Financial Toxicity in Renal Patients (FINTORE) Study: A Cross-Sectional Italian Study on Financial Burden in Kidney Disease-A Project Protocol

Financial toxicity (FT) refers to the negative impact of health-care costs on clinical conditions. In general, social determinants of health, especially poverty, socioenvironmental stressors, and psychological factors, are increasingly recognized as important determinants of non-communicable diseases, such as chronic kidney disease (CKD), and their consequences. We aim to investigate the prevalence of FT in patients at different stages of CKD treated in our universal health-care system and from pediatric nephrology, hemodialysis, peritoneal dialysis and renal transplantation clinics. FT will be assessed with the Patient-Reported Outcome for Fighting Financial Toxicity (PROFFIT) score, which was first developed by Italian oncologists. Our local ethics committee has approved the study. Our population sample will answer the sixteen questions of the PROFFIT questionnaire, seven of which are related to the outcome and nine the determinants of FT. Data will be analyzed in the pediatric and adult populations and by group stratification. We are confident that this study will raise awareness among health-care professionals of the high risk of adverse health outcomes in patients who have both kidney disease and high levels of FT. Strategies to reduce FT should be implemented to improve the standard of care for people with kidney disease and lead to truly patient-centered care.

Physical activity and exercise programs for kidney patients: an Italian survey of nephrology centres

BACKGROUND

Data on exercise activities in place, and on the interest for developing them in Nephrology Services in Italy is limited. To address this gap, we carried out this cross-sectional study to investigate the status of physical activity and exercise programs available in Italian Nephrology Centres. Additionally, research priorities on this topic were examined.

METHODS

We developed a 14-item electronic survey, which consisted of multiple-choice questions covering exercise training programs, physical assessment, barriers to exercise practice and to exercise programs, exercise and physical activity counselling practices, perceived exercise benefits, literature evidence, and research priorities. Data on the characteristics of the centres were also collected.

RESULTS

Sixty-two responses from Italian nephrology centres were collected. Ninety-three percent of the respondents were aware of the scientific evidence supporting the benefits of regular exercise programs for chronic kidney disease (CKD) patients. Additionally, in 75% of centres the nephrologists believed that physical activity counselling should be performed by the nephrologists. However, only 26% of centres provided exercise programs, mainly for dialysis patients, and 63% never or infrequently assessed physical activity in the context of patient management. Eighty-nine percent of centres reported barriers to implementing exercise programs, including lack of funding, institutional disinterest, patient refusal, and negative attitudes of the healthcare personnel. Forty-six research priorities related to exercise in CKD patients were suggested, with the majority focusing on impact of exercise programs and physical activity on cardiovascular, nutritional, and psychosocial outcomes.

CONCLUSION

This survey highlights the limited availability of exercise programs and physical activity evaluation in clinical practice in Italian Nephrology Centres. However, the survey also revealed a strong interest for counselling CKD patients on physical activity and implementing exercise prescriptions and interventions.

Effects of forest walking on physical and mental health in elderly populations: a systematic review

There is a growing awareness that spending time in nature is associated with improvement of well-being; nevertheless, the prescription of forest bathing is still limited. The aim of this systematic review was to explore the physiological and psychological benefits of different forest therapies on healthy and pathological elderly populations (>60 years) to identify the most-effective type, duration, and frequency of these interventions. A search for literature was carried out in December 2021 using PubMed, EMBASE, ResearchGate, Google Scholar and Web of Science. Grey literature was searched as well. After removal of the duplicates, within the 214 articles identified, ten met the inclusion criteria. The methodological quality of the selected studies was rated. Forest walking, alone and in combination with other activities is the most effective intervention. The selected studies reported a positive impact on physical components, including reduction in blood pressure and heart rate and improvements in cardiopulmonary and neurochemical parameters. Favorable modifications have also been noted in the psychological field, with improvements in depression, stress levels and in quality of life perception. In conclusion, forest walking may play an important role in promoting physical and mental health in healthy and pathological elderly populations. However, the lack of high-quality studies limits the strength of the results, calling for more trials.

Primary membranous nephropathy in the Italian region of Emilia Romagna: results of a multicenter study with extended follow-up

BACKGROUND

Since primary membranous nephropathy is a heterogeneous disease with variable outcomes and multiple possible therapeutic approaches, all 13 Nephrology Units of the Italian region Emilia Romagna decided to analyze their experience in the management of this challenging glomerular disease.

METHODS

We retrospectively studied 205 consecutive adult patients affected by biopsy-proven primary membranous nephropathy, recruited from January 2010 through December 2017. The primary outcome was patient and renal survival. The secondary outcome was the rate of complete remission and partial remission of proteinuria. Relapse incidence, treatment patterns and adverse events were also assessed.

RESULTS

Median (IQR) follow-up was 36 (24-60) months. Overall patient and renal survival were 87.4% after 5 years. At the end of follow-up, 83 patients (40%) had complete remission and 72 patients (35%) had partial remission. Among responders, less than a quarter (23%) relapsed. Most patients (83%) underwent immunosuppressive therapy within 6 months of biopsy. A cyclic regimen of corticosteroid and cytotoxic agents was the most commonly used treatment schedule (63%), followed by rituximab (28%). Multivariable analysis showed that the cyclic regimen significantly correlates with complete remission (odds ratio 0.26; 95% CI 0.08-0.79) when compared to rituximab (p < 0.05).

CONCLUSIONS

In our large study, both short- and long-term outcomes were positive and consistent with those published in the literature. Our data suggest that the use of immunosuppressive therapy within the first 6 months after biopsy appears to be a winning strategy, and that the cyclic regimen also warrants a prominent role in primary membranous nephropathy treatment, since definitive proof of rituximab superiority is lacking.

