Mortality Outcomes of Patients with Chronic Kidney Disease and Chronic Obstructive Pulmonary Disease

Association of Frailty with Postoperative Survival and Outcomes Following Hemodialysis Vascular Access Creation

BACKGROUND

The literature suggests that for patients to experience the purported advantages of an arteriovenous fistula (AVF) over arteriovenous graft (AVG), a minimum survival of 18 months is required. With the vascular access guideline shift away from "Fistula First" toward shared decision making, patient survival after vascular access creation is a major factor to consider in optimal access selection. The objective of this study is to examine outcomes of vascular access in patients with short survival and factors associated with short survival, including frailty.

METHODS

We performed a retrospective review of 200 access procedures performed between August 2018 and November 2020 at a single institution. Maturation was defined as the date when the surgeon deemed the access ready to be used for dialysis. A modified Risk Analysis Index (RAI) score was used to calculate frailty.

RESULTS

Within 3 years after access creation, 55 (27.5%) patients were recorded as dead (mortality within 3 years of access creation [3YMORT]). In the 3YMORT group, 5 did not follow-up with the surgeon prior to death and 22/34 (65%) of AVF versus 15/16 (94%) of AVGs were deemed mature prior to death (P = 0.03). Of the accesses that matured, the median days to maturation for AVF was 69 (interquartile range [IQR] 53, 87) versus 28 (IQR 18, 32) for AVG (P < 0.001). Patients in the 3YMORT group were older (70.6 vs. 63.4, P = 0.004) and had a lower body mass index (24.8 vs. 27.4, P = 0.03). Patients in the 3YMORT group had higher prevalence of dysrhythmia (35% vs. 15%, P = 0.002), chronic obstructive pulmonary disorder (20% vs. 10%, P = 0.048) and dialysis dependence at the time of access creation (91% vs. 75%, P = 0.01). There was no significant difference in sex, white race, Hispanic ethnicity, coronary artery disease, congestive heart failure, previous coronary artery bypass graft or percutaneous coronary intervention, diabetes, hypertension, and peripheral arterial disease between the 2 groups. The 3YMORT group had a significantly higher prevalence of frailty (78% vs. 49%, P = 0.0002). Patients categorized as frail by the RAI had a significantly higher risk of 3YMORT (odds ratio [OR] 3.74, 95% confidence interval [CI] 1.82-7.66) compared to nonfrail patients. Patients categorized as very frail by the RAI had an even higher risk of 3YMORT (OR 4.20, 95% CI 1.95-9.05), compared to nonfrail patients.

CONCLUSIONS

Patients with short life expectancy after vascular access creation may have high rates of AVF nonmaturation and longer time to maturation. Factors associated with high risk of mortality within 3 years of vascular access creation correlate well with factors included in the RAI frailty score. Patients who are frail or very frail may be appropriate candidates for AVG creation over AVF considering their high risk for short life expectancy.

Interorgan communication networks in the kidney-lung axis

The homeostasis and health of an organism depend on the coordinated interaction of specialized organs, which is regulated by interorgan communication networks of circulating soluble molecules and neuronal connections. Many diseases that seemingly affect one primary organ are really multiorgan diseases, with substantial secondary remote organ complications that underlie a large part of their morbidity and mortality. Acute kidney injury (AKI) frequently occurs in critically ill patients with multiorgan failure and is associated with high mortality, particularly when it occurs together with respiratory failure. Inflammatory lung lesions in patients with kidney failure that could be distinguished from pulmonary oedema due to volume overload were first reported in the 1930s, but have been largely overlooked in clinical settings. A series of studies over the past two decades have elucidated acute and chronic kidney-lung and lung-kidney interorgan communication networks involving various circulating inflammatory cytokines and chemokines, metabolites, uraemic toxins, immune cells and neuro-immune pathways. Further investigations are warranted to understand these clinical entities of high morbidity and mortality, and to develop effective treatments.

Trends in acute myocardial infarction mortality in the European Union, 2012-2020

AIMS

To assess the sex- and age-specific trends in acute myocardial infarction (AMI) mortality in the modern European Union (EU-27) member states between years 2012 and 2020.

METHODS AND RESULTS

Data on cause-specific deaths and population numbers by sex for each country of the EU-27 were retrieved through a publicly available European Statistical Office (EUROSTAT) dataset for the years 2012 to 2020. AMI-related deaths were ascertained when codes for AMI (ICD-10 codes I21.0-I22.0) were listed as the underlying cause of death in the medical death certificate. Deaths occurring before the age of 65 years were defined as premature deaths. To calculate annual trends, we assessed the average annual percent change (AAPC) with relative 95% confidence intervals (CIs) using joinpoint regression. During the study period, 1 793 314 deaths (1 048 044 males and 745 270 females) occurred in the EU-27 due to of AMI. The proportion of AMI-related deaths per 1000 total deaths decline from 5.0% to 3.5% both in the entire population (P for trend < 0.001) and in males or females, separately. Joinpoint regression analysis revealed a continuous linear decrease in age-adjusted AMI-related mortality from 2012 to 2020 among EU-27 members [AAPC: -4.6% (95% CI: -5.1 to -4.0), P < 0.001]. The age-adjusted mortality rate showed a plateau in some Eastern European countries and was more pronounced in EU-27 females and in subjects aged ≥65 years.

CONCLUSION

Over the last decade, the age-adjusted AMI-related mortality has been continuously declining in most of the in EU-27 member states. However, some disparities still exist between western and eastern European countries.

