Cardiovascular risk due to diabetes mellitus in patients with chronic kidney disease-prospective data from the German Chronic Kidney Disease cohort

Background

Diabetes mellitus (DM) and chronic kidney disease (CKD) are well-known cardiovascular and mortality risk factors. To what extent they act in an additive manner and whether the etiology of CKD modifies the risk is uncertain.

Methods

The multicenter, prospective, observational German Chronic Kidney Disease study comprises 5217 participants (1868 with DM) with a baseline mean estimated glomerular filtration rate of 30-60 mL/min/1.73 m2 and/or proteinuria >0.5 g/day. We categorized patients whose CKD was caused by cardiovascular or metabolic diseases (CKDcvm) with and without DM, as opposed to genuine CKD (CKDgen) with and without DM. Recorded outcomes were first events of non-cardiovascular and cardiovascular death, 4-point major adverse cardiovascular events (4-point MACE) and hospitalization for heart failure (HHF).

Results

During the 6.5-year follow-up 603 (12%) non-cardiovascular and 209 (4%) cardiovascular deaths, 645 (12%) 4-point MACE, and 398 (8%) HHF were observed, most frequently in patients with DM having CKDcvm. DM increased the risk of non-cardiovascular [hazard ratio (HR) 1.92; 95% confidence interval (CI) 1.59-2.32] and cardiovascular (HR 2.25; 95% CI 1.62-3.12) deaths, 4-point MACE (HR 1.93; 95% CI 1.62-2.31) and HHF (HR 1.87; 95% CI 1.48-2.36). Mortality risks were elevated by DM to a similar extent in CKDcvm and CKDgen, but for HHF in CKDcvm only (HR 2.07; 95% CI 1.55-2.77). In patients with DM, CKDcvm (versus CKDgen) only increased the risk for HHF (HR 1.93; 95% CI 1.15-3.22).

Conclusions

DM contributes to cardiovascular and mortality excess risk in patients with moderate to severe CKD in both, CKDcvm and CKDgen. Patients with DM and CKDcvm are particularly susceptible to HHF.

Copeptin, Natriuretic Peptides, and Cardiovascular Outcomes in Patients With CKD: The German Chronic Kidney Disease (GCKD) Study

Rationale & Objective

Copeptin and Midrange pro-atrial natriuretic peptide (MR-pro-ANP) are associated with outcomes independently of N-terminal pro-brain natriuretic peptide (NT-pro-BNP) in patients with heart failure (HF). The value of these markers in patients with chronic kidney disease (CKD) has not been studied.

Study Design

Prospective cohort study.

Setting & Participants

A total of 4,417 patients enrolled in the German Chronic Kidney Disease (GCKD) study with an estimated glomerular filtration rate of 30-60 mL/min/1.73m2 or overt proteinuria (urinary albumin-creatinine ratio >300mg/g or equivalent).

Exposures

Copeptin, MR-pro-ANP, and NT-pro-BNP levels were measured in baseline samples.

Outcomes

Noncardiovascular death, cardiovascular (CV) death, major adverse CV event (MACE), and hospitalization for HF.

Analytical Approach

HRs for associations of Copeptin, MR-pro-ANP, and NT-pro-BNP with outcomes were estimated using Cox regression analyses adjusted for established risk factors.

Results

During a maximum follow-up of 6.5 years, 413 non-CV deaths, 179 CV deaths, 519 MACE, and 388 hospitalizations for HF were observed. In Cox regression analyses adjusted for established risk factors, each one of the 3 markers were associated with all the 4 outcomes, albeit the highest HRs were found for NT-pro-BNP. When models were extended to include all the 3 markers, NT-pro-BNP remained associated with all 4 outcomes. Conversely, from the 2 novel markers, associations remained only for Copeptin with non-CV death (HR, 1.62; 95% CI, 1.04-2.54 for highest vs lowest quintile) and with hospitalizations for HF (HR, 1.73; 95% CI, 1.08-2.75).

Limitations

Single-point measurements of Copeptin, MR-pro-ANP, and NT-pro-BNP.

Conclusions

In patients with moderately severe CKD, we confirm NT-pro-BNP to be strongly associated with all outcomes examined. As the main finding, the novel marker Copeptin demonstrated independent associations with non-CV death and hospitalizations for HF, and should therefore be evaluated further for risk assessment in CKD.

