China collaborative study on dialysis: a multi-centers cohort study on cardiovascular diseases in patients on maintenance dialysis

Efficacy and Safety of Sacubitril/Valsartan in Hemodialysis Patients with Chronic Heart Failure: A Retrospective Study at a Single Center

BACKGROUND Heart failure and end-stage renal disease often coexist, and management of heart failure can be challenging in patients during hemodialysis. Sacubitril-valsartan (SV) is the first drug to receive regulatory approval for use in patients with chronic heart failure with reduced ejection fraction (HFrEF) and New York Heart Association (NYHA) classification II, III, or IV. This study aimed to evaluate the efficacy and safety of SV for use in chronic heart failure patients on maintenance hemodialysis (MHD). MATERIAL AND METHODS From September 2021 to October 2022, 28 patients on MHD with chronic heart failure at the hemodialysis center of Shaanxi Second Provincial People's Hospital were regularly followed. During the 12-week follow-up period, all patients were administered SV at doses of 100-400 mg per day. Biochemical indicators, echocardiographic parameters, life quality scores, and adverse events were evaluated. RESULTS We enrolled 28 patients. Compared with the baseline levels, NYHA class III in these patients treated with SV was significantly decreased from 60.71% to 32.14% (P<0.05), left ventricular ejection fraction (LVEF) was significantly improved from 44.29±8.92% to 53.32±7.88% (P<0.001), the Physical Component Summary (PCS) score was significantly improved from 40.0±6.41 to 56.20±9.86 (P<0.001), and the Mental Component Summary (MCS) score was significantly improved from 39.99±6.14 to 52.59±11.0 (P<0.001). CONCLUSIONS We demonstrated that SV improved NYHA classification and LVEF values of patients on MHD with chronic heart failure and also improved their quality of life.

Effect of sacubitril valsartan on heart failure with mid-range or preserved ejection fraction in patients on maintenance hemodialysis: real-world experience in a single-center, prospective study

BACKGROUND

This study aimed to evaluate the effect of sacubitril valsartan (SV) on heart failure (HF) hospitalization and cardiovascular mortality in patients on hemodialysis with HF with preserved ejection fraction (EF; HFpEF).

METHODS

This single-center, prospective study enrolled 155 stable hemodialysis patients with EF > 40% who were followed up for 12 months. Fifty-nine patients were treated with SV; the others were matched for EF (57.89 ± 9.35 vs. 58.00 ± 11.82, P = 0.9) at a ratio of 1:1 and included as controls. The target dosage of SV was 200 mg/day.

RESULTS

Twenty-three (23/155; 14.84%) had HF with mid-range EF (HFmrEF), while 132 (85.16%) had HFpEF. After SV treatment, the peak early diastolic transmitral flow velocity/peak early diastolic mitral annular tissue velocity(E/e') improved from 17.19 ± 8.74 to 12.80 ± 5.52 (P = 0.006), the left ventricular (LV) end-diastolic diameter decreased from 53.14 ± 7.67 mm to 51.56 ± 7.44 mm (P = 0.03), and the LV mass index decreased from 165.7 ± 44.6 g/m2 to 154.8 ± 24.0 g/m2 (P = 0.02). LVEF (P = 0.08) and LV global longitudinal strain (P = 0.7) did not change significantly. The composite outcome of first and recurrent HF hospitalization or cardiovascular death showed no difference between group. However, the Acute Dialysis Quality Initiative Workgroup (ADQI) HF class improved in 39 and 15 patients and worsened in 1 and 11 patients in the SV and control groups, respectively (P < 0.001). Age, diabetes mellitus, and pulmonary arterial pressure were independent risk factors for HF hospitalization and cardiovascular mortality in patients with HFpEF.

CONCLUSIONS

SV improved LV hypertrophy, diastolic function, and the ADQI class for HF; however, it failed to reduce the composite endpoints of HF hospitalization and cardiovascular disease-related mortality over 12 months of follow-up in patients on maintenance hemodialysis with EF of > 40%.

Effect of proximal artery restriction on flow reduction and cardiac function in hemodialysis patients with high-flow arteriovenous fistulas

OBJECTIVE

Arteriovenous fistula is the preferred vascular access for hemodialysis patients. High-flow arteriovenous fistula may cause high-output heart failure. Various procedures are used to reduce high-flow arteriovenous fistula. This study aimed to assess the efficacy of proximal artery restriction combined with distal artery ligation on flow reduction for high-flow arteriovenous fistula and on cardiac function and echocardiographic changes in patients undergoing hemodialysis.

