An unusual cause of rapidly progressive glomerulonephritis associated with ANCA vasculitis and ovarian malignancy - a relapse 39 years after initial treatment

A 69-year-old woman presented with severe anemia, proteinuria, microscopic hematuria and rapidly progressive renal failure. She was admitted to the nephrology department due to severe deterioration of renal function with complaints of malaise, fever, dry cough and occasional epistaxis that appeared 2 months prior to admission. Histopathologic examination of a specimen from kidney biopsy and immunologic findings revealed ANCA positive pauci-immune crescentic glomerulonephritis. The patient had a history of ovarian granulosa cell tumor and lung metastases that were treated surgically with postoperative radiotherapy and chemotherapy. Thoracic computed tomography showed tissue neoplasm in the right lung and ultrasound-guided percutaneous transthoracic biopsy confirmed granulosa cell tumor. That was a relapse, thirty-nine years after initial treatment of malignant disease and twenty-four years after surgical resection of metastases from both lungs. Although the association between malignancy and vasculitis has been well known for decades, this is the first described case of ANCA vasculitis associated with any type of gynecological malignancy and glomerulonephritis.

Factors influencing kidney transplantation rates: a study from the ERA Registry

BACKGROUND

Large international differences exist in kidney transplantation (KT) rates. We aimed to investigate which factors may explain the total, deceased donor, and living donor KT rates over the last decade.

METHODS

KT experts from 39 European countries completed the Kidney Transplantation Rate Survey on measures and barriers and their potential effect on the KT rate in their country. In the analyses, countries were divided into low, middle, and high KT rate countries based on the KT rate at the start of study period in 2010.

RESULTS

Experts from low KT rate countries reported more frequently to have taken measures regarding staff, equipment and facilities to increase total KT rate compared with middle and high KT rate countries. For donor type specific KT, the largest international differences in measures taken were reported for deceased donor KT, with middle and high KT rate countries taking more measures, such as the use of expanded criteria donor kidneys, the presence of transplantation coordinators, and (inter)national exchange of donor kidneys. Once a measure was taken, experts' opinion on its success was similar across the low, middle and high KT rate countries. Experts from low KT rate countries more often reported potential barriers, such as patients' lack of knowledge and distrust in the health care system.

CONCLUSIONS

In particular in low KT rate countries, KT rate might be stimulated by optimizing staff, equipment, and facilities. In addition, all countries may benefit from deceased and living donor specific measures.

Trends in kidney transplantation rate across Europe: Study from the ERA Registry

BACKGROUND

The aim of this study was to identify trends in total, deceased donor and living donor kidney transplantation (KT) rates in European countries.

METHODS

The European Renal Association (ERA) Registry and the Global Observatory on Donation and Transplantation (GODT) databases were used to obtain the number of KTs in individual European countries between 2010 and 2018. General population counts were obtained from Eurostat or the national bureaus of statistics. The KT rate per million population (pmp) and the average annual percentage change (APC) were calculated.

RESULTS

The total KT rate in the 40 participating countries increased with 1.9% annually (95% confidence interval (CI): 1.5, 2.2) from 29.6 pmp in 2010 to 34.7 pmp in 2018, reflecting an increase of 3.4 pmp in the deceased donor KT rate (from 21.6 pmp to 25.0 pmp, APC: 1.9% [95%CI: 1.3, 2.4]) and of 1.5 pmp in the living donor KT rate (from 8.1 pmp to 9.6 pmp, APC: 1.6% [95%CI: 1.0, 2.3]). The trends in KT rate varied widely across European countries. An East-West gradient was observed for deceased donor KT rate with Western European countries performing more KTs. In addition, most countries performed less living donor KTs. In 2018, Spain had the highest deceased donor KT rate (64.6 pmp) and Turkey the highest living donor KT rate (37.0 pmp).

CONCLUSIONS

The total KT rate increased due to a rise in the KT rate from deceased donors and to a lesser extent from living donors, with large differences between individual European countries.

MO644: Comparative Analysis of Survival and Morbidity in Home and Hospital Haemodialysis

BACKGROUND AND AIMS

Many studies have shown that home haemodialysis (HOHD) provides fewer complications and better outcomes as compared with hospital haemodialysis (HHD). The aim of this study was to compare morbidity and survival in patients on HOHD and HHD.

METHOD

We analysed 26 prevalent HOHD patients who were matched with 52 HHD patients according to sex, age and Davies Comorbidity Index (DCI). DCI is based on seven groups of comorbidities: ischaemic heart disease (IHD), left ventricular dysfunction (LVD), peripheral vascular disease (PVD), malignancy, diabetes mellitus (DM), systemic collagen vascular disease and other significant pathology. Grade 0 had patients without any of these comorbidities, grade 1 those with 1–2 and those with 3 or more comorbidities had grade 2. Patients were followed from January 2011 to January 2020. We analysed an overall number of hospitalizations during the study period, a number of hospitalizations per year (annual hospital admission rate) and longevity of in-hospital stay (days). We categorized each hospitalization into 1 of 4 causes: cardiovascular disease (CVD), infection, vascular access dysfunction, or other cause.

RESULTS

Median age for HOHD and HHD patients was 55.7 and 56 years respectively and 77% of patients in both groups were men. Majority of the patients in both groups had DCI 1 (65%), 31% had DCI 0 and only 4% had DCI 2. The most common comorbidity for both HOHD and HHD patients was IHD (35% and 29% respectively), followed by HCV infection (35% and 17% respectively) and PVD (11.5% and 15% respectively). There was no difference between HOHD and HHD patients in an overall number of hospitalization (3.7 ± 3.3 versus 3.9 ± 2.8;  P = .47), nor in annual admission rate for all-cause morbidity (0.5 ± 0.4 versus 0.6 ± 0.4;  P = .28), but HHD patients had longer in-hospital stay (7.4 ± 9.8 days versus 9.3 ± 8.7 days; P = .05). Cause-specific morbidity showed that HHD patients had a more frequent annual admission rate for CVD (0.2 ± 0.1 versus 0.4 ± 0.3;  P = .05), while there were no differences for infections (0.3 ± 0.2 versus 0.3 ± 0.3;  P = .9) nor vascular access complications (0.3 ± 0.3 versus 0.4 ± 0.3;  P = .3). Also, annual in-hospital stays for CVD (3.0 ± 3.1 versus 4.0 ± 4.5 days; P = .5), infection (6.4 ± 7.5 versus 5.7 ± 7.6 days; P = .6) and vascular access complications (6.0 ± 7.0 versus 7.7 ± 7.8 days; P = .5) did not differ between HOHD and HHD group. Kaplan–Meier curve revealed that survival in HOHD and HHD patients were 92.3% versus 90.4% at 3 years, 84.6% versus 70.2% at 5 years and 55.7% versus 50% at 9 years (log-rank test P = .5).

CONCLUSION

Our study has shown that HOHD and HHD patients had similar hospitalization rates, but patients on HOHD had better rehabilitation and shorter hospitalizations for all-cause morbidity. Despite this, HHD and HOHD patients had similar survival rates.

MO659: First Experience of Bamlanivimab for Covid-19 Positive Haemodialysis Patients: A Case-Control Study

BACKGROUND AND AIMS

The previous study showed a higher prevalence of coronavirus (COVID-19) in end-stage renal disease (ESRD) patients than in the general population (3.1% versus 0.1%). The presence of COVID-19 infection significantly increased the mortality rate of patients on dialysis compared to non-COVID patients (20.2% versus 0.2%). To date, no clear guidelines exist for the management of COVID-19 in renal patients. Bamlanivimab is a potent neutralizing monoclonal antibody that blocks severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) attachment and entry into human cells, which could potentially lead to therapeutic benefit. To our knowledge, this is the first study to use bamlanivimab in COVID-19+ haemodialysis (HD) patients with the aim to determine the effect of bamlanivimab on the mortality of these patients.

METHOD

We conducted a retrospective case-control study across a single HD centre of non-hospitalized HD patients, with documented positive SARS-CoV-2 testing. We analysed the period from October 1 to November 14 2021, in which COVID-19+ patients were dialyzed in our institution. Cases were defined as HD patients who received bamlanivimab and controls were patients who did not receive bamlanivimab. Descriptive statistics, including chi-squared and Mann–Whitney U test, were performed. We used multinomial logistic regression to find the independent relationship between bamlanivimab use, disease severity, coronary artery disease (CAD), heart failure and 1-month mortality risk.

