Early Results of Elective Endovascular Repair of Infrarenal Abdominal Aortic Aneurysms With the MinosTM Stent-Graft System

PURPOSE

A variety of last-generation endografts are currently available for standard endovascular repair (EVAR) of infrarenal abdominal aortic aneurysms (AAAs). The purpose of this study is to report the preliminary clinical outcomes of the Minos trimodular stent-graft system, which was recently introduced to the European market.

MATERIALS AND METHODS

Between February 2020 and 2022, we treated 41 consecutive AAA patients (mean age 72.2±8.5, 37 males) with elective standard EVAR using the Minos. The mean maximum diameter of AAAs was 54.7±6.6 mm, the mean proximal neck's (PN) diameter was 24.8±2.7 mm, while the relevant length and angulation were 16.0 mm and 21.7°, respectively. Overall, 22 (53.6%) patients presented with shorter and angulated PN, according to the stent-graft's instructions of use, and in 6 (14.6%) patients the PN angulation >60° was combined with concomitant iliac angulation >60°. Eleven (26.8%) EVARs were performed with concomitant enormous iliac artery narrowing and tortuosity. Finally, in 19 (46.3%) AAAs, the distal iliac landing zone was aneurysmatic and they were treated with the bell-bottom technique in 17 patients and with limb extension to the external iliac artery in two cases. We evaluated technical and clinical success of the index procedures, which was based on the combination of five factors: freedom from EVAR-related mortality, from graft-related endoleak of any type, from migration at any part of graft as well the absence of notable increase AAA's sac maximum diameter and the patency of bifurcated stent-graft and of access vessels.

RESULTS

Primary technical and clinical success of index procedures was 100%. During a median 12-month radiological follow-up the clinical success remained 100%. No type I or III endoleak, stent-graft migration, EVAR-related death, AAA rupture, or graft-related adverse events or reinterventions were documented. Four (9.8%) type II endoleaks were detected with stable AAA sac diameter. The overall incidence of sac regression was 34.1% (n=14).

CONCLUSION

The preliminary results of our series showed that Minos provided excellent feasibility and safety features even through angulated and tortuous iliac vessels and in short and angulated PNs. The overall clinical success at 1 year suggests that performance of Minos follows very high standards. Further validation of these promising results with long-term data is acquired to complete the evaluation of this recently introduced stent-graft system.

CLINICAL IMPACT

The current study explored the clinical performance of a new in market ultra-low profile bifurcated abdominal aortic stent-graft, the MINOS. The early and 12-month results of study suggest that implantation of this stent-graft in standard EVAR, even in hostile proximal aortic neck and iliac vessels conditions, follows very high clinical standards and encourage the further clinical use of MINOS.

Asymmetric dimethylarginine correlates with worsening peripheral microangiopathy in systemic sclerosis

BACKGROUND

Systemic sclerosis (SSc) is a connective tissue disease characterized primarily by micro-angiopathy and endothelial dysfunction which stimulate a fibrotic process. Asymmetric dimethylarginine (ADMA) is an endogenous nitric oxide (NO) inhibitor and represents a novel biomarker for vascular dysfunction. Nailfold video capillaroscopy (NVC) represents a non-invasive and reliable technique for the evaluation of microvasculopathy in SSc.

OBJECTIVES

The aim of this study was to examine the possible association between ADMA and microvascular involvement in patients with SSc.

METHODS

This was a cross-sectional study including consecutive SSc patients attending the Scleroderma Outpatient Clinic. ADMA was measured in serum samples using a commercial enzyme immunoassay. Participants underwent NVC with qualitative and semi-quantitative assessment and all NVC parameters were measured in the distal row of each finger. The findings were classified in one of the three qualitative NVC patterns: early, active, and late.

RESULTS

Eighty-one (92,6 % women) SSc individuals with mean age 55.44 ± 13.4 years were included in this analysis. Within-groups comparisons revealed a trend between higher ADMA levels and progressive micro-vasculopathy (1,29 [2,1] vs 1,57 [1,95] vs 2,41 [3,87]; for early, active and late patterns respectively, p = 0.039). Furthermore, ADMA concentration was significantly associated with the number of capillaries/mm (r = -0.235; p = 0.035).

CONCLUSIONS

Serum ADMA levels were significantly associated with advancing stages of microcirculatory abnormalities suggesting that ADMA may have a role in promoting microvascular endothelial dysfunction in SSc individuals.

Right ventricular performance in patients with heart failure with mildly reduced ejection fraction: the forgotten ventricle

Right ventricular (RV) function is a major determinant of prognosis and adverse outcomes in patients with heart failure (HF). It is largely unknown if HF with mildly reduced ejection fraction (HFmrEF) patients have some special characteristics in RV function (RVF) that may distinguish them from HF with reduced or preserved ejection fraction (HFrEF or HFpEF) patients. Standard echocardiography was performed to estimate RVF [tricuspid annular systolic velocity (TDSV), plane systolic excursion (TAPSE), TAPSE to pulmonary artery systolic pressure (TAPSE/PASP) and RV myocardial performance index (MPI-TEI index)] in a cross-sectional study. In 306 participants, the RV systolic function evaluated with TAPSE and TDSV was impaired in 39.1 and 24.2%, respectively. TAPSE, TAPSE/PASP and TDSV were lower in HFmrEF compared with HFpEF and higher compared with HFrEF (p < 0.001 for among-groups comparison). RV diastolic dysfunction varied between 12.6 and 43.8% depending on the echocardiographic parameter. Diastolic RVF determined by tricuspid inflow E/A wave ratio (Et/At) was impaired in less patients with HFmrEF compared with those with HFpEF or HFrEF (25.9% vs 48.4% vs 56.3%; p = 0.030, respectively). RV diastolic dysfunction by et'/at' (tissue Doppler tricuspid valve annulus e' and a' waves) was impaired in less patients with HFmrEF compared with HFrEF (11.8% vs 33.3%; p = 0.019). A multivariate regression analysis revealed a significant association between RV and LV systolic dysfunction. The present study shows a high prevalence of RV dysfunction in HFmrEF patients. Study findings provides some new insights on RV and LV systolic dysfunction coupling whereas RV diastolic dysfunction was not dependent on LV systolic dysfunction.

Endovascular Treatment of a Giant Renal Artery Aneurysm with High-Flow Renal Arteriovenous Malformation

Renal artery aneurysms (RAAs) are rare lesions with a prevalence of less than 1% in the general population. Renal arteriovenous malformations (AVMs) are rare lesions with an estimated incidence of less than 0.04%. The coexistence of these two clinical entities is extremely rare and narrows the available treatment options by endovascular or open surgery. We describe a case of a giant symptomatic RAA type III, which was combined with a high-flow renal AVM in the right kidney. Using two vascular plugs, the RAA was excluded successfully. The perfusion of the right kidney’s lower pole was preserved by implantation of two covered stents in the inferior segmental renal artery.

Prevalence and factors associated with hyperkalaemia in stable kidney transplant recipients

Background

Hyperkalaemia is a frequent and potentially life-threatening condition in patients with chronic kidney disease (CKD). Even after successful kidney transplantation (KTx), KTx recipients have mild to severe CKD. Moreover, they share comorbid conditions and frequently use medications that predispose to hyperkalaemia. This study aimed to examine the prevalence and factors associated with hyperkalaemia in this population.

Methods

Over a pre-specified period of 6 months (1 September 2019 to 31 March 2020), we recorded in cross-sectional fashion information on serum potassium (K⁺) and relevant demographics, comorbidities, medications, laboratory and transplant-associated variables in clinically stable KTx recipients attending the Transplant Outpatient Clinic of our Department. Ηyperkalaemia was classified as follows: serum K⁺ level >5.0 mEq/L; and further as >5.0 mEq/L with concomitant use of sodium (Na⁺) polystyrene sulphonate; serum K⁺ ≥5.2 mEq/L; serum K⁺ ≥5.5 mEq/L. Univariate and multiple logistic regression analyses were used to identify factors associated with serum K⁺ >5.0 mEq/L.

Results

The study population consisted of 582 stable KTx recipients, 369 (63.4%) males, aged 52.4 ± 13.5 years, with estimated glomerular filtration rate (eGFR) of 55.8 ± 20.1 mL/min/1.73 m² transplanted for >1 year. The prevalence of hyperkalaemia defined as K⁺ >5.0 mEq/L; >5.0 mEq/L and use of Na⁺ polystyrene sulphonate; K⁺ ≥5.2; or K⁺ ≥5.5 mEq/L, was: 22.7, 22.7, 14.4 and 4.1% (132, 132, 84 and 24 patients), respectively. In multivariate analysis, male gender [odds ratio (OR) = 2.020, 95% confidence interval (CI) 1.264–3.227] and use of renin–angiotensin–aldosterone system (RAAS) blockers (OR = 1.628, 95% CI 1.045–2.536) were independently associated with hyperkalaemia, while higher eGFR (OR = 0.967, 95% CI 0.955–0.979) and use of non-K⁺-sparing diuretics (OR = 0.140, 95% CI 0.046–0.430) were associated with lower odds of the disorder.

Conclusions

The prevalence of mild hyperkalaemia in stable KTx recipients is relatively high but that of moderate or severe hyperkalaemia is low. Among a wide range of factors studied, only male gender and RAAS blockade were associated with increased odds of hyperkalaemia, while higher eGFR and diuretics were associated with decreased odds of hyperkalaemia.

Assessment of hypertension in kidney transplantation by ambulatory blood pressure monitoring: a systematic review and meta-analysis

Background

Hypertension (HTN) is common following renal transplantation and it is associated with adverse effects on cardiovascular (CV) and graft health. Ambulatory blood pressure monitoring (ABPM) is the preferred method to characterize blood pressure (BP) status, since HTN misclassification by office BP (OBP) is quite common in this population. We performed a systematic review and meta-analysis aimed at determining the clinical utility of 24-h ABPM and its potential implications for the management of HTN in this population.

Methods

Ovid-MEDLINE and PubMed databases were searched for interventional or observational studies enrolling adult kidney transplant recipients (KTRs) undergoing 24-h ABP readings compared with OBP or home BP. The main outcome was the proportion of KTRs diagnosed with HTN by ABPM, home or OBP recordings. Additionally, day-night BP variability and dipper/non-dipper status were assessed.

Results

Forty-two eligible studies (4115 participants) were reviewed. A cumulative analysis including 27 studies (3481 participants) revealed a prevalence of uncontrolled HTN detected by ABPM of 56% [95% confidence interval (CI) 46-65%]. The pooled prevalence of uncontrolled HTN according to OBP was 47% (95% CI 36-58%) in 25 studies (3261 participants). Very few studies reported on home BP recordings. The average concordance rate between OBP and ABPM measurements in classifying patients as controlled or uncontrolled hypertensive was 66% (95% CI 59-73%). ABPM revealed HTN phenotypes among KTRs. Two pooled analyses of 11 and 10 studies, respectively, revealed an average prevalence of 26% (95% CI 19-33%) for masked HTN (MHT) and 10% (95% CI 6-17%) for white-coat HTN (WCH). The proportion of non-dippers was variable across the 28 studies that analysed dipping status, with an average prevalence of 54% (95% CI 45-63%).

Conclusions

In our systematic review, comparison of OBP versus ABP measurements disclosed a high proportion of MHT, uncontrolled HTN and, to a lesser extent, WCH in KTRs. These results suggest that HTN is not adequately diagnosed and controlled by OBP recordings in this population. Furthermore, the high prevalence of non-dippers confirmed that circadian rhythm is commonly disturbed in KTRs.