Plain-Language Summary

A blood sample-based biomarker that indicates high cardiovascular risk in a patient with kidney disease would help to guide interventions and has the potential to improve outcomes. In 4,417 patients of the German Chronic Kidney Disease study, we assessed the relationship of Copeptin, pro-atrial natriuretic peptide, and N-terminal pro-brain natriuretic peptide (NT-pro-BNP) with important outcomes over a follow-up period of 6.5 years. NT-pro-BNP was strongly associated with all of the 4 outcomes, including death unrelated to cardiovascular disease, death because of cardiovascular disease, a major cardiovascular event, and hospitalization for heart failure. Copeptin was associated with death unrelated to cardiovascular disease and hospitalization for heart failure. NT-pro-BNP and Copeptin are, therefore, promising candidates for a blood sample-based strategy to identify patients with kidney disease at high cardiovascular risk.

Prospective Cohort Study of Soluble Urokinase Plasminogen Activation Receptor and Cardiovascular Events in Patients With CKD

Introduction

Soluble urokinase plasminogen activation receptor (suPAR) is an immune-derived pathogenic factor for kidney and atherosclerotic disease. Whether the association between suPAR and cardiovascular (CV) outcomes is dependent on the severity of underlying kidney disease is unclear.

Methods

We measured serum suPAR levels in 4994 participants (mean age 60 years; 60% men; 36% with diabetes mellitus; mean estimated glomerular filtration rate (eGFR) 49 ml/min per 1.73 m2, SD 18) of the German Chronic Kidney Disease (GCKD) cohort and examined its association with all-cause death, CV death, and major CV events (MACE) across the range of eGFR and urine albumin-to-creatinine ratio (UACR).

Results

The median suPAR level was 1771 pg/ml (interquartile range [IQR] 1447-2254 pg/ml). SuPAR levels were positively and independently correlated with age, eGFR, UACR, and parathyroid hormone levels. There were 573 deaths, including 190 CV deaths and 683 MACE events at a follow-up time of 6.5 years. In multivariable analyses, suPAR levels (log2) were associated with all-cause death (hazard ratio [HR] 1.36, 95% confidence interval [CI] 1.21-1.53), CV death (HR 1.27, 95% CI 1.03-1.57), and MACE (HR 1.13, 95% CI 1.00-1.28), and were not found to differ according to diabetes mellitus status, baseline eGFR, UACR, or parathyroid hormone levels. In mediation analysis, suPAR's direct effect on all-cause death, CV death, and MACE accounted for 77%, 67%, and 60% of the total effect, respectively; whereas the effect mediated through eGFR accounted for 23%, 34%, and 40%, respectively.

Conclusion

In a large cohort of individuals with chronic kidney disease (CKD), suPAR levels were associated with mortality and CV outcomes independently of indices of kidney function, consistent with its independent role in the pathogenesis of atherosclerosis.

Association of mineral and bone biomarkers with adverse cardiovascular outcomes and mortality in the German Chronic Kidney Disease (GCKD) cohort

Mineral and bone disorder (MBD) in chronic kidney disease (CKD) is tightly linked to cardiovascular disease (CVD). In this study, we aimed to compare the prognostic value of nine MBD biomarkers to determine those associated best with adverse cardiovascular (CV) outcomes and mortality. In 5 217 participants of the German CKD (GCKD) study enrolled with an estimated glomerular filtration rate (eGFR) between 30-60 mL·min-1 per 1.73 m2 or overt proteinuria, serum osteoprotegerin (OPG), C-terminal fibroblast growth factor-23 (FGF23), intact parathyroid hormone (iPTH), bone alkaline phosphatase (BAP), cross-linked C-telopeptide of type 1 collagen (CTX1), procollagen 1 intact N-terminal propeptide (P1NP), phosphate, calcium, and 25-OH vitamin D were measured at baseline. Participants with missing values among these parameters (n = 971) were excluded, leaving a total of 4 246 participants for analysis. During a median follow-up of 6.5 years, 387 non-CV deaths, 173 CV deaths, 645 nonfatal major adverse CV events (MACEs) and 368 hospitalizations for congestive heart failure (CHF) were observed. OPG and FGF23 were associated with all outcomes, with the highest hazard ratios (HRs) for OPG. In the final Cox regression model, adjusted for CV risk factors, including kidney function and all other investigated biomarkers, each standard deviation increase in OPG was associated with non-CV death (HR 1.76, 95% CI: 1.35-2.30), CV death (HR 2.18, 95% CI: 1.50-3.16), MACE (HR 1.38, 95% CI: 1.12-1.71) and hospitalization for CHF (HR 2.05, 95% CI: 1.56-2.69). Out of the nine biomarkers examined, stratification based on serum OPG best identified the CKD patients who were at the highest risk for any adverse CV outcome and mortality.

