Acute kidney injury in patients undergoing endovascular or open repair of juxtarenal or pararenal aortic aneurysms

BACKGROUND

The aim of this cohort study was to report the proportion of patients who develop periprocedural acute kidney injury (AKI) after endovascular repair (ER) and open surgery (OS) in patients with juxta/pararenal abdominal aortic aneurysm and to assess potential risk factors for AKI. The study also aimed to report the short- and long-term outcomes of patients with and without AKI.

METHODS

This was a multicenter cohort study of five European academic high-volume centers (>50 OS or 50 ER infrarenal AAA repairs, plus >15 complex AAA repairs per year). All consecutively treated patients were extracted from a prospective vascular surgical registry and the data were scrutinized retrospectively. The primary end point for this study was the development of AKI. AKI was diagnosed when there is a two-fold increase of serum creatinine or decrease of glomerular filtration rate of >50% within 1 week of AAA repair. Secondary end points included long-term mortality and end-stage renal disease (ESRD).

RESULTS

AKI occurred in 16.6% of patients in the ER group vs 30.3% in the OS group (P < .001). The 30-day mortality rate was higher among patients with AKI in both ER (15.4% vs 3.1%; P = .006) and OS (13.2% vs 5.3%; P = .001) groups. Age, chronic kidney disease, presence of significant thrombus burden in the pararenal region, >1000 mL blood loss in ER group were associated with development of AKI. Age, diabetes mellitus, chronic kidney disease, presence of significant thrombus burden in the pararenal region, and a proximal clamping time of >30 minutes in the OS group were associated with the development of AKI, whereas renal perfusion during clamping was the protective factor against AKI development. After a median follow-up of 91 months, AKI was associated with higher mortality rates in both the ER group (58.9% vs 29.7%; P < .001) and the OS group (61.5% vs 27.3%; P < .001). After the same follow-up period, AKI was associated with a higher incidence of ESRD in both the ER group (12.8% vs 3.6%; P = .009) and the OS group (9.9% vs 2.9%; P < .001).

CONCLUSIONS

The current study identified important pre and postoperative factors associated with AKI after juxta/pararenal abdominal aortic aneurysm repair. Patients with postoperative AKI had significantly higher short- and long term mortality and higher incidence of ESRD than patients without AKI.

Comparison of palonosetron and ondansetron in preventing postoperative nausea and vomiting in renal transplantation recipients: a randomized clinical trial

BACKGROUND

End-stage renal diseases patients have a high risk of postoperative nausea and vomiting (PONV), which is multifactorial and need acute attention after renal transplantation for a successful outcome in term of an uneventful postoperative period. The study was done to compare the efficacy of palonosetron and ondansetron in preventing early and late-onset PONV in live donor renal transplantation recipients (LDRT).

METHODS

The prospective randomized double-blinded study was done on 112 consecutive patients planned for live donor renal transplantation. Patients of both sexes in the age group of 18...60 years were randomly divided into two groups: Group O (Ondansetron) and Group P (Palonosetron) with 56 patients in each group by computer-generated randomization. The study drug was administered intravenously (IV) slowly over 30.ßseconds, one hour before extubation. Postoperatively, the patients were accessed for PONV at 6, 24, and 72.ßhours using the Visual Analogue Scale (VAS) nausea score and PONV intensity scale.

RESULTS

The incidence of PONV in the study was found to be 30.35%. There was significant difference in incidence of PONV between Group P and Group O at 6.ßhours (12.5% vs. 32.1%, p.ß=.ß0.013) and 72.ßhours (1.8% vs. 33.9%, p.ß<.ß0.001), but insignificant difference at 24.ßhours (1.8% vs. 10.7%, p.ß=.ß0.113). VAS-nausea score was significantly lower in Group P as compared to Group O at a time point of 24.ßhours (45.54.ß...ß12.64 vs. 51.96.ß...ß14.70, p.ß=.ß0.015) and 72.ßhours (39.11.ß...ß10.32 vs. 45.7.ß...ß15.12, p.ß=.ß0.015).

CONCLUSION

Palonosetron is clinically superior to ondansetron in preventing early and delayed onset postoperative nausea and vomiting in live-related renal transplant recipients.

Occult hepatitis C virus infection in hemodialysis patients who achieved a sustained virological response to directly acting antiviral drugs: is it a concern?

PURPOSE

Hepatitis C virus infection is a major health problem in hemodialysis patients. Occult HCV infection is defined as the presence of HCV-RNA in hepatocytes or peripheral blood mononuclear cells without the detection of HCV-RNA in the serum. We aimed to evaluate the prevalence and predictors of occult HCV infection among hemodialysis patients after treatment with direct-acting antiviral agents.

METHODS

This research is a cross-sectional study that included 60 HCV patients maintained on regular HD patients who achieved 24 weeks of sustained virological response after treatment with direct-acting antiviral agents. Real-time PCR was performed to detect HCV-RNA in peripheral blood mononuclear cells.

RESULTS

HCV-RNA was detected in peripheral blood mononuclear cells of three patients (5%). Occult HCV infection cases were treated by Interferon/ribavirin before direct-acting antiviral agents and two of them had raised pre-treatment alanine aminotransferase levels. Logistic regression analyses revealed that high pre-treatment viral load and raised pre-treatment alanine aminotransferase were associated with an increased risk of occult HCV infection with p value of 0.041 and 0.029, respectively.

CONCLUSIONS

Occult HCV infection in hemodialysis patients who achieved sustained virological response after treatment with direct-acting antiviral agents may occur, and this may necessitate dual testing for HCV in both serum and peripheral blood mononuclear cells to ensure viral clearance.

CLINICAL TRIALS REGISTRATION

ClinicalTrials.gov NCT04719338.

Immunological features of ESRD patients undergoing hemodialysis of various ages

AIMS

To investigate the immunological characteristics of hemodialysis (HD) patients with end-stage renal disease (ESRD) of various ages, and the impact of age-related immune alterations on these patients, with a focus on peripheral T cells.

METHODS

From September 2016 to September 2019, HD patients were enrolled and followed prospectively for 3 years. Patients were divided into three groups based on their ages: < 45, 45 to 64, and ≥ 65. The distribution of T cell subsets in different age groups was investigated and compared. The effects of altered T cell subsets on overall survival were also investigated.

RESULTS

A total of 371 HD patients were enrolled. The reduced number of naive CD8+ T cells (P < 0.001) and increased number of EMRA CD8+ T cells (P = 0.024) were independently associated with the advanced age among all T cell subsets studied. Patient survival may be affected by numerical changes in naive CD8+ T cells. However, when HD patients were < 45 or ≥ 65 years, the reduction had no significant impact on survival. Only in HD patients aged 45 to 64 years, the number of naïve CD8+ T cells found to be insufficient but not deficient, identified as an independent predictor of poor survival.

CONCLUSIONS

The most significant age-related immune change in HD patients was a decrease in peripheral naive CD8+ T cells, which was an independent predictor of 3-year overall survival in HD patients aged 45 ~ 64 years.

Prevalence of obstructive sleep apnea in patients with chronic kidney disease: a hospital-based study

BACKGROUND

Chronic kidney disease (CKD) is has been rising over the past few years, and obstructive sleep apnea (OSA) is a prevalent comorbidity in this population.

AIM

To determine the prevalence of OSA in patients with chronic kidney disease stages I-V and end-stage renal disease (ESRD).

METHODS

Patients with CKD of varying grades and ESRD routinely visiting outpatient nephrology clinic or admitted in department of nephrology were included in the study. Stages I-III were categorized as early stages of CKD and stages IV-V and ESRD as late stages of CKD. Patients were categorized into a high risk group based on STOP-BANG and Berlin questionnaires. Patients who were high risk were subjected to in-hospital overnight level III polysomnography. Student's independent t-test and analysis of variance (ANOVA) were employed for the comparison of continuous variables. Chi-square test and Fisher's exact test, as appropriate, were used for the comparison of categorical variables.

RESULTS

Of 111 patients, 46 (41%) were found to have OSA. Of these patients, 15 (33%) had mild OSA (AHI 5-14/h), 13 (28%) had moderate OSA (15-29/h), and 18 (39%) had severe OSA (AHI ≥ 30/h). Overall, 31% of patients in the early stage of CKD and 45% in the late stage were found to have OSA.

CONCLUSION

This study demonstrated a high prevalence of OSA in patients with CKD when compared to the general population affecting both genders equally. The risk of OSA was higher in the advanced stages of CKD compared to the early stages, and dialysis had no effect on prevalence. Since OSA increases the cardiovascular morbidity in CKD the leading cause of death in these patients, early diagnosis and treatment of OSA may have promise to affect the mortality.

Demographic and clinical risk factors for diagnosis of sleep disorders in ESRD patients

BACKGROUND

Sleep disturbances in patients with end-stage renal disease (ESRD) are common and more prevalent than in the general population. This study aims to assess the demographic and clinical risk factors for the diagnosis of sleep disorders in ESRD patients.

METHODS

This study is a retrospective analysis of the United States Renal Data System (USRDS) to evaluate risk factors for the diagnosis of sleep disorders, including hypersomnolence, insomnia, restless leg syndrome (RLS), or obstructive or central sleep apnea (OSA/CSA). All ESRD subjects enrolled in the USRDS between 2004-2015 were eligible for inclusion. The risk factors analyzed were age, race, sex, ethnicity, access type, dialysis modality, and the Charlson Comorbidity Index (CCI). All statistical analysis was performed using SAS 9.4, and statistical significance was assessed using an alpha level of 0.05. Descriptive statistics on all variables overall and by each sleep diagnosis were determined.

RESULTS

Increasing age, black race, other race, and Hispanic ethnicity were associated with decreased risk of each sleep diagnosis while CCI was associated with increased risk. Females were at increased risk of RLS and insomnia while males were at increased risk of OSA/CSA. Catheter and graft access decreased risk of RLS but increased risk of insomnia compared to AVF access. Catheter access increased risk of OSA/CSA compared to graft access. Hemodialysis increased risk of OSA/CSA compared to peritoneal dialysis.

CONCLUSIONS

Some ESRD patients are at an increased risk for diagnosis of sleep disorders based on age, race, sex, comorbid health conditions, and dialysis modality.

Neuroticism as a moderator of symptom-related distress and depression in 4 noncancer end-of-life populations

OBJECTIVES

Neuroticism is a significant predictor of adverse psychological outcomes in patients with cancer. Less is known about how this relationship manifests in those with noncancer illness at the end-of-life (EOL). The objective of this study was to examine the impact of neuroticism as a moderator of physical symptoms and development of depression in patients with amyotrophic lateral sclerosis (ALS), chronic obstructive pulmonary disease (COPD), end-stage renal disease (ESRD), and frailty in the last 6 months of life.

