Kidney function predicts the risk of asymptomatic peripheral arterial disease in a Chinese community-based population

Purpose

Lower-extremity peripheral arterial disease (PAD) can predict the risk of subsequent cardiovascular disease (CVD) and all-cause mortality. Chronic kidney disease (CKD) as a precursor of CVD has been proven to be independently associated with PAD. However, few data exist regarding the prediction value of kidney function for incident asymptomatic PAD in community-based populations. We aimed to investigate the predicting value of estimated glomerular filtration rate (eGFR) for incident asymptomatic PAD in a Chinese community-based population. A total of 3549 subjects without PAD and eGFR?>?30 ml/min/1.73 m² were included.

Methods

PAD was defined by an ankle-brachial index (ABI)?≤?0.9. Multivariate regression models were used to evaluate the associations.

Results

Subjects were 56.69?±?8.56 years old and 35.9% were males. After 2.36 years of follow-up, the incidence of asymptomatic PAD was 3.1%. The risk of incident PAD was graded related to the categories of eGFR. Compared to participants with normal kidney function, the multivariate adjusted OR [95% CI] for new PAD was 1.31 (0.81–2.12) for those with mildly decreased kidney function, 4.13 (1.73–9.89) for those with grades 3 CKD (P for trend: 0.014). Baseline eGFR was significantly and linearly associated with incident PAD (OR [95% CI] for each 5 mL/min/1.73 m² decrease of eGFR: 1.23 [1.09–1.38]) in participants with baseline eGFR?<?90 mL/min/1.73 m² but not in those with baseline eGFR?≥?90 mL/min/1.73 m² after adjustment for covariates.

Conclusion

Kidney function was an independent risk factor for development of incident PAD in community-based population with baseline eGFR?≤?90 mL/min/1.73 m².

     

Estimated Glomerular Filtration Rate as a Risk Stratification Tool for Early Complications in Revision Total Hip and Knee Arthroplasty

BackgroundEstablishing an association between postoperative outcomes and the spectrum of renal function would allow for more informed decisions to manage surgical risks and improved patient-specific care. Estimated glomerular filtration rate (eGFR) can be calculated from standard prescreening measurements to gauge renal function. This work investigates the effect of eGFR, as a continuous and categorical variable, on mortality and major and minor complications in patients undergoing revision total knee and hip arthroplasty.Methods25,056 patients having undergone revision total hip and knee arthroplasty from 2013 to 2016 were identified using the National Quality Improvement Program database. The investigated outcomes included 30-day mortality, major complications, and minor complications. Multivariate regression models were created to evaluate the effect of eGFR on the outcomes of interest. Multivariate spline regressions were generated to assess for nonlinear relationships between eGFR as a continuous variable and the outcomes.ResultsOur study revealed that as eGFR decreased <60 mL/min/1.73 m², mortality (P = .0001), any major complication (P < .001), and any minor complication (P < .001) increased. Patients with eGFR 15-30 mL/min/1.73 m² had increased risk for mortality (P = .033). There was an increased risk for any major complication at an eGFR 30-60 and <15 mL/min/1.73 m², (P < .05). There was an increased risk of minor complications for those with hyperfiltration and <60 mL/min/1.73 m².ConclusionPatients with lower preoperative eGFR generally display an increased risk for complications after revision total hip and knee arthroplasty. Proper consideration should be given to this patient population before surgical intervention to allow for preventative measures to be taken to improve patient outcomes.     

The prognostic value of platelet-to-lymphocyte ratio on the long-term renal survival in patients with IgA nephropathy

Purpose

Platelet-to-lymphocyte ratio (PLR) was established showing the poor prognosis in several diseases, such as malignancies and cardiovascular diseases. But limited study has been conducted about the prognostic value of PLR on the long-term renal survival of patients with Immunoglobulin A nephropathy (IgAN).

Methods

We performed an observational cohort study enrolling patients with biopsy-proven IgAN recorded from November 2011 to March 2016. The definition of composite endpoint was eGFR decrease by 50%, eGFR?<?15 mL/min/1.73 m², initiation of dialysis, or renal transplantation. Patients were categorized by the magnitude of PLR tertiles into three groups. The Kaplan–Meier curves and multivariate Cox models were performed to determine the association of PLR with the renal survival of IgAN patients.