Role of hypertension in kidney transplant recipients

Cardiovascular events are one of the leading causes of mortality in kidney transplant recipients. Hypertension is the most common comorbidity accompanying chronic kidney disease, with prevalence remaining as high as 90% even after kidney transplantation. It is often poorly controlled. Abnormal blood pressure profiles, such as masked or white-coat hypertension, are also extremely common in these patients. The pathophysiology of blood pressure elevation in kidney transplant recipients is complex and includes transplantation-specific risk factors, which are added to the traditional or chronic kidney disease-related factors. Despite these observations, hypertension management has been an under-researched area in kidney transplantation. Thus, relevant evidence derives either from studies in the general population or from small trials in kidney transplant recipients. Based on the relevant guidelines in the general population, lifestyle modifications should probably be applied as the first step of hypertension management in kidney transplant recipients. The optimal pharmacological management of hypertension in kidney transplant recipients is also not clear. Dihydropyridine calcium channel blockers are commonly used as first line agents because of their lack of adverse effects on the kidney, while other antihypertensive drug classes are under-utilised due to fear of the possible haemodynamic consequences on renal function. This review summarizes the existing data on the pathophysiology, diagnosis, prognostic significance and management of hypertension in kidney transplantation.

Cardiac geometry, function, and remodeling patterns in patients under maintenance hemodialysis and peritoneal dialysis treatment

Cardiovascular disease is the leading cause of mortality in patients with end-stage-kidney disease. Evidence on the possible echocardiographic differences between hemodialysis and peritoneal dialysis (PD) is scarce. This study aimed to evaluate differences in left (LA) and right atrial (RA), left (LV) and right ventricular (RV) geometry, systolic and diastolic function in hemodialysis, and PD patients. Thirty-eight hemodialysis and 38 PD patients were matched for age, sex, and dialysis vintage. Two-dimensional and tissue-Doppler echocardiography, and lung ultrasound were performed during an interdialytic day in hemodialysis and before a programmed follow-up visit in PD patients. Vena cava diameter (11.09 ± 4.53 vs. 14.91 ± 4.30 mm; p < 0.001) was significantly lower in hemodialysis patients. Indices of LA, RA, LV, and RV dimensions were similar between the two groups. LVMi (116.91 [38.56] vs. 122.83 [52.33] g/m² ; p = 0.767) was similar, but relative wall thickness was marginally (0.40 [0.14] vs. 0.45 [0.15] cm; p = 0.055) lower in hemodialysis patients. LV hypertrophy prevalence was similar between groups (73.7% vs. 71.1%; p = 0.798), but hemodialysis patients presented eccentric and PD patients concentric LVH. Regarding ventricular systolic function, stroke volume (p = 0.030) and cardiac output (p = 0.036) were higher in hemodialysis, while RV systolic pressure (RVSP) (20.37 [22.54] vs. 27.68 [14.32] mm Hg; p = 0.009) was higher in PD. No significant differences were evidenced in diastolic function indices and lung water excess between the two groups. A moderate association was noted between ultrasound B-lines score and LA volume index (r = 0.465, p < 0.001), RVSP (r = 0.431, p < 0.001), and E/e' ratio (r = 0.304, p = 0.009). Hemodialysis and PD patients present largely similar echocardiographic indices reflecting cardiac geometry, systolic, and diastolic function, but different patterns of abnormal LV remodeling.

MO102LUNG ULTRASOUND-GUIDED DRY-WEIGHT REDUCTION DECREASES AMBULATORY BLOOD PRESSURE LEVELS IN HYPERTENSIVE HEMODIALYSIS PATIENTS: LONG-TERM ANALYSIS OF A LUST SUB-STUDY*

Background and Aims

Hypertension is highly prevalent and independently associated with adverse outcomes in patients undergoing hemodialysis. The main mechanism leading to BP elevation in these individuals is their inability to maintain water homeostasis. This study examines the long-term effects of dry-weight reduction with a standardized lung-ultrasound-guided strategy on ambulatory BP in hypertensive hemodialysis patients.

Method

This is the report of the 12-month trial phase of a randomized controlled trial in 71 clinically euvolemic, hemodialysis patients with hypertension. Patients were randomized (1:1 ratio) in the active group (23 male and 12 female), following dry-weight reduction guided by the total number of US-B lines prior to a mid-week dialysis session and the control group (24 male and 12 female), following standard-of-care treatment. A 48-hour ABPM was performed in all study participants at baseline and after 12 months.

Results

During follow-up more patients in the active compared to control group had dry weight reduction (71.4% vs 22.2%; p&lt;0.001). US-B lines -4.83±13.73 vs 5.53±16.01; p=0.005) and dry-weight (-1.68±2.38 vs 0.54±2.32; p&lt;0.001) decreased in the active and slightly increased in the control group. At 12 months, 48-hour SBP (136.19±14.78 vs 130.31±13.57; p=0.034) and DBP (80.72±9.83 vs 76.82±8.97; p=0.008) were lower compared to baseline in the active but similar in the control group. Changes in 48-hour SBP (-7.78±13.29 vs -0.10±14.75; p=0.021) were significantly greater in the active compared to the control group. Comparisons for intradialytic, 44-hour, Day-1, Day-2 and day- and night-time BP were to the same direction. The proportion of patients experiencing at least one episode of intradialytic hypotension was numerically lower in the active group (71.4% vs 88.9%, p=0.065).

Conclusion

A lung-ultrasound-guided strategy for dry-weight reduction can effectively and safely decrease ambulatory BP levels during a 12-month follow-up period This method is a simple treatment approach to improve hypertension management in hemodialysis patients.

MO108ACCURACY OF PERIDIALYTIC, INTRADIALYTIC AND SCHEDULED INTERDIALYTIC RECORDINGS FOR DIAGNOSING HIGH AMBULATORY BLOOD PRESSURE IN HEMODIALYSIS

Background and Aims

Hypertension is highly prevalent in hemodialysis patients. Current recommendations suggest the use of ambulatory-BP-monitoring (ABPM) as the gold-standard for hypertension diagnosis and management in these subjects. This study assessed the accuracy of peridialytic, intradialytic and scheduled interdialytic recordings in diagnosing high 44-h interdialytic BP.

Method

A total of 242 hemodialysis patients that underwent valid 48-h ABPM were included in the analysis. We used ambulatory BP as reference standard and tested the accuracy of the following BP metrics: Pre- and post-dialysis, Intradialytic, Intradialytic plus pre/post-dialysis readings and Scheduled interdialytic BP (out-of-dialysis day: readings at 8:00 am, 8:00 pm or their average).

Results

44-h SBP/DBP levels had significant differences with and pre- or post-dialysis BP, but no or minor differences with any of the other BP metrics. 44-h SBP and DBP correlated strongly with Intradialytic (r=0.713/0.753, p&lt;0.001), Intradialytic plus pre/post-dialysis (r=0.725/0.758, p&lt;0.001) and averaged Scheduled interdialytic BP (r=0.874/0.823, p&lt;0.001). Bland-Altman plots showed absence of systemic bias for all index metrics, but large between-method difference and wider 95% limits of agreement for pre- and post-dialysis BP compared to Intradialytic, Intradialytic plus pre/post-dialysis and averaged Scheduled interdialytic BP. In ROC-analysis for diagnosing 44-h SBP≥130mmHg, the Area-Under-the-Curve of pre-dialysis (0.723) and post-dialysis SBP (0.746) were significantly lower than that of Intradialytic (0.850), Intradialytic plus pre/post-dialysis (0.850) and Scheduled interdialytic SBP (0.917) (z-test, p&lt;0.001 for all pairwise comparisons). The corresponding sensitivity/specificity values were 76.6%/54.5%, 78.7%/59.4%, 73.0%/81.2%, 68.1%/88.1% and 82.3%/89.1%, respectively. Similar observations were made for DBP.

Conclusion

In contrast to pre- and post-dialysis BP, the average of intradialytic, intradialytic plus pre/post-dialysis or scheduled interdialytic BP recordings show reasonable agreement with ambulatory BP and may be used for hypertension diagnosis and management in hemodialysis.

FC 104CARDIAC GEOMETRY, FUNCTION, AND REMODELING PATTENRS AND LUNG WATER CONTENT IN PATIENTS UNDER MAINTENANCE HEMODIALYSIS AND PERITONEAL DIALYSIS TREATMENT

Background and Aims

Cardiovascular disease is the leading cause of mortality in patients with end-stage kidney disease (ESKD). Evidence on the possible echocardiographic differences between patients undergoing different dialysis modalities is scarce. This study aimed to evaluate differences in left (LA) and right atrial (RA) and left (LV) and right ventricular (RV) geometry, systolic and diastolic function, as well as lung water content in hemodialysis and peritoneal dialysis (PD) patients.

Method

A total of 38 hemodialysis and 38 PD patients receiving treatment for ≥3 months, matched in a 1:1 ratio for age, sex and dialysis vintage were included in this study. Lung ultrasound, two-dimensional and tissue-Doppler echocardiography were performed during an interdialytic day in hemodialysis and before a programmed follow-up visit in PD patients. To identify factors possible associated with LVH (left ventricular hypertrophy), we performed univariate and multivariate linear regression analyses in the total population studied.

Results

No significant differences were evidenced in ultrasound B-lines (4.00 [6.00] vs 3.00 [4.25]; p=0.623) between the two groups. Vena cava diameter (11.09±4.53 vs 14.91±4.30 mm; P&lt;0.001) was significantly lower in hemodialysis patients. Indices of LA, RA, LV and RV dimensions were similar between the two groups. LVMi (116.91 [38.56] vs 122.83 [52.33] g/m2; P=0.767) was similar, but relative wall thickness (RWT) was marginally (0.40 [0.14] vs 0.45 [0.15] cm; P=0.055) lower in hemodialysis patients. LV hypertrophy prevalence, defined as LVMi values &gt;95 or &gt;115 g/m2 for female and male patients, was similar between groups (73.7% vs 71.1%; p=0.798), but relative wall thickness (RWT) was numerically lower (0.40 [0.14] vs 0.45 [0.15] cm; P=0.055) and fractional shortening (29.12±7.07% vs 23.37±8.84%; P=0.003) was significantly higher in patients under hemodialysis compared to those under PD. Hemodialysis patients presented mainly eccentric (normal RWT and increased LVMi), while PD patients presented mainly concentric LVH (increased RWT and increased LVMi). Left atrial (LA), right atrial (RA) and ventricular (RV) echocardiographic indices were again similar between the two study groups. Ventricular systolic function was similar between-groups, except for stroke volume (78.97 [24.24] vs 64.66 [27.35] ml; P=0.030) and cardiac output (5.75 [2.29] vs 4.93 [2.10] L/min; P=0.036) which were higher in hemodialysis. With regards to RV systolic function indices, RV systolic pressure (RVSP) was significantly lower in the hemodialysis compared to the PD group (20.37 [22.54] vs 27.68 [14.32] mmHg; P=0.009). All diastolic function indices were similar between the two groups. Prevalence of mitral valve (MV) regurgitation was significantly lower in the hemodialysis group (10.5% vs 39.5%; p=0.004). According to the results of multivariate linear regression analysis, only male gender (β=20.677, 95%CI: 3.479 to 37.874; P=0.019) and number of US-B lines (β=0.892, 95%CI:0.071 to 1.713; P=0.034) were independently associated with LVMi.