RESULTS

Patients who received bamlanivimab frequently had the chronic obstructive pulmonary disease (COPD) than those in the control group. There were no significant differences between groups in any of the other parameters assessed (Table 1). Besides higher baseline ferritin levels in the control group, no other significant differences in biochemical markers were found between examined groups (Table 2). Over a 1-month follow-up, one patient (7.7%) died in the bamlinivimab group, while 8 patients (44.4%) died in the control group. Multinomial logistic regression revealed that no bamlanivimab treatment was given. CAD and disease severity increased the risks of mortality 39.1 times (P = 0.12), 81.7 times (P = 0.08) and 99.9 times (P = 0.04), respectively.

CONCLUSION

In COVID-19+ HD patients, bamlanivimab has been a safe and effective treatment method, lowering mortality although not statistically significant. We also discovered that having a more severe clinical presentation at baseline, as well as having a CAD, was related to a greater risk of mortality. Our findings imply that larger, more conclusive clinical studies of bamlanivimab in HD patients with COVID 19 should be conducted.

The fractal and textural analysis of glomeruli in obese and non-obese patients

Background

Fractal dimension is an indirect indicator of signal complexity. The aim was to evaluate the fractal and textural analysis parameters of glomeruli in obese and non-obese patients with glomerular diseases and association of these parameters with clinical features.

Methods

The study included 125 patients mean age 46 ± 15.2 years: obese (BMI ≥ 27 kg/m²—63 patients) and non-obese (BMI < 27 kg/m²—62 patients). Serum concentration of creatinine, protein, albumin, cholesterol, trygliceride, and daily proteinuria were measured. Formula Chronic Kidney Disease Epidemiology Colaboration (CKD-EPI) equation was calculated. Fractal (fractal dimension, lacunarity) and textural (angular second moment (ASM), textural correlation (COR), inverse difference moment (IDM), textural contrast (CON), variance) analysis parameters were compared between two groups.

Results

Obese patients had higher mean value of variance (t = 1.867), ASM (t = 1.532) and CON (t = 0.394) but without significant difference (P > 0.05) compared to non-obese. Mean value of COR (t = 0.108) and IDM (t = 0.185) were almost the same in two patient groups. Obese patients had higher value of lacunarity (t = 0.499) in comparison with non-obese, the mean value of fractal dimension (t = 0.225) was almost the same in two groups. Significantly positive association between variance and creatinine concentration (r = 0.499, P < 0.01), significantly negative association between variance and CKD-EPI (r = -0.448, P < 0.01), variance and sex (r = -0.339, P < 0.05) were found.

Conclusions

Variance showed significant correlation with serum creatinine concentration, CKD-EPI and sex. CON and IDM were significantly related to sex. Fractal and textural analysis parameters of glomeruli could become a supplement to histopathologic analysis of kidney tissue.

•

Variance showed significant correlation with eGFR calculated by CKD- EPI formula.

•

Significant correlation between variance and serum creatinine was found.

•

Textural contrast and inverse difference moment were significantly related to sex.

•

Fractal analysis of glomeruli could become supplement to histopathologic analysis.

•

Textural analyses of kidney tissue should become useful to histopathologic analysis.

MO408OBSTRUCTIVE NEPHROPATHY - STILL PREVALENT DISEASE

Background and Aims

Acute kidney injury (AKI) secondary to urinary obstruction is a common urological-nephrological problem. In this retrospective study, our goals were to describe the etiology, management and outcomes of patients with obstructive nephropathy who were hospitalized at Nephrology Department during 2019.

Method

AKI was defined by the RIFLE classification. Diagnosis of obstruction was defined by ultrasound imaging, intravenous pyelography and CT scan.

Results

During 2019 AKI secondary to urinary obstruction was diagnosed to 64 patients. 73% of them were male, average age 65 ± 16 years. About 60% of the patients had bilateral hydronephrosis, chronic kidney disease and anuria duration longer than 24h. The following desobstructive procedures were applied: urinary catheterization to 33 patients, percutaneous nephrostomy tube to 14 patients, double-J stent to 7 and other procedures to 10 patients. The most common causes of obstruction were malignancy and benign prostatic hyperplasia 60%, calculosis 17%, and other causes 20% such as neurogenic bladder and retroperitoneal fibrosis. As many as 30% of patients required acute hemodialysis treatment, of which 6% remained on a chronic program in period of three months. Out of all, 30% of patients had a partial recovery of kidney function, while 20% had complete recovery. The most common complication was infection and bleeding. The univariate logistic regression, adjusted for age and hemodialysis treatment, has shown that significant independent predictors for chronic kidney disease progression were anuria duration &gt;24h (RR 2.21; 95% CI 0.014-1.03; p=0.05), polyuria duration (RR 2.11; 95% CI 1.112-3.98; p=0.02) and duration of hospital treatment (RR 9.16; 95% CI 2.102-39.94; p=0.03). The most significant predictor of death was duration of hospital treatment (RR 9.16; 95% CI 2.102-3.399; p=0.003). Multivariate logistic regression did not shown significance any of the above risk factors.

Conclusion

Given that third of patients with obstructive nephropathy require acute HD, 6% remain in chronic HD, and almost one third require rehospitalization, close cooperation between a nephrologist and urologist is required. Rapid desobstructive procedures and careful monitoring after desobstruction is warranted. Requirement of regular screening remains opened for obstruction in vulnerable populations.

MO222DO WE OFTEN THINK OF MULTIPLE MYELOMA AS THE CAUSE OF KIDNEY DISEASE?

Background and Aims

Kidney disease is a common complication in patients with multiple myeloma and other plasma cell dyscrasias. This disease can be manifested by various kidney disorders, which can evolve as either an acute or chronic disorder. Cast nephropathy is the most common cause of severe acute kidney injury (AKI) in patients with multiple myeloma. Among newly diagnosed patients, 20 to 50 % have AKI or cronic kidney disease (CKD) at the time of diagnosis. Treatment of acute renal failure consists of good supportive care and anti-myeloma therapy. Introduction of novel agents has considerably improved outcome in patients with multiple myeloma and renal failure. The aim of this study was to identify the most common risk factors (RF) for mortality in patients with MM and renal failure.

Method

The study included 22 patients ( mean years 67 ± 12 years, 12 men). Who followed two years. We analyzed routine laboratory tests, Bence Jones protein, urinary protein excretion, and creatinine clearance. Plain radiography for the evaluation of skeleton lesions were performed for all patients.

Results

Overall two years mortality of patients with MM was 38.1% with no significant difference regard to patients' age and gender. About 33% of patients required renal replacement therapy and 19% remained on a chronic dialysis treatment program. Renal biopsy was performed in 9.1% of patients (1 - FSGS, 1 - LCCD, light chain deposition disease). Bone marrow transplant (stem cell transplant) was performed in 9.1% of patients. Of the associated comorbidities, 19% had DM, 81% had hypertension, CVD 52.4%. Osteolytic changes at the time of diagnosis were present in 52.4%. In older patients, kappa chains have been identified to a much more extent. Survival is significantly lower in dialysis dependent patients with a two-year survival of 30%. Binary logistic regression revealed that platelet decrease (OR = 0.982&lt; CI 0.961–1.003&lt; p = 0.09) and increase of IgA significantly influenced mortality (OR = 103,867&lt; CI 0.459–23567.201&lt; p = 0.09) can be considered as potential predictors of mortality. Comorbidity DM, HTA, CVD were not the predictors for mortality in patients with MM

Conclusion

Multiple myeloma associated with high mortality rate and kidney disease. High percentage of patients required renal replacement therapy (33%) and 19% remained on a chronic dialysis treatment program. Among the estimated parameters, the risk factors for mortality were significant decrease of platelet (p = 0.09) and increase IgA (p = 0.09). Survival is significantly lower in in dialysis dependent patients with a two-year survival of 30%.

MO383COVID - 19 AND AKUTE KIDNEY INJURY- A SINGLE CENTER EXPERIENCE

Background and Aims

The new coronavirus disease (COVID 19) has become a worldwide health emergency with a wide spectrum of clinical presentation, from common cold symptoms to multiorgan failure. A great number of medical centers have reported that patients with COVID-19 have developed acute kidney injury. The kidney is a target organ for SARS - COV2 because of ACE2 receptor, the binding site for this virus, is expressed in kidney tissue. The potential mechanisms for kidney injury are direct kidney injury, inflammation, activation of coagulation and complement cascades. Data from centers worldwide reported a wide range of AKI incidence, from 0,5% in China to 46% in USA. The aim of this study was to analyze incidence, risk factors and outcomes of AKI in hospitalized patients with COVID 19 who were treated from 01.04. to 01.06.2020. at Nephrology Department of University Clinical Center Zvezdara, which was at the time transformed into COVID hospital.

