patients who were at risk for malnutrition, based on nutrition screening tools, received oral nutritional supplements (ONS). SUA was measured every 2 months and the mean value was used for analysis. Kaplan–Meier survival analysis and Cox's regression were performed.

RESULTS

Included patients (51.9% males) had diabetes mellitus (33.8%), arterial hypertension (87.0%), ischemic heart disease (24.7%), chronic obstructive lung disease (3.9%), liver disease (3.9%) and were smokers (14.3%). They received an ONS in 63.6%. During the observation period, 50.6% of them died. We created tertile groups (low, medium and high) based on mean SUA &lt; 294 μmol/L, 294–337 μmol/L and &gt; 337 μmol/L, respectively. The low group had significantly lower body mass index (BMI) (P = 0.044), total iron binding capacity (TIBC) (P = 0.001), phase angle (P = 0.003) and dry lean mass (DLM) (P = 0.048), however there were no significant differences in prescription of ONS (P = 0.092). Kaplan–Meier survival analysis showed significantly higher mortality for patients in the low tertile group (P = 0.004). In Cox's regression model, SUA remained significant when adjusted for age, sex, BMI and comorbidities (P = 0.026). However, when adjusting for other markers of malnutrition and receiving ONS, only phase angle, albumin, DLM, fat free mass index and TIBC remained statistically significant.

CONCLUSION

Low SUA levels in chronic HD patients are associated with lower survival and can help identify individuals who are at risk for malnutrition. Further studies should be done to guide possible interventions.

MO891: Poor Tolerability of the Standard, Extended, 48h Ambulatory Blood Pressure Monitoring in Haemodialysis Patients

BACKGROUND AND AIMS

Ambulatory blood pressure monitoring (ABPM), extended to 44h or 48h for the diagnosis of hypertension in end-stage kidney disease (ESKD) patients, is recommended by Consensus Documents of the American Society of Nephrology and the European Renal Association. About 10%–20% of individuals in the general population report sleeping problems and other symptoms during 24 h ABPM. Because the longer recording period (44 or 48 h versus 24 h), the notorious sleeping disturbances and the high symptom burden of the ESKD population, the feasibility of the technique may be limited in this population. However, the large-scale tolerability of ABPM in the haemodialysis population, has never been investigated.

METHOD

We performed an international survey of feasibility and tolerability of 48 h ABPM in six centres in three European countries. These centres are led by motivated clinical nephrologists, all members of the EURECA-m working group. 48 h ABPM recording was proposed to a large, representative sample of the whole dialysis population of these centres. Well validated instruments (AAMI/ESH/ISO) were applied in all centres. As recommended by the European Society of Hypertension guidelines, recordings were made at 15-min intervals during the day and 30 min during the night. Reasons for refusal to undergo the test were accurately registered. A tolerability (symptoms) questionnaire and a specific questionnaire for sleep evaluation were administered to all participants who underwent 48h ABPM. Reasons for not completing of the ABPM monitoring were systematically recorded.

RESULTS

In the whole haemodialysis population of participating centres including 735 patients, 440 (60%) were invited to participate in the study. Among these patients, 119 (27%) refused to undergo ABPM recording. Reasons for refusal were fear of discomfort (n = 30, 25%), measurement too long (n = 22, 18%), logistic problems (n = 17, 14%), previous negative experience (n = 13, 11%), clinical reasons (n = 12, 10%), other reasons (n = 25). Among the 321 patients who performed the 48h ABPM recording, 29 (9%) did not complete it and the main reason for interrupting the recording were discomfort [12 patients (41%)], followed by device failure [10 patients (34%)]. Among symptoms developed during the ABPM study, frequent interruption of sleeping because of noise or discomfort was reported by 32% of patients, followed by itching (24%) and pain during the measurements (20%). The detailed list of symptoms, is reported in the Table 1.

CONCLUSION

Overall, about 25% of haemodialysis patients consider 48h ABPM a laborious and discomforting test and prejudicially refuse to undergo it. Among patients who undergo 48h ABPM, itching and interruption of sleeping are complained by about 1/3 of patients. These figures are substantially higher than those reported in studies in the general population and in hypertensive patients and point to peculiar barriers at applying extended ABPM recordings in the haemodialysis population. Studies applying more tolerable instruments and a minimum set of measurements over a shorter time, with a reduced number of measurements overnight, are clinical research priority for extending the use of ABPM in the haemodialysis population.

MO723: Ankle-Brachial Index is Associated with Subendocardial Viability Ratio in Chronic Hemodialysis Patients

BACKGROUND AND AIMS

Ankle-brachial index (ABI) is a marker of peripheral arterial disease and is associated with increased cardiovascular morbidity and mortality. Structural alterations in the arterial walls lead to functional central haemodynamic changes, potentially impacting pulse wave reflection and, consequently, myocardial perfusion.

The aim of this study was to determine the association between ABI and subendocardial viability ratio (SEVR) as a non-invasive measure of coronary perfusion in chronic haemodialysis patients.

METHOD

We measured ABI using an automated non-invasive waveform analysis device (MESI®, Slovenia) and SEVR using applanation tonometry (Sphygmocor, Atcor Medical, Sydney, Australia). All the measurements were performed on a non-dialysis day and SEVR on the non-arteriovenous fistula (non-AVF) hand. ABI was calculated as the ratio between systolic blood pressure on the non-AVF hand and systolic blood pressure on the calves of both legs. Mean ABI of both sides was used in the statistical analysis.

RESULTS

A total of 29 patients (mean age 63.6 ± 10.5 years, 69.0% male) were included. In Table 1, descriptive parameters are presented.

Of those, 4 patients (13.8%) have an ABI &lt;0.9 and the other 25 patients (86.2%) have a normal ABI between 0.9 and 1.3. Using the independent-samples T-test, patients with a lower ABI have a statistically significant lower SEVR compared with patients with normal ABI (109 versus 142%; P = 0.039).

CONCLUSION

Low ABI is independently associated with decreased subendocardial perfusion in chronic haemodialysis patients, suggesting that both methods of ABI and SEVR measurement may reflect an atherosclerotic process in peripheral and coronary arteries.

MO755: Comparison of Techniques for Fluid Status Assessment in Chronic Hemodialysis Patients

BACKGROUND AND AIMS

Several methods have been developed to assess hydration status in chronic haemodialysis (HD) patients. The aim of this study was to compare multifrequency body bioimpedance spectroscopy (MBIS) with ultrasound lung comet scores (ULCs) and inferior vena cava diameters (IVCD) using ultrasound to estimate dry weight on the non-dialysis day.

METHOD

We evaluated MBIS, ULCs at 28 typical sites and IVCD during expiration in 40 HD patients. All measurements were performed on a non-dialysis day. For MBIS measurement, we used the Body Composition Monitor (Fresenius Medical Care, Bad Homburg, Germany), and for ULCs and IVCD, we used an ultrasound device (Esaote MyLabOmega, Genoa, Italy). Overhydration was defined as &gt; 2L with MBIS, &gt; 15 ULCs, and &gt; 11.5 mm/m2 IVCD.