Results

330 patients with a median age of 34.0 years were followed for a median of 47.4 months, and 27 patients (8.2%) had reached the composite endpoints. There were no differences among the three groups (PLR?<?106, 106?≤?PLR?≤?137, and PLR?>?137) in demographic characteristics, mean arterial pressure (MAP), proteinuria, and estimated glomerular filtration rate (eGFR) at baseline. The Kaplan–Meier curves showed that the PLR?>?137 group was significantly more likely to poor renal outcomes than the other two groups. Using univariate and multivariate cox regression analyses, we found that PLR?>?137 was an independent prognostic factor for poor renal survival in patients with IgAN. Subgroup analysis revealed that the PLR remained the prognostic value for female patients or patients with eGFR less than 60 mL/min/1.73 m².

Conclusions

Our results underscored that baseline PLR was an independent prognostic factor for poor renal survival in patients with IgAN, especially for female patients or those patients with baseline eGFR less than 60 mL/min/1.73 m².

     

Baseline living‐donor kidney volume and function associate with 1‐year post‐nephrectomy kidney function

Living donors may develop kidney dysfunction more often than equally healthy populations. The purpose of this study was to determine whether computed tomography‐assessed remaining kidney volume indexed to body surface area (RKV/BSA) was associated with 1‐year post‐nephrectomy renal function independent of baseline renal function. Using multivariable regression, we modeled 1‐year estimated glomerular filtration rate (eGFR) and eGFR <60 mL /min/1.73 m² and considered pre‐determined baseline eGFR subgroups in 151 consecutive donors. Mean ± SD baseline age, eGFR, RKV, BSA, and RKV/BSA were 38 ± 11 years, 97 ± 16 mL/min/1.73 m², 153 ± 29 mL, 1.9 ± 0.2 m², and 80.0 ± 12.8 ml/m², respectively; 50% were female and 94% were white. Mean baseline eGFR was greater with increasing RKV/BSA tertiles (92 ± 14, 97 ± 16, 107 ± 16 mL/min/1.73 m²; P < 0.001). Post‐nephrectomy eGFR remained separated by RKV/BSA tertiles. At baseline, each SD greater RKV/BSA and eGFR was independently associated with higher adjusted 1‐year eGFR by 2.4 and 9.2 mL/min/1.73 m². Each SD greater age associated with 2.2 mL/min/1.73 m² lower adjusted 1‐year eGFR. Adjusted odds of 1‐year eGFR <60 increased significantly for donors with RKV/BSA <80 mL/m². With baseline eGFR <90, probability of 1‐year eGFR <60 increased to >80% with decreasing RKV/BSA values below 80 mL/m². Those with baseline eGFR >100 rarely developed 1‐year eGFR <60 if RKV/BSA remained >60 mL/m². RKV/BSA independently associated with 1‐year eGFR <60, especially with lower baseline eGFRs. Additional studies should evaluate the predictive utility of this measure and its potential role in donor evaluations and informed consent.     

Simultaneous Intestinal and Kidney Transplantation in Adults

Aim of the study: Intestinal transplantation (IT) is a life-saving procedure for carefully selected patients with intestinal failure. We evaluated patients who had undergone simultaneous intestinal and kidney transplantation (SIKT) to determine whether UK guidelines for inclusion of a renal allograft (dialysis dependent or estimated glomerular filtration rate ((eGFR)) < 45 ml/min/1.73 m²) are justified. Methods: A single centre analysis was undertaken of adults undergoing IT at the Cambridge Transplant Centre between December 2007 and January 2016. A prospectively maintained database was used to identify SIKT recipients and determine outcomes. Results: Over this period, 63 intestinal transplants were performed. Seven (11.1%) recipients received a SIKT. Five were pre-dialysis (median eGFR 29 ml/min/1.73 m², range 16–36 ml/min/1.73 m²). One recipient was on dialysis, and one needed bilateral nephrectomy at transplant. There were no primary kidney allograft failures and at three months, the median eGFR (55 ml/min/1.73 m² range 39–124) was similar to recipients of IT alone (median eGFR 56 ml/min/1.73 m² range 17–143 ml/min/1.73 m²). Two recipients required dialysis due to sepsis related kidney injury and died from multi-organ failure (20 and 63 months). Two died with a functioning renal transplant (10 and 15 months). The remaining three patients are alive at follow up (12–96 months) with an eGFR of 20–45 ml/min/1.73 m². Conclusion: Patients with significant renal impairment (eGFR <45 ml/min/1.73 m²), and receiving dialysis may benefit from SIKT. Patient survival and renal function are broadly comparable to those undergoing IT alone. Further studies are required to justify allocation of a kidney to this complex high risk group.     

Higher hemoglobin levels using darbepoetin alfa and kidney outcomes in advanced chronic kidney disease without diabetes: a prespecified secondary analysis of the PREDICT trial

Background

In the primary analysis of the PREDICT trial, a higher hemoglobin target (11–13 g/dl) with darbepoetin alfa did not improve renal outcomes compared with a lower hemoglobin target (9–11 g/dl) in advanced chronic kidney disease (CKD) without diabetes. Prespecified secondary analyses were performed to further study the effects of targeting higher hemoglobin levels on renal outcomes.