Conclusion

Hemodialysis and PD patients present similar volume overload, evaluated with lung ultrasound, and no significant differences in echocardiographic indices reflecting cardiac geometry, but different patterns of abnormal LV remodeling was evident in each dialysis modality, with hemodialysis presenting eccentric and PD concentric LVH. These results clearly support that PD is no better than HD with regards to cardiovascular stress, despite the fact that they experience a more stable volume status.

MO103PREDICTION OF CARDIOVASCULAR OUTCOMES WITH PERIDIALYTIC, INTRADIALYTIC, SCHEDULED INTERDIALYTIC AND AMBULATORY BP RECORDINGS IN HEMODIALYSIS PATIENTS

Background and Aims

Ambulatory-BP-monitoring (ABPM) is recommended for hypertension diagnosis and management in hemodialysis subjects due to high accuracy and strong associations with outcomes. The agreement and prediction of averaged intradialytic BP readings and home BP readings with ABPM and clinical outcomes is not known. This study assesses in parallel the association of pre-dialysis, intradialytic, scheduled interdialytic and ambulatory BP recordings with cardiovascular outcomes and mortality in this population.

Method

We prospectively followed for 49.1±25.6 months 242 hemodialysis patients with valid 48-hour ABPMs to examine the association of pre-dialysis, intradialytic, intradialytic plus pre/post-dialysis readings, scheduled interdialytic BP (the average of out-of-dialysis day readings at 8:00 am and 8:00 pm) and 44-hour ambulatory BP with outcomes. The primary end-point was a composite of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, resuscitation after cardiac arrest, hospitalization for heart failure, coronary revascularization procedure or peripheral revascularization procedure.

Results

Cumulative freedom from the primary end-point was significantly lower with increasing 44-hour SBP (group 1, &lt;120 mmHg, 64.2%; group 2, ≥120 to &lt;130 mmHg 60.4%, group 3, ≥130 to &lt;140 mmHg 45.3%; group 4, ≥140 mmHg 45.5%; logrank-p=0.016). Similar were the results for intradialytic (logrank-p=0.039), intradialytic plus pre/post-dialysis (logrank-p=0.044), and scheduled interdialytic SBP (logrank-p=0.030), but not for pre-dialysis SBP (logrank-p=0.570). With group 1 as the reference group, the Hazard Ratios of the primary end-point showed a gradual increase with higher BP levels with all BP metrics, except pre-dialysis SBP. An inverse association of DBP levels with outcomes was shown with all BP metrics.

Conclusion

Averaged intradialytic and scheduled home BP measurements (but not pre-dialysis readings) display similar patterns of prognostic associations with 44-hour ambulatory BP in hemodialysis patients and represent valid metrics for hypertension management in these individuals.

MO953PREVALENCE AND FACTORS ASSOCIATED WITH HYPERKALAEMIA IN STABLE KIDNEY TRANSPLANT RECIPIENTS WITH PRESERVED RENAL FUNCTION

Background and Aims

Hyperkalaemia is a frequent and potentially life-threatening condition in patients with CKD. Even after successful kidney transplantation, kidney transplant recipients have mild to severe CKD. Moreover, they share co-morbid conditions and frequently use medications that predispose to hyperkalaemia. This study aimed to examine the prevalence and factors associated with hyperkalaemia in this population.

Method

Over a pre-specified period of 6 months (September 1st 2019 to March 31st 2020), we recorded in a cross-sectional fashion information on serum potassium and relevant demographics, co-morbidities, medications, laboratory and transplant-associated variables in clinically stable kidney transplant recipients attending the Transplant Outpatient Clinic of our Department. Ηyperkalaemia was classified as follows: serum potassium level &gt;5 mEq/L or &gt;5 with concomitant use of sodium polystyrene sulfonate; ≥5.2; and ≥5.5 mEq/L. Univariate and multiple logistic regression analyses were used to identify factors associated with increased serum potassium &gt;5.0 mEq/L.

Results

The study population consisted of 582 stable kidney transplant recipients, 369 (63.4%) males, aged 52.4±13.5 years, with eGFR of 55.8±20.1 ml/min/1.73m2 transplanted for more than one year. The prevalence of hyperkalaemia defined as potassium &gt;5, &gt;5 and use of sodium polystyrene sulfonate, ≥ 5.2 or ≥5.5, was 22.7%, 22.7%, 14.4% and 4.1% (132, 132, 84 and 24 patients), respectively. In multivariate analysis, male gender (OR 2.020, 95% CI 1.264-3.227) and use of renin-angiotensin-aldosterone-system blockers (OR 1.628, 95% CI 1.045-2.536), were independently associated with hyperkalaemia, while higher eGFR (OR 0.967, 95% CI 0.955-0.979) and diuretic use (OR 0.140, 95% CI 0.046-0.430) were associated with lower odds of the disorder.

Conclusion

The prevalence of mild hyperkalaemia in stable kidney transplant recipients is common but that of moderate or severe hyperkalemia is relatively uncommon. Male gender and low eGFR are the most potent factors associated with hyperkalaemia. Among a wide range of factors only male gender, RAAS blockade and low eGFR increased the odds of hyperkalemia.

MO729LUNG ULTRASOUND GUIDED DRY-WEIGHT REDUCTION DECREASES CARDIAC CHAMBERS DIMENSIONS AND IMPROVES VENTRICULAR DIASTOLIC FUNCTION IN HEMODIALYSIS PATIENTS: LONG-TERM ANALYSIS OF A LUST SUB-STUDY

Background and Aims

Left ventricular hypertrophy (LVH) and dysfunction are highly prevalent in hemodialysis patients and independently associated with adverse outcomes. Few interventions were shown to effectively reduce LVH in hemodialysis. This study examines the long-term effects of dry-weight reduction with a standardized lung-ultrasound-guided strategy on echocardiographic indices of left and right cardiac chambers in hemodialysis patients.

Method

This is the report of the 12-month trial phase of a randomized controlled trial in 71 clinically euvolemic, hemodialysis patients with hypertension. Patients were randomized (1:1 ratio) in the active group (23 male and 12 female), following dry-weight reduction guided by the total number of US-B lines prior to a mid-week dialysis session and the control group (24 male and 12 female), following standard-of-care treatment. Among several assessments, participants underwent two-dimensional and tissue-Doppler echocardiographic (TDI) at baseline and study-end.

Results

During follow-up dry-weight reduction took place in more patients in the active compared with the control group (71.4% vs 22.2%; p&lt;0.001). Left atrial (LA) surface (-1.37±4.50 vs 1.28±5.00 cm2; P=0.006) and LA volume index (-3.22±11.82 vs 4.76±12.83 ml/m2; P=0.009) decreased in the active and increased in the usual-care group. Left ventricle (LV) diastolic (-0.94±11.45 vs 6.58±13.92 ml/m2; P=0.015) and systolic (-0.89±7.11 vs 3.38±7.89 ml/m2; P=0.018) volume index decreased only in the active group. LV mass index slightly decreased in the active (134.21±44.75 vs 133.57±45.51; P=0.844) and was marginally increased in the control group (134.21±40.96 vs 143.77±50.04 g/m2; P=0.089). Right ventricular (RV) systolic pressure was stable in the active (23.74±13.76 vs 24.35±12.99; P= 0.795) and significantly increased in the usual-care group (26.24±12.95 vs 31.20±16.13 mmHg; P=0.028). Reductions in LV A wave were greater in the active compared to the usual-care group (-4.98±15.11 vs 2.23±21.71 m/s; P=0.009). Changes in LV systolic and RV diastolic function indices were not different between the two groups.

Conclusion

Over 12 months, a lung-ultrasound-guided strategy for dry-weight reduction can effectively decrease cardiac chamber dimensions, prevent LVMi increase and improve LV diastolic and RV systolic function.

Dapagliflozin Does Not Affect Short-Term Blood Pressure Variability in Patients With Type 2 Diabetes Mellitus

BACKGROUND

Increased blood pressure variability (BPV) is associated with increased cardiovascular and all-cause mortality in patients with type-2 diabetes mellitus (T2DM). Sodium-glucose co-transporter 2 (SGLT-2) inhibitors decrease the incidence of cardiovascular events, renal events, and death in this population. This study aimed to evaluate the effect of dapagliflozin on short-term BPV in patients with T2DM.

METHODS

This is a secondary analysis of a double-blind, randomized, placebo-controlled trial in 85 patients with T2DM. Subjects were randomized to dapagliflozin 10 mg/day or placebo for 12 weeks. All participants underwent 24-hour ambulatory blood pressure (BP) monitoring with Mobil-O-Graph-NG device at baseline and study-end. SD, weighted SD (wSD), coefficient of variation, average real variability (ARV), and variation independent of mean were calculated for the 24-hour, daytime and nighttime periods.

RESULTS

Dapagliflozin reduced 24-hour brachial BP compared with placebo. From baseline to study-end 24-hour brachial BPV indexes did not change with dapagliflozin (SBP-ARV: 11.51 ± 3.45 vs. 11.05 ± 3.35; P = 0.326, SBP-wSD: 13.59 ± 3.60 vs. 13.48 ± 3.33; P = 0.811) or placebo (SBP-ARV: 11.47 ± 3.63 vs. 11.05 ± 3.00; P = 0.388, SBP-wSD: 13.85 ± 4.38 vs. 13.97 ± 3.87; P = 0.308). Similarly, no significant changes in BPV indexes for daytime and nighttime were observed in any group. At study-end, no between-group differences were observed for any BPV index. Deltas (Δ) of all indexes during follow-up were minimal and not different between groups (SBP-wSD: dapagliflozin: -0.11 ± 3.05 vs. placebo: 0.12 ± 4.20; P = 0.227).

CONCLUSIONS

This study is the first to evaluate the effects of an SGLT-2 inhibitor on short-term BPV in T2DM, showing no effect of dapagliflozin on all BPV indexes studied.

CLINICAL TRIALS REGISTRATION

Trial Number NCT02887677.

Accuracy of Peridialytic, Intradialytic, and Scheduled Interdialytic Recordings in Detecting Elevated Ambulatory Blood Pressure in Hemodialysis Patients

RATIONALE & OBJECTIVE

Current recommendations suggest the use of ambulatory blood pressure monitoring (ABPM) as the gold standard for hypertension diagnosis and management in hemodialysis patients. This study assesses the accuracy of peridialytic, intradialytic, and scheduled interdialytic recordings in detecting abnormally elevated 44-hour interdialytic blood pressure (BP).

STUDY DESIGN

Diagnostic test study.

SETTINGS & PARTICIPANTS

242 Greek hemodialysis patients who successfully underwent ABPM.

TESTS COMPARED

Ambulatory BP was used as the reference method to evaluate the accuracy of the following BP metrics: predialysis and postdialysis BP, intradialytic BP, intradialytic plus pre/postdialysis BP, and scheduled interdialytic BP (on an off-dialysis day at 8:00 am, 8:00 pm, and their average).

OUTCOME

44-hour ambulatory systolic BP/diastolic BP (SBP/DBP) ≥ 130/80 mm Hg.