RESULTS

Mean age of patients was 65 (40–89) years, and 29 (72.5%) were men. Other descriptive data are in Table 1. We found a significant correlation between MBIS and ULCs (r = 0.464, P &lt;0.003) and between MBIS and IVCD (r = 0.589, P &lt;0.001). Multiple regression analysis with the MBIS as the dependent variable and ULCs, IVCD, albumin and haemoglobin as independent variables confirmed a statistically significant relationship between MBIS and IVCD (β = 0.436; P &lt; 0.001). According to the overhydration criteria, 14 (35%) patients were overhydrated by MBIS, 8 (20%) patients by ULCs and 9 (22.5%) patients by IVCD. Only 4 (10%) patients met overhydration criteria simultaneously by all three methods (MBIS, ULCs and IVCD).

CONCLUSION

All methods were able to describe overhydration in HD patients on a non-dialysis day. The MBIS was associated with the IVCD.

The Role of Vascular Lesions in Diabetes Across a Spectrum of Clinical Kidney Disease

Introduction

The clinical-histologic correlation in diabetic nephropathy is not completely known.

Methods

We analyzed nephrectomy specimens from 90 patients with diabetes and diverse degrees of proteinuria and glomerular filtration rate (GFR).

Results

Thirty-six (40%) subjects had normoalbuminuria, 33 (37%) microalbuminuria, and 21 (23%) non-nephrotic proteinuria. Mean estimated GFR (eGFR) was 65±23 (40% <60 ml/min per 1.73 m²). About 170 glomeruli per patient were analyzed, and all samples included vascular tissue. Six subjects (7%) were classified in diabetic nephropathy class I, 61 (68%) in class II-a, 13 (14%) in class II-b, 9 (10%) class III, and 1 (1%) in class IV. Eighty percent to 90% of those with normoalbuminuria or microalbuminuria were classified in class II-a or II-b and <10% in class III; 52% of those with proteinuria were in class II-a, 15% in class II-b, and 19% in class III. Nodular sclerosis (57%) and mesangial expansion (15%) were more frequent in cases with proteinuria than in normoalbuminuria (28% and 8%; P = 0.028 and 0.017). About 20% to 30% of all cases, regardless the level of albuminuria or proteinuria or the histologic class had tubular atrophy, interstitial fibrosis, or inflammation in >10% to 20% of the sample. Moderate hyalinosis and arteriolar sclerosis were observed in 80% to 100% of cases with normoalbuminuria, microalbuminuria, proteinuria, as well as in class I, II, or III.

Conclusions

Weak correspondence between analytical parameters and kidney histology was found. Thus, disease may progress undetected from the early clinical stages of the disease. Finally, vascular damage was a very common finding, which highlights the role of ischemic intrarenal disease in diabetes.

Accelerated atherosclerosis in premenopausal women with rheumatoid arthritis - 15-year follow-up

Rheumatoid arthritis (RA) is a chronic inflammatory disease associated with increased mortality and morbidity due to the higher cardiovascular risk in these patients. Traditional risk factors are not the only answer for the accelerated atherosclerosis. In a long-term prospective study, we investigated the relationship between asymptomatic atherosclerosis and traditional risk factors and inflammatory markers in patients with RA and matched healthy controls. We studied the laboratory test results, the concentrations of inflammatory mediators, matrix metalloproteases (MMP), and inflammation markers in a total of 70 (60 at follow-up) premenopausal healthy women with RA and 40 (34 at follow-up) matched controls. We used the B-mode ultrasound imaging of carotid arteries for the detection of asymptomatic atherosclerosis. Correlation with different factors was evaluated. Statistically significant higher values of inflammatory markers such as selective adhesion molecules ICAM and VCAM, interleukin 6 (IL-6), tumor necrosis factor alpha (TNF-alpha), and MMP-3 in the patients group were found in the follow-up study. More plaques were found in the patients group (42.4% vs. 12.9%; p=0.005), as compared with the controls group. The patients had also higher values of cIMT (p=0.001). Using bivariate regression analysis only VCAM was found as a prognostic factor for plaque occurrence (r= 0. 341, p=0.016), but not for cIMT (r= -0.130, p=0.327) in premenopausal female patients with RA after the follow-up. Therefore, asymptomatic atherosclerosis is accelerated in premenopausal women with RA. The results of our follow-up study showed the association between inflammation and accelerated atherosclerosis. Furthermore, VCAM was found to have a statistically significant correlation with plaque occurrence in these patients.

Hyperuricemia, the heart, and the kidneys - to treat or not to treat?

Background

Hyperuricemia is a state in which the serum levels of uric acid are elevated. As such it has a pronounced effect on vascular and renal function with their consequences, while also showing some antioxidant effects that show to be beneficial.

Summary

Hyperuricemia has shown to have a J-shaped relationship with mortality, is frequently associated with development and progression of heart and kidney disease, and is correlated with malnutrition-inflammation-atherosclerosis syndrome, although several Mendelian studies have failed to show an association with morbidity and mortality. Hyperuricemia is usually associated with gout flares and tophi development but can also present as asymptomatic hyperuricemia. It is still uncertain whether asymptomatic hyperuricemia is an independent risk factor for cardiovascular or renal disease and as such its treatment is questionable.

Key messages

Some possible tools for future decision making are the use of noninvasive techniques such as pulse wave analysis, urinary sediment analysis, and joint ultrasound, which could help identify individuals with asymptomatic hyperuricemia that could benefit from urate lowering therapy most.

Diabetic patients with chronic kidney disease: Non-invasive assessment of cardiovascular risk

The prevalence and burden of diabetes mellitus and chronic kidney disease on global health and socioeconomic development is already heavy and still rising. Diabetes mellitus by itself is linked to adverse cardiovascular events, and the presence of concomitant chronic kidney disease further amplifies cardiovascular risk. The culmination of traditional (male gender, smoking, advanced age, obesity, arterial hypertension and dyslipidemia) and non-traditional risk factors (anemia, inflammation, proteinuria, volume overload, mineral metabolism abnormalities, oxidative stress, etc.) contributes to advanced atherosclerosis and increased cardiovascular risk. To decrease the morbidity and mortality of these patients due to cardiovascular causes, timely and efficient cardiovascular risk assessment is of huge importance. Cardiovascular risk assessment can be based on laboratory parameters, imaging techniques, arterial stiffness parameters, ankle-brachial index and 24 h blood pressure measurements. Newer methods include epigenetic markers, soluble adhesion molecules, cytokines and markers of oxidative stress. In this review, the authors present several non-invasive methods of cardiovascular risk assessment in patients with diabetes mellitus and chronic kidney disease.

Statin-Associated Necrotizing Myopathy Leading to Acute Kidney Injury: A Case Report

Statins or 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors are a mainstay of cardiovascular disease therapy. In addition to their lipid-lowering capabilities, they exhibit several pleiotropic effects. Their adverse reactions such as myalgias are not uncommon, but in rare cases, the resulting rhabdomyolysis can be fatal. Recently, more insight has been brought into the pathogenesis of statin-induced rhabdomyolysis, and immune-mediated necrotizing myopathies are diagnosed more frequently. We present a case of a female patient who was on chronic rosuvastatin therapy and developed necrotizing myopathy. The disease progressed to acute kidney and liver injury. We discontinued the drug, started supportive measures, and initiated renal replacement therapy with a high cutoff dialysis membrane once. Her recovery was prompt, with a normal control electromyography 2 weeks after discharge.