Prenatal ultrasound in fetuses with polycystic kidney appearance - expanding the diagnostic algorithm

PURPOSE

Report on the diagnosis of prenatally detected fetal kidneys with bilateral polycystic appearance in a single center between 1999 and 2020 with special focus on renal morphology and biometry, amniotic fluid and extrarenal findings and proposal for an diagnostic algorithm.

METHODS

Retrospective observational study including pregnancies with prenatally detected kidneys with bilateral polycystic appearance (n = 98). Cases and outcomes were compared according to prenatal findings with special focus on renal morphology, amount of amniotic fluid, and presence of extrarenal abnormalities.

RESULTS

Most frequent diagnoses were autosomal recessive polycystic kidney disease (ARPKD, 53.1%), Meckel-Gruber syndrome (MKS, 17.3%) and autosomal dominant polycystic kidney disease (ADPKD, 8.2%). Other diagnoses included: Joubert-, Jeune-, McKusick-Kaufman- and Bardet-Biedl syndrome, overgrowth syndromes, Mainzer-Saldino syndrome and renal tubular dysgenesis. Renal abnormalities most frequently observed were hyperechogenic parenchyma, kidney enlargement, changes of corticomedullary differentiation and cystic changes of various degree. Oligo- and anhydramnios were mainly seen in ARPKD, RTD and second-trimester MKS. Extrarenal findings included skeletal (35.7%) and cardiac (34.7%) abnormalities as well as abnormalities of the central nervous system (27.6%).

CONCLUSION

Gestational age at manifestation, kidney size, visibility of cysts, echogenicity, amniotic fluid volume, and the presence of associated extrarenal malformations allow to differentiate between the most frequent underlying diseases presenting with bilateral polycystic kidneys on prenatal ultrasound by following a diagnostic algorithm.

Differential prognostic utility of adiposity measures in chronic kidney disease

OBJECTIVE

Adipose tissue contributes to adverse outcomes in chronic kidney disease (CKD), but there is uncertainty regarding the prognostic relevance of different adiposity measures. We analyzed the associations of neck circumference (NC), waist circumference (WC), and body mass index (BMI) with clinical outcomes in patients with mild to severe CKD.

METHODS

The German Chronic Kidney Disease (GCKD) study is a prospective cohort study, which enrolled Caucasian adults with mild to severe CKD, defined as estimated glomerular filtration rate (eGFR): 30-60 mL/min/1.73 m², or >60 mL/min/1.73 m² in the presence of overt proteinuria. Associations of NC, WC and BMI with all-cause death, major cardiovascular events (MACE: a composite of non-fatal stroke, non-fatal myocardial infarction, peripheral artery disease intervention, and cardiovascular death), kidney failure (a composite of dialysis or transplantation) were analyzed using multivariable Cox proportional hazards regression models adjusted for confounders and the Akaike information criteria (AIC) were calculated. Models included sex interactions with adiposity measures.

RESULTS

A total of 4537 participants (59% male) were included in the analysis. During a 6.5-year follow-up, 339 participants died, 510 experienced MACE, and 341 developed kidney failure. In fully adjusted models, NC was associated with all-cause death in women (HR 1.080 per cm; 95% CI 1.009-1.155), but not in men. Irrespective of sex, WC was associated with all-cause death (HR 1.014 per cm; 95% CI 1.005-1.038). NC and WC showed no association with MACE or kidney failure. BMI was not associated with any of the analyzed outcomes. Models of all-cause death including WC offered the best (lowest) AIC.

CONCLUSION

In Caucasian patients with mild to severe CKD, higher NC (in women) and WC were significantly associated with increased risk of death from any cause, but BMI was not.

Clinical Decision Making for Intraoperative Auditory Brainstem Response Testing in Children following Tympanostomy Tube Placement

Intraoperative auditory brainstem response (ioABR) testing following tympanostomy tube (TT) placement may be biased due to temporary threshold shifts (TTS). The purpose of the study was to assess the evidence for TTS in children who have undergone ioABR using prolonged latencies of wave I (males > 1.95 ms, females > 1.88 ms) as a marker of a persisting air-bone gap. Eighty-three children underwent ioABR following surgical procedures at University Hospital Bonn, Germany. The primary outcome measure was the latency of wave I at 80-dB SPL. The total sample consisted of 66 males (79.5%) and 17 females (20.5%) with a mean (SD) age of 46.4 (26.6) months. Of 163 operated ears (83 children), 72 (44.2%) had no middle ear fluid, 19 (11.6%) serous fluid, and 72 (44.2%) mucoid fluid. The risk of having a prolonged latency of wave I at 80-dB SPL was OR 4.61 (95% CI 2.01-10.59; p < 0.001) in those with mucoid fluid as compared to those without mucoid fluid. Intraoperative ABR results should account for sex differences and be interpreted with caution and be verified. Ultimately, parents should be engaged in a preoperative discussion to decide if an ioABR should be postponed if mucoid fluid was found.

