Single-pill combination for treatment of hypertension: Just a matter of practicality or is there a real clinical benefit?

Elevated blood pressure (BP) is the largest contributor to the incident cardiovascular disease worldwide. Despite explicit guideline recommendations for the diagnosis and management of hypertension, a large proportion of patients remain undiagnosed, untreated, or treated but uncontrolled. Inadequate BP control is associated with many complex factors including patient preference, physician's inertia, health systems disparities, and poor adherence to prescribed antihypertensive drug treatment. The primary driver for reduced cardiovascular morbidity and mortality is lowering of BP ''per se'' and not class effects of specific pharmacotherapies. The recent ESH guidelines recommend the use of four major classes of drugs including renin-angiotensin-aldosterone system (RAS) blockers (angiotensin receptor blockers (ARB) or angiotensin-converting enzyme inhibitors (ACEi)), calcium channel blockers (CCB), thiazide and thiazide-like diuretics, and betablockers. Initiation of treatment for hypertension with a two-drug regimen, preferably in a single pill combination (SPC), is recommended for most patients. Preferred combinations should comprise a RAS blocker (either an ACEi or an ARB) with a CCB or thiazide/thiazide-like diuretic. These strategies are supported by robust evidence that combination therapy produces greater BP reductions than monotherapy, reduces side effects of the individual components, improves therapeutic adherence and long-term persistence on treatment, and permits achievement of earlier BP control.

[Ambulatory blood pressure monitoring, adult and pediatric population. A narrative review]

Hypertension has become a central risk factor for the development of cardiovascular disease, underscoring the importance of its accurate diagnosis. Numerous studies have established a close relationship between elevated systolic (SBP) and diastolic (DBP) blood pressure and an increased risk of cardiovascular event (CVE). Traditionally, blood pressure (BP) measurements performed in clinical settings have been the main method for diagnosing and assessing hypertension. However, in recent years, it has been recognized that BP measurements obtained outside the clinical setting, using self-monitoring blood pressure (SMBP) and ambulatory blood pressure monitoring (ABPM), offer a more realistic perspective of patients' daily lives and therefore provide more reliable results. Given the evolution of medical devices, diagnostic criteria, and the increasing relevance of certain components of ABPM in the prediction of adverse cardiovascular outcomes, a comprehensive update that is practical for daily clinical practice is required. The main objective of this article is to provide an updated review of ABPM, focusing on its importance in the evaluation of hypertension and its impact on public health in Colombia. In addition, it will discuss the implications of changes in diagnostic thresholds and provide concrete recommendations for the effective implementation of ABPM in clinical practice, allowing health professionals to make informed decisions and improve the care of their patients.

Mediastinitis secondary to invasive infection by group A Streptococcus in Spain

This study describes 5 mediastinitis cases secondary to invasive group A Streptococcus (iGAS) disease in a recent outbreak in Spain. Among 398 iGAS cases between January 2019-March 2023, 5 (1.3%) were mediastinitis, 4 occurring in December 2022, all secondary to pneumonia or deep neck infection. We outline the clinical outcome with a review of the scarce pediatric literature.  Conclusion: mediastinistis is a rare but severe complication of iGAS and a high level of suspicion is required to diagnose it. What is Known: • Group A Streptococcus can cause invasive and severe infections in children. • Mediastinitis is a severe complication from some bacterial infections, mainly secondary due to deep-neck abscesses. What is New: • Mediastinitis is an unrecognized complication due to an invasive group A Streptococcus (iGAS) infection. • In cases of a deep-neck abscess or complicated pneumonia a high clinical suspicion of iGAS mediastinitis is required, especially when the clinical course is not favorable.

Perspectives on improving blood pressure control to reduce the clinical and economic burden of hypertension

The clinical and economic burden of hypertension is high and continues to increase globally. Uncontrolled hypertension has severe but avoidable long-term consequences, including cardiovascular diseases, which are among the most burdensome and most preventable conditions in Europe. Yet, despite clear guidelines on screening, diagnosis and management of hypertension, a large proportion of patients remain undiagnosed or undertreated. Low adherence and persistence are common, exacerbating the issue of poor blood pressure (BP) control. Although current guidelines provide clear direction, implementation is hampered by barriers at the patient-, physician- and healthcare system levels. Underestimation of the impact of uncontrolled hypertension and limited health literacy lead to low adherence and persistence among patients, treatment inertia among physicians and a lack of decisive healthcare system action. Many options to improve BP control are available or under investigation. Patients would benefit from targeted health education, improved BP measurement, individualized treatment or simplified treatment regimens through single-pill combinations. For physicians, increasing awareness of the burden of hypertension, as well as offering training on monitoring and optimal management and provision of the necessary time to collaboratively engage with patients would be useful. Healthcare systems should establish nationwide strategies for hypertension screening and management. Furthermore, there is an unmet need to implement more comprehensive BP measurements to optimize management. In conclusion, an integrative, patient-focused, multimodal multidisciplinary approach to the management of hypertension by clinicians, payers and policymakers, involving patients, is required to achieve long-term improvements in population health and cost-efficiency for healthcare systems.

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

INTRODUCTION

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

OBJECTIVES

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

How low should blood pressure be in patients with chronic coronary and cerebrovascular diseases

Over the last three decades, there are an increasing number of investigators and meta-analyses focusing on the fact that lowering blood pressure levels below a critical point is no longer beneficial and possibly even deleterious. In recent years, several trials and meta-analyses assessing intensive blood pressure (BP) lowering found that intensive treatment and lower blood pressure levels are associated with a reduction in CV events and mortality. However, a careful examination of the results shows that current data are not easily applicable to the general hypertensive population. In addition, recommendations of different guidelines since 2017 so far suggest different BP levels regarding the systolic and diastolic thresholds to be achieved and maintained, particularly in specific clinical situations such as patients with coronary artery disease and stroke. The challenge is to better define the limits of intervention and to define phenotypes of patients who are particularly vulnerable to over-aggressive lowering of blood pressure. This article reviews the evidence, controversies and current state of knowledge regarding intensive BP lowering and the lower thresholds of BP to be achieved in patients with chronic coronary or cerebrovascular diseases.

Recurrence of immune complex and complement-mediated membranoproliferative glomerulonephritis in kidney transplantation

INTRODUCTION

Membranoproliferative glomerulonephritis (MPGN) represents a histologic pattern of glomerular injury that may be due to several aetiologies. Few studies have comprehensively analysed the recurrence of MPGN according to the current classification system.

METHODS

We collected a multicentre, retrospective cohort of 220 kidney graft recipients with biopsy-proven native kidney disease due to MPGN between 1981 and 2021 in 11 hospitals. Demographic, clinical and histologic parameters of prognostic interest were collected. The main outcomes were time to kidney failure, time to recurrence of MPGN and disease remission after recurrence.

RESULTS

The study group included 34 complement-mediated and 186 immune complex-mediated MPGN. A total of 81 patients (37%) reached kidney failure in a median follow-up of 79 months. The main predictors of this event were the development of rejection episodes and disease recurrence. In all, 54 patients (25%) had a disease recurrence in a median of 16 months after kidney transplantation. The incidence of recurrence was higher in patients with dysproteinaemia (67%) and complement-mediated MPGN (62%). In the multivariable model, complement-mediated MPGN emerged as a predictor of recurrence. A total of 33 patients reached kidney failure after recurrence. The main determinants of no remission were early time to recurrence (<15 months), estimated glomerular filtration rate <30 mL/min/1.73 m2 and serum albumin <3.5 g/dL at the time of recurrence.

