Ideal Timing and Predialysis Nephrology Care Duration for Dialysis Initiation: From Analysis of Japanese Dialysis Initiation Survey

Previous studies have suggested that early initiation of dialysis therapy was not superior in terms of patient survival. In this study, we analyzed the effects of renal function at the start of renal replacement therapy (RRT), duration of nephrology care, and comorbidity on 12‐month survival of end‐stage renal disease (ESRD) patients. The subjects in this study were 9695 new ESRD patients who started RRT in 2007. The average age of the subjects was 67.5 years, 64.1% of the subjects were male, and 42.9% had diabetes. During the 12‐month period after the start of RRT, 1546 patients died, and 35 patients received renal transplantation. Average estimated glomerular filtration rate (eGFR) at the initiation of dialysis was 6.52 ± 4.20 mL/min/1.73 m². By unadjusted logistic analysis, one‐year Odds Ratio (OR) of mortality in patients with eGFR more than 4–6 mL/min/1.73 m² was increased with increased eGFR at dialysis initiation, but the OR was identical among the groups with eGFR less than 4 mL/min/1.73 m². After adjustment for age, gender, underlying renal diseases, and other clinical characteristics at dialysis initiation, OR was identical among the groups with eGFR less than 8 mL/min/1.73 m². Furthermore, an OR increment was observed in eGFR less than 4 mL/min/1.73 m² group. In terms of the duration of nephrology care before dialysis initiation, 6 months or longer of nephrology care significantly decreased the OR of mortality after adjustment of covariance. Not only patients with sufficient residual renal function at the initiation of dialysis, but also patients with very low eGFR at the initiation of dialysis showed poor survival.     

Efficacy of Long‐Term Treatment With Tolvaptan to Prolong the Time Until Dialysis Initiation in Patients With Chronic Kidney Disease and Heart Failure

The short‐term effectiveness of tolvaptan (TLV) against heart failure has been established. TLV is known to decrease the worsening of renal function more than loop diuretics. Long‐term TLV administration decreases the rate of re‐hospitalization in heart failure and prevents deterioration of kidney function. If repeated hospitalization for heart failure can be prevented in patients having concurrent chronic kidney disease (CKD), the period until dialysis initiation may be prolonged. We investigated whether long‐term TLV management can extend the period until dialysis initiation in patients with CKD and heart failure. A retrospective, observational study was conducted among patients with CKD stage G4 and G5 admitted because of heart failure between April 2013 and July 2018. They were divided into those with TLV and those without TLV. They were followed up until August 2018 and relevant data was collected. Data from 115 patients (68 men and 47 women), with a mean age of 73.4 ± 11.9 (median 76.0 and IQR 66.5–82.0) years and a mean eGFR of 11.8 ± 5.7 (median 9.9 and IQR 7.5–14.8) mL/min/1.73m² were included in the analysis. Twenty‐five patients had received long‐term TLV treatment, and 90 had not. Multivariate analysis after adjustment showed that long‐term use of TLV significantly lowered the hazard ratio (HR) for time taken to reach dialysis initiation (HR: 0.3286, 95%CI: 0.1282–0.8423, P = 0.0205). Propensity score‐matched analysis showed similar results (HR: 0.3220, 95%CI: 0.1107–0.9369, P = 0.0376). In patients with CKD G4 and G5 and heart failure, long‐term treatment with TLV can prolong the time until dialysis initiation.     

Long‐Term Effects of Low‐Dose Spironolactone on Chronic Dialysis Patients: A Randomized Placebo‐Controlled Study

