Implementing a Health Utility Assessment Platform to Acquire Health Utilities in a Hemodialysis Outpatient Setting: Feasibility Study

BACKGROUND

Patients with end-stage kidney disease (ESKD) wait roughly 4 years for a kidney transplant. A potential way to reduce wait times is using hepatitis C virus (HCV)-viremic kidneys.

OBJECTIVE

As preparation for developing a shared decision-making tool to assist patients with ESKD with the decision to accept an HCV-viremic kidney transplant, our initial goal was to assess the feasibility of using The Gambler II, a health utility assessment tool, in an ambulatory dialysis clinic setting. Our secondary goals were to collect health utilities for patients with ESKD and to explore whether the use of race-matched versus race-mismatched exemplars impacted the knowledge gained during the assessment process.

METHODS

We used The Gambler II to elicit utilities for the following ESKD-related health states: hemodialysis, kidney transplant with HCV-unexposed kidney, and transplantation with HCV-viremic kidney. We created race exemplar video clips describing these health states and randomly assigned patients into the race-matched or race-mismatched video arms. We obtained utilities for these 3 health states from each patient, and we evaluated knowledge about ESKD and HCV-associated health conditions with pre- and postintervention knowledge assessments.

RESULTS

A total of 63 patients with hemodialysis from 4 outpatient Dialysis Center Inc sites completed the study. Mean adjusted standard gamble utilities for hemodialysis, transplant with HCV-unexposed kidney, and transplantation with HCV-viremic kidney were 82.5, 89, and 75.5, respectively. General group knowledge assessment scores improved by 10 points (P<.05) following utility assessment process. The use of race-matched exemplars had little effect on the results of the knowledge assessment of patients.

CONCLUSIONS

Using The Gambler II to collect utilities for patients with ESKD in an ambulatory dialysis clinic setting proved feasible. In addition, educational information about health states provided as part of the utility assessment process tool improved patients' knowledge and understanding about ESKD-related health states and implications of organ transplantation with HCV-viremic kidneys. A wide variation in patient health state utilities reinforces the importance of incorporating patients' preferences into decisions regarding use of HCV-viremic kidneys for transplantation.

Pregnancy-Related Acute Kidney Injury: Do We Know What to Do?

Pregnancy-related AKI is a global health problem and is associated with a higher risk of both maternal and fetal morbidity and mortality. Risk factors for developing AKI during pregnancy include older age, history of preeclampsia, and comorbidities like diabetes. Hyperemesis gravidarum is a common cause of AKI during the first trimester, and conditions such as preeclampsia, acute fatty liver disease of pregnancy, thrombotic thrombocytopenic purpura, hemolytic uremic syndrome, and placental abruption are important causes of AKI later in the pregnancy. Diagnosis of pregnancy-related AKI is challenging due to the lack of standard criteria and overlap of clinical manifestations among different etiologies. Timely diagnosis of pregnancy-related AKI is instrumental. Specific treatment includes steroids and immunosuppressive therapy for glomerulonephritis, prompt delivery for severe preeclampsia and acute fatty liver of pregnancy, plasmapheresis for thrombotic thrombocytopenic purpura, and eculizumab for the atypical hemolytic uremic syndrome. Due to the high complexity, management of pregnancy-related AKI should be performed by a multidisciplinary team consisting of a nephrologist, obstetrician, and neonatologist.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Prevalence and associated risk factors for intimate partner violence (IPV) in the Himalayan mountain villages of Pakistan

Introduction

Intimate partner Violence (IPV) against women includes all actions that violate one’s sense of self, physical body and sense of trust and involves episodes of violence of physical, psychological (emotional), or sexual nature, perpetrated by a current or former intimate partner.

Objectives

We estimated the prevalence of and risk factors for intimate partner violence (IPV) in the Himalayan mountain villages of Gilgit Baltistan in Pakistan.

Methods

We employed a cross-sectional study to randomly select ever married women (n=789) aged 18-49, in Pakistan. We used an adapted World Health Organization screening instrument to assess women’s experience of IPV in the previous 12 months. We used an indigenous validated instrument assess self-reported symptoms of major depression according to the DSM IV. Multivariable logistic regression analysis was used to identify significant predictors of IPV using adjusted odds ratio (AOR) with 95% confidence intervals (CI).