Food insecurity and kidney disease: a systematic review

BACKGROUND

The risk of developing and worsening chronic kidney disease (CKD) is associated with unhealthy dietary patterns. Food insecurity is defined by a limited or uncertain availability of nutritionally adequate and safe food; it is also associated with several chronic medical conditions. The aim of this systematic review is to investigate the current knowledge about the relationship between food insecurity and renal disease.

METHODS

We selected the pertinent publications by searching on the PubMed, Scopus, and the Web of Science databases, without any temporal limitations being imposed. The searching and selecting processes were carried out through pinpointed inclusion and exclusion criteria and in accordance with the Prisma statement.

RESULTS

Out of the 26,548 items that were first identified, only 9 studies were included in the systemic review. Eight out of the nine investigations were conducted in the US, and one was conducted in Iran. The studies evaluated the relationship between food insecurity and (i) kidney disease in children, (ii) kidney stones, (iii) CKD, (iv) cardiorenal syndrome, and (v) end stage renal disease (ESRD). In total, the different research groups enrolled 49,533 subjects, and food insecurity was reported to be a risk factor for hospitalization, kidney stones, CKD, ESRD, and mortality.

CONCLUSIONS

The relationship between food insecurity and renal disease has been underestimated. Food insecurity is a serious risk factor for health problems in both wealthy and poor populations; however, the true prevalence of the condition is unknown. Healthcare professionals need to take action to prevent the dramatic effect of food insecurity on CKD and on other chronic clinical conditions.

The Impact of Physical Exercise on microRNAs in Hemodialysis Patients: A Review and a Protocol for an Ancillary Study

Physical inactivity is considered a significant risk factor for mortality and morbidity among chronic hemodialysis (HD) patients. Therefore, physical exercise is recommended in the treatment of HD patients. Although the beneficial effects of physical exercise in HD patients are well-described in the literature, the underlying physiological mechanisms still need to be fully understood. Recently, microRNAs (miRNAs) have emerged as potential mediators of the therapeutic effects of physical exercise in healthy individuals. miRNAs are short, single-stranded, noncoding RNAs involved in gene expression regulation. Specifically, upon forming the RNA-induced silencing complex, miRNAs selectively bind to specific miRNAs within cells, reducing gene expression. miRNAs can be secreted by cells in an accessible form or enclosed within exosomes or extracellular vesicles. They can be detected in various body fluids, including serum (circulating miRNAs), facilitating the study of their diverse expression. Currently, there is no available data regarding the impact of physical exercise on the expression of miRNAs involved in osteogenic differentiation, a fundamental mechanism in the development of vascular calcification, for HD patients. Therefore, we have designed an observational and longitudinal case-control study to evaluate the expression of miR-9 and miR-30b in HD patients participating in a 3-month interdialytic physical exercise program. This paper aims to present the study protocol and review the expression of circulating miRNAs in HD patients and their modulation through physical exercise.

Comorbidity and in-hospital mortality in peritoneal dialysis patients: data of the Emilia Romagna region of Italy

OBJECTIVE

Kidney failure increases in-hospital mortality (IHM); however, comorbidity is crucial for predicting mortality in dialysis patients. Our aim was to evaluate the impact of comorbidity, assessed by modified Elixhauser index (mEI), Charlson Comorbidity Index (CCI), and age-adjusted CCI, on IHM in a cohort of peritoneal dialysis patients admitted to hospitals of the Emilia Romagna region (ERR) of Italy.

PATIENTS AND METHODS

All hospital admissions of peritoneal dialysis patients recorded between 2007 and 2021 in the ERR database were analyzed. The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) was used for detecting diagnoses and procedures, and the inclusion criterion was code 5498. Comorbidity burden was evaluated by three different scores, and hemodialysis (HD) treatment need was considered. IHM was our outcome.

RESULTS

During the 15 years of the study, 3,242 hospitalized peritoneal dialysis patients (62.7% males) were evaluated. Mean age was 62.8±20.6 years, 9.6% underwent HD, and IHM was 5.9% (n=192). IHM mortality was stable throughout the study period. Deceased subjects were older, were hospitalized longer, had a higher comorbidity burden, and had a higher percentage of HD treatment needs than survivors. Age, male sex, comorbidity burden, and HD treatment were predictors of IHM. Receiver operating characteristics (ROC) analysis confirmed the impact of comorbidity burden on IHM, especially when age was considered.

CONCLUSIONS

We conclude that in male, elderly hospitalized peritoneal dialysis patients with failing dialysis technique, comorbidity burden should be considered being a predictor of IHM.

Psychosocial determinants of healthcare use costs in kidney transplant recipients

Introduction

Psychosocial factors frequently occur in kidney transplant recipients (KTRs), leading to behavioral alterations and reduced therapeutic adherence. However, the burden of psychosocial disorders on costs for KTRs is unknown. The aim of the study is to identify predictors of healthcare costs due to hospital admissions and emergency department access in KTRs.

Methods

This is a longitudinal observational study conducted on KTRs aged >18 years, excluding patients with an insufficient level of autonomy and cognitive disorder. KTRs underwent psychosocial assessment via two interviews, namely the Mini-International Neuropsychiatric Interview 6.0 (MINI 6.0) and the Diagnostic Criteria for Psychosomatic Research Interview (DCPR) and via the Edmonton Symptom Assessment System Revised (ESAS-R) scale, a self-administrated questionnaire. Sociodemographic data and healthcare costs for hospital admissions and emergency department access were collected in the 2016-2021 period. Psychosocial determinants were as follows: (1) ESAS-R psychological and physical score; (2) symptomatic clusters determined by DCPR (illness behavior cluster, somatization cluster, and personological cluster); and (3) ICD diagnosis of adjustment disorder, anxiety disorder, and mood disorder. A multivariate regression model was used to test the association between psychosocial determinants and total healthcare costs.

