Coding practice in national and regional kidney biopsy registries.

BACKGROUND: Kidney biopsy registries all over the world benefit research, teaching and health policy. Comparison, aggregation and exchange of data is however greatly dependent on how registration and coding of kidney biopsy diagnoses are performed. This paper gives an overview over kidney biopsy registries, explores how these registries code kidney disease and identifies needs for improvement of coding practice. METHODS: A literature search was undertaken to identify biopsy registries for medical kidney diseases. These data were supplemented with information from personal contacts and from registry websites. A questionnaire was sent to all identified registries, investigating age of registries, scope, method of coding, possible mapping to international terminologies as well as self-reported problems and suggestions for improvement. RESULTS: Sixteen regional or national kidney biopsy registries were identified, of which 11 were older than 10 years. Most registries were located either in Europe (10/16) or in Asia (4/16). Registries most often use a proprietary coding system (12/16). Only a few of these coding systems were mapped to SNOMED CT (1), older SNOMED versions (2) or ERA-EDTA PRD (3). Lack of maintenance and updates of the coding system was the most commonly reported problem. CONCLUSIONS: There were large gaps in the global coverage of kidney biopsy registries. Limited use of international coding systems among existing registries hampers interoperability and exchange of data. The study underlines that the use of a common and uniform coding system is necessary to fully realize the potential of kidney biopsy registries.

Comparison of urea recirculation and thermodilution for monitoring of vascular access in patients undergoing hemodialysis.

Introduction It is important to monitor vascular access in patients with stage 5 chronic kidney disease receiving hemodialysis. Access recirculation can help to detect a need for intervention. OBJECTIVES: To compare urea recirculation with recirculation by thermodilution using blood temperature monitoring to predict a need for intervention of vascular access over a 6-month period. METHODS: We analyzed urea recirculation and blood temperature monitoring simultaneously in 61 patients undergoing hemodialysis. During the 6-month follow-up, we recorded all cases of angioplasty or surgery (thrombectomy or reanastomosis). In line with previous studies, we considered a value to be positive when urea recirculation was >10% and blood temperature monitoring >15%. Receiver operating characteristic curves were constructed. RESULTS: Mean urea recirculation was 9.5% ± 6.6% and mean blood temperature monitoring 12.9% ± 4.3% (p = 0.001). Urea recirculation >10% had a sensitivity of 80% and specificity of 78%. Blood temperature monitoring >15% had a sensitivity of 33% and specificity of 85%. During follow-up, 25% of patients developed need for intervention of vascular access. We found an association between vascular access dysfunction and urea recirculation. The Kaplan-Meier analysis confirmed an association between urea recirculation and risk of vascular access dysfunction (log rank = 17.2; p = 0.001). We were unable to confirm this association with blood temperature monitoring (log rank = 0.879; p = 0.656). CONCLUSION: Urea recirculation is better predictor of vascular access dysfunction than thermodilution.

Changes in the clinical presentation of immunoglobulin A nephropathy: data from the Spanish Registry of Glomerulonephritis.

Background: Immunoglobulin A nephropathy (IgAN) is the most common glomerulonephritis in the world, but there is little epidemiological data about possible changes in its presentation over the years. Available information about the influence of age on the form of clinical presentation is also scarce. Methods: The aim of the study was to analyse all renal biopsies performed between 1994 and 2013 and recorded in the Spanish Registry of Glomerulonephritis with a histological diagnosis of IgAN. The study was divided into five 4-year periods (1994-97, 1998-2001, 2002-05, 2006-09 and 2010-13) and patients were divided into four age groups: ≤16, 17-44, 45-64 and ≥65 years. Results: From 20.974 renal biopsies recorded, 2961 (14.1%) corresponded to IgAN. The prevalence of IgAN remained stable, but a significant increase in age [from 37.6 (SD 17.7) in 1994-97 to 44.9 (SD 16.8) years in 2010-13; P = 0.001] and worse renal function at presentation [from serum creatinine (SCr) 1.9 (SD 1.9) in 1994-97 to 2.3 (SD 2.1) mg/dL in 2010-13; P = 0.001] were observed over the years. Nephrotic-range proteinuria and acute kidney injury (AKI) as forms of presentation were significantly more common among patients ≥65 years (17.7% and 43.2%, respectively) as compared with the other age groups [≤16 (11.4% and 13.1%, respectively), 17-44 (13.1% and 13%, respectively) and 45-64 (12.1% and 21.3%, respectively)]. Blood pressure, SCr and proteinuria were also significantly higher at presentation among elderly patients. Conclusions: Although the prevalence of IgAN in Spain has remained stable over the years, patients are significantly older and present with significantly worse renal function in the last years. The incidence of nephrotic-range proteinuria (17.7%) and AKI (43.2%) as forms of presentation is remarkable among patients ≥65 years of age.

