CKD GENERAL AND CLINICAL EPIDEMIOLOGY 1
Patricia R Blank 2 3 11 12 15 16 20 21 23 25 26 33 35 36 40 41 47 48 49 52 56 57 64 65 75 76
Thomas D Szucs 2 3 11 12 15 16 20 21 23 25 26 33 35 36 40 41 47 48 49 52 56 57 64 65 75 76
0 Fresenius Asia Pacific , Hong Kong , Hong Kong
1 Fresenius Medical Care , Bad Homburg , Germany
2 University of Basel , Basel , Switzerland
3 Joselyn Reyes-Bahamonde
4 Fresenius Medical Care NA , Waltham, MA , USA
5 Imperial College , London , United Kingdom
6 Fresenius Latin America , Buenos Aires , Argentina
7 Maastricht University Medical Centre , Maastricht , Netherlands
8 UC Santa Barbara , Santa Barbara, CA , USA
9 Depatment of Nephrology, Dialysis and Hypertension , Bologna , Italy
10 UO Nefrologia e Dialisi , Imola , Italy
11 Department of Biomedical and Neuromotor Sciences, University of Bologna , Italy
12 Dino Gibertoni
13 Norwegian Heart Failure Registry , Lillehammer , Norway
14 National Taiwan University Hospital , Taipei , Taiwan
15 Far Eastern Memorial Hospital , New Taipei City , Taiwan
16 Viera Stubnova
17 Oslo University Hospital, Ullevål , Oslo , Norway
18 University of Granada , Granada , Spain
19 University of South Carolina , Columbia, SC , USA
20 Karolinska Institutet , Huddinge , Sweden
21 Juan J Carrero
22 Okayama University Graduate School of Medicine , Okayama , Japan
23 Naohiko Fujii
24 Osaka University , Suita, Osaka , Japan
25 University of Pennsylvania , Philadelphia, PA , USA
26 Paschal Ruggajo
27 Showa University School of Medicine , Tokyo , Japan
28 Tokyo Women's Medical University , Tokyo , Japan
29 Nakayamadera Imai Clinic , Takarazuka , Japan
30 Fukushima Medical University School of Medicine , Fukushima , Japan
31 Nagoya University , Aichi , Japan
32 Faculté d'Ingénierie et de Management de La Santé (ILIS), Université Lille 2 , Lille , France
33 Florent Occelli
34 Faculté de Médecine Pôle Recherche, Centre Hospitalier Universitaire de Lille , Lille , France
35 Faculté de Pharmacie, Université Lille 2 , Lille , France
36 Elisa Scalzotto
37 Centre Hospitalier Universitaire de Lille , Lille , France
38 Faculté de Médecine , Marseille , France
39 CHU Nancy , Pôle Qsp2 , Epidémiologie et Evaluation Cliniques et Université de Lorraine, Université Paris Descartes, Apemac , EA4360, Nancy , France
40 Groupe Hospitalier Pitie Salpetriere et Chaire de Recherche En Education Therapeutique , Paris , France
41 Corinne Isnard Bagnis
42 Laboratoire de Santé Publique, et Service Santé Publique et Information Médicale , Marseille , France
43 Agence de La Biomédecine , Saint Denis , France
44 Renaloo , Paris , France
45 Semmelweis University Budapest , Budapest , Hungary
46 McGill University Health Centre Royal Victoria Hospital , Montreal, QC , Canada
47 Kálmán Polner
48 St. Margit Hospital , Budapest , Hungary
49 Stefan Krivoshiev
50 Monklands Hospital , Airdrie , United Kingdom
51 Glasgow Renal and Transplant Unit , Glasgow , United Kingdom
52 Fundación Jiménez Díaz University Hospital , Madrid , Spain
53 Dumfries and Galloway Royal Infirmary , Dumfries , United Kingdom
54 Medical University of Graz , Graz , Austria
55 University of Heidelberg , Mannheim , Germany
56 Saarland University Hospital , Homburg / Saar , Germany
57 Stephen Zewinger
58 Inselspital Bern , Bern , Switzerland
59 Synlab Services LLC , Mannheim , Germany
60 University of Bonn , Bonn , Germany
61 Radboud University Medical Centre , Nijmegen , The Netherlands
62 Assistance Publique-Hôpitaux de Paris, Hôpital Robert-Debré , Paris , France
63 Alexion Pharmaceuticals, Inc. , Cheshire, CT , USA
64 CHU de Bordeaux , Bordeaux , France
65 Yahsou Delmas
66 Karolinska University Hospital , Stockholm , Sweden
67 CHU de Nantes-Hôpital Hotel Dieu , Nantes , France
68 Beatson West Scotland Cancer Centre , Glasgow , United Kingdom
69 Universite Paris Descartes and Hôpital Necker , Paris , France
70 Newcastle University , Newcastle-upon-Tyne , United Kingdom
71 Istituto G Gaslini , Genova , Italy
72 The Hospital for Sick Children , Toronto, ON , Canada
73 Jagiellonian University Medical College , Cracow , Poland
74 Medical University of Warsaw , Warsaw , Poland
75 Medical University of Gdansk , Gdansk , Poland
76 Lukasz Zdrojewski
Introduction and Aims: In hemodialysis (HD) patients low pre-HD serum sodium
(SNa+) and high Na+ gradients have been associated with higher mortality. Increased
pre-HD SNa+ variability has been linked to mortality, while stable SNa+ levels are
associated with better survival. Here we investigated the joint relationship of SNa+
variability (expressed as standard deviation, SD) and rate of change of SNa+ (slope of
SNa+) with the risk of all-cause death in incident HD patients.
Methods: We studied 20,193 incident HD patients (age 63.3±15.0 years, 59% males,
34% diabetic, relative interdialytic weight gain (IDWG%) 2.9%±1.0%, BMI 26.9±7.5
kg/m2) from Europe (N=14,763) and the U.S. (N=5,430). During baseline (first 12
months on HD) mean SNa+, SNa+ slope and SNa+ SD were computed. Patient
outcomes were noted in months 13 to 24 (follow-up). We investigated the joint effects
of SNa+ and a) SNa+ variability and (b) SNa+ slopes, respectively, during baseline on
probability of death during follow-up using logistic regression with smoothing spline
ANOVA models. Models were adjusted for age, gender, diabetes, IDWG%, serum
albumin, phosphorus and BMI.
Results: Risk of death was lowest with SNa+ around 138 to 141 mEq/L and SNa+ SD of
0 to 2 mEq/L. Deviations from this region in any direction were associated with
increased risk. The increase in mortality risk associated with higher SNa+ variability
was steepest at SNa+ levels <135 mEq/L (Fig 1). Stable SNa+ conferred the lowest risk
with SNa+ levels around 139 to 142 mEq/L (Fig 2). Mortality risk progressively
increased outside of this domain. Of note, over the range of our data, SNa+ departures
from this range carried a steeper risk increase than departures in SNa+ slope. Lastly,
while patients with SNa+ >136 mEq/L realized their best survival probability with SNa+
slopes around zero, in patients with SNa+ <136 mEq/L more positive SNa+ slopes were
always linked to better survival along the entire range of SNa+ slopes (Fig 2).
Conclusions: In line with earlier findings, this joint analysis of SNa+, SNa+ slope and
SNa+ variability suggests effects of SNa+ variability and rate of change at all levels of
SNa+ on mortality. Stable SNa+ appears to confer a survival benefit, whereas low SNa+
levels associate with an increased risk of all-cause death. Further research into these
dynamic aspects of SNa+ levels may help to identify patients at increased risk.
SP166 Figure 1: Estimated probability of death as a function of SNa+ SD for male,
diabetic patients with other continuous variables fixed at their median values.
SP166 Figure 2: Estimated probability of death as a function of SNa+ slope for male,
diabetic patients with other continuous variables fixed at their median values.
EPIDEMIOLOGY OF POTENTIALLY DANGEROUS
THERAPEUTIC PRESCRIBING IN HOSPITAL PATIENTS WITH
Introduction and Aims: The prescription of inadequate drugs combination can
introduce a significant risk of adverse drug related events, especially in renal
insufficiency patients. The aim of the present study was to assess the epidemiology of
potentially dangerous medical therapies among patients with concomitant renal
insufficiency in a hospital setting.
SP167 Table 1: Factors associated with present renal insufficiency
Higher lengths of stay
Higher lengths of stay
Therapeutic factors (drug
ACE-inhibitor/ Angiotensin I
OR (chi-square test)
(95% CI) p-value
Δmean (t-test): 17.4
Methods: By using administrative medical records from a Swiss hospital, demographic
(gender, age), clinical (length of stay (LOS), drug units administered) and potentially
dangerous drug combinations were analyzed and the association to present renal
insufficiency was measured. Univariate analyses determined the association of all
factors associated with present renal insufficiency. A multivariate regression model
assessed independent factors associated with the outcome.
Results: During the study period (October 2011-June 2013), 21'199 patients above 18
years were admitted (male gender: 49.9%; mean age: 62.4 years). In total, 941 patients
with renal insufficiency were identified. An average patient stayed for 5.3 days (median:
6.0 days) and received 52 drug units (median: 27.0 units) per episode. One or more
dangerous drug combinations were found in 2’025 (9.6%) patients. The unadjusted
univariate regression analyses indicated for several factors higher odds of concomitant
renal insufficiency (Table 1). All significant variables in the univariate analyses were
considered as candidates for the multivariate analysis. Independent factors for renal
insufficiency were male gender, age above 65 years, longer LOS (>3 days), higher
number of drug units (>27 units), and three dangerous drug-pairs (high-ceiling
diuretics+thiazides, acetylsalicylic acids+glucocorticoids, paracetamol+vitamin K
Conclusions: This study is a first study assessing the epidemiology of potentially
dangerous drugs in patients with renal insufficiency using a large data-set of Swiss
inpatients. Gender, age, LOS, drug units and various drug-drug interactions showed
significant association with the presence of renal insufficiency. Further research is
needed to improve the drug prescription management of patients with kidney
insufficiency in the hospital setting.
MORTALITY ATTRIBUTABLE TO CHRONIC KIDNEY DISESE: A
COHORT STUFY BASED ON THE ITALIAN PIRP REGISTRY
Introduction and Aims: Patients with chronic kidney disease experience poorer
outcomes compared with the general population. While epidemiological findings are
available on mortality related to kidney transplant and dialysis, evidence on mortality
attributable to chronic kidney disease is lacking. We analyzed the excess mortality
related to chronic kidney disease (CKD) by taking into account the expected mortality
of the general population, using a relative survival model. Subsequently, we modelled
the excess mortality rate found in CKD patients using a flexible parametric survival
Methods: We applied the excess mortality rate to a cohort of 9692 patients who
entered the Prevention of Progressive Renal Insufficiency Project (PIRP) registry
between 2006 and 2010 in Emilia-Romagna, a North-Eastern Italian region with about
4.3 million inhabitants, of whom 23% are aged 65 or more. The PIRP registry collects
clinical data on CKD patients who receive an individualized pharmacological and
dietary treatment aimed to reduce CKD progression. Matching with the general
population mortality was made using the mortality tables of the Emilia-Romagna
region by calendar year, gender and age for the years 2006-2010. Patients were followed
until the event of death or the end of the study. Relative survival allows to estimate the
difference in survival rates due specifically to CKD.
Results: Overall 5-years estimate of survival rate was 66.8% in the PIRP patients cohort
(Fig.1) and that expected from the general population was 78.8%, with an estimated
15.2% decrease in the survival rate of CKD patients (relative survival
ratio=RSR=0.848). Survival had a similar trend for each underlying nephropathy
(nephroangiosclerosis, diabetic nephropathy, glomerulonephrites and polycystic
kidney disease) over the five years of observation. Factors significantly associated with
excess mortality attributable to CKD per se were CKD stage (Excess Mortality Rate
Ratio=EMRR=6.4 for stage 4 and EMRR=14.5 for stage 5 compared with stage 3a),
being underweight (EMRR=2.53 compared with normal BMI), previous cardiovascular
events (EMRR=2.41), older age (EMRR=2.61 for 60-69 years, EMRR=3.5 for 70-79
years, EMRR=5.07 for >79 years compared with <50 years), and diabetes
Conclusions: Relative survival is a method only recently applied in the nephrology
field; it may be evaluated on CKD cohorts, for the chronic nature of the disease. Our
findings further underline that CKD patients are a particularly frail population; at each
stage of disease and even at older ages they have an excess of mortality on the overall
population. Because the large majority of patients are in the CKD stages 3 and 4, our
results provide additional useful information for primary care physicians and
nephrologists about factors to be monitored to decrease the risk of death from the onset
of the disease onwards.
GUIDANCE FOR CKD MANAGEMENT IN FRAIL AND OLD
PATIENTS: IDENTIFYING HIGH PRIORITY TOPICS
S N Van Der Veer1, I Nistor1, P. Bernaert1,2, D Bolignano1, E A Brown1, A Covic1,
K Farrington1, J Kooman1, J Macías2, A Mooney1, B C Van Munster2, N Van Den
Noortgate2, E Topinkova2, G Wirnsberger1,2, K J Jager1 and W Van Biesen1
1European Renal Best Practice (ERBP), Ghent, Belgium, 2European Union
Geriatric Medicine Society (EUGMS), Geneva, Switzerland
Introduction and Aims: The number of frail and old kidney patients is growing.
Therefore, European Renal Best Practice (ERBP) is establishing guidance for CKD
management in frail and elderly in collaboration with the European Union Geriatric
Medicine Society (EUGMS). This project aimed to identify what topics are considered
high priority by clinicians in order to ensure the guidance’s relevance for clinical
Methods: Figure 1 shows the entire scoping process. Main steps were: a literature
review, a survey among 563 European clinicians, and a face-to-face consensus meeting
with experts from nephrology and geriatrics. Using Nominal Group Technique, the
meeting comprised two rounds. In Round 1 experts individually and anonymously
rated each topic on a 9-point scale ranging from 1 (not at all important) to 9 (critically
important). A moderator then summarised the individual ratings and discussed this
with the group. In Round 2 experts had the opportunity to revise their original ratings
in the light of the group discussion. The priorities assigned in this last round formed
input for the final topic selection. We defined ‘consensus’ on a topic’s priority as all
ratings in a round falling within a 3-point range.
Results: The literature review together with suggestions from experts and European
clinicians resulted in a list of 46 topics to be potentially addressed in guidance for CKD
management in frail and older patients. When rating this list during the consensus
meeting the experts reached consensus on the importance of 3 topics in the Round
1. This number increased to 11 in Round 2, and included all top 5 high priority topics
The ERBP guideline development group is currently considering all top 5 topics for
inclusion in the guidance scope. Which type of guidance is most suitable will depend
on whether the topic is already covered by other guideline organisations, as well as on
expected availability of randomised studies.
Conclusions: Our scoping procedure allowed clinicians from all over Europe to
SP169 Figure 1: Guidance scoping procedure.