The purpose of this 2‐year multicentric, randomized, placebo‐controlled study was to evaluate the long‐term effects and adverse effects of spironolactone on chronic dialysis patients. A total of 253 non–heart failure dialysis patients with end‐stage renal disease were randomly assigned to 2‐year treatment with spironolactone (25 mg once daily, n=125) or a matching placebo (n=128) as add‐on therapy. The primary outcome was a composite of death from cardiocerebrovascular (CCV) events, aborted cardiac arrest, and sudden cardiac death, and the secondary outcome was death from all causes. Other CCV‐related indexes such as left ventricular mass index, left ventricular ejection fraction, heart rate variability, vascular endothelial function, and blood pressure–lowering effect were analyzed for patients who completed the whole 2‐year follow‐up study. Sociodemographic, clinical, and relevant laboratory data were also collected. During the 2‐year follow‐up, the primary outcome occurred less frequently in the spironolactone group vs the control group (7.2% vs 18.0%; adjusted hazard ratio [HR], 0.42; 95% confidence interval [CI], 0.26–0.78). Death from CCV events occurred in 4.0% of patients in the spironolactone group and in 11.7% of patients in the control group. Neither aborted cardiac arrest nor sudden cardiac death was significantly reduced by spironolactone treatment. The secondary outcome occurred less frequently in the spironolactone group vs the control group (9.6% vs 19.5%; adjusted HR, 0.52; 95% CI, 0.29–0.94). Other CCV‐related indexes except for heart rate variability were significantly improved. This study demonstrates that use of low‐dose spironolactone in non–heart failure dialysis patients can effectively reduce the risks of both CCV morbidity and mortality with few side effects. Moreover, the beneficial effect was mediated through improving the endothelial function or reducing left ventricular size independent of blood pressure changes, rather than mediation through changes in salt or potassium handling in the kidney.     

Temporal discrepancies in the association between the apoB/apoA‐I ratio and mortality in incident dialysis patients

Background. In the general population, a high apoB/apoA‐I ratio is a strong risk factor for cardiovascular disease and mortality. However, whether this is the case in chronic kidney disease (CKD) patients is currently unknown. Study design. The apoB/apoA‐I ratio was evaluated in 391 incident CKD stage 5 patients examined close to dialysis initiation, and again after 1 year of dialysis in a subgroup of 182 patients, subsequently followed for up to 3 years. Results. Baseline values of the apoB/apoA‐I ratio as well as changes in the ratio during the first year of dialysis correlated with body mass index (BMI) and fat mass. The baseline apoB/apoA‐I ratio showed no association with 4‐year mortality. However, after adjustment for confounders, a high apoB/apoA‐I ratio (>0.9) predicted short‐term (first year) survival [hazard ratio (HR): 0.35; 95% confidence interval (CI): 0.13–0.85)] and long‐term (next 3 years) mortality (HR: 1.72; 95% CI: 1.01–2.96). An increase in the apoB/apoA‐I ratio during the first year of dialysis was linked to a survival advantage thereafter (HR: 0.48; 95% CI: 0.22–0.98). However, this association lost its significance (HR: 0.62; 95% CI: 0.26–1.36) after adjustment for indices of protein‐energy wasting. Conclusions. A high apoB/apoA‐I ratio and an increase in this ratio during the first year on dialysis were associated with short‐term survival advantage in CKD patients. This paradoxical relationship represents an example of the so‐called reverse epidemiology phenomenon in CKD patients and suggests that the apoB/apoA‐I ratio should always be interpreted with caution in this patient population.     

Surgical and Oncologic Outcomes of Laparoscopic Radical Nephrectomy for Non‐Metastatic Renal Cancer in Long‐Term Dialysis Patients

This study aimed to compare the outcomes of laparoscopic radical nephrectomy (LRN) between patients undergoing dialysis for ≤240 and >240 months. Data from all dialysis patients with non‐metastatic renal cell carcinoma (RCC) treated with LRN between 2008 and 2015 in our hospital were evaluated retrospectively. Patients were divided into two groups, shorter‐ and longer‐term dialysis patients, according to the preoperative duration of dialysis (≤240 vs. >240 months). Of 174 patients, 58 (33.3%) were on longer‐term dialysis. Perioperative minor complications were significantly more frequent in the longer‐term dialysis patients (P = 0.03). There was no significant difference between the two groups in other perioperative outcomes. Patients on longer‐term dialysis more frequently had pathologically advanced RCC (P = 0.009) with poorer prognosis (P = 0.005). LRN for RCC in longer‐term dialysis patients appears to be safe and feasible; however, careful follow‐up is needed because these patients tend to have poorer prognosis.     