Methods

Patients with an estimated glomerular filtration rate (eGFR) 8–20 ml/min/1.73 m² without diabetes were randomly assigned 1:1 to the high- and low-hemoglobin groups. The differences between the groups were evaluated for the following endpoints and cohort sets: eGFR and proteinuria slopes, assessed using a mixed-effects model in the full analysis set and the per-protocol set that excluded patients with off-target hemoglobin levels; the primary endpoint of composite renal outcome, evaluated in the per-protocol set using the Cox model.

Results

In the full analysis set (high hemoglobin, n = 239; low hemoglobin, n = 240), eGFR and proteinuria slopes were not significantly different between the groups. In the per-protocol set (high hemoglobin, n = 136; low hemoglobin, n = 171), the high-hemoglobin group was associated with reduced composite renal outcome (adjusted hazard ratio: 0.64; 95% confidence interval: 0.43–0.96) and an improved eGFR slope (coefficient: + 1.00 ml/min/1.73 m²/year; 95% confidence interval: 0.38–1.63), while the proteinuria slope did not differ between the groups.

Conclusions

In the per-protocol set, the high-hemoglobin group demonstrated better kidney outcomes than the low-hemoglobin group, suggesting a potential benefit of maintaining higher hemoglobin levels in patients with advanced CKD without diabetes.

Clinical trial registration

Clinicaltrials.gov (identifier: NCT01581073).

     

Long‐term evolution,secular trends,and risk factors of renal dysfunction following cardiac transplantation

Recent reports suggest that individuals who underwent heart transplantation in the last decade have improved post‐transplant kidney function. The objectives of this retrospective study were to describe the incidence and to identify fixed and time‐dependent predictors of renal dysfunction in cardiac recipients transplanted over a 25‐year period (1983–2008). To illustrate temporal trends, patients (n = 306) were divided into five groups based on year of transplantation. The primary endpoint was the estimated glomerular filtration rate (eGFR) at year 1. Secondary endpoints were time to moderate (eGFR <60 ml/min/1.73 m²) and severe renal dysfunction (eGFR <30 ml/min/1.73 m²). Risk factor analyses relied on multivariable regression models. Kidney function was mildly impaired before transplant (median eGFR=61.0 ml/min/1.73 m²), improved at discharge (eGFR=72.3 ml/min/1.73 m²; P < 0.001), decreased considerably in the first year (eGFR = 54.7 ml/min/1.73 m²; P < 0.001), and deteriorated less rapidly thereafter. At year 1, 2004–2008 recipients exhibited a higher eGFR compared with all other patients (P < 0.001). Factors independently associated with eGFR at year 1 and with moderate and severe renal dysfunction included age, gender, pretransplant eGFR, blood pressure, glycemia, and use of prednisone (P < 0.05). In summary, kidney function worsens constantly up to two decades after cardiac transplantation, with the greatest decline occurring in the first year. Corticosteroid minimization and treatment of modifiable risk factors (hypertension, diabetes) may minimize renal deterioration.     

Pre‐ and postdonation kidney function in donors of a kidney paired donation with unique criteria for donor glomerular filtration rate – a longitudinal cohort analysis

Baseline predonation estimated GFR (eGFR) appears to predict the risk of postdonation chronic kidney disease in live donors. New KIDGO guidelines recommend an eGFR ≥90 ml/min/1.73 m² as an acceptable level of glomerular filtration rate (GFR) for kidney donation. In the Australian Paired Kidney Exchange (AKX) program, all donors with a raw measured GFR (mGFR) ≥80 ml/min are deemed suitable for donation, but the significance of this selection indicator is unclear. We analysed the first 129 live donors in the AKX program with at least 1‐year follow‐up linking records in the AKX database and ANZDATA. There were 73 male and 56 female donors; mean (±SD) age was 53 ± 11 years. Predonation eGFR was 94 ± 13 ml/min/1.73 m², mGFR 99 ± 17 ml/min/1.73 m² and raw mGFR 108 ± 18 ml/min. Baseline eGFR was <80 ml/min/1.73 m² in 19 donors, and <90 ml/min/1.73 m² in 42 donors. At 1 year postdonation eGFR was 68 ± 15 ml/min/1.73 m² and the predicted eGFR at 30 years postdonation was on average 50 (29–83) ml/min/1.73 m². The hypothetical mean age at end‐stage kidney disease was estimated to be 145 (95% CI 120–263) years. Over 30% of AKX live donors would have been excluded from donation using KDIGO guidelines. Using AKX donor guidelines, the majority of donors with predicted eGFR <30 ml/min/1.73 m² 30‐year postdonation were aged ≥50 years. Long‐term outcome data on AKX donors with low eGFR will need careful monitoring.     