A Long-Term Comparative Study Between One Anastomosis Gastric Bypass and Sleeve Gastrectomy

BACKGROUND

One anastomosis gastric bypass (OAGB) has become increasingly accepted in bariatric surgery and meanwhile represents the third most common procedure worldwide. While it shows promising weight loss results and comorbidity resolution, questions about issues such as reflux or nutritional deficiencies (ND) persist in the long term. On the other hand, the most frequently performed sleeve gastrectomy (SG) has to accept growing criticism regarding long-term results and reflux issues. There is a particular lack of long-term comparative data for both procedures. This study presents our long-term experience.

METHODS

We evaluated OAGB and SG patients retrospectively comparing for weight loss and resolution of comorbidities as well as perioperative and long-term complications in a follow-up period of 5 years.

RESULTS

Nine hundred eleven OAGB and 241 SG were included in the study. OAGB had a shorter operation time and hospital stay. Overall complication rate did not differ in both groups. Ulcers were more frequent in OAGB (7.7% vs. 1.7%, p = 0.001), whereas insufficient weight loss (IWL)/weight regain (WR) proved to be more prevalent in SG (25.7% vs. 6.4%, p < 0.001). The same held true for reflux (17.8% vs. 8.3%, p < .001). On the other hand, ND were more common in OAGB (20.0% vs. 12.0%, p = 0.005). Revisional surgery was more often indicated after SG. Analysis by linear mixed model showed that OAGB achieved a lower BMI/higher loss of BMI. Improvement of T2DM (94.6% vs. 85.2%, p = 0.008) and sleep apnea (88.8% vs. 78.8%, p = 0.01) was superior in OAGB.

CONCLUSIONS

OAGB had a superior effect on weight loss as well as improvement of T2DM and sleep apnea. Furthermore, long-term problems such as IWL/WR and reflux were more related to SG. On the other hand, a malabsorptive procedure such as OAGB showed a higher risk for ND. Our findings support the available data in the literature.

Heart-Type Fatty Acid Binding Protein, Cardiovascular Outcomes, and Death: Findings From the German CKD Cohort Study

RATIONALE & OBJECTIVE

Heart-type fatty acid binding protein (H-FABP) is a biomarker that has been shown to provide long-term prognostic information in patients with coronary artery disease independently of high-sensitivity troponin T (hs-TNT). We examined the independent associations of H-FABP with cardiovascular outcomes in patients with chronic kidney disease (CKD).

STUDY DESIGN

Prospective cohort study.

SETTING & PARTICIPANTS

4,951 patients enrolled in the German Chronic Kidney Disease (GCKD) study with an estimated glomerular filtration rate of 30-60 mL/min/1.73 m² or overt proteinuria (urinary albumin-creatinine ratio > 300 mg/g or equivalent).

EXPOSURE

Serum levels of H-FABP and hs-TNT were measured at study entry.

OUTCOME

Noncardiovascular (non-CV) death, CV death, combined major adverse CV events (MACE), and hospitalization for congestive heart failure (CHF).

ANALYTICAL APPROACH

Hazard ratios (HRs) for associations of H-FABP and hs-TNT with outcomes were estimated using Cox regression analyses adjusted for established risk factors.

RESULTS

During a maximum follow-up of 6.5 years, 579 non-CV deaths, 190 CV deaths, 522 MACE, and 381 CHF hospitalizations were observed. In Cox regression analyses adjusted for established risk factors, H-FABP was associated with all 4 outcomes, albeit with lower HRs than those found for hs-TNT. After further adjustment for hs-TNT levels, H-FABP was found to be associated with non-CV death (HR, 1.57 [95% CI, 1.14-2.18]) and MACE (HR, 1.40 [95% CI, 1.02-1.92]) but with neither CV death (HR, 1.64 [95% CI, 0.90-2.99]) nor CHF hospitalizations (HR, 1.02 [95% CI, 0.70-1.49]).

LIMITATIONS

Single-point measurements of H-FABP and hs-TNT. Uncertain generalizability to non-European populations.

