Stratified risks of infection-related hospitalization in patients with chronic kidney disease - A prospective cohort study

Iptacopan Reduces Proteinuria and Stabilizes Kidney Function in C3 Glomerulopathy

Introduction

C3 glomerulopathy (C3G) is a complex, chronic, ultra rare, progressive primary glomerulonephritis, resulting from alternative complement pathway overactivation, leading to kidney failure in most patients, and frequent recurrence in transplants. Iptacopan (LNP023) is an oral, proximal complement inhibitor specifically targeting factor B, that selectively inhibits the alternative complement pathway.

Methods

This was a phase 2 extension study of 26 adult patients with native kidney (cohort A), or recurrent C3G (post kidney transplantation; cohort B) receiving open label iptacopan.

Results

At 12 months, patients in cohort A had a significant reduction in 24-hour urine protein-to-creatinine ratio (UPCR; 57%; P < 0.0001; confidence interval [CI]: 0.31-0.59), an improvement in estimated glomerular filtration rate (eGFR; 6.83 ml/min per 1.73 m2; P = 0.0174; CI: 1.25-12.40), and an increase in serum C3 levels (geometric mean ratio to baseline: 3.53; P < 0.0001; CI: 3.01-4.15). In cohort B, most patients had normal urinary protein excretion at baseline (mean [range] 24-hour UPCR: 121 [9-445]), which was slightly lower by 12 months (21% reduction; CI: 0.48-1.31; P = 0.3151). In cohort B at 12 months, mean eGFR was at baseline values (mean change from baseline: -0.96 ml/min per 1.73 m2; P = 0.7335; CI: -6.60 to 4.69). Cohort B patients had significantly higher serum C3 values at 12 months compared with baseline (ratio:1.96; CI: 1.70-2.27; P < 0.0001). In cohorts A + B combined, the median difference in C3 deposit score on renal biopsy from baseline was -7.00 (CI: -12.00 to 4.00;) at 9 to 12 months treatment with iptacopan.

Conclusion

These data provide a clinical rationale for further evaluation of long-term treatment of C3G with iptacopan.

National Analysis of Preexisting Immunosuppressive Conditions and Infection-Related Readmissions Among Sepsis Survivors

BACKGROUND

Recurrent episodes of infection and subsequent sepsis are a frequent cause of readmission after sepsis hospitalization. Although persistent immune dysregulation initiated during the sepsis episode may play a role, the impact of preexisting immune suppression (including HIV, organ transplantation, and cancer) and common chronic diseases associated with immune suppression (diabetes and chronic kidney disease) on the risk of recurrent infections after sepsis is unknown.

OBJECTIVES

To investigate the role of preexisting immune-suppressive conditions (PISCs) and other common chronic diseases on infection-related readmissions after a sepsis admission.

METHODS

Using the US 2015 Nationwide Readmissions Database, we identified a retrospective cohort of adult patients with an unplanned sepsis index admission from April to September, excluding patients with sepsis during the preceding 90 days. We followed all sepsis survivors for subsequent infection-related admissions for 90 days. We identified clinical conditions using International Classification of Diseases coding.

RESULTS

We identified 649 029 unique unplanned sepsis admissions over 6 months; 189 604 (29.2%) had sepsis with PISC, and 459 425 (70.8%) had sepsis without PISC. Overall, sepsis survivors were older (median age, 70 years), and 145 156 (22.4%) experienced at least 1 infection-related readmission within 90 days. The incidence of infection-related readmission among sepsis survivors with PISC was 26.1%, whereas it was 20.8% for those without PISC. The excess risk of infection-related readmissions attributed to PISC was 5.3%, whereas the excess risk attributed to diabetes and chronic kidney disease was 3.7% and 4.7%, respectively. The background risk attributed to new-onset sepsis among participants with none of these conditions was 16.3%. Multivariable regression analysis adjusting for age, gender, and acute illness factors indicated that odds of infection-related readmission were strongly associated with PISC (odds ratio 1.30; 95% confidence interval, 1.29-1.32), closely followed by chronic kidney disease (1.28 [1.27-1.32]) and diabetes (1.17 [1.16-1.19]).

CONCLUSION

The risk of subsequent infection is higher among patients with PISC, although chronic kidney disease and diabetes are also important risk factors for subsequent infection and sepsis readmissions.