SP169 Table 1: Top 5 topics with highest priority regarding CKD management in frail/
contribute to determining the scope of renal guidance. It also increased expert
consensus on what topics were most important for being finally selected. Lastly, it
enabled us to identify what topics had the highest priority regarding CKD management
in frail and older patients. The next step will be for ERBP to develop appropriate
guidance for each of these topics, while taking into account existing guidance produced
by other organisations.
Introduction and Aims: Mineralocorticoid receptor antagonists, like spironolactone,
are recommended for patients with severe systolic heart failure (HF) treated with
ACE-inhibitors/ARBs and β-blockers. Renal dysfunction is prevalent in patients with
HF, but these patients have been systematically excluded from the trials that modern
HF treatment is based on. Use of spironolactone in patients with renal dysfunction may
be hazardous as it may cause hyperkalemia and worsening renal function. Thus, the
prognostic benefit of spironolactone in HF patients with renal dysfunction needs to be
further explored. Our aim was to investigate the effect of spironolactone on 5-year
survival in HF patients with renal dysfunction, correcting for confounding variables
both by propensity scores and traditional Cox regression analyses.
Methods: We included 3078 outpatients with chronic HF of any etiology and renal
dysfunction (eGFR < 60 ml/min/1.73 m2) using data from the Norwegian Heart Failure
Registry. Propensity scores for receiving spironolactone were calculated. Both
multivariate Cox regression analysis and propensity score adjusted Cox regression
model were used to investigate the independent prognostic effect of the use of
spironolactone on 5-year survival. Multiple imputation was used to replace missing
values. Interaction analyses were performed by entering product terms into the Cox
Results: Mean age was 75.8± 8.9 years, 67.0% were males, and median eGFR was 44.5
ml/min/1.73 m2 (interquartile range 35.0-52.5). Spironolactone was used by 29.9%, of
whom 71.4% used both ACEi/ARB and β-blocker. After 5 years, 51.5% patients were
alive in the Spironolactone group and 53.6% in the non-Spironolactone group. The use
of spironolactone was not associated with survival neither in the traditional
multivariate Cox regression analysis (HR 0.95, 95% CI 0.85-1.08, p = 0.469), nor in the
propensity score adjusted Cox model (HR 0.98, 95% CI 0.86-1.10, p=0.689). No
interactions were identified for severity of renal dysfunction, ejection fraction or the use
of ACEi/ARB and β- blockers.
Conclusions: Use of spironolactone did not affect 5-year survival in outpatients with
chronic HF and renal dysfunction.
RISK FACTORS OF DEVELOPMENT AND PROGRESSION OF
CHRONIC KIDNEY DISEASE: A SYSTEMATIC REVIEW AND
Introduction and Aims: Risk factors influencing the natural course of chronic kidney
disease (CKD) are complex and heterogenous, seldom systematic reviews or
meta-analyses have focused on this issue. In this study, we thus aim to identify the
currently known risk factors for disease development and progression in various stages
Methods: We systematically searched PubMed, MEDLINE, Scopus, and the Cochrane
Library for English publications from the earliest available date of indexing through 15
Oct 2012, for observational studies evaluating the risk factors of renal function decline.
Eligible studies should collect repeated information for evaluating the decline in renal
function. Studies in patients with any stage of CKD, as well as studies among the
general population, were included. The stages of CKD were defined by the K/DOQI
Clinical Practice Guidelines according to glomerular filtration rate and evidence of
kidney damage. Hazard ratios of a specific risk factor from studies with the same
SP171 Figure 1:: The hazard ratios of progression from CKD stage 3–5 to CKD stage
5D for (A) protein-uria <;1 g/day, (B) male gender, and (C) diabetes.
iii | Abstracts
baseline and follow-up stages of CKD, as well as the same outcome endpoints, were
pooled by meta-analysis. The pooled estimates of hazard ratio and 95% confidence
interval (CI) of risk factors for development or progression of CKD were calculated
using the method of DerSimonian and Laird random-effects model.
Results: We identified 40 studies, including 29 prospective cohort studies, 9
retrospective cohort studies, and 2 case-control studies. The follow-up time of the
included studies ranged from 1.5 to 12 years. The baseline CKD stages of the included
studies were various, ranged from normal to late stages. Only three risk factors from
studies of the same baseline and follow-up CKD stages were eligible for meta-analysis,
including proteinuria, male gender, and diabetes (Table 1). The hazard ratios of
progression from CKD stage 3-5 to CKD stage 5D were 1.64 (95% CI 1.01-2.66, I2 =
89.5%), 1.37 (95% CI 1.17-1.62, I2 = 56.8%), and 1.16 (95% CI 0.98-1.38, I2 = 28.2%)
for proteinuria > 1 g/day, male gender, and diabetes, respectively (Figure 1).
Conclusions: To the best of our knowledge, this study is the first systematic review of
the various risk factors determining the natural course of CKD. Due to high
heterogeneity, most of the studies and risk factors cannot be pooled by meta-analysis.
Our findings show that heavy proteinuria and male gender are strong predictors of the
progression from late stage CKD to end stage renal disease. Diabetes might play a
minor role in late stage CKD.
PARENTAL HISTORY OF PREMATURE CARDIOVASCULAR
DISEASE, KIDNEY FUNCTION AND KIDNEY FUNCTION
DECLINE; RESULTS FROM THE AEROBICS CENTER
Introduction and Aims: Parental history of cardiovascular disease (CVD) and chronic
kidney disease (CKD) are well documented predictors of offspring CVD and CKD,
respectively. Despite similar etiologies and interplay, it remains unknown if a broader
relationship between CVD and CKD exists across generations. We hypothesized that a
positive parental CVD history predisposes to impaired kidney function as well as more
rapid decline in kidney function over time.
Methods: We conducted a cross-sectional study on parental CVD history and renal
function in 13,241 community-based adult men and women from the Aerobics Center
Longitudinal Study (ACLS). Of those, 3,083 participants attended follow-up exams
(from 2 to 8 exams, approximately two years apart) and these longitudinal data were
used to study the rate of kidney function decline. Information of premature parental
CVD history (before the age of 50 years) was collected by protocol-standardized
questionnaires. Estimated glomerular filtration rate (eGFR) was assessed by serum
creatinine, and CKD was defined as eGFR<60mL/min/1.73m2. Linear mixed-effects
models assessed the annual rate of eGFR decline.
Results: 3,339 (25.2%) participants reported a history of parental CVD. Individuals
with parental CVD presented significantly lower eGFR compared with those without
parental CVD (69.4±12.9 vs. 74.8±14.2 mL/min/1.73m2, P<0.001). After multivariable
adjustment, parental CVD was independently associated with higher odds of having
CKD (adjusted odds ratio 1.68, 95% confidence interval 1.52 to 1.86). A linear
mixed-effects model showed that individuals with parental CVD had a faster decline in
eGFR compared with those without parental CVD (adjusted annual change of -0.15 vs.
-0.10 mL/min/1.73m2, P<0.05).
Conclusions: Parental history of CVD was associated with lower eGFR, higher
likelihood of CKD and faster rate of eGFR decline. Such findings may infer previously
unrecognized cross-generational links between both diseases and be of support in
community screening programs.
TUMOUR MARKERS AND KIDNEY FUNCTION: A
Giuseppe Coppolino1, Davide Bolignano2, Laura Rivoli1, Piera Presta1,
Giuseppe Mazza1 and Giorgio Fuiano1
1University-Hospital “Magna Grecia” di Catanzaro, Catanzaro, Italy, 2CNR-IFC
Institute of Clinical Physiology, Reggio Calabria, Italy
Introduction and Aims: Cancer patients are frequently identified and screened
following variations in tumor markers. These are useful tools as simple to use and
minimally invasive being measured in blood and urine. Established parameters, like
tumor markers half-life (t1/2) or doubling time may predict clinical variations but
pathological states, other than neoplasias, could increase the level of a tumor marker
(false positive), while, not every subject with cancer has abnormally high levels of an
associated marker (false negative). Kidney function is a key factor that might frequently
influence several tumor markers resulting in wrong diagnosis. The aim of our study
was to conduct a systematic review of current literature examining the association
between tumor markers and different renal impairment conditions.
Methods: We conducted a systematic research on MEDLINE database of papers
published between 1990 to 2013. We combined the following Medical Subject Heading
(MeSH) terms: ‘tumor marker’ or ‘neoplastic marker’ or the name of single neoplastic
marker combined with ‘renal disease’ or ‘chronic kidney disease’ or ‘renal failure’ or
‘haemodialysis’ or ‘peritoneal dialysis’ or ‘renal transplant’. Our research considered
these markers: Alpha-fetoprotein (AFP),Beta-2-microglobulin (B2M), Beta-HCG, CA
15-3 and CA 27.29, CA 125, CA 19-9, Total and free PSA, Chromogranin A. We
considered all types of clinical studies including parallel non-randomized, randomized
and crossover trials, observational studies and meta-analyses. Tumor markers were
investigated during single stages of chronic kidney disease ranging from
mild-to-moderate (stage 1, 2 or 3 CKD) to severe conditions (stage 4 or 5 CKD) and
during renal substitution therapy (a.e. haemodialysis or peritoneal dialysis) or after
Results: 748 references were initially retrieved; 231 studies were excluded because
duplicates or not pertinent with our topic. 418 references were discharged after full text
analysis considered not relevant, 12 being Narrative Reviews without new data to be
considered, 30 were in languages different from English and 26 having no data available
on renal impairment or renal replacement therapy. 31 full text articles were therefore
included in the final analysis. Worsening of renal function was strictly related to
significant increased levels of B2M, Beta-HCG, Chromogranin A, free PSA, CA 15-3
and CA 27.29 showing a linear correlation. In haemodialysis, tumor markers were
usually elevated but removed after treatment. In peritoneal dialysis patients only
Beta-HCG and CA 125 (in case of peritonitis) were meanly elevated. In Figure 1 we
summarized results of our analysis for every tumor marker in relation to renal
Conclusions: Physicians should consider with extreme care renal function as potential
confounder for tumor markers’ dosage, as it may results in wrong clinical diagnosis or
evaluation. Notwithstanding long-term data on larger cohort of patients are needed to
detect sensitivity and specificity of single markers and to identify specific levels to
consider as pathological during alterations of renal function.
ECONOMIC BURDEN OF ADVANCED CHRONIC KIDNEY
DISEASE (CKD) (PRE-DIALYSIS) IN A GERMAN COHORT WITH
TYPE 2 DIABETES AND WITHOUT DIABETES
Steven Marx1, Allison Petrilla2, Nora Hengst1 and Won C Lee2
1Abbvie, North Chicago, IL, 2IMS Health, Alexandria, VA
Introduction and Aims: The cost of treating end stage renal disease is substantial, but
the cost of care prior to initiation of dialysis is not well described in the literature. The
aim of this retrospective study is to understand the economic implications of kidney
function decline (before progression to dialysis) in a cohort of German CKD patients
with Type 2 diabetes (T2D), a known CKD risk factor, versus those without diabetes.
Methods: This retrospective database analysis utilized IMS Disease Analyzer primary
care EMR-European Union data to identify patients between 2007-2011 with reduced
kidney function (eGFR <60 mL/min/1.73m2) who received care from a primary care
physician (PCP) in Germany. Patients were stratified by diagnosis of T2D (versus No
Diabetes) and by CKD Stage (3, 4, 5-No Dialysis [ND]), those receiving dialysis were
excluded due to incomplete dialysis care records. To adjust for baseline demographic
and clinical differences between cohorts, patients were matched on index CKD stage
(3/4/5ND), age group, gender, insurance status, and key comorbid conditions, such as
hypertension, lipid disorders, and congestive heart failure. A variable follow-up period
was allowed. The primary study outcomes included per patient per year (PPPY)
resources utilization and direct healthcare expenditures (2010 USD) for all-cause and
cardiovascular-related direct health care services within each CKD stage from the PCP
perspective (comparison of T2D to No Diabetes cohort used Wilcoxon rank sum test
on the median). Regression modeling evaluated differences in the T2D vs. No Diabetes
cohort after adjusting for baseline covariates.
Results:Multivariate analysis adjusting for baseline covariates, demonstrated costs for
T2D patients in stages 4 and 5ND were 1.97 and 3.5 times the costs of patients in stage
3, p<0.0001, respectively.
Conclusions: This study provides evidence of an increase in resource utilization and
direct costs as kidney function declines. German CKD patients with T2D incur higher
costs and have greater medication burden, which may require more intensive
management from their PCP to help slow the progression to costly dialysis care. For
T2D patients, there was no visibility into the physician or patient’s enrollment in T2D
disease management programs, and for all study patients, limited visibility into the use
and costs associated with inpatient and specialist care within this EMR dataset.
Therefore, the true cost of managing CKD stages 3, 4, and 5 may be higher. Validation
studies, using other large EMR databases and disease registries, are warranted.
IS THE EXCESS RISK OF END-STAGE RENAL DISEASE
AFTER LOW BIRTH WEIGHT EXPLAINED BY GENETIC
Introduction and Aims: A previous Norwegian study showed that low birth weight
(LBW) conferred a 70% increased risk for end-stage renal disease (ESRD). To assess
whether genetic factors can explain this excess risk, we investigated risk of ESRD in
siblings of subjects with LBW.
Methods: The Medical Birth Registry of Norway has registered data on all births in
Norway since 1967. Sibling data have been registered in the Norwegian Population
Registry for almost all births since 1953. All patients with ESRD in Norway have since
1980 been registered in the Norwegian Renal Registry. We linked these registries and
investigated whether risk of ESRD was associated with LBW in the index subject itself
and/or LBW in at least one of its siblings. Cox regression statistics were used for the
Results: Of the 1,961,497 included subjects born between 1967 and 2009, 610
developed ESRD. Compared with subjects without LBW and no siblings with LBW,
subjects without LBW but a sibling with LBW had a relative risk (RR) of ESRD of 1.09
(95% confidence interval 0.80-1.48), subjects with LBW but no siblings with LBW had
a RR of 1.75(1.32-2.31), and subjects with LBW and a sibling with LBW had a RR of
1.71(1.13-2.60)(Table1). The relative risks remained virtually identical after
adjustments for gender, maternal disease and maternal preeclampsia. Similar, but
weaker, trends were observed when the analyses were done using small for gestational
age or preterm birth as exposure variables.
Conclusions: Genetic factors do not explain the excess ESRD risk with low birth
weight. These findings support the hypothesis that low birth weight per se may be a
causal risk factor of ESRD.
SP175 Table 1: Risk of ESRD according to index-sibling pairing lbw status.
