The Butterfly Effect: Multifaceted Consequences of Sensitizer Concentration Change in Phase Transition-based Luminescent Thermometer of LiYO2:Er3+,Yb3

In response to the ongoing quest for new, highly sensitive upconverting luminescent thermometers, this article introduces, for the first time, upconverting luminescent thermometers based on thermally induced structured phase transitions. As demonstrated, the transition from the low-temperature monoclinic to the high-temperature tetragonal structures of LiYO2:Yb3+,Er3+ induces multifaceted modification in the spectroscopic properties of the examined material, influencing the spectral positions of luminescence bands, energy gap values between thermally coupled energy levels, and the red-to-green emission intensities ratio. Moreover, as illustrated, both the color of the emitted light and the phase transition temperature (from 265 K, for LiYO2:Er3+, 1%Yb3+, to 180 K, for 10%Yb3+), and consequently, the thermometric parameters of the luminescent thermometer can be modulated by the concentration of Yb3+ sensitizer ions. Establishing a correlation between the phase transition temperature and the mismatch of ion radii between the host material and dopant ions allows for smooth adjustment of the thermometric performance of such a thermometer following specific application requirements. Three different thermometric approaches were investigated using thermally coupled levels (SR = 1.8%/K at 180 K for 1%Yb3+), green to red emission intensities ratio (SR = 1.5%/K at 305 K for 2%Yb3+), and single band ratiometric approach (SR = 2.5%/K at 240 K for 10%Yb3+). The thermally induced structural phase transition in LiYO2:Er3+,Yb3+ has enabled the development of multiple upconverting luminescent thermometers. This innovative approach opens avenues for advancing the field of luminescence thermometry, offering enhanced relative thermal sensitivity and adaptability for various applications.

Protein Biomarkers and Major Cardiovascular Events in Older People With Advanced CKD: The European Quality (EQUAL) Study

Rationale & Objective

Cardiovascular disease is the leading cause of morbidity and mortality in chronic kidney disease (CKD). We investigated 184 inflammatory and cardiovascular proteins to determine their potential as biomarkers for major cardiovascular events (MACEs).

Study Design

The European Quality (EQUAL) is an observational cohort study that enrolled people aged ≥65 years with an estimated glomerular filtration rate ≤20 mL/min/1.73 m2.

Setting & Participants

Recruited participants were split into the discovery (n = 611) and replication cohorts (n = 292).

Exposure

Levels of 184 blood proteins were measured at the baseline visit, and each protein was analyzed individually.

Outcome

MACE.

Analytical Approach

Cox proportional hazard models adjusted for age, sex, estimated glomerular filtration rate, previous MACE, and country were used to determine the risk of MACE. Proteins with false discovery rate adjusted P values of <0.05 in the discovery cohort were tested in the replication cohort. Sensitivity analyses were performed by adjusting for traditional risk factors, CKD-specific risk factors, and level of proteinuria and segregating atherosclerotic and nonatherosclerotic MACE.

Results

During a median follow-up of 2.9 years, 349 people (39%) experienced a MACE. Forty-eight proteins were associated with MACE in the discovery cohort; 9 of these were reproduced in the replication cohort. Three of these proteins maintained a strong association with MACE after adjustment for traditional and CKD-specific risk factors and proteinuria. Tenascin (TNC), fibroblast growth factor-23 (FGF-23), and V-set and immunoglobulin domain-containing protein 2 (VSIG2) were associated with both atherosclerotic and nonatherosclerotic MACE. All replicated proteins except carbonic anhydrase 1 and carbonic anhydrase 3 were associated with nonatherosclerotic MACE.

Limitations

Single protein concentration measurements and limited follow-up time.

Conclusions

Our findings corroborate previously reported relationships between FGF-23, vascular cell adhesion protein-1, TNC, and placental growth factor with cardiovascular outcomes in CKD. We identify 5 proteins not previously linked with MACE in CKD that may be targets for future therapies.

Plain-Language Summary

Kidney disease increases the risk of heart disease, stroke, and other vascular conditions. Blood tests that predict the likelihood of these problems may help to guide treatment, but studies are needed in people with kidney disease. We analyzed blood tests from older people with kidney disease, looking for proteins associated with higher risk of these conditions. Nine proteins were identified, of which 3 showed a strong effect after all other information was considered. This work supports previous research regarding 4 of these proteins and identifies 5 additional proteins that may be associated with higher risk. Further work is needed to confirm our findings and to determine whether these proteins can be used to guide treatment.

The impact of gender on the risk of cardiovascular events in older adults with advanced chronic kidney disease

Background

Patients with chronic kidney disease (CKD) are at a higher risk of major adverse cardiovascular events (MACE) compared with the general population, but gender differences in this risk, especially in older adults, are not fully known. We aim to identify gender differences in the risk of MACE in older European CKD patients, and explore factors that may explain these differences.

Methods

The European Quality study (EQUAL) is a prospective study on stage 4-5 CKD patients, ≥65 years old, not on dialysis, from Germany, Italy, the Netherlands, Poland, Sweden and the UK. Cox regression and cumulative incidence competing risk curves were used to identify gender differences in MACE risks. Mediation analysis was used to identify variables which may explain risk differences between men and women.

Results

A total of 417 men out of 1134 (37%) and 185 women out of 602 women (31%) experienced at least one MACE, over a follow-up period of 5 years. Women had an 18% lower risk of first MACE compared with men (hazard ratio 0.82; 95% confidence interval 0.69-0.97; P = .02), which was attenuated after adjusting for pre-existing cardiometabolic comorbidities and cardiovascular risk factors. There were no significant gender differences in the risk of recurrent MACE or fatal MACE. The risk difference in MACE by gender was larger in patients aged 65-75 years, compared with patients over 75 years.

Conclusions

In a cohort of older adults with advanced CKD, women had lower risks of MACE. These risk differences were partially explained by pre-existing cardiometabolic comorbidities and cardiovascular risk factors.

Association between CKD-MBD and mortality in older patients with advanced CKD-results from the EQUAL study

BACKGROUND

Chronic kidney disease-mineral and bone disorder (CKD-MBD) is a common complication of CKD; it is associated with higher mortality in dialysis patients, while its impact in non-dialysis patients remains mostly unknown. We investigated the associations between parathyroid hormone (PTH), phosphate and calcium (and their interactions), and all-cause, cardiovascular (CV) and non-CV mortality in older non-dialysis patients with advanced CKD.

METHODS

We used data from the European Quality study, which includes patients aged ≥65 years with estimated glomerular filtration rate ≤20 mL/min/1.73 m2 from six European countries. Sequentially adjusted Cox models were used to assess the association between baseline and time-dependent CKD-MBD biomarkers and all-cause, CV and non-CV mortality. Effect modification between biomarkers was also assessed.

RESULTS

In 1294 patients, the prevalence of CKD-MBD at baseline was 94%. Both PTH [adjusted hazard ratio (aHR) 1.12, 95% confidence interval (CI) 1.03-1.23, P = .01] and phosphate (aHR 1.35, 95% CI 1.00-1.84, P = .05), but not calcium (aHR 1.11, 95% CI 0.57-2.17, P = .76), were associated with all-cause mortality. Calcium was not independently associated with mortality, but modified the effect of phosphate, with the highest mortality risk found in patients with both hypercalcemia and hyperphosphatemia. PTH level was associated with CV mortality, but not with non-CV mortality, whereas phosphate was associated with both CV and non-CV mortality in most models.

CONCLUSIONS

CKD-MBD is very common in older non-dialysis patients with advanced CKD. PTH and phosphate are independently associated with all-cause mortality in this population. While PTH level is only associated with CV mortality, phosphate seems to be associated with both CV and non-CV mortality.

Clinical and patient-reported trajectories at end-of-life in older patients with advanced CKD

BACKGROUND

We explore longitudinal trajectories of clinical indicators, patient-reported outcomes, and hospitalizations, in the years preceding death in a population of older patients with advanced chronic kidney disease (CKD).

METHODS

The EQUAL study is a European observational prospective cohort study with an incident eGFR <20 ml/min per 1.73 m2 and ≥65 years of age. The evolution of each clinical indicator was explored using generalized additive models during the 4 years preceding death.

RESULTS

We included 661 decedents with a median time to death of 2.0 years (IQR 0.9-3.2). During the years preceding death, eGFR, Subjective Global Assessment score, and blood pressure declined, with accelerations seen at 6 months preceding death. Serum hemoglobin, hematocrit, cholesterol, calcium, albumin, and sodium values declined slowly during follow-up, with accelerations observed between 6 and 12 months preceding death. Physical and mental quality of life declined linearly throughout follow-up. The number of reported symptoms was stable up to 2 years prior to death, with an acceleration observed at 1 year prior to death. The rate of hospitalization was stable at around one hospitalization per person year, increasing exponentially at 6 months preceding death.

CONCLUSIONS

We identified clinically relevant physiological accelerations in patient trajectories that began ∼6 to 12 months prior to death, which are likely multifactorial in nature, but correlate with a surge in hospitalizations. Further research should focus on how to effectively use this knowledge to inform patient and family expectations, to benefit the planning of (end-of-life) care, and to establish clinical alert systems.

Serum Potassium and Risk of Death or Kidney Replacement Therapy in Older People With CKD Stages 4-5: Eight-Year Follow-up

RATIONALE & OBJECTIVE

Hypokalemia may accelerate kidney function decline. Both hypo- and hyperkalemia can cause sudden cardiac death. However, little is known about the relationship between serum potassium and death or the occurrence of kidney failure requiring replacement therapy (KRT). We investigated this relationship in older people with chronic kidney disease (CKD) stage 4-5.

STUDY DESIGN

Prospective observational cohort study.

