Niacinamide May Be Associated with Improved Outcomes in COVID-19-Related Acute Kidney Injury: An Observational Study

Background

AKI is a significant complication of coronavirus disease 2019 (COVID-19), with no effective therapy. Niacinamide, a vitamin B3 analogue, has some evidence of efficacy in non-COVID-19-related AKI. The objective of this study is to evaluate the association between niacinamide therapy and outcomes in patients with COVID-19-related AKI.

Methods

We implemented a quasi-experimental design with nonrandom, prospective allocation of niacinamide in 201 hospitalized adult patients, excluding those with baseline eGFR <15 ml/min per 1.73 m² on or off dialysis, with COVID-19-related AKI by Kidney Disease Improving Global Outcomes (KDIGO) criteria, in two hospitals with identical COVID-19 care algorithms, one of which additionally implemented treatment with niacinamide for COVID-19-related AKI. Patients on the niacinamide protocol (B3 patients) were compared against patients at the same institution before protocol commencement and contemporaneous patients at the non-niacinamide hospital (collectively, non-B3 patients). The primary outcome was a composite of death or RRT.

Results

A total of 38 out of 90 B3 patients and 62 out of 111 non-B3 patients died or received RRT. Using multivariable Cox proportional hazard modeling, niacinamide was associated with a lower risk of RRT or death (HR, 0.64; 95% CI, 0.40 to 1.00; P=0.05), an association driven by patients with KDIGO stage-2/3 AKI (HR, 0.29; 95% CI, 0.13 to 0.65; P=0.03; P interaction with KDIGO stage=0.03). Total mortality also followed this pattern (HR, 0.17; 95% CI, 0.05 to 0.52; in patients with KDIGO stage-2/3 AKI, P=0.002). Serum creatinine after AKI increased by 0.20 (SEM, 0.08) mg/dl per day among non-B3 patients with KDIGO stage-2/3 AKI, but was stable among comparable B3 patients (+0.01 [SEM, 0.06] mg/dl per day; P interaction=0.03).

Conclusions

Niacinamide was associated with lower risk of RRT/death and improved creatinine trajectory among patients with severe COVID-19-related AKI. Larger randomized studies are necessary to establish a causal relationship.

Five-year follow-up of patients with radio-contrast-induced acute renal injury. Can intravenous sodium-bicarbonate improve long-term outcomes?

BACKGROUND/PURPOSE

Radiocontrast-induced acute kidney injury (RAKI) is a frequent complication during angiography and is associated with adverse prognosis. Most of the studies evaluating the long-term outcome of patients with RAKI are based on institutional registries. This is the first prospective study to evaluate the 5-year outcomes of patients with RAKI, and assess the effect of sodium bicarbonate (SB) in the long-term outcomes of patients with chronic kidney disease (CKD) undergoing non-emergent coronary angiography.

MATERIALS/METHODS

382 CKD stage III-IV patients undergoing elective non-emergent coronary angiography were randomized to SB (n = 192) or normal saline (NS) solution (n = 190). Incidence of RAKI, in-hospital, 1- and 5-year mortality and renal replacement therapy (RRT), and 5-year major adverse renal and cardiovascular events (MARCE) were compared between groups. Outcomes of patient with and without RAKI were compared after five-years of prospective follow-up. Multivariate predictors of RAKI and death at 5-years were determined.

RESULTS

The use of SB did not improve the incidence of RAKI, in-hospital outcomes, survival, and freedom from RRT or MARCE after 5-years of follow-up. Patients that developed RAKI had a significantly higher mortality at 1-year [8.9% Vs. 1.2%] and 5-years (36% Vs. 11%) (P < 0.01).

CONCLUSIONS

Hydration with SB showed no benefit compared to NS in preventing RAKI. The use of SB was not superior to NS after 5-years of follow-up regarding MARCE, survival or freedom of RRT. Five-year mortality among patients who developed RAKI remains high, and further research is needed to find the best preventive strategy for this high-risk group of patients.

SUMMARY

Radiocontrast-induced acute-kidney-injury (RAKI) is associated with poor long-term outcomes in observational and short-term studies. Hydration with sodium bicarbonate (SB) had been evaluated in the prevention of RAKI; but its long-term effect has not been evaluated. We randomized 382 high high-risk patients undergoing coronary angiography to SB or normal saline following them for five years. SB showed no benefit in preventing RAKI, decreasing major adverse renal and cardiovascular events, improving survival or freedom from dialysis after 5-years. This is the first study to follow patients with RAKI for a period of 5-years, showing a significantly higher mortality in this group of patients.