CONCLUSIONS

One-fourth of the patients with native kidney disease due to MPGN developed clinical recurrence in the allograft, especially in cases with complement-mediated disease or in those associated with dysproteinaemia. The kidney outcomes of disease recurrence with currently available therapies are heterogeneous and thus more effective and individualized therapies are needed.

[Comprehensive Therapeutic Approach to Hypertension. Recommendations for Central America and the Caribbean]

Latin American hypertension guidelines, tailored to the needs of countries of Central and South America, should be applied and known by most Latin American physicians. The knowledge and implementation of the Guidelines is one of the greatest challenges of hypertension societies in Latin America such as the Central American and Caribbean Society of Arterial Hypertension (SCCH), the Latin American Society of Hypertension (LASH) and the Inter-American Society of Cardiology (SIAC). In 2020, the Inter-American Society of Cardiology (SIAC) published its position on the current Guidelines for Arterial Hypertension due to the need to standardize the evaluation, diagnosis, treatment and control of hypertension, establishing recommendations that should be adopted in all Latin American countries, aimed at optimizing the management of cardiovascular risk and achieving a substantial improvement in the reduction of cardiovascular events and mortality. This document intends to reinforce all proposals by the LASH guidelines and the position of the SIAC in relation to the therapeutic approach and pharmacological recommendations for patients with hypertension (HT), in order to achieve better HT control in the Central American and Caribbean area, and the consequently prognosis improvement of cardiovascular disease in the area.

Strategies to prevent SARS-CoV-2 transmission in hemodialysis centres across Europe - Lessons for the future

Background

Early reports on the pandemic nature of COVID-19 directed the nephrology community to develop infection prevention and control guidance. We aimed to make an inventory of strategies that dialysis centres followed to prevent infection with COVID-19 in the first pandemic wave.

Methods

We analyzed IPC measures taken by hemodialysis centres treating patients presenting with COVID-19 between March 1, 2020 and July 31, 2020 and that completed the European Renal Association COVID-19 Database centre questionnaire. Additionally, we made an inventory of guidelines published in European countries to prevent spread of SARS-CoV-2 in dialysis centres.

Results

Data from 73 dialysis units located in and bordering Europe were analyzed. All participating centres implemented IPC measures to mitigate the impact of SARS-CoV-2 during the first pandemic wave. Measures mentioned most often included triage with questions before entering the dialysis ward, measuring body temperature, hand disinfection, masking for all patients and staff, and personal protective equipment for staff members. These measures were also recommended in most of the 14 guidelines that were identified in the inventory of national guidelines and were also scored as being among the most important measures by the authors of this paper. Heterogeneity existed between centres and national guidelines regarding the minimal distance between dialysis chairs and recommendations regarding isolation and cohorting.

Conclusions

Although variation existed, measures to prevent transmission of SARS-CoV-2 were relatively similar across centres and national guidelines. Further research is needed to assess causal relationships between measures taken and spread of SARS-CoV-2.

Anti-glomerular Basement Membrane Glomerulonephritis: A Study in Real Life

Introduction

Anti-glomerular basement membrane (anti-GBM) disease is a severe entity with few therapeutic options including plasma exchange and immunosuppressive agents. The aim of this study was to analyze the clinical and pathological features that predict the evolution of end-stage kidney disease (ESKD) and the kidney survival in a cohort of patients with anti-GBM disease with renal involvement in real life.

Methods

A retrospective multicentre observational study including 72 patients from 18 nephrology departments with biopsy-proven anti-GBM disease from 1999 to 2019 was performed. Progression to ESKD in relation to clinical and histological variables was evaluated.

Results

Creatinine at admission was 8.6 (± 4) mg/dL and 61 patients (84.7%) required dialysis. Sixty-five patients (90.3%) underwent plasma exchange. Twenty-two patients (30.6%) presented pulmonary hemorrhage. Kidney survival was worse in patients with creatinine levels > 4.7 mg/dL (3 vs. 44% p < 0.01) and in patients with > 50% crescents (6 vs. 49%; p = 0.03). Dialysis dependence at admission and creatinine levels > 4.7 mg/dL remained independent significant predictors of ESKD in the multivariable analysis [HR (hazard ratio) 3.13 (1.25–7.84); HR 3 (1.01–9.14); p < 0.01]. The discrimination value for a creatinine level > 4.7 mg/dL and 50.5% crescents had an area under the curve (AUC) of 0.9 (95% CI 0.82–0.97; p < 0.001) and 0.77 (95% CI 0.56–0.98; p = 0.008), respectively. Kidney survival at 1 and 2 years was 13.5 and 11%, respectively. Patient survival at 5 years was 81%.

Conclusion

In real life, patients with severe anti-GBM disease (creatinine > 4.7 mg/dL and > 50% crescents) remained with devastating renal prognosis despite plasma exchange and immunosuppressive treatment. New therapies for the treatment of this rare renal disease are urgently needed.

MO1003: Role of Tacrolimus Trough Levels on Intra-Abdominal Pressure After Kidney Transplantation

BACKGROUND AND AIMS

Increased intra-abdominal pressure (IAP) is common after kidney transplantation (KT). However, the role of potential transplant-specific predictors of this complication, such as tacrolimus-associated endothelial dysfunction, remains unclear. We aimed to describe the relationship between tacrolimus trough levels and IAP in a sample of incident KT patients.

METHOD

Single-centre prospective cohort of deceased-donor KTs. Anesthesia, surgical technique and immunosuppression induction therapy were the same in all cases. IAP monitoring was performed according to WSACS guidelines using the urinary bladder technique (UnoMeter Abdo-Pressure kit). IAP values were registered every 8h during the first 72 h after surgery or until reoperation. Mean IAP values during the first 7 2h (72 h-IAP) were used in this analysis. The first measured tacrolimus trough levels after transplantation were included as a potential predictor of IAP. Patients without recorded tacrolimus trough levels during the first 7 days after surgery were excluded. The study was approved by the local ethics committee.

RESULTS

A total of 192 patients were enrolled in the study. Table 1A summarizes relevant patient and haemodynamic variables. Subjects with more severe intra-abdominal hypertension were more commonly males, with longer dialysis vintage, higher BMI and suffered diabetes more frequently. Multivariate linear regression analysis was used to examine potential predictors of 72 h-IAP, including male sex, months on dialysis, body mass index (BMI) (Table 1B), 72 h-fluid balance and tacrolimus trough levels. Recipient age, months on dialysis, BMI and tacrolimus trough levels were independent predictors of 72 h-IAP.

CONCLUSION

Tacrolimus-associated endothelial dysfunction may play a role in the increase of IAP after transplantation. In contrast, accumulated fluid balance, one of the strongest predictors of IAP in the ICU setting, failed to predict IAP values in our sample. These results offer new insight both into the pathophysiology of increased IAP and into the complex mechanisms of tacrolimus-associated nephrotoxicity in the early post-transplant period.

MO335: Reaching SCR 4.0 mg/dL, the Magical Number for KDIGO-2012 AKI Stage 3. Is it Adequate for Stratifying Severity of Acute on Chronic Kidney Disease?

BACKGROUND AND AIMS

Reaching a SCr ≥ 4 is one criterion of classification for stage 3 in the KDIGO-2012 AKI guidelines. No previous study has challenged this arbitrary cut point by comparing its performance on how patients with pure AKI (pAKI) versus acute on chronic kidney disease (AoCKD) reach that ‘magical number’, and how it affects the prognosis.