High Target Hemoglobin With Erythropoiesis‐Stimulating Agents Has Advantages in the Renal Function of Non‐Dialysis Chronic Kidney Disease Patients

We investigated the long‐term effects of maintaining high hemoglobin (Hb) on renal function in patients with chronic kidney disease not on dialysis. Subjects (Hb < 10 g/dL and serum creatinine (Cr) 2–6 mg/dL) were randomized to either a high Hb group (N = 161, 11.0 ≤ Hb < 13.0 g/dL) receiving darbepoetin alfa or to a low Hb group (N = 160, 9.0 ≤ Hb < 11.0 g/dL) with epoetin alfa, stratified according to baseline Hb and serum Cr levels, comorbidity of diabetes, and study centers. Primary endpoints were composites of the following events: doubling of serum Cr, initiation of dialysis, renal transplantation, or death. Three‐year cumulative renal survival rates (95% CI) were 39.9% (30.7–49.1%) and 32.4% (24.0–40.8%) in the high and low Hb groups, respectively (log‐rank test; P = 0.111). A Cox proportional‐hazards model adjusted by age, sex and the randomization factors showed a significantly lower event rate in the high Hb group (P = 0.035). The estimated hazard ratio (95% CI) for the high versus the low Hb group was 0.71 (0.52–0.98), the risk reduction was 29% in the high Hb group. Incidences of serious adverse cardiovascular events did not differ significantly between the high and low Hb groups (3.1% and 4.4%, respectively). No safety issues were noted in either group. Maintaining higher Hb levels with darbepoetin alfa better preserved renal function in patients with chronic kidney disease not on dialysis.     

Pre‐Dialysis Neutrophil‐Lymphocyte Ratio,a Novel and Strong Short‐Term Predictor of All‐Cause Mortality in Patients With Diabetic Nephropathy: Results From a Single‐Center Study

Neutrophil‐lymphocyte ratio (NLR) is an inflammatory marker affecting the prognosis of end‐stage renal disease (ESRD) patients. This study aimed to evaluate NLR levels predicting all‐cause mortality in ESRD patients with diabetic nephropathy (DN), which have not been evaluated. We recruited 151 isolated DN patients who started hemodialysis between January 2009 and December 2014 at the Japanese Red Cross Ishinomaki Hospital. The primary outcomes were 1‐ and 3‐year survival rates. The association between NLR and survival rate was evaluated using the Kaplan–Meier method and Cox proportional hazard regression analysis. Patients with an NLR ≥ 3.5 had a significantly higher mortality rate than did those with an NLR < 3.5 (log rank P = 0.02). The area under the curve (AUC) of 1‐year survival for NLR was significantly larger than that for other commonly used nutritional and inflammatory variables. NLR was a more accurate predictor than other well‐known markers.     

Favorable Long‐Term Survival in Patients Undergoing Multivessel‐PCI Compared to Predicted Prognosis of CABG Estimated by EuroSCORE: Procedural and Clinical Determinants of Long‐Term Outcome

Aims/Methods: Treatment of patients with multivessel coronary artery disease (CAD) has been an ongoing focus of recent clinical studies, questioning the ideal treatment. Randomized trials comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) have so far only included a minority of screened patients. Therefore, we analyzed data from 679 consecutive “all‐comer” patients, who underwent PCI in at least two main vessels. Expected in‐hospital mortality for CABG was calculated using the EuroSCORE and compared to the observed mortality rate during in‐hospital as well as long‐term follow‐up. Results: The patients were suffering from 2.5 ± 0.6 diseased vessels, and 2.8 ± 1.0 lesions were stented (32% of patients received at least one drug‐eluting stent [DES]; 20% of lesions were treated with DES). Forty‐seven percent of patients were treated for acute coronary syndrome (ACS) ( N = 176 ST‐elevation myocardial infarction [STEMI]; N = 140 non‐ST‐elevation myocardial infarction [NSTEMI]). The EuroSCORE was significantly higher in ACS patients compared to stable patients (logistic: STEMI 16.3 ± 17.2; NSTEMI 13.6 ± 13.0; stable CAD 3.9 ± 4.2). The observed in‐hospital mortality (STEMI 13.0%; NSTEMI 2.9%; stable CAD 1.7%, P < 0.001) was far lower than the estimated 30‐day mortality. Cox regression analysis identified an elevated logistic EuroSCORE (HR per quartile 2.7, P = 0.003), severely reduced left ventricular ejection fraction (HR 2.7, P < 0.001), elevated C‐reactive protein (HR 1.8, P = 0.012), and chronic renal failure (HR 2.8, P = 0.001) as independent predictors of long‐term mortality. Conclusions: The EuroSCORE, which is routinely used to estimate the perioperative risk of patients undergoing CABG, also predicts short‐ and long‐term prognosis of patients undergoing MV‐PCI. The observed mortality of patients undergoing MV‐PCI seems to be much lower than the estimated mortality of CABG.     