Method

This retrospective observational study included 51 patients who had normal kidney function before the infection with SARS COV2, and 7 of them developed dialysis non-dependent AKI. Analysis included data collection from the patients’ history including demographic, clinical and administrative data. Statistical analysis has been performed using SPSS software version 20 (IBM Corporation, New York, USA).

Results

Out of 51 patients 7 (13.7%) developed AKI, mean age was 59 + 16 years and 53% were male. Diabetes mellitus was present in 27 of patients with AKI, hypertension in 6/7, obesity in 3/7, coronary artery disease in 1/7 and 1 of 7 patients was smoker. These risk factors except obesity (p= 0.05) didn’t vary significantly between two groups (AKI and non AKI patients with COVID-19). Our results showed significant correlation between AKI development and obesity (p= 0.05, OR 4.75), Charlston index score (p=0.01), D dimer score (p=0.01), and CT COVID score (p=0.03). Regarding the outcome, COVID 19 patients with AKI showed 7-fold higher risk for fatal outcome (p= 0.046).

Conclusion

Obesity, higher D dimer values, worse CT findings and higher Charlston comorbidity score index were associated with acute kidney injury in patients with COVID 19. AKI proved to be significant risk factor for fatal outcome in patients with SARS COV2 infection.

MO851INCIDENCE AND MORTALITY OF CORONAVIRUS DISEASE (COVID 19) IN HEMODIALYSIS PATIENTS

Background and Aims

In December 2019, an outbreak of coronavirus disease 2019 (covid 19) due to SARS Cov2 began in China and spread worldwide. Hemodialysis patients represent a unique group of patients, mostly elderly, imunocompromised, with numerous comorbidities. Patients with end stage renal disease are thought to be at increased risk of disease, severe disease and death from Covid 19 infection. In addition, dialysis centers are a suitable place for an outbreak of the epidemic. All of the above represents a group of hemodialysis patients particularly susceptible to infection and the development of serious disease.

Method

We reviewed data of all maintenance hemodialysis patients in hemodialysis centar of Zvezdara Hospital, Belgrade, Serbia. We include all patients with COVID 19 infection in period between April 1 2020 and January 10 2021.

Results

Of 232 patients undergoing hemodialysis, 68 (29,31%) were infected with Sars-Cov-2. 46 (67,64%) patients were males and 22 (32,35%) females. The age range of the patients was 35 to 87 years, the mean age was 65,25. The underlyind cause of terminal renal failure in 25 patients was hipertensiv nefroangiosklerosis, 14 diabetic nephropathy, 10 opstructiv nephropathy, 9 polycystic kidney disease, and 10 other cause of kidney failure. The average of hemodialysis duration was 70,70 months. The average durations of disease was 15 days. Mortality has been estimated at 33,82% (23 patients). Among patients who died 8 (34,78%) were females, and 15 (65,21%) males.

Conclusion

The mortality among hemodialysis patients diagnosed with Covid 19 is high. Hemodialysis patients typically present with multiple comorbidities and are considered to be a high-risk group for infections. Hemodialysis patients with Covid-19 may have prolonged hospital stays and unfavorable prognoses and should be closely monitored.

MO521OUTCOME OF CHRONIC KIDNEY DISEASE PATIENTS WITH SARS COV-2 INFECTION- A SINGLE CENTRE EXPERIENCE

Background and Aims

Since the outbreak of COVID 19 there have been 88.1 million confirmed cases and 1,9 million deaths in 218 countries, while in Serbia we have had 39.867 cases of COVID 19 and 3479 deaths with approximate death rate of 1%. Fatality rate worldwide vary widely, from 0% in Singapore to 8,8% in Mexico with the average value of 3%. Although there are many published studies about COVID 19, influence of chronic kidney disease and chronic dialysis on outcome of patients with the coronavirus infection is still not clear. The aim of this study was to explore whether the presence of CKD including ESRD and chronic dialysis treatment increases COVID 19 patients’ risk for adverse clinical outcome.

Method

This retrospective study included 88 patients who were hospitalized at the Nephrology department in Zvezdara University Clinical Center which was transformed into a COVID hospital at the time. These patients were treated from 01.04.2020. to 01.06.2020. and 37 (42%) of them had CKD, while 51 (58%) had no signs of kidney disease. We analysed data collection from the patients’ history, including age, sex, comorbidities, symptoms, blood and radiology findings, therapy and outcome. We compared outcome (fatal and need for mechanical ventilation) between CKD and non CKD group and also analized dialysis as a risk factor for adverse outcome. Statistical analysis has been performed using SPSS software version 20 and OR was calculated using Logistic Regression.

Results

We analysed 88 patients, a mean age of 62+15 years, 59.1% males. Out of 88 patients, 37 had CKD, while 27 of them were on hemodialysis and 2 on peritoneal dialysis (CAPD). At the end of follow-up, 46 patients (52.3%) was discharged home, 27 (30.7%) was transferred to another hospital and 14 (15.9%) died. Regarding influence of CKD on COVID-19 patients’ outcome it was shown that patients with CKD had 3-fold higher chances for discharge than for the fatal outcome (p=0.05) and 4-fold less risk for use of the mechanical ventilation (ns) as compared to non CKD patients. We also found that ESRD and chronic dialysis affect outcome with statistical significance (p=0.01) in a way that it doubles the risk for the adverse outcome.

Conclusion

Patients with CKD, especially those with ESRD had significantly higher risk for the lethal outcome and higher chances to require the mechanical ventilation.

MO408OBSTRUCTIVE NEPHROPATHY - STILL PREVALENT DISEASE

Background and Aims

Acute kidney injury (AKI) secondary to urinary obstruction is a common urological-nephrological problem. In this retrospective study, our goals were to describe the etiology, management and outcomes of patients with obstructive nephropathy who were hospitalized at Nephrology Department during 2019.

Method

AKI was defined by the RIFLE classification. Diagnosis of obstruction was defined by ultrasound imaging, intravenous pyelography and CT scan.

Results

During 2019 AKI secondary to urinary obstruction was diagnosed to 64 patients. 73% of them were male, average age 65 ± 16 years. About 60% of the patients had bilateral hydronephrosis, chronic kidney disease and anuria duration longer than 24h. The following desobstructive procedures were applied: urinary catheterization to 33 patients, percutaneous nephrostomy tube to 14 patients, double-J stent to 7 and other procedures to 10 patients. The most common causes of obstruction were malignancy and benign prostatic hyperplasia 60%, calculosis 17%, and other causes 20% such as neurogenic bladder and retroperitoneal fibrosis. As many as 30% of patients required acute hemodialysis treatment, of which 6% remained on a chronic program in period of three months. Out of all, 30% of patients had a partial recovery of kidney function, while 20% had complete recovery. The most common complication was infection and bleeding. The univariate logistic regression, adjusted for age and hemodialysis treatment, has shown that significant independent predictors for chronic kidney disease progression were anuria duration &gt;24h (RR 2.21; 95% CI 0.014-1.03; p=0.05), polyuria duration (RR 2.11; 95% CI 1.112-3.98; p=0.02) and duration of hospital treatment (RR 9.16; 95% CI 2.102-39.94; p=0.03). The most significant predictor of death was duration of hospital treatment (RR 9.16; 95% CI 2.102-3.399; p=0.003). Multivariate logistic regression did not shown significance any of the above risk factors.

Conclusion

Given that third of patients with obstructive nephropathy require acute HD, 6% remain in chronic HD, and almost one third require rehospitalization, close cooperation between a nephrologist and urologist is required. Rapid desobstructive procedures and careful monitoring after desobstruction is warranted. Requirement of regular screening remains opened for obstruction in vulnerable populations.

MO698IS PERITONEAL DIALYSIS SUITABLE METHOD FOR OBESE PATIENTS?

Background and Aims

In recent years, obesity has reached epidemic proportions, and it's a great challenge to choose an adequate treatment for obese ESRD patients. The aim of the study was to analyze the outcome in patients with peritoneal dialysis with different degrees of nutrition expressed through body mass index at the beginning of treatment.

Method

The prospective clinical study included 53 incidental patients, who started peritoneal dialysis between June 2006 and August 2015. According to BMI on the beginning of treatment, patients were divided into three groups: normal weight: BMI of 18.5 - 24.9 kg/m2, n=17, overweight: BMI of 25 - 29.9 kg/m2, n=25, obese: BMI&gt; 30.0 kg/m2. n=11. Mechanical and infective complications, technique survival and patients survival were analyzed over 48 - months period.