Results

A total of 134 KTRs were enrolled, of whom 90 (67%) were men with a mean age of 56 years. A preliminary analysis of healthcare costs highlighted that higher healthcare costs are correlated with worse outcomes and death (p < 0.001). Somatization clusters (p = 0.020) and mood disorder (p < 0.001) were positively associated with costs due to total healthcare costs.

Conclusions

This study showed somatization and mood disorders could predict costs for hospital admissions and emergency department access and be possible risk factors for poor outcomes, including death, in KTRs.

[Tic douloureux sustained by an eye tumor]

Cancer is a major cause of morbidity and mortality in solid organ transplantation. Nonmelanoma skin cancer (NMSC) such as basocellular (BCC) and spinocellular (SCC) carcinoma, are common in renal transplant recipients. We report a case of an SCC affecting a lacrimal gland in a subject with kidney transplantation. A man aged 75 years who had suffered from glomerulopathy since 1967 and subsequently started haemodialysis, in 1989 was transplanted from a living donor. In 2019, he suffered paresthesia and pain in his right eyebrow arch and he was diagnosed to have neuralgia of the fifth cranial nerve. The failure of medical treatment and the development of a mass in his eyelid plus exophthalmos induced healthcare professionals to perform a magnetic resonance. The latter showed a retrobulbar mass measuring 39×22×16 mm3. Biopsy revealed an SCC and the patient underwent eye exenteration. Although NMSC of the eye is an extremely rare condition, risk factors such as male sex, history of glomerulopathy, and duration of immunosuppression should be taken into consideration at the time of the onset of eye symptoms.

The Impact of Cholecaciferol Supplementation on Bone Mineral Density in Long-Term Kidney Transplant Recipients

Although reduced bone mineral density (BMD) is associated with a higher risk of fractures, morbidity, and mortality in kidney transplant patients (KTRs), there is no consensus on optimal treatment for the alterations of BMD in this population. This study aims at assessing the effect of cholecalciferol supplementation on BMD over a follow-up period of 2 years in a cohort of long-term KTRs. Patients with age ≥ 18 years were included and divided into two subgroups based on treatment with bisphosphonate and/or calcimimetics and/or active vitamin D sterols (KTRs-treated) or never treated with the above medications (KTRs-free). BMD was evaluated at lumbar vertebral bodies (LV) and right femoral neck (FN) with standard DEXA at the beginning and end of the study. According to World Health Organization (WHO) criteria, results were expressed as T-score and Z-score. Osteoporosis and osteopenia were defined as T score ≤ −2.5 SD and T score < −1 and >−2.5 SD, respectively. Cholecalciferol was supplemented at a dose of 25,000 IU/week over 12 weeks followed by 1500 IU/day. KTRs-free (n. 69) and KTRs-treated (n. 49) consecutive outpatients entered the study. KTRs-free were younger (p < 0.05), with a lower prevalence of diabetes (p < 0.05) and of osteopenia at FN (46.3 % vs. 61.2 %) compared to KTRs-treated. At the entry none of the study subjects had a sufficient level of cholecalciferol; Z-score and T-score at LV and FN were not different between groups. At the end of the study period, serum cholecalciferol concentration was significantly increased in both groups (p < 0.001); the KTRs-free group presented an improvement in both T-score and Z-score at LV (p < 0.05) as well as a lower prevalence of osteoporotic cases (21.7% vs. 15.9%); in contrast, no changes were recorded in KTR-treated individuals. In conclusion, supplementation with cholecalciferol ameliorated Z-score and T-score at LV in long-term KTRs who had been never treated with active or inactive vitamin D sterols, bisphosphonates, and calcimimetics. Future endeavours are needed to confirm these preliminary findings.

Seasonal pattern in elderly hospitalized with acute kidney injury: a retrospective nationwide study in Italy

Purpose

Acute kidney injury (AKI) frequently complicates hospitalization and is associated with in-hospital mortality (IHM). It has been reported a seasonal trend in different clinical conditions. The aim of this study was to evaluate the possible relationship between seasons of the year and IHM in elderly hospitalized patients with AKI.

Methods

We selected all admissions complicated by AKI between 2000 and 2015 recorded in the Italian National Hospital Database. ICD-9-CM code 584.xx identified subjects with age ≥ 65 years and age, sex, comorbidity burden, need of dialysis treatment and IHM were compared in hospitalizations recorded during the four seasons. Moreover, we plotted the AKI observed/expected ratio and percentage of mortality during the study period.

Results

We evaluated 759,720 AKI hospitalizations (mean age 80.5 ± 7.8 years, 52.2% males). Patients hospitalized with AKI during winter months had higher age, prevalence of dialysis-dependent AKI, and number of deceased patients. In whole population IHM was higher in winter and lower in summer, while the AKI observed/expected ratio demonstrated two peaks, one in summer and one in winter. Logistic regression analysis demonstrated that parameters such as age, autumn, winter, comorbidity burden were positively associated with IHM.

Conclusion

We conclude that a seasonality exists in AKI, however, relationship between seasons and AKI could vary depending on the aspects considered. Both autumn and winter months are independent risk factors for IHM in patients with AKI regardless of age, sex and comorbidity burden. On the contrary, summer time reduces the risk of death during hospitalizations with AKI.