Results

The overall prevalence of IPV was 22.8% (95% CI: 20.0-25.9). Women exposed to IPV were less likely to have husbands educated at a college or a higher (AOR: 0.40; 95%CI: 0.22-0.70), household income in the middle or the highest tertile (AOR: 0.44; 95%CI: 0.29-0.68), and were more likely to have poor or very poor relationship with their mother in law (AOR=2.85; 95% CI: 1.90-4.28), to have a poor quality of health (AOR= 2.74; 95% CI: 1.92-3.92) poor quality of life (AOR= 3.54; 95%CI: 1.90-6.58), and higher odds of experiencing depressive symptoms (AOR=1.97; 95%CI:1.39-2.77).

Conclusions

IPV is a substantial public health burden in Himalayan mountain villages and merits serious attention.

Disclosure

No significant relationships.

POS1444 FLT1 AND EPHB2 ARE NOVEL GENETIC MARKERS ASSOCIATED WITH PANCREATITIS IN PATIENTS TAKING AZATHIOPRINE FOR IMMUNE-MEDIATED CONDITIONS: INTEGRATING GENOME- AND TRANSCRIPTOME-WIDE ASSOCIATION STUDIES

Background

Azathioprine (AZA) is a thiopurine immunosuppressant medication used to treat a variety of immune-mediated diseases. Unfortunately, its use is limited by adverse effects. Pancreatitis, a potentially severe, life-threatening side effect is independent of dose and necessitates AZA discontinuation given the high risk of recurrent pancreatitis with continued use or re-challenge. The mechanisms driving pancreatitis are unclear. While classic thiopurine-induced acute pancreatitis (TIAP) has been associated with HLA haplotypes, most patients taking AZA and presenting with pancreatitis do not fulfill the stringent criteria for TIAP.

Objectives

To identify genetic risk factors for pancreatitis in patients taking azathioprine for immune-mediated conditions.

Methods

Using a biobank linked to electronic health records (EHR) from a tertiary center, we identified new users of AZA. Patients were excluded if the primary indication for AZA was organ transplant or if there was a history of pancreatitis prior to AZA use. The analysis was restricted to patients with EHR-reported race as White due to insufficient case counts for the non-White group. We then identified patients with amylase or lipase values that exceeded twice the upper limit of normal (“>2x ULN”) or with ICD-9/ICD-10 codes for acute pancreatitis. Each record was manually reviewed to confirm the timing of AZA use in relation to laboratory derangements or ICD coding, as well as to further classify patients into three increasingly strict, but not exclusive categories: 1) pancreatic injury (amylase or lipase >2x ULN); 2) acute pancreatitis1, or 3) TIAP2. We completed genotyping with Illumina Infinium Expanded Multi-Ethnic Genotyping Array plus custom content data, employed Michigan Imputation servers for genetic imputation, and used PrediXcan (GTEx v8) to impute gene expression. We then conducted genome-wide association and transcriptome-wide association studies (GWAS, TWAS). Acknowledging the relatively small overall cohort, and possible imbalance of cases vs controls, we used the Firth logistic regression method, which is a penalized likelihood-based method.

Results

We studied 2127 AZA users (35.4% male; mean 44.5+/-17.2 years). The median AZA dose was 100mg/day (IQR: 50-125mg/day). Rheumatologic conditions (56.9%) and inflammatory bowel disease (40.4%) comprised the most common primary indications for AZA. Pancreatic injury, pancreatitis, and TIAP were diagnosed in 42 (2.0%), 16 (0.8%), and 9 (0.4%) patients, respectively. GWAS identified several significantly associated genes, many with overlapping TWAS findings in the pancreas and liver (Figure 1). From these, the two protein-encoding genes Fms Related Receptor Tyrosine Kinase-1 (FLT1) and Ephrin type-B receptor-2 (EPHB2) overlapped in two or more pancreatitis phenotypes in the TWAS and GWAS, respectively. EPHB2 was associated with a 8.6-fold (P=1.84 x 10-8) and a 31.4-fold (P=2.87x 10-8) higher likelihood of pancreatic injury and TIAP, respectively.

Figure 1.