Results

In terms of mechanical complications, there was no difference between the groups- malposition of the catheter (p = 0.769), leakage of dialysate (p = 0.462), hernia (p = 0.381). Exit sitе infection were most prevalent in group 3 - 1 episode/22 patient months vs 1 episode/30 patient months in groups 1 and 2, but without statistical significance (p = 0.272). However, the lowest incidence of peritonitis was in the group 3 - 1 episode/40 patient months vs 1 episode/30 patient months in group 2, and 1 episode/33 patient months in group 1, but even here the difference did not reach statistical significance (p = 0.624). Cardiovascular events – myocardial infarction, stroke and peripheral vascular disease were rare in all groups, with no statistical significance between groups. The incidence of hospitalizations was highest in the obese group – 1 episode/22 patient months vs 1 episode/27 patient months in group 2, and 1 episode/25 patient months in group 1 (p = 0.735). Kaplan Meier's analysis showed the worst, but not significant, survival of the technique in a group of obese patients (group 1 vs. group 2; p = 0.536; group 1 vs. group 3 - p= 0.662; group 2 vs. group 3 - p = 0.357). Also, overall patient survival was not differed between the groups (group 1 vs group 2 - p = 0.387; group 1 vs group 3 - p= 0.885; group 2 vs group 3 - p = 0.375). According to Cox's analysis, only values of total cholesterol at the end of the follow-up period (p = 0.027) and diastolic blood pressure (p = 0.013) were significantly associated with overall survival obese patients.

Conclusion

In the present study the degree of nutrition at the beginning of treatment had no significant effect on the outcome of peritoneal dialysis treatment. Therefore, patients should not be discouraged for peritoneal dialysis on the basis of BMI.

MO289IS THERE A ROLE OF INTERSTITIAL CHANGES ON THERAPY OUTCOME AMONG PATIENTS WITH FOCAL-SEGMENTAL GLOMERULAR SCLEROSIS AND MINIMAL CHANGE DISEASE?

Background and Aims

It is well-known that interstitial changes in patients with focal-segmental glomerulosclerosis (FSGS) and minimal change disease (MCD) are linked with disease chronicity and progression. The aim of this study was to analyze is there any connection between interstitial changes and outcome after “first line” therapy in patients with FSGS/MCD.

Method

From 2014 till 2019, biopsy proven diagnosis of FSGS/MCD was established in 40 patients. Interstitial changes were classified in three groups as following: 0-w/o changes; 1-mild changes; 2-severe changes. Patients with nephrotic syndrome (No=29) were treated with prednisolone (1mg/kg) and after six months we have registered therapy outcome as: CR-complete remission; PR-partial remission; EX-death; NO-no effect.

Results

Among treated patients (age 50.4±15.3 years, 15 men), CR was achieved in 10 patients (34.5%) and 6 out of these 10 (60%) had no interstitial changes. Partial remission was observed in 11 patients (37.9%), in 4 patients (13.8%) therapy did not have any effect, and 4 patients (13.8%) deceased (table 1). All patients in EX and NO group had interstitial changes. There were no significant difference in age, gender, proteinuria, albuminaemia, creatinine and glycaemia levels between groups except for hemoglobin levels that were significantly lower in EX group than in others (∑ 15.144; p=0.002) and urea levels that were significantly higher in EX group (∑ 138.057; p=0.024).

Conclusion

Patients with FSGS/MCD respond well on standard immunosuppressive protocol, particularly in absence of interstitial changes what may increase the chance for achieving complete remission.

MO871HEPARIN INDUCED THROMBOCYTOPENIA AND HEMODIALYSIS - SINGLE CENTRE EXPERINCE

Background and Aims

Heparin-induced thrombocytopenia (HIT) is a potentially fatal adverse reaction after administration of unfractionated or fractionated heparin, which underlies the generation of antibodies to the heparin complex and platelet factor 4 (PF4). It occurs in 5% of patients treated with unfractionated heparin and 0.5 - 1.5% fractionated heparin. The aim of the study is to determine the incidence and outcome of hemodialysis patients with HIT over 4-years period.

Method

This retrospective study analyzed patients who were tested for evidence of positive anti-heparin antibody in the period from 2015 to 2020 in Zvezdara University Medical Center. The diagnosis was confirmed by the 4T clinical scoring system, a positive antiheparin-PF4 ELISA test and a positive platelet aggregation test with heparin.

Results

During observation period, total of 64 tests were performed, out of which 23 patients were positive. Out of them, 14 patients were on HD, 7 patients (geriatric, surgery and cardiology departments) received therapy due to peripheral thrombosis, AIM or arrhythmia and 2 patients during 2020 due to SARS-CoV-2 bilateral pneumonia. All patients treated at nephrology, started hemodialysis (HD) with unfractionated heparin, while others were treated with LMWH. 4T scoring showed that 64% of patients had a moderate risk of developing HIT, while high risk was assessed in 36% of patients. Thrombotic complications in the form of deep venous thrombosis had 53% of patients and pulmonary thromboembolism had 17,5 % of patients. The greatest decrease in Tr was the most commonly observed between 10^th and 14^th day (61% of patients) and 39% from 4^th to 10^th day from start of heparin administration. In addition to heparin withdrawal and treatment with alternative non-heparin anticoagulation (fondaparinoux), 7 patients needed plasma treatment. 11 patients on HD were transferred to peritoneal dialysis (PD), and 3 patients recovered renal function. Overall mortality was 52%, and it was below 30% in hemodialysis patients.

Conclusion

HIT should be considered in patients at risk. It is necessary to abolish heparin treatment and use alternative method (PD) or alternative anticoagulation. Hemodialysis patients have better prognosis than other comparable patients

Influence of Pretransplant Factors on Posttransplant Anemia Recovery Rate in Primary Deceased Donor Kidney Transplant Recipients

OBJECTIVES

Our objective was to evaluate the influence of pretransplant risk factors on posttransplant anemia recovery.

MATERIALS AND METHODS

This single-center observational retrospective study included 80 deceased donor kidney transplant recipients who had been followed up to 16 months after kidney transplant. Time point of posttransplant anemia recovery was considered the time when hemoglobin of 11.0 g/dL was achieved and maintained for 3 consecutive monthly visits. We collected donor/transplant characteristics (age, sex, hypertension history, cause of death, donor kidney function, expanded criteria donor status, deceased donor score, HLA mismatch, and cold ischemia time) and recipient data (pretransplant hemoglobin, parathyroid hormone, kidney graft function, delayed graft function, acute rejection, infections, surgical bleeding, posttransplant parathyroid hormone, iron stores, and C-reactive protein and tacrolimus levels). We used univariate and multivariate Cox proportional hazards analyses and Kaplan-Meier plots to determine associations between variables and posttransplant anemia recovery rate. P < .05 was considered significant.

RESULTS

We identified 62 deceased donors (33 male; mean age 50 ± 15.1 years) and 80 kidney transplant recipients (52 male; mean age 47.0 ± 10.6 years). Mean pretransplant hemoglobin was 11.4 ± 1.5 g/dL. Donor age, deceased donor score, pretransplant parathyroid hormone, posttransplant transferrin saturation (all P < .05), and tacrolimus level (P < .01) were significantly related to posttransplant anemia recovery. Kaplan-Meier curve identified that recipients of deceased donors below 60 years old achieved hemoglobin of 11.0 g/dL more frequently and earlier than recipients of deceased donors above 60 years old (P < .05).

CONCLUSIONS

Deceased donor age, deceased donor score, pretransplant serum parathyroid hormone, posttransplant transferrin saturation, and tacrolimus level were significantly associated with posttransplant anemia recovery rate in deceased donor kidney transplant recipients. Anemia recovery was more frequent and earlier in recipients of deceased donors below 60 years than in recipients of donors 60 years old and above.