Outcomes of COVID-19 in Patients With a History of Cancer and Comorbid Cardiovascular Disease

BACKGROUND

Cancer and cardiovascular disease (CVD) are independently associated with adverse outcomes in patients with COVID-19. However, outcomes in patients with COVID-19 with both cancer and comorbid CVD are unknown.

METHODS

This retrospective study included 2,476 patients who tested positive for SARS-CoV-2 at 4 Massachusetts hospitals between March 11 and May 21, 2020. Patients were stratified by a history of either cancer (n=195) or CVD (n=414) and subsequently by the presence of both cancer and CVD (n=82). We compared outcomes between patients with and without cancer and patients with both cancer and CVD compared with patients with either condition alone. The primary endpoint was COVID-19-associated severe disease, defined as a composite of the need for mechanical ventilation, shock, or death. Secondary endpoints included death, shock, need for mechanical ventilation, need for supplemental oxygen, arrhythmia, venous thromboembolism, encephalopathy, abnormal troponin level, and length of stay.

RESULTS

Multivariable analysis identified cancer as an independent predictor of COVID-19-associated severe disease among all infected patients. Patients with cancer were more likely to develop COVID-19-associated severe disease than were those without cancer (hazard ratio [HR], 2.02; 95% CI, 1.53-2.68; P<.001). Furthermore, patients with both cancer and CVD had a higher likelihood of COVID-19-associated severe disease compared with those with either cancer (HR, 1.86; 95% CI, 1.11-3.10; P=.02) or CVD (HR, 1.79; 95% CI, 1.21-2.66; P=.004) alone. Patients died more frequently if they had both cancer and CVD compared with either cancer (35% vs 17%; P=.004) or CVD (35% vs 21%; P=.009) alone. Arrhythmias and encephalopathy were also more frequent in patients with both cancer and CVD compared with those with cancer alone.

CONCLUSIONS

Patients with a history of both cancer and CVD are at significantly higher risk of experiencing COVID-19-associated adverse outcomes. Aggressive public health measures are needed to mitigate the risks of COVID-19 infection in this vulnerable patient population.

Management of Cardiovascular Disease During Coronavirus Disease (COVID-19) Pandemic

Patients with pre-existing cardiovascular disease and risk factors are more likely to experience adverse outcomes associated with the novel coronavirus disease-2019 (COVID-19). Additionally, consistent reports of cardiac injury and de novo cardiac complications, including possible myocarditis, arrhythmia, and heart failure in patients without prior cardiovascular disease or significant risk factors, are emerging, possibly due to an accentuated host immune response and cytokine release syndrome. As the spread of the virus increases exponentially, many patients will require medical care either for COVID-19 related or traditional cardiovascular issues. While the COVID-19 pandemic is dominating the attention of the healthcare system, there is an unmet need for a standardized approach to deal with COVID-19 associated and other traditional cardiovascular issues during this period. We provide consensus guidance for the management of various cardiovascular conditions during the ongoing COVID-19 pandemic with the goal of providing the best care to all patients and minimizing the risk of exposure to frontline healthcare workers.

SAT-LB045 Maternal Obesity in Early Pregnancy Is Associated with the Decreased Active IGF-I Availability and Increased Leptin Concentrations

Introduction: Maternal obesity (MO) is the global health problem, associated with high fetal and maternal mortality. Cardiovascular remodelling in obese pregnant patients has been linked to development of preeclampsia. IGF-I is important for maternal adaptation to pregnancy, e.g. maternal tissue growth and metabolism. Pregnancy-associated plasma protein-A2 (PAPP-A2) is a metalloproteinase that specifically cleaves IGFBP-3 and IGFBP-5 releasing active IGF-I. Leptin, produced by placenta and adipose tissue, is a cytokine with cardio metabolic properties, the concentration of which is increased in obese subjects and in pregnant patients. The aim of this study was to evaluate serum levels of PAPP-A2 (as an indicator of IGF -I pathway activation) and Leptin in the obese and non-obese patients in first trimester of pregnancy. Glycosylated fibronectin (GlyFib) and Inhibin A (Inh A) were evaluated as additional a markers of remodelling and placental function (respectively). Material and methods. This was a prospective observational study, patients were enrolled during first trimester of pregnancy according to the IRB-approved protocol (L#17-136): obese (OB, BMI ≥ 30 kg/m², n=13) and non-obese (nOB, BMI<30 kg/m² , n=14). Patients with pre-pregnancy cardiovascular pathology were excluded. Concentrations of PAAP-A2, GlyFib, Inh A and Leptin were measured, using commercially available ELISAs: AL-109, AL-123 and AL-160 from AnshLab (Webster, TX, USA) and Invitrogen (Waltham, MA). The data are presented as Mean ± SEM. Results. In 3/13 OB and in 1/14 nOB patients PAAP-A2 concentrations were below 0.3 MoM (CI [4.8 - 34 ng/ml] and [CI 5.8-21 ng/ml] respectively). GlyFib (OB, 303.4 ± 35.6 µg/ml; nOB, 208.7 ± 19.26 µg/ml) and Leptin concentrations (OB, 72775 ± 3802 pg/ml; nOB, 48882 ± 4052 pg/ml) were increased in OB patients compared to nOB (*p<0.05; ***p<0.0005, Mann-Whitney test, respectively). Inh A concentrations (OB, 479.6 ± 105.9 pg/ml; nOB, 381 ± 81.65 pg/ml) did not differ between two groups. In the nOB population, incidence of preeclampsia was 1/15 (6.7%) which was not associated with low PAPP-A2 levels. In the OB population, incidence of preeclampsia was 3/10 (30%) where 2/3 of cases were associated with low PAPP-A2 levels. Discussion. IGF-I and Leptin regulate cardiovascular remodelling and placentation. The mismatch of these two factors might represent the mechanism of pathological cardiovascular adaptation in OB pregnant patients. Limitations of this study are small sample size, non-inclusion of other predisposed populations (PCOS, GDM, autoimmune disorders) and loss to follow-up. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. Abstracts presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