Evaluating the efficacy and safety of Holmium laser enucleation of the prostate in patients with obstructive uropathy attributable to bladder outlet obstruction

OBJECTIVE

To evaluate outcomes of Holmium laser enucleation of the prostate (HoLEP) in individuals presenting with obstructive-uropathy (OU) attributable to bladder outlet obstruction (BOO).

METHODS

We performed a retrospective review of patients who underwent HoLEP from August 2017 to January 2023 at our institution. We identified patients with preoperative OU defined by presence of chronic hydronephrosis suggestive of BOO and conducted a matched-pair analysis (1:2) with patients undergoing HoLEP without OU. Patients' demographic, perioperative and postoperative voiding parameters, serum creatinine level, and complications were analyzed up to one-year of follow-up.

RESULTS

Preoperative OU was present in 42 patients. Demographic and preoperative parameters were comparable except median preoperative creatinine (1.245 vs. 1.065 ng/ml, p < 0.001) and catheterization rates (76.2% vs. 25%, p < 0.001) were higher in the OU group. The mean duration of postoperative catheterization was longer in the OU group (3.83 vs. 2.26 days, p = 0.048). Two patients in the OU group developed postoperative acute kidney injury. There was no difference in the rate of postoperative complications, improvement in International Prostate Symptom Score and maximum urinary flow amongst both groups except a higher post-void residual volume at 3- and 12-months (p = 0.001 and p = 0.037, respectively) in OU patients. Patients noted significant improvement in serum creatinine level at 6-12 weeks postoperatively from peak baseline level (P = 0.002).

CONCLUSION

HoLEP is effective and safe in patients with OU suggestive of BOO, though they are at higher risk of postoperative acute kidney injury.

Chronic disease patients have fewer social contacts: A pilot survey with implications for transmission dynamics

Non-communicable diseases (NCD) are the most important cause of death in the world. The socio-economic costs associated with NCDs makes it imperative to prevent and control them in the 21st century. The severe toll that the COVID-19 pandemic has taken worldwide is an unfortunate illustration of our limited insight into the infectious risk for the global population. Co-incidence between NCD and infection offers an underexplored opportunity to design preventive policies. In a pilot survey, we observed that the NCD population displays a substantial reduction in their social contacting behavior as compared to the general population. This indicates that existing mathematical models based on contact surveys in the general population are not applicable to the NCD population and that the risk of acquiring an infection following a contact is probably underestimated. Our demonstration of reduced social mixing in several chronic conditions, raises the question to what extent the social mixing is influenced by the burden of disease. We advocate the design of disease-specific contact surveys to address how the burden of disease associates with social contact behavior and the risk of infection. The SARS-CoV-2 pandemic offers an unprecedented opportunity to gain insight into the importance of infection in the NCD population and to find ways to improve healthcare procedures.

The Impact of Infections on the Progression of Chronic Kidney Disease

Background and Objective: Infectious diseases continue to be a global burden and their impact is even worse if the patients already have other comorbidities. Because chronic kidney disease is very frequent, affecting 10% of the population, our study aims to explore the impact that infectious events have on its progression. Material and Methods: This is a retrospective, observational study based on a cohort of 238 dialyzed patients from the Nephrology Clinic of "Dr. Carol Davila" Clinical Hospital of Nephrology, Bucharest, who were followed from their first visit for five years, between 1 January 2007 and 1 January 2022. For each of them, the presence of an infectious event and the moment of the initiation of dialysis were recorded. Results: Statistical analysis showed that the patients who had at least one infectious episode were older (p = 0.004), their hemoglobin and lymphocytes were significantly lower (p = 0.03 and p = 0.02, respectively) and the time until the initiation of dialysis was lower (p = 0.007). Also, the preservation of kidney function was influenced by the number and the severity of infectious episodes. In the univariate Cox model, the following variables were associated with increased risk of dialysis: advanced age (p: 0.009; HR: 1.021; CI: 1.005 to 1.036), low hemoglobin (p: 0.001; HR: 0.861; CI: 0.786 to 0.943), previous diagnosis of chronic obstructive pulmonary disease (p: 0.002; HR: 2.467; CI: 1.376 to 4.424), presence of hematuria (p: 0.03; HR: 1.604; CI: 1.047 to 2.457) and increased values of proteinuria (p: 0.01; HR: 1.122; CI: 1.028 to 1.224) and of serum creatinine measured both at the time of the first visit and at the time of each infectious event (p: <0.001; HR: 1.262; CI: 1.141 to 1.396). Also, the presence of an infectious episode was associated with a 1.7-fold increase in the risk of dialysis initiation. The independent predictors of survival identified by the multivariate Cox model were age (p: 0.004; HR: 1.034; CI: 1.010-1.058), serum creatinine (p: <0.001; HR: 1.421; CI: 1.203 to 1.658) and proteinuria (p: <0.001; HR: 1.241; CI: 1.126 to 1.369) at the time of enrollment, but also the presence of an infectious episode during the patient's evolution (p: 0.04; HR: 1.705; CI: 1.013 to 2.868). Conclusions: In the evolution of patients with chronic kidney disease, an active search for individual factors favoring the occurrence of infectious episodes should be taken into consideration to prevent a faster progression toward end-stage kidney disease.