METHODS

A retrospective analysis was performed on data collected from the medical records of patients undergoing hemodialysis with heart failure and high-flow arteriovenous fistula between May 2018 and May 2021. Thirty-one patients were treated with proximal artery restriction (banding juxta-anastomosis of the proximal artery) combined with distal artery ligation (anastomosis distal artery ligation). Changes in the Acute Dialysis Quality Initiative Workgroup cardiac function class, blood pressure, and echocardiography before and 6 months after flow restriction were compared, and post-intervention primary patency was followed-up.

RESULTS

The technical success rate of the surgery was 100%, and no surgery-related adverse events occurred. Blood flow and blood flow/cardiac output decreased significantly after flow restriction. Blood flow decreased from 2047.21 ± 398.08 mL/min to 1001.36 ± 240.42 mL/min, and blood flow/cardiac output decreased from 40.18% ± 6.76% to 22.34% ± 7.21% (P < .001). Post-intervention primary patency of arteriovenous fistula at 6, 12, and 24 months was 96.8%, 93.5%, and 75.2%, respectively. The Acute Dialysis Quality Initiative Workgroup cardiac function class improved significantly after 6 months of flow restriction (P < .001). The systolic and diastolic left heart function improved, as evidenced by a significant decrease in left atrial volume index, left ventricular end-diastolic/end-systolic diameters, left ventricular end-diastolic volume, left ventricular mass index, cardiac output, and cardiac index and an increase in lateral peak velocity of longitudinal contraction, average septal-lateral s', and lateral early diastolic peak velocity after flow restriction (P < .05). Systolic pulmonary artery pressure decreased from 32.36 ± 8.56 mmHg to 27.57 ± 8.98 mmHg (P < .05), indicating an improvement in right heart function.

CONCLUSIONS

Proximal artery restriction combined with distal artery ligation effectively reduced the blood flow of high-flow arteriovenous fistula and improved cardiac function.

The relationship between platelet distribution width and new-onset cardiovascular disease events in patients with peritoneal dialysis

Objectives

The global mortality rate from chronic kidney disease (CKD) has increased over the past two decades. Typically, peritoneal dialysis (PD) remains a useful alternative treatment for end-stage renal disease. Cardiovascular disease (CVD) is the main complication in PD patients. In terms of prognosis, it is reported that platelet distribution width (PDW) can predict adverse CVD events. However, the relationship between PDW and new-onset CVD in PD patients is not clear. This study aimed to explore the relationship between PDW and new-onset CVD in PD patients.

Methods

This was a retrospective cohort study, from 4 July 2005 to 31 December 2019, and a total of 1557 patients were recruited. PDW was respectively categorized into two groups: PDW ≤13.2 fL and PDW >13.2 fL. The primary outcome was a new-onset CVD event. Cox proportional hazards models were performed to assess the hazard ratio (HR). Receiver-operating characteristic (ROC) curves were applied to evaluate the predictive accuracy of the PDW on CVD events.

Results

During follow-up, 114 new-onset CVD events were recorded. Cox proportional hazards models showed a higher risk of CVD events in patients with high PDW (HR = 1.862 95%CI 1.205–2.877, p = 0.005). Kaplan–Meier cumulative incidence curves showed the risk of the first occurrence of CVD events was greater in the high PDW group (p = 0.006).

Conclusions

High PDW is associated with new-onset cardiovascular disease events in PD patients.

Effectiveness of the Shenzhuo formula in the treatment of patients with macroalbuminuria secondary to diabetic kidney disease: protocol update and statistical analysis plan

Background

Diabetic kidney disease (DKD) is a significant complication of diabetes and has garnered considerable attention. Our previous retrospective study indicated that Shenzhuo formula (SZF) potentially reduces macroalbuminuria secondary to DKD.

Methods

This trial is a 24-week, randomized, multicentric, double-blinded, double-dummy clinical trial. A total of 120 patients with DKD will be equally and randomly divided into two groups: SZF+ irbesartan simulator or irbesartan + SZF simulator. The 24-h urinary protein change from baseline to week 24 is the primary outcome measure. The secondary outcome measures include serum creatinine, estimated glomerular filtration rate, urinary albumin excretion rate, improvement in traditional Chinese medicine symptoms, fasting blood glucose, 2-h postprandial plasma glucose, hemoglobin A1c, cholesterol, triglycerides, high density lipoprotein, low density lipoprotein, blood pressure, albumin to creatinine ratio, and the Audit of Diabetes-Dependent Quality of Life 19. Our recruitment began in May 2015; currently, we have recruited 100 participants, with a designed maximum sample size of 120. The interim results were reviewed at N = 60, and continuing recruitment was recommended. This statistical analysis plan includes our approach to missing data imputation, primary and secondary outcomes analyses, and safety endpoints.

Discussion

This statistical analysis plan will standardize the clinical trial’s statistical analysis and avoid outcome selective reporting bias and data-driven analysis. This trial will provide further clinical evidence regarding the effectiveness of SZF in managing macroalbuminuria secondary to DKD.