Conclusion

FLT1—a gene that encodes a receptor tyrosine kinase and is a member of the vascular endothelial growth factor receptor (VEGFR) family—and EPHB2—a gene that encodes a member of the Eph receptor family, which is the largest subgroup of the receptor tyrosine kinase family—are novel genetic markers associated with pancreatitis in patients taking AZA. VEGF can potentiate inflammation and the pancreas microenvironment is known to promote VEGF expression, which has been linked to pancreatic cancer development; anti-VEGF treatments have been investigated both for mitigating inflammation and also anti-pancreatic cancer treatment. Future studies validating our findings in AZA-induced pancreatitis are warranted.

References

[1]Crockett et al. Gastroenterology (2018). 154(4):1096-1101.

[2]Heap et al. Nature Genetics (2014). 46:1131-1134

Disclosure of Interests

Shailja Shah Consultant of: ad hoc consultant for Phathom pharmaceuticals, Tyler Reese: None declared, Jacy Zanussi: None declared, Alyson Dickson: None declared, Laura Daniel: None declared, Ran Tao: None declared, Tyne Miller-Fleming: None declared, Peter Straub: None declared, Adriana Hung: None declared, Puran Nepal: None declared, Wei-Qi Wei: None declared, Elizabeth Phillips: None declared, Nancy Cox: None declared, Charles M. Stein: None declared, QiPeng Feng: None declared, Cecilia P. Chung: None declared

POS0867 COMORBIDITY AND COMPLICATIONS PRIOR TO SYSTEMIC SCLEROSIS DIAGNOSIS: A RETROSPECTIVE COHORT ANALYSIS

Background

Systemic sclerosis (SSc) is a rare autoimmune disease characterized by progressive microvascular damage, collagen deposition and subsequent fibrosis of the skin and internal organs which contributes to substantial morbidity and premature death.1-2

Objectives

The objective was to evaluate the disease burden of SSc patients prior to their SSc diagnosis.

Methods

Patients with SSc were identified in a claims dataset (IBM MarketScan Commercial Database, 2015-2019) using ICD 10 diagnosis codes for SSc. Eligible subjects were required to have > 1 inpatient or >2 outpatient/office claims with a scleroderma diagnosis code on separate days and > 24 months of continuous health plan enrollment without a SSc diagnosis before the first SSc claim (‘index date’) and > 12 months of enrollment after the index date. Overall comorbid disease burden was assessed via the Charlson Comorbidity Index (CCI) 13-24 and 12 months before and 12 months after index date. The prevalence of SSc-related complications for atherosclerosis, pulmonary arterial hypertension (PAH), pulmonary fibrosis (PF), Raynaud’s Phenomenon (RP), and gastrointestinal (GI) complications (e.g., GERD, dysphagia, etc.) were identified using ICD codes and reported as percentages for the aforementioned time intervals relative to patients’ index dates.

Results

902 eligible SSc patients were identified for analysis. The mean age at index SSc diagnosis was 54.3 years and 84.7% of patients were female. Mean CCI scores 13-24 months before, 12 months before, and 12 months after index SSc diagnosis were 0.84, 1.13 and 1.30, respectively. From the time points 13-24 months before, 12 months before, and 12 months after index SSc diagnosis, increasing rates were also observed of atherosclerosis, PAH, PF, RP, and GI complications (Table 1).

Table 1.

Charlson Comorbidity Index (CCI) and systemic sclerosis-related complications by time-interval

Clinical characteristic13-24 months before Index12 months before Index12 months after IndexMean CCI (std dev)0.84 (1.58)1.13 (1.71)1.30 (1.75)Systemic sclerosis-related complicationsAtherosclerosis7%9%14%Pulmonary arterial hypertension (PAH)1%4%12%Pulmonary fibrosis (PF)5%8%16%Raynaud’s Phenomenon (RP)13%29%43%GI complications23%32%46%

Conclusion

Results from this analysis suggests that SSc-related sequalae are present at least two years prior to SSc diagnosis and rates of these complications increased markedly over time. Patients’ overall comorbid disease burden also worsened substantially over this period, likely because of these complications. The internal organ involvement is likely under reported due to requirements to link each diagnosis with an ICD-10 code. These data indicate the significant burden of SSc, prior to and after diagnosis, highlighting the need for awareness, prompt diagnosis, and effective therapies for SSc and its related complications.