Clinical characteristics of severe coronavirus disease 2019 patients with chronic obstructive pulmonary disease

OBJECTIVES

Coronavirus disease 2019 (COVID-19) in elderly and patients with chronic respiratory diseases (COPD) had a poor prognosis. COPD is one of the most common chronic respiratory diseases. We explore the epidemiological characteristics of patients with severe COVID-19 with COPD patients in order to provide medical evidence for the prevention and treatment of severe COVID-19.

METHODS

We retrospectively analyzed the clinical baseline characteristics, treatment strategies, disease progression and prognosis of 557 severe COVID-19 patients admitted to the West Court of Union Hospital of Huazhong University of Science and Technology from January 29, 2020 to April 8, 2020.

RESULTS

A total of 465 patients with severe COVID-19 were enrolled in the study, including 248 (53.3%) males and 217 (46.7%) females. The median age of severe COVID-19 patients was 62.0 years, and 53 patients were complicated with COPD. Common symptoms at the onset included fever (78.5%), dry cough (67.1%), shortness of breath (47.3%) and fatigue (40.9%). Compared with non-COPD patients, patients with COPD had significantly lower levels of SpO2 in admission (90.0% vs 92.0%, P=0.014). In terms of laboratory examinations, patients with COPD had higher levels of C-reactive protein, interleukin-6, procalcitonin, total bilirubin, blood urea nitrogen, serum creatinine, lipoprotein (a), high-sensitivity troponin I, and D-dimer, while had lower levels of platelet counts, albumin and apolipoprotein AI. Severe COVID-19 patients with COPD had higher Sequential Organ Failure Assessment scores [3.0(2.0, 3.0) vs 2.0(2.0, 3.0), P=0.038] and CURB-65 score [1.0(1.0, 2.0) vs1.0(0.0, 1.0), P<0.001], and a higher proportion of progressing to critical illness (28.3% vs 10.0%, P<0.001) with more complications [e.g. septic shock (15.1% vs 6.1%, P=0.034)], had higher incidence rates of antibiotic therapies (90.6% vs 77.2%, P=0.025), non-invasive (11.3% vs 1.7%, P<0.001) and invasive mechanical ventilation (17.0% vs 8.3%, P=0.039), ICU admission (17.0% vs 7.5%, P=0.021) and death (15.1% vs 6.1%, P=0.016). Cox proportion hazard model was carried out, and the results showed that comorbid COPD was an independent risk factor for severe COVID-19 patients progressing to critical type, after adjusting for age and gender [adjusted hazard ratio (AHR)=2.38(1.30-4.37), P=0.005] and additionally adjusting for chronic kidney diseases, hypertension, coronary heart disease [AHR=2.63(1.45-4.77), P<0.001], or additionally adjusting for some statistically significant laboratory findings [AHR=2.10(1.13-3.89), P=0.018].

CONCLUSIONS

Severe COVID-19 patients with COPD have higher levels of disease severity, proportion of progression to critical illness and mortality rate. Individualized treatment strategies should be adopted to improve the prognosis of severe COVID-19 patients.

Gender dimension in cardio-pulmonary continuum

Cardio-pulmonary diseases, which were once regarded as a man's illness, have been one of the leading causes of morbidity and mortality for both men and women in many countries in recent years. Both gender and sex influence the functional and structural changes in the human body and therefore play an important role in disease clinical manifestation, treatment choice, and/or response to treatment and prognosis of health outcomes. The gender dimension integrates sex and gender analysis in health sciences and medical research, however, it is still relatively overlooked suggesting the need for empowerment in the medical research community. Latest advances in the field of cardiovascular research have provided supportive evidence that the application of biological variables of sex has led to the understanding that heart disease in females may have different pathophysiology compared to males, particularly in younger adults. It has also resulted in new diagnostic techniques and a better understanding of symptomatology, while gender analysis has informed more appropriate risk stratification and prevention strategies. The existing knowledge in the pulmonary field shows the higher prevalence of pulmonary disorders among females, however, the role of gender as a socio-cultural construct has yet to be explored for the implementation of targeted interventions. The purpose of this review is to introduce the concept of gender dimension and its importance for the cardiopulmonary continuum with a focus on shared pathophysiology and disease presentation in addition to interrelation with chronic kidney disease. The review presents basic knowledge of what gender dimension means, and the application of sex and gender aspects in cardiovascular medicine with a specific focus on early pulmonary development, pulmonary hypertension, and chronic obstructive pulmonary disease (COPD). Early vascular aging and inflammation have been presented as a potential pathophysiological link, with further interactions between the cardiopulmonary continuum and chronic kidney disease. Finally, implications for potential future research have been provided to increase the impact of gender dimension on research excellence that would add value to everybody, foster toward precision medicine and ultimately improve human health.

Lung-kidney interactions and their role in chronic kidney disease-associated pulmonary diseases

Chronic illnesses rarely present in a vacuum, devoid of other complications, and chronic kidney disease is hardly an exception. Comorbidities associated with chronic kidney disease lead to faster disease progression, expedited dialysis dependency, and a higher mortality rate. Although chronic kidney disease is most commonly accompanied by cardiovascular diseases and diabetes, there is clear cross talk between the lungs and kidneys pH balance, phosphate metabolism, and immune system regulation. Our present understanding of the exact underlying mechanisms that contribute to chronic kidney disease-related pulmonary disease is poor. This review summarizes the current research on kidney-pulmonary interorgan cross talk in the context of chronic kidney disease, highlighting various acute and chronic pulmonary diseases that lead to further complications in patient care. Treatment options for patients presenting with chronic kidney disease and lung disease are explored by assessing activated molecular pathways and the body's compensatory response mechanisms following homeostatic imbalance. Understanding the link between the lungs and kidneys will potentially improve health outcomes for patients and guide healthcare professionals to better understand how and when to treat each of the pulmonary comorbidities that can present with chronic kidney disease.