Trial registration

Chinese Clinical Trial Registry ChiCTR-ICR-15006311. Registered on 26 May 2013. http://www.chictr.org.cn/showproj.aspx?proj=10862

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05961-8.

Risk factors for early death in urgent-start peritoneal dialysis patients: A multicenter retrospective cohort study

BACKGROUND

Assess risk factors for early death in patients who underwent urgent-start peritoneal dialysis (USPD).

METHODS

Patients who initiated USPD in five peritoneal dialysis centers from 2013 to 2019 were screened in this multicenter retrospective cohort study. Risk factors for all-cause mortality within 3 months were explored.

RESULTS

A total of 1265 USPD patients with 43 early deaths were included. Cox regression analyses showed that age older than 60 years (hazard ratio [HR], 3.054; 95% CI [1.597, 5.842]; p = 0.001), albumin less than 30 g/L (HR, 2.234; 95%CI [1.207, 4.136]; p = 0.011), blood glucose greater than 7 mmol/L (HR, 2.766; 95%CI [1.477, 5.180]; p = 0.001), higher estimated glomerular filtration rate (eGFR; HR, 1.121; 95%CI [1.071, 1.172]; p = 0.000), and poor stages of heart failure (class IV compared with class 0-I; HR, 5.165; 95%CI [2.544, 10.486]; p = 0.000) were independent predicting factors for early death.

CONCLUSIONS

Risk factors for early death were older age, hypoproteinemia, hyperglycemia, higher eGFR, and severe heart failure.

Cost-effectiveness analysis of hemodialysis plus hemoperfusion versus hemodialysis alone in adult patients with end-stage renal disease in China

Background

This study evaluates the cost-effectiveness of hemodialysis (HD) plus hemoperfusion (HP) with HD alone in adult patients with end-stage renal disease (ESRD) in China.

Methods

A Markov model was constructed to assess the cost-effectiveness of interventions over a lifetime horizon. Model parameters were informed by the HD/HP trial, the first randomized, open-label multicenter trial comparing survival outcomes and incidence of cardiovascular disease (CVD) for HD + HP versus HD alone, and supplemented by published literature and expert opinion. The primary outcome was the incremental cost-effectiveness ratio (ICER) with respect to quality adjusted life-years (QALY). The robustness of the results was examined in extensive sensitivity analyses. Analyses were conducted from a healthcare perspective. Costs were reported in both Chinese Renminbi (RMB) and US Dollars (USD) in 2019 values.

Results

The base case ICER of HD + HP is RMB 174,486 (USD 25,251) per QALY, which is lower than the RMB 212,676 (USD 30,778) willingness-to-pay threshold of three times Gross Domestic Product. This conclusion is sensitive to the mortality for patients with no severe CVD events, the incidence of CVD events, and the cost of HP and HD. At a willingness-to-pay threshold of RMB 212,676 (USD 30,778) per QALY gained, the probability that HD + HP is cost-effective is 58%.

Conclusions

Our results indicate a potential for HD + HP to be cost-effective for patients with ESRD. Further evidence on the longer-term impact of HD + HP on CVD event rates and mortality unrelated to CVD is needed to robustly demonstrate the cost-effectiveness of HD + HP.

Trial Registration

The HD/HP trial was registered with the Chinese Clinical Trial Registry (ChiCTR-IOR-16009332).

Association between serum advanced oxidation protein products and mortality risk in maintenance hemodialysis patients

BACKGROUND

The association between serum advanced oxidation protein products (AOPP) and mortality risk remains equivocal. We aimed to assess the correlation of serum AOPP levels with the risk of all-cause mortality in hemodialysis (HD) patients.

METHODS

A total of 1394 maintenance HD patients with complete data on AOPP and related parameters were included from China Collaborative Study on Dialysis (CCSD), a multi-center, prospective cohort study. The primary outcome was all-cause mortality, the secondary outcome was cardiovascular disease (CVD) mortality.

RESULTS

During a median follow-up duration of 5.2 years (IQR, 2.1-5.4), all-cause mortality occurred in 492 (31.4%) participants. Overall, there was a reversed L-shaped association between serum AOPP and all-cause mortality in HD patients (P for nonlinearity = 0.04), with an inflection point at 87 µmol/L. Accordingly, there was no significant association between serum AOPP and all-cause mortality (per SD increment; HR, 0.94; 95%CI, 0.84, 1.05) in participants with AOPP < 87 µmol/L. However, there was a positive relationship of serum AOPP and all-cause mortality (per SD increment; HR, 1.24; 95%CI, 1.08, 1.42) in those with AOPP ≥ 87 µmol/L. Moreover, a similar trend was found for CVD mortality.