METHODS

We met this objective using secondary data collected in the Dignity and Distress across End-of-Life Populations study. The data included N = 404 patients with ALS (N = 101), COPD (N = 100), ESRD (N = 101), and frailty (N = 102) in the estimated last 6 months of life, with a range of illness-related symptoms, assessed longitudinally at 2 time points. We examined neuroticism as a moderator of illness-related symptoms at Time 1 (∼6 months before death) and depression at Time 2 (∼3 months before death) using ordinary least squares regression.

RESULTS

Results revealed that neuroticism significantly moderated the relationship between the following symptoms and depression measured 3 months later: drowsiness, fatigue, shortness of breath, wellbeing (ALS); drowsiness, trouble sleeping, will to live, activity (COPD); constipation (ESRD); and weakness and will to live (frailty).

SIGNIFICANCE OF RESULTS

These findings suggest that neuroticism represents a vulnerability factor that either attenuates or amplifies the relationship of specific illness and depressive symptoms in these noncancer illness groups at the EOL. Identifying those high in neuroticism may provide insight into patient populations that require special care at the EOL.

Clinical outcomes in end stage renal disease on dialysis and severe coronary artery disease: A real-world study

BACKGROUND

The optimal management of patients with end-stage renal disease (ESRD) on dialysis with severe coronary artery disease (CAD) has not been determined.

METHODS

Between 2013 and 2017, all patients with ESRD on dialysis who had left main (LM) disease, triple vessel disease (TVD) and/or severe CAD for consideration of coronary artery bypass graft (CABG) were included. Patients were divided into 3 groups based on final treatment modality: CABG, percutaneous coronary intervention (PCI), optimal medical therapy (OMT). Outcome measures include in-hospital, 180-day, 1-year and overall mortality and major adverse cardiac events (MACE).

RESULTS

In total, 418 patients were included (CABG 11.0%, PCI 65.6%, OMT 23.4%). Overall, 1-year mortality and MACE rates were 27.5% and 55.0% respectively. Patients who underwent CABG were significantly younger, more likely to have LM disease and have no prior heart failure. In this non-randomized setting, treatment modality did not impact on 1-year mortality, although the CABG group had significantly lower 1-year MACE rates (CABG 32.6%, PCI 57.3%, OMT 59.2%; CABG vs. OMT p < 0.01, CABG vs. PCI p < 0.001). Independent predictors of overall mortality include STEMI presentation (HR 2.31, 95% CI 1.38-3.86), prior heart failure (HR 1.84, 95% CI 1.22-2.75), LM disease (HR 1.71, 95% CI 1.26-2.31), NSTE-ACS presentation (HR 1.40, 95% CI 1.03-1.91) and increased age (HR 1.02, 95% CI 1.01-1.04).

CONCLUSION

Treatment decisions for patients with severe CAD with ESRD on dialysis are complex. Understanding independent predictors of mortality and MACE in specific treatment subgroups may provide valuable insights into the selection of optimal treatment options.

Image-guided tunneled peritoneal dialysis catheter placement

Patients with end-stage renal disease (ESRD) often will ultimately require dialysis to survive. One type of dialysis is peritoneal dialysis (PD), which utilizes the vessel-rich peritoneum as a semi-permeable membrane to filter blood. In order to perform PD, a tunneled catheter must be placed through the abdominal wall and into the peritoneal space, with ideal positioning of the catheter within the most dependent portion of the pelvis, represented by the rectouterine or rectovesical space in women and men, respectively. There are several approaches to PD catheter insertion, including open surgical, laparoscopic surgical, blind percutaneous, and image-guided with the use of fluoroscopy techniques. Interventional radiology (through the use of image-guided percutaneous techniques) is an infrequently utilized resource to place PD catheters, and offers real-time imaging confirmation of catheter positioning with similar outcomes to more invasive surgical catheter insertion approaches. Although the vast majority of dialysis patients receive hemodialysis instead of peritoneal dialysis in the United States, some countries have moved towards a "Peritoneal Dialysis First" initiative, prioritizing initial PD, as it is less burdensome on healthcare facilities as it can be performed at home. In addition, the outbreak of the COVID-19 pandemic has produced shortages of medical supplies and delays in care delivery worldwide, while simultaneously generating a shift away from in-person medical visits and appointments. This shift may be met with more frequent utilization of imaged-guided PD catheter placement, reserving surgical and laparoscopic placement for complex patients who may require omental periprocedural revisions. This literature review outlines a brief history of PD, the various techniques of PD catheter insertion, patient selection criteria, and new COVID-19 considerations, in anticipation for the increased demand for PD in the United States.

Simultaneous replacement and removal of the peritoneal catheter is effective in patients with refractory tunnel infections sustained by S. aureus

BACKGROUND

In tunnel infection (TI) refractory to medical therapy or in case of TI that occurs simultaneously with peritonitis, the removal of the peritoneal catheter has been proposed. This approach requires the interruption of peritoneal dialysis (PD) and the creation of a temporary vascular access. However, simultaneous removal and reinsertion of the PD catheter (SCR) represents another possible therapeutic approach.

METHODS

We analysed the outcome of 20 patients (10 men and 10 women, mean age 65.5 ± 16.3 years) treated by CAPD for a mean period of 24.3 ± 14.2 months who underwent to SCR for the treatment of TI unresponsive to medical therapy or TI that occurred simultaneously with peritonitis at Fondazione Ca' Granda Ospedale Maggiore Policlinico. All the patients restarted CAPD exchanges within 24 h from catheter placement.

RESULTS

SCR was successful in 80% (16/20) of the cases. In particular, SCR was effective in 100% (11/11) of the TI with or without associated peritonitis sustained by S. aureus. However, SCR failed in 57% (4/7) of TI associated with relapsing peritonitis and in one patient with TI secondary to Enterobacter. No early mechanical complications (within 3 months after SCR) occurred when CAPD was restarted.

CONCLUSIONS

SCR of the PD catheter through double-purse string technique represents an effective treatment for TI without or with simultaneously peritonitis sustained by S. aureus avoiding the patient the need for temporary hemodialysis and second surgical procedure. However, SCR could be contraindicated in case of relapsing peritonitis.

Multifactorial analysis of renal anemia-associated substandard hemoglobin levels and prevalence of anemia in patients on maintenance hemodialysis in Liaoning Province: a cross-sectional study

BACKGROUND

In hemodialysis (HD) patients, anemia is greatly improved due to regular weekly use of iron and erythropoietin (EPO), but a large number of patients still show persistent anemia. We do a survey to elucidate the influencing factors that contribute to the failure of hemoglobin (Hb) to meet the standard and provide epidemiological data reference for promoting the recognition of renal anemia and improving the treatment effect of renal anemia.

METHODS

The clinical data of End-Stage Renal Disease (ESRD) HD patients in 22 tertiary hospital HD centers in Liaoning Province from September 2021 to June 2022 were collected by convenient sampling. According to the 2012 Kidney Disease: Improving Global Outcomes (KDIGO) anemia diagnostic criteria. The standard of Hb compliance: Hb ≥110 g/L is considered as Hb compliant, and Hb <110 g/L as Hb non-compliant. The factors influencing Hb up-to-standard in ESRD HD patients and their correlations were analyzed by comparison between the two groups.

RESULTS

The results of this study showed that among the 1,652 ESRD patients investigated in Liaoning Province, the prevalence rate of anemia was 89.29% (1,475/1,652), and the Hb compliance rate was 46.25% (764/1,652). The Hb compliance rate in maintenance hemodialysis (MHD) patients with different primary diseases was statistically significant (P<0.05). Compared with the Hb non-standard group, the gender, dialysis access, HD frequency, concurrent infection, primary disease of ESRD patients, red blood cell (RBC) count, hematocrit (HCT), mean RBC Hb concentration, mean RBC Hb content, platelet (PLT), albumin (ALB), total protein (TP), serum creatinine (Cr), serum calcium (Ca), serum potassium (K), ferritin (Fer), serum iron (SI), and transferrin (TRE) saturation were significantly different between both groups (P<0.05). Adrenaline was an independent risk factor affecting Hb failure in ESRD patients (OR =1.001, 95% CI: 1.000-1.002); dialysis frequency (OR =0.726, 95% CI: 0.601-0.878), ALB (OR =0.959, 95% CI: 0.929-0.990), TP (OR =0.982, 95% CI: 0.968-0.996), serum Cr (OR =0.959, 95% CI: 0.929-0.999), and SI (OR =0.961, 95% CI: 0.940-0.982) were protective factors affecting Hb failure in ESRD patients (P<0.05). Pearson correlation analysis showed that ALB, TP, serum Cr, serum Ca, serum K, SI, and TRE saturation were positively correlated with Hb (P<0.05).

CONCLUSIONS

The anemia rate of ESRD patients treated with MHD in Liaoning Province is high. Based on the results, increasing the frequency of dialysis can improve anemia. Parathyroid hormone levels need to be controlled.

Effects of β-blockers therapy on the 28-day and 3-year survival rates of end-stage renal disease patients with cardiovascular disease: a retrospective cohort study

Background

β-blockers have been used in the treatment of end-stage renal disease (ESRD) patients and cardiovascular disease (CVD) patients, separately. However, the effects of β-blockers on ESRD patients with CVD have not been fully investigated. This study sought to investigate the effects of β-blockers therapy on the 28-day and 3-year survival rates of ESRD patients with pre-existing CVD who were admitted to the intensive care unit (ICU).

Methods

After excluding patients without CVD, receiving a kidney transplant, not admitted to the ICU, and with missing baseline data, this cohort study included 1081 ESRD participants with CVD from the Medical Information Mark for Intensive Care III database. Baseline characteristics, including demographic data and clinical data, were collected. The outcomes were 28-day and 3-year survival rates of the patients. At the 28-day of ICU hospitalization, patients had a mean inpatient hospital stay of 24.7 days. At 3-year, the patients had a median survival time of 489.2 days. Univariate and multivariate Cox regression analyses were used to evaluate the effects of β-blockers therapy on the 28-day and 3-year survival outcomes of ESRD patients with CVD.