Predictors of Renal Function Worsening in Patients with Chronic Obstructive Pulmonary Disease (COPD): A Multicenter Observational Study

Background. Chronic obstructive pulmonary disease (COPD) patients have multiple comorbidities which may affect renal function. Chronic kidney disease (CKD) is a risk factor for adverse outcomes in COPD patients. The predictors of CKD in COPD are not well investigated. Methods. A multicenter observational cohort study including patients affected by COPD (GOLD stages 1 and 2) was carried out. Principal endpoints were the incidence of CKD, as defined by an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m², and the rapid decline of eGFR >5 mL/min/1.73 m²/year. Results. We enrolled 707 outpatients. Overall, 157 (22.2%) patients had CKD at baseline. Patients with CKD were older, with higher serum uric acid (UA) levels, and lower FEV₁. During a mean follow-up of 52.3 ± 30.2 months, 100 patients developed CKD, and 200 patients showed a rapid reduction of eGFR. Multivariable Cox regression analysis displayed that UA (hazard ratio (HR) 1.148, p < 0.0001) and diabetes (HR 1.050, p < 0.0001) were predictors of incident CKD. The independent predictors of rapidly declining renal function were represented by an increase of 1 mg/dL in UA (odds ratio (OR) 2.158, p < 0.0001)), an increase of 10 mL/min/1.73 m² in baseline eGFR (OR 1.054, p < 0.0001) and the presence of diabetes (OR 1.100, p < 0.009). Conclusions. This study shows that COPD patients have a significant worsening of renal function over time and that UA and diabetes were the two strongest predictors. Optimal management of these risk factors may reduce the incidence of CKD in this population thus probably improving clinical outcome.

Quality and quantity culture effectively restores functional and proliferative capacities of endothelial progenitor cell in end-stage renal disease patients

BACKGROUND

Endothelial cell dysfunction plays the crucial role in initiation and propagation of obstructive arteriosclerosis which ultimately causes arterial obstructive syndrome. Additionally, severe endothelial progenitor cells (EPC) dysfunction is always found in those of end-stage renal disease (ESRD) patients. This study tested the hypothesis that a novel method, named "quality and quantity (QQ) culture", could successfully improve the EPC proliferation and function in ESRD patients.

MATERIALS AND METHODS

Peripheral blood mononuclear cells (PBMNCs) were isolated from age-matched control subjects (i.e., normal renal function) (group 1) and ESRD patients (group 2), followed by culture in either conventional EPC culture for one month or in QQ culture for 7 days, respectively. The result showed that as compared to the conventional EPC culture method, the EPC population and M2-like population/ratio (M2/M1) were significantly enriched in QQ culture both in groups 1 and 2 (all p < 0.001), but these parameters did not differ between the groups. As compared with conventional EPC culture, the angiogenesis capacity and colony formation were significantly increased in QQ culture (all p < 0.001), but they showed no difference between groups 1 and 2. In RAW264.7 macrophages treated by liposaccharide, the gene expressions and ELISA findings of pro-inflammatory cytokines (IL-1β/IL-6/TGF-β) and inflammatory mediator (iNOS) were significantly reduced in QQ culture than in conventional EPC culture in groups 1 and 2 (all p < 0.001), but they showed no difference between the groups.

CONCLUSIONS

This study demonstrated that QQ culture enhanced number, proliferation, and angiogenesis of EPCs and anti-inflammatory capacity in ESRD patients.

Exercise intolerance in kidney diseases: physiological contributors and therapeutic strategies

Exertional fatigue, defined as the overwhelming and debilitating sense of sustained exhaustion that impacts the ability to perform activities of daily living, is highly prevalent in chronic kidney disease (CKD) and end-stage renal disease (ESRD). Subjective reports of exertional fatigue are paralleled by objective measurements of exercise intolerance throughout the spectrum of the disease. The prevalence of exercise intolerance is clinically noteworthy, as it leads to increased frailty, worsened quality of life, and an increased risk of mortality. The physiological underpinnings of exercise intolerance are multifaceted and still not fully understood. This review aims to provide a comprehensive outline of the potential physiological contributors, both central and peripheral, to kidney disease-related exercise intolerance and highlight current and prospective interventions to target this symptom. In this review, the CKD-related metabolic derangements, cardiac and pulmonary dysfunction, altered physiological responses to oxygen consumption, vascular derangements, and sarcopenia are discussed in the context of exercise intolerance. Lifestyle interventions to improve exertional fatigue, such as aerobic and resistance exercise training, are discussed, and the lack of dietary interventions to improve exercise tolerance is highlighted. Current and prospective pharmaceutical and nutraceutical strategies to improve exertional fatigue are also broached. An extensive understanding of the pathophysiological mechanisms of exercise intolerance will allow for the development of more targeted therapeutic approached to improve exertional fatigue and health-related quality of life in CKD and ESRD.