Adding access blood flow surveillance reduces thrombosis and improves arteriovenous fistula patency: a randomized controlled trial.

PURPOSE: Stenosis is the main cause of arteriovenous fistula (AVF) failure. It is still unclear whether surveillance based on vascular access blood flow (QA) enhances AVF function and longevity. METHODS: We conducted a three-year follow-up randomized, controlled, multicenter, open-label trial to compare QA-based surveillance and pre-emptive repair of subclinical stenosis with standard monitoring/surveillance techniques in prevalent mature AVFs. AVFs were randomized to either the control group (surveillance based on classic alarm criteria; n = 104) or to the QA group (QA measured quarterly using Doppler ultrasound [M-Turbo®] and ultrasound dilution [Transonic®] added to classic surveillance; n = 103).The criteria for intervention in the QA group were: 25% reduction in QA, QA<500 mL/min or significant stenosis with hemodynamic repercussion (peak systolic velocity [PSV] more than 400 cm/sc or PSV pre-stenosis/stenosis higher than 3). RESULTS: At the end of follow-up we observed a significant reduction in the thrombosis rate in the QA group (0.025 thrombosis/patient/year in the QA group vs. 0.086 thrombosis/patient/year in the control group [p = 0.007]). There was a significant improvement in the thrombosis-free patency rate (HR, 0.30; 95% CI, 0.11-0.82; p = 0.011) and in the secondary patency rate in the QA group (HR, 0.49; 95% CI, 0.26-0.93; p = 0.030), with no differences in the primary patency rate between the groups (HR, 0.98; 95% CI, 0.57-1.61; p = 0.935).There was greater need for a central venous catheter and more hospitalizations associated with vascular access in the control group (p = 0.034/p = 0.029).Total vascular access-related costs were higher in the control group (€227.194 vs. €133.807; p = 0.029). CONCLUSIONS: QA-based surveillance combining Doppler ultrasound and ultrasound dilution reduces the frequency of thrombosis, is cost effective, and improves thrombosis free and secondary patency in autologous AVF.

Universal Sustained Viral Response to the Combination of Ombitasvir/Paritaprevir/Ritonavir and Dasabuvir with/without Ribavirin in Patients on Hemodialysis Infected with Hepatitis C Virus Genotypes 1 and 4.

BACKGROUND: Hepatitis C virus (HCV) infection is highly prevalent among patients on hemodialysis (HD) and is associated with poor prognosis. Treatment with interferon and ribavirin is poorly tolerated, and few data are available on the impact of new direct-acting antivirals (DAAs). This study was intended to analyze the efficacy and safety of treatment with a combination of ombitasvir/paritaprevir/ritonavir and dasabuvir with/without ribavirin in HCV-infected patients on HD from 3 hospitals. METHODS: This is a multicentric study. We analyze the clinical course of all patients on HD with HCV infection who had been treated with the combination of ombitasvir/paritaprevir/ritonavir and dasabuvir in 3 hospitals in Madrid, Spain. All patients under treatment had undergone Transient elastography (FibroScan®) and HCV RNA (PCR) and HCV genotype were determined simultaneously. RESULTS: Thirty-five patients aged 53.3 ± 8.9 years (68.6% males) and with genotypes 1 and 4 were treated with the DAA regimen, and 17 were also given ribavirin. The most common etiology was glomerular disease. Sustained viral response was achieved in 100% of patients. Adverse effects were negligible, and no patient had to discontinue treatment. The most significant side effect was anemia, which led to a significant increase in the dose of erythropoiesis-stimulating agents. Anemia was more marked in patients receiving ribavirin. No patients required transfusions. CONCLUSION: A combination of ombitasvir/paritaprevir/ritonavir and dasabuvir with/without ribavirin for the treatment of HCV in patients on HD is highly effective and causes minimal side effects. This regimen represents a major advance in disease management. A considerable improvement in prognosis seems likely.