Index subject with LBW No No
Sibling with LBW No Yes
N - total
Introduction and Aims: Chronic kidney disease (CKD) has become a major public
health problem worldwide. A growing proportion of end-stage renal disease (ESRD) is
owing mainly to diabetic nephropathy (DN). Increasing evidences show notable
relationships between a lower socioeconomic status (SES) and the prevalence of CKD
in the general population (AJKD 2003) and the prevalence of DN in diabetic patients
(NDT 2011), respectively. Therefore, to elucidate the association between diabetes and
SES in CKD population is important. Moreover, as reported in the DOPPS study, in
which the Japanese sub-cohort showed intrinsically different characteristics and
outcomes than the other countries, to describe and evaluate the characteristics with
regard to SES in Japanese CKD population per se is also important. Using the baseline
data from the Japanese CKD prospective cohort (CKD-JAC), we studied the
association between SES and diabetes in CKD.
Methods: We conducted a cross-sectional, observational study. SES was assessed by a
questionnaire. Each SES component was reclassified into four approximately
equivalent groups. Associations were explored through multivariable logistic regression
analyses for diabetes and linear regression analyses for the parameters that were related
to diabetes and obesity adjusting for demographic factors, renal function,
comorbidities, medication, and nutritional status.
Results: Of 2,977 participants, 1,854 (62%) and 2,496 (84%) answered to the questions
about income and education, respectively. In univariate analysis, low income and
education were associated with older age, lower eGFR, and higher prevalence of
cardiovascular diseases and hypertension. There was a significantly higher prevalence
of diabetes among low income and education groups (40.9% and 48.2% in the lowest
and 27.6% and 31.1% in the highest, respectively), which was still significant after
T2D Cohort (n=1,805)
No Diabetes (n=1,805)
CKD Stage 3
CKD Stage 4
CKD Stage 5ND
CKD Stage 3
CKD Stage 4
CKD Stage 5ND
adjustment for age, sex, eGFR, and other comorbidities (P=0.043 for income and
P<0.001 for education). Adjusted odds ratios for diabetes were 1.4 [95%CI 1.1 - 1.9],
1.3 [1.0 - 1.8], 1.0 [0.8 - 1.4], [Ref ] for the lowest to the highest income groups, and 1.9
[1.5 - 2.5], 1.3 [1.0 - 1.6], 1.2 [0.9 - 1.6], [Ref ] across education groups, respectively.
Contrary to the previous reports from the Western countries, however, income levels
were positively associated with BMI in diabetic patients (P=0.030 for trend). There was
no significant association between education levels and BMI, HbA1c, and dietary
energy intake calculated by food questionnaire.
Conclusions: A lower SES was also associated with a higher prevalence of diabetes in
the Japanese CKD patients. However, obesity and nutritional excess were not
necessarily observed in the low SES groups in this population.
IN VITRO STUDY OF CARDIOTOXICITY OF THE UREMIC
SERUM USING CULTURED CARDIOMYOCYTES
Introduction and Aims: Cardiorenal syndrome (CRS) is defined as a disorders of the
heart and kidney whereby acute or chronic disfunction in one organ may induce acute
or chronic disfunction of the other. Traditional cardiovascular risk factors play an
important role in the incidence of cardiovascular mortality in Chronic Kidney Disease
(CKD) patients ( pts). The aim of this project is to establish an in vitro model to study
the mechanisms of CRS type 4 based on primary cardiomyocyte cultures from neonatal
rats (NRC) treated with either serum or ultrafiltrate from uremic pts.
Methods: The project was developed into the following phases: 1. Enrollment of pts,
healthy controls (CTRL) and collection of serum and ultrafiltrate samples; 2. Biochemical
analyses; 3. Isolation and culture of NRC; 4. Cell incubation with different percentage
(10%, 30% and 60%) for 24 and 48 hours of serum and 5.cellular phenotyping.
Results: Confocal immunofluorescence with an antibody to Cardiac Troponin I (cTnI)
and morphometric analyses shows sarcomeric disarrangement, increased vacuolization
and atrophic remodelling in NRC incubated with CKD serum, compared to healthy CTRL
serum- or ultrafiltrate-treated. Moreover, cell survival, as estimated by cell counting,
cell-cell and cell-matrix adhesion were reduced in CKD serum treated cultures. The figure
shows a representative image (10% for 24 hours) of NRC stained with an antibody to cTnI
(red); Nuclei were counter stained with DAPI (blue).
Conclusions: These results suggest that CKD serum causes direct effects on NRC leading
to alterations in cell morphology, intercellular interactions and cell survival, indicating that
cardiotoxic components can be found in the uremic serum. This assay will be used to aim
identify such components.
A SPATIAL CLUSTER DETECTION OF CHRONIC KIDNEY
DISEASE: RELATION TO DEPRIVATION AT SMALL SCALE
Introduction and Aims: In developed countries the burdens of End-Stage Renal
Disease (ESRD) grow up steadily. Nevertheless, strong geographic variations in the
incidence of treated ESRD are observed at multiple scales. In metropolitan France
crude incidence varies widely from 85.8 to 225.5 per million inhabitants ( pmi) between
districts in 2008 - 2009 (Couchoud et al., 2012). The reasons for these geographic
disparities remain elusive.
Spatial heterogeneity of diseases is commonly assessed by choropleth maps of
standardized incidence rates (SIR). Although necessary to bring out spatial patterns,
this approach did not enable detection of statistically significant geographical clusters.
Scan statistics methods have been developed to detect such clusters of events without
pre-selection bias, allowing relevant statistical inference and adjustment for
confounding factors (Kulldorff, 1997). These are very uncommon in the context of
Chronic Kidney Disease (CKD).
The aim of our study was to highlight significant atypical clusters in terms of incidence
using spatial scan statistics methodology and their association to social discrepancies.
Methods: The Renal Epidemiology and Information Network (REIN) is a national
CKD registry which lists all patients who started a Renal Replacement Therapy (RRT)
since 2002 and is today available in 22 regions of metropolitan France. Cases were
defined as all incident patients registered in REIN in the Nord - Pas de Calais region
among January 2005 and December 2012. Patients were grouped by their resident
canton (a small French administrative unit) at the time of the first RRT and stratified
by sex and 5-years age classes. Sociodemographic data were extracted from national
Canton centroid was used for our spatial analysis. Isotonic spatial scan statistics
(SaTScan software) were employed to detect the presence of ESRD clusters and identify
their location. The method was adjusted by means of indirect standardization for age
Results: Our study included 5362 patients who began a RRT between 2005 and 2012 in
the Nord - Pas de Calais. The overall crude annual incidence rate was 166 pmi and
varied from 35 to 396 pmi among the 170 cantons. Isotonic spatial scan statistics
revealed 3 significant clusters with inhomogeneous high incidence rates.
As deprivation (assessed with the Townsend index) was clearly associated to higher SIR
and wealth to lower SIR (relative risk increased significantly from 1 to 1.44),
socio-economic status explains partially these spatial disparities.
Conclusions: Spatial scan statistics help to distinguish contiguous areas of excess or
deficit that are not likely to have arisen by chance. The existence of spatial clusters
demonstrates significant disparities of ESRD incidence among the Nord - Pas de Calais
region of France at a small area aggregation level. This specificity may provide deeper
knowledge of patterns that could explain such disparities, as social discrepancies. It
would afterwards supply better understanding of environmental assumptions.
Couchoud C, Guihenneuc C, Bayer F et al. (2012) Medical practice patterns and
socio-economic factors may explain geographical variation of end-stage renal disease
incidence. NDT 27(6): 2312-22.
Kulldorff M. (1997) A spatial scan statistic. Commun Stat Theory Methods 26(6):
ESTIMATION OF GFR AT PATIENTS WITH NEPHROLITHIASIS
AFTER PERCUTANEOUS LITHOTRIPSY
Inkar Mansurova1, Mirzakarim Alchinbayev2 and Mohammad Aref Malikh2
1Scientific Centre of Urology, Almaty, Kazakhstan, 2Scientific Centre of Urology
named after B.U.Dzharbussynov, Almaty, Kazakhstan
Introduction and Aims: Urolithiasis is the most common urological pathology. And
urological diseases are one of the risk factors for chronic kidney disease (CKD).
Percutaneous nephrolithotripsy (PNL) is one of the modern methods of surgical
treatment of stones, but the technique of PNL requires a direct damage of the renal
parenchyma. Thus the most frequent consequences of PNL are development of CKD
and renal failure. The aim of the study was to reveal features of development of CKD
and renal failure after PNL.
Methods: We examined 32 patients with kidney stones. Inclusion criteria: age older
than 18 years, the presence of a single stone in the pelvis. Exclusion criteria: diabetes,
hypertension, congenital anomalies of the kidneys, previous operations on the kidneys,
obesity, blood creatinine above 120 mmol/l. PNL was conducted under spinal
anesthesia. Blood and urine tests were performed the next day after surgery, 3,7,14
days. Control study was carried out in 3-6 months. GFR was calculated by the
Cockcroft-Gault equation. Statistical analysis was performed by Statistica 6.0.
Results: The mean age of patients was 28,4 ± 5,1 years. Mean GFR before surgery was
108,8 ± 20,5 ml /min. Average stone size was 1,4 ± 0,4 cm. The results of study are
listed in Table 1. The study showed that renal function is reduced from the first days
after PNL. The decline in GFR below 90 ml / min was found in 18 patients (56.3%).
This is evidenced by the growth of proteinuria. Statistically significant changes of GFR
were found on 7th day after surgery (*p <0,05). Despite the improvement of renal
function after 1 month, GFR above 90 ml / min was determined only in 2 patients
(6.2%). Having analyzed data after 3 months, CKD was identified in 27 patients
(84.4%). After 6 months renal function was recovered at 9 patients.
Transient renal failure was observed in 6 patients on 14th day after surgery. In the
analysis of 6 months persistent renal failure was detected in 3 patients. Symptomatic
hypertension occurred in 8 patients (25%).
Conclusions: So after PNL there is 85% probability of developing CKD. In 56.3% of
the patients there was a significant decrease in GFR below 90 ml /min, and in 15.6%
less than 60 ml / min. Critical period of the development of renal dysfunction is 7th
SP179 Results of estimation of kidney function
day after surgery. In this period, addition of renoprotective therapy is highly
recommended. PNL is a critical risk factor for kidney failure, so this surgery method is
not applicable in patients with existing risk factors: hypertension, diabetes and renal
Introduction and Aims: Cardiac autonomic neuropathy (CAN) may be not
uncommon and early complication even in chronic kidney disease (CKD) 3, 4 without
diabetes mellitus. We explored the relationship of CAN in the view point of hydration
status, vascular status, and renal function in non-diabetic early CKD patients.
Methods: Thirty one CKD 3, 4 patients were enrolled. Hydration status (extracellular
water [ECW]/total body water [TBW]) was determined by bioimpedance analysis.
Brachial-ankle pulse wave velocity (baPWV) and neck ultrasonography for carotid
plaque and intima-media thickness were conducted for checking up of vascular status.
CAN was scored using Ewing’s method and we also expressed the standard deviation of
normal-to-normal interval (SDNN), low frequency/high frequency ratio (LF/HF ratio).
Serial serum creatinine change over at least 12 months was used for assessment of renal
function and expressed as reciprocal creatinine slope.
Results: Of the 31 patients, nine (9/31, 29%) have suffered with CAN. SDNN was
correlated with 1/creatinine slope (r= 0.598, P = 0.0004), ECW/TBW (r=-0.488, P
=0.0054). ECW/TBW was correlated with mean PWV ( p= 0.401, P= 0.0254). Mean 1/
creatinine slope was -0.002045 and used for marker of the deterioration of renal
function over one year. Deteriorated group (N=16) had a lower SDNN [20.94
(14.99~27.69), vs. 35.52 (26.35~43.14)] and more patients had a proteinuria (93.8% vs.
46.7). After logistic regression analysis according to renal function status, proteinuria
had a good relationship with the decline of renal function (coefficient: 1.5293, Std
Error: 0.61541, p=0.0130) and SDNN as marker of CAN only had marginal
relationship (coefficient: -0.0786, Std Error: 0.4458, p=0.0779).
Conclusions: We found that 29% of early CKD patients had CAN and there were
interrelationships among renal function, CAN, hydration status, and arteriosclerosis.
PERCEIVED INFORMATION LEVEL AND EDUCATIONAL
NEEDS IN DIALYSIS AND TRANSPLANTED PATIENTS
Introduction and Aims: ESRD patients need to make choices with regard to treatment
and therefore need sufficient level of information. In order to improve self care and
1/creatinine slope SDNN ECW/TBW Mean PWV
iii | Abstracts
SP180 Correlation Table:
SDNN r=0.598 p=0.0004 r=-0.488 p=0.0054 r=-0.318 p=0.0811
quality of life, not only knowledge but also counseling is critical. Part of it is provided
through educational programs. This national study aimed at analyzing the way ESRD
patients access information and participate to educational programs and describing
their needs in terms of counseling.
Methods: A cross-sectional study by mailed self-administrated questionnaire, was
performed on a ESRD representative sample constituted with 3386 dialysis patients
and 3555 renal transplanted (RT) patients, aged of 18 years and more, treated for at
least one year, included in one of the 21 (over 23) French regions taking part in the
REIN registry in 2010. Data on the way ESRD patients may access information and
educational programs as well as their needs in term of counseling, education,
information were collected in addition of sociodemographic and medical data.
Results: Perceived information level was high in dialysis (enough information 85.8%,
N=1252) and RT patients (enough information 81.9%, N=1658) both at diagnosis of
the disease and along treatment steps. Over 80% of both dialysis and RT patients felt
they were listened to (87.4% and 88.7% respectively). Despite attesting medical teams
considered their opinion (83.0% and 83.2% respectively), dialysis and RT patients
recognized they didn't feel involved into therapeutic choices made (63.2% and 67.5%
respectively). 24.1% and 17.7% of dialysis and RT respectively ( p<0.001) regularly
searched for information on disease and treatment, most frequently using internet for
RT patients or health professionals for dialysis patients. 40.3% of dialysis patients and
26.9% RT of patients expressed a need for help in improving quality of their life with
the disease ( p=0.0004). Almost half of the patients placed pain as their major area of
concern and need for help (54.1% dialysis and 47.9% of RT patients, p=0.0004).
Dialysis patients (49.5%) mentioned more trouble in expressing themselves and
sharing ideas on ESRD than RT patients (40.4%, p<0.0001) They wished to exchange
more with other patients and patients support groups. Only 14.1% of dialysis and
19.5% of RT patients confirmed they attended educational programs ( p<0.0004). RT
patients were more enclined into attending group sessions than dialysis patients. Very
few patients knew what educational programs really are (12.1% and 19.1% respectively)
and less than 10% remembered having being offered to participate.
Conclusions: In 2009, France has passed a law suggesting educational programs should
be available for chronic patients. Despite increasing offer, there is a need for more
information on those programs. CKD patients feel provided with enough information
but experience not enough involvement into therapeutic choices. This work raises
issues related to the effective dissemination of educational programs among CKD
patients in France.