Effects of Estimated Glomerular Filtration Rate on 30-Day Mortality and Postoperative Complications After Total Hip Arthroplasty: A Risk Stratification Instrument

BackgroundChronic kidney disease (CKD) is a relatively common comorbidity that has been shown to adversely affect outcomes in total hip arthroplasty (THA), as well as to increase the procedure's total costs. However, the effect of different stages of kidney disease and the association of estimated glomerular filtration rate (eGFR) with perioperative THA complications are less understood. Therefore, the aims of this study were to investigate the relationships between eGFR, both as a categorical and continuous variable and 30-day outcomes and complications.MethodsThe National Surgical Quality Improvement Program database was used to identify 101,925 primary THAs between January 1, 2008, and December 31, 2016. The following outcomes were assessed: 30-day mortality, 30-day major complications, 30-day minor complications, specific complications, and discharge disposition. To evaluate the effect of eGFR status on outcomes and complication, multivariate regression models were created to adjust for differences in patient demographics and comorbidities. In addition, multivariate spline regressions were developed to assess the nonlinear relationships between eGFR as a continuous variable and the outcomes of interest.ResultsOur study revealed that as eGFR decreases to <30 mL/min/1.73 m², there is an increased risk for mortality and nonhome discharge (P < .05). There was an increased risk for any major complication and any minor complication as well as several specific medical complications such as transfusion and myocardial infarction (P < .05) for an eGFR of <60 mL/min/1.73 m². Patients' eGFR had a nonlinear relationship with mortality (P = .0001), any major complication (P < .001), and any minor complication (P < .001), as well as a number of other specific medical complications. Once the eGFR, <60 mL/min/1.73 m² the increase was exponential for mortality, major complications, and minor complications. For example, mortality increased of 900% for <15 mL/min/1.73 m² or on dialysis, 600% for 15 to 30 mL/min/1.73 m² and 50% for 30 to 60 mL/min/1.73 m². Similarly, nonlinear relationships were discovered between eGFR and nonhome discharge (P < .001).ConclusionPatients with lower eGFR, and in particular those with <30 mL/min/1.73 m², are more likely to sustain medical complications and have 6 to 9 times higher mortality than patients with normal eGFR. THA patients with CKD should be appropriately counseled and advised on the risk of postoperative complications by using eGFR as a screening tool.     

Antithymocyte treatment of steroid-resistant acute rejection in renal transplantation

To evaluate the outcome of early (ER <3 months) and late (LR >3 months) episodes of corticosteroid resistant acute allograft rejection (CRR) treated with anti-thymocyte globulin (ATG) in pediatric renal allograft recipients. Retrospective study of 15 children, mean age 13.2y, who received ATG for the treatment of biopsy proven CRR over a 15 year period. Seven children received ATG for ER (median 26 days post transplantation) and 8 for LR (median 763 days). There was a significant improvement in the 3 month eGFR (70.3 ml/min/1.73m², SD 22.3, p = 0.018) when compared with the value prior to ATG treatment (23.3 ml/min/1.73m², SD 10.2) in the ER group. In the LR group (4 DSA positive) there was no improvement in the eGFR at 3 months (42 ml/min/1.73m², SD 10.5, p = 0.32) when compared with the value prior to ATG (38 ml/min/1.73m², SD 9.7). At final review, eGFR in the ER group was 72.3 ml/min/1.73m² (SD 33) vs. 37.7 ml/min/1.73m² (SD 17.9) in the LR group after a mean follow up of 10.4y and 1.2y, respectively. ATG therapy in CRR is associated with reversal of rejection and excellent graft outcome in children with ER. The benefits remain uncertain in LR, the etiology of which is multifactorial.     

A Higher Glomerular Filtration Rate Predicts Low Risk of Developing Chronic Kidney Disease in Living Kidney Donors

Background

The risk of developing chronic kidney disease (CKD) among living kidney donors (LKDs) is seldom included in evaluations of patients’ outcomes. Potential risk factors and new criteria for estimating the glomerular filtration rate (eGFR) indexed for body surface area (BSA) were investigated with a view to prevent the development of CKD in LKDs.