SETTING & PARTICIPANTS

We followed 1,714 patients (≥65 years old) from the European Quality (EQUAL) study for 8 years from their first estimated glomerular filtration rate (eGFR)<20mL/min/1.73m2 measurement.

EXPOSURE

Serum potassium was measured every 3 to 6 months and categorized as≤3.5,>3.5-≤4.0,>4.0-≤4.5,>4.5-≤5.0 (reference),>5.0-≤5.5, >5.5-≤6.0, and>6.0mmol/L.

OUTCOME

The combined outcome death before KRT or start of KRT.

ANALYTICAL APPROACH

The association between categorical and continuous time-varying potassium and death or KRT start was examined using Cox proportional hazards and restricted cubic spline analyses, adjusted for age, sex, diabetes, cardiovascular disease, renin-angiotensin-aldosterone system (RAAS) inhibition, eGFR, and subjective global assessment (SGA).

RESULTS

At baseline, 66% of participants were men, 42% had diabetes, 47% cardiovascular disease, and 54% used RAAS inhibitors. Their mean age was 76±7 (SD) years, mean eGFR was 17±5 (SD) mL/min/1.73m2, and mean SGA was 6.0±1.0 (SD). Over 8 years, 414 (24%) died before starting KRT, and 595 (35%) started KRT. Adjusted hazard ratios for death or KRT according to the potassium categories were 1.6 (95% CI, 1.1-2.3), 1.4 (95% CI, 1.1-1.7), 1.1 (95% CI, 1.0-1.4), 1 (reference), 1.1 (95% CI, 0.9-1.4), 1.8 (95% CI, 1.4-2.3), and 2.2 (95% CI, 1.5-3.3). Hazard ratios were lowest at a potassium of about 4.9mmol/L.

LIMITATIONS

Shorter intervals between potassium measurements would have allowed for more precise estimations.

CONCLUSIONS

We observed a U-shaped relationship between serum potassium and death or KRT start among patients with incident CKD 4-5, with a nadir risk at a potassium level of 4.9mmol/L. These findings underscore the potential importance of preventing both high and low potassium in patients with CKD 4-5.

PLAIN-LANGUAGE SUMMARY

Abnormal potassium blood levels may increase the risk of death or kidney function decline, especially in older people with chronic kidney disease (CKD). We studied 1,714 patients aged≥65 years with advanced CKD from the European Quality (EQUAL) study and followed them for 8 years. We found that both low and high levels of potassium were associated with an increased risk of death or start of kidney replacement therapy, with the lowest risk observed at a potassium level of 4.9 mmol/L. In patients with CKD, the focus is often on preventing high blood potassium. However, this relatively high optimum potassium level stresses the potential importance of also preventing low potassium levels in older patients with advanced CKD.

Symptom Burden before and after Dialysis Initiation in Older Patients

BACKGROUND AND OBJECTIVES

For older patients with kidney failure, lowering symptom burden may be more important than prolonging life. Dialysis initiation may affect individual kidney failure-related symptoms differently, but the change in symptoms before and after start of dialysis has not been studied. Therefore, we investigated the course of total and individual symptom number and burden before and after starting dialysis in older patients.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The European Quality (EQUAL) study is an ongoing, prospective, multicenter study in patients ≥65 years with an incident eGFR ≤20 ml/min per 1.73 m2. Using the dialysis symptom index (DSI), 30 symptoms were assessed every 3-6 months between 2012 and 2021. Scores for symptom number range from zero to 30 and, for burden, from zero to 150, with higher scores indicating more severity. Using mixed effects models, we studied symptoms during the year preceding and the year after dialysis initiation.

RESULTS

We included 456 incident patients on dialysis who filled out at least one DSI during the year before or after dialysis. At dialysis initiation, mean (SD) participant age was 76 (6) years, 75% were men, mean (SD) eGFR was 8 (3) ml/min per 1.73 m2, 44% had diabetes, and 46% had cardiovascular disease. In the year before dialysis initiation, symptom number increased +3.6 (95% confidence interval [95% CI], +2.5 to +4.6) and symptom burden increased +13.3 (95% CI, +9.5 to +17.0). In the year after, symptom number changed -0.9 (95% CI, -3.4 to +1.5) and burden decreased -5.9 (95% CI, -14.9 to -3.0). At dialysis initiation, "fatigue," "decreased interest in sex," and "difficulty becoming sexually aroused" had the highest prevalence of 81%, 69%, and 68%, respectively, with a burden of 2.7, 2.4, and 2.3, respectively. "Fatigue" somewhat improved after dialysis initiation, whereas the prevalence and burden of sexual symptoms further increased.

CONCLUSIONS

Symptom burden worsened considerably before and stabilized after dialysis initiation. "Fatigue," "decreased interest in sex," and "difficulty becoming sexually aroused" were considered most burdensome, of which only "fatigue" somewhat improved after dialysis initiation.

Nephropathic cystinosis in Poland: a 40-year retrospective study

INTRODUCTION

Nephropathic cystinosis (NC) is a rare, autosomal recessive disorder leading to lysosomal accumulation of cystine. It is caused by mutations in the CTNS gene encoding a cystine cotransporter cystinosin. The infantile (INC) and juvenile (JNC) forms are distinguished. The former, responsible for 95% of cases, is characterized by development of renal Fanconi syndrome, end-stage kidney disease (ESKD), and extrarenal complications. A therapy with cysteamine significantly improves outcomes. There are limited data on NC in the Central Eastern European countries.

OBJECTIVES

We aimed to evaluate the prevalence, genetic background, and clinical course of NC in the Polish population.

PATIENTS AND METHODS

We performed a retrospective analysis of data of all identified NC patients in Poland.

RESULTS

Between 1982 and 2017, 15 patients with NC (13 ICN, 2 JCN) were identified. The most common mutations of the CTNS gene were c.18_c.21delGACT and c.681+1G>A, whereas only 2 patients carried the 57 kb deletion. The majority (11/13) of INC patients with limited access to the cysteamine therapy developed ESKD at a median age of 11 years and 9 of them received kidney transplants. Three INC patients died at a median age of 24 years. In contrast, 2 INC patients treated adequately present normal kidney function and growth at the age of 13 and 11 years. Two JNC patients presented a milder course.

CONCLUSIONS

The prevalence of NC in Poland is much lower than in the Western countries and its molecular background appears to be different. The unfavorable course in the majority of INC patients was caused by a limited access to the cysteamine treatment.

The association between TMAO, CMPF, and clinical outcomes in advanced chronic kidney disease: results from the European QUALity (EQUAL) Study

BACKGROUND

Trimethylamine N-oxide (TMAO), a metabolite from red meat and fish consumption, plays a role in promoting cardiovascular events. However, data regarding TMAO and its impact on clinical outcomes are inconclusive, possibly due to its undetermined dietary source.

OBJECTIVES

We hypothesized that circulating TMAO derived from fish intake might cause less harm compared with red meat sources by examining the concomitant level of 3-carboxy-4-methyl-5-propyl-2-furanpropionate (CMPF), a known biomarker of fish intake, and investigated the association between TMAO, CMPF, and outcomes.

METHODS

Patients were recruited from the European QUALity (EQUAL) Study on treatment in advanced chronic kidney disease among individuals aged ≥65 y whose estimated glomerular filtration rate (eGFR) had dropped for the first time to ≤20 mL/min per 1.73 m2 during the last 6 mo. The association between TMAO, CMPF, and outcomes including all-cause mortality and kidney replacement therapy (KRT) was assessed among 737 patients. Patients were further stratified by median cutoffs of TMAO and CMPF, suggesting high/low red meat and fish intake.

RESULTS

During a median of 39 mo of follow-up, 232 patients died. Higher TMAO was independently associated with an increased risk of all-cause mortality (multivariable HR: 1.46; 95% CI: 1.17, 1.83). Higher CMPF was associated with a reduced risk of both all-cause mortality (HR: 0.79; 95% CI: 0.71, 0.89) and KRT (HR: 0.80; 95% CI: 0.71, 0.90), independently of TMAO and other clinically relevant confounders. In comparison to patients with low TMAO and CMPF, patients with low TMAO and high CMPF had reduced risk of all-cause mortality (adjusted HR: 0.49; 95% CI: 0.31, 0.73), whereas those with high TMAO and high CMPF showed no association across adjusted models.

CONCLUSIONS

High CMPF conferred an independent role in health benefits and might even counteract the unfavorable association between TMAO and outcomes. Whether higher circulating CMPF concentrations are due to fish consumption, and/or if CMPF is a protective factor, remains to be verified.

Angiotensin II Type 1 Receptor Antibodies Are Higher in Lupus Nephritis and Vasculitis than Other Glomerulonephritis Patients

Angiotensin II type 1 receptor (AT1R) antibodies are considered non-HLA (human leukocyte antigen) antibodies connected with humoral rejection after kidney transplantation. The role of AT1R antibodies in the pathogenesis of glomerular diseases and systemic vasculitis is unknown. We assessed the level of AT1R antibodies in 136 patients with different types of glomerulonephritis and systemic vasculitis and we observed kidney function and proteinuria, serum albumin and total protein levels for 2 years. The mean levels of AT1R antibodies were the following: 6.00 ± 1.31 U/ml in patients with membranous nephropathy (n = 18), 5.67 ± 1.31 U/ml with focal and segmental glomerulosclerosis (n = 25), 6.26 ± 2.25 U/ml with lupus nephropathy (n = 17), 10.60 ± 6.72 U/ml with IgA nephropathy (n = 14), 6.69 ± 2.52 U/ml with mesangial proliferative (non IgA) glomerulonephritis (n = 6), 6.63 ± 1.38 U/ml with systemic vasculitis (n = 56), including c-ANCA (anti-neutrophil cytoplasmic antibodies) vasculitis: 11.22 ± 10.78 U/ml (n = 40) and p-ANCA vasculitis: 12.65 ± 14.59 U/ml (n = 16). The mean AT1R antibodies level was higher in patients with lupus nephropathy and systemic vasculitis compared to glomerulonephritis groups. An inverse statistically significant correlation between AT1R antibodies and serum albumin (r =  − 0.51) in membranous nephropathy group was also found. Prospective analysis of creatinine levels indicated an increase of creatinine levels during time among patients with higher AT1R antibodies levels in p-ANCA vasculitis. Lupus nephropathy and systemic vasculitis patients may have high levels of AT1R antibodies. AT1R antibodies may be associated with the severity of membranous nephropathy and the course of p-ANCA vasculitis, although influence of concomitant factors is difficult to exclude.