PREGNANCY AND THE SUBSEQUENT RISK OF END STAGE
RENAL FAILURE IN PATIENTS WITH SYSTEMIC LUPUS
ERYTHEMATOUS: A NATIONWIDE POPULATION-BASED
Tung Min Yu1 and Chi-Yuan Li2
1Taichung Veterans General Hospital, Taichung, Taiwan, 2China Medical
University, Taichung, Taiwan
Introduction and Aims: Systemic lupus erythematosus (SLE) is a prototypical
autoimmune disease involving multiple organs, in particular the kidney, and most
affected female patients are at child-bearing age. The study aims to explore the risk and
renal outcomes of the pregnant women with systemic lupus erythematous in a
Methods: By using the National Research Dataset from 1997 to 2010, a total of 1525
lupus women with pregnancy, 3047 lupus patients without pregnancy and
3041matched pregnant women which were not lupus were enrolled. The renal survival
and associated risk factors were compared among these groups.
Results: Compared to the non-lupus pregnant cohort, the SLE women with pregnancy
were associated with a statistically significantly higher risk of ESRD than those in the
non-SLE cohort (IRR=1.45, 95% CI=1.22-1.72; adjusted HR=1.59, 95% CI=1.05-2.39)
and a lower renal survival was noted in the lupus pregnant women which reached a
statistical significance ( p=0.05). However, a comparable renal survival was found
between lupus patients with and without pregnancy which was statistically insignificant
Conclusions: In the large cohort study, we reported the overall renal outcomes in lupus
patients with a history of pregnancy and identified the associated risk factors of ESRD
in lupus patients after pregnancy. In addition, our data provide evidence supporting
the current recommendations calling for the avoidance of pregnancy in lupus patients
until the disease activity is quiescent.
CHRONIC KIDNEY DISEASES IN NATIONAL
REPRESENTATIVE SURVEY FOR ENDOCRINE AND KIDNEY
DISEASES IN BULGARIA
Introduction and Aims: We present results from first national representative study for
chronic kidney diseases in Bulgaria.
Methods: The survey involved 2032 people from 11 cities and adjacent villages in
Bulgaria (minimum number of required cases - 900). The number of cases required
from each region was determined by a statistician, and was based on the population of
the regions in the country. Distribution of studied contingent reflects the whole
country population for sex, age and residence. All tests were performed in the same
clinical laboratory. Criterion for presence of CKD was albuminuria (UACR >3 mg/
mmol) and/or eGFR <60 ml/min/1,73 m2. eGFR was calculated by CKD-EPI formula.
Results: The incidence of CKD for the whole group was 12,99% (12,7% in women and
13,3% in men). Distribution by CKD stages was: stage I - 4,43%, stage II - 3,20%, stage
IIIa - 4,28%, stage IIIb - 0,98%, stage IV - 0,05% and stage V - 0,05%. In four
geographic regions of the country incidence of CKD varies from 11,5% to 16,5%. In
cities it was 12,5%, in villages - 14,4%, in capital Sofia - 10,4%. With age the incidence
of CKD rises - 6,0% in age 20 to 44 y.o., 10,7% in age 45 - 59 y. and 25,3% above 60 y.o.
Frequency of CKD was the highest among people with confirmed diabetes - 27,1%. In
newly established diabetes it was 16,0%. Same incidence was found in people with
impaired glucose tolerance. Among people with arterial hypertension incidence of
CKD was 19%. In people with no signs of diabetes and hypertension CKD was 7,9%. In
this category the highest incidence was in obese people (BMI>30) - 10,7%, at matched
age. Parameters of mineral metabolism, PTH and Vit. D levels were studied as well. In
eGFR < 60ml/min/1,73 m2 mean PTH was 7,04±8,09 pmol/L, and 4,55±3,35 pmol/L in
eGFR >60 ml/min/1,73 m2 ( p<0,01). Difference for phosphatemia and for calcemia
was insignificant. Same was for 25OH Vit D3. Only in UACR >30 mg/mmol the level
of 25OH Vit D3 was significantly lower - 25,86±16,02 against 38,75±17,09 ( p<0,01).
11,7% of people with CKD were with increased levels of C-RP (above 10 mg/L) against
5,8% with no CKD. Mean value of triglicerides in people with eGFR <60 ml/min/1,73
m2 was 2,39±2,44 mmol/L, compared to 1,64±1,79 in eGFR >60 ml/min/1,73 m2
( p<0,01). Difference for total cholesterol and HDL cholesterol was insignificant.
Conclusions: CKD is a major health problem in Bulgaria. The incidence of CKD is the
highest among elderly people and in those with diabetes and arterial hypertension.
INTENSIVE PSYCHO-EDUCATION OF PATIENTS WITH
ADVANCED CHRONIC KIDNEY DISEASE, INVOLVING FAMILY
MEMBERS - INITIAL EXPERIENCE, REMARKABLE RESULTS
Introduction and Aims: Treatment adherence, modality selection and access to
transplantation are important determinants of morbidity and mortality in patients
with advanced chronic kidney disease (CKD). These factors could potentially be
enhanced by patient education. Very few studies have assessed the impact of involving
family members along the psycho-education process in this patient population. We
hypothesized, that utilizing multidisciplinary psycho-education in a special, one week
long, overnight camp-like situation, involving immediate family members of the
patients would lead to improved phosphate (PO4) and blood pressure (BP) control,
may slow progression of CKD and would facilitate the selection of home based dialysis
and live donor transplantation.
Methods: Patients followed at our predialysis clinic and their spouses participated
voluntarily in the psycho-education training program. The education program was
delivered by nephrologists, social workers, psychologists, physiotherapist and
dieticians. Topics included the medical aspects of CKD, dialysis modality selection,
transplant related issues, lifestyle related concerns, psychosocial issues and
rehabilitation. Participation was free, full financial support was provided by St. Margit
Hospital’s Kidney Foundation. Routine laboratory data, decline of GFR/year, dialysis
modality choice preferences were obtained from the clinic charts. Results obtained at
the last clinic visit before the education camp and 1-3 months after were compared
using paired Student-t and Wilcoxon tests. Medications, except ESA dose, have not
been changed during this period.
Results: Data from 34 patients (19 males, mean±SD age 63.4±15 years, eGFR 18.9±8
ml/min) are presented. Charlson comorbidity index was 3.5 (IQR 3). Serum PO4,
proteinuria and systolic BP measured 1-3 months after the training, all improved
significantly (1.69±0.4 vs 1.53±0.4 mmol/l, p=0.02; 1585 (IQR 1150) vs 1163 (IQR
1704) mg/day, p=0.04; 134±20 vs 125±17 mmHg, p=0.01, respectively). During the
follow-up six patients died. Of the remaining 28, 11 patients remained independent of
dialysis at the end of follow-up; in these patients the rate of decline of eGFR decreased
from 2.04 ml/min/year (IQR 11) before the camp to 0.85 ml/min/year (IQR 4). Five of
the relatives offered kidney donations, two patients received live donor transplant
during the follow up and nine patients were registered on the transplant waiting list. Of
the 16 patients who started dialysis, 9 had chosen PD. The numbers compare favorably
to Hungarian registry data (2010): PD penetrance 12.8%, wait-listed 10.7%, living
related transplantation 8.5%.
Conclusions: Complex, intensive psycho-education of patients with CKD, involving
family members resulted in a significant improvement of metabolic control without
medication change (likely due to improved adherence to diet and medication) and a
preferential selection of home dialysis. Similar education may slow the progression of
CKD and improve access to live donor transplant. Overall these results suggest that
similar training may reduce disease burden, morbidity and enhance quality of life in
patients with CKD.
INFLUENCE OF MDRD AND/OR CKD-EPI FORMULA
APPLICATION ON DETECTION AND EPIDEMIOLOGY
OF CHRONIC KIDNEY DISEASE
Lukasz Zdrojewski1, Tomasz Zdrojewski1 and BolesłAw Rutkowski1
1Medical University of Gdansk, Gdansk, Poland
Introduction and Aims: Chronic kidney disease (CKD) is a risk factor of
cardiovascular and general morbidity, end stage renal disease. Data on CKD prevalence
is biased by formula used to estimate glomerular filtration rate (eGFR). The KIDIGO
2012 guidelines recommend use of CKD-EPIcreat instead of MDRD formula to
calculate eGFR. The aim of this study was to assess the effect of application of different
eGFR formulas on CKD prevalence among adult polish citizens.
Methods: We studied data from two large population studies: 1) NATPOL 2011, which
included data from 2413 participants (1245 females; 1168 males), aged 18 to 79, and 2)
WOBASZ Senior, including data from 1013 participants (502 females and 511 males)
aged above 75 years. Concentration of serum and urine creatinine in both studies was
measured with an enzymatic method. Data on urine albumin concentration came only
from NATPOL2011 study. Albuminuria was measured once in a morning urine sample
with an immunoturbidimetric method. CKD was diagnosed for eGFR (estimated with
abbreviated MDRD formula and the 2009 CKD-EPIcreat formula) < 60 ml/min/1,73
m2 or eGFR≥60 ml/min/1,73 m2 with coexisting albuminuria (albumin-to-creatinine
ratio ≥30 mg/g).
Results: Prevalence of CKD in adults in Poland aged above 18 years for MDRD based
eGFR was 11,36%, and 10,75% for CKD-EPIcreat based eGFR ( p<0,001). It increased
with age. Comparing the eGFR estimation by MDRD and CKD-EPIcreat, in the age
group 18 to 39 CKD prevalence was equal by both methods and was 1,8%. In the age
group 40 to 64 years - 6,55% and 6,00%, 65-74 years - 20,09% and 18,14%, 75-84 years
- 21,18% and 20,16% respectively. The highest prevalence was observed in the age
group above 85 years, where both methods gave result of 30,43%. Calculated kappa
concordance coefficient for eGFR estimations by both methods was 0,966. Area under
the receiver operating characteristic curve (ROC) of specificity and sensitivity equals
0,968 (CI 95%: 0,954-0,982).
Conclusions: Prevalence of CKD in population of adults in Poland aged above 18 years
is high and comparable with other countries in Europe and worldwide. Estimated CKD
prevalence is lower when the CKD-EPIcreat formula is applied. This is because of
elsewhere proven better performance of this formula in higher values of eGFR and
earlier stages of CKD. The sensitivity of CKD detection is comparable for both
methods of eGFR estimation (MDRD and CKD-EPIcreat).
URINARY BETA-2 MICROGLOBULIN LEVEL IS ASSOCIATED
WITH CARDIOVASCULAR DISEASE IN PATIENTS WITH
PREDIALYTIC CHRONIC KIDNEY DISEASE
Introduction and Aims: Previous studies have shown that urinary beta-2
microglobulin (uBMG) correlates with tubulointerstitial lesions,which proved to
correlate with renal function and systemic arteriosclerosis. The relationship between
uBMG and incident cardiovascular diseases (CVD) remain unknown. Clinical
significances of uBMG have not been fully elucidated. We conducted a retrospective
study to evaluate the association of uBMG with the CVD incidence in patients with
non-dialysis chronic kidney disease (CKD).
Methods: One hundred ninety-one patients with CKD stage 4, 5 not on dialysis were
retrospectively enrolled from a single department of nephrology as a hospital cohort
from May 2008 to April 2013. For this study, we excluded patients with malignancy,
interstitial nephritis,or reflux nephropathy from enrollment. Analysis was based on the
remaining 134 participants. Specimens of urinary pH under 6.0 were not measured
because uBMG is denatured in its condition. Patients were devided into 2 groups
according to median values of uBMG/urinary creatinine ratio (cutoff value=29600 micro
g/gCr). In this study, CVD was defined as the occurence of stroke, of cardiac infarction,
of angina pectoris and the hospitalization for heart failure. Survival analysis was
performed using cumulative CVD event-free Kaplan-Meier curves and the curves were
compared between the 2 groups by log-rank test. Cox proportional hazard analysis was
used to examine the association between variables and cumulative incidence of CVD.
Results: The median follow-up period was 36.9 months. Baseline median age was 67.5
years old. Sixty eight percents of total patients were men, 47.0% had diabetes mellitus
and 35.0% had cardiovascular history. During the study period, CVD occurred in 39
patients. The CVD incidence significantly increased in patients with high uBMG group
(HR = 2.55, 95%CI =1.28 to 4.98) compared to those with low uBMG group(reference)
after the adjustment for age, gender, eGFR, urinary protein, systolic pressure.
Conclusions: These results suggest that the high uBMG level may be an independent
predictive marker for CVD in patients with CKD stage 4, 5 not on dialysis.
INCIDENCE AND RISK OF FRACTURE IN PATIENTS
ON RENAL REPLACEMENT THERAPY
Introduction and Aims: Patients on renal replacement therapy (RRT) are at increased
risk of bone fracture because of altered bone metabolism termed Chronic Kidney
Disease-Mineral and Bone Disorders (CKD-MBD). The incidence of bone fracture in
prevalent RRT patients is poorly defined. Aim: The aim was to quantify the incidence
of radiologically proven bone fracture in prevalent RRT patients and compare renal
transplant and dialysis patients.
Methods: We undertook a retrospective analysis of electronic patient records for all
prevalent renal transplant (RT), haemodialysis (HD) and peritoneal dialysis (PD)
patients across the West of Scotland. Study inception date was 7th July 2010 and
patients were followed until August 2013. All radiology reports from all hospitals in the
West of Scotland were included and searched to determine the number of fractures per
patient year. The endpoint of follow up was defined by date of death or last
documented biochemistry result.
Results: We identified 2096 patients on RRT at the start of the study. The RRT
modality at entry was: RT 1081 patients (51.6%), HD 907 (43.3%) and PD 108 (5.2%)
and mean ages (standard deviation) were 50.4 (13.3), 61.8 (15.8) and 57.9 (15.3) years
respectively. Median duration of follow up for RT patients was 1112 days, range 8-1155;
HD patients 1086 days, range 0 - 1189, and PD patients 1126 days, range 13-1155.
There were 337 fractures in 2096 of the patients giving an overall incidence of
radiologically proven fracture of 0.062 per patient year. (0.038,0.098 and 0.058 fractures
per patient year in RT, HD and PD patients respectively.
The risk ratio (RR) of fracture in HD group compared to RT was RR 2.60, (95%CI:
2.59- 2.61), and in HD compared to PD was 1.70 (95% CI: 1.68-1.70).
Conclusions: Our study show that relative risk of fracture is higher in patients on
haemodialysis compared to renal transplant patients and patients on peritoneal
dialysis. Further research is warranted to determine if the association between RRT
modality and fracture incidence is independent of other risk factors for fracture.