CONCLUSIONS

Elevated serum AOPP levels were associated with higher risk of all-cause mortality in Chinese maintenance HD patients.

Comparison of effectiveness and safety between ticagrelor and clopidogrel in patients with acute coronary syndrome and on dialysis in Taiwan

AIMS

This study aimed to evaluate and compare the effectiveness and safety between clopidogrel and ticagrelor in acute coronary syndrome (ACS) with renal dysfunction.

METHODS

We conducted a retrospective cohort study on patients on chronic dialysis and whose admission diagnosis between 1 July 2013 and 31 December 2016 included ACS. The primary effectiveness endpoint was a major adverse cardiovascular event (MACE), and the primary safety endpoint was a major bleeding event. The application of propensity scores through the inverse probability of treatment weighting (IPTW) was applied to the study groups. Cox regression was used to estimate hazard ratios (aHRs) of study endpoints. In addition, the competing risk was adjusted using the Fine and Gray competing risk model.

RESULTS

There were 1915 patients in the clopidogrel group and 270 patients in the ticagrelor group. At 12 months, the ticagrelor group had higher risks for MACE (aHR with IPTW: 1.29; 95% CI 1.16-1.44); death (aHR with IPTW: 1.65; 95% CI 1.47-1.86) and cardiac death (subdistribution HR [SHR] with IPTW: 1.64; 95% CI 1.41-1.91), compared with those in the clopidogrel group. For major bleeding event, the risk was significantly higher with ticagrelor than with clopidogrel (SHR with IPTW: 1.49; 95% CI 1.34-1.65). In terms of the risk for any bleeding event, there was no significant difference between the two groups (SHR with IPTW: 1.05; 95% CI 0.95-1.17).

CONCLUSIONS

Compared with clopidogrel, ticagrelor was associated with higher MACE, death, cardiac death and major bleeding risk within 12 months in patients with ACS and on dialysis.

Associations between Circulating Markers of Cholesterol Homeostasis and Macrovascular Events among Patients Undergoing Hemodialysis

Current strategies targeting serum cholesterol bring limited benefits to mortality and macrovascular events prevention among hemodialysis patients. Direct measurements and analysis on circulating markers of cholesterol homeostasis could be promising solutions to this bottleneck. We prospectively enrolled 90 maintenance hemodialysis patients and 9 healthy controls in 2019 for 1 year. We measured circulating desmosterol and lathosterol as markers for cholesterol synthesis and campesterol and sitosterol for cholesterol absorption. At baseline, hemodialysis patients showed higher levels of campesterol (p = 0.023) compared to healthy controls. During follow-up, we identified 14 (15.4%) patients who experienced macrovascular events. Comparisons of cholesterol homeostasis markers between cohorts with and without macrovascular events showed no significant differences in markers of cholesterol synthesis or absorption. Using logistic regression analysis, the odds ratio was not statistically significant for the prediction of macrovascular events after full-adjusting for age, sex, diabetes, serum albumin, cholesterol, and triglyceride. We concluded that hemodialysis patients demonstrated higher level of cholesterols absorption, indicated by circulating campesterol compared to healthy subjects. Markers for cholesterol homeostasis were not significantly associated with macrovascular events during a 1-year follow-up. Our results shed light on the novel therapeutic target of modulating cholesterol absorption in HD patients.

Serum and Tissue Levels of Advanced Glycation End Products and Risk of Mortality in Patients on Maintenance Hemodialysis

BACKGROUND

The relation of tissue and circulating advanced glycation end products (AGEs) with mortality in hemodialysis (HD) patients remains inconclusive. We aimed to investigate the association of serum AGEs (CML) and tissue AGEs estimated by skin autofluorescence (SAF) with all-cause and cardiovascular disease (CVD) mortality, and examine the possible modifiers for the association in HD patients with by far the largest sample size in any similar studies.

METHODS

A total of 1,634 HD patients were included from the China Cooperative Study on Dialysis (CCSD), a multicenter prospective cohort study. The primary and secondary outcomes were all-cause mortality and CVD mortality, respectively.

RESULTS

The median follow-up duration was 5.2 years. Overall, there was a positive relation of baseline SAF levels with the risk of all-cause mortality (per 1 AU increment, adjusted hazard ratio (HR), 1.30; 95% confidence interval (CI): 1.12, 1.50) and CVD mortality (per 1 AU increment, adjusted HR, 1.36; 95% CI: 1.14, 1.62). Moreover, a stronger positive association between baseline SAF (per 1 AU increment) and all-cause mortality was found in participants with shorter dialysis vintage, or lower C-reactive protein levels (Both p interactions <0.05). Nevertheless, there was no significant association between serum CML and the risk of mortality.