METHOD

Retrospective study of patients with AKI, classified according to the KDIGO-2012 guidelines. We analysed a sub-group of patients that reached a maximum SCr ≥ 4 and divided them in pAKI (basal eGFR ≥ 60) and AoCKD (≥15–≤59). We evaluated epidemiological and clinical variables, and compared the clinical outcomes needed for HD, in-hospital mortality and HD dependence at discharge. As 21 (6%) of AoCKD individuals already had a basal SCr ≥ 4.0, they were excluded in the analysis.

RESULTS

A total of 492 individuals met the inclusion criteria: 341 (69%) in the AoCKD group. Individuals in this group were older and had a higher Charlson's index. Table 1A summarizes the comparison of clinical characteristics, all patients in the pAKI group reached a four SCr with a rate of SCr increments ≥ 3×. We found no statistically significant difference in in-hospital mortality and the need for HD. The AoCKD group was more dependent on HD at discharge (Table 1B). Figure 1 shows the rate of SCr increments by which individuals reached &gt; 4.0 mg/dL.

CONCLUSION

We found that individuals in the AoCKD group differ in their basal characteristics from the pAKI group and need lesser increments in SCr to reach the magical number of 4.0 mg/dL to be classified in stage 3. May be, one size does not fit all, and individuals with prior CKD may benefit from a lower rate of SCr increase to stratify AKI severity. We consider that a pitfall in this staging criterion consists in the small portion of patients in the AoCKD group that have a basal SCr ≥ 4.0, with a skew to AKI-KDIGO stage 3.

MO442: COVID-19 Disease Severity and Risk of 12-Month CKD Progression

BACKGROUND AND AIMS

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has been in our daily practice for almost 2 years now. Since the beginning of the pandemic, we have aimed to study its most immediate effects on patients to find the best line of treatment or, at least, mitigate its worst outcomes. Nevertheless, we also know some long-term health consequences such as fatigue, sleep difficulties, headache, among others, but its long-term kidney effects are not entirely clear yet. The aim of this study was to describe if coronavirus disease's (COVID-19) severity increases the risk of chronic kidney disease (CKD) progression after a previous hospitalization and observe if there are any additional risk factors that could help us predict this outcome.

METHOD

In this study, a sample of consecutive patients who required admission due to COVID-19 during the first wave of the pandemic (from March to May of 2020) was recruited. Patients were followed for 12 months since initial admission. The composite outcome of the study included either death or CKD progression. CKD progression was defined as incremental progression to a higher KDIGO CKD stage compared to baseline pre COVID-19 renal function [(in mL/min/1.73 m2): estimated glomerular filtration rate (eGFR) ≥60; stage 3a: 45–59; stage 3b: 30–44; stage 4: 15–29; stage 5: &lt;15], or dialysis initiation. Cardiovascular disease was defined as a history of myocardial infarction, stroke, or peripheral vascular disease. Chronic lung diseases included asthma, chronic obstructive pulmonary disease and chronic bronchitis.

RESULTS

The sample was composed of 93 patients, of which 14 (15.1%) died during follow-up. Of those alive 12 months after initial admission, 17 (21.5%) suffered CKD progression. No patient required renal replacement therapy. Patients that suffered the composite outcome presented a higher prevalence of cancer, tended to be slightly older and suffered from additional comorbidities more frequently (Table). In multivariate logistic regression analysis, previous history of CKD [odds ratio (OR): 1.066 (0.433–2.624); P = 0.889], severe or critical COVID-19 on admission [OR: 0.657 (0.24–1.8); P =0.414] or ICU admission [OR: 0.986 (0.082–11.898); P = 0.991] failed to predict the composite outcome.

CONCLUSION

Our main hypothesis was that COVID-19 sequelae should be due to an exaggerated activation of the immune system against the virus. Thus, patients that suffered severe COVID-19 should be expected to develop more long-term health consequences of the infection when compared with those with milder disease. However, we failed to prove any link between COVID-19 severity and long-term CKD progression. History of CKD or ICU admission was also unable to predict the composite outcome.

Previous studies have described a relationship between COVID-19 severity and adverse renal outcomes, a relationship that we failed to observe. These discrepancies could be due to the small sample size of our study and the different definition of CKD progression applied. In addition, age could act as a potential modifier of CKD progression after admission due to COVID. More studies are required to further clarify the mechanisms and long-term renal consequences of COVID-19 and define potential lines of treatment.

MO334: Incidence of AKI Among Hospitalized COVID-19 Patients During the First and Sixth Waves of the Pandemic

BACKGROUND AND AIMS

During the last 2 years, we have witnessed several waves of the COVID-19 pandemic characterized by massive infections among the general population, sudden increases in the number of hospitalizations and variable rates of complications and mortality among patients.

Acute kidney injury (AKI) has been described as a common and serious complication of COVID-19. However, multiple factors that are involved in the development of this complication have been modified throughout these months, including the appearance of new variants of the virus, the modification of treatment protocols or the advancement of vaccination among the general population.

In this study, we aimed to compare the rates of AKI among patients who required admission due to COVID-19 in the first and current (sixth) waves of the pandemic.

METHOD

Consecutive patients that required admission due to COVID-19 in a tertiary referral hospital during the first (March to May 2020) and current (December 2021) waves of the pandemic were enrolled in the study. Patient characteristics, rates of AKI incidence, 28-day mortality and in-hospital length of stay were compared between groups. Viral infection was confirmed by real-time RT-qPCR in all cases. AKI was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines using peak serum creatinine and acute dialysis criteria. Multivariate logistic regression was performed to define potential predictors of AKI.

RESULTS

Table 1 summarizes demographic and clinical characteristics among enrolled patients. Compared with the current wave, patients admitted during the first wave were older, had higher baseline serum creatinine and lower baseline eGFR. During the first wave, patients presented higher peak serum creatinine values and a higher incidence of in-hospital AKI. Age, male sex, hypertension, diabetes, CKD and pandemic wave were included in multivariate logistic regression analysis as potential predictors of AKI. Only past history of hypertension [OR 2.867; 95% confidence interval (95% CI) 1.279–6.424; P-value: .011] and CKD (OR 2.418; 95% CI 1.237–4.73; P-value: .01) independently predicted AKI in the sample.

CONCLUSION

Despite multiple changes that have occurred throughout the pandemic, including new treatment protocols, the appearance of new variants of the virus with different clinical profiles or the extensive application of vaccines, these changes have not translated into a significant decrease in the risk of AKI among patients admitted due to COVID-19, which appears to still be conditioned mainly by comorbidities of each patient, including past history of CKD.

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

INTRODUCTION

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

OBJECTIVES

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Impact of intra-abdominal pressure on early kidney transplant outcomes

Increased intra-abdominal pressure (IAP) is common among post-surgical patients and may cause organ dysfunction. However, its impact after kidney transplantation on early postoperative complications and graft recovery remains unclear. We designed a prospective, observational cohort study to describe the prevalence and determinants of IAP, as well as its effect on delayed graft function, postoperative complications, and graft recovery. IAP was measured in 205 kidney transplant recipients every 8 h during the first 72 h after surgery using the urinary bladder technique. Intra-abdominal hypertension was defined as IAP ≥ 12 mmHg. Patients were followed for 6 months or until graft failure/death. Mean IAP was 12 ± 3.3 mmHg within the first 24 h. 78% of subjects presented with intra-abdominal hypertension during the first 72 h. Increased IAP was associated with higher renal resistive index [r = 0.213; P = 0.003] and lower urine output [r =  - 0.237; P < 0.001]. 72 h mean IAP was an independent risk factor for delayed graft function [OR: 1.31; 95% CI: 1.13-1.51], postoperative complications [OR: 1.17; 95% CI: 1.03-1.33], and absence of graft function recovery [HR for graft function recovery: 0.94; 95% CI: 0.88-0.99]. Increased IAP was highly prevalent after transplantation and was independently associated with delayed graft function, postoperative complications, and absence of graft function recovery. Routine IAP monitoring should be considered post-transplantation to facilitate early recognition of relevant complications.