VITAMIN D ANALOGUES, MORTALITY, AND
CARDIOVASCULAR RISK IN CHRONIC KIDNEY DISEASE:
A SYSTEMATIC REVIEW AND META-ANALYSIS OF
RANDOMIZED CONTROLLED TRIALS
Michelle C Mann1, Amy Hobbs1, Brenda R Hemmelgarn1, Derek Roberts1,
Sofia B Ahmed1 and Doreen Rabi1
1University of Calgary, Calgary, AB, Canada
iii | Abstracts
Introduction and Aims: Vitamin D deficiency has been reported to be highly
prevalent among adults with chronic kidney disease (CKD) and associated with both
all-cause and cardiovascular mortality. We sought to investigate the impact of vitamin
D supplementation on the pooled risk of mortality and adverse cardiovascular events,
including sudden cardiac death (SCD), by combining available data reported by
randomized controlled trials (RCTs). We also sought to determine whether the type of
vitamin D analogue administered explained heterogeneity in the reported risk of these
outcomes across trials.
Methods: Electronic bibliographic databases (PubMed, MEDLINE, EMBASE, and the
Cochrane Library) as well as nephrology journals and renal international conference
proceedings were searched on October 28th 2013. Studies were included if they
randomized patients with CKD (<60ml/min/1.73m2), including those undergoing
dialysis, to oral vitamin D supplementation versus placebo and reported either
mortality (all-cause or cardiovascular) and/or cardiovascular serious adverse events as
outcomes. Pooled relative risks, stratified by CKD stage, vitamin D analogue, weekly
standardized vitamin D dose, and percentage of diabetics in each trial, were calculated
using random effects models.
Results: Among 4,246 studies screened for inclusion, 11 RCTs (n=1,349) were included
in the systematic review. Meta-analysis suggested no significant effect of oral vitamin D
supplementation on all-cause mortality, cardiovascular mortality or serious
cardiovascular adverse events among patients with CKD. However, there was
substantial heterogeneity among these pooled estimates, which varied according to the
dosing regimen, trial duration, and length of follow-up.
Conclusions: Available RCTs currently do not provide evidence for a significant
relationship between vitamin D supplementation and all-cause mortality or
cardiovascular risk within the CKD population. However, existing trials are limited by
clinical heterogeneity and lack sufficient treatment duration or follow-up periods to
allow for effective quantification of potential survival or event rate benefit. Thus,
appropriately design trials are required to better investigate patient-important
outcomes of vitamin D therapy in the CKD population.
SP188 Figure 1: Relative risk of all-cause mortality and oral vitamin D
supplementation in CKD patients.
MODIFIABLE PREDICTORS OF VASCULAR STIFFNESS
Introduction and Aims: Vascular stiffness is a marker of vascular injury that predicts
cardiovascular outcomes. A correct understanding of the factors contributing to
vascular stiffness will contribute to the implementation of preventive and therapeutic
measures that improve patient outcomes. To define the predictors of vascular stiffness
as assessed by pulse wave velocity and analysis in patients undergoing ambulatory
blood pressure monitoring ABPM at a nephrology outpatient clinic.
Methods: Cross-sectional analysis of a prospective cohort of 122 individuals [86 males
(70%), mean age 60 ± 13 years; 107 CKD and 15 non-CKD]. 80 (65.6%) were diabetic
and 104 (85.2%) were hypertensive. Participants underwent 24-ABPM,
echocardiogram, Carotid-Femoral Pulse Wave Velocity (PWV) and Aortic Pulse Wave
Analysis (PWA) (using SphygmoCor) and biochemical studies. Six patients (5%) were
CKD stage 1, 56 (46%) stage 2, 28 (23%) stage 3A, 13 (11%) stage 3B and 4 (3%) stage
4. Albuminuria 1000 in 16 patients (13%).
Results: Mean PWV was 11.5 +/- 3.5 (m/sec). Higher than expected for age values
were observed in 54 (44.3%) patients. In univariate analysis age was inversely correlated
with 24 hours mean diastolic blood pressure (DBP) and mean heart rate (HR) ( p
0.0001 and 0.000 respectively), while was positively correlated with 24 hours mean
pulse pressure (PP) ( p 0.000) and aortic augmentation index (AIx) ( p 0.007).
Diabetes was associated with 24 mean systolic blood pressure (SBP) ( p 0.0039), mean
PP ( p 0.0000) and negatively with lower Buckberg index ( p 0.0058).
Urinary albumin/creatinine ratio (UACR) ratio was positively correlated with 24 mean
SBP ( p 0.0005), PP ( p0.0007) and AIx ( p 0.01), while there was a negative trend with
Buckberg index ( p 0.17)PWV was correlated positively with mean SBP ( p 0.001), PP
( p 0.001) and diabetes ( p 0.0001) and negatively with Buckberg index ( p 0.0059).
PWV was also positively correlated with UACR, serum uric acid (UA), and HbA1C ( p
0.0078, 0.0158 and 0.009), negatively correlated with eGFR ( p 0.001) with a negative
trend with serum magnesium (Mg) ( p 0.09).
AIx was higher among females ( p0.0044) and negatively correlated with hemoglobin
(Hb) ( p 0.0483) and Mg ( p 0.014). While Buckberg index was lower among females ( p
0.0005), positively correlated with Hb ( p 0.016) and negatively with HbA1C ( p
0.0054). In a multivariate analysis PWV independently correlated positively with age
( p 0.0000), SBP ( p 0.002), HbA1C ( p 0.0249), UACR ( p 0.0213) and negatively with
Buckberg index ( p 0.0531). The value of r2 for the model was 0.28. AIx independently
negatively correlated with gender ( p 0.0001), Mg ( p 0.0001) and positively with UA ( p
0.0086) with r2=0.36 for the model.
Conclusions: Age, SBP, HBA1C and UACR are the main associates of PWV, while
gender, magnesium and uric acid are the main determinants of Aix. This analysis
identifies HBA1C, UACR, magnesium and uric acid as potentially modifiable
determinants of vascular stiffness parameters.
ECONOMIC & HUMANISTIC BURDEN OF TYPE 2 DIABETES
WITH CHRONIC KIDNEY DISEASE IN BRAZIL
Steven Marx1, Dave Pomerantz2 and Jeffrey Vietri2
1Abbvie, North Chicago, IL, 2Kantar Health, New York, NY
Introduction and Aims: To assess the economic and humanistic burden of type 2
diabetes (T2DM) with chronic kidney disease (CKD) in Brazil.
Methods: Data were obtained from the Brazil 2011 National Health and Wellness
Survey, a self-administered cross-sectional survey of adults (aged 18+) in Brazil
(N=12,000). Recruitment employed stratified sampling and mixed methodology to
ensure representativeness. Outcomes included health status (SF-12v2), impairment to
work and non-work activities (WPAI), and healthcare visits (6 months).
Results: The sample included respondents without T2DM or CKD (n=10,873), with
CKD but not diabetes (n=579), and comorbid CKD and T2DM (n=65). Comorbid
patients were further divided by use of dialysis (52 without, 13 with). Physical
Component Summary Score declined from without T2DM and CKD (50.9), total
population (50.5), CKD (48.2), CKD and T2DM without dialysis (43.3), CKD and
T2DM with dialysis (43.3), to CKD & T2DM (43.1). Mean hospitalizations in the past
6 months increased from CKD (1.74), without T2DM and CKD (1.93), total
population (1.95), CKD and T2DM without dialysis (2.5), CKD and T2DM (3.35), to
CKD and T2DM with dialysis (7.33). Mean out-of-pocket healthcare expense (R$)
ranged from without T2DM & CKD (85.11) to T2DM and CKD with Dialysis (243.64).
Percentage of work time missed/impaired while at work due to health increased from
without CKD & T2DM (5.5/15.9), total population (5.7/16.5), CKD (7.4/22), T2DM &
CKD without dialysis (17/27.1), T2DM & CKD (18.8/31), to T2DM & CKD with
Conclusions: This is the first study to assess the economic and humanistic burden of
type 2 diabetes with chronic kidney disease patients in Brazil. Significant unmet needs
remain, and improved management of this condition could result in significant and
clinically meaningful gains in health status as well as alleviating a societal cost burden.
HDL CHOLESTEROL IS NOT VASOPROTECTIVE IN PATIENTS
WITH IMPAIRED RENAL FUNCTION
Introduction and Aims: In the general population, HDL cholesterol (HDL-C) is
associated with reduced cardiovascular events. However, recent experimental data
suggest that the vascular effects of HDL can be heterogeneous.
Methods: We examined the association of HDL-C with all-cause and cardiovascular
mortality in the Ludwigshafen Risk and Cardiovascular Health study comprising 3307
patients undergoing coronary angiography. Patients were followed for a median of 9.9
years. Estimated GFR (eGFR) was calculated using the Chronic Kidney Disease
Epidemiology Collaboration eGFR creatinine-cystatin C equation. The effect of
increasing HDL-C serum levels was assessed using Cox proportional hazard models.
Results: In participants with normal kidney function (eGFR>90 ml/min per 1.73 m2),
higher HDL-C levels associated with reduced risk for all-cause and cardiovascular
mortality and coronary artery disease severity (hazard ratio [HR] 0.51 [P=0.03]; HR
0.30 [P=0.01]). Conversely, in patients with mild (eGFR=60-89 ml/min per 1.73 m2)
and more advanced reduced kidney function (eGFR<60 ml/min per 1.73 m2), higher
HDL-C did not associate with lower risk for mortality (HR 0.68 [P=0.07]; HR 0.84
[P=0.50]; HR 1.18 [P=0.88]; HR 0.82 [P=0.60]). Moreover, Cox regression analyses
revealed that the interaction between HDL-C and eGFR associated with all- cause and
cardiovascular mortality (P=0.04 and P=0.02, respectively).
Conclusions: We confirmed a lack of association between higher HDL-C and lower
mortality in an independent cohort of patients with definite CKD (P=0.63). In
summary, higher HDL-C levels did not associate with reduced mortality risk and
coronary artery disease severity in patients with reduced kidney function. Indeed,
abnormal HDL function might confound the outcome of HDL-targeted therapies in
CARDIOVASCULAR RISK FACTORS AND THE RELATIONSHIP
WITH METABOLIC SYNDROME AND CHRONIC KIDNEY
Carmen D Caldararu1, Mirela L Gliga1, Ionut D Tarta1, Annamaria Szanto1,
Otilia Carlan1 and Grigore A Dogaru1
1University of Medicine and Pharmacy Targu Mures, Targu Mures, Romania
Introduction and Aims: The epidemic of chronic kidney disease and obesity
worldwide and the link with cardiovascular morbidity is an important topic of modern
medicine. To evaluate cardiovascular risk factors and their relationship with chronic
kidney disease (CKD) and metabolic syndrome (MS) in a population of patients
addmited in a nephrology department.
Methods: All patients admitted in the Nephrology Department of The County Clinic
Hospital Targu Mures between january 1, 2010 - december 31, 2013 were
retrospectively reviewed. Patients were evaluated with respect to their anthropometric
data, clinical data, and laboratory parameters to assess the presence of cardiovascular
risk factors, metabolic syndrome and chronic kidney disease. Cardiovascular risk
factors were compared for the following groups: A: patients with CKD and MS, B:
patients with CKD and without MS, C: patients without CKD and without MS, D:
patients with MS and without CKD. MS was defined as the presence of three or more
of the following: hypertension, diabetes mellitus or plasma glucose >100 mg/dl, body
mass index (BMI) over 30 kg/mp, triglycerides higher than 150 mg/dl, HDL cholesterol
under 40 mg/dl in females and under 50 mg/dl in males. CKD was defined as an
estimated glomerular filtration rate<60 ml/min/1.73 mp (MDRD equation). Data were
analyzed using SigmaStat version 5.0 and p was considered significant if <0.05.
Results: A total of 248 patients had all parameters needed for defining metabolic
syndrome. The prevalence of MS and CKD was 60.08% and 58.06% respectively. CKD
was more common in subjects with MS compared with those without ( p=0.01). Age
was significantly higher in group A vs C, with no other differences between the other
groups. Triglyceride levels and BMI were significantly higher in SM versus non-SM
patients (A vs B, A vs C, D vs B and D vs C). Total cholesterol showed no significant
differences between groups.
HDL cholesterol was significantly lower in SM groups (A vs B, A vs C and D vs C)
without differences between CKD groups (B vs C).
Systolic blood pressure was significantly higher in CKD and MS compared with no
CKd and no MS patients (A vs C), with no other differences between groups.
Conclusions: Patients with CKD and MS have the worst profile in terms of
cardiovascular risk factors. We found no significant difference for CKD without MS
patients compared to the group without CKD and without MS in terms of
cardiovascular risk factors.
Age and systolic blood pressure were significantly higher in CKD patients. BMI,
triglycerides were significantly higher and HDL cholesterol levels were significantly
lower in SM patients.
OCCURRENCE OF ISCHEMIC NEPHROPATHY IN PATIENTS
WITH ATHEROSCLEROTIC LESIONS. RETROSPECTIVE
Yuri Battaglia1, Marco Antonio Del Prete2, Maria Grazia De Gregorio2,
Carmela Errichiello2, Pietro Gisonni3, Luigi Russo2, Bernadette Scognamiglio2,
Alda Storari1 and Domenico Russo2
1Department of Nephrology, Aricispedale Sant’Anna, Ferrara, Italy, 2Department of
Nephrology, University Federico II, Napoli, Italy, 3Department of Diagnostic
Imaging, University Federico II, Napoli, Italy
Introduction and Aims: Ischemic renal disease (IRD) is caused by hemodynamically
significant mono or bilateral renal artery stenosis. IRD is responsible for reduction of
glomerular filtration rate (GFR) or loss of renal parenchyma. The exact prevalence of
IRD is not well known since it is often asymptomatic. Therefore few patients are
screened for IRD unless they become symptomatic. This study aimed at assessing the
prevalence of IRD, defining its clinic characteristics, evaluating useful imaging
procedures in a cohort of patients with chronic kidney disease not in dialysis (CKD)
and atherosclerotic lesions.
Methods: 1607 CKD patients were retrospectively evaluated. Inclusion criteria were:
CKD (I - V KDOQI stages), presence of atherosclerotic lesions anywhere in arterial
tree. Clinical characteristics (age, sex, blood pressure, body weight, BMI, height),
medical history ( previous cardiovascular events, history of cardiovascular events in
family, diabetes mellitus, hypertension), data of imaging procedures (angio-TC,
angio-RM, color doppler ultrasound (US), renal scintigraphy, angiography,
coronarography) were collected.
Results: 284 patients fulfilled inclusion criteria. Clinical characteristics are reported in
Fig 1. Causes of CKD were: hypertension (16,9%), diabetes mellitus (13%),
glomerulonephritis (10.9%), interstitial nephritis (3.2%), kidney stones (2.5%),
polycystic kidney disease (1.8%), unknown (40%). The prevalence of IRD was 11,3%.