Morphometric analysis of glomeruli, clinical features and outcome in obese and non-obese focal segmental glomerulosclerosis patients

Background/Aim. In the past three decades focal segmental glomerulosclerosis (FSGS) was commonly regarded as a part of obesity related glomerulopathy (ORG) a distinct entity featuring proteinuria, glomerulomegalia, progressive glomerulosclerosis and renal functional decline. The aims of the present study were to evaluate the glomerular morphometry, clinical features and two years outcome in obese and non-obese FSGS patients. Methods. The study included 35 FSGS patients (23 males, age 46.5?15.2 years); divided in two groups: obese (BMI ?27 kg/m2- 18 patients, age 47.2?15.5 years) and non-obese (BMI <27 kg/m2- 17 patients, age 45.7?15.2 years). The serum concentrations of proteins, albumin, cholesterol, triglyceride and creatinine were determined at the time the biopsy, 6, 12, 24 months after the biopsy. Formulas Cockcroft- Gault (BMI <27 kg/m2) and Cockcroft-GaultLBW(BMI ?27 kg/m2) were calculated. Glomerular radius (GR), glomerular volume (GV) and glomerular density (GD) were compared morphometrically between two groups. Results. At the time of kidney biopsy and 6 months later the obese had significantly lower GFR compared to non-obese. After 24 months follow-up there wasn?t any difference between groups. Obese had significantly higher GR (109.44?6,03 ?m vs 98.53?14,38 ?m) and GV (3.13?0.49 x106 ?m3 vs 2.26?0.83 x106 ?m3),only midly lower GD (1.91?0.39/mm2 vs 1.95?0.61/mm2) compared to non-obese. Significant positive association between GV and BMI (r=0.439) was found. After 12 months follow-up significantly higher percentage of non-obese patients reached complete remission (71.4% vs 37.5%) compared to obese (?2=0.041), but after 24 months there were no significant difference. Conclusion. Obese patients at the time of kidney biopsy and 6 months later had already the significant lower kidney function compared to non-obese. However, after 12 and 24 months, this difference was still lower and without significance as well as after 24 months percentage of patients with complete remission between two groups.

P1353IS AGE RISK FACTOR FOR TUNNELED VASCULAR CATHETER OUTCOMES?

Background and Aims

According to previous data, the prevalence of tunnelled cuffed vascular catheters (TCC) is more frequent in elderly as compared to younger HD patients. Still, it is not clear if elderly have decreased survival of TCC as compared with survival in younger.

Method

During the period from January 2010 to June 30, 2015, 110 permanent catheters were implanted in 64 patients (1.72 catheters per patient, 51.6% male mean age 67±12years, 20 diabetics). Out of all patients, 44 (68.7%) were older than 65 years, 12 (27.3%) were diabetic and 11 (25%) were previously treated with peritoneal dialysis. In the age-based subpopulations we compared the incidence of infections, thrombosis, chemical removal of thrombus by actilysis and TCC outcome.

Results

Reasons for TCC placement in elderly were inability of the second option and exhausted vascular approach and these reasons were found to be significantly more frequent compared to patients younger than 65 years (p = 0.020 ). Primary position of TCC was right jugular vein in both groups (39.1%, No = 25 vs 14.1% No = 9), more commonly in group of elderly patients, but there was no significant difference in the initial TCC position depending on the age structure of the patient (Hi square = 1.720, p = 0.886). The overall incidence of infections was 3.44 episodes per 1000 catheter days and patients' age did not affect TCC replacement, infection, thrombosis and inflammation. In the group of elderly, 27 patients had catheter infection (61.4%), 10 (22.7%) had catheter thrombosis and actilysis resolved thrombosis in 6 (13.6%) patients without significant difference as compared with younger patients. Catheter-induced bacteraemia were more common in TCC over 65 years (47 TCC vs. 12 TCC) but without statistical significance (p = 0.062). Similarly, exit site infection, was more common (14 TCC vs. 4 TCC) for those older than 65 years but also without statistical significance. Thrombosis of TCC occurred in 7 patients with TCC younger than 65 years and in 20 TCC in cohort of elderly (Hi square = 0.033, p = 0.535) (Table 1). Regarding treatment outcome, 19 (43.2%) elderly patients died while being treated with TCC, 12 patients (27.3%) changed treatment modality to peritoneal dialysis, 4 patients (9.1%) received arteriovenosus graft (AVG) and 9 patients had functional TCC at the end of follow up (20.5%) and no significant difference was found in the outcome compared to younger patients.

Conclusion

The reason for placement of TCC in elderly is the inability of other treatment options and exhaustion of vascular access. Concerning catheter related complication and outcome, there was no significant difference between the elderly and younger patient.

P0130THE MORPHOMETRIC ANALYSIS OF GLOMERULI IN OBESE AND NON-OBESE PATIENTS WITH GLOMERULAR DISEASES

Background and Aims

The aim of the study was to evaluate glomerular morphometry in obese and non-obese patients with glomerular diseases: FSGS, IgA nephropathy, membranous glomerulonephritis (MGN) and membranoproliferative glomerulonephritis (MPGN).

Method

The study included 125 patients with glomerular diseases (77 males, mean age 46± 15.2 years): obese (BMI&gt; 27kg/m2- 63 patients) and non-obese (BMI&lt; 27kg/m2-62 patients). The serum concentration of creatinine, proteins, albumin, cholesterol, trygliceride, daily proteinuria were measured at the time of kidney biopsy. Formula Cockcroft-Gault#(Cockcroft-Gault: non-obese) and Cockcroft-GaultLBW: obese) was calculated. Glomerular radius (GR), glomerular volume (GV) and glomerular density (GD) were compared morphometrically between two groups.

Results

At the time of kidney biopsy the obese had significantly lower eGFR, significantly higher creatinine, trygliceride, daily proteinuria compared to non-obese. Obese FSGS patients had significantly higher GR (109.44±6.03 μm vs 98.53±14.38 μm) and GV (3.13±0.49 x106 μm?vs 2.26±0.83 x106 μm?, only midly lower GD (1.91±0.39/mm2 vs 1.95±0.61/mm2) compared to non-obese. Obese IgA nephropathy patients had higher GR (110.69± 15.24 μm vs 107.77±14.53 μm), significantly higher GV(3.34±1.78 x106 μm?vs 2.31± 1.51 x106 μm? and significantly lower GD (1.21±0.29/mm2 vs 2.14±0.54/mm2) in comparation with non-obese. Significant positive association between GV and BMI (r=0.439; p&lt;0.01) in FSGS patients was found. Significant positive correlation between GV and BMI (r=0.683; p&lt; 0.01), but significant negative correlation between GD and BMI (r=-0.710; p&lt; 0.01) in IgA nephropathy patients were found. Obese MGN patients had lower GR (112.82± 13.65 μm vs 118.39± 14.52 μm), GV (3.57± 1.19 x106 μm?vs 4.07± 1.28 x106 μm? and GD (1.89± 0.17/ mm2 vs 1.91± 0.92/mm2) but without significance compared to non-obese. Obese MPGN patients had higher GR(105.89± 12.24 μm vs 92.73± 30.01 μm), GV (2.94± 0.91 x106 μm?vs 2.31± 1.27 x106 μm? and GD (2.32± 0.63/ mm2 vs 2.03± 0.73/ mm2) but without significance in comparation with non-obese. Significant negative association between GD and daily proteinuria (r=-0.417; p&lt;0.01) in MGN patients was found.

Conclusion

Obese FSGS patients had significantly higher GV, lower GD compared to non-obese. Obese IgA nephropathy patients had significantly higher GV and significantly lower GD. Obese MGN patients had lower and obese MPGN patients had higher morphometric parameters of glomeruli compared to non-obese. Significant positive correlation between GV and BMI in FSGS and IgA nephropathy patients were found.

P1577DOES VITAMIN E -COATED MEMBRANES INFLUENCE ON MARKERS OF OXIDATIVE STRESS IN HEMODIALZSIS PATIENTS WITH HOMOZYGOUS GST M1 GENE DELETION?

Background and Aims

Increased free radicals production and down-regulated antioxidant enzymes activities contribute to protein, lipid and DNA oxidative damage particularly in HD patients lacking for GSTM1 enzyme activity. At the same time, those patients exhibit higher mortality rate than those with active GSTM1 genotype. It has been shown that vitamin E-coated membranes (VitEM) may decrease oxidative stress and inflammatory status in overall HD patients. Therefore, for the first time we analyzed VitEM dialyzers in patients who are homozygote for GSTM1 gene deletion and in whom anti-oxidative and anti-inflammatory benefit could be the greatest.

Method

GSTM1 genotypes were determined by PCR in 170 chronic HD patients. Those with GSTM1-null genotype were randomized and 80 were included in the study. Forty of them were dialyzed for three months with VitEM, while other forty were dialyzed with high-flux polysufone membranes of the same surface. Markers of protein and lipid oxidative damage, inflammation (thiol groups, malondialdehyde (MDA), Interleukin-6 (IL-6)), together with plasma antioxidant activity (glutathione peroxidase (GPX), superoxide dismutase (SOD)) were determined at the start and at the end of the study.