Clinical triage of patients on kidney replacement therapy presenting with COVID-19: an ERACODA registry analysis

BACKGROUND

Patients on kidney replacement therapy (KRT) are at very high risk of coronavirus disease 2019 (COVID-19). The triage pathway for KRT patients presenting to hospitals with varying severity of COVID-19 illness remains ill-defined. We studied the clinical characteristics of patients at initial and subsequent hospital presentations and the impact on patient outcomes.

METHODS

The European Renal Association COVID-19 Database (ERACODA) was analysed for clinical and laboratory features of 1423 KRT patients with COVID-19 either hospitalized or non-hospitalized at initial triage and those re-presenting a second time. Predictors of outcomes (hospitalization, 28-day mortality) were then determined for all those not hospitalized at initial triage.

RESULTS

Among 1423 KRT patients with COVID-19 [haemodialysis (HD), n = 1017; transplant, n = 406), 25% (n = 355) were not hospitalized at first presentation due to mild illness (30% HD, 13% transplant). Of the non-hospitalized patients, only 10% (n = 36) re-presented a second time, with a 5-day median interval between the two presentations (interquartile range 2-7 days). Patients who re-presented had worsening respiratory symptoms, a decrease in oxygen saturation (97% versus 90%) and an increase in C-reactive protein (26 versus 73 mg/L) and were older (72 vs 63 years) compared with those who did not return a second time. The 28-day mortality between early admission (at first presentation) and deferred admission (at second presentation) was not significantly different (29% versus 25%; P = 0.6). Older age, prior smoking history, higher clinical frailty score and self-reported shortness of breath at first presentation were identified as risk predictors of mortality when re-presenting after discharge at initial triage.

CONCLUSIONS

This study provides evidence that KRT patients with COVID-19 and mild illness can be managed effectively with supported outpatient care and with vigilance of respiratory symptoms, especially in those with risk factors for poor outcomes. Our findings support a risk-stratified clinical approach to admissions and discharges of KRT patients presenting with COVID-19 to aid clinical triage and optimize resource utilization during the ongoing pandemic.

Cardiovascular multimorbidity and associated factors: the first Brazilian Registry of patients with hypertension

Background

Cardiometabolic multimorbidity (CM-MM) defined by the occurrence of at least two of morbidities (diabetes mellitus, stroke, acute myocardial infarction) is a important issue for health systems and it was associated with several health negative outcomes, especially decreasing of the life expectancy.

Purpose

To analyze the occurrence of CM-MM and associated factors among Brazilian patients with hypertension.

Methods

Cross-sectional study with participants of The First Brazilian Registry of Patients with Hypertension (BRH) from 45 sites in all regions of Brazil (n=2,646). For this study we select the individuals with ≥65 years (n=1,033) and CM-MM was defined with the presence of ≥2 of the following: diabetes mellitus, stroke, acute myocardial infarction evaluated by self related. CM-MM was analyzed according to sex, age, race, presence of others morbidities (dyslipidemia, myocardial revascularization, heart failure and chronic kidney disease), control of blood pressure, obesity, physical activity, actual smoking and alcohol consumption. The numerical variables were presented by median and interquartile range, the categorical variables by absolute and relative frequency. To verify the variables associated with the outcome, simple logistic regression was performed.

Results

CM-MM was present in 8.9% of participants. The median age was 71.6 (IQ: 67.9–76.8), female (59.7%), 65–70 years of age (39.6%), and 59.8% were white. Obesity was present in 55.8% and 48.4% of individuals have no blood pressure controlled. The occurrence of diabetes mellitus, stroke, and acute myocardial infarction was, respectively, 32.7%, 14.7% and 6.7%. A higher occurrence of CM-MM was observed in males, aged between 70 and 75 years old and with 75 years old or more, the presence of dyslipidemia; myocardial revascularization (MR); heart failure (HF) and kidney disease. The intersection size among diseases is represented in Figure 1. After multiple analysis, the following variables were associated with the presence of cardiovascular multimorbidity: male gender; age equal to or greater than 75 years and report of dyslipidemia, MR and HF.

Conclusions

The prevalence of CM-MM was high and an approach based on the clusters of cardiometabolic diseases can be a potent care strategy.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Intersection size among diseases CM-MM

Latin-American Ambulatory Blood Pressure Registry (MAPA-LATAM): An urgent need

Hypertension (HT) is one of the main risk factors for cardiovascular disease (CVD). Although it is a global problem, independently of economic situation, region, race or culture, the data available on Latin America are limited. Clinical guidelines emphasise the importance of obtaining reliable blood pressure readings. For this reason, the use of ambulatory blood pressure monitoring (ABPM) is recommended. This improves precision and reproducibility, resulting in better diagnosing and therapeutic decision-making, and constitutes a better estimation of prognosis than office measurements. Unfortunately, there is no global prospective ABPM registry for all of Latin America that analyses HT prevalence, the level of knowledge about it, treatment percentage and the degree of control. Consequently, the authors of this article consider its implementation a priority.

Signaling pathway deregulation and molecular alterations across pediatric medulloblastomas

Medulloblastomas (MBs) account for 15% of brain tumors in children under the age of 15. To date, the overall 5-year survival rate for all children is only around 60%. Recent advances in cancer genomics have led to a fundamental change in medulloblastoma classification and is evolving along with the genomic discoveries, allowing to regularly reclassify this disease. The previous molecular classification defined 4 groups (WNT-activated MB, SHH-activated MB and the groups 3 and 4 characterized partially by NMYC and MYC driven MBs). This stratification moved forward recently to better define these groups and their correlation to outcome. This new stratification into 7 novel subgroups was helpful to lay foundations and complementary data on the understanding regarding molecular pathways and gene mutations underlying medulloblastoma biology. This review was aimed at answering the recent key questions on MB genomics and go further in the relevance of those genes in MB development as well as in their targeted therapies.

FC 027COVID-19 IN PATIENTS ON KIDNEY REPLACEMENT THERAPY - CLINICAL CHARACTERISTICS AT TRIAGE ASSOCIATED WITH ADMISSION, READMISSION AND SHORT-TERM OUTCOMES

Background and Aims

Patients on kidney replacement therapy (KRT) are at high risk of developing severe COVID-19 illness and often require high intensity care and utilisation of hospital resources. During the ongoing pandemic, the optimal care pathway and triage for KRT patients presenting with varying severity of COVID-19 illness is unknown. We studied clinical factors and outcomes associated with admission, readmission and short-term outcomes.

Method

Data from the European Renal Association COVID-19 Database (ERACODA) was analysed. This database includes granular data on dialysis patients and kidney transplant recipients with COVID-19 from all over Europe. The clinical and laboratory features at first presentation of hospitalized and non-hospitalized patients and those who returned for second presentation were studied. In addition, possible predictors of outcome in those who were not hospitalized at first presentation were identified.