References

[1]Cutolo M, et al. Expert Rev Clin Immunol. 2019;15(7):753-764.

[2]Steen VD, Medsger TA. Ann Rheum Dis. 2007;66(7):940-944.

Disclosure of Interests

Dinesh Khanna Consultant of: Horizon Therapeutics, Daniel Furst Consultant of: Horizon Therapeutics, Justin W. Li Grant/research support from: Horizon Therapeutics, Saloni Shah Grant/research support from: Horizon Therapeutics, Tamara Lesperance Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Farah Ali Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Brian LaMoreaux Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics, Stephanie Taylor Shareholder of: Horizon Therapeutics, Employee of: Horizon Therapeutics

Comparative evaluation of different techniques for herniorrhaphy in calves

Umbilical hernia is one of the most common problems in young calves. This problem occurs in dairy sector as well as in the local farmers. Present study was conducted to compare outcomes of four different techniques of herniorrhaphy. Twenty four young calves (n=24) were divided in 4 groups (A, B, C, and D) which underwent four different surgical techniques. Group A underwent vicryl plus suture material and pants-over-west technique, Group B underwent mesh application with Dexon suture material by using simple interrupted suture pattern, Group C underwent closed method with Nylon No. 3 suture material by using vertical mattress suture pattern and Group D underwent clamp application method with Silk No. 2 suture material by using simple interrupted suture pattern. The result showed that mesh application method was comparatively better with respect to feed intake, body weight gain and healing time. There was no reoccurrence with non-significant hematological changes (p≤0.05). It is concluded that mesh application method is safer than other three techniques and there are no systemic effects of this surgical intervention on calves' health.

Analyzing the impact of Сovid-19 on the hotel industry in Nepal

COVID-19 pandemic has significantly affected the tourism and hospitality sectors across the globe. Due to the increase in the number of COVID positive cases, governments of countries have imposed strict lockdown globally as a precautionary measure to control the spread of the coronavirus, which has led to restrictions on travel and mobility of individuals from one place to the other. One of the countries that have been severely affected due to the lockdown is the economy of Nepal. Being a tourist-friendly nation, every year, Nepal’s tourism and hospitality sector contributes significantly to its GDP. With a restriction on travel and cancellation of bookings, one of the most important departments under this sector, the hotel industry, is currently struggling to survive due to loss of revenue. The present study tries to understand the challenges and strategies planned by the hotel industry stakeholders in Nepal. A primary survey conducted with hoteliers from 10 hotels reveals major concerns about maintaining a steady financial performance and expectations for government aid to help this sector come back to normalcy.

Impact of mapping technology on procedural characteristics during radiofrequency or cryoballoon pulmonary vein isolation for atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction: Cryoballoon ablation (CBA) is often associated with shorter procedure times along with tradeoffs such as increased fluoroscopy use compared to radiofrequency (RF) ablation of atrial fibrillation (AF), however the impact of mapping technology on these characteristics is not fully understood.

Purpose

To assess the effect of mapping technology on trends in fluoroscopy use and procedure times in AF pulmonary vein isolation (PVI) procedures with an RF or CBA catheter.

Methods

Acute procedure data from 210 de novo AF cases using a 3D mapping system was prospectively collected from 48 centers in eight countries. Choice of technology was left to physician discretion; a PVI only ablation strategy was utilized in all cases. Procedure data such as total procedure and fluoroscopy times from cases using either an RF or CBA catheter with either a grid-style mapping catheter (HD Grid) or circular mapping catheter (CMC) were compared.

Results

Of the 210 cases, RF ablation was used in 103 (49%), and CBA used in 107 (51%). In RF cases, a relatively even split between CMC and HD Grid use was observed (n=46, 45% vs. n=57, 55%), while a CMC was used in 100% of CBA cases (Figure 1). Across all cases, fluoroscopy and procedure times were significantly shorter when HD Grid was used (7.4±26.7 minutes; 108.2±46.3 minutes) compared to a CMC (20.4±17.6 minutes; 133.7±62.7) (p&lt;0.001; p=0.003). A similar trend was also observed in RF cases using HD Grid (7.4±26.7 minutes; 108.2±46.3 minutes) compared to a CMC (17.9±12.3 minutes; 175.1±50.5) (p=0.01; p&lt;0.001). Fluoroscopy times in RF cases with HD Grid (7.4±26.7 minutes) were significantly shorter compared to CBA cases with a CMC (21.5±19.4 minutes) (p&lt;0.001), while procedure times were similar (108.2±46.3 minutes; 116.0±59.2 minutes, p=0.20).