Abstract P183: Maternal Obesity is Associated With Altered Cardiovascular Remodeling During Pregnancy

Introduction: Maternal obesity (MO) is the strongest risk factor for hypertensive disorders of pregnancy. Both, pregnancy and obesity are associated with the activation of inflammatory pathways, however, the information regarding pregnancy-related cardiac changes in MO as well as the role of leptin in the process is conflicting. The aim of this study was to evaluate echocardiographic and serum inflammatory changes in normal/overweight (NPW) (BMI 18.0-29.9) and obese pregnant women (OPW) (BMI >30) in the first and second trimesters of pregnancy.

Material and Methods: Nine obese (BMI 33.6±2.9) and seven non-obese (BMI 25.5±2.3) nulliparious women, who met inclusion criteria, were enrolled into IRB approved protocol in the first trimester of pregnancy. Blood pressure (systolic: SBP and diastolic (DBP) and heart rate (HR) were measured, transthoracic echocardiography was performed in the first and second pregnancy trimesters. Data was compared using Mann-Whitney test.

Results: SBP, DBP and HR were within normal range, but higher in OPW, compared to NPW in both trimesters (Table 1). The left ventricular mass (LVM) was higher, and ratio of the early (E) to late (A) ventricular filling velocities (E/A ratio) was lower in OPW, compared to NPW in the first trimester. There was increase in stroke volume (SV), left atrium (LA) size, LVM and decrease in E/A in second, compared to first trimesters in both groups. SV enhanced less in OPW. Leptin concentration was higher in OPW and inversely correlated with stroke volume (SV) in the second trimester.

Conclusion: Maternal obesity alters pregnancy-driven changes in systolic and diastolic heart function.

Abstract 493: Serum Leptin and TNFa Levels in Relation to Systolic and Diastolic Heart Function in Obese and Normal-overweight Pregnant. First Trimester Data

Introduction: Maternal obesity (MO) defined as pre-pregnancy body-mass index (BMI) >30kg/m2, is the strongest risk factors for preeclampsia (PE). Information regarding cardiac changes in MO as well as the role of inflammatory biomarkers in PE pathogenesis is conflicting.

The aim of this study was to evaluate echocardiography changes in normal/ overweight pregnant (NP) (BMI 18.0-30) and obese pregnant women (OP) (BMI>30) and to correlate them to dynamics of biomarkers (leptin, TNFa, BNP, pentraxin-3, IL6) and mRNA.

Material and methods: There were 11 OP (BMI 33.6±2.9) and 13 NP (BMI 25.5±2.3) enrolled into this study in the first trimester of pregnancy. All patients were nulliparous. There were no differences between OP and NP according to age and number of previous pregnancies. Patients with pre-pregnancy cardiovascular pathology were excluded. The 2D echocardiography with Doppler was performed in each pregnancy trimester. Echocardiography results, leptin and TNFa in the first trimester are available for now.

Results: Left ventricular (LV) mass was significantly higher while ejection fraction (EF) and ratio of the early (E) to late (A) ventricular filling velocities (E/A ratio) appeared to be lower in OP, compared to NP (Table). Leptin was higher in OP. TNFa inversely correlated with stroke volume (SV), MO positively associated with leptin levels and negatively with E/A ratio (p<0.05).

Conclusion: Differences in systolic and diastolic heart function between OP and NW are being evident already in the first trimester. Involvement of leptin and TNFa; might be suggested. Identifying biochemical mechanisms driving cardiac changes in MO are crucial for PE prevention.