C-reactive protein-to-albumin ratio and six-month mortality in incident hemodialysis patients.

BACKGROUND: The first few months of hemodialysis (HD) are associated with a higher risk of mortality. Protein-energy malnutrition is a demonstrated major risk factor for mortality in this population. The C-Reactive Protein to Albumin ratio (CAR) has also been associated with increased mortality risk. The aim of this study was to determine the predictive value of CAR for six-month mortality in incident HD patients. METHODS: Retrospective analysis of incident HD patients between January 2014 and December 2019. CAR was calculated at the start of HD. We analyzed six-month mortality. A Cox regression was performed to predict six-month mortality and the discriminatory ability of CAR was determined using the receiver operating characteristic (ROC) curve. RESULTS: A total of 787 patients were analyzed (mean age 68.34 ± 15.5 years and 60.6% male). The 6-month mortality was 13.8% (n = 109). Patients who died were significantly older (p < 0.001), had more cardiovascular disease (p = 0.010), had central venous catheter at the start of HD (p < 0.001), lower parathyroid hormone (PTH) level (p = 0.014) and higher CAR (p = 0.015). The AUC for mortality prediction was 0.706 (95% CI (0.65-0.76), p < 0.001). The optimal CAR cutoff was ≥0.5, HR 5.36 (95% CI 3.21-8.96, p < 0.001). CONCLUSION: We demonstrated that higher CAR was significantly associated with a higher mortality risk in the first six months of HD, highlighting the prognostic importance of malnutrition and inflammation in patients starting chronic HD.

The potential association between influenza vaccination and lower incidence of renal cell carcinoma.

It is well-established that kidney cancer or renal cell carcinoma (RCC) occurs more commonly in chronic kidney disease (CKD) than in the general population, although the underlying mechanisms are incompletely understood. Beyond hereditary RCC syndromes; smoking, obesity and hypertension are widely known risk factors for RCC, irrespective of CKD. Kidney-specific factors such as episodes of acute kidney injury, nephrolithiasis and cyst formation have also been shown to be associated with RCC development. One potential and less explored factor is the role of viruses in the development of kidney cancer. In this issue of Clinical Kidney Journal, Lin et al. raise the interesting hypothesis that influenza vaccination may be associated with lower incidence of RCC in adults with CKD. We discuss potential mechanisms underlying this interesting observation in the context of immune dysregulation in CKD.

Preoperative assessment for vascular access: Vascular mapping and handgrip strength.

BACKGROUND: Reliable vascular access (VA) is required for patients receiving chronic hemodialysis (HD) treatment. Vascular mapping using duplex doppler ultrasonography (DUS) can aid in planning VA construction. Greater handgrip strength (HGS) was found to be associated with more developed distal vessels both in chronic kidney disease (CKD) patients and healthy individuals, and patients with lower HGS had worse morphologic vessel characteristics and were, therefore, less likely to construct distal VA. OBJECTIVES: This study aims to describe and analyze clinical, anthropometric, and laboratory characteristics of patients who underwent vascular mapping prior to VA creation. RESEARCH DESIGN: Prospective analysis. SUBJECTS: Adult patients with CKD referred for vascular mapping, at a tertiary center, between March 2021 and August 2021. MEASURES: Preoperative DUS by a single experienced nephrologist was carried out. HGS was measured using a hand dynamometer, and PAD was defined as ABI < 0.9. Sub-groups were analyzed according to distal vasculature size (<2 mm). RESULTS: A total of 80 patients were included, with a mean age of 65.7 ± 14.7 years; 67.5% were male, and 51.3% were on renal replacement therapy (RRT). Twelve (15%) participants had PAD. HGS was higher in the dominant arm (20.5 ± 12.0 vs 18.8 ± 11.2 kg). Fifty-eight (72.5%) patients had vessels smaller than 2 mm in diameter. There were no significant differences between groups concerning demographics or comorbidities (diabetes, HTN, PAD). HGS was significantly higher in patients with distal vasculature greater than or equal to 2 mm in diameter (dominant arm: 26.1 ± 15.5 vs 18.4 ± 9.7 kg, p = 0.010; non-dominant arm: 24.1 ± 15.3 vs 16.8 ± 8.6, p = 0.008). CONCLUSIONS: Higher HGS was associated with more developed distal cephalic vein and radial artery. Low HGS might be an indirect sign of suboptimal vascular characteristics, which might help predict the outcomes of VA creation and maturation.

Planning vascular access creation: The promising role of the kidney failure risk equation.