MO1011: The Effect of Vitamin D on Bone Mineral Density: A Real-Life Study in Long-Term Kidney Transplant Recipients Never Supplemented

BACKGROUND AND AIMS

Vitamin D insufficiency has been associated with decreased bone mineral density (BMD) in kidney transplant patients (KTRs). However, few data on BMD changes due to vitamin D supplementation in long-term KTRs are available. The purpose of our study is to ascertain the effect of 25-OH-vitamin D (25-OH-D) supplementation on the BMD over a follow-up period of up to 3 years in a real-life cohort of long-term KTRs never supplemented with 25-OH-D and not treated with active vitamin D, bisphosphonate and calciomimetics.

METHOD

Demographic, clinical and laboratory data were collected. Inclusion criteria were: (1) being a recipient of a kidney from a cadaveric or living donor, (2) age ≥ 18 years and (3) no therapy with inactive vitamin D sterols. Patients with parathyroidectomy and/or history of bone fractures were excluded. BMD was evaluated with standard DEXA, performed at baseline (before vitamin D supplementation) and at the end of the study period. BMD was assessed at lumbar vertebral bodies (LV) and right femoral neck (FN) by a single operator. Bone mineral content (BMC) was calculated in grams (g), bone area in centimetres squared (cm2), and BMD in g/cm2 (BMC divided by the area). According to WHO criteria, results were expressed as T-score [standard deviation (SD) relative to young healthy adults] and Z-score (SD relative to age-matched controls). Osteoporosis and osteopenia were defined as T-score ≤−2.5 SD and T-score &lt;−1 and &gt;−2.5 SD, respectively. According to plasma levels, 25-OH-D was supplemented as recommended for the general population. Linear mixed model analysis was implemented to test the impact of 25-OH-D use on Z-score, T-score and BMD changes (dependent variables) adjusted for sex, age, BMI and presence of diabetes. Z-score, T-score and BMD changes were defined as Z-score, T-score and BMD at follow-up, Z-score, T-score and BMD at study inception.

RESULTS

A total of 118 KTRs consecutive outpatients never supplemented with 25-OH-D, of whom 69 KTRs were untreated (KTRs-free) and 49 were treated (control group) with bisphosphonate (n = 13) and/or calcio-mimetics (n = 11) and/or active vitamin D (n = 29) were enrolled. Clinical and biochemical characteristics are shown in Table 1. At the basal DEXA, the percentage of osteopenia and osteoporosis was 39.0% and 21.2% at LV; 52.5% and 16.9% at FN, respectively. The mean study-period was 27.7 ± 3.4 months. Basal and follow-up Z-score, T-score and BMD at both measurement sites are reported in Table 2. In linear mixed model analysis, a positive interaction of 25-OH-D supplementation on T-score and Z-score changes at the lumbar vertebral bodies was found (P &lt; .05). At the end of the study, no statistical differences in Z-score, T-score and BMD gains were observed.

CONCLUSION

Prolonged supplementation with 25-OH-D affects Z-score and T-score at LV in long-term KTRs never supplemented with active or inactive vitamin D.

Bone Mineral Density Changes in Long-Term Kidney Transplant Recipients: A Real-Life Cohort Study of Native Vitamin D Supplementation

Vitamin D insufficiency has been associated with reduced bone mineral density (BMD) in kidney transplant patients (KTRs). However, the efficacy of vitamin D supplementation on BMD remains poorly defined, especially for long-term KTRs. We aimed to investigate the effect of native vitamin D supplementation on the BMD of KTRs during a 2-year follow-up. Demographic, clinical, and laboratory data were collected. BMD was evaluated with standard DEXA that was performed at baseline (before vitamin D supplementation) and at the end of study period. BMD was assessed at lumbar vertebral bodies (LV) and right femoral neck (FN) by a single operator. According to WHO criteria, results were expressed as the T-score (standard deviation (SD) relative to young healthy adults) and Z-score (SD relative to age-matched controls). Osteoporosis and osteopenia were defined as a T-score ≤ -2.5 SD and a T-score < -1 and a > -2.5 SD, respectively. Based on plasma levels, 25-OH-vitamin D (25-OH-D) was supplemented as recommended for the general population. Data from 100 KTRs were analyzed. The mean study period was 27.7 ± 3.4 months. At study inception, 25-OH-D insufficiency and deficiency were recorded in 65 and 35 patients. At the basal DEXA, the percentage of osteopenia and osteoporosis was 43.3% and 18.6% at LV and 54.1% and 12.2% at FN, respectively. At the end of the study, no differences in the Z-score and T-score gains were observed. During linear mixed model analysis, native vitamin D supplementation was found to have a negative nitration with Z-score changes at the right femoral neck in KTRs (p < 0.05). The mean dose of administered cholecalciferol was 13.396 ± 7.537 UI per week; increased 25-OH-D levels were found (p < 0.0001). Either low BMD or 25-OH-vitamin D concentration was observed in long-term KTRs. Prolonged supplementation with 25-OH-D did not modify BMD, Z-score, or T-score.

[Physical exercise in chronic kidney disease: an empty narrative or an effective intervention?]

Chronic kidney disease (CKD) is growing worldwide, with increasing numbers of patients facing end-stage renal disease, high cardiovascular risk, disability and mortality. Early recognition of CKD and improvements in lifestyle are crucial for maintaining or recovering both physical function and quality of life. It is well known that reducing sedentariness, increasing physical activity and initiating exercise programs counteract cardiovascular risk and frailty, limit deconditioning and sarcopenia, and improve mobility, without side-effects. However, these interventions, often requested by CKD patients themselves, are scarcely available. Indeed, it is necessary to identify and train specialists on exercise in CKD and to sensitize doctors and health personnel, so that they can direct patients towards an active lifestyle. On the other hand, effective and sustainable interventions, capable of overcoming patients' barriers to exercise, remain unexplored. Scientific societies, international research teams and administrators need to work together to avoid that exercise in nephrology remains an empty narrative, a niche interest without any translations into clinical practice, with no benefit to the physical and mental health of CKD patients.