Results

The 28-day and 3-year survival rates were 82.8% and 37.9%, respectively. The mean age of the all patients was 68 years, and 642 were male. After adjusting for age, race, hyperlipidemia, dialysis, simplified acute physiological score (SAPS) II, sequential organ failure assessment (SOFA) score, glucocorticoid, hemoglobin, diabetes, hypertension, the 28-day survival rate of the ESRD patients with CVD requiring intensive care who received β-blockers therapy was higher than that of the patients who did not receive the treatment. Similarly, after adjusting for age, race, hyperlipidemia, dialysis, SAPS II, SOFA score, glucocorticoid, hemoglobin, diabetes, hypertension, creatinine, the long-term survival rate of the patients who received β-blockers therapy was also higher than that of those who did not.

Conclusions

β-blockers therapy was associated with increased 28-day and 3-year survival rates in ESRD patients with CVD requiring intensive care. Our findings may provide a theoretical basis for the prognostic impact of β-blockers therapy among patients with ESRD and CVD who were admitted to the ICU.

The Role of a Clinical Psychologist in Pediatric Nephrology

Renal disease in pediatric patients tends to have a broad clinical spectrum from milder disease to severe progressive renal dysfunction requiring renal replacement therapy. Patients with chronic kidney disease (CKD) can have additional comorbidities including hypertension, diabetes, and obesity, which can add to the disease burden. The psychosocial or the mental component of the pediatric CKD patient is often overlooked by health care professionals due to a lack of resources and training in identifying psychological disorders. In addition, many components of kidney disease like fatigue from anemia and cognitive impairment make it difficult for the untrained physician to identify underlying psychological disorders. This review explores the complex psychosocial issues in patients with kidney disease and the need of more comprehensive multidisciplinary approach for treatment.

Gut microbiota diversity in middle-aged and elderly patients with end-stage diabetic kidney disease

BACKGROUND

Diabetic kidney disease (DKD) is the most common cause of end-stage renal disease (ESRD), but the mechanism between DKD and ESRD remains unclear. Some experts have put forward the "microbial-centered ESRD development theory", believing that the bacterial load caused by gut microecological imbalance and uremia toxin transfer are the core pathogenic links. The purpose of this study was to analyze the genomic characteristics of gut microbiota in patients with ESRD, specifically DKD or non-diabetic kidney disease (NDKD).

METHODS

In this cross-sectional study, patients with ESRD were recruited in a community, including 22 DKD patients and 22 NDKD patients matched using gender and age. Fecal samples of patients were collected for 16S rDNA sequencing and gut microbiota analysis. The distribution structure, diversity, and abundance of microflora in DKD patients were analyzed by constructing species evolutionary trees and analyzing alpha diversity, beta diversity, and linear discriminant analysis effect size (LEfSe).

RESULTS

The results of our study showed that there were statistically significant differences in the richness and species of gut microbiota at the total level between DKD patients and NDKD patients. The analysis of genus level between the two groups showed significant differences in 16 bacterial genera. Among them, Oscillibacter, Bilophila, UBA1819, Ruminococcaceae UCG-004, Anaerotruncus, Ruminococcaceae, and Ruminococcaceae NK4A214 bacteria in DKD patients were higher than those in NDKD patients.

CONCLUSIONS

16S rDNA sequencing technology was used in this study to analyze the characteristics of intestinal flora in ESRD patients with or without diabetes. We found that there was a significant difference in the intestinal flora of ESRD patients caused by DKD and NDKD, suggesting that these may be potential causative bacteria for the development of ERSD in DKD patients.

Extended spectrum beta lactamase producing Escherichia coli eustachian valve infective endocarditis

Endocarditis is an infection of the endocardium caused by a multitude of bacteria, including S. aureus, viridans streptococci, S. bovis, or S. epidermidis, among others. It can cause a variety of physical findings, including new onset murmur, Osler nodes, and Janeway lesions. Endocarditis is diagnosed with multiple positive blood cultures with transesophageal echocardiogram (TEE) showing valvular vegetations. In this article, we present a 47 year old female with a history of ESRD on dialysis who presented with a bleeding fistula found to be in septic shock. Diagnosis of eustachian valve endocarditis with E. Coli ESBL was made through positive blood cultures as well as using TEE. She was started on IV meropenem for seven days, to which the patient completed and eventually was discharged home with resolution of symptoms.

Cost-effectiveness analysis of hemodialysis plus hemoperfusion versus hemodialysis alone in adult patients with end-stage renal disease in China

Background

This study evaluates the cost-effectiveness of hemodialysis (HD) plus hemoperfusion (HP) with HD alone in adult patients with end-stage renal disease (ESRD) in China.

Methods

A Markov model was constructed to assess the cost-effectiveness of interventions over a lifetime horizon. Model parameters were informed by the HD/HP trial, the first randomized, open-label multicenter trial comparing survival outcomes and incidence of cardiovascular disease (CVD) for HD + HP versus HD alone, and supplemented by published literature and expert opinion. The primary outcome was the incremental cost-effectiveness ratio (ICER) with respect to quality adjusted life-years (QALY). The robustness of the results was examined in extensive sensitivity analyses. Analyses were conducted from a healthcare perspective. Costs were reported in both Chinese Renminbi (RMB) and US Dollars (USD) in 2019 values.

Results

The base case ICER of HD + HP is RMB 174,486 (USD 25,251) per QALY, which is lower than the RMB 212,676 (USD 30,778) willingness-to-pay threshold of three times Gross Domestic Product. This conclusion is sensitive to the mortality for patients with no severe CVD events, the incidence of CVD events, and the cost of HP and HD. At a willingness-to-pay threshold of RMB 212,676 (USD 30,778) per QALY gained, the probability that HD + HP is cost-effective is 58%.

Conclusions

Our results indicate a potential for HD + HP to be cost-effective for patients with ESRD. Further evidence on the longer-term impact of HD + HP on CVD event rates and mortality unrelated to CVD is needed to robustly demonstrate the cost-effectiveness of HD + HP.

Trial Registration

The HD/HP trial was registered with the Chinese Clinical Trial Registry (ChiCTR-IOR-16009332).

Frequency and risk factors of impaired left ventricular global longitudinal strain in patients with end-stage renal disease: a two-dimensional speckle-tracking echocardiographic study

Background

It has been identified that two-dimensional speckle-tracking imaging (2D-STI) enables the early detection of left ventricular (LV) systolic dysfunction. This study's objective was to evaluate the frequency of impaired LV global longitudinal strain (GLS) and investigate the factors in end-stage renal disease (ESRD) patients with preserved LV ejection fraction (LVEF) associated with the impaired GLS.

Methods

A total of 100 ESRD patients with preserved LVEF who underwent transthoracic echocardiography (TTE) were studied. The GLS was calculated as the average of peak longitudinal strain from 18 myocardial segments obtained utilizing the three-standard apical imagings. According to a predefined cutoff, a GLS absolute value of less than 18% was considered subclinical LV systolic dysfunction.

Results

Impaired LV GLS <18% was detected in 58 participants (58/100, 58%). Multivariate analysis exhibited that increased LV mass index was independently associated with impaired GLS <18% [odds ratio (OR): 1.028, 95% confidence interval (CI): 1.004-1.052, P=0.020]. For sequential logistic regression models, model 1, based on parameters included in multivariate logistic regression (χ²=30.0), was improved by the addition of the LV mass index (χ²=37.4, P<0.01).

Conclusions

The frequency of impaired LV GLS in ESRD patients with preserved LVEF was relatively high. An increased LVEF was independently associated with impaired LV GLS.

Variation in Peritoneal Dialysis-Related Peritonitis Outcomes in the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS)

RATIONALE & OBJECTIVE

Peritoneal dialysis (PD)-associated peritonitis is a significant PD-related complication. We describe the likelihood of cure after a peritonitis episode, exploring its association with various patient, peritonitis, and treatment characteristics.

STUDY DESIGN

Observational prospective cohort study.

SETTING & PARTICIPANTS

1,631 peritonitis episodes (1,190 patients, 126 facilities) in Australia, New Zealand, Canada, Japan, Thailand, the United Kingdom, and the United States.

EXPOSURE

Patient characteristics (demographics, patient history, laboratory values), peritonitis characteristics (organism category, concomitant exit-site infection), dialysis center characteristics (use of icodextrin and low glucose degradation product solutions, policies regarding antibiotic self-administration), and peritonitis treatment characteristics (antibiotic used).

OUTCOME

Cure, defined as absence of death, transfer to hemodialysis (HD), PD catheter removal, relapse, or recurrent peritonitis within 50 days of a peritonitis episode.

ANALYTICAL APPROACH

Mixed-effects logistic models.

RESULTS

Overall, 65% of episodes resulted in a cure. Adjusted odds ratios (AOR) for cure were similar across countries (range, 54%-68%), by age, sex, dialysis vintage, and diabetes status. Compared with Gram-positive peritonitis, the odds of cure were lower for Gram-negative (AOR, 0.41 [95% CI, 0.30-0.57]), polymicrobial (AOR, 0.30 [95% CI, 0.20-0.47]), and fungal (AOR, 0.01 [95% CI, 0.00-0.07]) peritonitis. Odds of cure were higher with automated PD versus continuous ambulatory PD (AOR, 1.36 [95% CI, 1.02-1.82]), facility icodextrin use (AOR per 10% greater icodextrin use, 1.06 [95% CI, 1.01-1.12]), empirical aminoglycoside use (AOR, 3.95 [95% CI, 1.23-12.68]), and ciprofloxacin use versus ceftazidime use for Gram-negative peritonitis (AOR, 5.73 [95% CI, 1.07-30.61]). Prior peritonitis episodes (AOR, 0.85 [95% CI, 0.74-0.99]) and concomitant exit-site infection (AOR, 0.41 [95% CI, 0.26-0.64]) were associated with a lower odds of cure.

LIMITATIONS

Sample selection may be biased and generalizability may be limited. Residual confounding and confounding by indication limit inferences. Use of facility-level treatment variables may not capture patient-level treatments.

CONCLUSIONS

Outcomes after peritonitis vary by patient characteristics, peritonitis characteristics, and modifiable peritonitis treatment practices. Differences in the odds of cure across infecting organisms and antibiotic regimens suggest that organism-specific treatment considerations warrant further investigation.

Changes in left ventricular and atrial mechanics and function after dialysis in patients with end-stage renal disease

Background

Hemodialysis (HD) can influence end-stage renal disease (ESRD) patients' circulatory system. The present study aimed to evaluate the effect of volume depletion on left ventricular (LV) and left atrial (LA) function and determine the volume-independent parameters before and after HD in patients with ESRD.

Methods

Between January 2018 and January 2019, we recruited long-term HD patients (n=40, 51.0±16.4 years), excluding those with structural cardiac disease. Echocardiographic parameters, including LV and LA volumes, flow Doppler, pulsed tissue Doppler, and speckle tracking echocardiography (STE) before and after HD (within 24 h), were examined, and the values were compared.