Mineralocorticoid Receptor Antagonists in Diabetic Kidney Disease

Diabetes mellitus is a global health issue and main cause of chronic kidney disease. Both diseases are also linked through high cardiovascular morbidity and mortality. Diabetic kidney disease (DKD) is present in up to 40% of diabetic patients; therefore, prevention and treatment of DKD are of utmost importance. Much research has been dedicated to the optimization of DKD treatment. In the last few years, mineralocorticoid receptor antagonists (MRA) have experienced a renaissance in this field with the development of non-steroidal MRA. Steroidal MRA have known cardiorenal benefits, but their use is limited by side effects, especially hyperkalemia. Non-steroidal MRA still block the damaging effects of mineralocorticoid receptor overactivation (extracellular fluid volume expansion, inflammation, fibrosis), but with fewer side effects (hormonal, hyperkalemia) than steroidal MRA. This review article summarizes the current knowledge and newer research conducted on MRA in DKD.

MO820INTRACELLULAR WATER BEFORE HEMODIALYSIS PREDICTS ALL-CAUSE MORTALITY IN HEMODIALYSIS PATIENTS

Background and Aims

Several factors may be responsible for the increased mortality in dialysis patients, but volume overload is considered among the main mechanisms of this association. Volume status is usually estimated using clinical criteria, i.e., patien's signs and symptoms, peridialytic blood pressure measurements, and intradialytic hemodynamic instability. Bioimpedance analysis (BIA) is another way to measure volume status in dialysis patients. BIA can measure overhydration (OH), extracellular water (ECW), intracellular water (ICW) and ECW/ICW ratio.

The aim of our study was to analyze the role of BIA parameters before and after hemodialysis (HD) on all-cause mortality.

Method

Eighty-three patients (mean age 64.2 years; 51 men) on maintenance HD were included. BIA was performed and blood pressure was measured before and after the HD session. Patients were followed for assigned time, until transplantation or death. The mean follow-up time was 1181±564 days.

Results

Descriptive statistics of our patients are shown in Table 1. During the follow-up period, 6 (7.2%) patients were transplanted and 39 (47%) patients died. Univariate Cox regression analysis showed that only ICW before HD was a significant predictor of all-cause mortality (HR=1.089; 95%CI: 1.01-1.17, p=0.018). OH, ECW, ECW/ICW ratio before and after HD and ICW after HD were not associated with survival. In multivariate Cox regression analysis including ICW before dialysis, age, dialysis vintage, pulse pressure before HD, hemoglobin, CRP and serum albumin, ICW before dialysis was an independent predictor of all-cause mortality (HR=1.102; 95%CI: 1.01-1.20, p=0.029) (Table 2).

Conclusion

ICW before HD predicts all-cause mortality in HD patients.

MO147ASSOCIATION OF CHA2DS2-VASC SCORE WITH CAROTID-FEMORAL PULSE WAVE VELOCITY IN CHRONIC KIDNEY DISEASE PATIENTS

Background and Aims

Chronic kidney disease (CKD) patients suffer from high cardiovascular morbidity and mortality. Arterial stiffness is an important parameter for the evaluation of cardiovascular risk. Carotid-femoral pulse wave velocity (cfPWV) is the gold standard measure for the assessment of arterial stiffness. CHA2DS2-VASc score was originally used to predict cerebral infarction in patients with atrial fibrillation (AF). However, it is also useful in predicting outcome in different cardiovascular conditions, independent of the presence of AF. Therefore, the aim of our research was to assess the association of CHA2DS2-VASc score with cfPWV in CKD patients.

Method

Eighty-seven non-dialysis CKD patients from our outpatient clinic were included. At the time of inclusion, medical history data and standard blood results were collected, CHA2DS2-VASc score was calculated, cfPWV measurements (SphygmoCor System) were done. Correlation between CHA2DS2-VASc score and cfPWV was assessed. Multiple regression analysis with cfPWV as dependent and CHA2DS2-VASc score, eGFR, urinary albumin/creatinine, haemoglobin, high sensitivity CRP, serum calcium, phosphate and intact PTH as independent variables was performed. Additionally, patients were divided into two groups according to median value of CHA2DS2-VASc score (group 1: CHA2DS2-VASc score ≤2, group 2: CHA2DS2-VASc score &gt;2). Data of both groups were compared by t-test or Mann-Whitney test.

Results

CHA2DS2-VASc score correlated with cfPWV (r=0.380, p=0.001). In multiple regression analysis only CHA2DS2-VASc score was significantly associated with cfPWV (p=0.001). Data of both groups of patients divided according to median value of CHA2DS2-VASc score are presented in table 1. cfPWV was significantly higher in group 2 (13.40±3.50 vs 10.46±2.93, p=0.001). Groups of patients also differed significantly in age, presence of diabetes, eGFR and serum phosphate.

Conclusion

CHA2DS2-VASc score is associated with cfPWV in CKD patients. Patients with a higher CHA2DS2-VASc score have stiffer arteries.

MO159CHA2DS2-VASC SCORE AS A PREDICTOR OF CARDIOVASCULAR MORTALITY IN CHRONIC KIDNEY DISEASE PATIENTS

Background and Aims

Cardiovascular mortality is high in chronic kidney disease (CKD) patients. Recognizing patients with higher cardiovascular risk might help in their treatment. CHA2DS2-VASc score was originally used to predict cerebral infarction in patients with atrial fibrillation (AF). However, it is also useful in predicting outcome in different cardiovascular conditions, independent of the presence of AF. Therefore, the aim of our research was to assess the role of CHA2DS2-VASc score in cardiovascular mortality in CKD patients.

Method

Eighty-seven non-dialysis CKD patients from our outpatient clinic were included. At the time of inclusion, medical history data and standard blood results were collected and CHA2DS2-VASc score was calculated. Patients were followed for assigned time or until their death. Mean follow-up time was 1696.45±564.60 days.

Results

Descriptive statistics of our patients are presented in table 1. During follow-up 11 patients suffered from cardiovascular death. Univariate Cox regression analysis showed that CHA2DS2-VASc score is a significant predictor of cardiovascular mortality (HR: 2.19, CI: 1.42-3.37, p=0.001). In multivariate Cox regression analysis in which CHA2DS2-VASc score, serum creatinine, urinary albumin/creatinine, haemoglobin, high sensitivity CRP and intact PTH were included, CHA2DS2-VASc score was an independent predictor of cardiovascular mortality (HR: 2.04, CI: 1.20-3.45, p=0.008) (table 2).

Conclusion

CHA2DS2-VASc score is a simple and quick way to identify cardiovascular risk in CKD patients.