Long‐Term Safety and Efficacy of Bixalomer in Hyperphosphatemic Patients With Chronic Kidney Disease Not on Dialysis

Bixalomer, a metal‐free, nonabsorbable phosphate binder, is approved in Japan to treat hyperphosphatemia in dialysis patients. Bixalomer is effective and has a favorable safety profile in predialysis patients with hyperphosphatemia. This study examined the long‐term effectiveness and safety of bixalomer in predialysis patients with hyperphosphatemia. This was a 48‐week, multicenter, open‐label, phase 3 study in Japanese predialysis patients with hyperphosphatemia. Patients received bixalomer at an initial dose of 1500 mg/day, which was titrated to a maximum of 7500 mg/day depending on patients’ serum phosphorus responses to bixalomer. A total of 105 patients received bixalomer treatment, and 39 completed the study. The most common reason for discontinuation was initiation of dialysis. Mean serum phosphorus concentrations decreased from 5.15 mg/dL at baseline to 4.67 mg/dL at Week 12 and then fluctuated slightly around this level until it reached 4.58 mg/dL at Week 48. The proportion of total patients achieving the target serum phosphorus concentration (≥2.5 to <4.6 mg/dL) increased after treatment to a maximum of 66.2% at Week 20 and subsequently decreased to 51.3% by Week 48. Most adverse events (AEs) occurred in the first 12 weeks of treatment. The incidence of AEs did not increase with long‐term treatment. Common AEs reported included nasopharyngitis (29.5%), constipation (19%), and upper respiratory tract inflammation (12.4%). These findings suggest that long‐term treatment with bixalomer is effective, well tolerated, and has no new safety concerns. Bixalomer may be an alternative treatment option for the long‐term management of hyperphosphatemia in patients with chronic kidney diseases.     

Effects of Cardiovascular Events on End‐Stage Renal Disease and Mortality in Patients With Chronic Kidney Disease Before Dialysis

Cardiovascular events (CVEs) are major complications in patients with chronic kidney disease (CKD). However, few studies have investigated the effects of CVEs on end‐stage renal disease (ESRD) and mortality of pre‐dialysis patients. We followed 377 CKD patients who were at stage ≥G3 at first clinic visit in the Shuuwa General Hospital between April 2005 and July 2014. After taking baseline patient data, we evaluated renal survival rates and all‐cause and CVE‐related mortality in patients with CVEs [(+)CVEs] and without CVEs [(?)CVEs]. A total of 99 CVEs occurred in 93 study patients (57.0% cardiac events, 43.0% cerebrovascular events, and 6.5% peripheral artery disease events). During the study period, 127 patients reached ESRD over a median of 4.51 years' follow‐up. Kaplan–Meier analysis found longer renal survival rates in the (?)CVEs group compared with the (+)CVEs group. Forty patients died during the study period over a median of 5.43 years' follow‐up. Survival rates for all‐cause and CVE‐related mortality of (?)CVEs patients were higher than in (+)CVEs patients. After adjustment for sex, age, current smoking, blood pressure, diabetes, estimated glomerular filtration rate, low‐density lipoprotein cholesterol, high‐density lipoprotein cholesterol, left ventricular hypertrophy, body mass index, albumin, hemoglobin, calcium, phosphate, C‐reactive protein, and spot urine protein, the occurrence of CVEs was still a significant risk factor for ESRD (HR 1.516, P = 0.017) and all‐cause mortality (HR 7.871, P < 0.001). Our findings suggest that the occurrence of CVEs is a potent risk factor for ESRD and mortality in CKD patients before dialysis.     