Conclusion(s)

Use of HD Grid resulted in significantly shorter procedure and fluoroscopy times compared to a CMC across all cases, including those using RF ablation. Fluoroscopy times were also significantly shorter in RF cases using HD Grid compared to CBA cases using a CMC, with similar procedure times. These observations suggest that use of HD Grid may better enable safer and more efficient PVI, specifically when employing RF ablation, in addition to safer and equally efficient RF PVI compared to CBA with a CMC. Further study in in a larger, randomized cohort may be necessary.

Global preferences in mapping technology and its impact on fluoroscopy and procedure times during catheter ablation of atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

Choice in mapping technology may play a critical role in reducing fluoroscopy and procedure times during atrial fibrillation (AF) ablation, however this relationship is not well studied.

Purpose

To assess the impact of mapping technology on trends in fluoroscopy use and procedure times in AF ablation procedures.

Methods

Acute procedure data from 525 AF cases was prospectively collected from 68 centers in nine countries. Choice of technology and ablation strategy, including PVI and substrate modification, were left to physician discretion. Procedure data such as total procedure and fluoroscopy times from cases using a grid-style mapping catheter (HD Grid) were compared to those using a circular mapping catheter (CMC).

Results

Of the 525 cases, HD Grid was used in 230 (44%), and CMC was used in 295 (56%). HD Grid was routinely used for both de novo and redo procedures while CMC was used predominantly for de novo procedures (Table 1). Similar procedure times were noted in redo PAF and redo PersAF procedures, while significantly shorter procedure times were observed for the HD Grid group in both de novo PAF and PersAF (113.9±48.8 vs. 125.9±56.3 minutes, p=0.04; and 142.8±53.2 vs. 169.8±52.2 minutes, p=0.001).

Overall fluoroscopy times were significantly shorter using HD Grid compared to a CMC (9.0±19.6 minutes vs. 19.8±16.4 minutes, p&lt;0.001), including significantly shorter fluoroscopy times in de novo PAF, de novo PersAF, and redo PAF (Table 1). There were 155 cases completed without fluoroscopy use; zero fluoroscopy cases accounted for 50% (114/230) and 14% (41/295) of total cases completed with HD Grid and a CMC, respectively (p&lt;0.001).

Conclusion(s)

Use of HD Grid was observed in a significantly higher portion of zero fluoroscopy cases and resulted in significantly shorter procedure and fluoroscopy times in both de novo PAF and de novo PersAF and significantly shorter fluoroscopy times in redo PAF. These observations suggest that use of HD Grid may better enable faster and safer procedures in these specific AF types compared to CMCs, although further analysis in a larger, randomized cohort may be warranted.

MO506: Disparities in Hospitalisation Rates Between Men and Women With and Without Chronic Kidney Disease in the Irish Health System

BACKGROUND AND AIMS

It is increasingly recognized that disparities in health care utilisation and associated clinical outcomes exist between men and women. Whether these sex disparities extend to patients with chronic kidney disease (CKD) is not well known. The primary goal of this study was to compare hospitalisation rates between men and women in the Irish health system and study the association of kidney function with hospitalization rates.

METHOD

We constructed a cohort of 125 890 patients from the National Kidney Disease Surveillance System (NKDSS) to compare hospitalization rates between men and women. Patients were recruited from 1 January 2005 to 31 December 2010 and followed until 31 December 2013. Hospitalization events were captured from the National Hospital In-Patient Enquiry (HIPE) system and linked to existing laboratory data systems. The primary cause of hospitalization was determined from the International Classification of Diseases (ICD-10), with causes grouped according to Major Diagnostic Categories (MDC). CKD was defined as an eGFR &lt;60 mL/min/1.72 m2. Crude rates were calculated as the total number of hospitalizations that occurred during follow-up divided by the total number of observed person-years. Negative binomial regression determined rate ratios (RR) for men versus women with adjustment for baseline casemix. The principal exposure was participant sex, classified as men or women.