Polymorphism in the GATM Locus Associated with Dialysis-Independent Chronic Kidney Disease but Not Dialysis-Dependent Kidney Failure

The ten most statistically significant estimated glomerular filtration rate (eGFRcrea)-associated loci from genome-wide association studies (GWAs) are tested for associations with chronic kidney disease (CKD) in 208 patients, including dialysis-independent CKD and dialysis-dependent end-stage renal disease (kidney failure). The allele A of intergenic SNP rs2453533 (near GATM) is more frequent in dialysis-independent CKD patients (n = 135, adjusted p = 0.020) but not dialysis-dependent kidney failure patients (n = 73) compared to healthy controls (n = 309). The allele C of intronic SNP rs4293393 (UMOD) is more frequent in healthy controls (adjusted p = 0.042) than in CKD patients. The Allele T of intronic SNP rs9895661 (BCAS3) is associated with decreased eGFRcys (adjusted p = 0.001) and eGFRcrea (adjusted p = 0.017). Our results provide further evidence of a genetic difference between dialysis-dialysis-independent CKD and dialysis-dependent kidney failure, and add the GATM gene locus to the list of loci associated only with dialysis-independent CKD. GATM risk allele carriers in the dialysis-independent group may have a genetic susceptibility to higher creatinine production rather than increased serum creatinine due to kidney malfunction, and therefore, do not progress to dialysis-dependent kidney failure. When using eGFRcrea for CKD diagnosis, physicians might benefit from information about creatinine-increasing loci.

CHA2DS2-VASc Score as a Predictor of Cardiovascular and All-Cause Mortality in Chronic Kidney Disease Patients

INTRODUCTION

Chronic kidney disease (CKD) is a risk factor for cardiovascular and all-cause mortality. Recognition of high-risk patients is important and could lead to a different approach and better treatment. The CHA2DS2-VASc score was originally used to predict cerebral infarction in patients with atrial fibrillation (AF), but it is also a useful predictor of outcome in other cardiovascular conditions, independent of AF. Therefore, the aim of our research was to assess the role of CHA2DS2-VASc score in predicting cardiovascular and all-cause mortality in CKD patients.

METHODS

Stable nondialysis CKD patients were included. At the time of inclusion, medical history data and standard blood results were collected and CHA2DS2-VASc score was calculated. Patients were followed till the same end date, until kidney transplantation or until their death.

RESULTS

Eighty-seven CKD patients were included (60.3 ± 12.8 years, 66% male). Mean follow-up time was 1,696.5 ± 564.6 days. During the follow-up, 21 patients died and 11 because of cardiovascular reasons. Univariate Cox regression analysis showed that CHA2DS2-VASc score is a significant predictor of cardiovascular and all-cause mortality. In multivariate Cox regression analysis, in which CHA2DS2-VASc score, serum creatinine, urinary albumin/creatinine, hemoglobin, high-sensitivity C-reactive protein, and intact parathyroid hormone were included, CHA2DS2-VASc score was an independent predictor of cardiovascular (HR: 2.04, CI: 1.20-3.45, p = 0.008) and all-cause mortality (HR: 2.06, CI: 1.43-2.97, p = 0.001). The same was true after adding total cholesterol, triglycerides, and smoking status to both the analyses.

CONCLUSION

The CHA2DS2-VASc score is a simple, practical, and quick way to identify the risk for cardiovascular and all-cause mortality in CKD patients.

Early Detection of Arteriovenous Fistula Stenosis in Hemodialysis Patients through Routine Measurements of Dialysis Dose (Kt/V)

BACKGROUND

Monitoring of arteriovenous (AV) fistula to detect hemodynamically important stenosis is crucial for the prevention of AV fistula thrombosis. The aim of our study was to analyze the importance of dialysis dose (Kt/V) during online postdilution hemodiafiltration (HDF) for early detection of AV fistula stenosis.

METHODS

Hemodialysis patients with AV fistula were included in this study. We compared a group of 44 patients who have undergone fistulography and subsequently percutaneous transluminal angioplasty (PTA) of significant AV fistula stenosis (active group) with a group of 44 age- and sex-matched patients without PTA (control group). Observational time in both groups was the same.

RESULTS

All patients had postdilution online HDF using a F5008 dialysis machine, which can measure online single-pool Kt/V. All data were analyzed during the performance of 2056 HDF procedures. In the active group, we found statistically significantly lower values of Kt/V, all 8 weeks before PTA. In the active group, there was a significant improvement in Kt/V in the first (p < 0.001) and second week (p = 0.049) after PTA. Three and 8 weeks after PTA, we did not find any statistically significant difference in Kt/V between both groups (p = 0.114; p = 0.058). Patients in the active group had statistically significantly lower substitution volumes and blood pump flow rates during HDF over the whole observation period before and after PTA. In contrast, there were no differences in venous pressure in the dialysis circuit between both groups throughout the observation period.

CONCLUSION

In hemodialysis patients with AV fistula, treated with online HDF, routine measurements of Kt/V during each HDF are a beneficial, quick, and straightforward method for early detection of hemodynamically significant AV fistula stenosis.

Review on Inflammation Markers in Chronic Kidney Disease

Chronic kidney disease (CKD) is one of the major health problems of the modern age. It represents an important public health challenge with an ever-lasting rising prevalence, which reached almost 700 million by the year 2017. Therefore, it is very important to identify patients at risk for CKD development and discover risk factors that cause the progression of the disease. Several studies have tackled this conundrum in recent years, novel markers have been identified, and new insights into the pathogenesis of CKD have been gained. This review summarizes the evidence on markers of inflammation and their role in the development and progression of CKD. It will focus primarily on cytokines, chemokines, and cell adhesion molecules. Nevertheless, further large, multicenter studies are needed to establish the role of these markers and confirm possible treatment options in everyday clinical practice.

The association between pulse wave analysis, carotid-femoral pulse wave velocity and peripheral arterial disease in patients with ischemic heart disease

INTRODUCTION

Functional changes in peripheral arterial disease (PAD) could play a role in higher cardiovascular risk in these patients.

METHODS

123 patients who underwent elective coronary angiography were included. Ankle-brachial index (ABI) was measured and arterial stiffness parameters were derived with applanation tonometry.

RESULTS

6 patients (4.9%) had a previously known PAD (Rutherford grade I). Mean ABI was 1.04 ± 0.12, mean subendocardial viability ratio (SEVR) 166.6 ± 32.7% and mean carotid-femoral pulse wave velocity (cfPWV) 10.3 ± 2.4 m/s. Most of the patients (n = 81, 65.9%) had coronary artery disease (CAD). There was no difference in ABI among different degrees of CAD. Patients with zero- and three-vessel CAD had significantly lower values of SEVR, compared to patients with one- and two-vessel CAD (159.5 ± 32.9%/158.1 ± 31.5% vs 181.0 ± 35.2%/166.8 ± 27.8%; p = 0.048). No significant difference was observed in cfPWV values. Spearman's correlation test showed an important correlation between ABI and SEVR (r = 0.196; p = 0.037) and between ABI and cfPWV (r = - 0.320; p ≤ 0.001). Multiple regression analysis confirmed an association between cfPWV and ABI (β = - 0.210; p = 0.003), cfPWV and mean arterial pressure (β = 0.064; p < 0.001), cfPWV and age (β = 0.113; p < 0.001) and between cfPWV and body mass index (BMI (β = - 0.195; p = 0.028), but not with arterial hypertension, dyslipidemia, diabetes mellitus or smoking status. SEVR was not statistically significantly associated with ABI using the same multiple regression model.