Asymptomatic Intradialytic Supraventricular Arrhythmias and Adverse Outcomes in Patients on Hemodialysis.

BACKGROUND AND OBJECTIVES: Supraventricular arrhythmias are associated with high morbidity and mortality. Nevertheless, this condition has received little attention in patients on hemodialysis. The objective of this study was to analyze the incidence of intradialysis supraventricular arrhythmia and its long-term prognostic value. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We designed an observational and prospective study in a cohort of patients on hemodialysis with a 10-year follow-up period. All patients were recruited for study participation and were not recruited for clinical indications. The study population comprised 77 patients (42 men and 35 women; mean age =58±15 years old) with sinus rhythm monitored using a Holter electrocardiogram over six consecutive hemodialysis sessions at recruitment. RESULTS: Hypertension was present in 68.8% of patients, and diabetes was present in 29.9% of patients. Supraventricular arrhythmias were recorded in 38 patients (49.3%); all of these were short, asymptomatic, and self-limiting. Age (hazard ratio, 1.04 per year; 95% confidence interval, 1.00 to 1.08) and right atrial enlargement (hazard ratio, 4.29; 95% confidence interval, 1.30 to 14.09) were associated with supraventricular arrhythmia in the multivariate analysis. During a median follow-up of 40 months, 57 patients died, and cardiovascular disease was the main cause of death (52.6%). The variables associated with all-cause mortality in the Cox model were age (hazard ratio, 1.04 per year; 95% confidence interval, 1.00 to 1.08), C-reactive protein (hazard ratio, 1.04 per 1 mg/L; 95% confidence interval, 1.00 to 1.08), and supraventricular arrhythmia (hazard ratio, 3.21; 95% confidence interval, 1.29 to 7.96). Patients with supraventricular arrhythmia also had a higher risk of nonfatal cardiovascular events (hazard ratio, 4.32; 95% confidence interval, 2.11 to 8.83) and symptomatic atrial fibrillation during follow-up (hazard ratio, 17.19; 95% confidence interval, 2.03 to 145.15). CONCLUSIONS: The incidence of intradialysis supraventricular arrhythmia was high in our hemodialysis study population. Supraventricular arrhythmias were short, asymptomatic, and self-limiting, and although silent, these arrhythmias were independently associated with mortality and cardiovascular events.

Fat tissue and inflammation in patients undergoing peritoneal dialysis.

BACKGROUND: Body weight has been increasing in the general population and is an established risk factor for hypertension, diabetes, and all-cause and cardiovascular mortality. Patients undergoing peritoneal dialysis (PD) gain weight, mainly during the first months of treatment. The aim of this study was to assess the relationship between body composition and metabolic and inflammatory status in patients undergoing PD. METHODS: This was a prospective, non-interventional study of prevalent patients receiving PD. Body composition was studied every 3 months using bioelectrical impedance (BCM(®)). We performed linear regression for each patient, including all BCM(®) measurements, to calculate annual changes in body composition. Thirty-one patients in our PD unit met the inclusion criteria. RESULTS: Median follow-up was 26 (range 17-27) months. Mean increase in weight was 1.8 ± 2.8 kg/year. However, BCM(®) analysis revealed a mean increase in fat mass of 3.0 ± 3.2 kg/year with a loss of lean mass of 2.3 ± 4.1 kg/year during follow-up. The increase in fat mass was associated with the conicity index, suggesting that increases in fat mass are based mainly on abdominal adipose tissue. Changes in fat mass were directly associated with inflammation parameters such as C-reactive protein (r = 0.382, P = 0.045) and inversely associated with high-density lipoprotein cholesterol (r=-0.50, P = 0.008). CONCLUSIONS: Follow-up of weight and body mass index can underestimate the fat mass increase and miss lean mass loss. The increase in fat mass is associated with proinflammatory state and alteration in lipid profile.