Quality of Life before and after the Start of Dialysis in Older Patients

BACKGROUND AND OBJECTIVES

In older people with kidney failure, improving health-related quality of life is often more important than solely prolonging life. However, little is known about the effect of dialysis initiation on health-related quality of life in older patients. Therefore, we investigated the evolution of health-related quality of life before and after starting dialysis in older patients with kidney failure.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The European Quality study is an ongoing prospective, multicenter study in patients aged ≥65 years with an incident eGFR ≤20 ml/min per 1.73 m². Between April 2012 and December 2021, health-related quality of life was assessed every 3-6 months using the 36-item Short-Form Health Survey (SF-36), providing a mental component summary (MCS) and a physical component summary (PCS). Scores range from zero to 100, with higher scores indicating better health-related quality of life. With linear mixed models, we explored the course of health-related quality of life during the year preceding and following dialysis initiation.

RESULTS

In total, 457 patients starting dialysis were included who filled out at least one SF-36 during follow-up. At dialysis initiation, mean ± SD age was 76±6 years, eGFR was 8±3 ml/min per 1.73 m², 75% were men, 9% smoked, 45% had diabetes, and 46% had cardiovascular disease. Median (interquartile range) MCS was 53 (38-73), and median PCS was 39 (27-58). During the year preceding dialysis, estimated mean change in MCS was -13 (95% confidence interval, -17 to -9), and in PCS, it was -11 (95% confidence interval, -15 to -7). In the year following dialysis, estimated mean change in MCS was +2 (95% confidence interval, -7 to +11), and in PCS, it was -2 (95% confidence interval, -11 to +7). Health-related quality-of-life patterns were similar for most mental (mental health, role emotional, social functioning, vitality) and physical domains (physical functioning, bodily pain, role physical).

CONCLUSIONS

Patients experienced a clinically relevant decline of both mental and physical health-related quality of life before dialysis initiation, which stabilized thereafter. These results may help inform older patients with kidney failure who decided to start dialysis.

FC093: Symptom Burden and Individual Symptoms Before and After Dialysis Initiation in Older Patients

BACKGROUND AND AIMS

In older people with end-stage kidney disease (ESKD), lowering symptom burden is likely more important than solely the prolongation of life. ESKD-related symptoms are multifactorial and dialysis initiation may affect distinct symptoms differently [1]. Symptoms caused by fluid overload (e.g. leg swelling) may be expected to improve, whereas those related to uremic toxins (e.g. itch) may remain. This, since protein-bound uremic toxins are dependent on tubular secretion and thus not sufficiently removed by dialysis treatment [2]. Furthermore, dialysis treatment itself may cause additional symptoms (e.g. fatigue). Therefore, we investigated the evolution of symptom burden and individual symptoms before and after starting dialysis in older ESKD patients.

METHOD

The European Quality (EQUAL) study is an ongoing prospective multicenter study in late stage 4/5 chronic kidney disease patients aged ≥65 years. Between April 2012 and December 2021, 30 kidney disease-related symptoms were assessed every 3–6 months using the dialysis symptom index (DSI). The sum score for symptom number ranges from 0 to 30 and for symptom severity from 0 to 150, with higher scores indicating a higher burden. We used mixed-effects models to study symptom burden and individual symptoms during the year preceding and following dialysis initiation.

RESULTS

In total, 456 incident dialysis patients were included. At baseline, dialysis initiation, mean (SD) age was 77 (6) years, eGFR 8 (4) mL/min/1.73 m2 75% were men, 45% had diabetes, 9% smoked and 45% had a history of cardiovascular disease. Mean (SD) number of symptoms was 15 (7) with a symptom severity of 46 (24). During the year preceding dialysis, symptom number increased by +3.4 [95% confidence interval (95% CI): +2.4 to +4.4] and severity by +13.9 (95% CI: +10.1 to +17.6). In the year following dialysis, symptom number decreased by –1.0 (95% CI: −2.1 to + 0.0) and symptom severity by –6.9 (95% CI: −10.8 to −3.0) (Figure 1). At start of dialysis, fatigue, decreased interest in sex and difficulty becoming sexually aroused had the highest prevalence of 81%, 69% and 68%, respectively, and highest burden with a mean severity of 2.7, 2.4 and 2.3, respectively. We observed three separate patterns in prevalence and severity of individual symptoms: (1) increase in the year before dialysis initiation and decrease in the year after (fatigue, trouble staying asleep, leg swelling, decreased appetite, shortness of breath, worrying, trouble falling asleep, difficulty concentrating, feeling irritable, feeling sad, feeling nervous, nausea, feeling anxious, constipation, restless legs and chest pain); (2) increase in the year before dialysis initiation and no change or continued increase in the year after (decreased interest in sex, difficulty becoming sexually aroused, itch, bone or joint pain, dizziness, diarrhea, tingling in feet and vomiting); and (3) no change in the year before or after dialysis initiation (muscle cramps, dry skin, dry mouth, muscle soreness, cough and headache) (Figure 2).

CONCLUSION

Symptom burden worsened considerably before dialysis initiation, and halted afterwards. Fatigue was the most common and burdensome symptom. Our results may emphasize the importance of discussing kidney-disease related symptoms in routine clinical care and considering their differing patterns of evolution before and after dialysis initiation. Increased physician awareness may lead to better symptom control and has been shown to improve total symptom burden [3].

FC007: The Impact of Sex on the Risk Of Major Adverse Cardiovascular Events in Older Adults with Advanced Chronic Kidney Disease: Results from the Equal Study

BACKGROUND AND AIMS

In the general population, men have a higher risk of major adverse cardiovascular events (MACE) compared with women, with this risk difference between men and women decreasing with increasing age. Patients with chronic kidney disease (CKD) are at a higher risk of MACE compared with the general population, but sex differences in this group, especially older adults, are not fully known. We aim to identify differences in the risk of (recurrent) MACE by sex in CKD patients over 65 years old from Europe and explore factors that may explain these differences.

METHOD

The European Quality study (EQUAL study) is a prospective study on stage 4–5 CKD patients not on dialysis from Germany, Italy, Poland, Sweden, the UK and the Netherlands who were ≥ 65 years old. Cox regression and cumulative incidence competing risk curves were used to calculate MACE risks. Mediation analysis was used to identify variables that may explain risk differences between men and women.

RESULTS

In 1136 men and 607 women, over a follow-up period of 5 years, 417 (37%) men and 185 (31%) women experienced at least one MACE, and there was a total of 1247 MACE. Men and women had 123 (14% of total MACE in men) and 54 (14% of total MACE in women) fatal MACE, respectively. The most common type of first MACE was peripheral vascular disease for men and congestive heart failure for women (Fig. 1). Accounting for the competing risk of non-MACE death, the probability of having a first MACE was 43% (95% CI: 40–47%) for men and 39% (95% CI: 34–44%) for women (Fig. 2), corresponding with a 18% lower relative risk of first MACE in women (HR: 0.82; 95% CI: 0.69–0.97; P = 0.02 ). There was no significant difference in the risk of recurrent MACE (HR: 0.91; 95% CI: 0.80–1.03; P = 0.14 ) or fatal MACE (HR: 0.84; 95% CI: 0.61–1.16; P = 0.30) between men and women. Adjusting for pre-existing comorbidities attenuated the MACE risk difference between men and women. MACE risk differences between men and women changed according to age group but not according to diabetes status. In those ≤ 75 years, women had a 25% lower risk of first MACE (HR: 0.75; 95% CI: 0.57–0.99; P = 0.04), which was 15% in those &gt; 75 years old (HR: 0.85; 95% CI: 0.68–1.06; P = 0.14 ). The risk difference of fatal MACE between men and women differed greatly between those ≤ 75 years old (HR: 1.38; 95% CI: 0.82–2.33; P = 0.22 ) and those &gt; 75 years (HR: 0.61; 95% CI: 0.41–0.93; P = 0.02).

CONCLUSION

Men had a higher probability of having a MACE over a 5-year period. Overall, women had lower risks of MACE compared with men, but risk differences between men and women changed with increasing age. Pre-existing comorbidities explained part of this risk difference.

Converting from face-to-face to postal follow-up and its effects on participant retention, response rates and errors: lessons from the EQUAL study in the UK

BACKGROUND

Prospective cohort studies are challenging to deliver, with one of the main difficulties lying in retention of participants. The need to socially distance during the COVID-19 pandemic has added to this challenge. The pre-COVID-19 adaptation of the European Quality (EQUAL) study in the UK to a remote form of follow-up for efficiency provides lessons for those who are considering changing their study design.

METHODS

The EQUAL study is an international prospective cohort study of patients ≥65 years of age with advanced chronic kidney disease. Initially, patients were invited to complete a questionnaire (SF-36, Dialysis Symptom Index and Renal Treatment Satisfaction Questionnaire) at research clinics every 3-6 months, known as "traditional follow-up" (TFU). In 2018, all living patients were invited to switch to "efficient follow-up" (EFU), which used an abbreviated questionnaire consisting of SF-12 and Dialysis Symptom Index. These were administered centrally by post. Response rates were calculated using returned questionnaires as a proportion of surviving invitees, and error rates presented as the average percentage of unanswered questions or unclear answers, of total questions in returned questionnaires. Response and error rates were calculated 6-monthly in TFU to allow comparisons with EFU.

