Fewer COVID-19-associated strokes and reduced severity during the second COVID-19 wave: The Madrid Stroke Network.

BACKGROUND AND PURPOSE: The experience gained during the first COVID-19 wave could have mitigated the negative impact on stroke care in the following waves. Our aims were to analyze the characteristics and outcomes of patients with stroke admitted during the second COVID-19 wave and to evaluate the differences in the stroke care provision compared with the first wave. METHODS: This retrospective multicenter cohort study included consecutive stroke patients admitted to any of the seven hospitals with stroke units (SUs) and endovascular treatment facilities in the Madrid Health Region. The characteristics of the stroke patients with or without a COVID-19 diagnosis were compared and the organizational changes in stroke care between the first wave (25 February to 25 April 2020) and second wave (21 July to 21 November 2020) were analyzed. RESULTS: A total of 550 and 1191 stroke patients were admitted during the first and second COVID-19 waves, respectively, with an average daily admission rate of nine patients in both waves. During the second wave, there was a decrease in stroke severity (median National Institutes of Health Stroke Scale 5 vs. 6; p = 0.000), in-hospital strokes (3% vs. 8.1%) and in-hospital mortality (9.9% vs. 15.9%). Furthermore, fewer patients experienced concurrent COVID-19 (6.8% vs. 19.1%), and they presented milder COVID-19 and less severe strokes. Fewer hospitals reported a reduction in the number of SU beds or deployment of SU personnel to COVID-19 dedicated wards during the second wave. CONCLUSIONS: During the second COVID-19 wave, fewer stroke patients were diagnosed with COVID-19, and they had less stroke severity and milder COVID-19.

Cost effectiveness of lanthanum carbonate in chronic kidney disease patients in Spain before and during dialysis.

AIMS: In Spain, the first line treatment of hyperphosphatemia in Chronic Kidney Disease (CKD) consists of calcium-based phosphate binders (CB). However, their use is associated with vascular calcification and an increased mortality risk. The aim of this study was to assess the incremental cost-effectiveness of second-line Lanthanum Carbonate (LC) treatment in patients not responding to CB (calcium carbonate and calcium acetate). MATERIAL AND METHODS: A lifetime Markov model was developed considering three health states (predialysis, dialysis and death). Transitions between states and efficacy data were obtained from randomized clinical trials and the European Dialysis and Transplant Association Annual report. Mortality rate was adjusted with the relative risk related to serum phosphorus levels. According to the Spanish healthcare system perspective, only medical direct costs were considered. Dialysis costs (2013 prices in Euros) were obtained from diagnosis-related groups. Drug costs were derived from ex-factory prices, adjusted with 7.5% mandatory rebate. Quality of life estimates were based on a published systematic review. Costs and benefits were discounted at 3%. Deterministic and probabilistic sensitivity analyses (PSA) were conducted. RESULTS: At the end of simulation, costs per patient with LC therapy were 1,169 and 5,044 with CB alone. 4.653 Quality Adjusted Life Years (QALYs) were gained per patient treated with LC, and 4.579 QALYs with CB. CB therapy is dominated by the LC strategy (i.e. lower costs, higher QALYs). Assuming a 30,000/QALY threshold, LC was dominant in 100% of PSA simulations. CONCLUSIONS: LC is a cost-effective second line treatment of hyperphosphatemia in CKD patients irrespective of dialysis status in Spain.

Impact of isolated hepatitis C virus (HCV) core-specific antibody detection and viral RNA amplification among HCV-seronegative dialysis patients at risk for infection.

Amplification of hepatitis C virus (HCV) RNA from blood detected occult HCV infections in 30.9% of 210 HCV-seronegative dialysis patients with abnormal liver enzyme levels that had evaded standard HCV testing practices. Isolated HCV core-specific antibody detection identified three additional anti-HCV screening-negative patients lacking HCV RNA amplification in blood who were considered potentially infectious. Together, these findings may affect management of the dialysis setting.