Methods

We conducted a retrospective study of LKDs from May 1983 to March 2011. The Mann–Whitney U test and χ² test were used to analyze the male versus female groups. Survival analysis was plotted as CKD-free survival and analyzed separately by different eGFR index classifications. The Cox regression model was used to identify potential risk factors for development of CKD.

Results

A total of 105 LKDs with a mean age of 46.3 ± 12.5 years had a mean eGFR indexed for BSA of 88.9 ± 21.5 ml/min per 1.73 m². After a mean duration of 5.4 ± 4.9 years’ follow-up, eGFR dropped to 61.4 ± 16.4 ml/min per 1.73 m² (p = 0.002). Median CKD-free survival was only 5.7 years. The difference between eGFR ≥ 80 ml/min per 1.73 m² and <80 ml/min per 1.73 m² was not statistically significant (p = 0.980). Multivariate Cox regression analysis showed that higher eGFR at donation (HR = 0.952, p = 0.0199) could be a protective factor. The receiver operating characteristic (ROC) curve for initial eGFR with best sensitivity of 52.78 % and specificity of 81.40 % was obtained with a cutoff value of 90.2 ml/min per 1.73 m² for preoperative eGFR. An eGFR of 90 ml/min per 1.73 m² yielded a significant survival curve (p = 0.0199) after 21 years of follow-up. Further classifications of eGFR >90 ml/min per 1.73 m² into 90–99 ml/min per 1.73 m², 100–109 ml/min per 1.73 m², and ≥110 ml/min per 1.73 m² were examined, but this survival curve was not statistically significant (p = 0.1247).

Conclusions

Living kidney donors will develop CKD after a long duration of follow-up if there is insufficiently high eGFR at donation. An eGFR above 90 ml/min per 1.73 m² before donation is the only factor that predicts prevention of CKD. Larger studies with longer duration of follow-up are necessary to clarify the clinical outcome of this postoperative CKD group, especially for patients with eGFR between 80 and 90 ml/min per 1.73 m².     

Total cholesterol to high-density lipoprotein cholesterol ratio is independently associated with CKD progression

Purpose

Although dyslipidemia can cause kidney damage, whether it independently contributes to the progression of chronic kidney disease (CKD) remains controversial. The research aims to evaluate the predictive value of serum lipids and their ratios in the progression of CKD.

Methods

The retrospective, case–control study included 380 adult subjects with CKD stage 3–4 (G3-4) at baseline. The end point of follow-up was the progression of CKD, defined as a composite of renal function rapid decline [an annual estimated glomerular filtration rate (eGFR) decline?>?5 mL/min/1.73 m²] or the new-onset end-stage renal disease (ESRD) [eGFR?<?15 mL/min/1.73 m²]. Logistic regression analysis was performed to examine the association between CKD progression and lipid parameters. Receiver operating characteristic (ROC) curve analysis was used to evaluate the predictive power of lipid parameters in the progression of CKD.

Results

Over a median follow-up of 3.0 years, 96 participants (25.3%) developed CKD progression. In multivariable logistic regression analysis, logarithm-transformed urinary albumin-to-creatinine ratio (log ACR) [odds ratio (OR) 1.834;95% confidence interval (CI) 1.253–2.685; P?=?0.002] and total cholesterol to high-density lipoprotein cholesterol ratio (TC/HDL-C) [OR 1.345; 95% CI 1.079–1.677; P?=?0.008] were independently associated with CKD progression. The ROC curve showed the combined predictor of ACR and TC/HDL-C ratio was acceptable for CKD progression diagnosis (area under the ROC curve [AUC]?=?0.716, sensitivity 50.0%, specificity 84.2%), and the cut-off value was ? 0.98.

Conclusions

The combination of TC/HDL-C ratio and ACR had predictive value in the progression of CKD, and may help identify the high-risk population with CKD.

     

Chronic Kidney Disease Increases the Risk of Hip Fracture: A Prospective Cohort Study in Korean Adults