Many cases (26%) of IRD were found among patients with previous diagnosis of
unknown CKD. Renal color-doppler US and renal scintigraphy was performed in CKD
patients with unknown cause in 42,6% and 11,9% respectively. Compared to others,
patients with IRD had higher prevalence of history of cardiovascular events in family
(46.9% Vs 33.7%) (ns), dyslipidemia (84.4% vs 69%) (ns) and previous cardiovascular
events (53.1% vs 32.1%) (ns). In contrast, presence of diabetes was lower (12.5% vs
36,5%) ( p = 0,04) in CKD patients with IRD. Aterosclerotic lesions was mainly
identified with echo-doppler of supra-aortic vessels (86%) in CKD patients.(Fig. 2).
The main imaging procedure used to detect renal artery stenosis was color-doppler US
(71,9%). Others imaging procuders were: angio TC (32%), renal scintigraphy (31%),
renal angiography (15%), angio RM (12%).
Conclusions: The present study shows that the IRD is frequently misdiagnosed. More
careful evaluation should be performed among patients with not well defined cause of
CKD and concomitant presence of aterosclerotic lesions on arterial tree. Color-doppler
US is the most useful imaging procedure to identify IRD.
SP193 Figure 1:
iii | Abstracts
SP193 Figure 2:
ADAPTIVE SERVO VENTILATION THERAPY FOR CHRONIC
KIDNEY DISEASE PATIENTS WITH CHRONIC HEART
FAILURE AND SLEEP APNEA SYNDROME
Akihiro Kuma1, Ryota Serino1, Tetsu Miyamoto1, Masahito Tamura1 and Yutaka Otsuji1
1University of Occupational and Environmental Health, Kitakyushu, Japan
Introduction and Aims: Heart failure (HF) complicated by CKD is particularly
difficult to treat. A recent study reported that CKD patients were also more likely to
have sleep apnea syndrome (SAS). Adaptive servo ventilation (ASV) has been indicated
for the treatment of HF with SAS, so here we investigated whether ASV also benefits
CKD patients with HF and SAS.
Methods: This single-center retrospective study was conducted with non-replacement
CKD patients. We selected a subgroup with drug-refractory HF and SAS. ASV group
patients received ASV (≥4 hr/day) for 6 months and control group patients were
received medication for HF treatment, but not ASV. Changes in cardiac and renal
function were assessed using the Wilcoxon signed-rank test and correlations by
Spearman’s rank correlation.
Results: ASV group (n=23) comprised 16 males (mean age, 66.8 ± 12.2 years) and
control group (n=14) comprised 11 males (mean age, 69.1 ± 14.6 years). eGFR
(median) of ASV group was 41.8 ml/min per 1.73m2 before ASV therapy (0 M), 51.5
ml/min per 1.73m2 1 month after ASV therapy (1 M) ( p=0.0071 vs 0 M), and
improved eGFR was maintained for 6 months (6 M; 48.4 ml/min per 1.73m2)
( p=0.5545 vs 1 M). However eGFR of control group was 49.40 (0M), 49.45 (1M)
( p=0.4703 vs 0M), and tended to decrease for 6 months (6M; 42.45) ( p=0.0596 vs 0M).
Left ventricular ejection fraction (LVEF; median) of ASV group was 29.1% (0 M),
38.2% (1 M) ( p=0.0019 vs 0 M), and no further change at 6M (38.5%; p=0.2166 vs 1
M). LVEF of control group was 40.0% (0M), 37.6% (1M) ( p=0.8993 vs 0M), and at 6M
(34.5%; p=0.7741vs 1M). In ASV group, no correlation was observed between baseline
eGFR and the improvement in LVEF (0-6 M) (ρ= 0.1610, p = 0.4856).
Conclusions: Daily ASV therapy improved cardiac and renal function in comorbid
CKD/HF/SAS patients for at least 6 months regardless of initial CKD severity.
ASSOCIATED FACTORS OF SELF CARE BEHAVIOR IN
CHRONIC KIDNEY DISEASE
1Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
Introduction and Aims: Self care behavior, including medical adherence and life
habit, may have an influence on renal function recline. The patients with chronic
kidney disease (CKD) usually have lower awareness of CKD and poor self care
behavior. This study tries to assess associated factors which affect self care behavior in
Methods: The cross-sectional study enrolled CKD stages 1-5 patients from October
2012 to January 2013. Self-care behavior in patients was evaluated using the structured
questionnaire. CKD was staged according to K/DOQI definitions and the estimated
glomerular filtration rate (eGFR) was calculated using the equation of the 4-variable
Modification of Diet in Renal Disease (MDRD) Study. We also collected clinical
characteristics in these patients.
Results: Of 444 CKD patients, the mean age was 63.9±13.1 years. The mean of CKD
duration was 7.5±6.5 years. The mean of total score of self care behavior was 71.6±9.5
in all CKD patients. There was a significant difference of total score of self care
behavior among different stages of CKD (P=0.002). There was also a significant
difference of diet control, regular exercise, medical adherence and blood pressure
measurement among different stages of CKD. Additionally, patients with female, old
age, and high level of education had higher total score of self care behavior.
Conclusions: Our findings show the difference of self-care behavior among different
stages of CKD. Further study is needed to evaluate whether the change of self care
behavior would improve renal function progression in multidisciplinary integrated care
ASSOCIATION BETWEEN THE BLOOD PRESSURE CONTROL
STATUS AND ONE YEAR DECLINE OF RENAL FUNCTION IN
NEWLY VISITED CKD PATIENTS IN JAPAN
Shotaro Naito1, Soichiro Iimori1, Tomokazu Okado1, Tatemitsu Rai1,
Shinichi Uchida1 and Sei Sasaki1
1Tokyo Medical and Dental University, Tokyo, Japan
Introduction and Aims: The appropriate target blood pressure levels for pre-dialysis
CKD patients varies depending on age, race, degree of urinary protein and the presence
of comorbidities such as diabetes, cardiovascular disease. We sought to evaluate the
appropriate target blood pressure levels for Japanese pre-dialysis CKD patients by
analyzing the association between the status of blood pressure control and the decline
of renal function for a one-year observation period.
Methods: We analyzed the data from a cohort of Japanese CKD patients not previously
treated by nephrologists at 16 nephrology centers in Tokyo areas (N=1138). We
prospectively analyzed the occurrence of the renal endpoint, defined as follows: a
decrease in the estimated GFR (eGFR) of ≥30 ml per minute per 1.73 m2 of
body-surface area if the initial eGFR was ≥60 ml per minute per 1.73 m2 at entry, or a
relative decrease in the eGFR of ≥50% if the initial eGFR was <60 ml per minute per
1.73 m2 at entry, or ESRD.
Results: 1) Therapeutic intervention by nephrologists significantly decreased blood
pressure of the participants. In the patients whose blood pressure measurements were
available at one year after enrollment (N=761), blood pressures at baseline and at the
one-year period were 139±21/78±14 mmHg and 131±17/73±12 mmHg, respectively.2)
Compared with at baseline, the rate of the patients treated with anti-hypertensive
agents at the one-year period increased from 78.8% to 84.2%, and the achievement rate
of the target blood pressure as defined in the KDIGO guideline, i.e., 140/90 mmHg for
the patients with urinary protein to creatinine ratio (UPCR) less than 0.15 g/g
creatinine, and 130/80 mmHg for the patients with UPCR more than 0.15 g/g
creatinine, increased from 37.8% to 57.3%. The decline of eGFR during the one-year
observation period was significantly smaller in patients who had achieved target blood
pressure at the baseline than those who had not (-0.42 ml per min per 1.73m2 per year
and -3.00 ml per min per 1.73m2 per year, respectively).3) During one year after
enrollment, 137 patients reached the renal endpoint. By Cox’s proportional hazards
analysis, the patients using diuretics were more likely to reach the renal endpoint
(adjusted hazard ratio 1.50, 95% confidence interval (CI) 1.04-2.15). The patients who
had achieved the target blood pressure at enrollment (adjusted hazard ratio 0.40, 95%
CI 0.24-0.67) were less likely to reach the renal endpoint after adjustment of age, sex,
urinary protein, and diabetes.4) Patients were stratified into 4 groups according to
blood pressure (low: ≤140/90 mmHg or high: >140/90 mmHg) and urinary protein
(low: UPCR <0.15 g/g creatinine or high: UPCR ≥0.15 g/g creatinine) at enrollment,
and the risk of eGFR decline was compared. Compared with the low blood pressure /
low UPCR group, the high blood pressure / high UPCR group was at the highest risk of
eGFR decline (adjusted hazard ratio 15.41, 95% CI 2.11-112.75), and the low blood
pressure / high UPCR group had a moderate risk (adjusted hazard ratio 7.97, 95% CI
1.07-59.11). However, the high blood pressure / low UPCR group was not at a
significantly higher risk of eGFR decline than the low blood pressure / low UPCR
Conclusions: Blood pressure control of newly visited CKD patients was significantly
improved by nephrologist care during one year after enrollment. Although blood
pressure became lower, decline in eGFR was also observed, nonetheless. Urinary
protein excretion was suggested to be a more important factor than blood pressure
control for progression of renal dysfunction.
DETERMINANTS AND BURDEN OF CHRONIC KIDNEY
DISEASE AMONG HIGH-RISK POPULATION IN KOREA:
RESULTS FROM A CROSS-SECTIONAL STUDY
Yong Un Kang1, Ha Yeon Kim1, Joon Seok Choi1, Chang Seong Kim1,
Eun Hui Bae1, Seong Kwon Ma1 and Soo Wan Kim1
1Chonnam National University Hospital, Gwangju, Republic of Korea
Introduction and Aims: The study was performed to investigate prevalence and risk
factors of chronic kidney disease (CKD) among high-risk population in Korea.
Methods: A total of 6042 (mean age, 73.0 ± 5.5 years) residents with age ≥ 65 and
diabetes or hypertension were randomly selected. All were screened for hematuria,
urine albumin-to-creatinine ratio (uACR) and renal function. Hematuria was
confirmed by urine microscopy for RBC > 3/HP. Albuminuria was defined as uACR ≥
30 mg/g or more. CKD was defined as hematuria or albuminuria or an estimated
glomerular filtration rate (eGFR) < 60 mL/min/1.73m2.
Results: Hematuria and albuminuria were detected in 8.8% and 22.6%, respectively,
whereas GFR < 60 mL/min/1.73m2 was found in 27.5% of all studied subjects. Overall
prevalence of CKD was 42.2% (female, 50.5%; male, 28.6%). Prevalences of CKD
according to stage were 2.4% stage 1, 12.2% stage 2, 24.8% stage 3, 2.3% stage 4, and
0.4% stage 5. Multivariate-adjusted analysis indicated that prevalence of CKD increased
in female (odds ratio 2.477, 95% confidence interval 2.200-2.789, P = 0.001). Age,
concomitant diabetes and hypertension, systolic blood pressure, and hemoglobin A1c
were independently associated with presence of CKD.
Conclusions: Prevalence of CKD was very high and strongly more associated with
female compared to man in high-risk population. Other predictors were age,
concomitant diabetes and hypertension, systolic blood pressure, and hemoglobin A1c.
DAY CASE RENAL BIOPSY IS SAFE AND EFFECTIVE
IRRESPECTIVE OF RENAL FUNCTION : RESULTS FROM A
Vasantha Muthu Muthuppalaniappan1, Conor Byrne1, Michael Sheaff1,
Ravindra Rajakariar1 and Mark Blunden1
1The Royal London Hospital, London, United Kingdom
Introduction and Aims: Percutaneous renal biopsy is an extremely useful diagnostic
test in renal disease in both native and transplant kidneys. There has been an increasing
move towards day case biopsy, as a more efficient use of patient and hospital time,
saving 2 inpatient days per biopsy at our centre. Concerns remain about the safety and
efficiency of day case biopsies especially in patients with significantly abnormal renal
function (eGFR <60ml/min).
Methods: Data was collected prospectively on 280 consecutive day-case renal biopsies,
performed in our dedicated short stay facility. All patients were deemed fit for day case
biopsy by virtue of a Hb >8g/dl, platelet count >100 and an INR and APTR <1.2. All
patients had these parameters measured less than a week prior to biopsy. Renal
function as judged by serum creatinine was also measured, patients with a creatinine
>300umol/L received 20 mcg of intravenous desmopressin (DDAVP) prior to biopsy.
Blood pressure pre-procedure was under 160/90 and where possible anti-platelet agents
were stopped one week prior to the biopsy. All biopsies were either supervised or
performed by a consultant nephrologist or renal trainee under ultrasound guidance
using either a Temno needle or biopsy gun of 16G or 18G. Patients were observed for 6
hours post biopsy and discharged if deemed suitable following a review from the Renal
Registrar on call. Biopsies were reviewed in our weekly histopathology MDT for
diagnostic adequacy of sample.
Results: In a one year period (November 2012 - Oct 2013) we performed 280 biopsies
(114 female, 166 male), comprised of 144 transplant renal biopsies and 136 native renal
biopsies. 57 of the transplant renal biopsies were 3 month protocol biopsies while the
remaining 87 were to investigate cause of decline in graft function. There were 206
biopsies performed in patients with eGFR<60ml/min. The amount of patients with an
eGFR of 0-9ml/min, 10-19ml/min, 20-29ml/min, 30-39ml/min, 40-59ml/min and
50-59ml/min, were 1, 28, 38, 64, 48 and 27 respectively. Biopsies were diagnostic in 277
cases (98.9%). Two transplant biopsies and one native biopsy was not diagnostic due to
inadequate sampling. Overall there were 3 minor complications with patients requiring
an overnight admission for transient macroscopic haematuria, with 2 cases being
native kidney and 1 transplant kidney. The 3 patients were haemodinamically stable
with no drop in haemoglobin count throughout their admission. Both the native renal
biopsies had eGFR>60ml/min while the eGFR for the transplant renal biopsy was
33ml/min. One patient had an accidental biopsy of their spleen as well as kidney and
was admitted to another trust four days later with a splenic haematoma.
Conclusions: Day case biopsy is generally a safe and an effective procedure. It provides
diagnostic information in >98% of cases and can be performed as an outpatient even
when significant renal impairment is present as demonstrated by our data. The
cancellation rates for biopsies were less when the procedure was organised as an
outpatient as opposed to organising a bed on the ward for inpatient biopsy. This has
also improved patient satisfaction and experience
TIME TO IMPROVEMENTS WITH ECULIZUMAB IN PATIENTS
WITH ATYPICAL HAEMOLYTIC URAEMIC SYNDROME OF
LONG DURATION AND CHRONIC KIDNEY DISEASE: 3-YEAR
Introduction and Aims: Atypical haemolytic uraemic syndrome (aHUS) is a rare,
genetic, life-threatening disease in which chronic complement activation leads to
systemic thrombotic microangiopathy. In the prospective clinical study, which involved
patients ( pts) with aHUS of long duration and CKD, eculizumab (Ecu) improved
haematologic and renal outcomes by 26 wks, and at 1- and 2-yr updates. These data
have been previously presented. We show here time to sustained improvement in a 3-yr
Methods: Pts aged ≥12 yrs with aHUS and receiving chronic plasma exchange/plasma
infusion (PE/PI) were enrolled into an open-label, single-arm study. After 8 wks of
observation, pts stopped PE/PI and received Ecu (900 mg/wk for 4 wks, 1200 mg at wk
5, 1200 mg q2w thereafter) for 26 wks, with the option of continuing treatment.