RESULTS

Of the 504 patients initially recruited, 236 were still alive at the time of conversion to EFU; 111 of these (47%) consented to the change in follow-up. In those who consented, median TFU was 34 months, ranging from 0 to 42 months. Their response rates fell steadily from 88% (98/111) at month 0 of TFU, to 20% (3/15) at month 42. The response rate for the first EFU questionnaire was 60% (59/99) of those alive from TFU. With this improvement in response rates, the first EFU also lowered errors to baseline levels seen in early follow-up, after having almost trebled throughout traditional follow-up.

CONCLUSIONS

Overall, this study demonstrates that administration of shorter follow-up questionnaires by post rather than in person does not negatively impact patient response or error rates. These results may be reassuring for researchers who are trying to limit face-to-face contact with patients during the COVID-19 pandemic.

Health-Related Quality-of-Life Trajectories over Time in Older Men and Women with Advanced Chronic Kidney Disease

BACKGROUND AND OBJECTIVES

The effect of sex on longitudinal health-related quality of life remains unknown in CKD. Here we assess differences in the sex-specific evolution of health-related quality of life in older men and women with advanced CKD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The European Quality Study on Treatment in Advanced Chronic Kidney Disease is a European observational prospective cohort study in referred patients with CKD and an incident eGFR<20 ml/min per 1.73 m² who are ≥65 years of age not on dialysis. Health-related quality of life was measured using the 36-Item Short Form Survey at 3- to 6-month intervals between April 2012 and September 2020, providing Physical Component Summary and Mental Component Summary scores. Trajectories were modeled by sex using linear mixed models, and sex differences in health-related quality-of-life slope were explored.

RESULTS

We included 5345 health-related quality-of-life measurements in 1421 participants. At baseline, women had considerably lower mean Physical Component Summary (42) and Mental Component Summary (60) compared with men (Physical Component Summary: 55; Mental Component Summary: 69; P<0.001). However, during follow-up, Physical Component Summary and Mental Component Summary scores declined approximately twice as fast in men (Physical Component Summary: 2.5 per year; 95% confidence interval, 1.8 to 3.1; Mental Component Summary: 2.7 per year; 95% confidence interval, 2.0 to 3.4) compared with in women (Physical Component Summary: 1.1 per year; 95% confidence interval, 0.1 to 2.0; Mental Component Summary: 1.6 per year; 95% confidence interval, 0.7 to 2.6). This difference was partly attenuated after adjusting for important covariates, notably eGFR decline. Higher serum phosphate, lower hemoglobin, and the presence of preexisting diabetes were associated with lower Physical Component Summary and Mental Component Summary scores in men but to a lesser extent in women.

CONCLUSIONS

Among older men and women with advanced CKD, women had lower health-related quality of life at baseline, but men experienced a more rapid decline in health-related quality of life over time.

Associations between depressive symptoms and disease progression in older patients with chronic kidney disease: results of the EQUAL study

Background

Depressive symptoms are associated with adverse clinical outcomes in patients with end-stage kidney disease; however, few small studies have examined this association in patients with earlier phases of chronic kidney disease (CKD). We studied associations between baseline depressive symptoms and clinical outcomes in older patients with advanced CKD and examined whether these associations differed depending on sex.

Methods

CKD patients (≥65 years; estimated glomerular filtration rate ≤20 mL/min/1.73 m²) were included from a European multicentre prospective cohort between 2012 and 2019. Depressive symptoms were measured by the five-item Mental Health Inventory (cut-off ≤70; 0–100 scale). Cox proportional hazard analysis was used to study associations between depressive symptoms and time to dialysis initiation, all-cause mortality and these outcomes combined. A joint model was used to study the association between depressive symptoms and kidney function over time. Analyses were adjusted for potential baseline confounders.

Results

Overall kidney function decline in 1326 patients was –0.12 mL/min/1.73 m²/month. A total of 515 patients showed depressive symptoms. No significant association was found between depressive symptoms and kidney function over time (P = 0.08). Unlike women, men with depressive symptoms had an increased mortality rate compared with those without symptoms [adjusted hazard ratio 1.41 (95% confidence interval 1.03–1.93)]. Depressive symptoms were not significantly associated with a higher hazard of dialysis initiation, or with the combined outcome (i.e. dialysis initiation and all-cause mortality).

Conclusions

There was no significant association between depressive symptoms at baseline and decline in kidney function over time in older patients with advanced CKD. Depressive symptoms at baseline were associated with a higher mortality rate in men.

The relationship between uremic toxins and symptoms in older men and women with advanced chronic kidney disease

Background

Patients with stage 4/5 chronic kidney disease (CKD) suffer from various symptoms. The retention of uremic solutes is thought to be associated with those symptoms. However, there are relatively few rigorous studies on the potential links between uremic toxins and symptoms in patients with CKD.

Methods

The EQUAL study is an ongoing observational cohort study of non-dialyzed patients with stage 4/5 CKD. EQUAL patients from Germany, Poland, Sweden and the UK were included in the present study (n = 795). Data and symptom self-report questionnaires were collected between April 2012 and September 2020. Baseline uric acid and parathyroid hormone and 10 uremic toxins were quantified. We tested the association between uremic toxins and symptoms and adjusted P-values for multiple testing.

Results

Symptoms were more frequent in women than in men with stage 4/5 CKD, while levels of various uremic toxins were higher in men. Only trimethylamine N-oxide (TMAO; positive association with fatigue), p-cresyl sulfate (PCS) with constipation and 3-carboxy-4-methyl-5-propyl-2-furanpropionic acid (negative association with shortness of breath) demonstrated moderately strong associations with symptoms in adjusted analyses. The association of phenylacetylglutamine with shortness of breath was consistent in both sexes, although it only reached statistical significance in the full population. In contrast, TMAO (fatigue) and PCS and phenylacetylglutamine (constipation) were only associated with symptoms in men, who presented higher serum levels than women.

Conclusion

Only a limited number of toxins were associated with symptoms in persons with stage 4/5 CKD. Other uremic toxins, uremia-related factors or psychosocial factors not yet explored might contribute to symptom burden.

Timing of dialysis initiation to reduce mortality and cardiovascular events in advanced chronic kidney disease: nationwide cohort study

OBJECTIVE

To identify the optimal estimated glomerular filtration rate (eGFR) at which to initiate dialysis in people with advanced chronic kidney disease.

DESIGN

Nationwide observational cohort study.

SETTING

National Swedish Renal Registry of patients referred to nephrologists.

PARTICIPANTS

Patients had a baseline eGFR between 10 and 20 mL/min/1.73 m2 and were included between 1 January 2007 and 31 December 2016, with follow-up until 1 June 2017.

MAIN OUTCOME MEASURES

The strict design criteria of a clinical trial were mimicked by using the cloning, censoring, and weighting method to eliminate immortal time bias, lead time bias, and survivor bias. A dynamic marginal structural model was used to estimate adjusted hazard ratios and absolute risks for five year all cause mortality and major adverse cardiovascular events (composite of cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke) for 15 dialysis initiation strategies with eGFR values between 4 and 19 mL/min/1.73 m2 in increments of 1 mL/min/1.73 m2. An eGFR between 6 and 7 mL/min/1.73 m2 (eGFR6-7) was taken as the reference.

RESULTS

Among 10 290 incident patients with advanced chronic kidney disease (median age 73 years; 3739 (36%) women; median eGFR 16.8 mL/min/1.73 m2), 3822 started dialysis, 4160 died, and 2446 had a major adverse cardiovascular event. A parabolic relation was observed for mortality, with the lowest risk for eGFR15-16. Compared with dialysis initiation at eGFR6-7, initiation at eGFR15-16 was associated with a 5.1% (95% confidence interval 2.5% to 6.9%) lower absolute five year mortality risk and 2.9% (0.2% to 5.5%) lower risk of a major adverse cardiovascular event, corresponding to hazard ratios of 0.89 (95% confidence interval 0.87 to 0.92) and 0.94 (0.91 to 0.98), respectively. This 5.1% absolute risk difference corresponded to a mean postponement of death of 1.6 months over five years of follow-up. However, dialysis would need to be started four years earlier. When emulating the intended strategies of the Initiating Dialysis Early and Late (IDEAL) trial (eGFR10-14 v eGFR5-7) and the achieved eGFRs in IDEAL (eGFR7-10 v eGFR5-7), hazard ratios for all cause mortality were 0.96 (0.94 to 0.99) and 0.97 (0.94 to 1.00), respectively, which are congruent with the findings of the randomised IDEAL trial.

CONCLUSIONS

Very early initiation of dialysis was associated with a modest reduction in mortality and cardiovascular events. For most patients, such a reduction may not outweigh the burden of a substantially longer period spent on dialysis.

Renal function decline in older men and women with advanced chronic kidney disease-results from the EQUAL study

INTRODUCTION

Understanding the mechanisms underlying the differences in renal decline between men and women may improve sex-specific clinical monitoring and management. To this end, we aimed to compare the slope of renal function decline in older men and women in chronic kidney disease (CKD) Stages 4 and 5, taking into account informative censoring related to the sex-specific risks of mortality and dialysis initiation.

METHODS

The European QUALity Study on treatment in advanced CKD (EQUAL) study is an observational prospective cohort study in Stages 4 and 5 CKD patients ≥65 years not on dialysis. Data on clinical and demographic patient characteristics were collected between April 2012 and December 2018. Estimated glomerular filtration rate (eGFR) was calculated using the CKD Epidemiology Collaboration equation. eGFR trajectory by sex was modelled using linear mixed models, and joint models were applied to deal with informative censoring.