This study was conducted to examine the association between renal function and hip fracture. We followed up 352,624 Korean adults, who participated in health examinations during 2009–2010 until 2013. Kidney function was assessed by creatinine-based estimated glomerular filtration rate (eGFR) and albuminuria using urine reagent strip results. The incidence of hip fracture was examined by hospital discharge records. Hazard ratios (HRs) for hip fracture were calculated using Cox proportional hazard models after adjusting for multiple confounders. During a mean follow-up of 4.0 years, 1177 participants suffered a hip fracture. Lower eGFR and more severe albuminuria were associated with a higher risk of hip fracture. The HRs for hip fracture were 1.89 (95% confidence interval [CI] 1.47–2.43) and 3.75 (95% CI 2.30–6.11) among participants with eGFRs of 30 to 44 and 15 to 29 mL/min/1.73m² relative to those with an eGFR ≥60 mL/min/1.73m², respectively. The HRs were 1.30 (95% CI 1.02–1.65) for moderate albuminuria and 1.58 (95% CI 1.07–2.35) for severe albuminuria (p for trend = 0.002). Participants with albuminuria had a higher risk of hip fracture than those without albuminuria, even when they belonged to the same eGFR category (HR = 1.75 versus 3.30 for an eGFR of 30 to 44 mL/min/1.73m²; HR = 2.72 versus 7.84 for an eGFR of 15 to 29 mL/min/1.73m²). The effects of each 10 mL/min/1.73m² decrease in eGFR were stronger with advancing albuminuria severity (p_interaction = 0.016). In conclusion, both low eGFR and albuminuria were risk factors for incident hip fracture in Korean adults. Moreover, these factors exerted a synergistic effect on the risk of hip fracture. © 2020 American Society for Bone and Mineral Research.     

Effect of estimated glomerular filtration rate on periprocedural myocardial infarction in patients undergoing elective percutaneous coronary intervention

Abstract

Backgrounds: Little is known about the effect of the estimated glomerular filtration rate (eGFR) on the periprocedural myocardial infarction (PMI). The aim of this study was to determine an eGFR value that is related with PMI development in patients with stable angina undergoing elective percutaneous coronary intervention (PCI). Method: A retrospective analysis was conducted of 257 consecutive PCI patients with stable angina pectoris. The patients were divided into three groups according to eGFR: Group 1: eGFR?>?90?mL/min/1.73?m², Group 2: eGFR?=?60–89?mL/min/1.73?m², and Group 3: eGFR?=?30–59?mL/min/1.73?m². Cardiac biomarkers were measured before, at 8, and at 24?h after the procedure. Results: Periprocedural myocardial infarction occurred in 19% of the study patients. The frequency of PMI was 13.8% in group 1, 15.2% in group 2, and 35% in group 3 (p?=?0.002). There was an inverse relationship with increasing cardiac biomarkers and decreasing eGFR values. Multiple regression analysis showed that an eGFR value between 30 and 59?mL/min/1.73?m² was an independent variable that significantly affected PMI development after PCI. Conclusions: An estimated glomerular filtration rate between 30 and 59?mL/min/1.73?m² is a predictor of developing PMI after elective PCI in patients with stable angina pectoris.     

Evaluation of a predictive model of end-stage kidney disease in a French-based cohort

Background

The risk of ESKD is highly heterogeneous among renal diseases, and risk scores were developed to account for multiple progression factors. Kidney failure risk equation (KFRE) is the most widely accepted, although external validation is scarce. The objective of this study was to evaluate the usefulness of this score in a French case–control cohort and test the pertinence of the proposed thresholds.

Methods

A retrospective case–control study comparing a group of patients starting renal replacement therapy (RRT) to a group of patients with CKD stages 3–5. Multivariate analysis to assess the predictors of ESKD risk. Discrimination of 4-, 6- and 8-variable scores using ROC curves and compared with eGFR alone and albumin/creatinine ratio (ACR) alone.

Results

314 patients with a ratio of 1 case for 1 control. In multivariate analysis, increasing age and higher eGFR were associated with a lower risk of ESKD (OR 0.62, 95% CI 0.48–0.79; and OR 0.72, 95% CI 0.59–0.86, respectively). The log-transformed ACR was associated with a higher risk of ESKD (OR 1.25 per log unit, 95% CI 1.02–1.55). The 4-variable score was significantly higher in the RRT group than in the CKD-ND group, and was more efficient than the eGFR (AUROC 0.66, 95% CI 0.60–0.72, p?=?0.018) and the log-transformed ACR (AUROC 0.63 95% CI 0.60–0.72, p?=?0.0087) to predict ESKD. The 6-variable score including BP metrics and diabetes was not more discriminant as the 4-variable score. The 8-variable score had similar performance compared with the 4-score (AUROC 8-variable score: 0.70, 95% CI 0.64–0.76, p?=?0.526). A 40% and 20% score thresholds were not superior to eGFR?<?15 and 20 mL/min/1.73 m², respectively. A 10% threshold was more specific than an eGFR?<?30 mL/min/1.73 m².

Conclusion

KFRE was highly discriminant between patients progressing to ESKD vs those non-progressing. The 4-variable score may help stratify renal risk and referral in the numerous patients with stage 3 CKD. Conversely, the proposed thresholds for creating vascular access or preemptive transplantation were not superior to eGFR alone.