BACKGROUND: Planning for vascular access (VA) creation is essential in pre-dialysis patients although optimal timing for VA referral and placement is debatable. Guidelines suggest referral when eGFR is 15-20 mL/min/1.73 m2. This study aimed to validate the use of kidney failure risk equation (KFRE) in VA planning. METHODS: Retrospective analysis of all adult patients with CKD who were referred for first VA placement, namely AVF or AVG, at a tertiary center, between January 2018 and December 2019. The four-variable KFRE was calculated. Start of KRT, mortality, and VA placement were assessed in a 2-year follow-up. We used Cox regression to predict KRT start and calculated the ROC curve. RESULTS: 256 patients were included and 64.5% were male, mean age was 70.4 ± 12.9 years and mean eGFR was 16.09 ± 10.43 mL/min/1.73 m2. One hundred fifty-nine patients required KRT (62.1%) and 72 (28.1%) died in the 2-year follow-up. The KFRE accurately predicted KRT start within 2-years (38.3 ± 23.8% vs 17.6 ± 20.9%, p < 0.001; HR 1.05 95% CI (1.06-1.12), p < 0.001), with an auROC of 0.788 (p < 0.001, 95% CI (0.733-0.837)). The optimal KFRE cut-off was >20%, with a HR of 9.2 (95% CI (5.06-16.60), p < 0.001). Patients with KFRE ⩾ 20% had a significant lower mean time from VA consult to KRT initiation (10.8 ± 9.4 vs 15.6 ± 10.3 months, p < 0.001). On a sub-analysis of patients with an eGFR < 20 mL/min/1.73 m2, a KFRE ⩾ 20% was also a significant predictor of 2-year start of KRT, with an HR of 6.61 (95% CI (3.49-12.52), p < 0.001). CONCLUSION: KFRE accurately predicted 2-year KRT start in this cohort of patients. A KFRE ⩾ 20% can help to establish higher priority patients for VA placement. The authors suggest referral for VA creation when eGFR < 20 mL/min/1.73 m2 and KFRE ⩾ 20%.

One-Year Mortality after Hemodialysis Initiation: The Prognostic Role of the CHA2DS2-VASc Score.

BACKGROUND: CKD is a significant cause of morbidity, cardiovascular and all-cause mortality. CHA2DS2-VASc is a score used in patients with atrial fibrillation to predict thromboembolic risk; it also appears to be useful to predict mortality risk. The aim of the study was to evaluate CHA2DS2-VASc scores as a tool for predicting one-year mortality after hemodialysis is started and for identifying factors associated with higher mortality. METHODS: Retrospective analysis of patients who started hemodialysis between January 2014 and December 2019 in Centro Hospitalar Universitário Lisboa Norte. We evaluated mortality within one year of hemodialysis initiation. The CHA2DS2-VASc score was calculated at the start of hemodialysis. RESULTS: Of 856 patients analyzed, their mean age was 68.3 ± 15.5 years and the majority were male (61.1%) and Caucasian (84.5%). Mortality within one-year after starting hemodialysis was 17.8% (n = 152). The CHA2DS2-VASc score was significantly higher (4.4 ± 1.7 vs. 3.5 ± 1.8, p < 0.001) in patients who died and satisfactorily predicted the one-year risk of mortality (AUC 0.646, 95% CI 0.6-0.7, p < 0.001), with a sensitivity of 71.7%, a specificity of 49.1%, a positive predictive value of 23.9% and a negative predictive value of 89.2%. In the multivariate analysis, CHA2DS2-VASc ≥3.5 (adjusted HR 2.24 95% CI (1.48-3.37), p < 0.001) and central venous catheter at dialysis initiation (adjusted HR 3.06 95% CI (1.93-4.85)) were significant predictors of one-year mortality. CONCLUSION: A CHA2DS2-VASc score ≥3.5 and central venous catheter at hemodialysis initiation were predictors of one-year mortality, allowing for risk stratification in hemodialysis patients.

Acute pericarditis after COVID 19 in a peritoneal dialysis patient.

COVID-19 is known to affect numerous organs which have ACE-2 receptors, lung being the most involved organ. Nevertheless, cardiac involvement is not uncommon and can occur through a variety of manifestations. The authors hereby report a case of pericarditis following SARS-CoV-2 infection. A 54-year-old man with end stage kidney disease under peritoneal dialysis presented with acute chest pain approximately 1 month after being diagnosed with COVID-19. Electrocardiogram revealed widespread ST segment elevation. The diagnosis of acute pericarditis secondary to the viral infection was made and the patient was treated accordingly. Etiology of acute pericarditis can be very varied, and, in many times, no cause is ascertained. In such circumstances, viral or immune mediated etiologies are assumed. In our case, since no cause was proven, pericarditis was assumed as secondary to the SARS-CoV-2 infection. This entity is probably underdiagnosed. In patients undergoing dialysis, uremic pericarditis is commonly the etiology. However, different causes must be taken into consideration, COVID-19 being one of them.