RESULTS

We included 7801 eGFR measurements in 1682 patients over a total of 2911 years of follow-up. Renal function declined by 14.0% [95% confidence interval (CI) 12.9-15.1%] on average each year. Renal function declined faster in men (16.2%/year, 95% CI 15.9-17.1%) compared with women (9.6%/year, 95% CI 6.3-12.1%), which remained largely unchanged after accounting for various mediators and for informative censoring due to mortality and dialysis initiation. Diabetes was identified as an important determinant of renal decline specifically in women.

CONCLUSION

In conclusion, renal function declines faster in men compared with women, which remained similar after adjustment for mediators and despite a higher risk of informative censoring in men. We demonstrate a disproportional negative impact of diabetes specifically in women.

FC 067WHEN TO INITIATE DIALYSIS TO REDUCE MORTALITY AND CARDIOVASCULAR EVENTS IN ADVANCED CKD: A NATIONWIDE COHORT STUDY

Background and Aims

There is currently no direct evidence to inform a specific glomerular filtration rate (GFR) to initiate maintenance dialysis. Previous studies are limited by the number of kidney function thresholds compared, immortal time or lead time biases, or small sample sizes. The only randomised trial (IDEAL) found no difference between early versus late start, but confidence intervals were wide.

Method

Nationwide observational cohort study using data from the Swedish Renal Registry between January 1, 2007 and December 31, 2016, with follow-up until June 1, 2017. Included individuals were receiving nephrologist care and had an eGFR between 10-20 ml/min/1.73m2. A randomized trial was emulated using the cloning, censoring and weighting method. Our primary analysis compared late (at an eGFR 5-7 ml/min/1.73m2 [eGFR5-7]), intermediate (eGFR7-10) and early (eGFR10-14) dialysis initiation to validate our analytical methods by comparison with IDEAL. Our secondary analysis compared fifteen dialysis initiation strategies with eGFR values ranging between 4 and 19 ml/min/1.73m2 in increments of 1 ml/min/1.73m2. Study outcomes were 5-year all-cause mortality and major adverse cardiovascular events (MACE; composite of cardiovascular death, non-fatal myocardial infarction and stroke). Adjusted hazard ratios [HR] and cumulative survival proportions were estimated using a dynamic marginal structural model.

Results

Among 10,290 individuals with advanced CKD (median age 73 years; 36% women; median eGFR 16.8 ml/min/1.73m2), 3725 individuals initiated dialysis, 4160 died and 2446 experienced MACE. In trial emulation, the 5-year mortality risk was 53.0% for eGFR5-7, 50.3% for eGFR7-10 and 49.7% for eGFR10-14. Compared with eGFR5-7, the 5-year absolute mortality risk difference was -2.7% (95% CI, -4.6% to -0.7%) for eGFR7-10 and -3.3% (95% CI, -5.2% to -1.3%) for eGFR10-14, with a HR of 0.97 (0.94-0.99) and 0.96 (0.94-0.99), respectively. The 5-year absolute MACE risk differences were -1.1% (95% CI, -3.8% to 2.1%) for eGFR7-10 and -3.6% (95% CI, -6.0% to -1.0%) for eGFR10-14 compared with eGFR5-7, with a HR of 1.00 (0.97-1.04) and 0.96 (0.97-1.00), respectively. When analysing fifteen eGFR thresholds, initiation at eGFR15-16 was associated with the largest reduction in mortality (absolute difference, -5.9% [95% CI, -8.0% to -3.1%]; HR, 0.88 [95% CI, 0.85-0.92]) and MACE (absolute difference, -4.5% [95% CI, -7.6% to -1.4%]; HR, 0.92 [95% CI, 0.89-0.97]), compared with eGFR4-5. This -5.9% absolute risk difference translates to a mean postponement of death of 1.8 months over 5-years of follow-up. However, dialysis would need to be initiated on average 14 months earlier.

Conclusion

Early dialysis initiation was associated with a modest reduction in mortality and cardiovascular events. Such a reduction may not outweigh the burden of longer dialysis treatment duration for the patient.

FC 112HEALTH-RELATED QUALITY OF LIFE (HRQOL) AND SYMPTOM BURDEN BEFORE AND AFTER START OF DIALYSIS IN OLDER PATIENTS

Background and Aims

The number of older (≥65y) people with ESKD starting chronic dialysis increased substantially the past decade because of ageing of the population due to improved health care. In addition, older age is no longer a contraindication for dialysis. Finally, older individuals are more often ineligible for kidney transplantation. Many older people with stage 5 CKD non-dialysis have a low health-related quality of life (HRQOL) and high symptom burden. In this group, improving HRQOL and lowering symptom burden may be deemed more important than solely the prolongation of life. Little is known about the effect of dialysis treatment on HRQOL and symptom burden. Therefore, we investigated the evolution of HRQOL and symptoms before and after the start of dialysis in older ESKD patients.

Method

The European Quality (EQUAL) study is an ongoing European prospective multi-center follow-up study in late stage 4/5 CKD patients aged ≥65 years. For the present analyses, we included all patients who started dialysis. HRQOL was assessed every 3-6 months using the RAND-36 questionnaire, resulting in a physical component summary (PCS) and a mental component summary (MCS) score. Component scores ranged from 0-100 with higher scores indicating a better HRQOL. Kidney disease-related symptom burden was assessed every 3-6 months using the dialysis symptom index (DSI). The sum score for symptom number ranged from 0 to 30 and for symptom severity from 0 to 150, with higher scores indicating a higher symptom burden. We used linear mixed models (LMM) to explore the evolution of mental and physical HRQOL, symptom number and symptom severity during the year preceding and following dialysis initiation.

Results

In total, 571 older dialysis patients were included. At baseline (dialysis initiation), mean (SD) age was 76 (6) years, 74% were men, 47% had diabetes, 9% were current smokers, 34% had cardiovascular disease and the mean (SD) residual kidney function was 8.6 (4.4) ml/min/1.73m2. Mean (SD) MSC was 55 (23), PSC was 43 (21), and the number of symptoms was 15 (7) with a symptom severity of 88 (18). Overall, LMM showed that in the year preceding dialysis MCS decreased by 15.7 (95% CI: 11.9 to 19.5), PCS decreased by 12.0 (8.2 to 15.7), symptom number increased by 3.5 (2.5 to 4.6) and symptom severity increased by 5.3 (1.8 to 8.8). In the year following dialysis, MCS increased by 1.9 (-2.7 to 6.5), PCS decreased by 2.1 (-6.9 to 2.8), symptom number decreased by 0.9 (-0.3 to 2.1) and symptom severity decreased by 7.6 (2.8 to 12.4).

Conclusion

Both mental and physical HRQOL, as well as symptom number and severity, worsened considerably during the year preceding dialysis, but stabilized after dialysis initiation. These results could aid nephrologists in informing older ESKD patients who consider starting dialysis and improve the shared decision making process.

FC 068QUALITY OF LIFE OVER TIME IN OLDER MEN AND WOMEN WITH ADVANCED CKD - RESULTS FROM THE EQUAL STUDY

Background and Aims

Differences between the sexes are apparent in the epidemiology of CKD. Cross-sectional studies show that women consistently report a poorer health-related quality of life (QoL) than men, however, longitudinal studies are lacking. Here we investigate the sex-specific evolution of QoL over time in advanced CKD. As a secondary aim, we explore the sex-specific determinants of QoL.

Method

EQUAL is an observational prospective cohort study in stages 4 and 5 CKD patients ≥65 years not on dialysis with an incident estimated glomerular filtration rate (eGFR) &lt; 20 ml/min/1.73m². Data on QoL (measured using the RAND-36), clinical and demographic patient characteristics were collected between April 2012 and September 2020. QoL trajectories were modelled by sex using linear mixed models, and joint models were applied to deal with informative censoring. We followed patients until death or dialysis initiation.

Results

We included 5151 QoL measurements in 1416 patients over a total of 1986 person years of follow-up. Overall, the physical component summary (PCS) declined with 2.0 (95% CI 1.4-2.6) points and the mental component summary (MCS) by 2.4 (95% CI 1.8-3.0) points per year. Although women had overall lower QoL scores, figure 1 demonstrates that PCS and MCS declined more than twice as fast in men (PCS: 2.4 per year, 95% CI 1.7 – 3.1, MCS: 2.9 per year, 95% CI 2.2 – 3.6) compared with women (PCS: 1.1 per year, 95% CI -0.2 – 2.0, MCS: 1.5 per year, 95% CI 0.5 – 2.4). We identified a non-linear interaction effect between sex and eGFR levels on QoL, demonstrating a stronger negative effect of decreased eGFR on both PCS (p=0.02) and MCS (p=0.04) in men compared with women. Subsequent adjustment for renal decline attenuated the difference in rate of QoL decline between men and women (difference after adjustment; PCS: 1.1, 95% CI -0.1 – 2.2, MCS: 1.2, 95% 0.0 – 2.3). In univariable analyses, higher serum haemoglobin was more beneficial to QoL in men compared to women (p-value for interaction; PCS: p=0.03, MCS: p=0.01). Higher serum phosphate had a strong harmful effect on both PCS and MCS in men, but not in women (PCS & MCS: p&lt;0.001). The presence of pre-existing diabetes had a negative effect on PCS and MCS in men, but to a lesser extent in women (PCS: p=0.02, MCS: p=0.01).

Conclusion

Despite the higher overall QoL reported by men, both their physical and mental QoL declined approximately twice as fast compared with women. The faster decline in men was mediated in part by their lower levels of renal function, which had a stronger impact on their QoL as compared with women. Furthermore, in exploratory analyses we identified that high levels of phosphate, low levels of haemoglobin, and pre-existing diabetes were more detrimental to QoL in men than in women.