Results

Seventy-five patients’ finished the study. There were no significant differences in baseline characteristics between the two groups (age, sex, body weight, dialysis vintage, vascular access, presence of diabetes, dialyzers surface, Kt/V and CRP). Also, there were no significant differences at baseline markers of protein and lipid oxidative damage, inflammation and plasma antioxidant activity. After three months of therapy, GPX, MDA, thiol groups increased significantly in both groups, but without statistical significance between groups (Table 1). SOD did not change significantly during three month period. IL-6 increased in control group, at the same time decreased in VitEM group, but without statistical significance.

Conclusion

Vitamin E-coated membranes did not influence markers of oxidative stress in HD patients with GSTM1-null genotype. Further studies in the field are required.

P1087HOME HEMODIALYSIS THROUGH THE YEARS

Background and Aims

Outcome of dialysis patients differ considerably across the globe and many studies confirmed that home-based treatments offer some advantages, not only in regard of quality of life but also regarding of patients’ outcome. History of home hemodialysis (HOHD) in our country dates from 1971. and since that time many patients were treated with this dialysis modality. HOHD changed over the time together with general improving of dialysis techniques and we aimed to analyze the results of treatment of our population treated by HOHD during different time points.

Method

We analyzed patients characteristics, dialysis and uremia-related complications and survival of patients on HOHD during three different time points: 2001. (No=70), 2011. (No=29) and 2019. (No=22).

Results

The most frequent reason for ESRD in 2001, 2011 and 2019. was glomerulonephritis (48%, 45%, 36% respectively), followed by polycystic kidney disease 24% in 2011. and 36% in 2019. Diabetes mellitus (DM) was rarely cause of ESRD: in 2001. 2.1%; 4.5% in 2019. and none in 2011. In 2001. the patients were more frequently treated using high flux membranes (HF) as compared to HDF (87.1% vs.12.9%), and through years this changed in favor of HDF (48% vs. 52% in 2011, and 13.6% vs. 86.4% in 2019). Anti HCV prevalence was 27.4%, 38%, 27%, in 2001, 2011. and 2019. respectively. Anemia status was better controlled in recent years revealed by Hb level: 10.5±2.0 g/dl in 2001, 12.1±1.6 in 2011. and 11.9±2.3 in 2019. with almost similar percentage of patients treated with ESA (31%, 28% and 36% respectively). In 2001, parathyroid hormone level (iPTH) was 379±236 pmol/l and only 20% of patients underwent parathyroidectomy while in 2011. and in 2019. parathyroidectomy was performed in 69% and 59% of patients respectively. Therefore, in 2011. and in 2019. mean iPTH level was 33.8±48.5 and 40±46.2pmol/l respectively. Kaplan-Mayer analysis confirmed ten-year survival of 42% for period 1982-2001, and the most frequent reasons for death were infection and cardiovascular diseases. During the period 2011. to 2019., ten-year survival was 88% and cardiovascular diseases led to death in most of the cases.

Conclusion

our results have shown that HOHD treatment improved through the years considering patients’ survival, anemia status and secondary hyperparathyroidism treatment. Apart from HDF, the other factors have to be taken into consideration.

P1231ASSISTED PERITONEAL DIALYSIS IN ESRD PATIENTS

Background and Aims

Peritoneal dialysis is an important form of treatment for patients with end stage chronic kidney failure requiring renal replacement therapy but its use may be limitted by growing number of elderly and disabled patients. Often, they choose an assisted peritoneal dialysis (assCAPD) as first option, that can be performed by relative or a nurs. The aim of this research was to analyse differences between two groups of patients (CAPD vs. assCAPD) in order to establish if two variants are comparable in regard of patients outcome.

Method

We analysed 61 patient divided into two groups (ass CAPD, N= 16 and CAPD, N= 45) who were dialysed in Zvezdara University hospital for more than 3 months and correlated number of peritonitis, exit site infections and overall mortality rates between two groups during the period of 60 months. Assistance was provided on the volontary basis by family member.

Results

Patients in assCAPD group were unsignificantly older (68+11vs. 60 + 12 years) and had higher comorbidity score. The groups were homogeneous according the presence of diabetes mellitus, CRP and PTH levels. There were no significant difference between the two of groups in the number of peritonitis (p=0,77), exit site infections (p=0,37) and overall survival (p= 0,74, Figure 1.).

Conclusion

Family member provides very good assistance in peritoneal dialysis giving the results that are comparable to that of self-performing CAPD patients. This is therefore very successful treatmen option for a special population of ESRD patients who can not performe CAPD on their own.

P1510INCIDENCE AND OUTCOME HEMODIALYSIS PATIENCE WITH HEPARIN INDUCED THROMBOCYTOPENIA - FOUR YEAR EXPERIENCE ZVEZDARA UNIVERSITY MEDICAL CENTER

Background and Aims

Heparin-induced thrombocytopenia (HIT) is a potentially fatal adverse reaction after administration of unfractionated or fractionated heparin, which underlies the generation of antibodies to the heparin complex and platelet factor 4 (PF4). It occurs in 5% of patients treated with unfractionated heparin and 0.5 - 1.5% fractionated heparin. The aim of the study is to determine the incidence and outcome of hemodialysis patients with HIT over 4 years period.

Method

Our retrospective study analyzed patients who were tested for evidence of positive anti-heparin antibody in the period from 2015 to 2019 in Zvezdara University Medical Center. The diagnosis was confirmed by the 4T clinical scoring system, a positive antiheparin-PF4 ELISA test and a positive platelet aggregation test with heparin.

Results

During observation period, total of 54 tests were performed on HIT suspected patients, out of which 21 patients were positive. Out of them, 14 patients were on HD, and other 7 (geriatric, surgery and cardiology departments) received therapy due to peripheral thrombosis, AIM or arrhythmia. All patients treated at nephrology, started hemodialysis (HD) with unfractionated heparin, while others were treated with LMWH. 4T scoring showed that 64% of patients had a moderate risk of developing HIT, while high risk was assessed in 36% of patients. Thrombotic complications in the form of deep venous thrombosis had 50% of patients, pulmonary thromboembolism had 11% of patients. The greatest decrease in Tr was most commonly observed between 10th and 14th day (61% of patients) and 39% from 4th to 10th day from start of heparin administration. In addition to heparin withdrawal and treatment with alternative nonheparin anticoagulation (fondaparinoux), 5 patients needed plasma treatment. 11 patients on HD were transferred to peritoneal dialysis (PD), and 2 patients recovered renal function. Overall mortality was 52%, while in nephrology patients was below 30%.

Conclusion

HIT should be considered in patients at risk. It is necessary to abolish heparin treatment and use alternative method (PD) or alternative anticoagulation. Hemodialysis patients have better prognosis than other comparable patients.

P1093BENEFITS OF HOME HEMODIALYSIS

Background and Aims

Home hemodialysis (HOHD) has been available as a modality of renal replacement therapy since the 1960s, in our center since 1972. Despite better patients’ outcome provided by HOHD comparing to hospital hemodialysis (HHD), its adoption has been limited worldwide. The aim of this study was to compare anemia, nutrition, mineral metabolism and morbidity in patients on HOHD and HHD.

Method

we analyzed dialysis and uremia related complications and morbidity in 19 HOHD patients in comparison with patients on HHD (N= 57). Each HOHD patient was previously matched with three patients on HHD by sex, age and reason for end stage renal disease (ESRD). Patients on HHD were on dialysis 3x4 h per week while patients on HOHD had dialysis on consecutive days in duration of 5-6 hours. Also, patients on HOHD were more frequent on hemodiafiltration (HDF), 89.5% of them, as compared to HHD patients (only 21.4%).

Results

All patients on HOHD were using AVF as vascular access for HD, and most of the analyzed HHD patients (only 5.3% used AVG). As revealed by hemoglobin level (Hgb) patients on HOHD had significantly better anemia control than HHD patients (12±2.3 vs. 10.2±1g/dl, p=0.004), despite the lower ferritin level (94±117 vs. 256±175ng/ml, p=0,001) and less frequent use of erythropoietin-stimulating agents (ESA), (and only 31% on HOHD vs 80% patients on HHD, p=0,001). By analyzing patients that used ESA therapy, we revealed that HOHD patients had lower weekly dose of ESA (5333±3265 IU vs. 6068±4145 IU). The values of intact parathyroid hormone (iPTH), did not differ significantly between HOHD (311±419pg/ml ; min 5,25, max 1529) and HHD (233±212pg/ml; min 19,25, max 926), but higher percentage of patients in HOHD group underwent parathyroidectomy (63% vs. 3.5%). The average values of calcium, and phosphorus did not significantly differ between HOHD and HHD patients (2.4±0.3 vs. 2.3±0.2mmol/l; 1.5±0.5 vs. 1.6±0.5mmol/l, respectively). HOHD patients had significantly higher albumin level (43±4.5 vs. 40.6±4g/l, p=0,035). There was no difference in annual hospital admission rate (0.4±0.5 vs. 0.6±0.7, p=0.35) between groups, but HHD patients had longer in-hospital stay. (4.8±5.3 days for HOHD vs. 7.3±9.3 days for HHD; p=0.16). Vascular access complications were most frequent reason for hospitalization in both groups (37%), followed by cardiovascular complications 13.6%, in HOHD group and infectious complications in HHD group 24%.