RESULTS

Of the 125 890 participants, 55.1% were women, with a mean age of 54.1 (SD: 17.7) years. Compared with women, men were on average significantly older (55.1 versis 53.3 years), had higher eGFR (83.3 versus 82.4 mL/min/1.72 m2), more diabetes (22.9% versus 17.0%) and higher levels of inflammatory markers (P &lt; .001 for all). During a median follow-up of 7.7 years, there were 93 515 hospitalizations.

Crude hospitalization rates (per 100 person years) were marginally higher in men than in women {11.1, [95% confidence interval (95% CI) 11.0–1.2 versus 9.8), 95% CI 9.70–9.9/100 pyr]} in the overall cohort, which changed little with adjustment for age. With each worsening category of kidney function, hospitalization rates increased substantially from 8.1 (8.0–8.3) to 28.6 (27.0–30.3) in men and from 8.1 (8.0–8.3) to 24.7 (23.5–25.9) in women, respectively. However, within each category, rates of hospitalization were significantly higher for men than for women (P-value interaction, &lt;.001). In stratified analyses, the men-to-women risk ratios increased from 1.11 (1.02–1.21) for eGFR &gt;90 mL/min to 1.50 (1.34–1.68) for GFR 45–59 mL/min/m² (Table 1). A similar pattern was observed when the 60 mL/min eGFR threshold was used (Table 1). The excess hospitalizations in men compared with women were in general due to higher rates of hospitalizations from circulatory disorders (5.2 versus 3.2/100 pyr), respiratory illness (4.0 versus 2.8/100 pyr), and diseases of the digestive system (2.5 versus 2.0/100 pyr), as shown in Fig. 1.

CONCLUSION

Men and women with CKD experienced hospitalization rates that were far higher than those without CKD. Hospitalization rates were greater in men than women across all stages of CKD, which was not explained by age or acute illness indicators. The excess hospitalizations in men were largely attributed to common cardio-respiratory-digestive illnesses. CKD is a major risk amplifier for hospitalization in both men and women and should be identified in all patients prior to hospitalization to ensure effective risk stratification and optimal management.

MO515: Mortality Differences Between Men and Women With Chronic Kidney Disease in the Irish Health System: The National Kidney Disease Surveillance Programme

BACKGROUND AND AIMS

Chronic kidney disease is associated with higher mortality compared with the general population, but mortality differences between men and women with CKD are poorly understood. Although the prevalence of CKD is consistently higher in women than in men, emerging studies suggest that men experience poorer survival. The primary goal of this study was to compare mortality rates between men and women in the Irish health system and determine whether kidney function influenced these sex-specific risks.

METHOD

We created a cohort of 125 890 patients from the National Kidney Disease Surveillance System (NKDSS) to compare mortality rates between men and women. Patients were recruited from 1 January 2005 to 31 December 2010 and followed until 31 December 2013. Kidney function was determined using the CKD-EPI equation, generating estimated glomerular filtration rate (mL/min/1.73 m2) (eGFR). The primary outcome was all-cause mortality from national records provided by the Central Statistics Office (CSO). The principal exposure was participant sex, classified as men or women. Patients were censored at the date of initiation of dialysis or kidney transplantation, death, loss to follow-up or end of follow-up 31 December 2013. Mortality risks were compared using the Fine-Gray approach, which accounted for the competing risks of renal replacement therapy. Adjustments were made for baseline age, kidney function and blood biomarkers, which indicated the presence and severity of clinical disease.

RESULTS

Of the 125 890 participants, 55.1% were women, with a mean age of 54.1 (SD: 17.7) years. The median follow-up was 7.75 years (IQR: 6.33–8.55), 243 patients (0.19%) patients progressed to RRT and 14 179 patients (11.26%) died. Overall, mortality rates were significantly higher in men than in women (18.4 versus 16.6 deaths/1000 pyrs, respectively). Compared with women, men with CKD experienced significantly higher rates of death and RRT, P &lt; .001 (Figure 1a). With each worsening GFR category, crude mortality rates increased by 18-fold in women compared with 9-fold in men. The P-value for the interaction of sex and GFR with mortality was &lt;0.001. 