Results

Following HD, alteration in LV end-systolic volume was not detected, whereas LV end-diastolic volume (90.18±23.91 vs. 84.21±23.54 mL, P=0.036) and LV ejection fraction (LVEF; 64.63%±6.56% vs. 62.84%±6.56%, P=0.049) decreased. Peak early diastolic trans-mitral flow velocity (E-wave; 82.22±20.13 vs. 72.43±18.32 cm/s, P<0.001), peak early diastolic tissue Doppler velocity (e'; 6.45±1.88 vs. 5.77±1.63 cm/s, P<0.001) at the septal side of the mitral annulus, the ratio of early to late Doppler velocities of diastolic mitral inflow (0.90±0.27 vs. 0.79±0.23, P<0.001), and the average E/e' ratio (12.54±4.08 vs. 11.28±4.52, P=0.049) decreased significantly. No significant difference was found in peak blood flow velocity at the mitral valve during late diastole and e' at the lateral side of the mitral annulus after HD. LA volume index (35.55±12.61 vs. 30.22±9.80 mL/m², P<0.001), tricuspid regurgitation velocity (260.11±36.54 vs. 242.37±32.22 cm/s, P=0.002), and pulmonary artery systolic pressure (33.63±11.29 vs. 29.94±7.80 mmHg, P=0.006) significantly decreased. LV global longitudinal systolic strain (GLS) of 4-chamber view (-24.37%±3.02% vs. -23.38%±3.33%, P=0.019), rather than global circumferential systolic strain, exhibited significant change after HD. Significant changes were also found in LV longitudinal early diastolic strain rate (LSRe; 1.17±0.25 vs. 1.05±0.24 s^-1, P<0.001) and early diastolic global radial velocity (Ve; 2.62±0.59 vs. 2.25±0.67 cm/s, P=0.011) after HD, but not in other strain rates and global radial velocity measurements. LA maximal volume (35.55±12.61 vs. 30.22±9.80 mL/m², P<0.001), LA total emptying fraction (54.19%±10.39% vs. 49.63%±11.05%, P=0.009), and LA passive emptying fraction (32.23%±12.86% vs. 26.81%±9.28%, P=0.004) decreased significantly after HD, while LA minimal volume, the volume at the onset of atrial systole, and LA active emptying fraction after HD were not significantly different.

Conclusions

Most indices of systolic (LVEF and GLS of 4-chamber view) and early diastolic function (E-wave, e', LSRe, global radial Ve, and LA passive emptying fraction) were preload dependent. Late diastolic indices, including LV late diastolic global longitudinal strain rate, late diastolic global radial velocity, and LA active emptying fraction, did not change with volume depletion.

Management of diabetes mellitus in dialysis patients: Obstacles and challenges

BACKGROUND AND AIMS

Diabetic kidney disease (DKD) is a major health issue that is associated with an increased risk of morbidity and mortality. The treatment of DKD is challenging given changes in blood glucose homeostasis, unclear accuracy of glucose metrics, and altered kinetics of the blood glucose-lowering medications. There is uncertainty surrounding the optimal glycemic target in this population although recent epidemiologic data suggest that HbA1c ranges of 6-8%, as well as 7-9%, are associated with increased survival rates among diabetic dialysis patients. Furthermore, the treatment of diabetes in patients maintained on dialysis is challenging, and many blood glucose-lowering medications are renally metabolized and excreted hence requiring dose adjustment or avoidance in dialysis patients.

METHOD

ology: PubMed, Google Scholar, and Medline were searched for all literature discussing the management of diabetes in dialysis patients.

RESULTS

The literature was discussed under many subheadings providing the latest evidence in the treatment of diabetes in dialysis patients.

CONCLUSION

The management of diabetes in dialysis is very complex requiring a multi-disciplinary team involving endocrinologists and nephrologists to achieve targets and reduce morbidity and mortality.

Pregnancy-triggered atypical hemolytic uremic syndrome (aHUS): a Global aHUS Registry analysis

Background

Atypical hemolytic uremic syndrome (aHUS) is a rare disease in which uncontrolled terminal complement activation leads to systemic thrombotic microangiopathy (TMA). Pregnancy can trigger aHUS and, without complement inhibition, many women with pregnancy-triggered aHUS (p-aHUS) progress to end-stage renal disease (ESRD) with a high risk of morbidity. Owing to relatively small patient numbers, published characterizations of p-aHUS have been limited, thus the Global aHUS Registry (NCT01522183, April 2012) provides a unique opportunity to analyze data from a large single cohort of women with p-aHUS.

Methods

The demographics and clinical characteristics of women with p-aHUS (n = 51) were compared with those of women of childbearing age with aHUS and no identified trigger (non-p-aHUS, n = 397). Outcome evaluations, including renal survival according to time to ESRD, were compared for patients with and without eculizumab treatment (a complement C5 inhibitor) in both aHUS groups.

Results

Baseline demographics and clinical characteristics were broadly similar in both groups. The proportion of women with p-aHUS and non-p-aHUS with pathogenic variant(s) in complement genes and/or anti-complement factor H antibodies was similar (45% and 43%, respectively), as was the proportion with a family history of aHUS (12% and 13%, respectively). Eculizumab treatment led to significantly improved renal outcomes in women with aHUS, regardless of whether aHUS was triggered by pregnancy or not: adjusted hazard ratio for time to ESRD was 0.06 (p = 0.006) in the p-aHUS group and 0.20 (p < 0.0001) in the non-p-aHUS group.

Conclusion

Findings from this study support the characterization of p-aHUS as a complement-mediated TMA.

Graphic abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s40620-021-01025-x.

Predialysis nephrology care amongst Palestinian hemodialysis patients and its impact on initial vascular access type

Referral time for end-stage renal disease (ESRD) patients to nephrologists and initial vascular access method are considered significant factors that impact health outcomes at the time of hemodialysis (HD) initiation. Native arteriovenous fistula (AVF) is strongly recommended as initial access. However, little is known about the referral rate among ESRD receiving HD in Palestine and its correlation with AVF creation. In Ramallah Hemodialysis Center, we investigated the pre-dialysis nephrology care and AVF usage in 156 patients. Type of access at HD initiation was temporary central venous catheter (CVC) in 114 (73%), tunneled hemodialysis catheter (TDC) in 21 (13%) and AVF in 21 (13%). Out of all participants, 120 (77%) were seen by nephrologist prior to dialysis. Of the participants who initiated dialysis with a CVC, 36 (31%) had not received prior nephrology care. All participants who initiated dialysis with functional AVF had received prior nephrology care. Patients who were not seen by a nephrologist prior to HD initiation had no chance at starting HD with AVF, whereas 17% of those who had nephrology care >12 months started with AVF. In conclusion, a relatively large percentage of Palestinian HD patients who were maintained on HD did not have any predialysis nephrology care. In addition, patients who received predialysis nephrology care were significantly more likely to start their HD through AVF whereas all those without predialysis nephrology care started through CVC. More in-depth national studies focusing on improving nephrology referral in ESRD patients are needed to increase AVF utilization.

Assessment of health-related quality of life and its determinants in the pre-dialysis patients with chronic kidney disease

PURPOSE

Health-related quality of life (HRQoL) is increasingly being considered as a critical parameter to measure how the disease affects patients' health status, especially for long-term ailments like chronic kidney disease (CKD). This study aimed to assess the HRQoL and its determinants in pre-dialysis patients with CKD.

METHODS

This cross-sectional study recruited patients with CKD stages one to four. Data were collected using the HRQoL Questionnaire (15D). Descriptive statistics were used to summarize patients' characteristics. Chi-square test or Fisher's exact test was used to explore the association between independent variables and the HRQoL. Multivariate logistic regression analyses were employed to investigate the determinants of HRQoL. A P value of less than 0.05 was considered statistically significant.

RESULTS

Two hundred and twenty patients were enrolled in the study (average age 52.7 ± 12.4 years, 61.8% females, and 69.1% with CKD stage 4). The average multidimensional utility score of the study population was 0.82 ± 0.13, while the single-attribute utility scores ranged from 0.73 to 0.89. The speech, and discomfort and symptoms dimensions had the highest (0.89) and lowest (0.73) single-attribute utility scores, respectively. The patients who were uneducated [Adjusted Odds Ratio (AOR) 0.34, 95% CI (0.12-0.97)] were significantly less likely to have poor HRQoL compared to those with tertiary education level. Additionally, unemployed [AOR 4.69, 95% CI (1.69-13.02)], and self-employed patients [AOR 4.25, 95% CI (1.26-14.38)] were significantly more likely to have poor HRQoL compared to the retirees CONCLUSIONS: This study shows that the overall HRQoL of the participants was high, though a considerable proportion of them had poor HRQoL, while the discomfort and symptoms dimension was the most impacted. Being educated, unemployed, and self-employed were significantly and independently associated with poor overall HRQoL.

The role of personal attitudes of control and responsibility for the uptake of peritoneal dialysis- a national survey among dialysis patients

BACKGROUND

Although most patients are suitable for both hemodialysis (HD) and peritoneal dialysis (PD), there seem to be differences in the outlook of patients who choose one modality over the other. There is currently limited literature about the impact of patients' personal attitudes on the decision for PD or HD. In this study, we tried to find out whether there were differences between patients who were on HD and PD in their desire for control and responsibility for their treatment.

METHODS

The data were drawn from a nationwide postal survey of 630 HD and PD patients. Patients' desire for control was measured by scores on the internal locus of control (ILOC) scale. Patients were also asked how important taking responsibility for their dialysis had been for their treatment decision (ITR). Two multivariate logistic regression models, both adjusted for age, were applied to investigate whether there were differences between HD and PD patients in ILOC and ITR. Having one generic measure (ILOC) and one tailored to the dialysis context (ITR) gave the opportunity to investigate if it is a generic personality trait or rather a specific attitude that affects choice of dialysis modality.

RESULTS

PD patients were younger and showed higher ILOC and ITR values. Multivariate logistic regression models adjusted for age confirmed the significant influence of ILOC and ITR on the uptake of PD. The odds ratios for being in the PD group were 1.53 for ILOC (p = 0.030; 95% CI 1.04-2.25), 1.49 for ITR (p = 0.019; 95% CI 1.07-2.07), and 0.95 (p = 0.000; 95% CI 0.94-0.97) for age in both models.