RESULTS

The 44-hour SBP/DBP levels differed significantly from predialysis and postdialysis BP but showed no or minor differences compared with the other BP metrics. Bland-Altman plots showed an absence of systematic bias for all metrics but large between-method difference and wider 95% limits of agreement for predialysis and postdialysis BP compared with intradialytic, intradialytic plus pre/postdialysis, and averaged scheduled interdialytic BP. The sensitivity/specificity and κ-statistic for diagnosing 44-hour SBP ≥ 130 mm Hg were low for predialysis (86.5%/38.6%, κ-statistic = 0.27) and postdialysis BP (63.1%/73.3%, κ-statistic = 0.35), but better for intradialytic BP (77.3%/76.2%, κ-statistic = 0.53), intradialytic plus pre/postdialysis BP (76.6%/72.3%, κ-statistic = 0.49), and scheduled interdialytic BP (87.9%/77.2%, κ-statistic = 0.66). In receiver operating characteristic (ROC) analyses, the areas under the curve (AUC) of predialysis SBP (AUC = 0.723) and postdialysis SBP (AUC = 0.746) were significantly lower than that of intradialytic SBP (AUC = 0.850), intradialytic plus pre/postdialysis SBP (AUC = 0.850), and scheduled interdialytic SBP (AUC = 0.917) (z test, P < 0.001 for all pairwise comparisons). Similar observations were made for DBP.

LIMITATIONS

Typical home BP data were not obtained, and no assessment was obtained of the reproducibility of the examined metrics over time.

CONCLUSIONS

Intradialytic, intradialytic plus pre/postdialysis, and scheduled interdialytic BP measurements were more accurate in detecting elevated 44-hour BP than predialysis and postdialysis BP. Averaged intradialytic BP recordings or scheduled readings at the off-dialysis day appear to be promising approaches to the diagnosis of elevated BP in hemodialysis.

Acute kidney injury is more common in men than women after accounting for socioeconomic status, ethnicity, alcohol intake and smoking history

Background

The association of several comorbidities, including diabetes mellitus, hypertension, cardiovascular disease, heart failure and chronic kidney or liver disease, with acute kidney injury (AKI) is well established. Evidence on the effect of sex and socioeconomic factors are scarce. This study was designed to examine the association of sex and socioeconomic factors with AKI and AKI-related mortality and further to evaluate the additional relationship with other possible risk factors for AKI occurrence.

Methods

We included 3534 patients (1878 males with mean age 61.1 ± 17.7 and 1656 females 1656 with mean age 60.3 ± 20.0 years) admitted to Queen Elizabeth or Heartlands Hospitals, Birmingham, between October 2013 and January 2016. Patients were prospectively followed-up for a median 47.70 [IQR, 18.20] months. Study-endpoints were incidence of AKI, based on KDIGO-AKI Guidelines, and all-cause mortality. Data acquisition was automated, and information on mortality was collected from the Hospital Episode Statistics and Office of National Statistics. Socioeconomic status was evaluated with the Index of Multiple Deprivation (IMD).

Results

Incidence of AKI was higher in men compared to women (11.3% vs 7.1%; P < 0.001). Model regression analysis revealed significant association of male sex with higher AKI risk (OR, 1.659; 95% CI, 1.311–2.099; P < 0.001); this association remained significant after adjustment for age, eGFR, IMD, smoking, alcohol consumption, ethnicity, existing comorbidities and treatment (OR, 1.599; 95% CI, 1.215–2.103; P = 0.001). All-cause mortality was higher in patients with compared to those without AKI. Males with AKI had higher mortality rates in the first 6-month and 1-year periods after the index AKI event. The association of male sex with mortality was independent of socioeconomic factors but was not statistically significant after adjustment for existing comorbidities.

Conclusions

Men are at higher risk of AKI and this association is independent from existing risk factors for AKI. The association between male sex and AKI-related mortality was not independent from existing comorbidities. A better understanding of factors associated with AKI may help accurately identify high-risk patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13293-021-00373-4.

Blood pressure monitoring in kidney transplantation: a systematic review on hypertension and target organ damage

BACKGROUND

Sparse studies show that ambulatory blood pressure monitoring (ABPM) is superior to office BP (oBP) measurements to predict target organ damage and cardiovascular (CV) events in kidney transplant recipients (KTRs). We performed a systematic review aimed at determining the potential associations between BP recordings by different methods and renal and CV outcomes in this population.

METHODS

Major medical databases were searched for studies enrolling adult KTRs undergoing 24h ABPM compared to office or home BP measurements. Main outcomes were: associations between different BP recordings and renal and CV outcomes. Additionally, any association between the circadian BP pattern (dipping/non-dipping status) and outcomes was assessed.

RESULTS

Twenty-two studies (2078 participants) were reviewed. Amongst 12 studies collecting data on renal endpoints, ten studies found that BP assessed by ABPM was a stronger predictor of renal function decline, assessed by serum creatinine (SCr) and/or creatinine clearance (CrCl) or estimated glomerular filtration rate (eGFR), than traditional office measurements. Twelve studies analyzed the relation between different BP recordings and CV target organ damages and reported robust correlations between echocardiographic abnormalities [i.e. left ventricular mass index (LVM/LVMI)] and 24h ABPM, but not with office BPs. Furthermore, 24h ABPM correlated better than oBP with markers of vascular damage, such as carotid intima-media thickness (IMT), diffuse thickening, and endothelial dysfunction. Additionally, abnormal circadian BP pattern (non-dippers and reverse dippers) identified a group of kidney recipients at risk for kidney function loss and CV abnormalities.

CONCLUSIONS

In our systematic review, ABPM reflected target organ damage more closely than oBP in KTRs. Furthermore, altered circadian BP profile associated with renal and CV target organ damages.

Changes in left ventricular structure and function associated with renal transplantation: a systematic review and meta-analysis

Aims

This study aimed to examine if the cardiac changes associated with uraemic cardiomyopathy are reversed by renal transplantation.

Methods and results

MEDLINE, Embase, OpenGrey, and the Cochrane Library databases were searched from 1950 to March 2020. The primary outcome measure was left ventricular mass index. Secondary outcome measures included left ventricular dimensions and measures of diastolic and systolic function. Studies were included if they used any imaging modality both before and after successful renal transplantation. Data were analysed through meta‐analysis approaches. Weight of evidence was assessed through the Grading of Recommendations Assessment, Development and Evaluation system. Twenty‐three studies used echocardiography, and three used cardiac magnetic resonance imaging as their imaging modality. The methodological quality of the evidence was generally poor. Four studies followed up control groups, two using cardiac magnetic resonance imaging and two using echocardiography. Meta‐analysis of these studies indicated that there was no difference in left ventricular mass index between groups following transplantation {standardized mean difference −0.07 [95% confidence interval (CI) −0.41 to 0.26]; P = 0.67}. There was also no difference observed in left ventricular ejection fraction [mean difference 0.39% (95% CI −4.09% to 4.87%); P = 0.86] or left ventricular end‐diastolic volume [standardized mean difference −0.24 (95% CI −0.94 to 0.45); P = 0.49]. Inconsistent reporting of changes in diastolic dysfunction did not allow for any meaningful analysis or interpretation.

Conclusions

The evidence does not support the notion that uraemic cardiomyopathy is reversible by renal transplantation. However, the evidence is limited by methodological weaknesses, which should be considered when interpreting these findings.

Renin-angiotensin system blockade in patients with chronic kidney disease: benefits, problems in everyday clinical use, and open questions for advanced renal dysfunction

Management of hypertension and albuminuria are considered among the primary goals of treatment to slow the progression of chronic kidney disease (CKD). Renin-angiotensin system (RAS) blockers, i.e., angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) are the main drugs to achieve these goals. Seminal studies have showed that RAS blockers present significant renoprotective effects in CKD patients with very high albuminuria. In post hoc analyses of such trials, these renoprotective effects appeared more robust in patients with more advanced CKD. However, randomized trials specifically addressing whether RAS blockers should be initiated or maintained in patients with advanced CKD are scarce and do not include subjects with normoalbuminuria, thus, many clinicians are unconvinced for the beneficial effects of RAS blockade in these patients. Further, the fear of hyperkalemia or acute renal decline is another factor due to which RAS blockers are usually underprescribed and are easily discontinued in patients with more advanced CKD; i.e., those in Stages 4 and 5. This review summarizes evidence from the literature regarding the use of RAS blockers in patients with advanced CKD.

The Beneficial Hemodynamic Actions of SGLT-2 Inhibitors beyond the Management of Hyperglycemia

Type 2 diabetes mellitus (DM) is a public health burden and its co-existence with hypertension is long established in the context of the metabolic syndrome. Both DM and hypertension are major risk factors, for end-stage renal disease, cardiovascular events and mortality. Strict blood pressure (BP) control in diabetics has been associated with a cardiovascular and renal risk decrease. Inhibitors of the sodium-glucose co-transporter 2 (SGLT-2) in the proximal tubule is a relatively novel class of agents for the treatment of type 2 DM. Inhibition of SGLT-2 co-transporter combines proximal tubule diuretic and osmotic diuretic action leading to glucose reabsorption reduction and mild natriuretic and diuretic effects. On this basis, several studies showed that treatment with SGLT-2 inhibitors can effectively decrease hyperglycemia but also increase BP control and reduce renal outcomes and cardiovascular mortality. Based on such evidence, the recent guidelines for the management of type 2 DM now suggest that SGLT-2 inhibitors should be preferred among oral agents in combination with metformin, in patients at increased cardiovascular risk, chronic kidney disease or heart failure. This review summarizes the existing data from studies evaluating the effect of SGLT-2 inhibitors on BP, and its potential value for cardio- and nephroprotection.

The effect of admission and pre-admission serum creatinine as baseline to assess incidence and outcomes of acute kidney injury in acute medical admissions

BACKGROUND

Acute kidney injury (AKI) in hospital-admitted patients is a common complication associated with increased mortality. The diagnosis of AKI relies on the ascertainment of peak increase in serum creatinine (SCr). This study evaluated the incidence of AKI using the increase from mean 7-365 days pre-admission (AKIpre) and admission (AKIadm) SCr levels, and examined the associations of AKI and changes in SCr levels with all-cause mortality.

METHODS

A total of 2436 patients admitted to a tertiary hospital were recruited and followed-up for a median of 47.70 (interquartile range 18.20) months. AKI incidence and severity were defined according to the Kidney Disease: Improving Global Outcomes-AKI Guidelines. Follow-up data were collected from the Hospital Episode Statistics and Office of National Statistics. Mortality was evaluated during a short- (30 days), mid- (1 year) and long-term (4 years) period.

RESULTS

No difference in the AKI rates using AKIpre and AKIadm (12.5% versus 12.2%; P = 0.695) or in the AKI severity (P = 0.261) was evident. Agreement between the two definitions was modest (Kappa-statistic = 0.596, P < 0.001). Patients with AKIpre or AKIadm had increased all-cause mortality compared with those without AKI during all follow-up periods. In fully adjusted regression analysis, AKIpre [hazard ratio (HR) = 2.226, 95% confidence interval (CI) 1.140-4.347; P = 0.027] and AKIadm (HR = 2.105, 95% CI 1.090-4.064; P = 0.027) remained associated with 30-day mortality. Results for the 1- and 4-year periods were similar. Increases of >4.00 μmol/L and >6.06% from pre-admission or >6.00 μmol/L and >17.24% from admission SCr levels presented increased mortality risk during follow-up.

CONCLUSIONS

Use of admission or pre-admission SCr provides similar incidence rates, but they diagnose different sets of patients. Even minor increases in SCr, below those required for the classification of AKI, were associated with increased mortality. These findings can help the clinicians to identify patients at higher risk for adverse outcomes.

Can the assessment of ultrasound lung water in haemodialysis patients be simplified?

BACKGROUND

Lung ultrasound (US) reliably estimates lung water and it is increasingly applied in clinical practice in dialysis patients. A semi-quantitative US score summing up the US-B lines (an equivalent of B lines in the standard chest X-ray) at 28 sites in the intercostal spaces (Jambrik et al. Usefulness of ultrasound lung comets as a non-radiologic sign of extravascular lung water. Am J Cardiol 2004; 93: 1265-1270) is the most used score.