Exploring the Level of Post Traumatic Growth in Kidney Transplant Recipients via Network Analysis

Although kidney transplant can lead to psychiatric disorders, psychosocial syndromes and demoralization, a positive post-traumatic growth (PTG) can occur in kidney transplant recipients (KTRs). However, the PTG-Inventory (PTGI), a reliable tool to measure PTG is scarcely used to explore the effect of this stressful event in KTRs. Thus, the purpose of our study was to assess the level of PTG and its correlation with demoralization, physical and emotional symptoms or problems via network analysis in KTRs. Additionally, we aimed at exploring the association of PTG with psychiatric diagnoses, Diagnostic Criteria for Psychosomatic Research (DCPR) conditions, and medical variables. A total of 134 KTRs were tested using MINI International Neuropsychiatric Interview 6.0 (MINI 6.0), DCPR interview, PTGI, Edmonton Symptom Assessment System (ESAS), Canadian Problem Checklist (CPC) and Demoralization scale (DS-IT). PTGI was used to investigate the positive psychological experience of patients after KT. It consists of 21 items divided in five factors. Routine biochemistry, immunosuppressive agents, socio-demographic and clinical data were collected. A symptom network analysis was conducted among PTGI, ESAS and DS-IT. Mean score of PTGI total of sample was 52.81 ± 19.81 with higher scores in women (58.53 ± 21.57) than in men (50.04 ± 18.39) (p < 0.05). PTGI-Relating to Others (16.50 ± 7.99) sub-score was markedly higher than other PTGI factor sub-scores. KTRs with DCPR-alexithymia or International Classification of Diseases, tenth revision (ICD-10) anxiety disorders diagnosis had lower PTGI total score and higher PTGI-Personal Strength sub-score, respectively (p < 0.05). The network analysis identified two communities: PTGI and ESAS with DS-IT. DS-IT Disheartenment, DS-IT Hopelessness and PTGI Relating to Others were the most central items in the network. After 1000 bootstrap procedures, the Exploratory graph analysis revealed the presence of a median of two communities in the network in 97.5% of the bootstrap iterations. A more extensive use of PTGI should be encouraged to identify and enhance the positive psychological changes after KT.

Infodemiology of renal diseases: a novel opportunity to investigate public global interest

OBJECTIVE

The aim of this study was to investigate the global community interest about renal diseases through relative search volumes (RSVs) of Google Trends (GT).

MATERIALS AND METHODS

The online interest for the search terms hematuria (H), proteinuria (P), chronic kidney disease (CKD) and dialysis (D) was measured by evaluating RSVs from 2010 to 2019. All countries listed in GT were analysed and those presenting RSVs related to all search terms were considered following geographical position.

RESULTS

Mean values of RSVs for D, CKD, H and P were 80±9%, 11±2%, 17±2% and 11±1%, respectively. D is the search term most frequently typed in English-speaking countries. On the other hand, in Latin Countries, the interest for P and H was higher than D. Searching for D, CKD and H are highly correlated whilst correlation coefficients between RSVs for D, CKD, and H with P are lower. Since 2010, the interest for renal diseases maintained stable.

CONCLUSIONS

GT is a reliable tool in evaluating global interest for renal diseases in different geographical areas and temporal patterns. Although infodemiology represents a method for investigating the dissemination of information at a global level, our results suggest the need for increasing general population's interest for renal diseases especially, and move from simple interest to global awareness in the view of prevention strategies.

Infodemiology of solid organ transplantation: relationship to the Global Observatory on Donation and Transplantation data

OBJECTIVE

Although transplantation medicine has been continuously improving, its impact on the general population needs to be evaluated. This study describes the global community interest in solid organ transplantation (SOT) using Google Trends, comparing relative search volumes (RSVs) and data from the World Health Organization (WHO) Global Observatory on Donation and Transplantation (GODT) regarding SOT activity all around the world.

MATERIALS AND METHODS

The online interest for the search terms "kidney transplantation", "liver transplantation", "heart transplantation" and "lung transplantation" was measured, evaluating RSVs and the number of worldwide SOT recorded in the GODT website from 2008 to 2018.

RESULTS

The mean values of RSVs were 51.7±16.8 for liver transplantation, 39.8±9.6 for kidney transplantation, 22.4±7.4 for heart transplantation and 15.4±5.2 for lung transplantation, and these values gradually reduced during the study period. Anglo Saxon countries had the highest interest for SOT, and the mean values of RSVs per year and annual numbers of SOT were inversely correlated.

CONCLUSIONS

Despite the apparent interest and awareness, we found that public interest in SOT is decreasing. Access to information is crucial for improving understanding of transplantation and motivation to donate. Health care professionals could take advantage by using the internet, and evaluation of RSVs could represent valuable feedback.

MO946THE LEVEL OF POST-TRAUMATIC GROWTH IN KIDNEY TRANSPLANT RECIPIENTS WITH LONG TERM DURATION OF GRAFT

Background and Aims

Kidney transplant (KT)can cause a psychological trauma due to changes in self-perception, in interpersonal relationships, and in the philosophy of life. However, the exposure to this traumatic event might lead to not only stress disorders but also positive growth. Primary aim of study was to evaluate the prevalence of post-traumatic growth (PTG)in KTRs. Secondary aim was to explore any association between PTG and psychiatric, psychosocial and medical variables, specifically psychiatric diagnoses, demoralization, as well as physical and general problems or symptoms.