CONCLUSION

Reduced ABI was associated with increased cfPWV, but not with advanced CAD or decreased SEVR.

P0737THE ASSOCIATION BETWEEN CYSTATIN C AND ARTERIAL STIFFNESS IN NON-CKD PATIENTS

Background and Aims

Serum cystatin C (cysC) is produced by all nucleated cells at a constant rate, is filtered freely by the glomerulus and metabolized after tubular reabsorption. It is influenced less by age, gender and muscle mass compared to serum creatinine. These properties make it an important marker in detecting renal impairment. Arterial stiffness is a hallmark of atherosclerosis and is connected to cardiovascular events and mortality. In patients with chronic kidney disease (CKD), cysC correlates with increased arterial stiffness, but less is known about the association between cysC and arterial stiffness in non-CKD patients.

Method

The study was performed at the University Medical Centre Maribor between October 1st 2018 and January 1st 2020. Basic demographic and laboratory data were recorded. To estimate glomerular filtration rate (eGFR), Chronic Kidney Disease Epidemiology (CKD-EPI) equation was used. Patients with previously diagnosed CKD and/or eGFR ≤ 60 ml/min/1.73m2 at the time of admission, known malignancy, thyroid disease and/or on steroid therapy were not enrolled in the study. Arterial stiffness was measured with applanation tonometry (Sphygmocor®, Australia), carotid-femoral pulse wave velocity (cfPWV) was used as the gold standard of central arterial stiffness and subendocardial viability ratio (SEVR) was used as the marker of myocardial perfusion. SPSS® version 22 was used for statistical analysis.

Results

111 patients (65.8% male, average age 64.3±9.4 years) were included in our study. Most common comorbidities were arterial hypertension (n=86, 77.5%), hyperlipidaemia (n=64, 57.7%) and diabetes mellitus (n=22, 19.8%). Mean creatinine value was 77.7±13.8 μmol/L (range 49-108 μmol/L), mean eGFR was 81.3±9.4 ml/min/1.73m2 (range 62-90 ml/min/1.73m2) and mean value of cysC was 0.94±0.18 mg/L (range 0.67-1.63 mg/L). Mean SEVR value was 165.7±36.1% (range 92-299%) and mean cfPWV value was 10.1±2.4 m/s (range 6.2-16.8 m/s). Significant correlation was found between cysC and SEVR (r=-0.316, p&lt;0.001) and between cysC and cfPWV (r=0.472, p&lt;0.001). Multiple regression analysis of arterial stiffness indices and cysC, age, gender, diabetes mellitus, arterial hypertension, eGFR and hyperlipidemia, showed statistically significant association between cysC and cfPWV (ß=0.220, p=0.038) and cysC and SEVR (ß=-0.278, p=0.017).

Conclusion

Serum cysC is independently associated with increased arterial stiffness, reduced myocardial perfusion and increased cardiovascular risk in non-CKD patients.

P1095USE OF CYTOKINE ADSORBING MEMBRANES IN PATIENTS WITH ACUTE RENAL FAILURE IN INTENSIVE CARE UNITS

Background and Aims

Use of cytokine adsorbents has been proposed as a novel therapeutic approach in sepsis management. Our aim was to evaluate laboratory markers, clinical parameters and SOFA (Sequential Organ Failure Assessment) score in patients who were treated with cytokine adsorbing membrane (CytoSorb®, CytoSorbents Corp. New Jersey, USA) and continuous veno-venous haemodialysis.

Method

We included adult patients with septic shock and acute renal failure. We retrospectively collected laboratory results (leukocytes, thrombocytes, C-reactive protein, procalcitonin, lactate, urea, creatinine, bilirubin, PaO2), clinical parameters (mean arterial pressure (MAP), FiO2, residual diuresis), SOFA score and vasopressor use at the beginning and at the end of the procedure.

Results

We included 69 patients, 51 men, aged 56.6 ± 15 years. 51 patients had 1 procedure, 14 patients had 2 procedures, 3 patients had 3 procedures and 1 patient had 4 procedures. Median time from admission to initiation of procedure was 47 hours, median treatment time was 23.6 hours.

We discovered significant improvement in procalcitonin (35.36 ± 37.33 ng/mL vs. 24.25 ± 31.18 ng/mL; p&lt;0.001), creatinine (345.06 ± 174.65 μmol/L vs. 233.11 ± 108.82 μmol/L; p&lt;0.0001), SOFA score (14.20 ± 2.64 vs. 12.69 ± 3.52; p&lt;0.001) and FiO2 (48.17 ± 21.17 % vs. 44.63 ± 21.45 %; p=0.020).

Patients with more than 1 procedure showed statistically significant reduction in lactate level (5.40 ± 4.74 mmol/L vs. 2.46 ± 1.74 mmol/L; p=0.010) and vasopressin dose (1.26 ± 1.61 vs. 0.88 ± 3.2 IU/h; p=0.022).

Conclusion

We observed potential beneficial effect of adsorptive membrane use in septic patients. According to our results two or more procedures were associated with improved laboratory markers and lower vasopressor requirement.

P1303ASSOCIATION BETWEEN PULSE PRESSURE AND EXTRACELLULAR TO INTRACELLULAR WATER RATIO IN HEMODIALYSIS PATIENTS

Background and Aims

Optimal fluid management is a challenge in patients with end-stage kidney disease (ESRD) on maintenance hemodialysis (HD). Multifrequency bioimpedance spectroscopy (MBIS) is a non-invasive method to estimate body composition, including estimates of extracellular water (ECW) and intracellular water (ICW) and the ratio between both spaces (ECW/ICW). Pulse pressure is a significant risk factor of cardiovascular disease and death in general and dialysis population. Our study aimed to analyse the correlation between systolic, diastolic and pulse pressure with body composition status in ESRD patients before HD.

Method

We performed a retrospective single-centre cohort study in 93 HD patients. The body composition was measured using the portable whole-body MBIS device, Body Composition Monitor-BCM(®) (Fresenius Medical Care, Bad Homburg, Germany). Blood pressure was measured with OMRON monitors.

Results

The mean age of patients was 64 ± 13 years, mean dialysis vintage 63 (1-352) months, 61% were men, all patients had arteriovenous fistula as vascular access. Sixty-nine (74.2%) patients were fluid overload (FO) with &gt; 1.1 L overhydration. Other data are presented in table 1. We found a statistically significant correlation between the pulse pressure and ECW/ICW ratio (r=0.258; P=0.033) in FO patients. In contrast, there was no significant correlation between systolic, diastolic blood pressure and ECW/ICW ratio in FO patients.