MIF associated with pulmonary hypertension susceptibility and severity in non-dialysis Chronic kidney disease patients

Pulmonary hypertension (PAH) is one of the more serious complications of Chronic kidney disease (CKD), and its exact pathogenesis has not been clarified. As an upstream proinflammatory factor, macrophage migration inhibitor (MIF) is involved in the occurrence and development of many diseases. This study aimed to detect the relationship between serum MIF and PAH in non-dialysis CKD patients. A total of 382 non-dialysis CKD patients were enrolled in this study. Bio-Plex cytokine assay was used to detect MIF. CKD patients were divided into the PAH group and non-PAH group according to echocardiographic results. Relative risk was determined by logistic regression analysis. The pulmonary artery pressure in the CKD group was higher than that in the control group ( p < 0.01). Pulmonary arterial pressure was higher in stage 4 to 5 CKD patients than in Stage 1 to 3 CKD patients ( p < 0. 01), and the incidence of PAH was also increased ( p < 0. 01). MIF in the CKD group were higher than in the control group ( p < 0.05). MIF in CKD patients with PAH were higher than those without PAH ( p < 0.05). Multivariate logistic regression analysis showed that MIF is correlated with PAH (OR = 10.745; 95% CI 2.288–89.447, p < 0.05). PAH is common in non-dialysis CKD patients, and with the deterioration of kidney disease, the incidence of PAH is gradually increased, indicating that MIF plays an important role in the development of PAH in CKD patients.

Distribution and impact of age in patients with implantable cardioverter-defibrillators regarding early complications and 1-year clinical outcome: results from the German Device Registry

BACKGROUND

Patients receiving implantable-cardioverter-defibrillators (ICD) in clinical practice are often older or younger than in clinical trials. Whether older patients benefit from ICD-therapy in a similar way as younger patients is under debate. The objective of this study was to provide real-world data regarding outcomes with respect to age in a large cohort in the German Device Registry.

METHODS

Within the registry data from 50 German centers were collected between January 2007 and February 2014.

RESULTS

Our analysis included 3239 ICD patients representing a group of young (28%; group I: < 58 years), intermediate aged (50%; group II: 58-74 years), and elderly patients (22%; group III: 75-92 years). Intergroup comparison of all groups was performed followed by individual comparison vs. group II serving as age-reference group. Procedure-related complications did not differ between all groups. Analysis of the primary endpoint, 1-year all-cause mortality, revealed an increased mortality in the elderly and a decreased mortality in the young cohort vs. the reference group II (group I 2.1%, group II 6.2%, group III 13.2%; p < 0.001). While all-cause rehospitalizations did not differ, we observed a difference in reported device revisions showing more device revisions required in younger patients (group I 8.9%, group II 6.8%, group III 4.0%; p = 0.001).

CONCLUSIONS

One-year mortality was doubled in elderly ICD patients probably due to non-cardiac causes. These results further underpin the need for re-evaluating the primary prevention ICD indication in octo- and nonagenarians. Young patients show lower mortality rates but seem to bear higher risk of device-related complications, which highlights the need for improved measures to reduce device-related complications in the young.

Association among chronic kidney disease, airflow limitation, and mortality in a community-based population: The Yamagata (Takahata) study

Chronic kidney disease (CKD) and chronic obstructive pulmonary disease (COPD) are known risk factors for mortality. In this study, we examined the overlap of CKD and airflow limitation (AFL) that characterises COPD and its effect on 10-year mortality in a community-based population. This study included 1,233 health check-up participants (mean age, 63.7 years; 46.7% men). We defined serum creatinine-based CKD (CKDcr) and serum cystatin C-based CKD (CKDcys) as glomerular filtration rate <60 mL/min/1.73 m², estimated using serum creatinine or cystatin C, and/or dipstick proteinuria ≥1+. AFL was defined as forced expiratory volume in 1 s to forced vital capacity ratio <70% on spirometry. Compared with subjects without AFL, those with AFL showed a significantly higher prevalence of CKDcys but not of CKDcr. Cox proportional hazard analysis adjusted for confounders showed that the hazard ratio (95% confidence interval) for all-cause mortality was 1.45 (0.77–2.63) in subjects with CKDcys alone, 1.29 (0.60–2.54) in those with AFL alone, and 2.94 (1.33–6.12) in those with both CKDcys and AFL, with subjects without both AFL and CKD as the reference. This study showed that AFL and CKDcys are strongly associated and that their overlap is a significant risk factor for mortality in community-based populations.

Diagnosis and Management of Pulmonary Hypertension in Patients With CKD

Pulmonary hypertension (PH) is a highly prevalent and important condition in adults with chronic kidney disease (CKD). In this review, we summarize the definition of PH, discuss its pathophysiology and classifications, and describe diagnostic and management strategies in patients with CKD, including those with kidney failure treated by kidney replacement therapy. In the general population, PH is classified into 5 groups based on clinical presentation, pathology, hemodynamics, and management strategies. In this classification system, PH in CKD is placed in a diverse group with unclear or multifactorial mechanisms, although underlying cardiovascular disease may account for most cases. CKD may itself directly incite pulmonary circulatory dysfunction and remodeling through uremic toxins, inflammation, endothelial dysfunction, and altered vasoregulation. Despite several studies describing the higher prevalence of PH in CKD and kidney failure, along with an association with poor outcomes, high-quality evidence is not available for its diagnostic and management strategies in those with CKD. In CKD not requiring kidney replacement therapy, volume management along with treatment of underlying risk factors for PH are critical. In those receiving hemodialysis, options are limited and transition to peritoneal dialysis may be considered if recurrent hypotension precludes optimal volume control.