International prescribing patterns and polypharmacy in older people with advanced chronic kidney disease: results from the European Quality study

BACKGROUND

People with chronic kidney disease (CKD) are at high risk of polypharmacy. However, no previous study has investigated international prescribing patterns in this group. This article aims to examine prescribing and polypharmacy patterns among older people with advanced CKD across the countries involved in the European Quality (EQUAL) study.

METHODS

The EQUAL study is an international prospective cohort study of patients ≥65 years of age with advanced CKD. Baseline demographic, clinical and medication data were analysed and reported descriptively. Polypharmacy was defined as ≥5 medications and hyperpolypharmacy as ≥10. Univariable and multivariable linear regressions were used to determine associations between country and the number of prescribed medications. Univariable and multivariable logistic regression were used to determine associations between country and hyperpolypharmacy.

RESULTS

Of the 1317 participants from five European countries, 91% were experiencing polypharmacy and 43% were experiencing hyperpolypharmacy. Cardiovascular medications were the most prescribed medications (mean 3.5 per person). There were international differences in prescribing, with significantly greater hyperpolypharmacy in Germany {odds ratio (OR) 2.75 [95% confidence interval (CI) 1.73-4.37]; P < 0.001, reference group UK}, the Netherlands [OR 1.91 (95% CI 1.32-2.76); P = 0.001] and Italy [OR 1.57 (95% CI 1.15-2.15); P = 0.004]. People in Poland experienced the least hyperpolypharmacy [OR 0.39 (95% CI 0.17-0.87); P = 0.021].

CONCLUSIONS

Hyperpolypharmacy is common among older people with advanced CKD, with significant international differences in the number of medications prescribed. Practice variation may represent a lack of consensus regarding appropriate prescribing for this high-risk group for whom pharmacological treatment has great potential for harm as well as benefit.

Kidney Failure Prediction Models: A Comprehensive External Validation Study in Patients with Advanced CKD

BACKGROUND

Various prediction models have been developed to predict the risk of kidney failure in patients with CKD. However, guideline-recommended models have yet to be compared head to head, their validation in patients with advanced CKD is lacking, and most do not account for competing risks.

METHODS

To externally validate 11 existing models of kidney failure, taking the competing risk of death into account, we included patients with advanced CKD from two large cohorts: the European Quality Study (EQUAL), an ongoing European prospective, multicenter cohort study of older patients with advanced CKD, and the Swedish Renal Registry (SRR), an ongoing registry of nephrology-referred patients with CKD in Sweden. The outcome of the models was kidney failure (defined as RRT-treated ESKD). We assessed model performance with discrimination and calibration.

RESULTS

The study included 1580 patients from EQUAL and 13,489 patients from SRR. The average c statistic over the 11 validated models was 0.74 in EQUAL and 0.80 in SRR, compared with 0.89 in previous validations. Most models with longer prediction horizons overestimated the risk of kidney failure considerably. The 5-year Kidney Failure Risk Equation (KFRE) overpredicted risk by 10%-18%. The four- and eight-variable 2-year KFRE and the 4-year Grams model showed excellent calibration and good discrimination in both cohorts.

CONCLUSIONS

Some existing models can accurately predict kidney failure in patients with advanced CKD. KFRE performed well for a shorter time frame (2 years), despite not accounting for competing events. Models predicting over a longer time frame (5 years) overestimated risk because of the competing risk of death. The Grams model, which accounts for the latter, is suitable for longer-term predictions (4 years).

Patient-Reported Measures and Lifestyle Are Associated With Deterioration in Nutritional Status in CKD Stage 4-5: The EQUAL Cohort Study

OBJECTIVE

The aim of this study was to explore the changes in nutritional status before dialysis initiation and to identify modifiable risk factors of nutritional status decline in older adults with advanced renal disease.

DESIGN AND METHODS

The European Quality Study on treatment in advanced chronic kidney disease (EQUAL) is a prospective, observational cohort study involving six European countries. We included 1,103 adults >65 years with incident estimated glomerular filtration rate <20 mL/min/1.73 m² not on dialysis, attending nephrology care. Nutritional status was assessed with the 7-point Subjective Global Assessment tool (7-p SGA), patient-reported outcomes with RAND-36 and the Dialysis Symptom Index. Logistic regression was used to estimate the associations between potential risk factors and SGA decline.

RESULTS

The majority of the patients had a normal nutritional status at baseline, 28% were moderately malnourished (SGA ≤5). Overall, mean SGA decreased by -0.18 points/year, (95% confidence interval -0.21; -0.14). More than one-third of the study participants (34.9%) deteriorated in nutritional status (1 point decline in SGA) and 10.9% had a severe decline in SGA (≥2 points). The proportion of patients with low SGA (≤5) increased every 6 months. Those who dropped in SGA also declined in estimated glomerular filtration rate and mental health score. Every 10 points decrease in physical function score increased the odds of decline in SGA by 23%. Lower physical function score at baseline, gastrointestinal symptoms, and smoking were risk factors for impaired nutritional status. There was an interaction between diabetes and physical function on SGA decline.

CONCLUSIONS

Nutritional status deteriorated in more than one-third of the study participants during the first year of follow-up. Lower patient-reported physical function, more gastrointestinal symptoms, and current smoking were associated with decline in nutritional status.

Kidney function and symptom development over time in elderly patients with advanced chronic kidney disease: results of the EQUAL cohort study

BACKGROUND

Initiation of renal replacement therapy often results from a combination of kidney function deterioration and symptoms related to chronic kidney disease (CKD) progression. We investigated the association between kidney function decline and symptom development in patients with advanced CKD.

METHODS

In the European Quality study on treatment in advanced CKD (EQUAL study), a European prospective cohort study, patients with advanced CKD aged ≥65 years and a kidney function that dropped <20 mL/min/1.73 m2 were followed for 1 year. Linear mixed-effects models were used to assess the association between kidney function decline and symptom development. The sum score for symptom number ranged from 0 to 33 and for overall symptom severity from 0 to 165, using the Dialysis Symptom Index.

RESULTS

At least one kidney function estimate with symptom number or overall symptom severity was available for 1109 and 1019 patients, respectively. The mean (95% confidence interval) annual kidney function decline was 1.70 (1.32; 2.08) mL/min/1.73 m2. The mean overall increase in symptom number and severity was 0.73 (0.28; 1.19) and 2.93 (1.34; 4.52) per year, respectively. A cross-sectional association between the level of kidney function and symptoms was lacking. Furthermore, kidney function at cohort entry was not associated with symptom development. However, each mL/min/1.73 m2 of annual kidney function decline was associated with an extra annual increase of 0.23 (0.07; 0.39) in the number of symptoms and 0.87 (0.35; 1.40) in overall symptom severity.

CONCLUSIONS

A faster kidney function decline was associated with a steeper increase in both symptom number and severity. Considering the modest association, our results seem to suggest that repeated thorough assessment of symptom development during outpatient clinic visits, in addition to the monitoring of kidney function decline, is important for clinical decision-making.

Using datasets to ascertain the generalisability of clinical cohorts: the example of European QUALity Study on the treatment of advanced chronic kidney disease (EQUAL)

BACKGROUND

Cohort studies are among the most robust of observational studies but have issues with external validity. This study assesses threats to external validity (generalisability) in the European QUALity (EQUAL) study, a cohort study of people over 65 years with stage 4/5 chronic kidney disease.

METHODS

Patients meeting the EQUAL inclusion criteria were identified in The Health Improvement Network database and stratified into those attending renal units (secondary care cohort-SCC) and not (primary care cohort-PCC). Survival, progression to renal replacement therapy (RRT), and hospitalisation were compared.

RESULTS

The analysis included 250, 633, and 2,464 patients in EQUAL, PCC, and SCC. EQUAL had a higher proportion of men in comparison to PCC and SCC (60.0% vs. 34.8% vs. 51.4%). Increasing age (≥85 years odds ratio (OR) 0.25 (95% confidence interval (CI) 0.15-0.40)) and comorbidity (Charlson Comorbidity Index ≥ 4 OR 0.69 (CI 0.52-0.91)) were associated with non-participation in EQUAL. EQUAL had a higher proportion of patients starting RRT at 1 year compared to SCC (8.1% vs. 2.1%%, p < 0.001). Patients in the PCC and SCC had increased risk of Hospitalisation (incidence rate ratio=1.76 (95% CI 1.27-2.47) & 2.13 (95% CI 1.59-2.86)) and mortality at one year (hazard ratio=3.48 (95% CI 2.1-5.7) & 1.7 (95% CI 1.1-2.7)) compared to EQUAL.

CONCLUSIONS

This study provides evidence of how participants in a cohort study can differ from the broader population of patients, which is essential when considering external validity and applying to local practice.

The use of different dialysis membranes in therapy of patients with multiple myeloma

Free light chains accumulation is the reason of kidney injury in patients with multiple myeloma. The removal of free light chains can improve patients prognosis and survival, and in some cases allows for dialysotherapy discontinuation. Unfortunately, conventional dialysis is not effective enough in terms of free light chains removal. New high cut-off (HCO) techniques remove free light chains more effectively than conventional dialysis. In some cases, this technique may turn out better than hemodiafiltration. However, there are some differences between specific techniques in the removal of kappa and lambda light chains. Lambda light chains are better removed by polymethyl methacrylate membranes with a change of filter during dialysis. Kappa light chains are thoroughly removed by polymethyl methacrylate membranes and HCO (35,000 Da) polysulfone membranes. Unfortunately, it is very difficult to differentiate between the effect of HCO dialysis therapy and concomitant chemotherapy because some of the data is not fully conclusive. Using the proper technique for an individual patient may give optimally effective treatment results.

MO074RENAL FUNCTION DECLINE IN OLDER MEN AND WOMEN WITH ADVANCED CKD - RESULTS FROM THE EQUAL STUDY

Background and Aims

Understanding the mechanisms underlying the differences in renal decline between men and women may improve sex-specific clinical monitoring and management. To this end, we aimed to compare the slope of renal function decline in older men and women in CKD 4-5, taking into account informative censoring related to the sex-specific risks of mortality and dialysis initiation.