Conclusion

Our study has shown that HOHD provides some advantages over HHD including better quality of life and better anemia and nutrition control, better control of parathyroid function and shorter in-hospital stay. More frequent and longer dialysis sessions may be possible reason including HDF.

P0905INFLUENCE OF TUMOR NECROSIS FACTOR ON MINERAL BONE DISEASE IN ESRD PATIENTS

Background and Aims

Serum levels of parathyreoid hormone is the main cause of mineral disorders in patients on chronic hemodialysis, and it well known that this hormone acts as an uremic toxine and contributes to oxidative stress and overall mortality rate. However, there are many observations which imply that the protean manifestations of renal bone disease cannot be explained simply by abnormalities of PTH or vitamin D metabolites. For example, levels of PTH correlate relatively poorly with various parameters of bone histology. It has been shown that uremia leads to cytokijne imbalance with overbalance of proinflammatory citokines such as TNF. Also, studies showed that calcimimetic therapy decreases not only PTH levels, but also levels of TNF. The aim was to analyse tumor necrosis factor (TNF) gene polymorphisms in group of hemodialysis patients and to correlate the findings with presence of secondary hyperparathyroidism.

Method

This cross sectional study included 202 patients on regular hemodialysis for more than six months in University Medical Centar Zvezdara. Venous blood for genotyping and for PTH analysis was collected on midweek dialysis session from each patient. Genetic analysis was performed by using polymerase chain reaction. Patients are diveded in two groups regarding the level of PTH, so that first group had normal PTH levels or mild SHPT, while patients in second group had sever SHPT. We analysed influence of genetic polymorphism for TNF on apperance of SHPT.

Results

The results have shown 3 fold lower risk for developing SHPT in GG homozygots for TNF gene with statistical significance (p=0,01)- Table 1.

Conclusion

Parathyreoid gland hyperfunction is multifactorial disorder and there are emerging evidence that cytokines as endogenous modulators have an important impact on its pathogenesis.

Does the pathohistological pattern of renal biopsy change during time?

Biopsy registries are one of the most important sources of accurate epidemiological data and the clinical presentation of renal diseases. A detailed analysis of clinicopathologic correlations over a period of 20 years (1987-2006) was performed earlier by our centre. The aim of this study was to check the current state and to register possible changes in clinicopathologic findings recorded under better socioeconomical circumstances and new management. Records of 665 renal biopsies performed at our institution were prospectively followed from 2007 to 2014. The results were compared with our previously published data. The average annual incidence of renal biopsies increased by 10% and included more elderly patients. Nephrotic syndrome (NS) remained the most common clinical indication for biopsy, while acute kidney injury participated more frequently than in the previous study (p < 0.001). Membranous nephropathy (MN) was still the most common cause of NS. Primary glomerulonephritis (PGN) remained the most prevalent disease, while MN was the most prevalent PGN. In comparison with the earlier period, MN was a more common diagnosis (p = 0.002), while the prevalence of mesangioproliferative non-IgA nephropathy decreased significantly during the time (p = 0.012). LN remained the most frequent secondary glomerulonephritis. The pathohistological pattern of renal biopsy remained largely unchanged during time. However, acute kidney injury was more frequently an indication for biopsy in the current study. The significant increase of biopsied elderly patients is due to the rise in their relative numbers in our population.

Comparative Survival Analysis of Urea Kinetic Based Indices

Background

Although urea kinetic modeling indices for measuring dialysis dose are recommended by world expert groups, it is not quite clear whether some of these are superior in predicting the outcome over others. This prospective, single-center study was carried out with the aim to compare predictive value of different indices and methods of measuring dialysis dose.

Methods

The analysis included 93 anuric patients having been on hemodialysis for at least 2 years who were followed-up for 75-months. The dialysis dose was measured by Kt/V (formal UKM, 3 and 2 urea samples), Kt/V (Daugirdas), Kt/V (Lowrie), eKt/V (Daugirdas), URR and TAC urea.

Results

Correlations between dialysis indices and survival time were significant for all indices (p<0.01) except for TAC. All indices, except for TAC urea, were significant predictors of mortality (multivariate Cox regression analysis; p<0.01) and differences of significant levels among these colinear parameters were small.

Conclusion

All examined indices except for TAC urea were highly predictive of patient mortality. Daugirdas and Lowrie simplified Kt/V indices are as predictive of all-cause mortality as more complex formal UKM methods in long-term patients on a 3×4h/week schedule.

Hemodialysis Modality, Percentage of Body Fat, and Patient Survival

Background

A number of studies have reported lower mortality of overweight hemodialysis patients. This post hoc analysis of an observational prospective single-center study was aimed at elucidating whether both being overweight and surviving longer could result from changes in the hemodialysis modality.

Methods

The study included a cohort of 242 patients who were gradually switched from cuprophane membrane and acetate dialysis to polysulfone (including high-flux) membranes and bicarbonate dialysis. The analysis involved 12 months of baseline data obtained during the first calendar year after the patients entered the study (1994–2001) and repeated measurements for up to 132 months of follow-up (until 2004). Anthropometric measurements were made during the winter season and the percentage of body fat (%fat) was calculated from triceps, biceps, subscapular, and suprailiac skinfolds (K/DOQI guidelines). Kt/V, normalized protein catabolic rate, and cardiovascular comorbidity were also determined and laboratory analyses undertaken.

Results

Significant correlations were found between %fat and bicarbonate dialysate as well as polysulfone membrane and high-flux membrane. The linear mixed model showed dependence of %fat on polysulfone and high-flux membrane (p<0.01) Multivariate Cox regression (time-dependent covariates) found %fat to be an independent factor for longer survival, in addition to polysulfone and high-flux membranes.

Conclusion

Changes in hemodialysis modality were followed by both higher body fat percentage and patient survival. The reverse epidemiology of overweight patients might be at least partially the result of the influence of nonnutritional factors, such as a change in hemodialysis modality (introducing biocompatible high-flux and low-flux membranes and bicarbonate dialysis).

Association of kidney fibrosis with urinary peptides: a path towards non-invasive liquid biopsies?

Chronic kidney disease (CKD) is a prevalent cause of morbidity and mortality worldwide. A hallmark of CKD progression is renal fibrosis characterized by excessive accumulation of extracellular matrix (ECM) proteins. In this study, we aimed to investigate the correlation of the urinary proteome classifier CKD273 and individual urinary peptides with the degree of fibrosis. In total, 42 kidney biopsies and urine samples were examined. The percentage of fibrosis per total tissue area was assessed in Masson trichrome stained kidney tissues. The urinary proteome was analysed by capillary electrophoresis coupled to mass spectrometry. CKD273 displayed a significant and positive correlation with the degree of fibrosis (Rho = 0.430, P = 0.0044), while the routinely used parameters (glomerular filtration rate, urine albumin-to-creatinine ratio and urine protein-to-creatinine ratio) did not (Rho = -0.222; -0.137; -0.070 and P = 0.16; 0.39; 0.66, respectively). We identified seven fibrosis-associated peptides displaying a significant and negative correlation with the degree of fibrosis. All peptides were collagen fragments, suggesting that these may be causally related to the observed accumulation of ECM in the kidneys. CKD273 and specific peptides are significantly associated with kidney fibrosis; such an association could not be detected by other biomarkers for CKD. These non-invasive fibrosis-related biomarkers can potentially be implemented in future trials.