CONCLUSIONS

Our analysis shows the impact of personal attitudes on the uptake of PD. Participants who generally want to keep control of their lives and take responsibility for their dialysis treatment tended to choose PD. As PD is a home dialysis treatment that requires patients to participate and contribute, it is beneficial if patients' personalities support the treatment procedure. Having two completely different treatment options that suit to different personalities gives us the opportunity to consider the relationship between personal attitudes and choice of dialysis modality.

TRIAL REGISTRATION

The MAU-PD study is registered at the German Clinical Trials Register.

DRKS-ID

DRKS00012555 . Date of Registration in DRKS: 2018/01/04.

The relationship between abnormal cortical activity in the anterior cingulate gyrus and cognitive dysfunction in patients with end- stage renal disease: a fMRI study on the amplitude of low- frequency fluctuations

BACKGROUND

End-stage renal disease (ESRD) patients often have cognitive dysfunction. The abnormal changes in the brains of ESRD patients are difficult to detect with routine imaging examination. Cognitive performance scales are also not an ideal tool because assessments using these scales can be subjective and might be difficult to administer in some ESRD patients. Functional magnetic resonance has the advantages of non-radiation, multidirectional imaging, good repeatability. Using resting-state functional magnetic resonance imaging (rs-fMRI) and an amplitude of low-frequency fluctuation (ALFF) algorithm, this study characterized spontaneous brain activity and explored its relationship with cognitive function in ESRD patients. The aim of this study was to provide objective functional imaging evidence to reveal the pathophysiological mechanism of cognitive dysfunction in ESRD patients.

METHODS

This study recruited 35 ESRD patients and 25 healthy controls (HC) who were matched to the ESRD group by age, sex, and years of education. All study subjects were examined by Montreal Cognitive Assessment (MoCA) and rs-fMRI. Data Processing & Analysis of Brain Imaging (DPABI) V4.3 software was used to preprocess the data to obtain ALFF maps. The ALFF value of the cingulate gyrus was compared between the ESRD and HC groups. Subsequently, the correlation between the ALFF value of the cingulate gyrus and the MoCA score was analyzed in ESRD patients.

RESULTS

Compared with the HC group, the ESRD group had a significantly lower MoCA score (P<0.05). The ALFF values of the anterior and middle cingulate gyri were significantly lower in the ESRD patients (Gaussian random field (GRF) corrected, voxel-level significance: P<0.001, cluster-level significance: P<0.05). No increased ALFF was observed in any brain regions. The ALFF values of the bilateral anterior cingulate gyri were positively correlated with the MoCA scores (r=0.768, 0.625, GRF corrected, voxel-level significance: P<0.01, cluster-level significance: P<0.05).

CONCLUSIONS

Patients with ESRD showed impaired spontaneous brain activity in the bilateral anterior and middle cingulate gyri, suggesting that ALFF of the anterior cingulate gyrus may be an imaging indicator of cognitive dysfunction in ESRD patients.

Long-term prognosis in patients with end-stage renal disease after coronary artery bypass grafting

Background

Cardiovascular disease is a major cause of morbidity and mortality in patients with end-stage renal disease (ESRD). Coronary artery bypass grafting (CABG) is beneficial in selected patients with ESRD. This study investigates the survival outcomes and prognostic factors in ESRD patients who underwent CABG.

Methods

A retrospective analysis was performed for 149 patients with ESRD who underwent isolated CABG between 2006 and 2015.

Results

Mean age was 59.4±8.7 years and 106 patients (71.1%) were male. Operative mortality occurred in 20 patients (13.4%). Overall survival was 81.1%±3.2% at 1 year, 41.5%±4.3% at 5 years and 19.2%±4.2% at 10 years. Median survival was 4.3 years. Multivariable analysis identified age [P=0.001, odds ratio (OR): 1.15 per 1-year increase, 95% confidence interval (CI): 1.06-1.25], preoperative left ventricular ejection fraction (LVEF) (P=0.020, OR: 0.94, 95% CI: 0.89-0.99) and non-elective status of operation (P=0.049, OR: 3.34, 95% CI: 1.00-11.1) as predictors of operative mortality. Cox regression analysis identified age [P<0.001, hazard ratio (HR): 1.05 per 1-year increase, 95% CI: 1.03-1.08], New York Heart Association (NYHA) class III or IV status (P=0.010, HR: 1.75, 95% CI: 1.15-2.67) and the use of a left internal mammary artery (LIMA) to left anterior descending artery (LIMA-LAD) graft (P=0.029, HR: 0.42, 95% CI: 0.19-0.92) as factors influencing long-term survival.

Conclusions

CABG is associated with high operative mortality and poor long-term survival in ESRD patients. Age and NYHA class influenced late survival. LIMA-LAD grafting conferred a long-term survival advantage.

Urinary magnesium predicts risk of cardiovascular disease in Chronic Kidney Disease stage 1-4 patients

Observational studies on dietary or circulating magnesium and risk of cardiovascular disease (CVD) in Chronic Kidney Disease (CKD) stage 1-4 have reported no-to-modest inverse associations. 24 h Urinary magnesium concentration (24 h UMg), an indicator of intestinal magnesium absorption, may provide better insight into the connection of CKD progression. We examined 3179 participants aged 18-74 years with CKD stage 1-4 in the Chinese Cohort Study of Chronic Kidney Disease (C-STRIDE) study, a prospective population-based cohort study. Data were analysed using Spearman rank-order correlation coefficients for all comparisons. We also performed a time-to-event analysis of the data using the Kaplan-Meier survival model, Cox proportional hazard model and competing risk Fine and Gray subdistribution hazard model. During a median follow-up of 4.19 years (interquartile range, 3.43-5.09 years), when modelling end-stage renal disease (ESRD), CVD and death, 24 h UMg was associated with risk of CVD (HR, 1.612 (95% CI, 1.056-2.460)), while no significant association with ESRD and death endpoints could be detected. 24 h UMg risk variants display a modest association with CVD in CKD stage 1-4 patients. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT03041987. Registered January 1, 2012. (retrospectively registered) (https://www.clinicaltrials.gov/ct2/show/NCT03041987?term=Chinese+Cohort+Study+of+Chronic+Kidney+Disease+%28C-STRIDE%29&rank=1).

Cerebral blood flow characteristics following hemodialysis initiation in older adults: A prospective longitudinal pilot study using arterial spin labeling imaging

PURPOSE

To investigate cerebral blood flow (CBF) characteristics before and after hemodialysis initiation and their longitudinal associations with global cognitive function in older adults.

METHODS

A cohort of 17 older end-stage renal disease patients anticipating standard thrice-weekly hemodialysis and a group of 11 age- and sex-matched healthy control volunteers were recruited for brain perfusion imaging studies using arterial spin labeling. Hemodialysis patients participated in a prospective longitudinal study using brain magnetic resonance imaging and global cognitive assessment using the Modified Mini-Mental State Examination (3MS) at two time points: baseline, 2.9 ± 0.9 months before, and follow-up, 6.4 ± 2.4 months after hemodialysis initiation. Healthy controls were imaged once using the same protocol. CBF analyses were performed globally in grey and white matter and regionally in the hippocampus and orbitofrontal cortex. Covariate-adjusted linear mixed-effects models were used for statistical analyses (significance: p < 0.05; marginal significance: p < 0.1).

RESULTS

At baseline, global and regional CBF was significantly higher in hemodialysis patients than in healthy controls. However, after approximately 6 months of hemodialysis, CBF declined substantially in hemodialysis patients, and became comparable to those in healthy controls. Specifically, in the hemodialysis patients, CBF declined non-significantly globally for grey and white matter and significantly regionally in the hippocampus and orbitofrontal cortex. Marginally significant associations were observed between 3MS scores and regional CBF measurements in the hippocampus and orbitofrontal cortex at baseline and follow-up, and between longitudinal changes.

CONCLUSION

The significant decline in CBF after hemodialysis initiation and the observed association between longitudinal changes in regional CBF and 3MS scores suggest that decreased brain perfusion may contribute to the observed cognitive decline.

Health Policy and Kidney Care in the United States: Core Curriculum 2020

Kidney care in the United States is highly regulated, reflecting the dominance of Medicare as the primary payer for dialysis since inclusion of the end-stage renal disease (ESRD) benefit into payment policy in 1973. In the ensuing decades, bundled payments have been introduced for dialysis and quality programs have been adopted for both ESRD and nondialysis chronic kidney disease care. In this installment of the Core Curriculum in Nephrology, we review the key laws and regulations affecting kidney care in the United States, the Medicare ESRD program, quality assessment and pay-for-performance programs including the ESRD Quality Incentive Program, incentives and disincentives for specific kidney failure care modalities, and recent landmark initiatives to promote more coordinated kidney care across the spectrum of kidney disease. Additional discussion covers policies guiding the care of undocumented immigrants and provision of hospice and palliative care to people with kidney failure. Last, we discuss how the kidney community can activate to advocate effectively to promote better kidney care in the United States.

Successful treatment of two Japanese ESRD cases with severe COVID-19 pneumonia

Novel coronavirus disease 2019 (COVID-19) is a highly infectious and deadly disease, spreading worldwide. There are limited data about the clinical course of end-stage renal disease (ESRD) patients infected with COVID-19. However, previous cohort studies showed a high mortality rate of ESRD patients infected with COVID-19. We report here two Japanese ESRD patients confirmed with severe COVID-19 pneumonia. Case 1 was a 60-year-old man with ESRD due to diabetic nephropathy who were infected with COVID-19 and exhibited acute respiratory distress syndrome (ARDS) requiring mechanical ventilation and intensive care unit (ICU) admission. He was treated with tocilizumab and intravenous immunoglobulin (IVIG). After 6 days of treatment in ICU, he was extubated. Case 2 was a 68-year-old woman undergoing maintenance hemodialysis for 17 years who also exhibited ARDS due to COVID-19. Her clinical course resembles case 1. Our experience of these two cases indicates that anti-cytokine therapy might be effective for severe COVID-19 pneumonia in ESRD patients.

Melatonin receptor 1A gene polymorphism rs13140012 and serum melatonin in atherosclerotic versus non-atherosclerotic Egyptian ESRD patients: pilot study

Aim

To study the relationship between melatonin levels and Melatonin membrane receptor 1A (MTNR1A) SNP (rs13140012) in end-stage renal disease patients (ESRD) in Alexandria, Egypt on maintenance hemodialysis with or without atherosclerosis.

Materials and methods

40 end-stage renal disease patients on regular hemodialysis were divided into 2 subgroups, one with (n = 20) and one without atherosclerosis (n = 20) and normal subjects (n = 40). Serum melatonin, carotid intimal medial thickness (CIMT) were measured. Melatonin membrane receptor 1A (MTNR1A) SNP (rs13140012) genotyping was done using 5'nuclease Allelic discrimination.