Method

The EQUAL study is an observational prospective cohort study in stage 4-5 CKD patients ≥65 years not on dialysis. Data on clinical and demographic patient characteristics were collected between April 2012 to December 2018. eGFR was calculated using the CKD-EPI equation. Linear mixed models were used to model the eGFR trajectory by sex, and joint models were applied to deal with informative censoring.

Results

We included 7801 eGFR measurements in 1682 patients over 2911 years of follow-up. Renal function declined 14.0% (95% CI 12.9%-15.1%) on average each year. Renal function declined faster in men (16.2% per year, 95% CI 15.9%-17.1%) compared with women (9.6% per year, 95% CI 6.3%-12.1%), which remained largely unchanged after accounting for various mediators, and for informative censoring due to mortality and dialysis initiation. We identified effect modification by diabetes, with faster declines in renal function found especially in women with diabetes.

Conclusion

In conclusion, renal function declines faster in men compared with women, which remained similar after adjustment for mediators, and despite a higher risk of informative censoring in men. We demonstrate a disproportional negative impact of diabetes specifically in women.

The Global Longitudinal Strain in Renal Transplant Recipients and Immunosuppressive Regimen

BACKGROUND

Echocardiographic global longitudinal strain (GLS) has recently been considered as a more effective assessment than the ejection fraction (EF) in detecting subtle changes of left ventricular (LV) systolic function. The aim of the study is to compare GLS in renal transplant recipients (RTrs) with preserved LVEF, depending on the recipient's immunosuppressive regimen. The impaired GLS was considered to be > -18%.

METHODS

A total of 84 RTrs were divided into 2 groups depending on immunosuppressive regimen: group 1, which included 32 patients (aged 62.3 ± 7.5) receiving mammalian target of rapamycin inhibitors, and group 2, which included 52 patients (aged 58.9 ± 13.9 treated with calcineurin inhibitors. In all patients, echocardiography was performed, including calculation of GLS, and laboratory and clinical markers of cardiovascular risk were assessed.

RESULTS

The frequency of men was significantly higher in group 1 (P = .01). There were no differences between the groups in age, body mass index, frequency of diabetes, hypertension, time of hemodialysis (HD) before kidney transplantation (KTx), time after KTx, concentration of cholesterol and creatinine, echocardiographic linear parameters, and LV mass. The estimated glomerular filtration rate and triglyceride concentration were significantly higher in group 1. The mean value of GLS was similar in both groups (-19.8 [-3.5] vs -18.9 [-3.0]; P = .22). The multivariate logistic regression analysis revealed that duration of HD > 26 months is associated with GLS ≥ -18% (odds ratio 2.95, 95% CI 1.08-7.99, P = .03) CONCLUSIONS: The frequency of impaired GLS in RTr was similar regardless of the type of the immunosuppressive regimen. The impaired GLS was associated with duration of HD before KTx.

The impact of symptoms on health-related quality of life in elderly pre-dialysis patients: effect and importance in the EQUAL study

BACKGROUND

Quality of life (QoL) is an important outcome in chronic kidney disease (CKD). Patients feel that symptoms are an important determinant of QoL. However, this relation is unknown. The aims of this study were to investigate the impact of the number and severity of symptoms on QoL in elderly pre-dialysis patients, assessed by both the effect of symptoms and their importance relative to kidney function, and other clinical variables on QoL.

METHODS

The European Quality study (EQUAL study) is an ongoing European prospective follow-up study in late Stage 4/5 CKD patients aged ≥65 years. We used patients included between March 2012 and December 2015. Patients scored their symptoms with the Dialysis Symptom Index, and QoL with the research and development-36 (RAND-36) item Health Survey (RAND-36). The RAND-36 results in a physical component summary (PCS) and a mental component summary (MCS). We used linear regression to estimate the relation between symptoms and QoL at baseline and after 6 months, and to calculate the variance in QoL explained by symptoms.

RESULTS

The baseline questionnaire was filled in by 1079 (73%) patients (median age 75 years, 66% male, 98% Caucasian), and the follow up questionnaire by 627 (42%) patients. At baseline, every additional symptom changed MCS with -0.81 [95% confidence interval (CI): -0.91 to -0.71] and PCS with -0.50 (95% CI: -0.62 to -0.39). In univariable analyses, number of symptoms explained 22% of MCS variance and 11% of PCS variance, whereas estimated glomerular filtration rate only explained 1%.

CONCLUSIONS

In elderly CKD Stage 4/5 patients, symptoms have a substantial impact on QoL. This indicates symptoms should have a more prominent role in clinical decision-making.

Uraemic symptom burden and clinical condition in women and men of ≥65 years of age with advanced chronic kidney disease: results from the EQUAL study

BACKGROUND

The epidemiology and prognosis of chronic kidney disease (CKD) differ by sex. We aimed to compare symptom prevalence and the clinical state in women and men of ≥65 years of age with advanced CKD receiving routine nephrology care.

METHODS

The European QUALity study on treatment in advanced chronic kidney disease (EQUAL) study follows patients from six European countries of ≥65 years of age  years whose estimated glomerular filtration rate (eGFR) dropped to ≤20 mL/min/1.73 m2 for the first time during the last 6 months. The Dialysis Symptom Index was used to assess the prevalence and severity of 33 uraemic symptoms. Data on the clinical state at baseline were collected from medical records. Prevalence was standardized using the age distribution of women as the reference.

RESULTS

The results in women (n = 512) and men (n = 967) did not differ with age (77.0 versus 75.7 years) or eGFR (19.0 versus 18.5). The median number of symptoms was 14 [interquartile range (IQR) 9-19] in women, and 11 (IQR 7-16) in men. Women most frequently reported fatigue {39% [95% confidence interval (CI) 34-45]} and bone/joint pain [37% (95% CI 32-42)] as severe symptoms, whereas more men reported difficulty in becoming sexually aroused [32% (95% CI 28-35)] and a decreased interest in sex [31% (95% CI 28-35)]. Anaemia [73% (95% CI 69-77) versus 85% (95% CI 82-87)] was less common in women than in men, as were smoking history and cardiovascular comorbidity. However, a diagnosis of liver disease other than cirrhosis, psychiatric disease and mild malnutrition were more common among women.

CONCLUSIONS

Women in secondary care with an incident eGFR ≤20 mL/min/1.73 m2 reported a higher symptom burden, while their clinical state was considered similar or even more favourable as compared with men.

Aortic root dilation in kidney transplant recipients

INTRODUCTION Aortic root (AoR) dilation is associated with cardiac damage and higher cardiovascular risk. Cardiovascular disease is the most common cause of death in patients after kidney transplantation (KTx ). OBJECTIVES The aim of this study was to assess the prevalence of enlarged AoR diameter in KTx recipients. Patients with bicuspid aortic valve, significant valvular disease, or evidence of connective tissue disorder were excluded. PATIENTS AND METHODS A total of 87 KTx recipients were divided into 2 groups depending on immunosuppressive regimen: 41 patients receiving mammalian target of rapamycin inhibitors (mTORi) and 46 patients treated with calcineurin inhibitors (CNIs). In all patients, echocardiography was performed, laboratory and clinical markers of cardiovascular risk were assessed, and the AoR diameter was calculated. RESULTS There were no differences between groups in age, sex, body surface area, body mass index, frequency of diabetes, hypertension, dyslipidemia, time after replacement therapy, creatinine levels, and estimated glomerular filtration rate. In the CNI group, the observed and calculated AoR diameters were similar (P = 0.8). In the mTORi group, the observed AoR diameter was higher than the calculated one (P = 0.002). The concentric and eccentric left ventricular hypertrophy was similar in both groups (P = 0.12 and P = 0.69, respectively). In the stepwise regression analysis, the AoR diameter was associated with body surface area and mTORi treatment. CONCLUSIONS KTx recipients have a high prevalence of AoR dilation. Immunosuppressive regimen based on mTORi increases the incidence of AoR enlargement.

Combined Liver-Kidney Transplantation in Children: Single-Center Experiences and Long-Term Results

Combined liver-kidney transplantation (CLKT) is a rare procedure in pediatric patients in which liver and kidney from 1 donor are transplanted to a recipient during a single operation. The aim of our study was to analyze indications and results of CLKT in children.

MATERIALS AND METHODS

Between 1990 and 2017 we performed 722 liver transplantations in children; we performed 920 kidney transplantations in children since 1984. Among them, 25 received CLKT. Primary diagnosis was fibro-polycystic liver and kidney disease in 17 patients, primary hyperoxaluria type 1 in 6 patients, and atypical hemolytic uremic syndrome-related renal failure in 2 children. Age of patients at CLKT was 3 to 23 years (median 16 years) and body mass was 11 to 55 kg (median 35.5kg). All patients received whole liver graft. Kidney graft was transplanted after liver reperfusion before biliary anastomosis. Cold ischemia time was 5.5 to 13.3 hours (median 9.4 hours) for liver transplants and 7.3 to 15 hours (median 10.4 hours) for kidney transplants. In 8 patients X-match was positive. We analyzed posttransplant (Tx) course and late results in our group of pediatric recipients of combined grafts.

RESULTS

Tx follow-up ranged from 1.5 to 17 years (median 4.5 years). Two patients died: 1 patient with oxalosis lost renal graft and died 2.6 years after Tx due to complications of long-term dialysis, and 1 died due to massive bleeding in early postoperative period. Twelve patients were transferred under the care of adult transplantation centers. Six patients were dialyzed after CLKT due to acute tubular necrosis, and time of kidney function recovery was 10 to 27 days in these patients. In 1 patient with aHUS, renal function did not recover. In children with oxalosis, hemodialysis was performed for 1 month after Tx as a standard, with the aim to remove accumulated oxalate. Primary immunosuppression consisted of daclizumab or basiliximab, tacrolimus, mycophenolate mofetil, and steroids. Acute rejection occurred in 4 liver and 3 kidney grafts. One patient required liver retransplantation due to hepatitis C virus recurrence and 2 patients required kidney retransplantation. Two patients required dialysis.