In stratified analyses, the magnitude of the sHR for men versus women decreased with each descending eGFR category from a peak of 2.17 (1.88–2.49) for eGFR &gt;90 mL/min down to 1.21 (0.98–1.49) for eGFR &lt;29 mL/min/1.72 m2 (Table 1) and was no longer significant in the eGFR &lt;29 mL/min/1.72 m² category.

CONCLUSION

Although women have a higher burden of CKD than men in the Irish health system, the overall risks of death and RRT were far greater in men than in women. However, the excess risk in men diminished with increasing severity of kidney disease such that mortality risks for women approached those of men with advanced kidney disease. While these findings may have a biologic basis, fundamental disparities in care delivery, quality or accessibility between men and women is a far more likely explanation.

Acute kidney injury during pregnancy in kidney transplant recipients

Pregnancy-related acute kidney injury (AKI) is a public health problem and remains an important cause of maternal and fetal morbidity and mortality. The incidence of pregnancy-related AKI has increased in developed countries due to increase in maternal age and higher detection rates. Pregnancy in women with kidney transplants is associated with higher adverse outcomes like preeclampsia, preterm births, and allograft dysfunction, but limited data exist on causes and outcomes of pregnancy-related AKI in the kidney transplant population. Diagnosis of AKI during pregnancy remains challenging in kidney transplant recipients due to lack of diagnostic criteria. Management of pregnancy-related AKI in the kidney transplant population requires a multidisciplinary team consisting of transplant nephrologists, high-risk obstetricians, and neonatologists. In this review, we discuss pregnancy-related acute kidney injury in women with kidney transplants, etiologies, pregnancy outcomes, and management strategies. This article is protected by copyright. All rights reserved.

Sex and Gender Differences in Kidney Transplantation

Sex and gender often are used interchangeably, but are two distinct entities, with sex being the biological attribute and gender including the social, psychological, and cultural aspects of one's identity. Kidney transplantation has been proven to be the best treatment for end-stage kidney disease, improving both quality of life and life-expectancy for most patients. However, gender disparities in access to and outcomes of kidney transplantation remain despite the plethora of evidence showing the advantages of kidney transplantation to our patients. Data have shown that women are less likely to be waitlisted for a kidney transplant and to receive a deceased donor or a living donor kidney. On the other hand, women are more likely than men to become living kidney donors. Although some state the latter is the result of the female gender to nurture and care for loved ones, others believe this observation is because women often are incompatible with their spouse or child because pregnancy is a strong sensitizing event, which stems from the biological rather than the social differences between the sexes. Influence of sex and gender is not limited to access to kidney transplantation, but rather exist in other areas of transplant medicine, such as the difference observed in transplant outcomes between the sexes, variability in immunosuppression metabolism, and even in more contemporary areas such as recent data showing sex-based differences in outcomes of kidney transplant recipients with coronavirus disease-2019, with males having an increased incidence of acute kidney injury and death.

Cylindrospermopsin impairs zebrafish (Danio rerio) embryo development

Cyanotoxins are among common contaminants that can impair human, animal, and environmental health. Cylindrospermopsin (CYN) is an abundant form of cyanotoxins elevated following algal bloom in the water worldwide. Previous studies have described CYN effects on several organs in mammals. However, little is known about its toxicity mechanisms in other vertebrates. This study aims to characterize the developmental effects of CYN using zebrafish larvae as an aquatic model organism. A wide range of CYN concentrations (0-2000 μg/L) was tested using a morphometric approach for survival, hatching, various growth and developmental abnormalities. We also investigated the expression of genes related to oxidative stress, osmoregulation, and thyroid function. Exposure to CYN resulted in decreased growth, increased developmental abnormalities such as pericardial and yolk sac edema as well as swim bladder absence. In addition, CYN increased tr1a, and decreased dio1 and dio3 transcript levels which are involved in thyroid-mediated function. It also increased transcript levels related to oxidative stress, including hsp70, ahr1a, cyp1a, gpx and cat. Lastly, CYN exposure increased aqp3a and decreased dab2, which are involved in osmoregulation with a threshold of 10 μg/L. The present study demonstrates multiple effects of exposure to environmentally relevant CYN concentrations in zebrafish embryos.