Method

KTRs followed up in a single nephrology Unit, were evaluated. Each patient was individually administered MINI International Neuropsychiatric Interview 6.0. and DCPR interview to evaluate ICD-10 psychiatric diagnoses and DCPR diagnoses. PTG Inventory (PTGI), ESAS-revised, CPC, and DS-IT were given as self-report instruments to be filled in. PTGI was used to investigate positive psychological experience of patients after KT on a 0 to 5-point Likert scale(0=I did not experience this change as a result of my KT;5=I experienced this change to a very great degree as a result of my KT).It consists of 21 items divided in five factors: New Possibilities(NP),Relating to Others(RO),Personal Strength(PS),Spiritual Change(SC),and Appreciation of Life(AL).ESAS-revised, DS-IT and CPC were used to examine the severity of physical and psychological symptoms on a 0 to 10 scale; to measure the severity of demoralization on a 0 to 4 scale and to evaluate the physical and general problems in a yes/no(0–1)format, respectively.

Results

Data pertaining to 134 out of 143 consecutive outpatients were collected. Clinical characteristics of sample and ranking order of ICD and DCPR diagnoses are shown in Tab.1.Mean score of PTGI total of sample was 52.02 (±20.69).SC(4.26±2.94)experience was markedly lower than RO(16.26±8.18),NP(11.25±5.56),PS(10.91±5.33)and AL(9.77±3.72).PS changes were higher in KTRs with adaption ICD diagnosis(p&lt;0.001);while no SC change was found in KTRs with an ICD diagnosis of mood disorders(p&lt;0.01).DCPR diagnosis of alexithymia and Irritability were associated with low RO score(13.74±6.51 and 13.97±6.95,respectively)(p &lt;0.05).AL subscale was positively correlated with ESAS anxiety symptom and ESAS psychological distress sub-score(p&lt;0.05); and negatively with DS-lT loss of meaning and purpose subscale(p&lt;0.05).Women(57.2±23.07)had higher scores of PTGI than men (49.5±19.04)(p &lt;0.05).No significant correlation was found between CPC problems, blood chemistry and socio-demographic characteristics, including months after transplant.

Conclusion

This study shows that KTRs had moderate-to-high levels of PTG which did not change after KT overtime. Also, lower RO score was associated with DCPR diagnosis of alexithymia, highlighting the potential ability of PTGI to identify KTRs who need psychological support. Further multicentre studies should be conducted to investigate the positive psychological changes after KT.

Deficiency in the Screening Process of Fabry Disease: Analysis of Chronic Kidney Patients Not on Dialysis

Fabry Disease (FD), a rare and progressive, X-linked lysosomal storage disorder, is caused by mutations in the α-galactosidase A (GLA) gene which leads to enzymatic deficiency of GLA. Misdiagnosed and undiagnosed FD cases are common for the variable FD phenotype, ranging from asymptomatic and/or impairment of single organs, which is typically seen in females and in patients with late-onset mutation, to multiple organ disease, which is frequently found in males with classic GLA mutation. Consequently, for an early diagnosis and an efficient treatment of FD, three different strategies of screening, new-born screening, high-risk screening and familiar screening, have been conducted. However, most of FD screening in the CKD population has been carried out in hemodialysis patients and kidney transplant recipients, for whom the renal damage is already irreversible, so the effectiveness of enzymatic replacement therapy is limited and delayed therapeutic intervention results in worse long-term outcomes. This review investigates the actual strategies of screening initiatives for the identification of FD, examining in detail those performed in CKD patients not on dialysis.

A Personalized Patient-Centered Intervention to Empower through Physical Activity the Patient in the Dialysis Center: Study Protocol for a Pragmatic Nonrandomized Clinical Trial

Sedentariness of patients affected by end-stage kidney disease (ESKD) expose them to high risk of unfavorable clinical outcomes. Exercise training is effective in improving physical function, quality of life (QoL) and long-term outcomes. However, the existing barriers related to patients, programs and dialysis staff limit patient participation and call for new strategies. This pragmatic nonrandomized trial will test the impact on ESKD population of an intervention proposed by an exercise facilitator regularly present in a dialysis center. The patient will be free to choose among three-month walking and/or resistance low-intensity training programs: (a) guided physical activity increase; (b) home-based exercise; (c) in-hospital (pre/post dialysis) supervised exercise; (d) performance assessment only. The first phase will define feasibility and the characteristics and preference of responders. The second phase will evaluate safety and patients’ adherence. Outcome measures will be collected at baseline, after three-month and at six-month follow-up. They will include: aerobic capacity, QoL, gait speed, strength, depression and long-term clinical outcomes (hospitalization and mortality). The trial was approved by the Area-Vasta Emilia-Romagna Centro Ethics Committee with approval number 48/2019. Written informed consent will be obtained from all participants. The results of the study will be presented in international congresses, published in peer-reviewed journals and communicated to the patient community. Registration details: Clinicaltrials.gov NCT04282616 [Registered:24/02/2020].