Results

Among 1,423 KRT patients (haemodialysis; 1017/kidney transplant; 406) with COVID-19, 25% (n=355) were not hospitalized at first presentation. Of them, only 10% (n=36), presented for a second time in the hospital. The median interval between the first and second presentation was 5 days (Interquartile interval: 2-7 days). Patients who re-presented had worsening of pulmonary symptoms, a fall in oxygen saturation (97% to 90%), and an increase in C-reactive protein (26 mg/L to 73 mg/L) between their attendances. Patients who re-presented after initial assessment were older (72 vs. 63 years) and initially more often had pulmonary symptoms and abnormalities on lung imaging compared with those who did not present for a second time. The 28-day mortality rate of patients admitted at the second presentation was similar to that of patients admitted at first presentation (26.5% vs. 29.7%, p=0. 61). Among patients who were not hospitalized at first presentation (mortality 6%), age, prior smoking, clinical frailty scale, and shortness of breath at first presentation were identified as predictors of mortality.

Conclusion

KRT patients with COVID-19 and mild pulmonary abnormalities and no signs of pulmonary insufficiency can be safely returned without hospitalization. These patients should be advised to seek immediate contact when they develop respiratory distress. Our findings provide support for a risk-stratified clinical approach to admissions of KRT patients presenting with COVID-19. The study findings may be valuable for clinical triage and optimising hospital capacity utilisation during the ongoing pandemic.

MO206MALE SEX IS ASSOCIATED WITH IN-HOSPITAL DEATH IN NON-DIALYSIS CKD PATIENTS WITH COVID-19

Background and Aims

Coronavirus disease (COVID-19), caused by Severe Acute Respiratory Syndrome-Coronavirus 2 (SARS-CoV-2) can lead to significant organ injury. CKD has been associated with increased mortality in previous epidemics, and male sex has been correlated with worse outcomes during COVID-19 in the general population. Our aim was to describe the differential effect of sex as a risk factor for in-hospital mortality among non-dialysis CKD subjects.

Method

Multicenter, observational cohort study including 136 adult patients with CKD and 136 age- and sex-matched controls who required admission for COVID-19 in three academic hospitals in Spain. Viral infection was confirmed by real-time RT-qPCR and/or serologic testing in all cases. Disease severity on admission was classified according to the WHO—China Joint Mission Report on COVID-19. The presence of CKD was defined as sustained eGFR <60 and >15 ml/min/1.73m2 within the 6 months prior to COVID-19 hospitalization. Demographic and clinical data were gathered from medical records. Outcomes were recorded during the following 28 days after admission. We applied Cox proportional hazards models, adjusted for age, sex, hypertension, diabetes and severe or critical disease at presentation.

Results

Due to the matched design, no differences were found regarding age and sex between cohorts. CKD patients suffered more frequently from hypertension and diabetes and presented higher 28-day mortality after hospital admission due to COVID-19 compared with age- and sex-matched controls (40.4 vs. 24.3%; P=0.004). In adjusted Cox regression analysis among CKD patients, only age (HR: 1.087, 95% CI: 1.047-1.128) and male sex (HR: 1.883, 95% CI: 1.045-3.391) were independent predictors of 28-day mortality. Comparatively, among patients without CKD, only age acted as an independent predictor for 28-day mortality (HR: 1.082, 95% CI: 1.033-1.133). None of the variables included in adjusted regression was able to predict ICU admission in any of the cohorts.

Conclusion

Male sex is associated with increased mortality, but not with ICU admission, after hospitalization due to COVID-19 among non-dialysis CKD patients. That effect was not observed among hospitalized controls without CKD.

MO120STONE COMPOSITION AND CARDIOVASCULAR DISEASE IN PATIENTS WIITH NEPHROLITHIASIS

Background and Aims

Kidney stone disease is widely prevalent in the general population and has been associated with multiple comorbidities including hypertension, diabetes, chronic kidney disease and cardiovascular disease. We aimed to describe the possible link between stone composition and cardiovascular disease and its differential effect among women and men.

Method

Retrospective review of patients with known stone composition seen in a nephrolithiasis unit in the last five years. Anthropometric and clinical data were gathered from the hospital records. Stone composition was defined as such if ≥50% of the stone was made from a single component. Cardiovascular disease included coronary artery disease, stroke and peripheral vascular disease. Unadjusted and adjusted logistic regression analysis were applied to describe the potential relationship between stone composition and cardiovascular disease.

Results

337 patients were included in the study sample. Median age was 57 (IQR 47-67), 61.1% males. 58.2% suffered from recurrent stone disease and 28.5% from family history of stone formation. 32.9% of patients had hypertension, 22,4% diabetes and 13,1% chronic kidney disease. The most common kidney stone component was calcium oxalate (38.6%) followed by calcium phosphate (21.3%), uric acid (14.2%), struvite (8%) and brushite (0.9%). Only uric acid as main stone component was associated with cardiovascular disease among men but not women in our sample in univariate analysis. That relationship was lost in adjusted logistic regression analysis.

Conclusion

Calcium oxalate and phosphate were the most common components of kidney stones. No relationship was found between stone composition and cardiovascular disease in the study sample.

MO381RISK FACTORS FOR AKI DURING COVID-19 AMONG NON-DIALYSIS CKD PATIENTS

Background and Aims

AKI is a strong risk factor for adverse outcomes during Coronavirus disease (COVID-19) in the general population. CKD has been correlated with increased risk of AKI both in the outpatient and inpatient settings. We aimed to define potential risk factors for AKI among patients with non-dialysis CKD admitted due to COVID-19.

Method

Multicenter, observational cohort study including 136 adult patients with CKDand 136 age- and sex-matched controls who required admission for COVID-19 in three academic hospitals. Viral infection was confirmed by real-time RT-qPCR and/or serologic testing in all cases. Disease severity on admission was classified according to the WHO—China Joint Mission Report on COVID-19; briefly subjects with COVID-19 were divided into mild (laboratory confirmed, without pneumonia), moderate (laboratory confirmed with pneumonia), severe (dyspnea and/or lung infiltrates >50% of the lung field within 24–48 h) and critical (respiratory failure requiring mechanical ventilation, shock, or other organ failure that requires intensive care). AKI was defined using the 2012 KDIGO classification. CKD was defined as sustained eGFR <60 and >15 ml/min/1.73m2 within the 6 months prior to COVID-19 hospitalization. Baseline eGFR was calculated using the CKD-EPI equation. Demographic and clinical data were gathered from medical records. Outcomes were recorded during the following 28 days after admission. We applied logistic regression analysis to describe potential predictors for AKI.

Results

Median age was 80 years (IQR: 70-86). 58.8% of patients were males. The most common symptom on admission was fever (68.8%), followed by cough (57.7%). The majority of subjects presented with severe COVID-19 on admission (75.7%). During 28-day follow-up, 87 patients (32%) developed Stage 1 AKI, 17 subjects (6.3%) developed Stage 2 AKI and 12 patients (4.4%) developed Stage 3 AKI.

AKI was more frequent (61 vs 24.3%) and more severe (Stage 2 AKI: 10.3 vs 2.2%; Stage 3 AKI: 6.6 vs 2.2%) among CKD patients. In adjusted logistic regression analysis, only disease severity and baseline eGFR were independent predictors for AKI in COVID-19 patients that required hospitalization.

Conclusion

CKD patients suffer AKI more frequently and of higher severity during COVID-19. Baseline eGFR, along with COVID-19 severity, are strong predictor factors of AKI in this setting.

Impact of tricuspid regurgitation severity and repair on aortic valve replacement

BACKGROUND

Aortic stenosis is one of the most prevalent valve diseases but is rarely accompanied by tricuspid regurgitation. Our objective was to analyse the impact of tricuspid regurgitation severity and its surgical treatment on prognosis of patients undergoing aortic valve replacement.