     

The correlation between preoperative renal scintigraphy and postoperative renal function in upper urinary tract urothelial carcinoma patients following radical nephroureterectomy

ObjectiveTo predict the renal function after nephroureterectomy (NUR) for upper urinary tract urothelial cancer (UTUC) based on preoperative technetium-99m mercaptoacetyltriglycine (99mTc-MAG3) renal scintigraphy.Subjects and methodsWe retrospectively reviewed 238 patients who originally underwent nephroureterectomy for UTUC between 2007 and 2010. Of these patients, 129 underwent MAG3 renal scintigraphy before unilateral NUR. Serum creatinine was measured in all of the patients before surgery, and renal function was monitored for one year after surgery. Preoperative and postoperative eGFRs were compared and analyzed based on the preoperative MAG3 renal scintigraphy.ResultsA total of 129 patients, including 62 men (48%) and 67 women (52%) with an average age at surgery of 69.0 years (range from 48 to 87) were included in this study. The mean preoperative creatinine level was 1.42 mg/dL, and the baseline eGFR was 54.76 ml/min/1.73 m². One year after NUR, the mean creatinine level was 1.89 mg/dL, and the eGFR was 44.44 ml/min/1.73 m², a mean decrease of 18.73%. The preoperative effective renal plasma flow (ERPF) of the operated kidney was 91.65 ml/min/1.73 m², and that of the remaining kidney 158.30 ml/ min/1.73 m². The average preoperative ERPF of the resected kidney accounted for 34% of total preoperative ERPF, which was statistically significant in its relation to the decrease in eGFR. The decrease in eGFR ratio was also significantly correlated with the calculated decrease in ERPF ratio (R² = 0.279, p < 0.001). The predictive equation of renal function one year after NUR was established as following: eGFR decreased ratio = –0.80 × predictive ERPF decreased ratio +0.72.ConclusionWe developed an equation to predict postnephroureterectomy 1 year eGFR before surgery based on preoperative MAG3 renal scintigraphy results and preoperative eGFR. The equation could be more accurate in the situation if the diseased kidney is not hydronephrotic.     

Long-term renal and overall survival of critically ill patients with acute renal injury who received continuous renal replacement therapy

Background: Acute kidney injury (AKI) is associated with the increased short-term mortality of critically ill patients on continuous renal replacement therapy (CRRT). The aim of this research was to evaluate the association of kidney function at discharge with the long-term renal and overall survival of critically ill patients with AKI who were on CRRT in an intensive care unit (ICU).

Methods: We retrospectively collected data for critically ill patients with AKI who were admitted to ICU on CRRT at a tertiary metropolitan hospital in China between 2008 and 2013. The patients were followed up to their death or to 30 September 2016 by telephone.

Results: A total of 403 patients were enrolled in this study. The 1-, 3- and 5-year patient survival rates were 64.3?±?2.4, 55.8?±?2.5 and 46.3?±?2.7%, respectively. In multivariate analysis, age, sepsis, decreased renal perfusion (including volume contraction, congestive heart failure, hypotension and cardiac arrest), preexisting kidney disease, Apache II score, Saps II score, vasopressors and eGFR <45?mL/min/1.73?m² at discharge were independent factors for worse long-term patient survival. And age, preexisting kidney disease, Apache II score, mechanical ventilation (MV) and eGFR <45?mL/min/1.73?m² at discharge were also associated with worse renal survival.

Conclusions: This study showed that impaired kidney function at discharge was shown to be an important risk factor affecting the long-term renal survival rates of critically ill patients with AKI. An eGFR <45?mL/min/1.73?m² was an independent risk factor for decreased overall survival and renal survival.     

Comparison of renal function after open radical cystectomy,extracorporeal robot assisted radical cystectomy,and intracorporeal robot assisted radical cystectomy