The Use of Demoralization Scale in Italian Kidney Transplant Recipients

Demoralization is a commonly observed syndrome in medically ill patients. The risk of demoralization may increase in patients after a kidney transplant (KTRs) because of the stressful nature of renal transplantation, psychosocial challenges, and adjustment needs. No study is available on demoralization amongst KTRs. The purpose of our study was to evaluate the validity of the Italian version of the Demoralization Scale (DS-IT) and the prevalence of demoralization in KTRs. Also, we aimed at exploring the association of the DS-IT with International Classification of Diseases (ICD) psychiatric diagnoses, post-traumatic growth (PTG), psychological and physical symptoms, and daily-life problems. A total of 134 KTRs were administered the MINI International Neuropsychiatric Interview 6.0. and the Diagnostic Criteria for Psychosomatic Research-Demoralization (DCPR/D) Interview. The DS-IT, the Edmonton Symptom Assessment System (ESAS), the Canadian Problem Checklist (CPC), were used to measure demoralization, physical and psychological symptoms, and daily-life problems; also, positive psychological experience of kidney transplantation was assessed with the PTG Inventory. Routine biochemistry and sociodemographic data were collected. Exploratory factor analysis demonstrated a four-dimensional factor structure of the DS-IT, explaining 55% of the variance (loss of meaning and purpose, disheartenment, dysphoria, and sense of failure). DS-IT Cronbach alpha coefficients indicated good or acceptable level of internal consistency. The area under the Receiving Operating Characteristics (ROC) curve for DS-IT (against the DCPR/D interview as a gold standard) was 0.92. The DS-IT optimal cut-off points were ≥20 (sensitivity 0.87, specificity 0.82). By examining the level of demoralization, 14.2%, 46.3%, 24.6%, and 14.6% of our sample were classified as having no, low, moderate, and high demoralization, respectively, with differences according to the ICD psychiatric diagnoses (p < 0.001). DS-IT Total and subscales scores were positively correlated with scores of ESAS symptoms and CPC score. A correlation between DS-IT loss of meaning and purpose subscale and PTGI appreciation of life subscale (p < 0.05) was found. This study shows, for the first time, a satisfactory level of reliability of the DS-IT and a high prevalence of severe demoralization in KTRs.

P1621VITAMIN D SUPPLEMENTATION: CHANGES IN BONE MINERAL DENSITY IN KIDNEY TRANSPLANT PATIENTS WITH LONG TERM DURATION OF THE GRAFT

Background and Aims

In the medical literature, several studies have linked bone mineral density (BMD) with vitamin D deficiency in kidney transplant patients (KTRs). However, in spite of the fact that ergocalciferol, cholecalciferol and calcifediol reduce parathyroid hormone (PTH) and improves calcium levels, their effects on the bone mineral density (BMD) in KTRs remain undefined. In consideration of the lack of data available, we aim at investigating the effect of inactive form of vitamin D supplementation on the BMD over a follow-up period up to 2 year, in a real-life cohort of long-term kidney transplant(KT).

Method

This study was carried out in KTRs who were followed up in a Nephrology Unit. Exclusion criteria were parathyroidectomy, therapy with bisphosphonate, previous history of bone fractures. Demographic, clinical and immunosuppressive agents were collected. Based on 25-OH-D levels, KTRs were classified as suffering from deficiency (&lt; 30 ng/mL). BMD was evaluated at lumbar vertebral bodies (LV) and right femoral hip (FH) by a single operator, using a standard dual energy X-ray absorptiometry. According to WHO criteria, results were expressed as T-score (standard deviation [SD] relative to young healthy adults), and Z-score (SD relative to age-matched controls). Osteoporosis and osteopenia were defined as T score ≤ −2.5 SD and T score &lt; −1 and &gt; −2.5 SD, respectively. Laboratory data, 25-OH-D, and BMD were measured at baseline and after 24 months of supplementation therapy. Vitamin D deficiency was corrected using standard treatment strategy recommended for general population. Continuous variables were expressed as mean ± SD whereas categorical variables as percentage. The Student’s t test and chi-square test were used to compare to compare continuous and categorical variables, respectively. For before and after comparisons of continuous variables, the paired t-test or one-sample Wilcoxon signed rank test were used based on variable’s distribution.

Results

Data pertaining to 111 out of 133 consecutive outpatients were collected, of whom most were males (69.4%), no-smokers (89.1%) and treated with glucocorticoids (84%). The mean age was 53.9±11.6 years and months after transplant was 161.6±128.3. No statistical differences were found among patients with normal BMD, osteopenia or osteoporosis at LV and FH in terms of age at transplant, gender distribution, time on dialysis, BMI and eGFR, serum calcium, serum phosphate, 25-OH-D and iPTH. At baseline, 25-OH-D was 13.9±7.2 ng/ml and the prevalence of osteopenia/osteoporosis was 40.9% (T-Score -1.69±0.37; Z-score -1.16±1.09) and 21.8 % (T-Score -3.15±0.50; Z-score -2.27±0.58) at LV; 55.3 % (T-Score -1.8±0.46; Z-score -0.84±0.633) and 14 % (T-Score -2.83±0.39; Z-score -1.65±0.49) at FH. After 27.6±3.7 months of therapy with cholecalciferol at mean dose of 13.396±7.537 UI at week, 25-OH-D values increased to 29.4±9.4 ng/ml (p&lt;0.0001) while no statistically significant changes were found in Z-score and T-score at both sites, except for a mild improvement in lumbar vertebral Z-score, reaching −0.82± 0.7 (p = 0.06) in KTRs with osteopenia

Conclusion

Our study showed BMD remained stable after up to 2 years of inactive vitamin D therapy in long-term kidney transplant with vitamin D deficiency. A mild increase in Z-score was observed in the L-spine. Further designated studies should be conducted to demonstrate the effect of vitamin D on BMD.