New expectations in the treatment of anemia in chronic kidney disease. / Nuevas expectativas en el tratamiento de la anemia en la enfermedad renal crónica.

The new drugs developed for the treatment of anemia in chronic kidney disease patients, together with their mechanisms of action are reviewed. At present, many of them are already in advanced stages of clinical trials and is expected to be incorporated into the therapeutic arsenal in the coming years. The potential benefits and possible limitations are also described.

Daily Home Hemodialysis Is an Available Option for Renal Replacement Therapy in Spain.

The objective of the present study was to analyze the characteristics and survival of patients from our hospital who started home hemodialysis. We analyzed all patients receiving home hemodialysis from 1969 to 2015 (51 patients; age 45 ± 23 years; men 77%). We collected characteristics, hospital admission, and mortality. After a median follow-up of 43 (22-76) months, we found 0-1 hospital admissions per year. Sixty-nine percent received a kidney transplant, and the global mortality was 10%. Survival at 5 years was 96%. Mean equivalent renal urea clearance was 15.6 ± 4.2 mL/min, the ß-2 microglobulin reduction rate was 67 ± 18%, the number of antihypertension drugs was 0.7 ± 0.3, and the erythropoietin resistance index was 3.7 ± 2.1 IU/kg/week/g/dL. Daily home hemodialysis is a viable option for renal replacement therapy and should be offered alongside other therapies.

The impact of access blood flow surveillance on reduction of thrombosis in native arteriovenous fistula: a randomized clinical trial.

PURPOSE: The usefulness of access blood flow (QA) measurement is an ongoing controversy. Although all vascular access (VA) clinical guidelines recommend monitoring and surveillance protocols to prevent VA thrombosis, randomized clinical trials (RCTs) have failed to consistently show the benefits of QA-based surveillance protocols. We present a 3-year follow-up multicenter, prospective, open-label, controlled RCT, to evaluate the usefulness of QA measurement using Doppler ultrasound (DU) and ultrasound dilution method (UDM), in a prevalent hemodialysis population with native arteriovenous fistula (AVF). METHODS: Classical monitoring and surveillance methods are applied in all patients, the control group (n = 98) and the QA group (n = 98). Besides this, DU and UDM are performed in the QA group every three months. When QA is under 500 ml/min or there is a >25% decrease in QA the patient goes for fistulography, surgery or close clinical/surveillance observation. Thrombosis rate, assisted primary patency rate, primary patency rate and secondary patency rate are measured. RESULTS: After one-year follow-up we found a significant reduction in thrombosis rate (0.022 thrombosis/patient/year at risk in the QA group compared to 0.099 thrombosis/patient/year at risk in the control group [p = 0.030]). Assisted primary patency rate was significantly higher in the QA group than in control AVF (hazard ratio [HR] 0.23, 95% confidence interval [CI] 0.05-0.99; p = 0.030). In the QA group, the numbers unddergoing angioplasty and surgery were higher but with no significant difference in non-assisted primary patency rate (HR 1.41, 95% CI 0.72-2.84; p = 0.293). There was a non-significant improvement in secondary patency rate in the QA group (HR 0.510, 95% CI 0.17-1.50; p = 0.207). CONCLUSIONS: The measurement of QA combining DU and UDM shows a reduction in thrombosis rate and an increased assisted primary patency rate in AVF after one-year follow-up. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02111655.

Albumin leakage in online hemodiafiltration, more convective transport, more losses?