Practical Approach to Evaluate Asymptomatic Coronary Artery Disease in End‐Stage Renal Disease Patients at the Initiation of Dialysis

The high prevalence of significant asymptomatic coronary artery disease (CAD) has been reported in patients with end‐stage renal disease (ESRD) at the initiation of dialysis. However, the approach to evaluate asymptomatic CAD for these patients has not been established. The aim of this study is to assess the applicability of our practical approach at the initiation of dialysis. We prospectively enrolled 182 consecutive ESRD patients who initiated dialysis. After echocardiography as primary screening, pharmacologic stress thallium‐201 scintigraphy and/or coronary angiography (CAG) were performed to diagnose CAD. The patients were classified into two groups: those with coronary artery stenosis by CAG (CAD+ group), those without coronary artery stenosis by CAG or with negative scintigraphy examination (CAD? group). Of the eligible 93 patients without the history of CAD, 22 patients were allocated to the CAD+ group (18 of 26 patients with abnormal echocardiography and 4 of 13 patients with positive scintigraphy examination) and 71 patients to the CAD? group. Patients were followed up for an average of 520 ± 304 days. The event‐free survival rate of major adverse cardiac events was significantly lower in the CAD+ group than in the CAD? group (P < 0.001). There was no cardiovascular event including major adverse cardiac events, unstable angina, coronary revascularization or stroke in the CAD? group during the first year of dialysis. Patients without CAD diagnosed by our approach had favorable clinical outcomes. Our approach may be useful for screening of occult CAD in ESRD patients at the initiation of dialysis.     

Long‐term mortality and renal outcome in a cohort of 100 patients with Lupus Nephritis

Objective

To evaluate the long‐term mortality and renal outcome in a cohort of Danish patients with lupus nephritis (LN) and to identify outcome predictors among findings registered at the time of the first renal biopsy.

Methods

The cohort consisted of 100 patients diagnosed with LN (World Health Organization classes I–VI) between 1971 and 1995 and followed for a median duration of 14.7 years (range 0.01–36.9 years). Standardized mortality ratios (SMRs) were calculated on the basis of national age‐, sex‐, and calendar‐year period–specific death rates.

Results

Thirty‐seven deaths occurred in the cohort, corresponding to an overall SMR of 6.8 (95% confidence interval [95% CI] 4.9–9.4). Excess mortality was observed throughout followup. The SMR estimates were 9.0 (95% CI 4.7–17.1), 6.2 (95% CI 4.0–9.5), and 6.6 (95% CI 3.1–13.8) for patients diagnosed during the calendar‐year periods 1971–1979, 1980–1989, and 1990–1995, respectively. The cumulative renal survival after 5, 10, and 20 years of followup was 87%, 83%, and 73%, respectively. The risk of end‐stage renal disease (ESRD) did not decrease significantly across calendar‐year periods. Systolic blood pressure ≥180 mm Hg, focal segmental nephritis, and advanced sclerosing nephritis were identified as baseline predictors of death in multivariate regression analyses, while systolic blood pressure ≥180 mm Hg, serum creatinine level ≥140 μmoles/liter, and diagnostic delay predicted progression to ESRD.

Conclusion

LN is associated with excess long‐term mortality, and patients may progress to ESRD even after prolonged followup. Our analyses indicate that focal segmental histopathology at disease onset constitutes an important risk factor for death among LN patients. Moreover, our data underscore the importance of early intervention, blood pressure control, and long‐term followup in LN.     

