Cardiovascular risk in chronic renal disease and transplantation prevention and management

NT-proBNP in the Prognosis of Death or Need for Renal Replacement Therapy in Patients with Stage 3-5 Chronic Kidney Disease

BACKGROUND

The risk of cardiovascular (CV) complications is much greater in patients with chronic kidney disease (CKD). The aim of this study was to assess predictors of mortality, renal failure progression, and the need for dialysis in patients with CKD.

METHODS

The study group consisted of 70 patients with stage 3-5 CKD, followed up on average for 33.4 ± 15.6 months. Laboratory tests and echocardiography were performed on all patients. Composite endpoints were defined as (1) all-cause mortality and (2) mortality or renal replacement therapy (RRT), defined as the initiation of dialysis therapy.

RESULTS

During the observation period, 13 patients died and 11 began dialysis therapy. NT-proBNP was found to be a significant predictor in receiver operating characteristic curve analysis for all study endpoints. The optimal cutoff value for NT-proBNP as a predictor of mortality was 569.8 pg/mL, with a sensitivity of 53.8% and a specificity of 89.1%. For mortality or RRT, the cutoff value for NT-proBNP was 384.9 pg/mL, with a sensitivity and specificity of 70.8 and 72.7%, respectively. In a multivariate regression analysis, NT-proBNP was an independent predictor of mortality with an OR = 7.5 (95% CI: 1.05-53.87; p = 0.044) and of mortality or RRT with an OR = 4.7 (95% CI: 1.01-22.66; p = 0.048).

CONCLUSIONS

NT-proBNP is an independent predictor of mortality in patients with CKD and can also be useful for CV risk stratification in this patient population.

Antiphospholipid Syndrome and Kidney Involvement: New Insights

Antiphospholipid syndrome is an autoimmune disorder characterized by vascular thromboses and pregnancy morbidity associated with antiphospholipid antibodies: lupus anticoagulant, IgG or IgM anticardiolipin or anti-beta 2-glycoprotein I. The kidney is one of the major target organs in antiphospholipid syndrome (APS). However, beyond the known involvement of the kidney in primary and associated APS, we may be observing a new form of APS within the context of renal failure. This review describes the classical kidney manifestations of APS and provides new considerations to be taken into account.

Real-time myocardial contrast echocardiography as a useful tool to select candidates for coronary revascularization among patients with end-stage renal disease - a 3-year follow-up study

PURPOSE

To evaluate a real-time myocardial contrast echocardiography (MCE) as a tool to select candidates for coronary revascularization among patients with ESRD and to assess the rate of revascularization and mortality.

MATERIAL/METHODS

58 ESRD patients were screened for CAD using MCE. We analyzed the rate of coronary revascularization during 3-year follow-up. Patients with and without perfusion disturbances on MCE were compared.

RESULTS

CAD was found in 46.2% patients out of 39 who underwent coronary angiography. 11 (39.3%) patients out of 28 from the group with perfusion defects on MCE underwent revascularization procedure (21.4% - PCI, 17.9% - CABG). No one from the group without perfusion defects had revascularization procedure. Perfusion defect (OR 1.37 CI 1.37-1.86, p=0.022) was related to revascularization in multivariant analysis (OR 12.87, CI 1.86-89.21, p=0.025). There was no difference in mortality between the group which underwent invasive procedures and treated conservatively (p=0.6643). In ROC analysis defects on MCE and CAD on angiography were equally good in anticipating combined end-point (AUC 0.716, CI 95% 0.544-0.851 and AUC 0.747, CI 95% 0.577-0.875, p=0.701) and death (AUC 0.752, CI 95% 0.582-0.878 and AUC 0.729, CI 95% 0.558-0.861, p=0.805).

CONCLUSIONS

Our results indicate that MCE is a safe and uncomplicated method which may help along with other methods to select candidates for coronary revascularization among ESRD patients. In our study coronary revascularization procedures were successful but they did not improve patients' survival on 3-year follow-up.

IgA antibodies against β2 glycoprotein I in hemodialysis patients are an independent risk factor for mortality

Cardiovascular complications are the most important cause of death in patients on dialysis with end-stage renal disease. Antibodies reacting with β-glycoprotein I seem to play a pathogenic role in antiphospholipid syndrome and stroke and are involved in the origin of atherosclerosis. Here we evaluated the presence of anticardiolipin and anti-β-glycoprotein I antibodies together with other vascular risk factors and their relationship with mortality and cardiovascular morbidity in a cohort of 124 hemodialysis patients prospectively followed for 2 years. Of these, 41 patients were significantly positive for IgA anti-β-glycoprotein I, and the remaining had normal values. At 24 months, overall and cardiovascular mortality and thrombotic events were all significantly higher in patients with high anti-β-glycoprotein I antibodies. Multivariate analysis using Cox regression modeling found that age, hypoalbuminemia, use of dialysis catheters, and IgA β-glycoprotein I antibodies were independent risk factors for death. Thus, IgA antibodies to β-glycoprotein I are detrimental to the clinical outcome of hemodialysis patients.

Outcome of kidney transplantation using organs from executed prisoners: is it justified beyond the ethical issue?

BACKGROUND

Kidney transplantation using organs from executed prisoners is a subject of controversy from the viewpoint of ethics. However, few reports have addressed the clinical outcome beyond the ethical issue.

METHODS

Between January 1990 and September 2004, a total of 435 kidney transplant recipients (group M) who underwent transplantation in 26 different hospitals in China were followed up at our hospital. It is believed that all the organs came from executed prisoners. The clinical data were retrieved and compared to those of 200 kidney transplant recipients (group T) who underwent transplantation in our hospital during the same period.

RESULTS

There was no significant difference between these 2 groups (T vs. M) in terms of hepatitis B virus infection (10.5% vs. 12.1%) or surgical complication rate (6.5% vs. 5.6%). The 1st-year acute rejection rate was significantly lower in group M (31.1% vs. 24.5%, p=0.015). The 1-year, 5-year, and 10-year patient survival rates were 94.3%, 89.5%, and 85.2%, respectively, for group T and 92.6%, 83.6%, and 76.7%, respectively, for group M (p>0.05); the corresponding graft survival rates were 91.4%, 82.6%, and 66.9%, respectively, for group T and 91.6%, 80.0%, and 61.4%, respectively, for group M (p>0.05). When patients were stratified according to the year of transplantation, patients who underwent transplantation between 2000 and 2004 had significantly better graft survival rates in both groups.

CONCLUSION

We conclude that kidney transplantation using organs from executed prisoners had a clinical outcome similar to that of transplantation performed in our hospital during the same period.