Online hemodiafiltration (OL-HDF) has now demonstrated some benefits in reducing mortality. It seems that rising convective volumes improve the outcomes, but the risks of it, such as albumin leakage, are not well defined yet. The aim of the present study was to evaluate the albumin leakage using two different filters with 20 and 30 L of post-dilution OL-HDF. In this cross-sectional study, 20 prevalent patients receiving post-dilution OL-HDL were included. We analyzed two dialyzers: FX1000, FMC and Polyflux 210H, Gambro. During four consecutive dialysis sessions, monitors were programmed using control-volume to obtain 20 or 30 L with both dialyzers. We collected albumin samples of the effluent at 5, 15, 30, 45 and 60 min and performed area under the curve (AUC) determinations for evaluating the losses. Mean patient age was 60 ± 9 years, and 70% were men. Albumin leakage was significant higher with Polyflux 210H when compared to FX 1000 FMC. A convective volume of 30 L produced greater albumin leakage than 20 L with both filters, though only with the FX 1000 FMC was it significant (minimum albumin leakage during first hour with FX 1000 FMC 20 L: 79.2 [0.0-175.7] mg; 30 liters: 403.3 [63.5-960.7] mg; with PF 210 Gambro 20 L: 869.1 [420.0-3214.7] mg; 30 L: 1841.7 [443.8-3417.5] mg). During OL-HDF, convective transport causes albumin leakage at least during the first hour. The albumin concentration in the effluent differs according to the type of filter used and the convective volume.

Intraperitoneal fluid overestimates hydration status assessment by bioimpedance spectroscopy.

BACKGROUND: Bioimpedance spectroscopy (BIS) is a valuable tool to assess nutrition and volume status in peritoneal dialysis (PD) patients. However, data about the influence of intraperitoneal fluid on body composition measures are conflicting, and there is no clear consensus about whether the abdomen should be drained before the procedure. We designed a comparison study to detect the influence of intra-abdominal fluid on BIS results. METHODS: We performed 73 pairs of BIS measurements in 34 stable PD patients, first with the peritoneum filled with a 1.36% glucose dialysate solution and then after the solution was drained. Patients stayed in the supine position for 10 minutes before the BIS procedure, and the electrodes were not moved between measures. Clinical and demographic data were collected, as were analytic parameters of nutrition and volume status. RESULTS: Fluid overload is overestimated when BIS is performed with a full abdomen (1.82 ± 1.73 L vs 1.64 ± 1.68 L, p = 0.043). We also found a spurious overestimation in extracellular water (16.40 ± 3.21 L vs 16.24 ± 3.16 L, p < 0.001) and in relative overhydration (8.29% ± 6.96% vs 7.14% ± 6.79%, p = 0.017). No differences in intracellular water or parameters of nutrition were found. We observed negative correlations for the extracellular water overestimation with age (r = -0.245, p = 0.037), serum B-type natriuretic peptide (r = -0.366, p = 0.036), body mass index (r = -0.248, p = 0.035), and lean tissue index (r = -0.427, p = 0.001). The difference in extracellular water correlated only with body mass index (r = -0.259, p = 0.039). We also found that, assessed at 50 KHz, whole-body impedance (-4.52 ± 8.37, p = 0.001) and phase angle (-0.08 ± 0.23 degrees, p = 0.002) were both lower when BIS was performed in patients with a full abdomen. CONCLUSIONS: Fluid overload is overestimated by BIS when performed in patients with dialysate in the peritoneum. The observed differences are greater in younger, more poorly nourished, or less overhydrated patients. If more precise results are required, we suggest that the abdomen be drained before BIS is performed.

Study on overhydration in dialysis patients and its association with inflammation.

BACKGROUND:  Patients with chronic kidney disease receiving haemodialysis (HD) have permanent variations in hydration status that may affect their survival.  OBJECTIVES:  To analyse hydration status and body composition in patients on haemodialysis and its relation to inflammation.  METHODS:  We included 128 prevalent clinically stable patients on haemodialysis. We analysed body composition using spectroscopic bioimpedance and inflammation using blood parameters.  RESULTS:  Patients with higher lean tissue had less intracellular (p=0.02) and extracellular water (p = 0.001). We did not find association with fat tissue and hydration. Mean overhydration was 7.5 %. We found an association between overhydration adjusted to extracellular water (OH/ECW) higher than 15 % similar to 10 %. They were both associated with low prealbumin levels (p = 0.001 and p = 0.05 respectively) and low levels of fat tissue (p = 0.001 and p = 0.05 respectively).  CONCLUSIONS:  Overhydration defined as OH/ECW higher than 10 % and 15 % are related to low prealbumin levels and low fat tissue. We suggest decreasing the overhydration limit measured by bioimpedance to OH/ECW higher than 10 %.