A clinical nomogram for the prediction of early mortality in elderly patients initiating dialysis for end-stage renal disease

Background

The number of elderly patients (> 80 years of age) with end-stage renal disease is rapidly increasing. The initiation of dialysis extends the duration of survival; however, the rate of early mortality, that which occurs within the first few months after the initiation of dialysis, is reportedly higher than the rate of late mortality.

Methods

We retrospectively studied a cohort of 300 patients, aged 80 years or older, in whom dialysis was initiated between January 1, 2010, and December 31, 2017, at TOHO Hospital (Gunma, Japan). The rate of early mortality was assessed using the Kaplan-Meier method, and the equivalence of survival curves was tested using log-rank tests. The univariate and multivariate analyses were performed using the Cox proportional hazards model. To evaluate nomogram performance, we assessed both the discrimination and calibration of these models. Two hundred bootstrap resamples were used for internal validation of the accuracy estimates to reduce overfit bias and to determine 95% confidence intervals.

Results

The nomogram was built using the following nine predictors: serum albumin grams per deciliter (hazard ratio [HR] 0.63, p < 0.001), congestive heart failure (HR 1.81, p = 0.004), chronic obstructive pulmonary disease (HR 2.47, p = 0.014), peripheral vascular disease (HR 2.03, p = 0.019), hemiplegia (HR 2.06, p = 0.001), malignant tumors (no metastasis; HR 2.00, p < 0.001), metastatic malignant tumors (HR 4.67, p = 0.006), cardiovascular disease (HR 1.59, p = 0.002), bone fractures due to falls within 1 year (HR 1.85, p = 0.011), and Karnofsky Performance Status (HR 0.98, p < 0.001).

Conclusions

We developed and validated a nomogram that predicts early mortality in elderly patients at the initiation of dialysis for end-stage renal disease. The nomogram may help nephrologists make a shared decision with patients and families regarding the initiation of dialysis.

National Analyses on Survival in Maltese Adult Patients on Renal Replacement Therapy Started During 2009–2012

Chronic kidney disease patients on maintenance dialysis (CKD 5D) experience major morbidity and mortality. No data on survival in Maltese dialysis patients exist; therefore, the aim of this study was to rigorously examine survival statistics in a complete cohort of Maltese CKD 5D patients. The study population was comprised of all incident chronic patients (N=328) starting dialysis at the renal unit, Mater Dei hospital, Msida, Malta, for 4 consecutive years (2009–2012). Each yearly cohort was analysed in detail up to 31st December 2017, providing up to 8 years follow-up. Demographics (male 65%; female 35%), aetiology of renal failure (diabetic kidney disease: n=191; 58.2%), comorbidities, transplant status, and death were documented. Data collection and follow up were completed and statistical analysis was performed on the aggregated cohorts with SPSS version 23 with censoring up to 31st December 2017. The cumulative adjusted 5-year overall survival in Maltese CKD 5D patients was 0.36 and 0.25 at 8 years. No statistical difference was observed according to the year of starting dialysis. Cox regression analysis showed that age and transplant status influenced survival. The unadjusted hazard of death increased by 3% for every 1-year increase in age and was increased by 7% if the patient did not receive a transplant, and overall 22% (n=72) of the entire cohort eventually received transplants. This study reports an approximate 65% mortality at 5 years in Maltese haemodialysis patients, a poor prognosis that, despite optimal medical management, is consistent with worldwide reports.

Major comorbidities lead to the risk of adverse cardiovascular events in chronic obstructive pulmonary disease patients using inhaled long-acting bronchodilators: a case-control study

BACKGROUND

While inhaled bronchodilators reduce symptoms and acute exacerbations of chronic obstructive pulmonary disease (COPD), their use is associated with increased cardiovascular events in some studies. This study investigates the risk of adverse events associated with the use of inhaled bronchodilators in COPD patients with multimorbidity.

METHODS

A case-control study was conducted between January 2015 and December 2017, and patients with spirometry-confirmed diagnosis of COPD (N = 1565) using inhaled long-acting bronchodilators were enrolled. Medical records were reviewed and clinical data, including age, gender, smoking status, major comorbidities, lung function stage, history of exacerbations, bronchodilator regimens, and treatment duration were analyzed. Major adverse cardiovascular events occurring during long-acting bronchodilator use were recorded.

RESULTS

The most common comorbidities were cardiovascular disease (CVD) (53.6%) and chronic kidney disease (CKD) (25.8%). We observed that CVD (odds ratio [OR], 5.77), CKD (OR, 2.02) and history of frequent exacerbations (OR, 2.37) were independent risk factors for cardiovascular events, regardless of the type of bronchodilators use. Moreover, COPD patients with both CKD and CVD had higher risk (6.32-fold) of adverse cardiovascular effects than those with neither comorbidity. Eighty-seven of 1565 (5.56%) COPD patients died during this study period. Of them, 21.8% (19/87) were cardiovascular-related and 73.6% (64/87) patients were respiratory-related mortality. Among COPD patients using long-acting bronchodilators, CKD was the only risk factor to predict cardiovascular events and cardiovascular-related mortality (OR, 4.87; 95% confidence interval [CI], 1.75-13.55].

CONCLUSIONS

COPD patients had higher risk of cardiovascular events were associated with their CVD and/or CKD comorbidities and history of frequent exacerbations, rather than associated with their use of inhaled bronchodilators.