CONCLUSIONS

In patients undergoing long-term HD, baseline SAF, but not serum CML, was significantly associated with the risk of all-cause and CVD death.

Comparison of cardiovascular mortality in hemodialysis versus peritoneal dialysis

PURPOSE

Cardiovascular disease is a significant cause of morbidity and mortality in dialysis patients. With the increasing prevalence of dialysis patients, there is a need to systematically identify the epidemiology of cardiovascular disease in hemodialysis and peritoneal dialysis patients.

METHODS

A meta-analysis was conducted in reference to the MOOSE and PRISMA guidelines. Database searches were conducted on Medline and Embase on 17 March 2020. Meta-analysis of proportions was used to summarize the overall prevalence of events. Pairwise comparisons were used to compare between hemodialysis and peritoneal dialysis, and meta-regression was applied to identify the factors influencing disease.

RESULTS

A total of 28 studies were included in the review and prevalence of cardiovascular disease events including coronary artery disease, coronary artery complications, congestive heart failure, peripheral arterial disease, atrial fibrillation, and cardiovascular mortality were summarized. Atrial fibrillation (RR 1.287 CI 1.154-1.436, p < 0.001), congestive heart failure (RR 1.229 CI 1.074-1.407, p = 0.003), and peripheral arterial disease (RR 1.132 CI 1.021-1.255, p = 0.019) were more common in hemodialysis patients, but cardiovascular mortality was lower in hemodialysis relative to peritoneal dialysis patients. (RR 0.892 CI 0.828-0.960, p = 0.002).

CONCLUSION

The authors have found fewer cardiovascular events but higher cardiovascular mortality in patients on PD as compared to those on HD. Future research is required to establish the causality between dialysis modality and the cardiovascular outcomes described.

The benefit of early survival on PD versus HD—Why this is (still) very important

There are a number of misconceptions around the identified early survival benefit of peritoneal dialysis (PD) relative to hemodialysis (HD), including that such benefits “even out in the end” since the relative risk of death over time eventually encompasses 1.0 (or even an estimate that is unfavorable to PD); that the early benefit is, in fact, most likely due to unmeasured confounding; and such benefits are only due to the influence of central venous catheters and “crash starters” in the HD group. In fact, the early survival benefit results in a substantial gain of patient life years in PD cohorts relative to HD ones, even if it the benefit appears to “even out in the end,” is relatively insensitive to unmeasured confounding, and persists even when the effects of central venous catheters are accounted for. In this review, the calculations and arguments are made to support these tenets. Survival on dialysis is still one of the most important considerations for all stakeholders in the end-stage kidney disease community, including patients who rank it among their top priorities. Shared decision-making is a fundamental patient right and requires both balanced information and an iterative mechanism for a consensual decision based on shared understanding and purpose. A cornerstone of this process should be an explicit discussion of the early survival benefit of PD relative to HD.

Clinical Studies of Interventions to Mitigate Cardiovascular Risk in Peritoneal Dialysis Patients

Cardiovascular disease (CVD) is highly prevalent in the peritoneal dialysis (PD) population, affecting up to 60% of cohorts. CVD is the primary cause of death in up to 40% of PD patients in Australia, New Zealand, and the United States. Cardiovascular mortality rates are reported to be approximately 14 per 100 patient-years, which are 10- to 20-fold greater than those of age- and sex-matched controls. The excess risk of CVD is related to a combination of traditional risk factors (such as hypertension, dyslipidemia, obesity, smoking, sedentary lifestyle, and insulin resistance), nontraditional (kidney disease-related) risk factors (such as anemia, chronic volume overload, inflammation, malnutrition, hyperuricemia, and mineral and bone disorder), and PD-specific risk factors (such as dialysis solutions, glycation end products, hypokalemia, residual kidney function, and ultrafiltration failure). Interventions targeting these factors may mitigate cardiovascular risk, although high-level clinical evidence is lacking. This review summarizes the evidence relating to cardiovascular interventions targeting modifiable CVD risk factors in PD patients, as well as highlighting the key recommendations of the International Society for Peritoneal Dialysis Cardiovascular and Metabolic Guidelines.

Peritoneal dialysis has optimal intradialytic hemodynamics and preserves residual renal function: Why isn't it better than hemodialysis?

Rates of cardiovascular mortality are disproportionately high in patients with end stage kidney disease receiving dialysis. However, it is now generally accepted that patient survival is broadly equivalent between the two most frequently used forms of dialysis, in-center hemodialysis (HD) and peritoneal dialysis (PD). This equivalent patient survival is notable when considering how specific aspects of HD have been shown to contribute to morbidity and mortality. These include more rapid loss of residual renal function (RRF), HD-induced myocardial and cerebral ischemia, and risk factors associated with the intermittent delivery of HD. Potential mechanisms specific to PD that may drive cardiovascular disease include the metabolic consequences of excessive absorption of glucose and glucose degradation products (GDPs), inadequate volume control, and high rates of hypokalemia. The aim of this review is to compare and contrast the different drivers of adverse outcomes between the dialysis modalities, as greater understanding of this may help in patient-centered decision-making when considering options for renal replacement therapy.