Procalcitonin as an early predictor of acute infection in hemodialysis patients.

BACKGROUND AND AIMS: Hemodialysis patients have a greater risk of infection than individuals not on dialysis. Procalcitonin has been shown to rise in bacterial from but widely studied in hemodialysis patients. The present study evaluates procalcitonin as an early predictor of infection in this population. METHODS: A historical cohorts study was made of 211 prevalent hemodialysis patients (median age 73 years [range 60-80], 58% males) covering the period 2005-2012. Serum samples were thawed and patients were followed-up on for 40±25 months (0-84). Demographic and laboratory test (including inflammatory values) data were recorded at baseline. During follow-up, all infections were documented and analyzed. RESULTS: During follow-up, 112 patients (53.3%) suffered acute infection. A positive correlation was established for procalcitonin and C-reactive protein (σ=0.482, p<0.0001). Procalcitonin was the only inflammatory marker capable of predicting infection at one month (p=0.023) in a model with all the studied inflammatory markers. C-reactive protein was the best predictor of infection over global follow-up (p=0.003), after adjusting for all the studied factors. CONCLUSIONS: Procalcitonin is an early predictor of infection in the first 30 days in hemodialysis patients. However, in relation to the long-term prognosis, C-reactive protein is the most important independent predictor of infection.

The effect of replacing aluminium hydroxide with calcium acetate/magnesium carbonate on serum phosphorus control in haemodialysis patients.

INTRODUCTION: Calcium acetate/magnesium carbonate (MgCO3) is a phosphorus binder with advantages in terms of cost, safety and tolerance and it has a similar efficacy to other drugs. The objective of the study is to assess the effects of replacing aluminium hydroxide [Al(OH3)] with MgCO3 on phosphorus and calcium metabolism in a cohort of haemodialysis patients. MATERIALS AND METHODS: We included 21 patients with phosphorus <5mg/dl, with Al(OH3) as the only binder. The conversion to MgCO3 was carried out without changing the number of pills. We recorded clinical-demographic characteristics, treatment for secondary hyperparathyroidism and laboratory parameters before conversion and every month for four months. RESULTS: Phosphataemia decreased from 4.52 ± 0.99 to 4.02 ± 1.07 mg/dl (p=.027), and there was a decrease in the calcium-phosphorus product from 40.20 ± 10.44 to 35.16 ± 11.06 mg2/dl2 (p=.037). We did not observe significant changes in levels of calcium, parathyroid hormone or 25-OH-vitamin D3. The daily number of pills prescribed was reduced from 3.33 ± 2.29 to 2.15 ± 2.21 (p=.020). Concomitant treatments were not altered. We observed an initial significant increase in magnesaemia from 2.21 ± 0.24 to 2.43 ± 0.39 mg/dl (p=.001), which subsequently remained stable. We found a decrease in serum aluminium from 14.91 ± 8.55 to 8.47 ± 3.98 µg/l (p=.004), with levels within the recommended range in all patients. CONCLUSIONS: MgCO3 allowed good control of serum phosphorus in haemodialysis patients who were previously well controlled with Al(OH)3, using fewer daily pills. There was a slight increase in serum magnesium, without short-term clinical significance. We do not know the effects of this increase in the longer term.

[Metabolic syndrome is associated with cardiovascular events in haemodialysis]. / El síndrome metabólico se asocia con eventos cardiovasculares en hemodiálisis.