Frailty and the risk of infection-related hospitalizations in older age: Differences by sex

OBJECTIVES

To investigate the extent to which frailty is associated with infection-related hospitalizations in older men and women, and to explore whether, among women, previous exposure to endogenous estrogens in terms of age at menopause and number of pregnancies modify such a relationship.

STUDY DESIGN

The sample comprised 2784 participants in the Progetto Veneto Anziani aged ≥65 years. At baseline and after 4.4 years, frailty was identified according to the presence of three or more of the following: weakness, exhaustion, weight loss, low physical activity, and low walking speed. A passive follow-up on infection-related hospitalizations and mortality was performed for 10 years of observation through linkage with regional registers.

MAIN OUTCOME MEASURES

The association between frailty and infection-related hospitalizations was assessed through mixed-effects Cox regressions.

RESULTS

Frailty was significantly associated with a 78 % higher risk of infection-related hospitalization, with stronger results in men (hazard ratio = 2.32, 95 % confidence interval 1.63-3.30) than in women (hazard ratio = 1.54, 95 % confidence interval 1.18-2.02). Focusing on women, we found a possible modifying effect for the number of pregnancies but not menopausal age. Women who had experienced one or no pregnancy demonstrated a higher hazard of infection-related hospitalization as a function of frailty (hazard ratio = 3.00, 95 % confidence interval 1.58-5.71) than women who had experienced two or more pregnancies (hazard ratio = 1.68, 95 % confidence interval 1.18-2.39).

CONCLUSION

Frailty in older age increases the risk of infection-related hospitalizations, especially in men. The "immunologic advantage" of the female sex in younger age seems to persist also after menopause as a function of the number of pregnancies a woman has experienced.

Effect of chronic kidney disease on all-cause mortality in tuberculosis disease: an Australian cohort study

BACKGROUND

While there has been a recent epidemiological and clinical focus on the interaction between diabetes and tuberculosis, the interaction between chronic kidney disease and tuberculosis has been less studied. In particular, little is known of the effect of eGFR levels well above that seen in end stage kidney disease on mortality.

METHODS

We conducted a retrospective cohort study of 653 adults from a large Australian hospital network, using data from a state-wide registry of reported tuberculosis cases between 2010 and 2018, with ascertainment of diabetes status and renal function data from hospital medical records and laboratory data. Cox proportional hazards regression models were used to calculate hazard ratios for all-cause mortality associated with categories of chronic kidney disease in adults with tuberculosis disease.

RESULTS

Total number of deaths was 25 (3.8%). Compared to tuberculosis cases with eGFR ≥ 60 ml/min, all-cause mortality was higher for those with chronic kidney disease from an eGFR level of 45 ml/min. The association was independent of sex, age and diabetes status with adjusted hazard ratio of 4.6 (95% CI: 1.5, 14.4) for eGFR 30-44 ml/min and 8.3 (95% CI: 2.9, 23.7) for eGFR < 30 ml/min.

CONCLUSIONS

Our results suggest a notably increased risk of all-cause mortality even in those with more moderate degrees of renal impairment, in a low tuberculosis prevalence setting. The impact of these findings on a population basis are at least as significant as that found with diabetes and warrant further investigation in populations with higher tuberculosis prevalence.

The Preventable Productivity Burden of Kidney Disease in Australia

BACKGROUND

Kidney disease is associated with impaired work productivity. However, the collective effect of missed work days, reduced output at work, and early withdrawal from the workforce is rarely considered in health-economic evaluations.