Haematologic parameters assessed included: platelet count normalisation ( platelet
count ≥150 x 109/L), and haematologic normalisation ( platelet count ≥150 x 109/L and
LDH ≤ upper limit of normal (ULN); primary endpoint). Renal parameters assessed
included: ≥25% decrease in serum creatinine from baseline (BL), improvement in
eGFR ≥15 mL/min/1.73m2, and chronic kidney disease improvement ≥1 stage.
Results: Twenty pts were enrolled into the main study, with 19 continuing Ecu
treatment in the extension. At BL, median (range) time from onset of current
manifestation to treatment was 8.6 (1.2-45) mo, eGFR was 28 (6-72) mL/min/1.73m2,
90% pts had an eGFR ≤60 mL/min/1.73m2, 17/20 had platelets ≥150 x 109/L, and 16/
20 had LDH≤ULN. At the 3-yr update, pts had a median (range) treatment duration of
156 (26-176) wks, with 16 receiving Ecu for ≥30 mo. Long-term results were consistent
with the prior 2-yr analysis with maintenance or improvements in haematologic and
renal parameters. Fig 1 depicts the fractions of pts who had reached the various
parameters assessed in relation to time on Ecu. Serious adverse events possibly or
probably related to treatment were reported in 3 pts. One death (unrelated to Ecu)
occurred in the extension phase.
Conclusions: The results from this 3-yr update confirm the maintained efficacy of
long-term Ecu treatment reported previously in pts with aHUS. The data also show
that renal parameters improved more slowly than haematologic parameters in this
population with CKD previously managed with PE/PI. These results support the need
for long-term Ecu treatment, but this needs to be confirmed by the long-term
follow-up study currently ongoing.
SP199 Fig 1.: Cumulative percentages of pts achieving a) haematologic parameters and
b) renal parameters.
HOSPITAL ADMISSIONS IN CHRONIC KIDNEY DISEASE AND
COMPARISON TO THOSE WITH NORMAL RENAL FUNCTION
Angharad Marks1, Corri Black1, Laura Clark1, Gordon Prescott1, Lynn Robertson1,
William Simpson1, William Simpson1 and Nicholas Fluck1
1University of Aberdeen & NHS Grampian, Aberdeen, United Kingdom
Introduction and Aims: Chronic kidney disease (CKD) is associated with much
mortality and morbidity. Part of this morbidity may be experienced as an in-patient in
hospital. Admission to hospital is a major health event and has implications for health
services, patients and their carers. The admission burden that might be attributable to
CKD is not clear. We aimed to describe the burden of hospital admissions in the first
and fifth year after a baseline measurement of renal function, categorising patients by
their baseline level of renal function.
Methods: The GLOMMS-II cohort contained all individuals with a low eGFR (<60 ml/
min/1.73m2) measured in the health service region in 2003 (in 1/3 of these the low
eGFR was not present for at least 90 days i.e. not chronic); all those with raised PCR
and ACR; all those receiving RRT; and a 20,000 sample of those with only normal
eGFR measurements in 2003. Data-linkage to hospital episode statistics for the first
and fifth subsequent years for each individual allowed a simple count of the number of
admissions of all those still alive at the beginning of the first and fifth subsequent year
to be made and the percentage with none, 1 to 5 and 6 or more admissions to be
calculated. Those with stage 3-5 CKD (low eGFR for >90 days) and normal renal
function are presented here.
Results: Of the 18687 with stage 3-5 CKD, 18137 were still alive at 1.1.2004 and 13091
at 1.1.2008. For the 19834 with normal renal function in 2003, the equivalent figures
were 19595 and 18334. Overall 66% of those with stage 3 to 5 had no admissions in
both 2004 and 2008, however this varied with level of renal function - only ~43% of
stage 5 and ~69% of stage 3a. This is compared to ~81% of those with a normal
measurement of renal function in 2003.
Conclusions: Those with CKD have a higher number of hospital admissions than
those with normal renal function. Numbers of hospital admissions are higher with
more advanced CKD, and this pattern is sustained over time. For the current time,
CKD prevalence in a region could be used to augment health-care service planning, as
a marker of potential health-care service use. In the future, exploration of reasons for
admission could potentially identify alternative ways of managing these individuals
that may not necessitate hospital admission.
THE EFFECT OF MULTIDISCIPLINARY INTEGRATED CARE
PROGRAM ON CHRONIC KIDNEY DISEASE PROGRESSION
1Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
Introduction and Aims: Chronic kidney disease (CKD) is a public health issue
worldwide. The prevalence and incidence of CKD are gradually increasing. The
medical expenses of maintenance dialysis are the heavy burdens of health insurance in
Taiwan. Whether multidisciplinary integrated care may assist in improving clinical
outcome for CKD patients has not been well-known. This study tried to analyze the
effect of multidisciplinary integrated care program on CKD progression.
Methods: This study used the structured questionnaires to evaluate clinical
characteristics and self-management in CKD patients with and without participating in
multidisciplinary integrated care program (118 and 117 patients, respectively). The
decline in kidney function was assessed by the estimated glomerular filtration rate
(eGFR) slope, defined as the regression coefficient between eGFR and time in units of
ml/min/1.73 m2 per year. Rapid renal progression was defined as the lowest quartile
(the eGFR slope < -3 ml/min/1.73 m2 per year, an integer near the cutoff point between
the lowest two quartiles of the eGFR slope).
Results: The scores of self management questionnaire, including diet control and
regular exercise, were higher in patients receiving multidisciplinary integrated care
program than those without receiving multidisciplinary integrated care program. The
significant difference of eGFR decline was shown between CKD patients with and
without participating in multidisciplinary integrated care program (-0.81 ± 6.38 v.s.
-2.98 ± 8.68 ml/min/1.73m2/ year, P<0.05). The behavior of diet control and weight
control and self care scores were negatively correlated with eGFR decline.
Conclusions: Multidisciplinary integrated care program may help improving self care
and diminishing renal function decline in CKD.
ALCOHOL CONSUMPTION IS INVERSELY ASSOCIATED WITH
STAGE 3 CHRONIC KIDNEY DISEASE IN TAIWANESE MEN
Yueh Han Hsu1,2,3, Hsiang Chu Pai3, Yao Mao Chang4, Wen Hsin Liu2 and Chih Cheng Hsu5,6
iii | Abstracts
1China Medical University, Taichung City, Taiwan, 2Ditmanson Medical Foundation
Chia-Yi Christian Hospital, Chia-yi City, Taiwan, 3Min-Hwei College of Health Care
Management, Tainan City, Taiwan, 4Taipei Medical University, Taipei City, Taiwan,
5National Health Research Institutes, Miaoli County, Taiwan, 6China Medical
University and Hospital, Taichung City, Taiwan
Introduction and Aims: Chronic kidney disease (CKD) is a major global public health
burden, but there is limited understanding of the relationship of alcohol consumption
Methods: In this cross-sectional multivariable study, all participants of a health
check-up program in Ditmanson Medical Foundation Chia-Yi Christian Hospital in
Taiwan from 2003 to 2009 (15 353 women and 11 900 men) were included for analysis.
Estimated glomerular filtration rate was used to define CKD stage and history of
alcohol consumption was obtained by self-reporting. Multivariable logistic regression
analyses of gender-specific association of alcohol drinking with stage 3 CKD were
conducted. A trend tests was conducted to check the dose-response relationship of
alcohol consumption with renal disease. A sensitivity test was conducted to rule out the
likelihood of reverse causality.
Results: The prevalence of stage 3 CKD was lower in drinkers than non-drinkers ( p <
0.001) and the percentage of drinkers with stage 3 CKD was less than that of
non-drinkers. Multivariable analysis indicated that alcohol consumption was
negatively associated with the presence of stage 3 CKD in men (adjusted odds ratio
[aOR] for occasional drinking: 0.68, 95% CI: 0.59~0.78, p < 0.001; aOR for frequent
drinking: 0.47, 95% CI: 0.35~0.63, p < 0.001). Advanced age, hypertension, anemia,
BMI of at least 24, hyperuricemia, and proteinuria were also associated with stage 3
CKD in men. Trend tests indicated lower odds of having stage 3 CKD with increased
alcohol consumption in both genders. Subgroup analyses and sensitivity tests also
indicated the reverse association between alcohol consumption and stage 3 CKD in
men regardless of age, diabetes status, and other risky behaviors.
Conclusions: Alcohol consumption was inversely associated with stage 3 CKD in
Taiwanese men. However, considering the potential of other health damage with
alcohol consumption, the current results should be interpreted cautiously.
PREVALENCE OF RISK FACTORS FOR CHRONIC KIDNEY
DISEASE IN CENTRAL RUSSIA
Mikhail Shvetsov1,2, Sofia Nagaytseva1, Andrey Gerasimov1, Yury Shalyagin3,
Ekaterina Ivanova3 and Eugeniy Shilov1
1I.M. Sechenov First Moscow State Medical University, Moscow, Russian
Federation, 2Lomonosov Moscow State University, Moscow, Russian Federation,
3Moscow Regional Center of Medical Prevention, Moscow, Russian Federation
Introduction and Aims: Although the prevalence of chronic kidney disease (CKD) is
high, screening the general population is not recommended but is indicated for
high-risk persons only. In the last years several tools as the SCORED questionnaire
were developed to prompt health care professionals and laypersons to consider
underlying kidney disease. It was also found that different countries and ethnic groups
can vary by the patterns of CKD risk factors and need different approaches for CKD
evaluation. The aim of our study was to determine the prevalence of CKD risk factors
in an unselected population of Central Russia as a first step for future campaign for
early intervention and prevention.
Methods: During the World Kidney Day activities 1623 subjects (390 men and 1233
women, mean age 46 ± 16 years) applying to Health Centers (a part of medical
prevention system in Russia) in 22 towns of the Moscow Region were studied for CKD
risk factors. We developed questionnaire collecting information about health
complaints, lifestyle, medical and family history. Blood pressure (BP), body mass index
(BMI) and urine albumin concentration (AU) by dipstick test were measured. CKD
was detected if AU was >30 mg/L.
Results: AU>30 mg/L as a marker of CKD was found in 42% of cases and only 10.6%
of respondents had history of proteinuria, 11.2% - history of ultrasound CKD signs.
Prevalence of CKD risk factors in respondents was high: hypertension in 39.7%,
diabetes in 4%, obesity in 30.0%, history of hyperlipidemia in 26.3%, smoking in 37.4%,
analgesic abuse in 30.1%, family history of CKD in 11.2%. CKD was also significantly
associated with elderly age and many health complaints reflecting cardiovascular and
urinary disorders: edema, nocturia, low back pain, urinary incontinence, urinary
retention, chest pain, palpitation, dyspnea, leg muscles pain, loss of appetite, thirst.
Stepwise multiple regression analysis revealed 7 independent factors for CKD risk
SP203 Stepwise multiple regression analysis of CKD risk factors in respondents
History of high cholesterol
History of proteinuria
Family history of CKD
(Table). Interestingly history of hyperlipidemia was included to the final model but not
obesity. Using this regression model we developed CKD probability index.
Conclusions: Our data reflect high prevalence of CKD in Russian population.
Hypertension, diabetes, hyperlipidemia, smoking are the main risk factors which can be
Questionnaire collecting information about health complaints, lifestyle, medical and
family history is a simple and useful tool for estimation of CKD risk so as the need for
laboratory tests and more precise medical examination. If the presence of CKD is
confirmed, the questionnaire data could be helpful for developing of individual lifestyle
correction plan and diet.
PATHOLOGICAL AND CLINICAL ANALYSIS OF EARLY
MYCOBACTERIUM TUBERCULOSIS-RELATED RENAL
Yanning Zhang1 and Wei Zuo2
1Shenyang Jinhua Hospital, Shenyang, China, 2The North Hospital, Shenyang,
Introduction and Aims: To investigate Mycobacterium tuberculosis-related renal
damage and explore diagnostic methods as well as clinical and pathological
Methods: Thirty-three patients treated at the Department of Nephrology for
tuberculosis-related glomerular or interstitial renal disease (active or old tuberculous
lesions combined with pathological tubercles in kidney, positive Mycobacterium
tuberculosis DNA in renal tissues or positive Mycobacterium tuberculosis in urine
culture) were used as the experimental group. The renal tissues of each group were
collected and analyzed for the presence of MTB-DNA (Mycobacterium
tuberculosis-DNA) using PCR. Mycobacterium tuberculosis antigen 85 (MTB-Ag85)
was detected in renal tissues with an immunohistochemical SABC assay. The clinical
and pathological characteristics of the 33 patients were summarized.
Results: 1. According to the standard of positive Mycobacterium tuberculosis in urine
culture, the sensitivity of the MTB-DNA and MTB-Ag85 methods was80%, 85.7%,
respectively, and the specificity of the methods was 100%, 75%, respectively. PCR
detection of MTB-DNA and immunohistochemical SABC labeling of MTB-Ag85 in
renal tissues contributed to the early diagnosis of MTB-related renal damage.
2. Clinical manifestations varied in early MTB infection-related renal damage. There
were many types of pathological changes with high incidences of mesangial
proliferative nephritis and IgA nephropathy.
Conclusions: Our study suggests that attention should be given to tuberculosis
infection-induced allergic syndrome in patients with renal damage and unexplained
fever, joint pain, rash, and fatigue combined with elevated serum γ-globulin, elevated
IgA, and multiple-organ damage. Such patients should be further examined for old or
active tuberculosis lesions outside the kidney. Patients with MTB-DNA (+) in renal
biopsy tissues should be suspected as having pathological renal tuberculosis and should
receive experimental treatment with anti-tuberculosis drugs.
NATURAL HISTORY OF CHRONIC KIDNEY DISEASE WITH
TYPE 2 DIABETES PROGRESSION WITH ALBUMINURIA
Steven Marx1, Shivaji Manthena1 and Jay Newmark1
1Abbvie, North Chicago, IL
Introduction and Aims: The objective of the study is to describe baseline
characteristics of type 2 diabetes (T2D) / chronic kidney disease (CKD) patients with
albuminuria and associated outcomes.
Methods: A retrospective cohort analysis from 01/1989 to 12/2011 was conducted in
60,387 CKD with T2D utilizing GE Health Care database. Included in the analysis, adult
subjects >30 yo with T2D before the index date. T2D is defined by at least one
ICD-9-CM code, and/or at least two prescriptions of an oral anti-diabetic agent before
index date. CKD is defined by two estimating glomerular filtration rate (eGFR) between
25-75 ml/min/1.73m2 utilizing the EPI-CKD equation. The first eGFR between 25-75 is
used as the index date. Subjects were divided into three cohorts: UACR less than 30,
UACR 30-299, and UACR >299. Kaplan Meier curves and cox proportional hazard
regressions adjusted for baseline characteristics of time to: 50% increase in serum
creatinine (50%SC), doubling of serum creatinine (DSC), renal replacement therapy
(RRT), and first change in CKD to Stage 3a, 3b, 4, or 5 were compared.