Evaluation of Long‐Term Combination Therapy With Peritoneal Dialysis and Hemodialysis

It is well known that a combination therapy with peritoneal dialysis (PD) and hemodialysis (HD) is feasible and may improve clinical status in patients for whom adequate solute and fluid removal is difficult to achieve with PD alone. The objective of the present study was to evaluate whether the therapy is useful in the likelihood of long‐term peritoneal membrane and cardiac function. The therapy was 6 days of PD and one session of HD per week. Physical, biochemical, dialysate‐to‐plasma ratio of creatinine (D/P Cr), arteriovenous fistula (AVF) blood flow, and left ventricular mass index (LVMI) data were prospectively analyzed in 30 patients with measurements performed at 0 and 6 months, and for 21 patients, 12 or 18 months after initiation of the therapy. The levels of hemoglobin (Hb) after therapy were significantly higher than those at the initiation of therapy. The levels of LVMI and human atrial natriuretic peptide (hANP) after therapy were significantly lower than those at the initiation of therapy, whereas AVF blood flow did not change significantly. D/P Cr levels at 6 months after the therapy were significantly lower than those at the initiation of therapy. D/P Cr levels at 12 or 18 months after the therapy were not aggravated. It appears that the therapy improves Hb levels and cardiac function because of adjusting body fluid status. It was indicated that peritoneal function after therapy may be improved. Therefore, combination therapy is useful from the lifestyle viewpoint of patients in the transition period of PD to HD with end‐stage kidney disease.     

Comparative Survival among Older Adults with Advanced Kidney Disease Managed Conservatively Versus with Dialysis

Background and objectives

Outcomes of older patients with ESRD undergoing RRT or conservative management (CM) are uncertain. Adequate survival data, specifically of older patients, are needed for proper counseling. We compared survival of older renal patients choosing either CM or RRT.

Design, setting, participants, & measurements

A retrospective survival analysis was performed of a single-center cohort in a nonacademic teaching hospital in The Netherlands from 2004 to 2014. Patients with ESRD ages ≥70 years old at the time that they opted for CM or RRT were included. Patients with acute on chronic renal failure needing immediate start of dialysis were excluded.

Results

In total, 107 patients chose CM, and 204 chose RRT. Patients choosing CM were older (mean±SD: 83±4.5 versus 76±4.4 years; P<0.001). The Davies comorbidity scores did not differ significantly between both groups. Median survival of those choosing RRT was higher than those choosing CM from time of modality choice (median; 75th to 25th percentiles: 3.1, 1.5–6.9 versus 1.5, 0.7–3.0 years; log-rank test: P<0.001) and all other starting points (P<0.001 in all patients). However, the survival advantage of patients choosing RRT was no longer observed in patients ages ≥80 years old (median; 75th to 25th percentiles: 2.1, 1.5–3.4 versus 1.4, 0.7–3.0 years; log-rank test: P=0.08). The survival advantage was also substantially reduced in patients ages ≥70 years old with Davies comorbidity scores of ≥3, particularly with cardiovascular comorbidity, although the RRT group maintained its survival advantage at the 5% significance level (median; 75th to 25th percentiles: 1.8, 0.7–4.1 versus 1.0, 0.6–1.4 years; log-rank test: P=0.02).

Conclusions

In this single–center observational study, there was no statistically significant survival advantage among patients ages ≥80 years old choosing RRT over CM. Comorbidity was associated with a lower survival advantage. This provides important information for decision making in older patients with ESRD. CM could be a reasonable alternative to RRT in selected patients.     

Waist Circumference but Not Body Mass Index Predicts Long‐Term Mortality in Elderly Subjects with Chronic Heart Failure