Efficacy and safety of nicorandil on perioperative myocardial injury in patients undergoing elective percutaneous coronary intervention: results of the PENMIPCI trial

Background

Previous studies have indicated that nicorandil can reduce perioperative myocardial injury (PMI) in patients undergoing elective percutaneous coronary intervention (ePCI), but this conclusion is still controversial. Additionally, studies reporting on the safety of nicorandil are lacking. Therefore, we performed this prospective study to evaluate the efficacy and safety of nicorandil on PMI in patients undergoing ePCI.

Methods

One hundred and forty-six patients with coronary heart disease (CHD) scheduled to undergo ePCI were randomly assigned to the nicorandil group (n=74) or control group (n=72). The primary outcomes were the change in cardiac troponin T (cTnT) and creatine kinase-MB (CK-MB) at 12 and 24 hours after surgery. The secondary outcome was the incidence of major adverse cardiac events (MACE), which was a composite of cardiac death, nonfatal myocardial infarction, new heart failure or coronary revascularization.

Results

There was no difference in age (54.76±5.93 vs 56.35±5.22) between the nicorandil group and the control group. In addition, no differences were observed in the cTnT and CK-MB levels between the two groups at admission (all P⩾0.05). Compared with those in the control group, the cTnT (0.15±0.12 vs 0.12±0.10 at 12 hours and 0.17±0.12 vs 0.13±0.10 at 24 hours) and CK-MB (15.35±8.23 vs 12.31±7.93 at 12 hours and 13.63±8.87 vs 11.13±5.71 at 24 hours) levels in the nicorandil group were significantly decreased after surgery (all P⩽0.05). Furthermore, nicorandil did not increase the incidence of MACE in the nicorandil group compared with the control group (12.16% vs 12.50%).

Conclusions

Nicorandil can reduce PMI in patients undergoing ePCI and does not increase the incidence of MACE.

Clinical Trial Registration

URL: http://www.chictr.org.cn/. Unique Identifier: ChiCTR-IOR-17012056.

The comparison of risk of stroke in patients with peritoneal dialysis and hemodialysis: A systematic review and meta-analysis

OBJECTIVE

Several studies have demonstrated that end-stage renal disease (ESRD) patients on dialysis are at higher risk for cerebrovascular events, especially those on hemodialysis. However, the risk of stroke in patients on peritoneal dialysis (PD) compared to those on hemodialysis (HD) remains unclear. We performed this meta-analysis to assess the risks of stroke in ESRD patients on PD compared to HD.

METHODS

A systematic review was conducted using MEDLINE, EMBASE, Cochrane databases from inception through January 2018 to identify studies that evaluated the risks of stroke (all types of stroke, ischemic stroke or hemorrhagic stroke) in ESRD patients on different dialysis modalities. Effect estimates from the individual study were extracted and combined using random-effect, generic inverse variance method of DerSimonian and Laird.

RESULTS

Fifteen cohort studies with a total of 1 289 572 ESRD patients (over 1 140 942 on HD and 122 534 on PD) were enrolled. Compared with HD, PD was associated with a significantly decreased risk of hemorrhagic stroke with pooled OR of 0.84 (95% CI: 0.76-0.92). However, there were no differences in risks of all types of stroke or ischemic stroke in those on PD compared to HD with pooled ORs of 1.06 (95% CI: 0.91-1.22) and 1.01 (95% CI: 0.80-1.18,), respectively.

CONCLUSIONS

PD status is associated with 16% lower risk of hemorrhagic stroke compared to HD, but the risks of all types of stroke and hemorrhagic stroke are not statistically different in PD patients when compared to HD patients.

Red blood cell distribution width as a marker of cerebral infarction in hemodialysis patients

Background: Red blood cell distribution width (RDW) is a cardiovascular biomarker. We evaluated the association between RDW and cerebral stroke risk in hemodialysis patients.

Methods: A cohort of 442 adult patients on hemodialysis was studied. Strokes were defined according to ICD-10 diagnosis codes. Routine complete blood counts, evaluated every 3–6 months, were used for RDW values.