CONCLUSIONS

CLKT in children results in low rate of rejection and high rate of patient and graft survival.

Prevalence and Risk of Protein-Energy Wasting Assessed by Subjective Global Assessment in Older Adults With Advanced Chronic Kidney Disease: Results From the EQUAL Study

OBJECTIVES

Prevalence and risk factors for protein-energy wasting (PEW) are poorly studied in the nondialysis, older population with advanced chronic kidney disease (CKD). Our aim was to evaluate the prevalence of PEW in advanced stage CKD patients aged greater than 65 years. Furthermore, we aimed to describe risk factors for PEW in the overall study population and among obese individuals.

DESIGN

Prospective observational cohort study.

METHODS

The EQUAL study, a European Quality Study on treatment in advanced chronic kidney disease, is a multicenter prospective observational cohort study in six European countries. We included patients aged ≥65 years with incident glomerular filtration rate <20mL/min/1.73m² not on dialysis attending nephrology care. PEW was assessed by 7-point Subjective Global Assessment (7-p SGA).

RESULTS

In general, the study cohort (n = 1,334) was overweight (mean body mass index [BMI] 28.4 kg/m²). The majority of the patients had a normal nutritional status (SGA 6-7), 26% had moderate PEW (SGA 3-5), and less than 1% had severe PEW (SGA 1-2). Muscle wasting and loss of fat tissue were the most frequent alterations according to the SGA subscales, especially in those aged >80 years. The prevalence of PEW was higher among women, increased with age, and was higher in those with depression/dementia. PEW was the most common in those with underweight (BMI <22 kg/m²), 55% or normal weight (BMI 22-25 kg/m²), 40%. In obese individuals (BMI >30 kg/m²), 25% were diagnosed with protein wasting. Risk factors for SGA ≤5 in obese people were similar to those for the overall study population.

CONCLUSION

This European multicenter study shows that the prevalence of PEW is high in patients with advanced CKD aged >65 years. The risk of PEW increases substantially with age and is commonly characterized by muscle wasting. Our study suggests that focus on nutrition should start early in the follow-up of older adults with CKD.

Dialysis-Related Parameters Influence Remodeling in the Venous Part of the Native Arteriovenous Fistula

BACKGROUND

The aim of this study was to evaluate the association of hemodynamic parameters related to hemodialysis and antropometric parameters of patients with changes in the venous part of the arteriovenous fistula (AVF) at points of needling.

METHODS

Two hundred forty-two hemodialysis (HD) patients (60.3% men), with median age 65 (interquartile range [IQR] 56-75) years, on HD treatment for a median of 49 (IQR 20-88) months with functioning fistula were recruited for the study. The history of vascular access, comorbidity, antropometric (body mass index, body surface area, and body composition), and dialysis-related parameters were analyzed. The cross-sectional area of upper extremity vessels were measured using ultrasound and included 2 points: A (arterial point for blood aspiration) and V (venous point for returning the blood after purification). The difference between A and V (A-V) was calculated.

RESULTS

The median cross-sectional area of A was larger than V (1.04 [IQR 0.58-1.7] vs. 0.74 cm² [IQR: 0.41-1.39], P <0.0001). The median difference between A and V (A-V) was 0.17 cm² and positively correlated with mean blood flow (Qb), effective Kt/V, and time of AVF use. Other analyzed factors had no influence on A-V. In the multivariate analysis, the independent factor increasing the difference (A-V) was mean blood flow measured during HD sessions.

CONCLUSIONS

The needling and utilization of AVF for hemodialysis may affect vein anatomy, namely causing dilatation at the arterial point and narrowing at venous point of AVF. We suggest that blood pump velocity of the dialysis machine may have an impact on these changes, but practical importance of these findings has to be elucidated. The significance of (A-V) factor in the prognosis of fistula complications should be further studied and confirmed in the prospective trials.

Increased Granulocyte Heparanase Activity in Neutrophils from Patients with Lupus Nephritis and Idiopathic Membranous Nephropathy

Heparanase is a β-glucuronidase that cleaves sugar chains of heparan sulfate proteoglycans. It is believed that heparanase may be involved in the pathogenesis of proteinuria. The aim of this study was to assess the significance of heparanase in the pathogenesis of particular glomerulonephritis types. The evaluation of heparanase activity in serum, urine, and granulocytes and superoxide dismutase (SOD) activity in granulocytes of patients with lupus nephritis (n = 17), membranous nephropathy (n = 11), IgA nephropathy (n = 12), focal and segmental glomerulosclerosis (n = 18), mesangiocapillary glomerulonephritis (n = 12) and in 19 healthy volunteers were performed. The heparanase activity in granulocytes of patients with lupus nephritis and membranous nephropathy was higher than heparanase activity in granulocytes in the control group (p = 0.02 in both cases). This is the first observation of this phenomenon. There was no difference between SOD activity in granulocytes of patients with all assessed types of glomerulonephritis and the control group. A positive correlation between heparanase activity in urine and double-strain DNA antibodies (r = 0.51; p = 0.04), and reverse correlations between heparanase in urine and hemolytic activity of the complement (r = −0.57; p = 0.03) in the lupus nephritis group, and between heparanase activity in granulocytes and serum total protein level (r = −0.69; p = 0.02) in membranous nephropathy were observed. Increase in heparanase activity without changes in superoxide dismutase activity in the granulocytes from patients with lupus nephritis and membranous nephropathy was observed. It may be used as one of the markers of these disease activities.

Beneficial effect of bilateral native nephrectomy as complete denervation on left ventricular mass and function in renal transplant recipients

INTRODUCTION

Left ventricular hypertrophy (LVH) is a risk factor for cardiovascular morbidity and mortality in renal transplant recipients. The development of LVH is connected with excessive activation of the sympathetic nervous system. A bilateral nephrectomy is an example of complete renal denervation.

OBJECTIVES

The aim of this study was to evaluate the effect of pretransplant bilateral native nephrectomy on left ventricular mass and function during a long-term follow-up of patients after kidney transplantation.

PATIENTS AND METHODS

The study group consisted of 32 renal transplant recipients who had previously undergone pretransplant bilateral native nephrectomy. The control group involved 32 recipients with preserved native kidneys, matched for age, sex, creatinine levels, estimated glomerular filtration rate, immunosuppressive treatment, and the time of renal replacement therapy. All patients were evaluated by echocardiography, and 16 patients--by cardiac magnetic resonance (CMR). In addition, all patients had their arterial blood pressure (BP) and metabolic markers measured.

RESULTS

In comparison with controls, the study group had lower systolic BP (P = 0.048) and received a lower number of antihypertensive agents (P = 0.001). Lipid and hemoglobin levels were similar in both groups. The study group had a lower left ventricular mass index (LVMI; P = 0.001) and left atrial volume index (LAVI; P = 0.004). The left ventricular mass evaluated by CMR was also lower in the study group (P <0.001). Mild left ventricular diastolic dysfunction (LVDD) was more frequent in the study group compared with the control group ( P <0.001).

CONCLUSIONS

In a long-term follow-up of patients after kidney transplantation, the bilateral native nephrectomy before transplantation was associated with a lower LVMI and LAVI as well as a lower grade of LVDD. These patients had lower systolic BP and used fewer antihypertensive drugs.

Cardiovascular risk in kidney transplant recipients receiving mammalian target of rapamycin inhibitors

Cardiovascular diseases (CVD) are the leading cause of mortality in renal transplant recipients. Various traditional and unconventional cardiovascular risk factors are potentiated by the adverse effects of immunosuppressive drugs. The mammalian target of rapamycin (mTOR) inhibitors have shown cardioprotective effects in experimental studies, but their influence on CVD in renal transplantation is unclear. The study included 115 kidney transplant recipients treated with mTOR inhibitors with steroids. A group of 38 patients received additionally small doses of calcineurin inhibitor. The control group consisted of 58 kidney transplant recipients randomly chosen among the population of patients transplanted at the same time, who received a calcineurin inhibitor, mycophenolate mofetil or sodium plus steroids. No differences in age, gender, duration of pretransplantat dialysis, time after transplantation, body mass index or glycated hemoglobin existed between the groups. Blood pressure and number of antihypertensive agents, high-density lipoprotein cholesterol, and uric acid levels were similar. The prevalence of diabetic, ischemic, or hypertensive nephropathy as the reason for end-stage renal disease was similar (P=.08). The study group showed higher mean values of total cholesterol (249 vs 204.6 mg/dL; P<.0001) and low-density lipoprotein 136.5 vs 117.7 mg/dL; (P=.015), as well as median values of triglycerides (202 vs 142 mg/dL; P<.0001) and proteinuria (P=.0002). mean estimated glomerular filtration rate was lower in the study group (42.9 vs 51.9 mL/min; P=.0003). Posttransplant diabetes appeared in 38% of the study group compared to 20% of the controls (P=.08). The incidence of coronary artery disease was higher among patients treated with mTOR inhibitors (P=.04). CVD, defined as myocardial infarction, percutaneous coronary intervention, stroke, aortic aneurysm, pulmonary thromboembolism, sudden cardiac death appeared in 26 study group compared with four control patients (P=.24). The risk of any CVD was not significantly higher among patients receiving mTOR inhibitors hazard ratio 1.94; 95% confidence interval 0.83-4.52). In conclusion, no correlation was observed between the duration of mTOR therapy and CVD.