BACKGROUND: Metabolic syndrome (MS) is a cardiovascular risk factor and is associated with mortality in the general population and in patients with chronic kidney disease. However, few studies have been carried out in patients on haemodialysis (HD). OBJECTIVES: The objective of the study is to analyse the effect of MS on the occurrence of cardiovascular events in HD. The secondary objective is to determine the influence of the fat tissue index and conicity index on cardiovascular events. METHODS: A prospective study including 100 patients on HD. The follow-up period was 3 years. Cardiovascular events and mortality were recorded. MS was defined in accordance with ATPIII and IDF criteria. RESULTS: MS prevalence as defined by the ATPIII was 32%, and by the IDF, 29%. The concordance between the two definitions was high (kappa index 0.79, 95% confidence interval 0.65 to 0.92). The risk of cardiovascular events was higher in patients with MS (Log Rank 6.185, p = 0.013), with a fat tissue index greater than 11.5 kg/m(2) (log rank 10.220, p=.001) and a conicity index greater than 1.2 (log rank 6.393, p=.011). In the Cox analysis, adjusted for age and sex, patients with MS had twice the risk of being admitted due to a cardiovascular event (odds ratio 1.93, 1.022 to 3.6, p=.043). Mortality was 35% in the 3 year follow-up period with no differences between the groups with and without MS. CONCLUSIONS: MS is a very prevalent disease in HD patients and its presence doubles the risk of hospitalisation due to cardiovascular events in the short term.

Factors related with the progression of chronic kidney disease.

BACKGROUND: Our aims were to determine the rate of progression of chronic kidney disease (CKD) and to identify predictors, with particular emphasis on bone and mineral metabolism. METHODS: Retrospective and observational study including 300 patients with advanced CKD (61.2% males, 33.1% diabetics; age 65.6±14 years). Mean follow-up time was 19.4±10.1 months. Baseline estimated glomerular filtration rate (eGFR) (MDRD-4) was 22.5±7.18 mL/min. To calculate the rate of decline in eGFR, we used the slope of the regression line between all determinations of eGFR and follow-up time. We calculated the mean values for proteinuria and serum phosphate, calcium, uric acid, and PTH, as well as 24-hour urinary excretion of urea nitrogen over time for each patient. Follow-up was at least 6 months and included at least 4 measurements of eGFR. RESULTS: The mean rate of decline eGFR (-1.64 mL/min/1.73 m²/year) was inversely correlated with serum phosphate levels (4.3±2.1 mg/dL, P<.001), PTH (256.3±193.7 ng/L, p<.001) and proteinuria (0.84±1.31 g/day, P=.004) and directly correlated with mean serum calcium (P<.001) and the presence of hypertension (P<.02). However, only serum phosphate, serum PTH, and proteinuria persisted as predictors in the multivariate analysis. Stable-GFR patients (positive slope) were older (P=.041) and had lower serum phosphate and PTH levels (P<.01 and P<.01 respectively) and lower proteinuria (P<.01). CONCLUSIONS: The rate of decrease in eGFR was correlated with serum phosphate and PTH levels and proteinuria. All of these factors can be modified with an adequate treatment.

Diastolic dysfunction and high levels of new cardiac biomarkers as risk factors for cardiovascular events and mortality in hemodialysis patients.

BACKGROUND/AIMS: Cardiovascular events (CVEs) are the most frequent cause of death in hemodialysis (HD). We aim to determine cardiovascular and mortality risk factors. METHODS: A historical cohort study was made of 211 prevalent HD patients [73 (60-80) years, 58% males] between 2005 and 2012. Demographic, laboratory test and echocardiographic values were recorded. During follow-up, CVEs and mortality were documented and analyzed. RESULTS: 94 patients suffered a CVE. Age, history of cardiovascular disease (CVD), peripheral vascular disease, cardiac markers, systolic and diastolic dysfunction (DD) were associated to CVEs. Low albumin (RR 0.414, p = 0.002), DD (1.876, p = 0.038) and previous CVD (3.723, p < 0.001) were identified as independent predictors of CVEs. 98 patients died. Age, a history of CVD, peripheral vascular disease, cardiac markers, DD, dialysis vintage, and a vascular access different from autologous fistulae were associated to mortality. Low albumin (RR 0.499, p = 0.046), DD (RR 2.414, p = 0.017) and a vascular access different from autologous fistulae (RR 2.058, p = 0.034) were independent predictors of mortality. CONCLUSIONS: DD is an emergent risk factor for death and CVEs in dialysis. Low albumin is also a predictor for CVE. Non-autologous fistulae and low albumin are predictors for death. Nt-proBNP and hsTnT offer good information for identifying high-risk patients, but they do not predict events independently as they are only cardiac damage markers.