METHODS

To determine the effect on work productivity of preventing incident cases of kidney disease, using the novel measure "productivity-adjusted life year" (PALY), we constructed a dynamic life table model for the Australian working-age population (aged 15-69 years) over 10 years (2020-2029), stratified by kidney-disease status. Input data, including productivity estimates, were sourced from the literature. We ascribed a financial value to the PALY metric in terms of gross domestic product (GDP) per equivalent full-time worker and assessed the total number of years lived, total PALYs, and broader economic costs (GDP per PALY). We repeated the model simulation, assuming a reduced kidney-disease incidence; the differences reflected the effects of preventing new kidney-disease cases. Outcomes were discounted by 5% annually.

RESULTS

Our projections indicate that, from 2020 to 2029, the estimated number of new kidney-disease cases will exceed 161,000. Preventing 10% of new cases of kidney disease during this period would result in >300 premature deaths averted and approximately 550 years of life and 7600 PALYs saved-equivalent to a savings of US$1.1 billion in GDP or US$67,000 per new case avoided.

CONCLUSIONS

Pursuing a relatively modest target for preventing kidney disease in Australia may prolong years of life lived and increase productive life years, resulting in substantial economic benefit. Our findings highlight the need for investment in preventive measures to reduce future cases of kidney disease.

Understanding variations and influencing factors on length of stay for T2DM patients based on a multilevel model

Aim

Shortening the length of stay (LOS) is a potential and sustainable way to relieve the pressure that type 2 diabetes mellitus (T2DM) patients placed on the public health system.

Method

Multi-stage random sampling was used to obtain qualified hospitals and electronic medical records for patients discharged with T2DM in 2018. A box-cox transformation was adopted to normalize LOS. Multilevel model was used to verify hospital cluster effect on LOS variations and screen potential factors for LOS variations from both individual and hospital levels.

Result

50 hospitals and a total of 12,888 T2DM patients were included. Significant differences in LOS variations between hospitals, and a hospital cluster effect on LOS variations (t = 92.188, P<0.001) was detected. The results showed that female patients, patients with new rural cooperative’ medical insurance, hospitals with more beds, and hospitals with faster bed turnovers had shorter LOS. Conversely, elderly patients, patients with urban workers’ medical insurance, patients requiring surgery, patients with the International Classification of Diseases coded complication types E11.1, E11.2, E11.4, E11.5, and other complications cardiovascular diseases, grade III hospitals, hospitals with a lower doctor-to-nurse ratio, and hospitals with more daily visits per doctor had longer LOS.

Conclusions

The evidence proved that hospital cluster effect on LOS variation did exist. Complications and patients features at individual level, as well as organization and resource characteristics at hospital level, had impacted LOS variations to varying degrees. To shorten LOS and better meet the medical demand for T2DM patients, limited health resources must be allocated and utilized rationally at hospital level, and the patients with the characteristics of longer LOS risk must be identified in time. More influencing factors on LOS variations at different levels are still worth of comprehensive exploration in the future.

The Association Between Body Mass Index and the Risk of Hospitalization and Mortality due to Infection: A Prospective Cohort Study

Background

We aim to determine whether obesity increases the risk of various infections using a large prospective population-based cohort.

Methods

A total of 120 864 adults were recruited from the New Taipei City health screening program from 2005 to 2008. Statistics for hospitalization and mortality due to infection were obtained from the National Health Insurance Database and the National Death Registry in Taiwan.

Results

During a mean follow-up period of 7.61 years, there were 438, 7582, 5298, and 1480 first hospitalizations due to infection in the underweight, normal, overweight, and obese groups, respectively. Obesity significantly increases the risk of hospitalization for intra-abdominal infections (adjusted hazard ratio [aHR], 1.19; 95% CI, 1.00–1.40), including diverticulitis, liver abscess, acute cholecystitis and anal and rectal abscess, reproductive and urinary tract infection (aHR, 1.38; 95% CI, 1.26–1.50), skin and soft tissue infection (aHR, 2.46; 95% CI, 2.15–2.81), osteomyelitis (aHR, 1.70; 95% CI, 1.14–2.54), and necrotizing fasciitis (aHR, 3.54; 95% CI,1.87–6.67), and this relationship is dose-dependent. This study shows that there is a U-shaped association between body mass index (BMI) and hospitalization for lower respiratory tract infection, septicemia, and the summation of all infections and that underweight people are at the greatest risk, followed by obese people. There is a clear negative relationship between BMI and infection-related mortality.

Conclusions

The pattern that BMI affects the risk of hospitalization and mortality due to infection varies widely across infection sites. It is necessary to tailor preventive and therapeutic measures against different infections in hosts with different BMIs.