Ultrasonography of Quadriceps Femoris Muscle and Subcutaneous Fat Tissue and Body Composition by BIVA in Chronic Dialysis Patients

Protein Energy Wasting (PEW) in hemodialysis (HD) patients is a multifactorial condition due to specific pathology-related pathogenetic mechanisms, leading to loss of skeletal muscle mass in HD patients. Computed Tomography and Magnetic Resonance Imaging still represent the gold standard techniques for body composition assessment. However, their widespread application in clinical practice is difficult and body composition evaluation in HD patients is mainly based on conventional anthropometric nutritional indexes and bioelectrical impedance vector analysis (BIVA). Little data is currently available on ultrasound (US)-based measurements of muscle mass and fat tissue in this clinical setting. The purpose of our study is to ascertain: (1) if there are differences between quadriceps rectus femoris muscle (QRFM) thickness and abdominal/thigh subcutaneous fat tissue (SFT) measured by US between HD patients and healthy subjects; (2) if there is any correlation between QRFM and abdominal/thigh SFT thickness by US, and BIVA/conventional nutritional indexes in HD patients. We enrolled 65 consecutive HD patients and 33 healthy subjects. Demographic and laboratory were collected. The malnutrition inflammation score (MIS) was calculated. Using B-mode US system, the QRFM and SFT thicknesses were measured at the level of three landmarks in both thighs (superior anterior iliac spine, upper pole of the patella, the midpoint of the tract included between the previous points). SFT was also measured at the level of the periumbilical point. The mono frequency (50 KHz) BIVA was conducted using bioelectrical measurements (Rz, resistance; Xc, reactance; adjusted for height, Rz/H and Xc/H; PA, phase angle). 58.5% were men and the mean age was 69 (SD 13.7) years. QRFM and thigh SFT thicknesses were reduced in HD patients as compared to healthy subjects (p < 0.01). Similarly, also BIVA parameters, expression of lean body mass, were lower (p < 0.001), except for Rz and Rz/H in HD patients. The average QRFM thickness of both thighs at top, mid, lower landmarks were positively correlated with PA and body cell mass (BCM) by BIVA, while negatively correlated with Rz/H (p < 0.05). Abdominal SFT was positively correlated with PA, BCM and basal metabolic rate (BMR) (p < 0.05). Our study shows that ultrasound QRFM and thigh SFT thicknesses were reduced in HD patients and that muscle ultrasound measurements were significantly correlated with BIVA parameters.

Screening Performance of Edmonton Symptom Assessment System in Kidney Transplant Recipients

An average prevalence of 35% for psychiatric comorbidity has been reported in kidney transplant recipients (KTRs) and an even higher prevalence of other psychosocial syndromes, as defined by the Diagnostic Criteria for Psychosomatic Research (DCPR), has also been found in this population. Consequently, an easy, simple, rapid psychiatric tool is needed to measure physical and psychological symptoms of distress in KTRs. Recently, the Edmonton Symptom Assessment System (ESAS), a pragmatic patient-centred symptom assessment tool, was validated in a single cohort of KTRs. The aims of this study were: to test the screening performances of ESAS for the International Classification of Diseases-10th Revision (ICD-10) psychiatric diagnoses in KTRs; to investigate the optimal cut-off points for ESAS physical, psychological and global subscales in detecting ICD-10 psychiatric diagnoses; and to compare ESAS scores among KTR with ICD-10 diagnosis and DCPR diagnosis. 134 KTRs were evaluated and administered the MINI International Neuropsychiatric Interview 6.0 and the DCPR Interview. The ESAS and Canadian Problem Checklist (CPC) were given as self-report instruments to be filled in and were used to examine the severity of physical and psychological symptoms and daily-life problems. The physical distress sub-score (ESAS-PHYS), psychological distress sub-score (ESAS-PSY) and global distress score (ESAS-TOT) were obtained by summing up scores of six physical symptoms, four psychological symptoms and all single ESAS symptoms, respectively. Routine biochemistry, immunosuppressive agents, socio-demographic and clinical data were collected. Receiving Operating Characteristic (ROC) analysis was used to examine the ability of the ESAS emotional distress (DT) item, ESAS-TOT, ESAS-PSY and ESAS-PHYS, to detect psychiatric cases defined by using MINI6.0. The area under the ROC curve for ESAS-TOT, ESAS-PHYS, ESAS-PSY and DT item were 0.85, 0.73, 0.89, and 0.77, respectively. The DT item, ESAS-TOT and ESAS-PSY optimal cut-off points were ≥4 (sensitivity 0.74, specificity 0.73), ≥20 (sensitivity 0.85, specificity 0.74) and ≥12 (sensitivity 0.85, specificity 0.80), respectively. No valid ESAS-PHYS cut-off was found (sensitivity <0.7, specificity <0.7). Thirty-nine (84.8%) KTRs with ICD-10 diagnosis did exceed both ESAS-TOT and ESAS-PSY cut-offs. Higher scores on the ESAS symptoms (except shortness of breath and lack of appetite) and on the CPC problems were found for ICD-10 cases and DCRP cases than for ICD-10 no-cases and DCPR no-cases. This study shows that ESAS had an optimal screening performance (84.8%) to identify ICD-10 psychiatric diagnosis, evaluated with MINI; furthermore, ESAS-TOT and ESAS-PSY cut-off points could provide a guide for clinical symptom management in KTRs.

Vitamin D in kidney transplant recipients

Kidney transplant recipients (KTRs) are susceptible to low levels of vitamin D, which may be responsible for mineral and bone metabolism disorders and play some role in the occurrence of cardiovascular, metabolic, immunologic, neoplastic, and infectious complications after kidney transplant. Kidney Disease Improving Global Outcomes (KDIGO) guidelines of the year 2017 recommended vitamin D supplementation in the first 12 months after transplant using the same treatment strategies for the general population. However, no recommendations are provided after the first 12 months due to a lack of sufficient data. This review analyses some studies that assessed the vitamin D status of KTRs and the effects of nutritional and active vitamin D supplementation on bone mineral density, cardiovascular disease, proteinuria, and graft function in KTRs.