METHODS

We compared the prognostic performance for death, and cardiovascular (CV) events of the 28-sites US score with a score restricted to eight sites in a cohort of 303 haemodialysis (HD) patients.

RESULTS

The 8- and the 28-sites scores were highly inter-related (Spearman's ρ = 0.93, P < 0.001), and their concordance index was fairly good (k = 0.79, 95% confidence interval 0.74-0.84). During a mean follow-up of 3 years, 112 patients died, and 129 experienced a CV event. At univariate and multivariate analysis, both scores were associated with mortality (P ≤ 0.01) and CV events (P ≤ 0.05). The explained variances (R2) for death and CV events of the 28-sites score in multivariate models including major risk factors for these outcomes in the end-stage kidney disease (ESKD) population were 3.9 and 2.2%, and those of the 8-sites score were 3.1 and 2.4%, respectively. The median time needed to perform the examination was 3.05 min [interquartile range (IQR) 2.22-5.00 min] for the 28-sites score and 1.35 min (IQR 1.16-2.00 min) for the 8-sites score.

CONCLUSION

The 8-sites score is tightly related to the classical Jambrik 28-sites score and this score holds an almost identical predictive power to the reference score. Even though the 28-sites score can be completed just in ∼3 min, the 8-sites score requires only ∼1.30 min, and it is, therefore, better suited for application in everyday clinical practice in HD units.

Serum Copeptin, NLPR3, and suPAR Levels among Patients with Autosomal-Dominant Polycystic Kidney Disease with and without Impaired Renal Function

BACKGROUND

The pathophysiology of renal disease progression in autosomal-dominant polycystic kidney disease (ADPKD) involves not only cystogenesis but also endothelial dysfunction, leading to the activation of inflammatory and fibrotic pathways. This study evaluated the levels of biomarkers related to osmoregulation, immune system activation, and tubular injury in ADPKD patients with impaired or preserved renal function.

METHODS

This study included 26 ADPKD patients with modestly impaired renal function (estimated glomerular filtration rate [eGFR] 45-70 mL/min/1.73 m2; Group A), 26 age- and sex-matched ADPKD patients with relatively preserved renal function (eGFR >70 mL/min/1.73 m2; Group B), and 26 age- and sex-matched controls (Group C). Serum levels of copeptin, the inflammasome nucleotide-binding and oligomerization domain-like receptors pyrin domain-containing protein 3 (NLRP3), and soluble urokinase-type plasminogen activator receptor (suPAR) were measured with ELISA techniques.

RESULTS

Patients in Group A had higher levels of copeptin (median [interquartile range]: 50.44 [334.85] pg/mL), NLRP3 (5.86 [3.89] ng/mL), and suPAR (390.05 [476.53] pg/mL) compared to patients in Group B (32.38 [58.33], p = 0.042; 2.42 [1.96], p < 0.001; and 313.78 [178.85], p = 0.035, respectively) and Group C (6.75 [6.43]; 1.09 [0.56]; and 198.30 [28.53], respectively; p < 0.001 for all comparisons). Levels of all studied markers were also significantly higher in Group B patients compared to controls (p < 0.001), despite having similar eGFR. In patients with ADPKD, all studied biomarkers were correlated positively with asymmetric-dimethylarginine (ADMA) and endocan levels, and negatively with eGFR. ADMA and endocan levels were the only parameters independently associated with increased copeptin levels.

CONCLUSIONS

This study showed that ADPKD patients with impaired and preserved renal function had higher copeptin, NLRP3, and suPAR levels than controls. Such findings support that cystogenesis and inflammation are associated with endothelial dysfunction, even in the early stages of ADKPD.

Volume overload in hemodialysis: diagnosis, cardiovascular consequences, and management

Volume overload in haemodialysis (HD) patients associates with hypertension and cardiac dysfunction and is a major risk factor for all-cause and cardiovascular mortality in this population. The diagnosis of volume excess and estimation of dry weight is based largely on clinical criteria and has a notoriously poor diagnostic accuracy. The search for accurate and objective methods to evaluate dry weight and to diagnose subclinical volume overload has been intensively pursued over the last 3 decades. Most methods have not been tested in appropriate clinical trials and their usefulness in clinical practice remains uncertain, except for bioimpedance spectroscopy and lung ultrasound (US). Bioimpedance spectroscopy is possibly the most widely used method to subjectively quantify fluid distributions over body compartments and produces reliable and reproducible results. Lung US provides reliable estimates of extravascular water in the lung, a critical parameter of the central circulation that in large part reflects the left ventricular end-diastolic pressure. To maximize cardiovascular tolerance, fluid removal in volume-expanded HD patients should be gradual and distributed over a sufficiently long time window. This review summarizes current knowledge about the diagnosis, prognosis and treatment of volume overload in HD patients.

Comparison of ambulatory central hemodynamics and arterial stiffness in patients with diabetic and non-diabetic CKD

Increased arterial stiffness is independently associated with renal function decline in patients with diabetes mellitus (DM). Whether DM has additional deleterious effects on central hemodynamics and arterial stiffness in chronic kidney disease (CKD) patients is yet unknown. This study aimed to compare ambulatory central BP, arterial stiffness parameters, and trajectories between patients with diabetic and non‐diabetic CKD. This study examined 48 diabetic and 48 non‐diabetic adult patients (>18 years) with CKD (eGFR: <90 and ≥15 ml/min/1.73 m²), matched in a 1:1 ratio for age, sex, and eGFR within CKD stages (2, 3a, 3b and 4). All patients underwent 24‐h ABPM with the Mobil‐O‐Graph device. Parameters of central hemodynamics [central systolic (cSBP) and diastolic blood pressure (cDBP), pulse pressure (PP)], wave reflection [augmentation index (AIx), and pressure (AP)] and pulse wave velocity (PWV) were estimated from the 24‐h recordings. Diabetic CKD patients had higher 24‐h cSBP (118.57 ± 10.05 vs. 111.59 ± 9.46, P = .001) and 24‐h cPP (41.48 ± 6.80 vs. 35.25 ± 6.98, P < .001) but similar 24‐h cDBP (77.09 ± 8.14 vs. 76.34 ± 6.75 mmHg, P = .625) levels compared to patients with non‐diabetic CKD. During day‐ and nighttime periods, cSBP and cPP levels were higher in diabetics compared to non‐diabetics. 24‐h PWV (10.10 ± 1.62 vs. 9.61 ± 1.80 m/s, P = .165) was numerically higher in patients with DM, but no between‐group differences were noted in augmentation pressure and index. In multivariate analysis, DM, female gender, and peripheral SBP were independently associated with higher cPP levels. Patients with diabetic CKD have higher ambulatory cSBP and increased arterial stiffness, as indicated by higher ambulatory cPP. These finding suggest that DM is a factor independently contributing to the adverse macrocirculatory profile of CKD patients.

The presence of diabetes mellitus further impairs structural and functional capillary density in patients with chronic kidney disease

OBJECTIVE

Endothelial dysfunction has been associated with increased cardiovascular events and overall mortality. Microvascular damage is prevalent both in diabetes mellitus (DM) and chronic kidney disease (CKD). Our aim was to compare microcirculatory function parameters in diabetic and non-diabetic CKD patients via nailfold video-capillaroscopy.

METHODS

We included 48 diabetic and 48 non-diabetic adult CKD patients. All participants underwent nailfold video-capillaroscopy, during which capillary density was measured at normal conditions (baseline), after a 4-minute arterial occlusion (postocclusive reactive hyperemia), and at the end of a 2-minute venous occlusion (congestion phase).

RESULTS

Diabetic patients presented significantly lower capillary density during reactive hyperemia (36.3 ± 3.8 vs 38.3 ± 4.3 capillaries/mm² , P = .022) and at venous congestion (37.8 ± 4.0 vs 39.8 ± 4.2 capillaries/mm² , P = .015). When stratified according to CKD stages, only in stage 3b capillary density was significantly lower in diabetic compared to non-diabetic subjects at baseline, during postocclusive hyperemia (36.8 ± 2.7 vs 40.0 ± 4.3 capillaries/mm² , P = .037) and venous congestion (38.3 ± 2.8 vs 41.5 ± 3.5 capillaries/mm² , P = .022).

CONCLUSIONS

Capillary density during postocclusive hyperemia and after venous congestion is lower in diabetic compared to non-diabetic CKD patients, a finding indicative that diabetes is an additional factor contributing to microcirculatory structural and functional impairment in CKD. These differences are more prominent in CKD stage 3b.

Haemodialysis and peritoneal dialysis patients have severely impaired post-occlusive skin forearm vasodilatory response assessed with laser speckle contrast imaging

Background

Endothelial dysfunction is associated with cardiovascular events and mortality in various disease states, including end-stage renal disease (ESRD). Novel technological approaches have emerged for real-time assessment of endothelial reactivity. This study examined skin microcirculation using laser speckle contrast imaging (LSCI) before and after arterial occlusion in ESRD patients undergoing haemodialysis (HD) or peritoneal dialysis (PD).

Methods

The 38 HD patients were matched in a 1:1 ratio with 38 PD patients (for age, sex and dialysis vintage) and 38 controls (for age and sex). Skin microvascular reactivity parameters assessed with LSCI included baseline perfusion, occlusion perfusion and peak perfusion during post-occlusive reactive hyperaemia (PORH); time to peak perfusion; proportional change from baseline to peak perfusion; baseline and peak cutaneous vascular conductance (CVC); proportional change from baseline to peak CVC and amplitude of the PORH response (i.e. the difference between peak and baseline CVC).

Results

Baseline perfusion [HD: 46.97 ± 14.6; PD: 49.32 ± 18.07; controls: 42.02 ± 11.94 laser specle perfusion units (LSPU), P = 0.097] and peak post-occlusion perfusion (104.77 ± 28.68 versus 109.04 ± 40.77 versus 116.96 ± 30.96 LSPU, P = 0.238) did not differ significantly between groups. However, the post-occlusive vascular response was completely different since the proportional increase from baseline to peak perfusion (HD: 133 ± 66; PD: 149 ± 125; controls: 187 ± 61%, P = 0.001) was significantly lower in ESRD patients and time to peak response was lower in HD but similar in PD patients compared with controls (HD: 7.24 ± 6.99; PD: 10.68 ± 9.45; controls: 11.11 ± 5.1 s, Kruskal–Wallis P = 0.003; pairwise comparisons: HD versus controls, P = 0.002; HD versus PD, P = 0.154; PD versus controls, P = 0.406). ESRD patients also had lower levels of peak CVC, indicating the maximum capillary recruitment (HD: 1.05 ± 0.3; PD: 1.07 ± 0.44; controls: 1.57 ± 0.52 LSPU/mmHg, P < 0.001), lower proportional increase of CVC at peak (P < 0.001) and lower amplitude of the PORH response, a measure of the difference between baseline and maximum capillary recruitment (P = 0.001).

Conclusions

Using this novel non-invasive technology, endothelial post-occlusive forearm skin vasodilatory response was found to be similar between HD and PD patients and significantly impaired compared with controls. Future studies are needed to assess the prognostic implications of this microcirculatory functional defect.

The Effects of Nebivolol and Irbesartan on Ambulatory Aortic Blood Pressure and Arterial Stiffness in Hemodialysis Patients with Intradialytic Hypertension

BACKGROUND

Intradialytic hypertension occurs in 5-15% of hemodialysis patients and is associated with increased cardiovascular risk, but the responsible mechanisms remain unknown. This study examined the effects of nebivolol and irbesartan on ambulatory central blood pressure (BP), arterial stiffness, and wave-reflection parameters in patients with intradialytic hypertension.