Usefulness of tissue Doppler on early detection of cardiac disease in Fabry patients and potential role of enzyme replacement therapy (ERT) for avoiding progression of disease.

AIMS: Cardiac involvement, including progressive cardiomyopathy, is common in Fabry disease and is a leading cause of premature mortality. We sought to determine if tissue Doppler imaging (TDI) could identify Fabry disease patients at risk for the development of cardiomyopathy and if enzyme replacement therapy (ERT) with agalsidase alfa might slow or prevent the progression of cardiac involvement. METHODS AND RESULTS: Fabry disease patients were enrolled in this prospective, observational study. Echocardiography was performed at baseline and periodically throughout the study. A single investigator, blinded to both the type of assessment (baseline or follow-up) and enzyme replacement status of the patient, evaluated all echocardiograms. Seventy-six patients (26 male, 50 females) were enrolled in the study. Twenty men and 13 women were treated with agalsidase alfa during the study. At baseline, increasing interventricular septum thickness was significantly associated with decreasing TDI velocities. Twenty-nine patients >18 years old (23 females) had no evidence of cardiac involvement at baseline (normal LVM and normal TDI velocities). In this cohort, 80% (16 of 20) of patients not on ERT progressed to demonstrating an abnormal TDI velocity during follow-up, whereas only 33% (3 of 9) of patients on ERT progressed to TDI abnormalities (P= 0.031). CONCLUSION: In Fabry disease, reduced TDI velocity seems to be the initial sign of cardiac involvement that occurs before the development of cardiac hypertrophy. ERT with agalsidase alfa delays the onset of cardiac involvement and should be considered at an earlier stage of the disease, even in the absence of left ventricular hypertrophy.

Relationship between residual renal function, inflammation, and anemia in peritoneal dialysis.

In peritoneal dialysis (PD) patients, we analyzed the relationship between residual renal function (RRF) and well-known predictors of mortality such as anemia, inflammation, and nutrition. We also investigated possible associations between the foregoing parameters and cardiovascular comorbidity, peritoneal transport rate, statin and antihypertensive treatments, and ultrafiltration volume. Our study enrolled 24 patients (17 men, 7 women; mean age: 56 +/- 12 years) who had started PD at our hospital between 1998 and 2004. Patients who had been hospitalized or had had peritonitis before the study were excluded. Nutrition status, inflammation, anemia, RRF and dialysis adequacy were assessed after 1-2 months. We found that RRF was positively correlated with normalized protein equivalent of nitrogen appearance (nPNA: r = 0. 52, p = 0. 03) and negatively correlated with C-reactive protein (CRP: r = -0.47, p < 0.01) and peritoneal ultrafiltration (r = -0.42, p < 0.05). Only the nPNA and CRP correlations remained statistically significant on multivariate logistic regression analysis (CRP: r = 0.8, p = 0.011; nPNA: p = 0.013). Moreover, as compared with patients without inflammation, patients with inflammation had significantly lower hemoglobin (Hgb) levels (11.8 +/- 1.1 g/dL vs. 13.2 +/- 1.2 g/dL, p < 0.02), serum prealbumin levels (27.3 +/- 8 mg/dL vs. 36.6 +/- 9 mg/dL, p < 0.05), and serum transferrin levels (168 +/- 34 mg/dL vs. 202 +/- 31 mg/dL, p < 0.05), and a higher erythropoietin resistance index (ERI: 10 +/- 4 vs. 6 +/- 3.5, p < 0. 02). We observed no differences in RRF or nutrition status between the patients with high and with low peritoneal transport. Regarding comorbidity, patients with pre-existing cardiovascular disease had higher CRP levels (0.8 +/- 0.4 mg/dL vs. 0.4 +/- 0.4 mg/dL, p < 0.05) and lower mean Hgb levels (13.3 +/- 1 g/dL vs. 14.4 +/- 1 g/dL, p < 0.05) than did patients without such pre-existing disease. A strong, predictable association exists between RRF and inflammation and nutrition status in incident patients on PD. Serum CRP is a good indicator of inflammation, which correlates well with nutrition status, anemia, and responsiveness to erythropoietin therapy.