Results

Serum melatonin was significantly lower in ESRD patients [1.6 to 11.30 (pg/mL) with a median of 2.5] than the control group [20.50 to 56.40 (pg/mL) with a median of 35.20]. Serum melatonin was significantly lower in atherosclerotic patients subgroup [1.6–2.50 (pg/mL) with a median value of 2.30] than non-atherosclerotic patients subgroup [2.0–11.30 (pg/mL) with a median of 4.9]. No significant association was found between serum melatonin and (MTNR1A) SNP (rs13140012) (p = 0.633).

Conclusion

These results lead us to suggest that melatonin production is impaired in ESRD patients (included in this pilot study), and this impairment is more evident in atherosclerotic ESRD patients.

The impact of the superficial cuff position on the exit site and tunnel infections in CAPD patients

BACKGROUND

Peritoneal dialysis (PD) related infections continue to be a major cause of morbidity and mortality in patients on PD. In the last ten years, in order to reduce cuff and exit-site infections, in continuous ambulatory peritoneal dialysis (CAPD) patients, we have positioned the superficial cuff subcutaneously 4 cm instead of 2 cm internal to the exit-site.

METHODS

We analysed the infective episodes occurred in 123 CAPD patients (88 men and 35 women, mean age 62.4 ± 16.8) treated for 3337 months between 1st January 2011 and 31th December 2018 at Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico.

RESULTS

31 of the 123 patients (25.2%) developed 52 episodes of exit site infection, with an incidence of 1 episode every 64.1 patient-months. The cumulative probability of remaining infection free was 80.7% at 12 months and 61.8% at 36 months. Gram-positive organism accounted for 78.7% of exit site infections. Forty-one episodes (87%) were successfully treated with medical therapy. Peritonitis incidence was 1 episode every 51.7 and 1 episode every 49.2 patient-months, in patients with or without a history of exit site infection respectively. The overall incidence of tunnel infection was 1 episode every 278.1 patient-months.

CONCLUSIONS

Positioning the superficial cuff subcutaneously at least 4 cm internal to the exit-site might prevent the bacterial cuff colonization and reduce ESIs, tunnel infections and peritonitis.

Immediate Abnormal Intrinsic Brain Activity Patterns in Patients with End-stage Renal Disease During a Single Dialysis Session : Resting-state Functional MRI Study

PURPOSE

To investigate cerebral amplitude of low-frequency fluctuations (ALFF) changes during a single hemodialysis (HD) in end-stage renal disease (ESRD) patients who need maintenance HD.

MATERIALS AND METHODS

A total of 24 patients and 27 healthy subjects were included. The patients underwent neuropsychological tests and took twice resting-state fMRI (rs-fMRI) (before and after HD). Healthy group had one rs-fMRI. The zALFF based on rs-fMRI was calculated. Paired t and independent t test was applied to compare zALFF among groups. The associations between zALFF and duration of HD, ultrafiltration volume, and neuropsychological tests was calculated by partial correlation.

RESULTS

Compared to healthy group, patients before HD showed significant worse performances on digit symbol test (DST) and serial dotting test (SDT). Patients after HD performed DST better than before HD. The patients after HD showed higher zALFF in left putamen than before HD. Multiple regions of both HD groups showed significant lower zALFF than healthy group. The zALFF of left putamen of patients after HD was significant negative correlated with the ultrafiltration volume (R = -0.679). The zALFF in patients before HD exhibited significantly positive or negative correlations with DST and SDT in multiple regions. The zALFF of patients after HD significantly negative correlated with DST in right temporal, positive and negative correlated with ultrafiltration volume in right frontal, left putamen respectively.

CONCLUSION

ESRD patients showed changed spontaneous brain activity and cognitive impairments. After a single HD session, patients performed better in neuropsychological test, and spontaneous brain activity changed in left putamen. Ultrafiltration volume might be associated with activity of left putamen.

Evaluation of salivary flow rate, pH, and buffer capacities in end-stage renal disease patients versus control - A prospective comparative study

Background:

Saliva plays a major role in preserving the integrity of oral tissues. Chronic renal failure patient undergoes many oral and salivary changes for which they require special oral health care. The patient undergoing hemodialysis session has altered salivary composition. Many changes occur during hemodialysis that severely affect the flow rate and the biochemical composition of saliva.

Methods:

A total of 50 patients of end-stage renal disease undergoing hemodialysis for renal insufficiency were selected based on inclusion and exclusion criteria set prior to the study. These patients were compared with the control group who had already undergone hemodialysis. A total of 30 patients were selected as a control group. In this study, unstimulated whole saliva was collected by the spitting method before and after the dialysis session. Salivary flow rate, pH, and buffering capacities were measured.

Results:

Hemodialysis had a significant effect on the salivary flow rate. The mean pH of unstimulated whole saliva showed no significant changes before and after dialysis. The concentrations of urea, creatinine, chloride, and potassium in the whole saliva changed markedly before and after a hemodialysis session, whereas no significant difference was seen in the concentration of sodium and calcium.

Conclusion:

Through this study, we came into a conclusion that hemodialysis had a significant effect on salivary secretion and the biochemical composition of saliva. We conclude that the observed changes in salivary concentrations and the flow rate are mainly due to an increased watery secretion from the salivary glands and also saliva can be used as a tool for monitoring hemodialysis.

Effects of surrounding environment on incidence of end stage renal disease

The rising prevalence and incidence of end-stage renal disease (ESRD) have been noted around the world. However, no study has been conducted to examine the effect of surrounding environment on incidence of ESRD. This study assessed the associations of exposure to PM2.5 level and surrounding green spaces, separately, with incidence of ESRD in Taiwan. Demographic and clinical data used in this study was retrieved from the National Health Insurance Research Database from 2003 to 2012. PM2.5 data collected from the Environmental Protection Administration of Taiwan and a hybrid land-use regression model was used to approximate long-term exposure to PM2.5. Percentage of exposure to surrounding green spaces was used to determine individual exposure level. Cox proportional hazards models with a generalized estimating equation were applied to investigate the effect of surrounding environment on incidence of ESRD. The results showed significant positive association between exposure to PM2.5 level and incidence of ESRD; but inverse association between exposure to surrounding green spaces and incidence of ESRD (adjusted hazard ratio (AHR) = 1.08, 95% CI: 1.00-1.15 for exposure to PM2.5 level; AHR = 0.90, 95%CI: 0.84-0.98 for surrounding green spaces). Together, the findings from this study have added suggestive evidence on the adverse effect of exposure to PM2.5 level and the beneficial effect of exposure to surrounding green spaces on the incidence of ESRD in a general population in Taiwan.

The CHA2DS2-VASc score predicts chronic kidney disease among patients with atrial fibrillation

BACKGROUND

It is unclear how the CHA2DS2-VASc score can predict subsequent chronic kidney disease (CKD) and end-stage renal disease (ESRD) among atrial fibrillation (AF) patients.

METHODS

We identified incident AF patients without CKD between 2000 and 2013 from the National Health Insurance Research Database (NHIRD) of Taiwan and calculated the CHA₂DS₂-VASc score for each patient. Adjusted hazard ratio (HR) with 95% confidence interval (CI) was estimated from multivariate cause-specific Cox models to assess the risk of CKD and ESRD associated with the CHA₂DS₂-VASc score.

RESULTS

A total of 8764 participants with AF who did not have CKD were included in the analysis. The mean age was 69.63 ± 13.48 years and 4800 (54.8%) were males. The adjusted HR of CKD displayed a stepwise increase with the increase in the CHA₂DS₂-VASc score. When compared with those with a CHA₂DS₂-VASc score of 0, the adjusted HRs of CKD were 1.57 (95% CI 1.09-2.26), 2.04 (95% CI 1.42-2.94), 2.48 (95% CI 1.70-3.62), 2.88 (95% CI 1.95-4.26), 3.29 (95% CI 2.18-4.95) and 4.00 (95% CI 2.61-6.13) for the AF patients with a CHA₂DS₂-VASc score of 1, 2, 3, 4, 5 and ≥ 6, respectively. Similarly, as the CHA₂DS₂-VASc score increased, the adjusted HR of ESRD showed a gradual increase.

CONCLUSIONS

Patients with a higher CHA₂DS₂-VASc score were linked to a higher risk of CKD and ESRD in a dose-dependent effect, i.e. the incidence of CKD/ESRD increased with the increasing CHA₂DS₂-VASc score.

The relationship between hemodialysis mortality and the Chinese medical insurance type

Objectives: In China, there are two major medical insurance models: the Urban Basic Medical Insurance (UBMI) and the New Cooperative Medical Scheme (NCMS). The aim of the present study was to evaluate the association of the medical insurance type of patients undergoing hemodialysis (HD) with their survival.

Methods: We retrospectively analyzed the end-stage renal disease adult patients initiating HD between January 2010 and December 2014 in Zhejiang province, followed up through 31 December 2015. Patients who had received HD for over 3 months were separated into two groups, based on different medical insurance type. Demographic, clinical data, and clinical outcomes were analyzed. The survival rates were calculated by using the Kaplan–Meier method.

Results: A total of 6779 patients (59 ± 16 years old, 4331 males (63.9%)) with UBMI and 7177 (59 ± 16 years old, 3778 males (52.8%)) with NCMS enrolled from 226 hemodialysis units. Compared with UBMI group, patients with NCMS had a smaller percentage of hypertensive nephropathy, diabetes mellitus and arteriovenous fistula, faced with more problems in anemia, hypoalbuminemia and metabolism of calcium and phosphorous. The 1-, 3- and 5-year survival rates were 95.4, 84.4, and 74.1% in UBMI group, 93.1, 79.7, and 67.7% in NCMS group, respectively. Patients with NCMS showed higher all-cause mortality compared with UBMI (p < 0.001). In multivariate Cox proportional hazards model, NCMS was independently associated with higher mortality (AHR = 1.53; 95% CI 1.38 ∼ 1.68).

Conclusions: The medical insurance model was independently associated with HD patient survival, NCMS was associated with increased mortality among patients undergoing maintenance hemodialysis in China.

Associations between hepatitis B infection and chronic kidney disease: 10-Year results from the U.S. National Inpatient Sample

INTRODUCTION

Viral hepatitis infection is associated with negative impacts on renal function that may lead to nephropathy. We investigated associations between chronic hepatitis B virus (HBV) infection and chronic kidney disease (CKD) and/or end-stage renal disease (ESRD) in a large, representative sample from a nationwide U.S.