METHODS

This is a prespecified analysis of a single-blind, randomized, cross-over study in 38 hemodialysis patients with intradialytic hypertension. Patients were randomized to nebivolol 5 mg followed byirbesartan 150 mg, or vice versa. In a non-randomized manner, the first half of the patients (n = 19) received a single drug dose 1 h prior to dialysis session and the remaining received the drugs for a whole week before the evaluation. Ambulatory central BP, arterial stiffness, and wave-reflection parameters were estimated with Mobil-O-Graph NG device, during a midweek dialysis day.

RESULTS

Intake of a single dose of nebivolol or irbesartan resulted in lower postdialysis central systolic BP (c-SBP) (baseline: 140.9 ± 15.4; nebivolol: 130.3 ± 19.5, p = 0.009; irbesartan: 127.3 ± 24.4 mm Hg, p = 0.007). Single-dose nebivolol also produced marginally lower 24-h c-SBP (p = 0.064) and lower 24-h central diastolic BP (c-DBP) (p = 0.029). Weekly administration of both drugs reduced postdialysis c-SBP (baseline: 144.1 ± 15.3; nebivolol: 131.8 ± 14.1, p = 0.014; irbesartan: 126.4 ± 17.8, p = 0.001) and 24-h c-SBP and c-DBP (baseline: 135.5 ± 10.3/91.9 ± 9.2; nebivolol: 126.4 ± 8.4/86.6 ± 7.2, p < 0.001/p = 0.002; irbesartan: 128.7 ± 11.6/87.0 ± 9.4, p = 0.061/p = 0.051 mm Hg). Single-dose intake of both drugs did not affect heart rate-adjusted augmentation index [AIx(75)], but decreased postdialysis pulse wave velocity (PWV). Importantly, weekly administration of both drugs reduced 24-h PWV (baseline: 10.0 ± 2.5; nebivolol: 9.7 ± 2.5, p = 0.012; irbesartan: 9.7 ± 2.7, p = 0.041). In between drug-group comparisons, no significant differences were noted.

CONCLUSIONS

This is the first randomized evaluation on the effects of pharmacological interventions on central BP and PWV in patients with intradialytic hypertension. Weekly administration of both nebivolol and irbesartan reduced 24-h central BP and PWV, but not AIx(75).

Heart Failure and Atrial Fibrillation Modify the Associations of Nocturnal Blood Pressure Dipping Pattern With Mortality in Hemodialysis Patients

Heart failure (HF), hypertension, and abnormal nocturnal blood pressure dipping are highly prevalent in hemodialysis patients. Atrial fibrillation (AF) and HF might be important mediators for the association of abnormal dipping patterns with worse prognosis. Thus, the aim of this study is to investigate the association of dipping with mortality in hemodialysis patients and to assess the influence of AF and HF. In total, 525 hemodialysis patients underwent 24-hour ambulatory blood pressure monitoring. All-cause and cardiovascular mortality served as end points. Patients were categorized according to their systolic dipping pattern (dipper, nondipper, and reverse dipper). Cox regression analysis was performed to determine the association between dipping pattern and study end points with dipping as reference. Subgroup analysis was performed for patients with and without AF or HF. In total, 185 patients with AF or HF and 340 patients without AF or HF were included. During a median follow-up of 37.8 months, 177 patients died; 81 from cardiovascular causes. Nondipping and reverse dipping were significantly associated with all-cause mortality in the whole cohort (nondipper: hazard ratio, 1.95 [1.22-3.14]; P=0.006; reverse dipper: hazard ratio, 2.31 [1.42-3.76]; P<0.001) and in patients without AF or HF (nondipper: hazard ratio, 2.78 [1.16-6.66]; P=0.02; reverse dipper: hazard ratio, 4.48 [1.87-10.71]; P<0.001) but not in patients with AF or HF. For cardiovascular mortality, associations were again significant in patients without AF or HF and in the whole cohort. The observed associations remained significant after adjustment for possible confounders. This study provides well-powered evidence for the association between abnormal dipping patterns and mortality in hemodialysis patients and suggests that HF or AF modifies this association.

Associations of serum sclerostin and Dickkopf-related protein-1 proteins with future cardiovascular events and mortality in haemodialysis patients: a prospective cohort study

Background

Sclerostin and Dickkopf-related protein-1 (Dkk-1) proteins are inhibitors of the canonical Wnt/β-catenin bone pathway. Sclerostin but not Dkk-1 is associated with increased arterial stiffness. This study examined the prognostic significance of sclerostin and Dkk-1 levels for cardiovascular outcomes and mortality in haemodialysis (HD) patients.

Methods

Serum sclerostin and Dkk-1 levels were measured with enzyme-linked immunosorbent assay in 80 HD patients that were followed-up for a median of 45 months. Factors that could interfere with the association of sclerostin and Dkk-1 with outcomes [including carotid–femoral pulse wave velocity (PWV), parathyroid hormone (PTH), calcium–phosphate product and others] were assessed at baseline. The primary endpoint was a combination of all-cause death, non-fatal myocardial infarction, non-fatal stroke, coronary revascularization, hospitalization for decompensated heart failure and new-onset atrial fibrillation. Secondary endpoints included cardiovascular and all-cause mortality.

Results

Cumulative freedom from the primary endpoint was significantly lower for higher tertiles of sclerostin (77.8, 69.2 and 40.7%; Tertiles 1–3, respectively; log-rank P = 0.004). The risk for the primary outcome gradually increased for higher sclerostin tertiles [Tertile 3: hazard ratio (HR) = 3.847, 95% confidence interval (CI) 1.502–9.851]. No significant association was evident between sclerostin and all-cause mortality, whereas higher sclerostin levels presented a trend towards higher risk for cardiovascular mortality. Dkk-1 levels exhibited no association with the risk of the primary or secondary endpoints. In stepwise Cox regression modelled analysis, sclerostin levels were associated with the primary outcome, independently of PTH, calcium–phosphate product, serum albumin, C-reactive protein and PWV levels (HR = 2.921, 95% CI 1.401–6.090; P = 0.004).

Conclusions

High sclerostin levels are associated with lower cumulative freedom and higher risk for a composite endpoint of cardiovascular events and mortality. Dkk-1 exhibited no association with the future risk of adverse outcomes.

SGLT-2 inhibitors and nephroprotection: current evidence and future perspectives

Chronic kidney disease (CKD) is a major public health issue and an independent risk factor for cardiovascular and all-cause mortality. Diabetic kidney disease develops in 30-50% of diabetic patients and it is the leading cause of end-stage renal disease in the Western world. Strict blood pressure control and renin-angiotensin system (RAS) blocker use are the cornerstones of CKD treatment; however, their application in everyday clinical practice is not always ideal and in many patients CKD progression still occurs. Accumulated evidence in the past few years clearly suggests that sodium-glucose co-transporter-2 (SGLT-2) inhibitors present potent nephroprotective properties. In clinical trials in patients with type 2 diabetes mellitus, these agents were shown to reduce albuminuria and proteinuria by 30-50% and the incidence of composite hard renal outcomes by 40-50%. Furthermore, their mechanism of action appears rather solid, as they interfere with the major mechanism of proteinuric CKD progression, i.e., glomerular hypertension and hyperfiltration. The present review summarizes the current evidence from human trials on the effects of SGLT-2 inhibitors on nephroprotection and discusses their position in everyday clinical practice.

Hypoxia and Endothelial Dysfunction in Autosomal-Dominant Polycystic Kidney Disease

Autosomal-dominant polycystic kidney disease (ADPKD) is the most prevalent inherited kidney disease, characterized by growth of bilateral renal cysts, hypertension, and multiple extrarenal complications that eventually can lead to renal failure. It is caused by mutations in PKD1 or PKD2 genes encoding the proteins polycystin-1 and polycystin-2, respectively. Over the past few years, studies investigating the role of primary cilia and polycystins, present not only on the surface of renal tubular cells but also on vascular endothelial cells, have advanced our understanding of the pathogenesis of ADPKD and have shown that mechanisms other than cyst formation also contribute to renal functional decline in this disease. Among them, increased oxidative stress, endothelial dysfunction, and hypoxia may play central roles because they occur early in the disease process and precede the onset of hypertension and renal functional decline. Endothelial dysfunction is linked to higher asymmetric dimethylarginine levels and reduced nitric oxide bioavailability, which would cause regional vasoconstriction and impaired renal blood flow. The resulting hypoxia would increase the levels of hypoxia-inducible-transcription factor 1α and other angiogenetic factors, which, in turn, may drive cyst growth. In this review, we summarize the existing evidence for roles of endothelial dysfunction, oxidative stress, and hypoxia in the pathogenesis of ADPKD.

P1294AMBULATORY BLOOD PRESSURE PROFILE IN PERITONEAL DIALYSIS COMPARED TO HEMODIALYSIS AND CHRONIC KIDNEY DISEASE PATIENTS

Background and Aims

Hypertension is highly prevalent in dialysis patients and is often poorly controlled. Data on the ambulatory blood pressure (BP) profile of patients undergoing peritoneal dialysis (PD) are scarce. The aim of this study is to compare the ambulatory BP profile of PD patients with that of hemodialysis (HD) and to pre-dialysis CKD patients.

Method

38 patients undergoing PD were matched in a 1:2 ratio for age, gender and dialysis vintage with 76 HD patients and in a 1:1 ratio for age and gender with 38 CKD stages 2-4 patients. Patients under PD and HD underwent 48-hour and CKD patients 24-hour ambulatory BP monitoring. BP levels were compared for the 48hour, 1st and 2nd 24hour, daytime and nighttime periods. Two-way mixed ANOVA analysis for repeated measurements was used to evaluate the effect of dialysis modality and time on ambulatory BP in PD and HD.

Results

During all periods studied, SBP and DBP were numerically higher but not statistically different in PD than in HD patients. SBP was significantly higher in PD or HD compared with predialysis CKD (PD:138.38±20.97; HD:133.75±15.5; CKD:125.52±13.4 mmHg, p=0.003; PD vs CKD: p=0.003; HD vs CKD: p=0.041 accordingly); significant differences were also evident during the daytime and nighttime periods. DBP displayed a similar trend in the total period studied (PD:82.34±15.22; HD:80.47±11.13; CKD:76.81±7.82 mmHg, p=0.108), but the difference significant only during the second nighttime period. Repeated-measurements analysis showed no effect of dialysis modality and no interaction between modality and time on ambulatory BP during all periods studied.

Conclusion

Average BP levels are similar between PD and HD patients, but higher for both groups compared to CKD counterparts. The dialysis modality had no significant effect on ambulatory BP profile.

P1252ASSOCIATIONS OF SERUM SCLEROSTIN AND DKK-1 PROTEIN WITH FUTURE CARDIOVASCULAR EVENTS AND MORTALITY IN HEMODIALYSIS PATIENTS; A PROSPECTIVE COHORT STUDY

Background and Aims

Sclerostin and Dickkopf-1 (Dkk-1) protein are inhibitors of the canonical Wnt/β-catenin bone pathway. Sclerostin but not Dkk-1 is associated with increased arterial stiffness. This study examined the prognostic significance of serum sclerostin and Dickkopf-related protein-1 (Dkk-1) levels for cardiovascular outcomes and mortality in hemodialysis patients.