METHODS

Retrospective cohort study including all patients presenting with aortic stenosis with some degree of tricuspid regurgitation between 2001 and 2018. Patients were divided into groups according to the degree of tricuspid regurgitation.

RESULTS

From a sample of 8,080 patients with aortic stenosis, 143 (1,8%) presented with more than trace tricuspid regurgitation. Among patients with mild, moderate, or severe tricuspid regurgitation, we observed no differences in 30-day (15,1 vs 14,8 vs 8,7%;p=0,727), 12-month (51,2 vs 56 vs 55%;p=0,892) or 5-year (64 vs 73,3 vs 66,7%;p=0,798) survival. Aortic valve replacement plus tricuspid annuloplasty, when compared with aortic valve replacement only was associated with longer ICU stay (9 vs 3 days;p=0,043) but not higher 30-day (0 vs 15,5%;p=0,112), 12-month (38,5 vs 54,3%;p=0,278) or 5-year mortality (57,1 vs 67.1%;p=0,594). Only history of liver disease and postoperative major morbidity were independent predictors of survival 30 days, 12 months and 5 years after surgery.

CONCLUSIONS

Severity of tricuspid regurgitation in patients with aortic stenosis was not associated with increased mortality. Tricuspid annuloplasty did not improve survival in this subset of patients but was associated with increased postoperative morbidity.

Paternal safety of the use of mycophenolic acid in kidney transplant recipients. Results of the EMVARON study

BACKGROUND

The use of mycophenolic acid (MPA) in women during pregnancy causes an increase in miscarriages and birth defects with a typical embryopathy profile. Although epidemiological data does not suggest a greater risk among the offspring of male kidney transplant recipients, the European Medicines Agency and The Spanish Agency of Medicines and Medical Devices introduced the recommendation of using contraceptive methods.

METHODS

We conducted a national retrospective study in 15 Spanish Kidney Transplant Centers to evaluate the frequency of miscarriages and birth defects between the offspring from male kidney transplants recipients. We included 151 males who had fathered 239 offspring, 225 under MPA and 14 without MPA.

RESULTS

The results of our study showed an incidence of miscarriages in the MPA group of 9.8%, and of birth defects of 4%.

CONCLUSIONS

We observed an incidence of miscarriages between the offspring fathered by kidney transplant males under MPA lower than the general population. The incidence of birth defects was similar to the incidence described in other studies and the fact that we did not find the typical embryopathy profile makes it difficult to associate them to the use of MPA. Because of that, we urge the European and Spanish Agencies to reconsider their recommendations for males.

Outcomes of COVID-19 Among Hospitalized Patients With Non-dialysis CKD

Background: Coronavirus disease 2019 (COVID-19), caused by Severe Acute Respiratory Syndrome-Corona Virus 2 has generated significant impact on global health worldwide. COVID-19 can cause pneumonia and organ injury. Chronic kidney disease (CKD) has been associated with increased mortality in previous epidemics, but there is a paucity of data regarding actual risks for non-dialysis CKD patients with COVID-19.

Methods: Multicenter, observational cohort study including 136 non-dialysis CKD patients and 136 age- and sex-matched controls that required hospitalization due to COVID-19. Patients with end-stage renal disease, a kidney transplant or without registered baseline glomerular filtration rate prior to COVID-19 infection were excluded. CKD and acute kidney injury (AKI) were defined according to KDIGO criteria.

Results: CKD patients had higher white blood cell count and D-dimer and lower lymphocyte percentage. No differences were found regarding symptoms on admission. CKD was associated with higher rate of AKI (61 vs. 24.3%) and mortality (40.4 vs. 24.3%). Patients with AKI had the highest hazard for death (AKI/non-CKD HR:7.04, 95% CI:2.87–17.29; AKI/CKD HR:5.25, 95% CI: 2.29–12.02), followed by CKD subjects without AKI (HR:3.39, 95% CI:1.36–8.46). CKD status did not condition ICU admission or length of in-hospital stay.

Conclusions: CKD patients that require hospitalization due to COVID-19 are exposed to higher risk of death and AKI.

Validation of a survival benefit estimator tool in a cohort of European kidney transplant recipients

Pre-transplant prognostic scores help to optimize donor/recipient allocation and to minimize organ discard rates. Since most of these scores come from the US, direct application in non-US populations is not advisable. The Survival Benefit Estimator (SBE), built upon the Estimated Post-Transplant Survival (EPTS) and the Kidney Donor Profile Index (KDPI), has not been externally validated. We aimed to examine SBE in a cohort of Spanish kidney transplant recipients. We designed a retrospective cohort-based study of deceased-donor kidney transplants carried out in two different Spanish hospitals. Unadjusted and adjusted Cox models were applied for patient survival. Predictive models were compared using Harrell’s C statistics. SBE, EPTS and KDPI were independently associated with patient survival (p ≤ 0.01 in all models). Model discrimination measured with Harrell’s C statistics ranged from 0.57 (KDPI) to 0.69 (SBE) and 0.71 (EPTS). After adjustment, SBE presented similar calibration and discrimination power to that of EPTS. SBE tended to underestimate actual survival, mainly among high EPTS recipients/high KDPI donors. SBE performed acceptably well at discriminating post-transplant survival in a cohort of Spanish deceased-donor kidney transplant recipients, although its use as the main allocation guide, especially for high KDPI donors or high EPTS recipients requires further testing.

COVID-19 in Grade 4-5 Chronic Kidney Disease Patients

Introduction

Chronic kidney disease (CKD) increases the risk of mortality during coronavirus disease 2019 (COVID-19) episodes, and some reports have underlined the high incidence and severity of this infection in dialysis patients. Information on COVID-19 in nondialysis CKD patients is not available yet.

Case Reports

Here we present 7 patients with grade 4–5 CKD who developed symptomatic COVID-19; they comprise 2.6% of our 267 advanced CKD patients. The estimated GFR was between 12 and 20 mL/min during the month prior to COVID-19. The 3 major symptoms were fever, cough, and dyspnea, and 5 patients showed bilateral pneumonia. Hydroxychloroquine, azithromycin, ceftriaxone, and steroids were the most frequently prescribed drugs. Two patients needed noninvasive mechanical ventilation. All patients showed minimal to moderate kidney function deterioration during admission, with an eGFR decline below 5 mL/min in 6 cases. No patient required acute dialysis. Six patients were discharged alive and remained dialysis free athe t the time of reporting, and one 76-year-old patient died.

Conclusions

COVID-19 affects grade 4–5 CKD patients, but prognosis may be acceptable if prompt supportive measures are applied. These findings should be confirmed in larger cohorts, and further observations will be needed to understand the full spectrum of clinical features and the optimal approach to COVID-19 in patients with advanced CKD.

[Choice optimisation of radiation therapy technique for central neurocytomas from literature data]

Neurocytomas represent 0,25 to 0,5 of brain tumours. These tumours have neuronal differentiation. It's a young adult disease. The main treatment is neurosurgery. The place of other therapies is still unclear, noticeably with regards to radiotherapy. This review aim is to determine the place and the modalities of radiotherapy in the management of neurocytomas. A literature search using PubMed allowed to select the most relevant studies. Finally, 22 studies were selected according to pre-established criteria to answer the problem. All studies were retrospective studies except one. The analysis conclusion defined radiotherapy as a treatment of choice in selected patients, when surgical resection was incomplete or when tumour was atypical.