DATABASE

METHODS

This population-based, retrospective observational study extracted data from the U.S. Nationwide Inpatient Sample (NIS) database, including adults ≥18 years old admitted to U.S. hospitals between 2005 and 2014 with records of chronic HBV infection in medical history. The final analytic sample included 70,674 HBV-infected patients and 282,696 matched non-HBV controls. Study endpoints were prevalent CKD and ESRD. Associations between CKD/ESRD and HBV and patients' clinical characteristics were determined by logistic regression analysis.

RESULTS

HBV infection was associated with slightly increased risk of prevalent CKD (OR: 1.06, 95% CI: 1.004-1.119) and an approximate 2-times risk of prevalent ESRD (OR: 1.98, 95% CI: 1.880-2.086). HBV infection in both genders was associated with slightly increased risk of CKD (males, OR: 1.09, 95% CI: 1.02-1.16; females, OR: 1.07, 95% CI: 0.98,1.17), and significantly associated with increased risk for CKD among non-diabetic patients (OR: 1.23, 95% CI: 1.15-1.32), white patients (OR: 1.14, 95% CI: 1.06-1.23) and Asian/Pacific Islanders (OR: 1.13, 95% CI: 0.98-1.30).

CONCLUSIONS

Chronic HBV infection is associated with slightly increased risk for CKD and greater risk for ESRD in males and females, Whites and Asian/Pacific Islanders and non-diabetic patients.

Gallbladder tuberculosis in a dialysis patient: a case-report

BACKGROUND

The diagnosis of gallbladder tuberculosis remains elusive even to the most experienced clinicians. Our aim is to describe our experience of this rare disease, and to raise awareness of the increasing likelihood of tuberculosis in chronic kidney disease (CKD) patient.

CASE PRESENTATION

We report a rare case of gallbladder tuberculosis in a chronic kidney disease patient on hemodialysis. This combination is rarely reported in literature. No signs of abdominal tuberculosis were observed besides a clinical profile consistent with CKD in our patient. The clinical signs of uremia masks those of abdominal tuberculosis and render the pre-operative diagnosis of tuberculosis more difficult.

CONCLUSIONS

The clinical signs of uremia conceal those of abdominal tuberculosis. The diagnosis of tuberculosis in CKD patients hinges mainly on a high index of suspicion, perioperative findings and histological examination.

"Removal of nitrate and nitrite by hemodialysis in end-stage renal disease and by sustained low-efficiency dialysis in acute kidney injury"

BACKGROUND & PURPOSE

It is well established that end-stage renal disease (ESRD) is associated with increased cardiovascular morbidity and mortality both in the adult and pediatric population. Although the underlying molecular mechanisms are poorly understood, compromised nitric oxide (NO) bioactivity has been suggested as a contributing factor. With this in mind, we investigated the effects of hemodialysis on NO homeostasis and bioactivity in blood.

METHODS & RESULTS

Plasma and dialysate samples were obtained before and after hemodialysis sessions from adults (n = 33) and pediatric patients (n = 10) with ESRD on chronic renal replacement therapy, and from critically ill adults with acute kidney injury (n = 12) at their first sustained low-efficiency dialysis session. Levels of nitrate, nitrite, cyclic guanosine monophosphate (cGMP) and amino acids relevant for NO homeostasis were analyzed. We consistently found that nitrate and cGMP levels in plasma were significantly reduced after hemodialysis, whereas post-dialysis nitrite and amino acids coupled to NO synthase activity (i.e., arginine and citrulline) were only significantly reduced in adults with ESRD. The amount of excreted nitrate and nitrite during dialysis were similar to daily endogenous levels that would be expected from endothelial NO synthase activity.

CONCLUSIONS

Our results show that hemodialysis significantly reduces circulating levels of nitrate and cGMP, indicating that this medical procedure may impair NO synthesis and potentially NO signaling pathways.

The role of soluble B cell-activating factor in further stratifying the risk of antibody-mediated rejection post-renal transplant: A meta-analysis

BACKGROUND

We conducted a meta-analysis to evaluate the predictive value of serum soluble B cell-activating factor (sBAFF) for antibody-mediated rejection (ABMR), which remains controversial.

METHODS

Systematic literature search was performed in PubMed, EMBASE, Scopus, Cochrane Library, Web of Science and three Chinese databases. Studies of any relevant design were included. Random and fixed-effects meta-analytical models were used. Study quality, publication bias, and heterogeneity were assessed. This study was registered with PROSPERO (CRD42019109198).

RESULTS

Nine observational studies were included in the meta-analysis, including 1302 cases (median NOS quality score = 8, range 6-8). The incidence of ABMR was significantly higher in the high sBAFF group than in the low sBAFF level group (Risk ratio [RR] 2.04 [95% CI 1.52-2.74], I² = 26%, P < 0.01, N = 1014). The subgroup analysis showed that regardless of pre-transplant donor-specific antibody (DSA) status, the high sBAFF level group still had a significantly higher incidence of ABMR. sBAFF was not associated with the risk of TCMR. The sBAFF level was significantly higher in the anti-HLA-antibody (+) group than in anti-HLA-antibody (-) patients before or after kidney transplantation (Standardized mean difference [SMD] 0.43 [0.29-0.56], P < 0.01, I² = 34%, N = 1001).

CONCLUSION

sBAFF is a promising biomarker to further stratify the risk of ABMR post-renal transplant.

LDL-apheresis-induced remission of focal segmental glomerulosclerosis recurrence in pediatric renal transplant recipients

BACKGROUND

Focal segmental glomerulosclerosis (FSGS) in pediatric patients is typically difficult to treat and will progress to end-stage renal disease (ESRD) in about 10% of cases. Following kidney transplantation, FSGS can recur in up to 56% of renal allografts-with a near 100% recurrence in subsequent transplants.

METHODS

Four different pediatric centers across the USA and the UK employed a protocol using LDL-apheresis (LDL-A) and pulse solumedrol to treat recurrent FSGS after transplantation in seven patients. All the patients included in this series demonstrated immediate, or early, recurrence of FSGS, which clinically presented as nephrotic-range proteinuria within hours to days after implantation of the kidney.

RESULTS

All patients experienced reductions in urinary protein to creatinine ratios resulting in partial or complete remission. All patients demonstrated improvements in their estimated GFRs at their most recent follow-up since LDL-A discontinuation.

CONCLUSIONS

This case series describes the successful treatment, across four different pediatric centers, of seven pediatric patients with recurrent post-transplant FSGS using the Liposorber® LA-15 in combination with pulse solumedrol.

Clinical and pathological features of immunoglobulin A nephropathy patients with nephrotic syndrome

IgA nephropathy (IgAN) is the most common glomerulonephritis worldwide. The classic manifestation of IgAN is episodic hematuria and proteinuria. Nephrotic syndrome (NS) is not very common in IgAN, reported to occur in only 5-10% of IgAN patients. However, the clinical and pathological characteristics and long-term outcomes of patients with NS-IgAN at onset remain unknown. A retrospective study was conducted, enrolling 1165 patients with biopsy-proven IgAN from West China Hospital in 2008-2015. Patients with renal biopsy of minimal change disease with mesangial IgA deposits were excluded. The renal endpoint was defined as 50% decrease in eGFR or progressing into end-stage renal disease (ESRD). A total of 1165 patients were enrolled with average age of 34.58, and 171 (14.7%) patients were presented with NS. Comparing NS and non-NS groups, significance differences were shown in hypertension (HTN), 24-h urine protein, serum albumin, serum creatine, eGFR and uric acid. NS group had severe pathological changes such as endocapillary hypercellularity, tubular atrophy or interstitial fibrosis and crescent, but less segmental glomerulosclerosis or adhesion and global sclerosis. During the average follow-up of 44.27 months, 29.8% (51/171) NS patients and 15.8% (157/994) non-NS patients progressed to the renal endpoint. 5-year renal survival rates were 73.1% and 87.8% (P < 0.001) in NS and non-NS groups, respectively. This study demonstrated that IgAN patients with NS had higher serum creatine, lower eGFR, lower uric acid, more acute lesions and poor prognosis. NS was an independent risk factor for progression to the renal endpoint.

Arrhythmias in Patients on Maintenance Dialysis: A Cross-sectional Study

RATIONALE & OBJECTIVE

Patients with kidney failure treated with maintenance dialysis experience a high rate of mortality, in part due to sudden cardiac death caused by arrhythmias. The prevalence of arrhythmias, including the subset that are clinically significant, is not well known. This study sought to estimate the prevalence of arrhythmias, characterize the pattern of arrhythmic events in relation to dialysis treatments, and identify associated clinical characteristics.

STUDY DESIGN

Cross-sectional study.

SETTING & PARTICIPANTS

152 patients with kidney failure treated with maintenance dialysis in Denmark.

EXPOSURES

Dialysis treatment; clinical characteristics; cardiac output and preload defined using echocardiography.

OUTCOMES

Prevalence and pattern of arrhythmias on 48-hour Holter monitoring; odds ratios for arrhythmias.

ANALYTICAL APPROACH

Descriptive analysis of the prevalence of arrhythmias. Pattern of arrhythmias described using a repeated-measures negative binomial regression model. Associations between clinical characteristics and echocardiographic findings with arrhythmias were assessed using logistic regression.

RESULTS

Among the 152 patients studied, 83.6% were treated with in-center dialysis; 10.5%, with home hemodialysis; and 5.9%, with peritoneal dialysis. Premature atrial and ventricular complexes were seen in nearly all patients and 41% had paroxysmal supraventricular tachycardia. Clinically significant arrhythmias included persistent atrial fibrillation observed among 8.6% of patients, paroxysmal atrial fibrillation among 3.9%, nonsustained ventricular tachycardia among 19.7%, bradycardia among 4.6%, advanced second-degree atrioventricular block among 1.3%, and third-degree atrioventricular block among 2.6%. Premature ventricular complexes were more common on dialysis days, while tachyarrhythmias were more often observed during dialysis and in the immediate postdialytic period. Older age (OR per 10 years older, 1.53; 95% CI, 1.15-2.03; P=0.003), elevated preload (OR, 4.02; 95% CI, 1.05-15.35; P=0.04), and lower cardiac output (OR per 1L/min greater, 0.66; 95% CI, 0.44-1.00; P=0.05) were independently associated with clinically significant arrhythmias.

LIMITATIONS

Arrhythmia monitoring limited to 48 hours; small sample size; heterogeneous nature of the population, risk for residual confounding.

CONCLUSIONS

Arrhythmias, including clinically significant abnormal rhythms, were common. Tachyarrhythmias were more frequent during dialysis and the immediate postdialytic period. The relevance of these findings to clinical outcomes requires additional study.