Conclusion

Only pulse pressure and not systolic or diastolic blood pressure values measured before HD are associated with ECW/ICW ratio in FO patients.

P1185LUNG COMETS AND EVALUATION OF HYDRATION STATUS IN PERITONEAL DIALYSIS PATIENTS

Background and Aims

Assessment of optimal hydration status in patients with end-stage renal disease (ESRD) on peritoneal dialysis (PD) is a challenge. Multiple diagnostic options to determine hydration status in PD patients are available. Multifrequency bioimpedance spectroscopy (MBIS) is a cheap, simple and non-invasive method of estimating body composition, including estimates of total body water (TBW), extracellular water (ECW), intracellular water (ICW) and the ratio between both spaces (ECW/ICW). Lung ultrasonography (LUS) and lung B-lines (lung comets) can be used for the evaluation of extravascular lung water. Ultrasound evaluation of inferior vena cava (UIVC) provides rapid, non-invasive assessment of a patient's hemodynamic and volume status. N-terminal pro-brain natriuretic peptide (NT-proBNP) is related to fluid status and fluid distribution. The aim of our study was to assess fluid status in PD patients comparing four different methods: MBIS, LUS, UIVC and NT-proBNP.

Method

We performed a single-centre cohort study in 19 PD patients. The body composition was measured using the portable whole-body MBIS device, Body Composition Monitor-BCM(®) (Fresenius Medical Care, Bad Homburg, Germany), LUS with portable US device (VScan, General Electrics Corporate), UIVC index with SonoSite US device. NT-proBNP was measured in a one-step sandwich chemiluminescent immunoassay (Dimension Vista® System 1500, Siemens Healthcare Diagnostics Inc., Newark, NJ, USA).

Results

The mean age of patients was 54 ± 10 years, mean dialysis vintage 53 (10-194) months, 63% were men. Thirteen (68.4%) patients had fluid overload (FO) &gt; 1.1 L. Data of patients are presented in table 1. We found a statistically significant correlation between the number of lung comets and ECW/ICW ratio (r = 0.496, P = 0.031) and NT-proBNP (r = 0.759, P &lt; 0.0001). In contrast, there was no significant correlation between the number of lung comets and UIVC (r = 0.221, P &lt; 0.364).

Conclusion

According to our results, LUS with lung comets, MBIS with ECW/ICW ratio and NT-proBNP are useful and complementary methods for evaluation of fluid status in PD patients.

SGLT-2 inhibitors and GLP-1 receptor agonists for nephroprotection and cardioprotection in patients with diabetes mellitus and chronic kidney disease. A consensus statement by the EURECA-m and the DIABESITY working groups of the ERA-EDTA

Chronic kidney disease (CKD) in patients with diabetes mellitus (DM) is a major problem of public health. Currently, many of these patients experience progression of cardiovascular and renal disease, even when receiving optimal treatment. In previous years, several new drug classes for the treatment of type 2 DM have emerged, including inhibitors of renal sodium-glucose co-transporter-2 (SGLT-2) and glucagon-like peptide-1 (GLP-1) receptor agonists. Apart from reducing glycaemia, these classes were reported to have other beneficial effects for the cardiovascular and renal systems, such as weight loss and blood pressure reduction. Most importantly, in contrast to all previous studies with anti-diabetic agents, a series of recent randomized, placebo-controlled outcome trials showed that SGLT-2 inhibitors and GLP-1 receptor agonists are able to reduce cardiovascular events and all-cause mortality, as well as progression of renal disease, in patients with type 2 DM. This document presents in detail the available evidence on the cardioprotective and nephroprotective effects of SGLT-2 inhibitors and GLP-1 analogues, analyses the potential mechanisms involved in these actions and discusses their place in the treatment of patients with CKD and DM.

Anemia on admission and long-term mortality risk in patients with acute ischemic stroke

BACKGROUND

Anemia is associated with adverse outcomes in patients with acute myocardial infarction and congestive heart failure. Additionally, it has been shown that anemia increases the short-term mortality risk in patients with acute stroke.

OBJECTIVES

The aim of our study was to determine the importance of anemia as a long-term mortality risk factor by itself or in combination with other risk factors.

MATERIAL AND METHODS

We included 390 Caucasian patients with acute ischemic stroke in our study. Their progress was followed from the day of their admission until their death or a max. of 1,669 days. Stroke and anemia were defined according to the World Health Organization (WHO) criteria.

RESULTS

Anemia was present in 57 (14.6%) patients. The patients with anemia were older (p < 0.01) and more likely to be female (p < 0.001). They had higher NIHSS scores on admission (p < 0.001) and discharge (p < 0.001), lower estimated glomerular filtration rates (eGFRs) (p < 0.001), lower serum LDL cholesterol (p < 0.01) and lower serum albumin levels (p < 0.001), while their serum C-reactive protein (CRP) levels were higher (p < 0.001). The Kaplan-Meier curves showed that patients with anemia had higher mortality (p < 0.001). Cox's regression analysis revealed that anemia at admission was a predictor of long-term mortality in these patients (hazard ratio (HR) = 2.448, 95% confidence interval (95% CI) = 1.773-3.490; p < 0.001). Anemia remained a strong predictor of mortality after adjusting for other risk factors as well.

CONCLUSIONS

Anemia was frequent among our patients and was an independent predictor of long-term mortality even after adjusting for other risk factors.

The effect of high-flux hemodialysis and post-dilution hemodiafiltration on platelet closure time in patients with end stage renal disease

INTRODUCTION

We aimed to compare prospectively the effect of high-flux hemodialysis and post-dilution hemodiafiltration on platelets.

METHODS

Twenty-two hemodialysis patients were treated with one high-flux hemodialysis and one post-dilution hemodiafiltration procedure. PFA-100 closure times (collagen/epinephrine-CEPI and collagen/adenosine diphosphate-CADP) were measured before and after the procedure, as well as platelet count, hemoglobin, hematocrit, and red blood cell count. All pre-dialysis and post-dialysis samples were taken from the afferent line.

FINDINGS

The platelet count after vs. before hemodialysis did not change significantly (229.3 ± 55.0 x10⁹ /L vs. 233.6 ± 55.8 × 10⁹ /L; P = 0.269), but was significantly lower after post-dilution hemodiafiltration (215.5 ± 51.7 × 10⁹ /L vs. 245.3 ± 59.9 × 10⁹ /L; P < 0.0001). CEPI after vs. before hemodialysis was not significantly prolonged (192.9 ± 60.8 s vs. 173.4 ± 52.5 s; P = 0.147), and the same applied to CADP (143.6 ± 40.3 s vs. 142.6 ± 38.4 s; P = 0.897). CEPI after vs. before post-dilution hemodiafiltration was significantly prolonged (268.3 ± 41.3 s vs. 176.4 ± 54.0 s; P < 0.0001) as was CADP (221.0 ± 53.9 s vs.133.9 ± 31.1 s; P < 0.0001).

DISCUSSION

Only after post-dilution hemodiafiltration, we found a lower platelet count and prolonged platelet closure times.