Predictors of Long-term Mortality after Hospitalization for Severe COPD Exacerbation

Introduction:Chronic obstructive pulmonary disease (COPD) is a global health problem resulting in significant morbidity. Acute exacerbation of COPD (AECOPD) is a severe complication associated with increased short- and long-term mortality. Identifying predictors of long-term mortality after a severe AECOPD may improve management and long-term outcome of this disease. Materials and methods:A two-year prospective cohort study was undertaken in an academical medical center between 2016 and 2018. Patients with severe AECOPD who required non-invasive ventilation (NIV) were included. Baseline characteristics at inclusion, comorbidities (kidney dysfunction, left heart disease, diabetes), number of prior episodes of AECOPD and indication for long-term oxygen therapy (LTOT) or non-invasive ventilation (LTNIV) were recorded. Patients were monitored for a two-year period after initial admission. Outcomes were six-month, one-year and two-year mortality, irrespective of cause. Outcomes:51 patients (31 male, mean age 68.1) were included in the study. Mortality rates at six months, one year and two years were 20, 26 and 36%, respectively. Patients receiving LTOT and LTNIV at discharge had lower mortality at two years versus patients with no indication for LTOT and LTNIV at discharge. Absence of LTOT increased six-month mortality (OR .2, 95% CI, .04 to .90) and one-year mortality (p<.05). FEV1 and BMI were also correlated with long-term mortality in univariate analysis, p<.05. Age, number of prior episodes of AECOPD or the presence of comorbidities had no influence on long-term mortality. Conclusion:After an episode of severe AECOPD, LTOT is associated with lower long-term mortality when compared to patients with no severe hypoxemia at discharge. A decreased lung function and body mass index increase long-term mortality.

Association of Extreme Heat Events With Hospital Admission or Mortality Among Patients With End-Stage Renal Disease

Importance

Extreme heat events (EHEs) are increasing in frequency, duration, and intensity, and this trend is projected to continue as part of ongoing climate change. There is a paucity of data regarding how EHEs may affect highly vulnerable populations, such as patients with end-stage renal disease (ESRD). Such data are needed to inform ESRD patient management guidelines in a changing climate.

Objectives

To investigate the association between EHEs and the risk of hospital admission or mortality among patients with ESRD and further characterize how this risk may vary among races/ethnicities or patients with preexisting comorbidities.

Design, Setting, and Participants

This study used hospital admission and mortality records of patients with ESRD who underwent hemodialysis treatment at Fresenius Kidney Care clinics in Boston, Massachusetts; Philadelphia, Pennsylvania; or New York, New York, from January 1, 2001, to December 31, 2012. Data were analyzed using a time-stratified case-crossover design with conditional Poisson regression to investigate associations between EHEs and risk of hospital admission or mortality among patients with ESRD. Data were analyzed from July 1, 2017, to March 31, 2019.

Exposures

Calendar day- and location-specific 95th-percentile maximum temperature thresholds were calculated using daily meteorological data from 1960 to 1989. These thresholds were used to identify EHEs in each of the 3 cities during the study.

Main Outcomes and Measures

Daily all-cause hospital admission and all-cause mortality among patients with ESRD.

Results

The study included 7445 patients with ESRD (mean [SD] age, 61.1 [14.1] years; 4283 [57.5%] men), among whom 2953 deaths (39.7%) and 44 941 hospital admissions (mean [SD], 6.0 [7.5] per patient) were recorded. Extreme heat events were associated with increased risk of same-day hospital admission (rate ratio [RR], 1.27; 95% CI, 1.13-1.43) and same-day mortality (RR, 1.31; 95% CI, 1.01-1.70) among patients with ESRD. There was some heterogeneity in risk, with patients in Boston showing statistically significant increased risk for hospital admission (RR, 1.15; 95% CI, 1.00-1.31) and mortality (RR, 1.45; 95% CI, 1.04-2.02) associated with cumulative exposure to EHEs, while such risk was absent among patients with ESRD in Philadelphia. While increases in risks were similar among non-Hispanic black and non-Hispanic white patients, findings among Hispanic and Asian patients were less clear. After stratifying by preexisting comorbidities, cumulative lag exposure to EHEs was associated with increased risk of mortality among patients with ESRD living with congestive heart failure (RR, 1.55; 95% CI, 1.27-1.89), chronic obstructive pulmonary disease (RR, 1.60; 95% CI, 1.24-2.06), or diabetes (RR, 1.83; 95% CI, 1.51-2.21).

Conclusions and Relevance

In this study, extreme heat events were associated with increased risk of hospital admission or mortality among patients with ESRD, and the association was potentially affected by geographic region and race/ethnicity. Future studies with larger populations and broader geographic coverage are needed to better characterize this variability in risk and inform ESRD management guidelines and differential risk variables, given the projected increases in the frequency, duration, and intensity of EHEs.

Consequences of chronic kidney disease in chronic obstructive pulmonary disease

Background

The combination of chronic obstructive pulmonary disease (COPD) and chronic kidney disease (CKD) is associated with a higher prevalence of comorbidities and increased mortality. The impact of kidney function on patient-centered outcomes in COPD has not been evaluated.

Methods

Patients from the German COPD and Systemic Consequences - Comorbidities Network (COSYCONET) cohort COPD were analysed. CKD was diagnosed if the estimated glomerular filtration rate (eGFR) measurements were < 60 mL/min/1.73m² at study inclusion and six month later. The effect of CKD, on comorbidities, symptoms [modified British Medical Research Council dyspnoea scale], physical capacity [six-minute walk test, and timed up and go] and St George’s Respiratory Questionnaire were analysed. Restricted cubic spline models were used to evaluate a nonlinear relationship between eGFR with patient-centered outcomes, cox survival analysis was applied to evaluate mortality.