The relationship between hemodialysis mortality and the Chinese medical insurance type

Objective: In China, there are two major medical insurance models: the Urban Basic Medical Insurance (UBMI) and the New Cooperative Medical Scheme (NCMS). The aim of the present study was to evaluate the association of the medical insurance type of patients undergoing hemodialysis (HD) with their survival. Methods: We retrospectively analyzed the end-stage renal disease adult patients initiating HD between January 2010 and December 2014 in Zhejiang province, followed up through 31 December 2015. Patients who had received HD for over 3 months were separated into two groups, based on different medical insurance type. Demographic, clinical data, and clinical outcomes were analyzed. The survival rates were calculated by using the Kaplan-Meier method. Results: A total of 6779 patients (59 ± 16 years old, 4331 males (63.9%)) with UBMI and 7177 (59 ± 16 years old, 3778 males (52.8%)) with NCMS enrolled from 226 hemodialysis units. Compared with UBMI group, patients with NCMS had a smaller percentage of hypertensive nephropathy, diabetes mellitus and arteriovenous fistula, faced with more problems in anemia, hypoalbuminemia and metabolism of calcium and phosphorous. The 1-, 3- and 5-year survival rates were 95.4%, 84.4%, and 74.1% in UBMI group, 93.1%, 79.7%, and 67.7% in NCMS group, respectively. Patients with NCMS showed higher all-cause mortality compared with UBMI (p < .001). In multivariate Cox proportional hazards model, NCMS was independently associated with higher mortality (AHR = 1.53; 95% CI 1.38 ∼ 1.68). Conclusions: The medical insurance model was independently associated with HD patient survival, NCMS was associated with increased mortality among patients undergoing maintenance hemodialysis in China.

Investigation of the variants at the binding site of inflammatory transcription factor NF-κB in patients with end-stage renal disease

Background

A chronic inflammatory state is a prominent feature in patients with end-stage renal disease (ESRD). Nuclear factor-kappa B (NF-κB) is a transcription factor that regulates the expression of genes involved in inflammation. Some genetic studies have demonstrated that the NF-κB genetic mutation could cause kidney injury and kidney disease progression. However, the association of a gene polymorphism in the transcription factor binding site of NF-κB with kidney disease is not clear.

Methods

We used the Taiwan Biobank database, the University of California, Santa Cruz, reference genome, and a chromatin immunoprecipitation sequencing database to find single nucleotide polymorphisms (SNPs) at potential binding sites of NF-κB. In addition, we performed a case–control study and genotyped 847 patients with ESRD and 846 healthy controls at Tri-Service General Hospital from 2015 to 2016. Furthermore, we used the ChIP assay to identify the binding activity of different genotypes and used Luciferase reporter assay to examine the function of the rs9395890 polymorphism.

Result

The results of biometric screening in the databases revealed 15 SNPs with the potential binding site of NF-κB. Genotype distributions of rs9395890 were significantly different in ESRD cases and healthy controls (P = 0.049). The ChIP assay revealed an approximately 1.49-fold enrichment of NF-κB of the variant type TT when compared to that of the wild-type GG in rs9395890 (P = 0.027; TT = 3.20 ± 0.16, GT = 2.81 ± 0.20, GG = 1.71 ± 0.18). The luciferase reporter assay showed that the NF-κB binding site activity in T allele was slightly higher than that in G allele, though it is not significant.

Conclusions

Our findings indicate that rs9395890 is associated with susceptibility to ESRD in Taiwan population.

Electronic supplementary material

The online version of this article (10.1186/s12882-019-1471-2) contains supplementary material, which is available to authorized users.

Post-surgical outcomes of patients with chronic kidney disease and end stage renal disease undergoing radical prostatectomy: 10-year results from the US National Inpatient Sample

Background

Chronic kidney disease (CKD) and end stage renal disease (ESRD) are not well characterized in prostate cancer patients. This study aimed to examine the clinical characteristics and postsurgical outcomes of patients with or without CKD and ESRD undergoing radical prostatectomy for prostate cancer.

Methods

This population-based, retrospective study used patient data from the Nationwide Inpatient Sample, the largest all-payer US inpatient care database. From 2005 to 2014, 136,790 male patients aged > 20 years diagnosed with prostate cancer and who received radical prostatectomy were included. Postoperative complications, postoperative acute kidney injury (AKI) and urinary complications, and length of hospital stay were compared between patients with or without underlying CKD and ESRD.

Results

After adjusting for relevant factors, the CKD group had a significantly higher risk of postoperative complications than the non-CKD group. In addition, the CKD group had a 5-times greater risk of postoperative AKI and urinary complications than the non-CKD group. Both CKD and ESRD groups had significantly longer hospital stays than the non-CKD group. Patients receiving RARP had a lower risk of postoperative complications than those who received open radical prostatectomy, regardless of having CKD or not. Both non-CKD and CKD patients receiving RARP had shorter hospital stays than those who received open surgery.

Conclusions

Prostate cancer patients with underlying CKD had significantly greater risk of postoperative complications, postoperative AKI and urinary complications, and longer hospital stays than those without CKD. The use of RARP significantly shortened hospital stays and reduced complications for these patients.

Electronic supplementary material

The online version of this article (10.1186/s12882-019-1455-2) contains supplementary material, which is available to authorized users.

Altered Autonomic Reactivity During Lower Body Negative Pressure in End-Stage Renal Disease

BACKGROUND

End stage renal disease (ESRD) is characterized by autonomic dysfunction. During orthostatic stress, sympathetic (SNS) activity increases and parasympathetic (PNS) activity decreases to maintain arterial blood pressure (BP). We hypothesized that ESRD patients have impaired ability to adjust cardiac SNS and PNS activity during orthostasis, which could contribute to increased blood pressure variability, orthostatic intolerance and falls.

METHODS

We measured beat-to-beat BP and Electrocardiography at baseline and during increasing lower body negative pressure (LBNP) in 20 ESRD patients and 18 matched controls (CON). Heart rate variability was quantified as total power (TP) and standard deviation of the N-N interval, reflecting both SNS and PNS; high frequency (HF), root mean square of successive differences of neighboring N-N intervals (RMSSD), and percent of consecutive N-N intervals differing >50 milliseconds (pNN50), reflecting cardiac PNS activity; and low frequency (LF) and LF/HF, reflecting sympoathovagal balance. BP variability was quantified as the standard deviation in systolic (SDSAP) and diastolic (SDDAP) BP.

RESULTS

Baseline HF, RMSSD, and pNN50 were significantly lower in ESRD (P < 0.05). While CON had a significant decrease in HF (P = 0.015), RMSSD (P = 0.003), and pNN50 (P = 0.005) during LBNP, there was no change in heart rate variability in ESRD. There was no significant difference in BP response, but ESRD had a significantly blunted heart rate response during graded LBNP compared to controls (P < 0.001). There was no significant difference in SDSAP or SDDAP during LBNP between groups (P > 0.05).

CONCLUSIONS

These data suggest that ESRD patients have impaired autonomic adjustments to orthostatic stress.

Revisiting racial differences in ESRD due to ADPKD in the United States

Introduction

Autosomal dominant polycystic kidney disease (ADPKD) affects all races. Whether the progression of ADPKD varies by race remains unclear.

Methods

In this retrospective cohort study from 2004 to 2013 non-Hispanic blacks and non-Hispanic whites of all ages classified in the US Renal Data System (USRDS) with incident ESRD from ADPKD (n = 23,647), hypertension/large vessel disease (n = 296,352), or diabetes mellitus (n = 451,760) were stratified into five-year age categories ranging from < 40 to > 75 (e.g., < 40, 40–44, 45–49, …, 75+). The Cochran-Mantel-Haenszel test was used to determine the association of race and incidence of ESRD from ADPKD, diabetes, or hypertension. The difference in the proportions of ESRD in non-Hispanic black and non-Hispanic white patients at each age categorical bin was compared by two-sample proportion test. The age of ESRD onset between non-Hispanic black and non-Hispanic white patients at each year was compared using two-sample t-test with unequal variance.

Results

1.068% of non-Hispanic blacks and 2.778% of non-Hispanic whites had ESRD attributed to ADPKD. Non-Hispanic blacks were less likely than non-Hispanic whites to have ESRD attributed to ADPKD (odds ratio (OR) (95% CI) = 0.38 (0.36–0.39), p <  0.0001). Using US Census data as the denominator to adjust for population differences non-Hispanic blacks were still slightly under-represented (OR (95% CI) 0.94 (0.91–0.96), p = 0.004). However, non-Hispanic blacks with ADPKD had a younger age of ESRD (54.4 years ±13) than non-Hispanic whites (55.9 years ±12.8) (p <  0.0001). For those < 40 years old, more non-Hispanic blacks had incident ESRD from ADPKD than non-Hispanic whites (9.49% vs. 7.68%, difference (95% CI) = 1.81% (0.87–2.84%), p <  0.001) for the combined years examined.

Conclusions

As previously shown, we find the incidence of ESRD from ADPKD in non-Hispanic blacks is lower than in non-Hispanic whites. Among the younger ADPKD population (age < 40), however, more non-Hispanic blacks initiated dialysis than non-Hispanic whites. Non-Hispanic blacks with ADPKD initiated dialysis younger than non-Hispanic whites. A potential implication of these findings may be that black race should be considered an additional risk factor for progression in ADPKD.

Recurrence of Goodpasture syndrome without circulating anti-glomerular basement membrane antibodies after kidney transplant, a case report

BACKGROUND

Goodpasture Syndrome (GS) is an autoimmune disease caused by the development of auto-antibodies against the Glomerular Basement Membrane (GBM). Linear deposit of immunoglobulins G on the GBM detected by immunofluorescence analysis of renal biopsies is a GS pathognomonic finding. GS is commonly monophasic and its incidence is 1.6 case per million per year.

CASE PRESENTATION

This report describes and discusses the case of a 40-year-old woman who one year after allograft kidney transplant, presented with acute pulmonary and renal symptoms of GS, leading to acute graft dysfunction, without circulating anti-GBM antibody detection in laboratory assays. She received a living donor kidney transplant 4 years after the first diagnosis of GS without circulating anti-GBM antibodies, when considered in remission.

CONCLUSIONS

In both episodes, the diagnosis of GS was based exclusively on the kidney biopsy that showed rapidly progressing glomerulonephritis with deposition of immunoglobulins G on the GBM. Although rare, the management of patients with GS without circulating anti-GBM antibodies is difficult due to the lack of standardized follow-up guidelines to reduce the risk of GS recurrence after kidney transplantation.