OBJECTIVES: To examine whether waist circumference (WC) and body‐mass index (BMI) can predict long‐term mortality in elderly subjects with and without chronic heart failure (CHF). DESIGN: Longitudinal evaluation with a 12‐year follow‐up. SETTING: Campania, a region of southern Italy. PARTICIPANTS: One thousand three hundred thirty‐two subjects aged 65 and older selected from the electoral rolls of Campania. MEASUREMENTS: The relationship between WC or BMI and mortality during a 12‐year follow‐up in 125 subjects with and 1,143 subjects without CHF. RESULTS: Mortality increased as WC increased in elderly subjects without CHF (from 47.8% to 56.7%, P=.01), and the increase was even greater in patients with CHF (from 58.1% to 82.0%, P=.01). In contrast, mortality decreased as BMI increased in elderly subjects without CHF (from 53.8% to 46.1%, P0 =.046) but not in those with CHF. According to Cox regression analysis, BMI protected against long‐term mortality in the absence but not in the presence of CHF. In the absence of CHF, WC was associated with a 2% increased risk of long‐term mortality for each 1‐cm greater WC (Hazard Ratio (HR)=1.02, 95% confidence interval (CI)=1.01–1.03; P<.001), versus 5% increased in the presence of CHF (HR=1.06, 95% CI=1.02–1.10; P<.001). CONCLUSION: WC, but not BMI, is predictive of long‐term mortality in elderly individuals with CHF and to a lesser extent in those without CHF.     

An 18‐year follow‐up study of a lupus cohort in Shanghai

Aim: To investigate the long‐term prognosis of systemic lupus erythematosus (SLE) and its risk factors. Methods: An 18‐year (1980–1998) clustering follow‐up study of 50 patients with SLE was performed. Results: The overall survival rate at 1, 5, 10, 15 and 18 years after the onset of illness was 98%, 98%, 84%, 76%, and 70%, respectively. The two major causes of death were infection and renal failure. Cox proportional hazard regression analysis showed that the presence of ≥ 7 of the American College of Rheumatology criteria for SLE at diagnosis and vasculitis were associated with worse survival. Thirteen (26%) patients were in remission with complete discontinuation of drugs, with the mean remission duration being 12 years (range: 2–17 years). Conclusion: It is possible for patients with SLE to get long‐term remission through timely and effective treatment. Prevention of infection and renal failure and reducing dosage of corticosteroids by combined treatment with immunosuppressive drugs may enhance prognosis and survival in SLE.     

Ventricular Function in Patients with End‐Stage Renal Disease Starting Dialysis Therapy: A Tissue Doppler Imaging Study

Background: Heart failure is prevalent in end‐stage renal disease (ESRD) patients on long‐term dialysis. Detection of right ventricular (RV) dysfunction before starting dialysis may help to identify patients at a higher risk of developing heart failure. Aim: To assess RV function in predialysis patients using tissue Doppler imaging (TDI) derived myocardial performance index of RV (MPI‐RV). Methods: Echocardiography including pulsed TDI of lateral tricuspid annulus was performed in 41 patients with ESRD before starting dialysis therapy and 12 age and gender matched healthy controls. RV dysfunction was defined as MPI > 0.4; a value above the median MPI in controls. Results: Compared to controls, ESRD patients had significantly higher blood pressure and lower hemoglobin level. MPI‐RV was significantly impaired in ESRD patients compared to control (0.6 vs. 0.4, P < 0.001). RV dysfunction was identified in 23 ESRD patients (56%). ESRD patients had significantly lower e’ velocity and e’/a’ ratio as compared with controls. Pulmonary hypertension was detected in 15 (36.5%) patients. Among ESRD patients, no correlation was detected between MPI‐RV and calculated mean pulmonary artery pressure (r =–0.13, P = 0.47), pulmonary artery systolic pressure (r =–0.12, P = 0.6), left ventricular ejection fraction (r = 0.294, P = 0.06), or MPI of left ventricle (r = 0.3, P = 0.065). ESRD patients with and without pulmonary hypertension had similar MPI‐RV (0.6 vs.0.62, P = 0.32). Conclusion: Subclinical RV dysfunction—as estimated by TDI derived MPI—is highly prevalent among ESRD patients even before starting dialysis therapy. Pulmonary hypertension is not significantly associated with RV dysfunction in these patients.     

Long‐term followup of patients treated with total lymphoid irradiation for lupus nephritis

Objective

To describe the long‐term survival, renal condition, and morbidity outcomes in patients who received total lymphoid irradiation (TLI) for the treatment of lupus nephritis.