Effects of angiotensin II receptor blocker (irbesartan) on peritoneal membrane functions.

Angiotensin II receptor blockers (ARBs) are effective in controlling blood pressure and have been shown to reduce proteinuria with fewer adverse effects than angiotensin converting enzyme inhibitors. In the present prospective study, we evaluated the action of irbesartan, an ARB with a long half life, on proteinuria, peritoneal protein losses, and peritoneal transport in patients with chronic renal failure (CRF) undergoing peritoneal dialysis (PD). We enrolled 15 stable patients (11 with diuresis of more than 500 mL/day; 40% women; 40% with diabetes) into the study. Mean age of the patients was 65 +/- 15 years, and mean time on PD was 33 +/- 21 months. The study was performed in two stages. In stage I, patients received no irbesartan. In stage II, patients received 30 days of treatment with irbesartan (145 +/- 72 mg/day). After treatment with irbesartan, and no changes in blood pressure level as compared with baseline, we observed a reduction in proteinuria (r = 0.690, p < 0.05), decreased peritoneal protein losses at 4 hours' and 24 hours' dwell time (r = 0.910 and r = 0.930, p < 0.001), decreased peritoneal Kt/V(r = 0.586, p < 0.05), and increased peritoneal creatinine clearance (r = 0.943, p < 0.001). Levels of serum albumin (r = 0.630, p < 0.05), prealbumin (r = 0.810, p < 0.001), and transferrin (r = 0.551, p < 0.05) increased after treatment with irbesartan. We conclude that treatment with irbesartan in patients with CRF undergoing PD modifies peritoneal transport and reduces peritoneal and urinary protein loss. This effect probably has a positive impact on nutritional parameters. Further studies are required to elucidate the mechanisms involved.

Erythropoietin requirements: a comparative multicenter study between peritoneal dialysis and hemodialysis.

BACKGROUND: The management of anemia with erythropoietin (EPO) is important in the global treatment of dialysis patients. There is a general impression that anemia control with EPO is obtained more easily in peritoneal dialysis (PD) patients than in hemodialysis (HD) patients. The EPO administration route has to be the same to compare the two techniques adequately. METHODS: To compare EPO action by subcutaneous (SC) route in HD and PD, 132 stable patients were recruited (HD: 69, PD: 63) from six centers, with adequate dialysis criteria (Kt/V in HD >1.3; weekly Kt/V in PD >1.8). In a cross-sectional study, the EPO dose/week, the number of EPO doses/week, hemoglobin (Hb), ferritin, transferrin saturation index (TS), albumin and intact parathyroid hormone (iPTH) were analyzed. Iron treatment, comorbidity and ACE inhibitors (ACEI) and angiotensin II antagonist (AIIA) treatment were recorded. A multivariate regression model was used in the statistical analysis. RESULTS: The mean Hb level was the same in both groups, HD 11.6 (1.3) g/dL, PD 11.4 (1.4) g/dL, p=0.3. The SC, EPO doses required to obtain the Hb levels were higher in HD than in PD patients, with a difference of 64.3 u/Kg/week, statistically significant in the multivariate regression model (p=0.001, 95% CI 42.6-86.0). The number of EPO doses/week was also higher in HD patients (65% of HD patients with > or = 3 doses, 19% of PD patients with three or more doses, p<0.001). TS was similar in both groups, while ferritin was higher in HD patients, with a higher percentage of HD patients using intravenous (i.v.) iron (HD 77% vs. PD 49%, p=0.001). Serum albumin and iPTH were lower in PD patients (p<0.001 and p=0.04, respectively), but the percentage of patients with intact parathyroid hormone (iPTH) >500 pg/mL was similar in both groups (HD 17%, PD 14%). CONCLUSIONS: With the same administration route, PD patients showed a reduced EPO requirement, and less frequent EPO administration than HD patients, to obtain the same Hb level. No other factors, except those involved in better depuration of erythropoiesis inhibitors in PD, seemed responsible for the different EPO requirements.