Results

2274 patients were analysed, with CKD diagnosed in 161 (7.1%). Spline models adjusted for age, gender, BMI, FEV₁ and cardiovascular comorbidities revealed independent associations between eGFR with modified British Medical Research Council dyspnoea scale, St George’s Respiratory Questionnaire, (p < 0.001 and p = 0.011), six-minute walk test (p = 0.015) and timed up and go (p < 0.001). CKD was associated with increased mortality, independently from for other cardiovascular comorbidities (hazard ratio 2.3; p < 0.001).

Conclusion

These data show that CKD is a relevant comorbidity in COPD patients which impacts on patient-centered outcomes and mortality.

Trial registration

NCT01245933

Electronic supplementary material

The online version of this article (10.1186/s12931-019-1107-x) contains supplementary material, which is available to authorized users.

Aerobic exercise effects in renal function and quality of life of patients with advanced chronic kidney disease

BACKGROUND

To date, the therapeutic effects of exercise have not yet been evaluated regarding renal function parameters and quality of life specifically in patients with advanced chronic kidney disease. Thus, the study aim was to evaluate the effects of aerobic exercise in renal function and quality of life in patients with advanced chronic kidney disease.

METHODS

A quasi-experimental prospective study [NCT03301987] was carried out. Nine patients with advanced chronic kidney disease were recruited from a hospital nephrology unit. Kidney function parameters such as creatinine, creatinine clearance, urea clearance, glomerular filtration rate, and creatinine/weight proportion, as well as the Kidney Disease Quality of Life SF-36 (KDQoL-SF36) were measured at baseline and after 1 month of aerobic exercise.

RESULTS

Significant increases (P <.05) were observed for creatinine/weight proportion as well as symptoms, effects, charge, and physical domains of the KDQoL-SF36 after 1 month of therapeutic exercise. The other parameters did not show any statistically significant difference (P >.05).

CONCLUSIONS

Aerobic exercise may cause improvements in renal function and quality of life of patients with advanced chronic kidney disease. Further studies about therapeutic exercise protocols specifically in patients with advanced stages of chronic kidney disease should be carried out in order to study their effectiveness and safety.

The association between COPD and outcomes of patients with advanced chronic kidney disease

Objective

The aim of this study was to investigate the impact of COPD on the outcomes of patients with advanced chronic kidney disease (CKD).

Patients and methods

All patients with advanced CKD from 2000 to 2010 were identified from the Taiwanese National Health Insurance Research Database. Associations between COPD and the risk of long-term dialysis and all-cause mortality were assessed.

Results

A total of 33,399 advanced CKD patients were enrolled, of whom 31,536 did not have COPD (non-COPD group) and 1,863 had COPD (COPD group). The incidence of end-stage renal disease (ESRD) was higher for those with COPD than those without COPD (744.2 per 1,000 person-years vs 724.6 per 1,000 person-years, adjusted HR [aHR] 1.04; 95% CI 0.96–1.12). The cumulative incidence rates of ESRD were similar between the COPD and non-COPD groups (log-rank test, P=0.356). Overall, the patients with COPD had a higher risk of death than those without COPD (151.7 per 1,000 person-years vs 125.5 per 1,000 person-years, aHR 1.22; 95% CI 1.11–1.33). The cumulative mortality rate was higher in the COPD group than in the non-COPD group (log-rank test, P<0.001).

Conclusion

COPD increased the risk of mortality among the advanced CKD patients in this study, especially the elderly and male patients. In contrast, COPD did not increase the risk of ESRD among the advanced CKD patients.

Chronic respiratory disease: an unrecognized risk factor in dialysis

Background

Few studies have analysed the impact of chronic respiratory disease (CRD) on outcomes in dialysis. We therefore sought to describe patients with CRD and end-stage renal disease and their outcomes after dialysis start, compared with patients without CRD, focusing especially on causes of death, access to renal transplantation and causes of hospital admissions.

Methods

The study included 52 797 adults aged 18 years and older who began dialysis from 2008 to 2013 and are recorded in the French national REIN registry. Survival, specific mortality and access to the waiting list and to renal transplantation were analysed, with adjustment for various comorbidities and consideration of competitive risks. The numbers of hospitalizations and hospital days, together with their causes, were analysed through an indirect link between the REIN database and the national French hospital discharge database.

Results

The frequency of CRD at dialysis start was 12% and was associated with various other comorbidities, including obesity and tobacco use. After adjustment for those comorbidities, CRD remained associated with a higher risk of death [hazard ratio (HR) 1.20, 95% confidence interval (CI) 1.16-1.25]. Patients with CRD were 30% less likely to undergo transplantation (HR 0.67, 95% CI 0.6-0.7) than patients without CRD. Their risk of dying from a respiratory disease was 8.8 times higher; their risk of dying from infection was also higher. Patients with CRD had a higher rate of admissions and more hospital days, for all causes and for every cause, except cancer.

Conclusions

CRD was associated with higher risks of death and hospital admissions and with lower likelihoods of being wait-listed for and undergoing renal transplantation. Increasing clinical awareness by patients and doctors and encouragement of spirometry use should promote more accurate clinical diagnosis and better preventive care for CRD.