Methods

Twenty‐one patients with biopsy‐proven, diffuse membranoproliferative glomerulonephritis and significant proteinuria of >2.5 grams/day received TLI from 1980 to 1987 at Stanford University Medical Center. All patients had previously failed to respond to treatment with high‐dose corticosteroids or therapy with corticosteroids plus immunosuppressive agents (azathioprine, cyclophosphamide, or chlorambucil).

Results

The mean duration of followup since TLI was 10.7 years. Fifteen of 21 patients (71%) remained alive at the time of this assessment. Nine of the 21 patients (43%) survived without developing end‐stage renal disease (ESRD). The probability of long‐term survival without ESRD and without need for additional immunosuppressive agents after TLI was 19% (4 of 21). Factors predicting renal failure at the time of TLI included elevated creatinine levels, increased interstitial fibrosis on renal biopsy, and increased fractional excretion of immunoglobulin and albumin. Malignancies were found in 4 patients, and opportunistic infections occurred in 7 patients.

Conclusion

Overall, patients with lupus nephritis treated with TLI do not appear to have better 10‐year survival with lower incidence of ESRD compared with patients in published series treated with conventional immunosuppressive therapies. However, in this series of patients, treatment with conventional immunosuppressive therapies had been unsuccessful and given the limited number of adverse events and the efficacy seen in some patients, TLI appears to be a reasonable therapeutic option for the treatment of severe lupus nephritis among patients who fail to respond under standard cytotoxic regimens.

     

Double Filtration Plasmapheresis in the Treatment of Antineutrophil Cytoplasmic Autoantibody Associated Vasculitis With Severe Renal Failure: A Preliminary Study of 15 Patients

Our aim was to investigate the clinical efficacy of double filtration plasmapheresis (DFPP) in the treatment of antineutrophil cytoplasmic autoantibody‐(ANCA) associated vasculitis (AAV) with severe renal involvement. Fifteen AAV patients who had severe renal failure (median SCr 5.6(IQR 5.2–9.0) mg/dL) and needed initial renal replacement therapy (RRT) were treated with DFPP and immunosuppressive therapy. Two plasma volumes were processed during each DFPP session. The changes of serum ANCA and renal function were investigated. After the DFPP treatment for three to five sessions, serum MPO‐ANCA level decreased from 250.0 ± 86.9 RU/mL to 70.5 ± 64.7RU/mL (P = 0.00), with a median reduction rate of 67.6%. Eleven patients (73.3%) no longer needed from RRT 3 months after DFPP treatment, while another four patients remained on dialysis. During the follow up for median 10 (IQR 6–24) months, SCr level decreased to normal in one patient, one patient progressed into ESRD. The 1 year renal survival rate was 62.9%. Five (33.3%) patients were complicated with pulmonary infection. DFPP combined with immunosuppressive therapy could increase the renal recovery rate through rapidly decreasing serum ANCA levels for AAV patients with severe renal failure, but its clinical efficacy and impact on long‐term renal survival require further studies.     

Characteristics and Prognosis of Hepatocellular Carcinoma in Japanese Patients Undergoing Dialysis

Patients with end‐stage renal disease who are undergoing dialysis may be at high risk of developing hepatocellular carcinoma (HCC). We investigated the characteristics and prognosis of HCC in patients undergoing dialysis in Japan. Patients characteristics, progression of HCC at diagnosis, and survival rates after diagnosis were compared between 108 HCC patients undergoing dialysis and 526 non‐dialysis patients followed up at liver center. The comparisons were also performed after adjusting for patient age, gender, platelet count, and etiology using propensity‐score matching. HCC was more advanced in patients undergoing dialysis than in non‐dialysis controls. The 3‐ and 5‐year survival rates of patients undergoing dialysis were 56.3% and 38.3%, respectively, which were lower than those of non‐dialysis controls (66.5% and 52.7%, respectively, P = 0.0026). The results were the same after propensity score matching (P = 0.0014). In Japan, HCC was more advanced at diagnosis in patients undergoing dialysis in comparison to HCC in patients at liver centers, resulting in a lower survival rate after diagnosis.