Cystatin C as a predictor of mortality in elderly patients with chronic kidney disease

BACKGROUND

The prevalence of chronic kidney disease (CKD) in the elderly is high. Serum cystatin C is an accurate marker of kidney function and it also has prognostic utility in CKD patients. The aim of our study was to determine the prediction of serum cystatin C and other markers of kidney function on long-term survival in elderly CKD patients.

METHODS

Fifty eight adult Caucasian patients, older than 65 years, without known malignancy, thyroid disease and/or not on steroid therapy were enrolled in the study. In each patient, ⁵¹CrEDTA clearance, serum creatinine, serum cystatin C, and estimated glomerular filtration rate using different equations were determined on the same day and patients were then followed for 11 years or until their death.

RESULTS

The means are as follows: ⁵¹CrEDTA clearance 53.3 ± 17.4 ml/min/1.73 m², serum creatinine 1.62 ± 0.5 mg/dl, serum cystatin C 1.79 ± 0.5 mg/l, Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) creatinine equation 40.1 ± 14 ml/min/1.73 m², Berlin Initiative Study 2 (BIS2) equation 38.9 ± 10.7 ml/min/1.73 m², full age spectrum (FAS) creatinine equation 43.8 ± 13.8 ml/min/1.73 m², FAS cystatin C equation 40.1 ± 11.7 ml/min/1.73 m². In the follow up period, 47 (81%) patients died. Cox regression analysis showed different hazard ratios (HRs) for death: for ⁵¹CrEDTA clearance HR 1.022 (95% CI 1.004-1.042; p = .015), serum creatinine HR 1.013 (95% CI 1.006-1.019; p = .001), serum cystatin C HR 2.028 (95% CI 1.267-3.241; p = .003), CKD-EPI creatinine equation HR 1.048 (95% CI 1.019-1.076; p = .001), BIS2 equation HR 1.055 (95% CI 1.021-1.088; p = .001), FAS creatinine equation HR 1.046 (95% CI 1.017-1.074; p = .001), FAS cystatin C equation HR 1.039 (95% CI 1.010-1.071; p = .009).

CONCLUSIONS

Our results showed the highest HR for serum cystatin C among kidney function markers for prediction of outcome in elderly CKD patients.

Medical and surgical co-management - A strategy of improving the quality and outcomes of perioperative care

With the increase of ageing population, rates of chronic diseases and complex medical conditions, the management of high-risk surgical patients is likely to become a great concern in most countries. Considering all these factors, it is certainly rational and intuitive that internists should be included into a collaborative model of medical and surgical co-management, where their multi-potentiality and synthesis capacity require them to coordinate the multidisciplinary team and to be the leading agent of change. In this regard, our aim was to present the official position and approach of the Working Group on Professional Issues and Quality of Care of the European Federation of Internal Medicine (EFIM), for implementation of this strategy of care, encouraging internists to assume an important role and to provide continuity of multidisciplinary care, from the decision to operate through to rehabilitation and recovery. Moving from the traditional model of medical care of the surgical patients to the co-management model, from a reactive simple consultation to a new pro-active continued service, may optimize the quality and perioperative care, improving the survival, shortening hospital stays, replacing the old strategy of late and complication treatment to an early and preventive one.

A Case of ‘Sweet’ Hydrothorax in a Patient on Peritoneal Dialysis

Non-infectious complications are an important cause of peritoneal dialysis failure. Increased intra-abdominal pressure resulting from dialysate inflow into the peritoneal cavity can cause leaks, including hydrothorax due to pleuroperitoneal communication. The authors describe a patient on peritoneal dialysis with a newly discovered pleural effusion with a high glucose level. The patient was treated conservatively with peritoneal dialysis cessation and switched to haemodialysis with complete resolution of the pleural effusion. After 5 weeks, the patient successfully restarted peritoneal dialysis without recurrence of the hydrothorax.

Beta Cell Functional Adaptation and Dysfunction in Insulin Resistance and the Role of Chronic Kidney Disease

BACKGROUND

Beta cells are central in the pathophysiology of diabetes, since their functional adaptation maintains euglycemia in insulin-resistant individuals and beta cell dysfunction is required for the clinical picture of frank diabetes. The pathophysiological mechanisms driving compensation and decompensation are incompletely understood and little is known about the influence of chronic kidney disease (CKD) on beta cell function.

SUMMARY

In compensated insulin resistance, beta cells enhance their function at all stages in the stimulus-secretion coupling cascade, from the most proximal membrane depolarization to the intermediate increase in intracellular calcium concentration and the most distal granule fusion. Intercellular coupling is not disrupted at this early stage during disease progression. Later during progression, when hyperglycemia becomes more apparent owing to insufficient beta cell compensation, intracellular stimulus-secretion coupling becomes enhanced to an even larger degree, but intercellular coupling becomes disrupted, indicating that ineffective cell-to-cell signal transmission may be the earliest event in progression to frank diabetes. CKD can negatively affect beta cell function through increased levels of urea that reduce beta cell glucose utilization and impair insulin secretion, and possibly also through factors other than urea. It remains to be investigated whether urea and other factors of CKD can also affect intercellular coupling. Key messages: Beta cells enhance intracellular stimulus-secretion coupling in early insulin resistance. With worsening insulin resistance, intracellular coupling enhances even more, but intercellular coupling becomes disrupted. CKD negatively impacts beta cell function, but its influence on intercellular coupling awaits further studies.

MicroRNA-142-3p improves vascular relaxation in uremia

BACKGROUND AND AIMS

Chronic kidney disease (CKD) is strongly associated with a high burden of cardiovascular morbidity and mortality. Therefore, we aimed to characterize the putative role of microRNAs (miR)s in uremic vascular remodelling and endothelial dysfunction.

METHODS

We investigated the expression pattern of miRs in two independent end-stage renal disease (ESRD) cohorts and in the animal model of uremic DBA/2 mice via quantitative RT-PCR. Moreover, DBA/2 mice were treated with intravenous injections of synthetic miR-142-3p mimic and were analysed for functional and morphological vascular changes by mass spectrometry and wire myography.

RESULTS

The expression pattern of miRs was regulated in ESRD patients and was reversible after kidney transplantation. Out of tested miRs, only blood miR-142-3p was negatively associated with carotid-femoral pulse-wave velocity in CKD 5D patients. We validated these findings in a murine uremic model and found similar suppression of miR-142-3p as well as decreased acetylcholine-mediated vascular relaxation of the aorta. Therefore, we designed experiments to restore bioavailability of aortic miR-142-3p in vivo via intravenous injection of synthetic miR-142-3p mimic. This intervention restored acetylcholine-mediated vascular relaxation.

CONCLUSIONS

Taken together, we provide compelling evidence, both in humans and in mice, that miR-142-3p constitutes a potential pharmacological agent to prevent endothelial dysfunction and increased arterial stiffness in ESRD.

Derived Subendocardial Viability Ratio and Cardiovascular Events in Patients with Chronic Kidney Disease

BACKGROUND

Chronic kidney disease (CKD) is a well-known mortality risk factor. The subendocardial viability ratio (SEVR) is one of the pulse wave analysis parameters that constitutes a non-invasive measure of coronary perfusion. We aimed to assess the prognostic value of the SEVR for cardiovascular outcome in non-dialysis CKD patients.