Impact of chronic kidney disease among Korean adults with chronic obstructive pulmonary disease

PURPOSE

Chronic kidney disease (CKD) is an emerging issue in patients with chronic obstructive pulmonary disease (COPD). In COPD, loss of muscle mass is relatively common finding, and diagnosis of CKD should be based on measured or estimated GFR (Cavailles et al. Eur Respir Rev 22:454-475, 2013; Gosker et al. Am J Clin Nutr 71:1033-1047, 2000; Delanaye and Mariat Nat Rev Nephrol 9:513-522, 2013). We aimed to determine the prevalence and impact of CKD, defined by using chronic kidney disease epidemiology collaboration (CKD-EPI) equation, in COPD patients.

METHODS

This study analyzed data of 3393 adults 40 years of age or older who completed pulmonary function tests in the fifth Korea National Health and Nutritional Examination Survey 2012. Participants with normal lung function (NLF) and COPD were included. CKD was defined as an eGFR <60 mL/min/1.73 m². Multivariate logistic regression analysis was performed to evaluate the relationship between CKD and COPD.

RESULTS

Among 3393 participants, 528 (15.6%) were classified as COPD. The prevalence values of participants with eGFR level ≥90, 60-90, and <60 mL/min/1.73 m² were 54.1, 43.6, and 2.2% in those with NLF and 39.8, 51.5, and 8.7% in those with COPD (p = 0.000). We analyzed the relationship between COPD and all factors that had a statistically significant association with COPD. The significant factors were older age, lower education, BMI, pulmonary tuberculosis, current bronchial asthma, smoking, and CKD.

CONCLUSIONS

In a Korean population ≥40 years old, the prevalence of participants with COPD is 15.6%. CKD is an independent risk factor for COPD. In addition to CKD, older age, lower education, BMI, pulmonary tuberculosis, current bronchial asthma, and smoking are significantly associated with COPD.

Lung and kidney: a dangerous liaison? A population-based cohort study in COPD patients in Italy

Background

COPD is among the major causes of death, and it is associated with several comorbid conditions. Chronic kidney disease (CKD) is frequently diagnosed in older people living in Western societies and could impact COPD patients’ mortality. We evaluated the relationship between burden of comorbidities, CKD, and mortality in a population-based cohort of patients discharged with a diagnosis of COPD.

Methods

A longitudinal cohort study was conducted evaluating 27,272 COPD patients. Recruitment of COPD subjects and identification of CKD and other comorbidities summarized by the Charlson comorbidity index (CCI) were based on claims data coded according to the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). Severity of COPD was classified by hospital diagnosis or exemption from medical charges due to respiratory failure or previous hospitalizations for COPD. The impact of comorbidities on survival was assessed by Cox regression.

Results

Less than 40% of patients were still alive at the end of a median follow-up of 37 months (17 months for patients who died and 56 months for those alive at the end of follow-up). After adjustment for age, gender, and severity score of COPD, CKD (hazard ratio =1.36, 95% confidence interval 1.30–1.42) independently from comorbidities summarized by the CCI was a significant risk factor for mortality.

Conclusion

In spite of limitations due to the use of claims data, long-term survival of COPD patients was heavily affected by the presence of CKD and other comorbidities.

Obstructive and Restrictive Lung Function Measures and CKD: National Health and Nutrition Examination Survey (NHANES) 2007-2012

BACKGROUND

Prevalence and factors associated with obstructive and restrictive lung function in people with chronic kidney disease (CKD) are unknown.

STUDY DESIGN

Cross-sectional and longitudinal analyses.

SETTING & PARTICIPANTS

Participants aged 40 to 79 years from NHANES (National Health and Nutrition Examination Survey) 2007 to 2012 who underwent spirometry testing.

PREDICTOR

CKD (estimated glomerular filtration rate [eGFR] >15-<60mL/min/1.73m(2) or urinary albumin-creatinine ratio ≥ 30mg/g).

OUTCOMES

Restrictive lung function (defined as FEV1/FVC≥0.70 and baseline FVC<80% predicted), obstructive lung function (defined as FEV1/FVC<0.70 based on postbronchodilator spirometric results), and mortality data (available for 2007-2008 and 2009-2010 survey periods).

RESULTS

7,610 participants (CKD=1,338; non-CKD=6,272) were included. Prevalences of obstructive lung function adjusted to the mean age of 55 years and 50% men in the CKD and non-CKD groups were 15.6% and 13.3%, respectively (P=0.2). Similarly, adjusted prevalences of restrictive lung function in the CKD and non-CKD groups were 9.8% and 6.7%, respectively (P=0.01). Presence of albumin-creatinine ratio ≥ 30mg/g was associated with obstructive (OR, 1.42; 95% CI, 1.07-1.88) and restrictive lung function (OR, 1.43; 95% CI, 1.01-2.03) in the entire study cohort. eGFR<60mL/min/1.73m(2) was associated with higher odds of obstructive lung function. In a multivariable Cox model, age (HR, 1.07; 95% CI, 1.04-1.11) and presence of obstructive lung function (HR, 2.68; 95% CI, 1.80-3.97), but not CKD measures, were associated with death.

LIMITATIONS

Small proportion of participants with advanced kidney disease.

CONCLUSIONS

In a representative sample of US adults, impaired lung function is common in those with and without CKD. Albuminuria was independently associated with both obstructive and restrictive lung function, and eGFR<60mL/min/1.73m(2) was associated with higher odds of obstructive lung function. Older age and obstructive lung function were associated with higher likelihood of death. Further studies examining the burden of lung disease in advanced CKD are needed.