Acute Renal Failure - A Serious Complication in Patients After Kidney Transplantation

Free radical-mediated injury releases proinflammatory cytokines and activates innate immunity. It has been suggested that the early innate response and the ischemic tissue damage play roles in the development of adaptive responses, which may lead to acute kidney rejection. Various durations of hypothermic kidney storage before transplantation add to ischemic tissue damage. The final stage of ischemic injury occurs during reperfusion that develops hours or days after the initial insult. Repair and regeneration processes occur together with cellular apoptosis, autophagy and necrosis and a favorable outcome is expected if regeneration prevails. Along the entire transplantation time course, there is a great demand for novel immune and nonimmune injury biomarkers. The use of these markers can be of great help in the monitoring of kidney injury in potential kidney donors, where acute kidney damage can be overlooked, in predicting acute transplant dysfunction during the early post-transplant periods, or in predicting chronic changes in long term followup. Numerous investigations have demonstrated that biomarkers that have the highest predictive value in acute kidney injury include NGAL, Cystatin C, KIM-1, IL-18, and L-FABP. Most investigations show that the ideal biomarker to fulfill all the needs in renal transplant has not been identified yet. Although, in many animal models, new biomarkers are emerging for predicting acute and chronic allograft damage, in human allograft analysis they are still not routinely accepted and renal biopsy still remains the gold standard.

Acute Renal Failure in Transplanted Kidneys

Free radical-mediated injury releases proinflammatory cytokines and activates innate immunity. It has been suggested that the early innate response and the ischemic tissue damage play roles in the development of adaptive responses, which may lead to acute kidney rejection. Various durations of hypothermic kidney storage before transplantation add to ischemic tissue damage. The final stage of ischemic injury occurs during reperfusion that develops hours or days after the initial insult. Repair and regeneration processes occur together with cellular apoptosis, autophagy and necrosis and a favorable outcome is expected if regeneration prevails. Along the entire transplantation time course, there is a great demand for novel immune and nonimmune injury biomarkers. The use of these markers can be of great help in the monitoring of kidney injury in potential kidney donors, where acute kidney damage can be overlooked, in predicting acute transplant dysfunction during the early post-transplant periods, or in predicting chronic changes in long term followup. Numerous investigations have demonstrated that biomarkers that have the highest predictive value in acute kidney injury include NGAL, Cystatin C, KIM-1, IL-18, and L-FABP. Most investigations show that the ideal biomarker to fulfill all the needs in renal transplant has not been identified yet. Although, in many animal models, new biomarkers are emerging for predicting acute and chronic allograft damage, in human allograft analysis they are still not routinely accepted and renal biopsy still remains the gold standard.

Epidemic varicella zoster virus reactivation in renal transplant recipients: a case report

Immunosuppression after transplantation renders the transplant recipient susceptible to a broad array of viral pathogens. Of 31 patients transplanted during 2012 in our center, 6 (19.3%) experienced varicella zoster virus (VZV) reactivation. The median time from transplantation to reactivation was 6.2 months. Immunosuppression consisted of antithymocyte globulin in 5 patients and basiliximab in 1, followed by tacrolimus, mycophenolic acid, and prednisolone. Two patients had T-cell-mediated rejection and were treated with pulse doses of corticosteroids. All patients received valganciclovir as prophylaxis of CMV infection. In 3 patients a disseminated vesicular skin rash was the sole manifestation of VZV reactivation. Two were successfully treated with acyclovir and 1 with ganciclovir. Ramsay Hunt syndrome complicated herpes zoster in the fourth patient, whereas the remaining 2 patients had visceral involvement, pneumonitis, and encephalitis, and died in spite of full doses of antiviral therapy. This was the first case of "epidemic" VZV reactivation in the 35-year history of our transplant center. VZV-specific cellular immunity pretransplantation is not sufficient to protect kidney transplant recipients from herpes zoster episodes. Considering the potentially devastating consequences of VZV reactivation, additional treatment options and universal prophylaxis should be contemplated.

Wide acquired arteriovenous fistula between main renal artery and interlobar vein treated with nephrectomy

A case of renal arteriovenous fistula between the main renal artery and interlobar vein diagnosed 25 years after percutaneous renal biopsy was presented. A 62-year-old female was referred to a urologist with dilatation of the left renal pyelocalyceal system diagnosed after abdominal ultrasonography, while intravenous urography did not confirm that finding. Historically, she underwent renal biopsy 25 years ago without any complication. Her hypertension was well controlled during the last 10 years, although three antihypertensive drugs with occasional additional diuretics were necessary during the last 6 months. Color Duplex Ultrasonography, arteriography and Multi-Slice Computed Tomography revealed the presence of renal arteriovenous fistula between the main renal artery and interlobar vein, as well as severe dilatation of all interlobar veins, renal, ovarian and adrenal vein on the left side. Urological and vascular surgeons operated to ligate the fistula and preserve the kidney. However, it was not possible to reach the fistula inside the kidney and nephrectomy was performed.

Application of artificial neural networks in estimating predictive factors and therapeutic efficacy in idiopathic membranous nephropathy

Idiopathic membranous nephropathy (IMN) is one of the most frequent causes of the nephrotic syndrome in adults and one of the most common cause of chronic renal failure among primary glomerular diseases. The aim of this study was to develop artificial neural networks (ANN) to investigate factors of poor outcome for IMN and to evaluate the efficacy of different therapeutic protocols. Data were collected retrospectively for 124 patients with IMN (82 males, mean based on the received therapy patients were divided into three groups: corticosteroids only (group 1), cyclophsophamide with corticosteroids (group 2), and so called Ponticelli protocol (group 3). After achieving satisfactory truthfulness of the transcription function of ANN through clustering, we have applied the efficacy analysis to all patients and then compared them to each group separately, and evaluated the influence of initial characteristics on disease outcome as well as the therapy efficacy. The greatest therapy inefficiency was recorded for isolated corticosteroid therapy (29.41%) and the smallest inefficiency for Ponticelli protocol, for which the greatest accuracy of prognosis was recorded (82.09%). The greatest negative prognostic influence had kidney insufficiency (22%), quantitative proteinuria (15%) and index of interstitial infiltration (14%). Based on our results, we can recommend that patients diagnosed with IMN with renal insufficiency, nephrotic syndrome or a high degree of interstitial infiltration at the time of diagnosis should be treated concomitantly with cytotoxic drugs and corticosteroids, particularly with the Ponticelli protocol.

Resolving erythrocytosis and hypertension after open surgical extirpation of giant renal cyst measuring 30 cm: case report

The case of giant renal cyst measuring 30 cm, accompanied by abdominal swelling and erythrocytosis, is presented. A 45-year-old male presented with large abdominal mass, atrophic left kidney, hypertension, and erythrocytosis. The patient underwent multiple preoperative phlebotomies, open extirpation of the cyst, and nephrectomy. After the surgery, erythrocytosis ceased completely, blood pressure became normal without any medications whereas function of the remaining kidney was stable. The giant renal cysts measuring more than 15 cm are extremely rare. However, they can cause erythrocytosis and hypertension very frequently, especially in the case of cysts originating from the proximal tubule. To our knowledge, this is the largest renal cyst published in the literature that caused the above-mentioned complications.

Effect of carvedilol on pulse pressure and left ventricular hypertrophy in spontaneously hypertensive rats with adriamycin nephropathy

Recent studies indicated pulse pressure as a risk factor for left ventricular hypertrophy, myocardial infarction, congestive heart failure and stroke as well as chronic renal failure progression. The present study examined the effects of carvedilol and its combination with captopril on blood pressure, left ventricular hypertrophy, kidney vascular changes and kidney function in spontaneously hypertensive rats with adriamycin nephropathy. Four groups of 20 SHR each were involved: (1) control group: SHR; (2) ADR group: SHR treated with ADR (2mg/kg i.v. twice in 20 days); (3) ADR-C group: SHR treated with ADR and carvedilol (30 mg/kg/day) and (4) ADR-CC group: SHR treated with ADR and carvedilol (30 mg/kg/day) and captopril (60 mg/kg/day). Systolic-, diastolic- and mean-pressures and pulse pressure were determined at weeks 6 and 12 after the second ADR injection; and body weight, creatinine clearance and proteinuria at weeks -3, 6 and 12. The rats were sacrificed at week 6 or 12, the weights of the left and right ventricles and kidneys measured and the kidney vascular index was calculated as described by Bader and Mayer. Both carvedilol alone and combined with captopril significantly reduced systemic blood pressure but the effect of the latter was more pronounced and registered from week 4 till the end of the study. Carvedilol and its combination with captopril significantly decreased SBP, DBP and MAP. They also decreased PP, prevented the development of LVH, and renal vascular changes and slowed the progression of chronic renal failure and these effects were stronger in the ADR-CC group than in the ADR-C group. The antihypertensive drugs failed to prevent proteinuria in ADR SHR. Significant positive correlations were found between PP (but not SBP, DBP and MAP) and both proteinuria and Ccr in all groups of rats. In conclusion, carvedilol alone, but more strongly in combination with captopril, significantly reduced blood pressure, PP, LVH, renal blood vessel changes and chronic renal failure progression.