Results: Overall 49% of the subjects had a UACR level, and the number of subjects with
an UACR increased in progressive years. Subjects with UACR>299 were more likely to be
younger, male, have higher blood pressures, have worse lipid profiles, and receive
angiotensin converting enzyme inhibitor, angiotensin receptor blocker, and diuretics.
Kaplan Meier curves demonstrated faster progression with UACR>299 compared to
UACR 30-299 compared to UACR<30 for 50%SC, DSC, RRT and change in stage. Cox
Proportional hazard models adjusted for baseline variables UACR<30 versus UACR
30-299 50%SC 1.19 p=0.0006, DSC 1.29 p=0.0033, Change in Stage 1.12 p<0.0001, RRT
1.65 p=0.4339; and UACR<30 versus UACR>299 50%SC 2.36 p<0.001, DSC 2.99
p<0.0001, change in stage 1.60 p<0.0001, and RRT 1.28 p=0.7176.
Conclusions: While less than half the subjects had a UACR level, UACR testing increased
from 1998 to 2011. More severe albuminuria was associated with more rapid progression
of CKD stage, 50% increase in serum creatinine, and doubling of serum creatinine.
PREVALENCE OF DIABETES MELLITUS AND ARTERIAL
HYPERTENSION IN ADULTS WITH CHRONIC KIDNEY
DISEASE. RESULTS OF THE NATPOL 2011 SURVEY
Introduction and Aims: Diabetes mellitus (DM) and arterial hypertension (AH) are
diseases leading to and causing progression of chronic kidney disease (CKD). NATPOL
2011 is the first study on prevalence of DM and AH in representative group of adults
with CKD in Poland. The aim of the study was to assess the prevalence of DM and AH
in adults with CKD in Poland.
Methods: The study was conducted on a representative probe of 2413 of adults in
Poland (1245 females - F; 1168 males - M), aged 18 to 79. The response rate was 66,5%.
In each subject a detailed medical history was taken, arterial pressure and
anthropometric parameters were measured, blood and urine samples were taken. The
concentration of serum and urine creatinine were measured with an enzymatic
method, whereas urine albumin concentration was measured with an
immunoturbidimetric method. Urine albumin concentration was measured once in a
morning urine sample. CKD was diagnosed for eGFR (estimated with CKD-EPIcreat
formula) <60 ml/min/1,73 m2 or eGFR ≥60 ml/min/1,73 m2 with coexisting
albuminuria (albumin-to-creatinine ratio ≥30 mg/g). Diagnosis of DM was based on
patient’s declaration and/or if the fasting glucose was ≥126 mg/dl on two separate
measurements. AH was diagnosed when the blood pressure of the two measurements
taken on two separate visits was elevated ≥140/90 mmHg and/or the patient was
receiving hypotensive drug(s).
Results: Prevalence of DM in adults with CKD was 18,5% whereas in population
without CKD 4,5%, p<0,001. After adjustment for age difference between the group
with CKD (mean age 73,0 y.) and without CKD (mean age 53,0 y.), chance of having
DM (OR; logistic regression) in patients with CKD was 1,91 (95% CI: 1,14-3,21).
Prevalence of CKD in population of patients with DM was 20,3%. Prevalence of AH in
adults with CKD was 67,8%, whereas in population without CKD 29%, p<0,001. After
adjustment for age difference between the group with CKD and without CKD, chance
of having AH(OR; logistic regression) in patients with CKD was 1,47 (95% CI: 1,01
2,14). Prevalence of CKD in population of patients with AH was 12,6%.
Conclusions: Prevalence of DM and AH is significantly more frequent in adults with
CKD. CKD is more frequent among adults with DM and AH comparing to population
without these diseases.
NEPHROTOXICITY OF IFOSFAMIDE IN ADULT PATIENTS
Gaël Ensergueix1,2, Alexandre Karras1, Charlène Levi1, Sophie Chauvet1,
Claire Trivin1, Maxence Ficheux3, Jean François Augusto4, Rémi Boudet5,
Tristan Chambaraud2, Pascaline Boudou-Rouquette6, Nicole Tubiana-Mathieu7,
Jean Claude Aldigier2, Christian Jacquot1, Marie Essig2 and Eric Thervet1
1Service de Néphrologie, Hôpital Européen Georges Pompidou (HEGP), Paris,
France, 2Service de Néphrologie, Dialyse et Transplantation Rénale, CHU
Dupuytren, Limoges, France, 3Service de Néphrologie, Dialyse et Transplantation
Rénale, CHU Clémenceau, Caen, France, 4Service de Néphrologie, Dialyse et
Transplantation Rénale, CHU d'Angers, France, 5Service de Néphrologie et
Dialyse, CH de Brive-la-Gaillarde, France, 6Service d'Oncologie, Hôpital Cochin,
Paris, France, 7Service d'Oncologie, CHU Dupuytren, Limoges, France
Introduction and Aims: Ifosfamide (IFO) is an alkylating agents used as an
antineoplasic drug in several types of solid cancers, especially sarcomas. IFO renal
side-effects have previously been described in pediatric populations but not in adult
patients. The aim of this study was to describe the clinical and histological features of
the IFO-associated nephrotoxicity.
Methods: We conducted an observational, retrospective study in 5 nephrology centers.
All adult patients admitted for renal failure (eGFR<60 ml/min/1.73 m2) or tubular
dysfunction after IFO therapy were included.
Results: We have included 9 patients (5 men and 4 women) with a mean age at
diagnosis of 49.1 (18-76). All received IFO for sarcoma treatment between 1975 and
2012. The mean cumulative dose of IFO was 34 905 mg (8 640 to 72 000). Of note, 6
patients also received cisplatin treatment. The renal presentation was an acute kidney
injury (AKI) occurring during the first month following IFO administration (n=3), a
slowly progressive chronic kidney disease (CKD) detected 6 to 24 months after IFO
therapy (n=4) and a proximal tubulopathy consisting in a Fanconi syndrome (n=2).
Renal biopsy was performed in 5 cases, showing by optical microscopy marked
proximal tubular mitochondrial cytopathy in 4 cases, tubule-interstitial inflammation
in 2 and severe tubular atrophy/interstitial fibrosis in 2.
After a mean follow-up of 16 months, 3 patients reached end-stage renal disease
(ESRD). The mean eGFR of the 6 remaining patients is 29 ml/min/1.73m2 at the last
follow-up. One AKI patient requiring initial hemodialysis experienced a progressive
improvement of renal function. Of note, corticosteroids were used in 2 cases without
improvement of the CKD progression.
Conclusions: In adult patients, IFO nephrotoxicity is secondary to tubulo-interstitial
injury, presenting either as AKI immediately following IFO administration, or as CKD
diagnosed several months after discontinuation, with a progression to ESRD despite
symptomatic treatment. Prospective, large-scale studies are needed to determine the
precise incidence, the pathophysiological mechanisms and the risk factors associated
with this severe side-effect.
THE ASSOCIATION OF KIDNEY FUNCTION WITH REPETITIVE
BREATH-HOLD DIVING ACTIVITIES OF HAENYEO, KOREAN
WOMEN UNASSISTED DIVER
Yun Jung Oh1 and Chung Sik Lee1
1Cheju Halla General Hospital, Jeju, Republic of Korea
Introduction and Aims: The effects of repetitive deep breath-hold diving on health
have been reported in previous studies, which include cold water stress, chronic
headache, and various hemodynamic changes such as decreased cardiac output and lung
function. However, renal response to high-pressure environment associated with diving
has not investigated yet. We aimed to examine the association between kidney
function and breath-hold diving activities of Korean women divers, haenyeo who
traditionally harvest marine products controlling breathing without any apparatus in
Methods: A cross-sectional study was performed using the medical records of 2,251
women divers who presented to a hospital for health check-up and the Fourth Korea
National Health and Nutrition Examination Surveys 2008-2009, consisted of 15,744
females aged 20 years or older. We compared the clinical characteristics of women divers
to those of general population.
Results: The mean age of women divers was 67 years and the majorities were in sixties
and seventies (35.4% and 35.3%). The mean estimated GFR (eGFR) of women divers
and general population were 71.3 mL/min/1.73m2 and 91.3 mL/min/1.73m2,
respectively. The prevalence of hypertension (20.3% vs. 28%) and diabetes (5.1% vs.
9.1%) were lower in divers compared to general population, but cardiovascular disease
(CVD) (3.5% vs. 0.8%) was more prevalent in divers. We limited the field of analysis to
subjects aged ≥60 years, because most of women divers included for this analysis were
older than 60years. In subgroup analysis for subjects aged ≥60 years, mean eGFR (69.0
mL/min/1.73m vs. 80.8 mL/min/1.73m2) was lower in diver. The estimated mean value
of eGFR was significantly lower in divers compared to general population, even after
adjustment for multiple covariates (P<0.05). In addition, multivariate analysis showed
higher prevalence of CVD in women divers (OR 3.197, P<0.05).
Conclusions: Kidney function was more decreased in Korean women divers compared
to general population, suggesting that prolonged repetitive breath-hold diving may exert
adverse influence on kidney function.
THE COST EFFECTIVENESS OF A LOW CLEARANCE
Anabela Malho Guedes1, Ana Paula Silva1, Carlos Gonçalves2, Sandra Sampaio1,
Elsa Morgado1, Viriato Santos1, Idalecio Bernardo1 and Pedro Leão Neves1
1Hospital de Faro, Faro, Portugal, 2Fresenius Medical Care, Lisboa, Portugal
Introduction and Aims: The projected growth in spending for the treatment of
end-stage renal failure threatens to become unsustainable for most countries. Different
sources suggest that patients with progressive chronic kidney disease should be
managed in a multidisciplinary care setting. Given that multidisciplinary teams impact
health care resources, it is imperative to evaluate their effectiveness. The purpose of this
study was to evaluate the impact of exposure to conventional nephrology care or low
clearance clinic team (LCC) care prior to dialysis initiation on patient outcomes and
expenditure after dialysis initiation.
Methods: This study considered incident haemodialysis patients attending the LCC vs
receiving standard nephrologist care at our Centre, between 2008 and 2011. Costs were
calculated based on the Portuguese capitation system introduced in 2008.
Results: During the evaluation period, 176 patients initiated dialysis after receiving
more than 3 months of nephrology care, 113 exposed to the LCC and 63 receiving
standard nephrologist care. There were no demographic differences between groups,
receiving an average of 43 months of nephrology care. LCC group started dialysis with
higher eGFR (10.1 vs 8.3 ml/min/1.73m2, p= 0.002), higher albumin (3.8 vs 3.5 g/dl,
p=0.020), lower PTH (549.7 vs 841.1 pg/ml, p=0.008); in this group, a higher
proportion of patients started dialysis with a definitive vascular access (85.8% vs 65.5%,
p=0.002). The biochemical parameters were comparable after 6 and 12 months, but the
costs to achieve the same analytical objective were much lower in the LCC group
(3737.7 vs 5087.3 euros, p= 0.005), and (6336.4 vs 8024.6 euros, p=0.035) after 6 and
12 months, respectively. There were no differences in survival or morbidity between
groups. Older age was associated with greater risk hospitalization ( p=0.032) and death
( p<0.001); a definitive vascular access correlated with lower hospitalization ( p= 0.006)
and a trend to lower risk of death ( p=0.051).
Conclusions: Better biochemical variables and presence of a definitive vascular access
at dialysis initiation in the LCC, resulted in a lower expenditure during the first year of
iii | Abstracts
CKD PREDICTION AND PROGNOSTICATION: AN INEXACT
SCIENCE - A 2008 US POPULATION-WIDE CKD TO ESRD
RATES ANALYSIS AND A 2011 CROSS-SECTIONAL STUDY
OF CKD STAGE TRANSLATIONS IN A MAYO CLINIC
HEALTH SYSTEM LABORATORY DATABASE: THE
CONCEPT OF “PROGRESSORS” AND
Macaulay Onuigbo1 and Nneoma Agbasi2
1Mayo Clinic, Rochester, MN, USA & Mayo Clinic Health System, Eau Claire, WI,
USA, Eau Claire, WI, 2North East London NHS Foundation Trust, United
Kingdom., London, United Kingdom
Introduction and aims: By common consensus, and according to the 2002 NKF
KDOQI guidelines, chronic kidney disease (CKD) is a chronic, progressive disease
presenting with predictable time-dependent loss of GFR, subsequent inexorable
development of ESRD, and need for RRT. This explains why the 2002 NKF guidelines
established CKD stages I, II, III, IV and V. Notwithstanding this notion of a
predictable, linear and time-dependent evolution of CKD to ESRD, there is an
accumulative weight of evidence in the literature to suggest a more unpredictable
course of events regarding CKD to ESRD progression. Furthermore, different CKD
cohort reports demonstrate very different ESRD rates among CKD patients.
Studies methods: A. We compared estimated US CKD population-wide ESRD
incidence based on reported CKD literature statistics to actual USRDS reported ESRD
incidence for 2008.
B. We retrospectively analyzed translational eGFR changes of CKD IV patients in a
Mayo Clinic Laboratory database over two years, April 2009 - April 2011.
A. Projected ESRD rates from CKD in the US in 2008 - 840,000 - versus actual reported
USRDS ESRD in 2008 - 112,476: A whopping 650% overestimation by current CKD
literature estimations (Figure 1).
B. After excluding 62 ESRD patients, and a small number who received RRT for AKI,
of 241 patients with stage IV CKD in the Mayo Clinic Laboratory database, 102M:139F,
over 95% demonstrated stable eGFR within 5 points (<25% baseline), over two years
(Figures 2 & 3).
Current CKD cohort literature statistics overestimate annualized ESRD rates among the
US CKD population (Figure 1). The Mayo Clinic Laboratory database CKD IV review
showed fairly stable eGFR values, over 2 years (Figures 2 & 3). We conclude that we as
nephrologists in particular, and physicians in general, still do not fully understand the
true natural history of CKD. Moreover, from current literature, and again as confirmed
by our database 2-year snapshot analysis, it would appear that some CKD patients
simply remain stable and do not progress (the so-called nonprogressors), whereas
other CKD patients appear more susceptible to progression (the so-called progressors).
In a 2011 Canadian report, Sikaneta et al. reported that CKD staging changed in 40%
of the cohort (including 7.4% in whom CKD stage improved), but remained static in
762 (60.4%) patients. These results warrant further study and investigation of the
natural history of CKD in the general population so as to enable truly evidence-based
efficient yet cost-effective and optimized CKD care around the world.
SP209bis Figure 1: Overstimation of US 2008 ESRD Rates by Current CKD literature