Results: Among 442 hemodialysis patients, during the 50-month follow-up, there were 62 cases (14.0%) of cerebral stroke: 41 (9.3%) with cerebral infarction and 21 (4.8%) with cerebral hemorrhage. Compared with nonstroke patients, a significantly higher RDW was measured in patients with cerebral stroke and cerebral infarction. However, no significant difference was seen in RDW between patients with cerebral hemorrhage and nonstroke patients. After adjustment by age, hypertension, albumin, Charlson Comorbidity Score, and C-reactive protein in different multivariable Cox regression models, patients with the highest mean RDW quartile had a 2.55-fold (hazard ratio = 3.55; 95% confidence interval: 1.33–9.51) higher risk of developing cerebral infarction relative to those with the lowest mean RDW quartile. RDW was not an independent risk factor for cerebral hemorrhage.

Conclusions: Increased RDW is an independent risk factor of cerebral infarction in hemodialysis patients.

Ablation of FGFR2 in Fibroblasts Ameliorates Kidney Fibrosis after Ischemia/Reperfusion Injury in Mice

Background

Fibroblast growth factors (FGFs) are heparin-binding proteins involved in a variety of biological processes. However, the role and mechanisms of FGF/FGFR2 signaling in fibroblast activation and kidney fibrosis need further investigation.

Methods

In this study, a mouse model with fibroblast-specific FGFR2 gene disruption was generated. The knockouts were born normal and no kidney dysfunction or histological abnormality was found within 2 months after birth. A kidney ischemia/reperfusion injury (IRI) model was created.

Results

Kidney fibrosis was developed in the control littermates within 2 and 4 weeks after IRI, while in the knockouts, total collagen deposition, fibronectin, and alpha smooth muscle actin expression were decreased compared to those in the control littermates. In addition, the numbers of Ki-67-positive interstitial cells as well as TUNEL-positive interstitial cells were lower in the knockout kidneys at 4 weeks after IRI. Phosphorylated extracellular regulated protein kinase 1/2 was decreased in the knockout kidneys at 2 and 4 weeks after IRI compared to those in the control littermates.

Conclusion

These results suggest that FGF/FGFR2 signaling may promote the proliferation and activation of kidney fibroblasts, which contribute to the development of kidney fibrosis.

Treatment with haemodiafiltration stabilises vascular stiffness (measured by aortic pulse wave velocity) compared to haemodialysis

BACKGROUND/AIMS

Cerebrovascular diseases such as stroke are increased in dialysis patients, and haemodiafiltration has been reported to reduce cerebrovascular mortality compared to haemodialysis. We wished to determine whether haemodiafiltration improves arterial stiffness.

METHODS

We audited aortic pulse wave velocity (PWV) measurements 6 months apart in 3 cohorts of patients: 69 treated with haemodialysis, 78 who converted from haemodialysis to haemodiafiltration and 142 treated with haemodiafiltration.

RESULTS

Cohorts were well matched for age (means ± SD: haemodialysis 64 ± 15 years vs. haemodialysis to haemodiafiltration 64 ± 17 years vs. haemodiafiltration 67 ± 16 years), sex (male 65 vs. 59 vs. 63%), diabetes (45 vs. 56.4 vs. 44%) and body mass index (26 ± 6 vs. 26 ± 5 vs. 26 ± 5), respectively. Systolic blood pressure did not differ over time (haemodialysis 143 ± 25 vs. 146 ± 27 mm Hg, haemodialysis to haemodiafiltration 153 ± 26 vs. 154 ± 25 mm Hg, haemodiafiltration 149 ± 31 vs. 148 ± 30 mm Hg) or between groups. Aortic PWV significantly increased in the haemodialysis group (9.5 ± 1.9 vs. 10.2 ± 2.2 m/s, p < 0.01) and haemodialysis to haemodiafiltration group (9.4 ± 1.9 vs. 10.1 ± 2.2 m/s, p < 0.01), but did not change with haemodiafiltration (9.9 ± 2.1 vs. 10.1 ± 2.2 m/s).

CONCLUSIONS

Aortic PWV, a measure of vascular stiffness, stabilised with haemodiafiltration. Our preliminary findings require further investigation to determine how haemodiafiltration may potentially improve vascular stiffness.

Cardiovascular risk assessment in low-resource settings: a consensus document of the European Society of Hypertension Working Group on Hypertension and Cardiovascular Risk in Low Resource Settings

The Global Burden of Diseases, Injuries, and Risk Factors Study 2010 confirms ischemic heart disease and stroke as the leading cause of death and that hypertension is the main associated risk factor worldwide. How best to respond to the rising prevalence of hypertension in resource-deprived settings is a topic of ongoing public-health debate and discussion. In low-income and middle-income countries, socioeconomic inequality and cultural factors play a role both in the development of risk factors and in the access to care. In Europe, cultural barriers and poor communication between health systems and migrants may limit migrants from receiving appropriate prevention, diagnosis, and treatment. To use more efficiently resources available and to make treatment cost-effective at the patient level, cardiovascular risk approach is now recommended. In 2011, The European Society of Hypertension established a Working Group on 'Hypertension and Cardiovascular risk in low resource settings', which brought together cardiologists, diabetologists, nephrologists, clinical trialists, epidemiologists, economists, and other stakeholders to review current strategies for cardiovascular risk assessment in population studies in low-income and middle-income countries, their limitations, possible improvements, and future interests in screening programs. This report summarizes current evidence and presents highlights of unmet needs.