P1714INTRA-ABDOMINAL PRESSURE IS ASSOCIATED WITH HIGHER RENAL RESISTIVE INDEX AFTER RENAL TRANSPLANTATION

Background and Aims

The renal arterial resistive index (RRI) reflects renal hemodynamics non-invasively using Doppler arterial waveforms. RRI is defined by factors such as age, sex, weight, height or mean arterial pressure. Intra-abdominal hypertension (IAH) is a common complication among post-surgical patients that can affect renal blood flow. We aimed to determine the relationship between intra-abdominal pressure (IAP) and RRI in a sample of incident kidney transplant patients (KTs).

Method

Single-center prospective cohort of deceased-donor KTs. Anesthesia, surgical technique and immunosuppression induction therapy was the same in all cases. IAP monitoring was performed according to WSACS guidelines using the urinary bladder technique (UnoMeter Abdo-Pressure kit). IAP values were registered every 8h during the first 72h after surgery or until reoperation. Mean IAP values during the first 24h (24h-IAP) were used in this analysis. Doppler ultrasonography was performed 24h after surgery. RRI was calculated using the following formula: (peak systolic velocity – end-diastolic velocity)/peak systolic velocity. The study was approved by the local ethics committee and written informed consent was obtained in all cases.

Results

137 patients were enrolled. Table 1 summarizes relevant patient and hemodynamic variables. Stepwise multivariate linear regression analysis was used to examine independent predictors of RRI in this sample, including all variables in Table 1. Age (β=0.005, std.error=0.001, P&lt;0.001), dialysis vintage (β=0.001, std.error&lt;0.001, P=0.02) and 24h-IAP (β=0.005, std.error=0.003, P=0.041) were independent predictors of RRI.

Conclusion

Increased IAP in the first 24h after surgery is common in KTs and is correlated with higher RRI, which is associated with increased risk of graft loss and death.

P0575TIME TO NEPHROLOGY CONSULTATION AND MORTALITY RISK IN COMMMUNITY ACQUIRED AKI

Background and Aims

Acute Kidney Injury (AKI) is the most frequent cause of Nephrology consultation. Although time to nephrology consultation (TNC) has been object of study, few works focus on its influence on in-hospital mortality in patients with community acquired AKI (CA-AKI).

Method

We picked cases of CA-AKI, and divided individuals in dead in-hospital and survivors. We analyzed clinical and epidemiological variables, and categorized AKI with the KDIGO-2012 stages. We compared clinical outcomes and influence of TNC in mortality.

Results

We included 420 patients, 92 (22%) in the mortality group. These individuals were older, had higher Charlson’s Index, were hospitalized in critical care units, and were classified in KDIGO-2012 Stage 3 more frequently (Table 1). TNC was higher in the dead patients and was significantly associated with mortality HR 1.28 (CI 95% 1.03-1.55, P=0,009). In KDIGO Stages 1 and 2 TNC was shorter in the survivors group, and in Stage 3 we found no differences. In general wards (medical and surgical), TNC was higher in the mortality group, with no differences in the consults from critical units (Table 1). In the survival curves we observe a decline in survival in patients with TNC ≥2 days since admission (Figure 1).

Conclusion

We found that a longer TNC was associated with a poorer survival. This finding would indicate that earlier nephrology attention could impact in-hospital mortality. We interpret the longer TNC in less severe AKI stages as a warning of the unawareness and late recognition of AKI in other specialties. More well designed and larger studies are needed to prove that electronic alerts offer a survival benefit.

P1644SAPS AND EPTS SCORES AS PREDICTORS OF RENAL FUNCTION IN RECENT RENAL TRANSPLANTATION

Background and Aims

The risk scores used in Critical Care Units estimate the severity and mortality of patients. The SAPS (Simplified Acute Physiologic Score) and its SAPS II and SAPS III variants calculate the severity by collecting the values recorded in the first 24 hours. The EPTS (Estimated Post-Transplant-Survival) is used as a reference for the allocation of organs in the US by the OPTN. The objective is to determine its use in recent renal transplant units as estimator of subsequent renal function, in services where patients move from the operating room to a nephrological intermediate care unit.

Method

The SAPS (II and III) and OPTN scores were applied in 87 (N = 87) consecutive renal transplanted patients. The point value of each of the scales was evaluated with the creatinine values at hospital discharge, and one month after the transplant. The scores obtained on the SAPS scales were divided as follows (SAPSIIA &lt;20 points, SAPSIIB ≥20 points) (SAPSIII A &lt;30 points, SAPSIIIB ≥30 points). In the EPTS scale, two cut-off points were used to divide the groups (20% Score; EPTS-IA ≤20%, EPTS-IB&gt; 20%), (Score 40%; EPTS-IIA ≤40%, EPTS -IIB&gt; 40). The sérum creatinine means of each of the groups were compared. Data were analyzed with SPSS 20.0.0

Results

Significant differences were found in serum creatinine levels in renal function at the first month of transplantation in the SAPS II groups (SAPS IIA 1.38 mg / dl, SAPS IIB 1.79 mg / dl; P = 0.017 95% CI). With an area under the ROC curve of 0.65 (P = 0.017 95% CI). In the SAPS III groups no significant differences were found. In the EPTS scales, there were also significant differences in creatinine one month after the transplant in the group with a score of 40% (EPTS-IIA ≤40% 1.42 mg / dl, EPTS-IIB&gt; 40 1.81 mg / dl; P = 0.024 95% CI) With an Area under the ROC curve of 0.64 (P = 0.037 95% CI).

Conclusion

The SAPSII and EPTS scores can be a useful tool in estimating renal function one month after renal transplantation, giving a prognosis of renal graft function. The combined use of these scales together with other functional graft tests could have an important relevance in the management and follow-up of recent renal transplantation. Other studies with larger sample sizes are necessary to establish the appropriate cut-off points for the scales.

P1717OUTCOMES OF INCREASED INTRA-ABDOMINAL PRESSURE AFTER KIDNEY TRANSPLANTATION

Background and Aims

Increased intra-abdominal pressure (IAP) is commonly found among post-surgical patients and can induce organ dysfunction. However, its prevalence and impact after kidney transplantation have not been adequately described. We aimed to study the prevalence of increased IAP after kidney transplantation and its consequences on transplant outcomes.

Method

IAP was prospectively measured in 121 kidney transplant recipients every 8h during the first 72h after surgery using the urinary bladder technique (UnoMeter Abdo-Pressure kit). Mean IAP values during the first 24h (24h-IAP) were used in this analysis. Grading of intra-abdominal hypertension was defined according to WSACS guidelines. Patients were followed for at least 12 months or until graft failure or death. The study was approved by the local ethics committee and informed consent was obtained in all cases.

Results

24h-IAP was 12.6±3.5 mmHg. 84.2% of subjects presented with intra-abdominal hypertension during the first 72h after kidney transplantation. Body mass index (OR: 1.35, 95% CI 1.12-1.63; P=0.002), male sex (OR: 3.34, 95% CI 1.1-10.3; P=0.032) and hemodialysis as renal replacement therapy before transplantation (OR: 4.35, 95% CI 1.32-14.4; P=0.016) were independent determinants of intra-abdominal hypertension. IAP was an independent risk factor for delayed graft function (*model adjusted for recipient age, sex, history of previous kidney transplants, recipient comorbidities, donor terminal serum creatinine and comorbidities, number of HLA mismatches &gt;4, cold ischemia time and donation after cardiac death status), graft failure and death (**model adjusted for all variables included in the previous model plus delayed graft failure) (Figure).