Method

Serum sclerostin and Dkk-1 levels were measured with ELISA in 80 hemodialysis patients that were followed-up for a median of 45 months. Several factors that could interfere in the association of sclerostin and Dkk-1 with outcomes (including carotid-femoral pulse-wave-velocity (PWV), parathyroid hormone, calcium-phospate product and others) were assessed at baseline The primary end-point was a combination of all-cause death, non-fatal myocardial infarction, non-fatal stroke, coronary revascularization, hospitalization for decompensated heart failure and new-onset atrial fibrillation. Secondary end-points included cardiovascular and all-cause mortality.

Results

Cumulative freedom from the primary endpoint was significantly lower for higher tertiles of sclerostin (77.8%, 69.2%, and 40.7% for tertiles 1 to 3 respectively; log-rank-p=0.004). The corresponding risk for the primary outcome was gradually increasing for higher tertiles of sclerostin (Tertile 3: HR: 3.847, 95%CI: 1.502-9.851). No significant association was evident between sclerostin and all-cause mortality, whereas higher sclerostin levels presented a trend towards higher risk for cardiovascular mortality. Dkk-1 levels exhibited no association with the risk of the primary or the secondary endpoints. In stepwise Cox regression modeled analysis, sclerostin levels were associated with the primary outcome, independently of PTH, calcium-phosphate product, serum albumin, CRP and PWV levels (HR: 2.921, 95%CI: 1.401–6.090; p=0.004).

Conclusion

High serum sclerostin levels are associated with lower cumulative freedom and higher risk for a composite cardiovascular endpoint but not for all-cause mortality. Dkk-1 protein exhibited no association with the future risk of cardiovascular events.

P1012NAIL CAPILLARY DENSITY DURING POSTOCCLUSIVE REACTIVE HYPEREMIA AND VENOUS CONGESTION IS MORE IMPAIRED IN DIABETIC COMPARED TO NON-DIABETIC CKD PATIENTS

Background and Aims

Αlterations in endothelial function and capillary circulation have been associated with increased cardiovascular events and overall mortality. Both diabetes mellitus (DM) and chronic kidney disease (CKD) have been associated with microcirculatory damage. Nailfold video-capillaroscory can provide a thorough assessment of capillary density and microcirculation changes. This is the first study examining in comparison microcirculatory function parameters in diabetic and non-diabetic patients with CKD.

Method

We included 48 diabetic and 48 non-diabetic adult patients (&gt;18 years) with CKD (eGFR: &lt;90 and ≥15mL/min/1.73m2), matched in a 1:1 ratio for age, sex and eGFR within each CKD stage (2, 3a, 3b and 4). All participants underwent nailfold video-capillaroscopy, during which capillary density was measured at normal conditions (baseline), after a 4-minute arterial occlusion (postocclusive reactive hyperemia) and at the end of a 2-minute venous occlusion (congestion phase).

Results

Baseline demographic, anthropometric and laboratory characteristics were similar between patients with and without diabetes in total and in CKD stages. Overall, no significant differences at baseline capillary density were observed between groups; however diabetic patients presented significantly lower capillary density during reactive hyperemia (36.3±3.8 vs 38.3±4.3 capillaries/mm2, p=0.022) and at venous congestion (37.8±4.0 vs 39.8±4.2 capillaries/mm2, p=0.015). When stratified according to CKD stages, the between-group differences in parameters of interest were not significant in stages 2, 3a and 4. In stage 3b, capillary density was significantly lower in diabetic compared to non-diabetic subjects at baseline (31.1±2.8 vs 33.4±3.4 capillaries/mm2, p=0.044), during postocclusive hyperemia (36.8±2.7 vs 40.0±4.3 capillaries/mm2, p=0.037) and venous congestion (38.3±2.8 vs 41.5±3.5 capillaries/mm2, p=0.022).

Conclusion

Capillary density during postocclusive reactive hyperemia and after venous congestion is lower in diabetic compared to non-diabetic CKD patients, a finding indicative that diabetes is an additional factor contributing to microcirculatory functional impairment in CKD. These differences are more prominent in CKD stage 3b, and less prominent in earlier and later stages.

P1270INCREASED SCLEROSTIN, BUT NOT DKK-1 PROTEIN, IS ASSOCIATED WITH ELEVATED PULSE WAVE VELOCITY IN HEMODIALYSIS SUBJECTS

Background and Aims

Sclerostin and Dickkopf-1 (Dkk-1) protein are inhibitors of the canonical Wnt/β-catenin bone pathway. Pilot data suggest that sclerostin may be involved in vascular changes in CKD, but data on Dkk-1 effects are scarce. This is the first study investigating simultaneously the associations of sclerostin and Dkk-1 with arterial stiffness in hemodialysis patients.

Method

80 patients on chronic hemodialysis had carotid-femoral pulse wave velocity (PWV), central BP and wave reflections evaluated with applanation tonometry (Sphygmocor) in a mid-week non-dialysis day. Serum levels of sclerostin and Dkk-1 were measured with ELISA. A large set of demographic, co-morbid, laboratory and drug parameters were used in the analyses.

Results

Subjects with PWV&gt;9.5 m/sec (high arterial stiffness group, n=40) were older, had higher BMI, higher prevalence of hypertension, diabetes and coronary-heart-disease and higher peripheral SBP, central SBP, C- reactive protein and serum sclerostin (p=0.02), but similar Dkk-1 compared to subjects with low PWV. When dichotomizing the population by sclerostin levels, those with high sclerostin had higher PWV than patients with low sclerostin levels (10.63±2.71 vs 9.77±3.13, p=0.048). Increased sclerostin (&gt;200 pg/ml) was significantly associated with increased PWV (&gt;9.5 m/s) (HR:2.778, 95%CI:1.123-6.868, per pg/ml increase); this association remained significant after stepwise adjustment for Dkk-1, iPTH and calcium x phosphate product. In contrast, no association was noted between Dkk-1 and PWV (HR: 1.000, 95%CI: 0.416-2.403).

Conclusion

Serum sclerostin is associated with PWV independently of routine markers of CKD-MBD in hemodialysis patients. In contrast Dkk-1 has no association with arterial stiffness and is rather not pathophysiologically involved in relevant vascular changes.

P0763A COMPARATIVE STUDY OF ARTERIAL STIFFNESS AND WAVE REFLECTIONS IN DIABETIC AND NON-DIABETIC PATIENTS WITH CKD

Background and Aims

Arterial stiffness is associated with increased risk for target-organ damage, cardiovascular events and overall mortality in the general population, patients with diabetes mellitus and patients with chronic kidney disease (CKD) of all stages. This is the first study to evaluate in comparison arterial stiffness and arterial wave reflections in diabetic and non-diabetic patients with CKD.

Method

This study included 48 diabetic and 48 non-diabetic adult patients (&gt;18 years) with CKD (eGFR: &lt;90 και ≥15mL/min/1.73m2), matched in a 1:1 ratio for age, sex and eGFR within each CKD stage (2, 3a, 3b and 4). All patients underwent carotid-femoral pulse wave velocity (PWV), central blood pressure (BP), and wave reflections measurement with applanation tonometry (Sphygmocor, Atcor Medical, Australia).

Results

Office systolic and diastolic blood pressure was similar between diabetic and non-diabetic subjects with CKD in total and across CKD stages. Office brachial pulse pressure (PP) was significantly lower in non-diabetics (49.00±8.0 vs 52.67±8.7 mmHg, p= 0.034). Office PWV was marginally higher in diabetics compared with non-diabetics (10.89±2.0 vs 10.06±2.2 m/sec, p=0.056). In CKD stages 2 and 4, no significant difference in PWV between the two groups was noted, but PWV was higher for diabetics in CKD stages 3a (11.28±1.4 vs 9.83±1.5 m/sec, p=0.023) and 3b (11.13±1.9 vs 9.46±1.2 m/sec, p=0.016). Heart-rate-adjusted augmentation index [AIx(HR75)] was higher in diabetic compared with non-diabetic subjects only in CKD stage 4 (32.08±4.2 vs 25.92±6.6%, p=0.013).

Conclusion

Diabetic CKD patients present higher arterial stiffness than non-diabetic counterparts. The additional contribution of diabetes towards increased arterial stiffness is more prominent in patients with moderately impaired renal function (CKD stage 3a and 3b), whereas at stage 4, PWV was increased independent of diabetes presence.

P0156SHORT-TERM BLOOD PRESSURE VARIABILITY IN DIABETIC AND NON-DIABETIC PATIENTS WITH CKD STAGE 2, 3A, 3B AND 4

Background and Aims

Blood pressure variability (BPV) is an important risk factor for cardiovascular events and mortality in patients with chronic kidney disease (CKD). Previous evidence suggests that BPV is gradually increasing across CKD stages. Whether type 2 diabetes mellitus (DM) is an additional risk factor for increased BPV has never been studied. The aim of this study is to examine in comparison BPV in diabetic and non-diabetic patients with CKD.

Method

We included 48 diabetic and 48 non-diabetic adult patients (&gt;18 years) with CKD (eGFR: &lt;90 και ≥15mL/min/1.73m2), matched in a 1:1 ratio for age, sex and eGFR within each CKD stage (2, 3a, 3b and 4). All patients underwent 24-hour ambulatory blood pressure (BP) measurement with the Mobil-O-Graph device. Brachial BP variability was calculated with validated formulas. We calculated standard deviation (SD), weighted SD (wSD), coefficient of variation (CV), and average real variability (ARV) of BP during the 24-hour, day- and night-time periods with validated formulas.

Results

In total population, ambulatory systolic BP (SBP) levels were significantly higher in diabetics compared to non-diabetic counterparts in all studied periods. No significant differences were evidence for ambulatory diastolic BP (DBP) in total or across CKD stages. In total, 24-hour SBP SD (15.43±4.34 vs 13.38±3.35, p=0.011), wSD (14.41±4.11 vs 12.53±3.19, p=0.014) and ARV (10.94±2.75 vs 9.46±2.10, p=0.004) were higher in patients with DM compared to those without DM. In addition, 24hour DBP SD (11.04±2.39 vs 9.80±2.28, p=0.010), wSD (10.30±2.52vs 9.05±1.99, p=0.008), CV (14.77±3.05 vs 13.14±2.96, p=0.009) and ARV (8.23±2.10 vs 7.10±1.33, p=0.002) were again different between groups. Across CKD stages 2 and 3a, BPV indices were insignificantly higher in patients with DM. In CKD Stage 3b, 24-hour SBP-SD (16.30±4.52 vs 11.35±2.62, p=0.003), wSD (15.42±4.54 vs 10.77±2.30, p=0.004), ARV (12.46±3.19 vs 8.34±2.07, p=0.001) and 24-hour DBP-CV (14.84±3.63 vs 12.18±1.91, p=0.035) were higher in diabetic compared to non-diabetic patients. In contrast, no difference between groups existed in CKD Stage 4.

Conclusion

Patients with DM present increased BPV in CKD Stages 2, 3a and 3b (moderately impaired renal function). This difference is not apparent in patients with advanced CKD at Stage 4.

P1442CAN THE ASSESSMENT OF ULTRASOUND LUNG WATER IN HEMODIALYSIS PATIENTS BE SIMPLIFIED?

Background and Aims

Lung Ultrasound (US) reliably estimates lung water and it is increasingly applied in clinical practice in dialysis patients. Lung water is currently measured by applying a semi-quantitative US score summing up the US-B lines (an equivalent of B lines in standard X-rays of the thorax) detected in 28 lung intercostal spaces (LIS) (Jambrik Z et al., Am J Cardiol 2004; 93:1265-70). A simplified assessment restricted to 8 LIS only (Gutierrez M et al., Arthritis Research & Therapy, 2011;13:R134) has been proposed. However, the agreement among this simplified score and the reference score has not been studied and the prognostic value of the simplified score (8-LIS) has not been face to face compared with the 28-LIS score.