METHODS

A total of 98 CKD patients (mean age 60 years) were prospectively followed up from the date of the SEVR measurement until their death or the start of dialysis/transplantation, maximally up to 7.1 years (mean 5 years). According to the manufacturer's instructions regarding normal SEVR values, the patients were divided into a low SEVR group (SEVR ≤130%, n = 26) and a normal SEVR group (SEVR > 130%, n = 72).

RESULTS

During the follow-up period, 13 patients (13.3%) suffered fatal and 23 patients (23.5%) suffered combined (non-fatal and fatal) cardiovascular events. In the patients who died of cardiovascular causes, the SEVR values were statistically significantly lower (130 vs. 154%; p = 0.017) than in those who survived. A Kaplan-Meier survival analysis showed that the cardiovascular survival rate in the low SEVR group of patients was statistically significantly lower (log-rank test: p < 0.001). Using an unadjusted Cox regression analysis, the patients in the low SEVR group had a 5.6-fold higher risk (95% CI: 1.8-17.3; p = 0.002) of fatal cardiovascular events and a 2.7-fold higher risk (95% CI: 1.1-6.3; p = 0.024) of combined fatal and non-fatal cardiovascular events. In the adjusted Cox regression model, the patients in the low SEVR group had a 16-fold higher risk (95% CI: 1.2-9.7; p = 0.004) of fatal cardiovascular events and a 7-fold higher risk (95% CI: 1-9.7; p = 0.009) of combined fatal and non-fatal cardiovascular events.

CONCLUSIONS

An SEVR < 130% predicts fatal and non-fatal cardiovascular events in non-dialysis CKD patients.

Impact of KDIGO-Defined Acute Kidney Injury on Mortality after Percutaneous Coronary Intervention for Acute Myocardial Infarction

BACKGROUND

There are limited data regarding the incidence and long-term impact of acute kidney injury (AKI) according to the KDIGO guidelines on the outcome in patients with myocardial infarction (MI) treated with percutaneous coronary intervention (PCI). The aim of the study was to evaluate the prevalence of AKI, as classified by the KDIGO criteria, and its association with long-term mortality.

METHODS

Data from 5,859 MI patients undergoing PCI at our institution were analyzed. We compared the group without and with AKI according to the KDIGO criteria in relation to long-term mortality.

RESULTS

AKI was documented in 499 (8.5%) patients. AKI stage 1 occurred in 6.2% of patients, AKI stage 2 in 0.9% of patients, and AKI stage 3 in 1.5% of patients. Patients with AKI had a higher long-term mortality (57.3 vs. 20.6%; p < 0.0001). The mortality was 50.3% in AKI stage 1, 56.9% in AKI stage 2, and 87.2% in AKI stage 3. The hazard ratios for all-cause mortality for AKI stages 1-3 were 1.77, 1.85, and 6.30 compared to patients with no AKI. Cardiogenic shock, bleeding, heart failure, age, renal dysfunction, diabetes, hyperlipidemia, ST-elevation MI, contrast volume/glomerular filtration ratio, P2Y12 receptor antagonists, and radial access were associated with the development of AKI.

CONCLUSION

A slight increase in serum creatinine was associated with a progressive increase in long-term mortality in patients with AKI according to the KDIGO definition.

Hospital ambulatory medicine: A leading strategy for Internal Medicine in Europe

Addressing the current collision course between growing healthcare demands, rising costs and limited resources is an extremely complex challenge for most healthcare systems worldwide. Given the consensus that this critical reality is unsustainable from staff, consumer, and financial perspectives, our aim was to describe the official position and approach of the Working Group on Professional Issues and Quality of Care of the European Federation of Internal Medicine (EFIM), for encouraging internists to lead a thorough reengineering of hospital operational procedures by the implementation of innovative hospital ambulatory care strategies. Among these, we include outpatient and ambulatory care strategies, quick diagnostic units, hospital-at-home, observation units and daycare hospitals. Moving from traditional 'bed-based' inpatient care to hospital ambulatory medicine may optimize patient flow, relieve pressure on hospital bed availability by avoiding hospital admissions and shortening unnecessary hospital stays, reduce hospital-acquired complications, increase the capacity of hospitals with minor structural investments, increase efficiency, and offer patients a broader, more appropriate and more satisfactory spectrum of delivery options.

Students as partners: Our experience of setting up and working in a student engagement friendly framework

BACKGROUND

Student engagement (SE) in the curriculum is a positive indicator in the development of students deeply involved in their learning. It also has several benefits for the schools' level of educational innovation and quality assurance.

METHOD

In order to identify the most important pearls from the last decade of educational developments within the field of SE at the Faculty of Medicine University of Maribor, we searched through our school's archives, publications and research in the field of medical education.

RESULTS

Three areas were identified as the most important SE complements: (i) peer teaching, (ii) school governance, and (iii) extracurricular activities. The paper highlights how many student-driven initiatives move from informal frameworks toward a formal structure, elective courses, and, in the end, compulsory components of the curriculum.

DISCUSSION

As demonstrated by the three educational achievements at our school, fostering a high level of SE can lead to innovative curricular changes, benefit the whole school and enable students to deliver highly impactful extracurricular projects.

Newer glomerular filtration rate estimating equations for the full age spectrum based on serum creatinine and cystatin C in predicting mortality in patients with ischemic stroke

BACKGROUND

Renal dysfunction is associated with increased risk of mortality. The novel Full Age Spectrum (FAS) equations estimating the glomerular filtration rate (GFR) based on serum creatinine (FAScrea) and cystatin C (FAScysC) are validated across the entire age spectrum and are superior markers of renal function compared to other equations. Possible association of these equations with mortality in patients with ischemic stroke is not known.

PATIENTS AND METHODS

We included 390 patients (207 men, 183 women) in our observational cohort study who had suffered from an ischemic stroke and followed-up on for 3 years. Serum creatinine and cystatin C were measured at admission; GFR was estimated according to the FAScrea, CKD-EPIcrea, FAScysC and CKD-EPIcysC equations. The values of estimated GFRs were divided into quintiles.

RESULTS

During the follow-up period, 173 (44.4%) patients died. The association of hazard ratios for FAScrea and CKD-EPIcrea with all-cause mortality was J-shaped and only significantly higher when comparing the fifth quintile hazard ratio for mortality with the first quintile (P < 0.001). For FAScysC and CKD-EPIcysC, hazard ratios increased from the first to the fifth quintile linearly. In an adjusted analysis, FAScrea and CKD-EPIcrea were not associated with all-cause mortality and the hazard ratios of the fifth quintile of FAScysC (P = 0.008) and CKD-EPIcysC (P = 0.042) were significantly associated with mortality compared to the first quintile.

CONCLUSIONS

In patients with an ischemic stroke, estimated GFR based on serum cystatin (FAScysC and CKD-EPIcysC) was a better predictor of all-cause and cardiovascular mortality than estimated GFR based on serum creatinine.