Conclusion

Increased IAP was highly common after transplant surgery and was associated with higher rates of delayed graft function, graft failure and death. Routine IAP monitoring should be considered after transplantation to facilitate early identification of complications and initiation of the appropriate treatment to stop its effects.

MO013PATERNAL SAFETY OF THE USE OF MYCOPHENOLIC ACID BY KIDNEY TRANSPLANT RECIPIENTS. RESULTS OF THE EMVARON STUDY

Background and Aims

Mycophenolic acid (MPA) is one of the most used immunosuppressive drugs. It is teratogenic in women with a typical embryopathy profile. Regarding its effect on the children of male kidney transplant recipients, although clinical evidence does not indicate a greater risk of malformations, the European Medicines Agency and the Spanish Agency for Medicines and Health Products introduced in 2015 the recommendation to use contraceptive methods because of their genotoxic potential.

For this reason, we propose to study the results of the Spanish Kidney Transplant Centers.

Method

Multicenter retrospective observational study in which 15 Kidney Transplant Centers have participated. Of 3934 men ≤ 60 years old that received a kidney transplant between 2000 and 2015, 3023 were contacted, and 159 men who fathered at least one post-transplant pregnancy (total 252 fetuses) were included. We compared the incidence of abortions and live births with malformations among those who received MPA at the time of conception vs. those who did not.

Results

In the 252 fetuses (characteristics in table 1) there was an exitus and no differences were detected in the incidence of abortions between the group exposed to MPA (n = 230) and the unexposed group (n = 22), 11.3% vs 18.2%, p = 0.31. Among the 221 live-born fetuses, no differences were found in congenital malformations between the group exposed to MPA (n = 203) and the unexposed (n = 18) 4.9% vs. 16.7%, p = 0.07. Among the malformations described, the typical embryopathy profile of the MPA was not found.

Conclusion

According to the data of this retrospective national multicenter study, the use of MPA in male kidney transplant recipients does not cause a greater number of abortions or congenital malformations.

For these reasons, and given the evidence also published by other groups, it seems necessary to reevaluate the recommendation given on contraception in men treated with MPA.

P1728FUROSEMIDE STRESS TEST PREDICTS DISCHARGE SERUM CREATININE AFTER KIDNEY TRANSPLANTATION

Background and Aims

Acute tubular necrosis is a common complication after kidney transplantation and is closely related to delayed graft function (DGF) and slower graft function recovery after surgery. The furosemide stress test (FST) uses a standardized dose of furosemide to evaluate the integrity of the renal tubule and determine which patients have developed severe tubular damage. We aimed to apply the FST to a sample of incident deceased-donor kidney transplant recipients and describe its association with DGF and serum creatinine (SCr) at discharge.

Method

Single-center prospective observational study of deceased-donor kidney transplant recipients. The FST, a standardized bolus dose of furosemide (1.5 mg/kg) was administered between the 3rd and 5th day after surgery. Patients were excluded if, during that time period, they presented evidence of active bleeding, obstructive uropathy or volume depletion. Urine output (UO) 60 and 120 min after FST was registered. To reduce the risk of hypovolemia, each ml of UO produced for six hours after FST was replaced with 1 ml of normal saline.

Results

25 patients were included in the study. Mean 2h FST UO was 1012±570 ml. Demographic and clinical data are summarized in Table 1. Subjects that suffered DGF had a significantly lower 2h FST UO (534 vs 1164 ml; P=0.015). In adjusted linear regression analysis only a 2h FST UO&lt;1000 ml (β=0.906; 95%CI: 0.04-1.772; P=0.041) and DGF (β=1.592; 95%CI: 0.488-2.696; P=0.008) were independent predictors of SCr at discharge (model adjusted for recipient age, cold ischemia time, number of HLA mismatches, donor SCr and donor hypertension).

Conclusion

Recipients with a 2h FST UO &lt;1000 ml suffered DGF more frequently. FST and DGF were independent predictors of SCr at discharge. A standardized FST could help clinicians distinguish patients with more severe tubular dysfunction and higher risk of DGF.

P0208DIFFERENTIAL ADAPTATION OF RENAL FUNCTION IN TWO TYPES OF INTENSE PHYSICAL EXERCISE

Background and Aims

Marathon running induces AKI even in adequately prepared and healthy athletes. Heat stress, maintained during more than 2h, has been proposed as one of the leading causes of AKI in marathons runners. Other possible explanations of AKI in this setting could be associated with a reduction of blood supply to the kidneys during the exercise, inadequate hydration or actual structural damage due to microtraumatisms. However, the effect of vigorous exercise of shorter duration on renal function has not been previously described although most risk factors described could also affect kidney function in this type of physical activity.

Method

40 volunteer healthy athletes were enrolled in this study. Subjects participated in two physical tests (10km running, 1.5km swimming) which were separated by at least two weeks from each other. These tests were chosen because of their similar oxygen consumption rate and metabolic load. Vitals, blood and urine samples were collected immediately before and after each test. Informed consent was obtained from all participants. The project was funded by Consejería de Sanidad, Junta de Castilla y León (GRS1732/A/18).

Results

Athletes ranged from 23 to 53 years old. 35% were female. A comparison of hemodynamic and analytical parameters is summarized in Table 1. Running induced a significantly higher rise of serum creatinine and inflammatory markers compared to swimming. Additionally, running caused an increment of serum phosphorus and uric acid levels. Both types of exercise caused a mild increase of urinary albumin/creatinine ratio.

Conclusion

Compared to swimming, running was associated with a greater rise of serum creatinine, possibly linked to a higher degree of acute inflammation and blood flow redistribution to the muscles. The rise of serum uric acid levels may be associated with increased metabolism and reduced elimination of this molecule while running.

Role of the Furosemide Stress Test in Renal Injury Prognosis

Risk stratification and accurate patient prognosis are pending issues in the management of patients with kidney disease. The furosemide stress test (FST) has been proposed as a low-cost, fast, safe, and easy-to-perform test to assess tubular integrity, especially when compared to novel plasma and urinary biomarkers. However, the findings regarding its clinical use published so far provide insufficient evidence to recommend the generalized application of the test in daily clinical routine. Dosage, timing, and clinical outcomes of the FST proposed thus far have been significantly different, which further accentuates the need for standardization in the application of the test in order to facilitate the comparison of results between series. This review will summarize published research regarding the usefulness of the FST in different settings, providing the reader some insights about the possible implications of FST in clinical decision-making in patients with kidney disease and the challenges that research will have to address in the near future before widely applying the FST.

[Impact of cognitive biases in therapeutic inertia in arterial hypertension: Not everything is as it seems]

Therapeutic inertia is defined as the failure to take therapeutic decisions, such as initiating, adding or increasing the dose of a drug during patient follow-up, despite there being an indication to do so. It is currently considered that therapeutic inertia is a considerable impediment to achieving adequate control of hypertension, and this has implications for the prognosis of the disease. Therapeutic inertia might be due to various factors involving physicians, patients and the health system. Many studies have attempted to find determinants for therapeutic inertia in hypertension and to explain the reasons why health professionals in charge of treatment are failing to make the appropriate modifications to therapy. The many reasons for therapeutic inertia on the part of physicians include the various cognitive and affective biases that influence clinical reasoning and decision-making during healthcare activity in doctors' surgeries. Identifying and recognising these cognitive and affective biases could be important for planning educational strategies for health professionals. This requires a multi-dimensional approach, including knowledge beyond that observed in terms of insufficient information and updating on the disease, and starting to analyse and consider other reasons. Preventing therapeutic inertia should be made a priority along with other important measures to control hypertension and minimise its consequences.