PurposeRenal function outcomes following robot-assisted radical cystectomy (RARC) have not been well established. We sought to compare long-term renal function outcomes between open radical cystectomy, RARC with extracorporeal urinary diversion and intracorporeal urinary diversion at a high volume institution.Materials and MethodsWe retrospectively reviewed our institutional bladder cancer database for patients who underwent RC from 2010 to 2019 with pre-operative estimated glomerular filtration rate (eGFR) > 45 ml/min/1.73m². Changes in renal function were assessed through locally weighted scatter plot smoothing and comparison of median eGFR between surgical groups. Chronic Kidney Disease Stage 3B was defined as eGFR < 45 ml/min/1.73m². Renal function decline was defined as a ≥10 ml/min/1.73m² drop in eGFR. Kaplan Meier method with log-rank was used to compare CKD 3B-free survival and renal function decline. Cox Proportional Hazards model was used to identify predictors of CKD 3B.ResultsSix hundred and forty four patients were included with median follow-up of 32 months (IQR 12–56). Preoperative characteristics were similar among the groups with no differences in median pre-operative eGFR (ORC: 74.6, extracorporeal urinary diversion: 74.3, intracorporeal urinary diversion: 71.6 ml/min/1.73m², P = 0.15). Median postoperative eGFR on follow up was not different between groups (P = 0.56). 33% of patients developed CKD 3B. There were no differences in CKD 3B-free survival by surgical approach (P = 0.23) or urinary diversion (P = 0.09). 64% of patients experienced renal function decline with a median time of 2.4 years (P 0.23). Predictors of CKD were pathologic T3 disease or greater (HR: 1.77, P = 0.01), ureteroenteric anastomotic stricture (HR: 2.80, P < 0.001), preoperative CKD Stage 2 (HR: 1.81, P =0.02), and preoperative CKD Stage 3A (HR: 5.56, P < 0.001).ConclusionRenal function decline is common after RC. Tumor stage, pre-operative eGFR, and ureteral stricture development, not surgical approach, influence renal function decline.     

Kidney failure,CKD progression and mortality after nephrectomy

Purpose

This study tested the hypothesis that progression of chronic kidney disease (CKD) is less aggressive in patients whose primary cause of CKD was nephrectomy, compared with non-surgical causes.

Methods

A sample of 5983 patients from five specialist nephrology practices was ascertained from the Queensland CKD Registry. Rates of kidney failure/death were compared on primary aetiology of CKD using multivariable Cox proportional hazards models. CKD progression was compared using multivariable linear and logistic regression analyses.

Results

Of 235 patients with an acquired single kidney as their primary cause of CKD, 24 (10%) and 38 (17%) developed kidney failure or died at median [IQR] follow-up times of 12.9 [2.5–31.0] and 33.6 [18.0–57.9] months after recruitment. Among patients with an eGFR?<?45 mL/min per 1.73m² at recruitment, patients with diabetic nephropathy and PCKD had the highest rates (per 1000 person-years) of kidney failure (107.8, 95% CI 71.0–163.8; 75.5, 95% CI 65.6–87.1); whereas, patients with glomerulonephritis and an acquired single kidney had lower rates (52.9, 95% CI 38.8–72.1; 34.6, 95% CI 20.5–58.4, respectively). Among patients with an eGFR?≥?45 mL/min per 1.73m², those with diabetic nephropathy had the highest rates of kidney failure (16.6, 95% CI 92.5–117.3); whereas, those with glomerulonephritis, PCKD and acquired single kidney had a lower risk (11.3, 95% CI 7.1–17.9; 11.7, 95% CI 3.8–36.2; 10.7, 95% CI 4.0–28.4, respectively).

Conclusion

Patients who developed CKD after nephrectomy had similar rates of adverse events to most other causes of CKD, except for diabetic nephropathy which was consistently associated with worse outcomes. While CKD after nephrectomy is not the most aggressive cause of kidney disease, it is by no means benign, and is associated with a tangible risk of kidney failure and death, which is comparable to other major causes of CKD.

     

Trends in the Timing and Clinical Context of Maintenance Dialysis Initiation

Whether secular trends in eGFR at dialysis initiation reflect changes in clinical presentation over time is unknown. We reviewed the medical records of a random sample of patients who initiated maintenance dialysis in the Department of Veterans Affairs (VA) in fiscal years 2000–2009 (n=1691) to characterize trends in clinical presentation in relation to eGFR at initiation. Between fiscal years 2000–2004 and 2005–2009, mean eGFR at initiation increased from 9.8±5.8 to 11.0±5.5 ml/min per 1.73 m² (P<0.001), the percentage of patients with an eGFR of 10–15 ml/min per 1.73 m² increased from 23.4% to 29.9% (P=0.002), and the percentage of patients with an eGFR>15 ml/min per 1.73 m² increased from 12.1% to 16.3% (P=0.01). The proportion of patients who were acutely ill at the time of initiation and the proportion of patients for whom the decision to initiate dialysis was based only on level of kidney function did not change over time. Frequencies of documented clinical signs and/or symptoms were similar during both time periods. The adjusted odds of initiating dialysis at an eGFR of 10–15 or >15 ml/min per 1.73 m² (versus <10 ml/min per 1.73 m²) during the later versus earlier time period were 1.43 (95% confidence interval [95% CI], 1.13 to 1.81) and 1.46 (95% CI, 1.09 to 1.97), respectively. In conclusion, trends in eGFR at dialysis initiation at VA medical centers do not seem to reflect changes in the clinical context in which dialysis is initiated.