Method

We included in the analysis in a cohort of 303 hemodialysis (HD) patients in which the pre-dialysis US-BL score was measured at baseline with both the semi-quantitative by Jambrik and the simplified Gutierrez method. The time needed for performing the 28-LIS and the 8-LIS score by six independent assessors with various experience -from low to high- on lung US assessment was accurately measured and recorded. Patients were divided into 4 categories, according to pre-established cut-offs specific for the two methods (28-LIS score: &lt;5; 6-15; 16-30; &gt;30 US-BL; 8-LIS score: &lt;10; 11-20; 21-50; &gt;50 US-BL) The prediction power of these scores for death and fatal and non-fatal cardiovascular events was assessed by the explained variance (R2).

Results

The 28-LIS score and the 8-LIS score were highly inter-related (Spearman’s ρ=0.93, P&lt;0.001). During a mean follow-up of 3 years, 112 patients died and 129 experienced a CV event. At univariate and multivariate analysis, both scores were associated to the study outcomes (Tab.1). The explained variance (R2) of the 28-LIS score for death was 4.1% and that for CV events 4.6%. The corresponding R2 of the 8-LIS score were 5.4% (death) and 4.7%, (CV events), to values close to those of the 28-LIS score. Accordingly, when the two scores were separately added to a clinical model including easily available clinical variables (age, gender, smoking, diabetes, cardiovascular comorbidities, cholesterol, arterial pressure, BMI, anti-hypertensive treatment, NYHA class as well as dialysis vintage, hemoglobin, albumin, phosphate and CRP) the R2 of the model including the 28-LIS score (death: 31.1%; CV events: 23.9%) were again very similar to those of the 8-LIS score (30.7% and 23.1%, respectively). The median time needed to perform the examination was 3:05 min (IQR 2:22 – 5:00 min) for the 28 LIS score and 1:35 min (IQR 1:16 – 2:00 min) for the 8 LIS score.

Conclusion

The simplified Gutierrez 8-LIS score is tightly related to the classical Jambrik 28 LIS score and the two scores hold an almost identical predictive power. Even though the 28-LIS score demands less than 5 minutes, the 8-LIS score can be done in only about 90 sec. and it is therefore better suited for application in everyday clinical practice in hemodialysis units.

P0162HEMODIALYSIS AND PERITONEAL DIALYSIS PATIENTS HAVE SEVERELY IMPAIRED ENDOTHELIAL POST-OCCLUSIVE FOREARM VASODILATORY RESPONSE ASSESSED WITH LASER SPECKLE CONTRAST IMAGING

Background and Aims

Endothelial dysfunction is associated with cardiovascular events and mortality in various disease states, including end-stage-renal-disease (ESRD). Novel technological approaches have emerged for real-time assessment of endothelial reactivity. This study examined forearm skin microcirculation using Laser Speckle Contrast Imaging (LSCi) before and after arterial occlusion in ESRD patients undergoing hemodialysis (HD) or peritoneal dialysis (PD)

Method

38 patients undergoing HD were matched in a 1:1 ratio with 38 PD patients (for age, sex and dialysis vintage) and 38 controls (for age and sex). Skin microvascular reactivity parameters assessed with LSCI included baseline perfusion, occlusion perfusion, and peak perfusion during post-occlusive reactive hyperemia (PORH); time to peak perfusion; proportional change from baseline to peak perfusion; baseline and peak cutaneous vascular conductance (CVC); proportional change from baseline to peak CVC; and the amplitude of the PORH response (calculated as the difference between peak and baseline CVC).

Results

Baseline perfusion [HD: 46.97±14.6; PD: 49.32±18.07; controls: 42.02±11.94 Laser-Specle-Perfusion-Units (LSPU), p=0.097] and peak post-occlusion perfusion (104.77±28.68 vs 109.04±40.77 vs 116.96±30.96 LSPU, p=0.238) did not differ between groups. However, the post-occlusive vascular response was completely different, since time to peak response (HD: 7.24±6.99; PD: 10.68±9.45; controls: 11.11±5.1 sec, p=0.003) and the (%) increase from baseline to peak perfusion (HD: 133%±66; PD: 149%±125; controls: 187%±61, p=0.001) was significantly lower in ESRD patients.

ESRD patients had also lower levels of peak CVC, indicating the maximum capillary recruitment (HD: 1.05±0.3; PD: 1.07±0.44; controls: 1.57±0.52 LSPU/mmHg, p&lt;0.001), lower % increase of CVC at peak (p=0.001), and lower amplitude of the PORH response (p=0.001) (a measure of the difference between baseline and maximum capillary recruitment).

Conclusion

Using this novel non-invasive technology endothelial post-occlusive skin vasodilatory response was found to be similar between HD and PD patients and significantly impaired compared to controls. Future studies are needed to assess the prognostic implications of this microcirculatory functional defect.

SO036THE EFFECT OF DAPAGLIFLOZIN ON AMBULATORY AORTIC BLOOD PRESSURE AND ARTERIAL STIFFNESS PARAMETERS IN PATIENTS WITH TYPE-2 DIABETES MELLITUS: A DOUBLE-BLIND RANDOMIZED CLINICAL TRIAL

Background and Aims

Arterial stiffness is a prominent risk factor for heart failure and overall mortality in patients with type-2 diabetes mellitus (DM). Sodium-glucose co-transporter 2 (SGLT-2) inhibitors reduce the incidence of heart failure and death in these patients. The aim of this study is to evaluate the effects of dapagliflozin on ambulatory central blood pressure (BP) levels and arterial stiffness parameters in patients with type-2 DM.

Method

This is a double-blind, randomized, placebo-controlled clinical trial including 85 adult patients with type-2 DM on monotherapy or combination therapy with two of: metformin, sulphonylurea, DDP-4 inhibitor, or insulin. Patients were randomized in a 1:1 ratio to oral dapagliflozin 10 mg per day or placebo for 12 weeks. Study participants underwent 24-h ambulatory BP monitoring with the Mobil-O-Graph NG monitor at baseline and study-end.

Results

Baseline demographic, clinical and laboratory parameters were similar in the two groups (age 61.74±6.73 vs 60.64±9.35; p=0.534). During follow-up, 24-hour central SBP/DBP significantly decreased in dapagliflozin (117.41±10.52/78.88±7.25 vs 113.30±8.75/77.25±6.54; p=0.002/p=0.047), but not in the placebo group. Corresponding reductions of 24-hour central SBP (-4.12±8.00 vs -0.65±7.77; p=0.046) were greater with dapagliflozin than placebo. Aortic pulse pressure (PP) decreased only in the dapagliflozin group (38.53±7.44 vs 36.05±6.59 mmHg; p=0.004). 24-hour heart-rate adjusted augmentation-index significantly decreased with dapagliflozin. Importantly, there was a significant difference in the change of 24-hour PWV (-0.16±0.32 vs 0.02±0.27; p=0.007) favoring dapagliflozin.

Conclusion

Treatment with dapagliflozin significantly reduces ambulatory central BP and PWV levels in type-2 diabetics. Improvement in these parameters may substantially contribute to the cardiovascular benefits of SGLT-2 inhibitors.

P1287A COMPARATIVE STUDY OF BLOOD PRESSURE VARIABILITY INDICES BETWEEN PATIENTS UNDERGOING PERITONEAL DIALYSIS AND THOSE UNDER HEMODIALYSIS OR WITH CHRONIC KIDNEY DISEASE

Background and Aims

Blood pressure variability (BPV) indices have been independently associated with cardiovascular events and mortality in hemodialysis (HD) patients. Data on short-term BPV in patients on peritoneal dialysis (PD) are totally absent. This study examined short-term BPV parameters of patients undergoing PD in comparison to HD and pre-dialysis chronic kidney disease (CKD) patients.

Method

38 PD patients were matched for age, gender and dialysis vintage with 76 HD in 1:2 ratio patients and for age and gender with 38 patients with CKD stage 2-4 in 1:1 ration. BPV parameters [standard deviation (SD), weighted SD (wSD), coefficient-of-variation (CV) and average-real-variability (ARV)] were calculated from data from 48hour (PD, HD) and 24hour (CKD) ambulatory BP monitoring according to validated formulas.

Results

There were no significant differences in BPV indexes studied between PD and HD patients but all BPV indexes in these patients were numerically higher than those in CKD patients. Systolic ARV was significantly higher in PD or HD compared with predialysis CKD during the first and the second interdialytic 24hour periods, both daytime period and nighttime 2 (1st 24hour period: PD:11.86±3.19; HD:11.23±3.45; CKD:9.81±2.49, p=0.016, 2nd 24hour period: PD: 12.18±4.11; HD: 12.96±4.57; CKD: 9.81±2.49, p&lt;0.001). Analysis of diastolic ARV and systolic and diastolic wSD showed similar results. Τhere were no differences with regards to dipping pattern and systolic and diastolic CV during all periods studied.

Conclusion

BPV indices are similar between PD and HD patients and higher compared to CKD counterparts. Despite what was theoretically expected, PD patients demonstrate high fluctuations in BP in the absence of abrupt shifts in volume.

P1026THE EFFECT OF DAPAGLIFLOZIN ON 24-HOUR BLOOD PRESSURE IN PATIENTS WITH TYPE-2 DIABETES MELLITUS: A DOUBLE-BLIND RANDOMIZED CLINICAL TRIAL

Background and Aims

Arterial hypertension is present in &gt;90% of patients with type-2 diabetes mellitus (DM). Previous evidence suggests that sodium-glucose transporter 2 (SGLT-2) inhibitors can effectively manage hyperglycemia, but also reduce office blood pressure (BP) levels. The aim of this study is to evaluate the effects of dapagliflozin on ambulatory brachial BP in patients with type-2 DM.

Method

This is a double-blind, randomized, placebo-controlled clinical trial including 85 adult patients with type-2 DM on monotherapy or combination therapy with two of: metformin, sulphonylurea, DDP-4 inhibitor, or insulin. Patients were randomized in a 1:1 ratio to oral dapagliflozin 10 mg per day or placebo for 12 weeks. Study participants underwent 24-h ambulatory BP monitoring with the Mobil-O-Graph NG monitor at baseline and study-end.

Results

Baseline demographic, clinical and laboratory parameters were similar in the two groups (age 61.74±6.73 vs 60.64±9.35; p=0.534). During follow-up, 24-hour brachial SBP decreased in the active (128.97±12.57 vs 123.17±12.35; p&lt;0.001) but was similar in the control group (128.95±12.41 vs 128.86±13.45; p=0.942). Corresponding changes in 24-hour SBP levels was greater in the dapagliflozin group compared with the placebo group (-5.80±9.48 vs -0.10±8.70 mmHg; p=0.005). Similarly, 24-hour DBP decreased in the active (77.33±7.30 vs 75.11±6.37; p=0.008) and was unchanged in the placebo group (78.86±8.66 vs 78.96±7.64; p=0.911). Decrease in brachial pulse pressure (PP) was greater in the active group (-3.57±6.67 vs -0.21±6.31 mmHg; p=0.019), while 24-hour heart rate was stable in both groups. Dapagliflozin and placebo treatments were associated with similar rates of generally mild adverse effects.

Conclusion

Treatment with dapagliflozin can produce statistically significant and clinically meaningful reductions in 24-hour BP levels in type-2 diabetics. These agents can improve BP control in this population.