Is the dialysate calcium concentration of 1.75 mmol/L suitable for Chinese patients on maintenance hemodialysis?

We studied the effects of increasing the dialysate calcium concentration (DCa) to 1.75 mmol/L on controlling chronic kidney disease-mineral and bone disorder in Chinese patients on maintenance hemodialysis (MHD). We reviewed the data of MHD patients in one center (cohort 1) during prior 10 years and analyzed the risk factors of mortality and transference calcification (TC) in120 MHD patients surviving in 2003 (cohort 2). A multicenter, prospective, parallel-group, controlled trial (cohort 3) was also conducted from January 2011 to December 2012. The DCa at one center was increased from 1.5 to 1.75 mmol/L but was not changed at the other two centers. The clinical outcomes, biochemical parameters, medicine treatments, and TC markers [aortic arch calcification score (AoACS)] were compared between groups. In cohort 1, the annual mean serum iPTH increased significantly over 10 years. In cohort 1, 72 patients survived for 10 years, whose doses of calcium salts and active vitamin D3 and AoACs increased progressively. In cohort 2, the main cause of death was cardiocerebrovascular disease (CCVD) (n = 18, 48.6 %). Male sex and lower serum calcium concentrations were independent risk factors for CCVD mortality. In cohort 3, serum phosphorus, iPTH, and 25(OH)D decreased and serum calcium increased significantly; also, the doses of calcium and vitamin D3 decreased from 2011 to 2012 in the DCa 1.75 group. There were no significant differences in clinical outcomes either between groups or between the two calendar years. Our results indicate that increasing DCa to 1.75 mmol/L can decrease the elevated levels of serum iPTH and phosphorus, reduce the doses of calcium and vitamin D3, and be safe for short periods of time.

Cardiovascular complications in diabetic patients undergoing regular hemodialysis: a 5-year observational study

We aimed to study the vascular outcomes in hemodialysis (HD) patients based on their diabetic status. A cohort observational study was conducted among patients undergoing regular HD with a 5-year follow-up. Of the 252 consecutive HD patients, 60% were diabetic. Compared with nondiabetics, diabetics were 11 years older, 4 years lesser on HD, and more likely to have prior cerebrovascular and coronary artery disease (CAD). Overall 5-year follow-up showed that diabetic patients had higher rates of HD vascular accesses (57% vs 41%, P = .01), CAD (64% vs 33%, P = .001), major amputations (8.6% vs 0%, P = .003), and mortality (66% vs 23%, P = .001). On multivariate analysis, independent predictors of mortality included number of vascular accesses in nondiabetics and HD duration, CAD, and peripheral artery disease in diabetic patients. Diabetes mellitus is associated with a significant vascular burden and mortality among HD patients. Moreover, our finding highlights the vascular impact of renal failure and HD.

A comorbidity index for mortality prediction in Chinese patients with ESRD receiving hemodialysis

BACKGROUND AND OBJECTIVES

Chinese patients with ESRD have different comorbidity patterns than white patients with ESRD and require a validated comorbidity index. The objective of this study was to develop a new index for mortality prediction in 2006-2009 Taiwanese incident hemodialysis patients.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Data were retrieved from 2005 to 2010 Taiwan National Health Insurance claim records, and follow-up was available until December 31, 2010. The same comorbid conditions as the US Renal Data System (USRDS) index that occurred during a 12-month period from 9 months before to 3 months after dialysis initiation were used to construct the index. Integer weight of the comorbid conditions was derived from coefficient estimates of Cox regression for all-cause mortality, and the index was internally validated. The performance of the index was assessed by discrimination, calibration, and reclassification.

RESULTS

A total of 30,303 hemodialysis patients were included in this study. The weight for individual comorbid conditions of this index differed from that of the USRDS index. The performance of this index was similar to that of USRDS and Charlson indices in terms of model fit statistics, overall predictive ability, discrimination, and calibration. Hosmer-Lemeshow test showed that all three indices demonstrated significant differences between predicted and observed mortality rates. When patients were categorized by the predicted 2.5-year survival probabilities, the index achieved a net reclassification improvement of 4.71% (P<0.001), referenced to USRDS index.

CONCLUSIONS

Compared with USRDS index, this new index demonstrated better reclassification ability, but future studies should address the clinical significance.