CONCLUSIONS

In this large cohort of patients with CKD, H-FABP was associated with non-CV death and MACE, even after adjustment for hs-TNT. Whether measurement of H-FABP improves cardiovascular disease risk prediction in these patients warrants further studies.

The Cardiovascular Literature-Based Risk Algorithm (CALIBRA): Predicting Cardiovascular Events in Patients With Non-Dialysis Dependent Chronic Kidney Disease

Background and Objectives

Cardiovascular (CV) disease is the main cause of morbidity and mortality in patients suffering from chronic kidney disease (CKD). Although it is widely recognized that CV risk assessment represents an essential prerequisite for clinical management, existing prognostic models appear not to be entirely adequate for CKD patients. We derived a literature-based, naïve-bayes model predicting the yearly risk of CV hospitalizations among patients suffering from CKD, referred as the CArdiovascular, LIterature-Based, Risk Algorithm (CALIBRA).

Methods

CALIBRA incorporates 31 variables including traditional and CKD-specific risk factors. It was validated in two independent CKD populations: the FMC NephroCare cohort (European Clinical Database, EuCliD®) and the German Chronic Kidney Disease (GCKD) study prospective cohort. CALIBRA performance was evaluated by c-statistics and calibration charts. In addition, CALIBRA discrimination was compared with that of three validated tools currently used for CV prediction in CKD, namely the Framingham Heart Study (FHS) risk score, the atherosclerotic cardiovascular disease risk score (ASCVD), and the Individual Data Analysis of Antihypertensive Intervention Trials (INDANA) calculator. Superiority was defined as a ΔAUC>0.05.

Results

CALIBRA showed good discrimination in both the EuCliD® medical registry (AUC 0.79, 95%CI 0.76-0.81) and the GCKD cohort (AUC 0.73, 95%CI 0.70-0.76). CALIBRA demonstrated improved accuracy compared to the benchmark models in EuCliD® (FHS: ΔAUC=-0.22, p<0.001; ASCVD: ΔAUC=-0.17, p<0.001; INDANA: ΔAUC=-0.14, p<0.001) and GCKD (FHS: ΔAUC=-0.16, p<0.001; ASCVD: ΔAUC=-0.12, p<0.001; INDANA: ΔAUC=-0.04, p<0.001) populations. Accuracy of the CALIBRA score was stable also for patients showing missing variables.

Conclusion

CALIBRA provides accurate and robust stratification of CKD patients according to CV risk and allows score calculations with improved accuracy compared to established CV risk scores also in real-world clinical cohorts with considerable missingness rates. Our results support the generalizability of CALIBRA across different CKD populations and clinical settings.

Association of osteopontin with kidney function and kidney failure in chronic kidney disease patients: the GCKD study

BACKGROUND

Osteopontin (OPN), synthesized in the thick ascending limb of Henle's loop and in the distal tubule, is involved in the pathogenesis of kidney fibrosis, a hallmark of kidney failure (KF). In a cohort of chronic kidney disease (CKD) patients, we evaluated OPN's association with kidney markers and KF.

METHODS

OPN was measured from baseline serum samples of German Chronic Kidney Disease study participants. Cross-sectional regression models for estimated glomerular filtration rate (eGFR) and urinary albumin-to-creatinine ratio (UACR) as well as Cox regression models for all-cause mortality and KF were evaluated to estimate the OPN effect. Additionally, predictive ability, of OPN and time-dependent population-attributable fraction were evaluated.

RESULTS

Over a median follow-up of 6.5 years, 471 KF events and 629 deaths occurred among 4,950 CKD patients. One-unit higher log(OPN) was associated with 5.5 mL/min/1.73m2 lower eGFR (95%CI: [-6.4,-4.6]) and 1% change in OPN with 0.7% higher UACR (estimated effect 0.7, 95%CI: [0.6,0.8]). Moreover, higher OPN levels were associated with a higher risk of KF (hazard ratio [HR] 1.4, 95%CI: [1.2,1.7]) and all-cause mortality (HR 1.5, 95%CI: [1.3,1.8]). After 6 years, 31% of the KF events could be attributed to higher OPN levels (95%CI: [3%,56%]).

CONCLUSIONS

In this study, higher OPN levels were associated with kidney function markers worsening, and a higher risk for adverse outcomes. A larger proportion of KF could be attributed to higher OPN levels warranting further research on OPN with regards to its role in CKD progression and possible treatment options.

Educational Attainment Is Associated With Kidney and Cardiovascular Outcomes in CKD

Introduction

Prospective data on impact of educational attainment on prognosis in patients with chronic kidney disease (CKD) are scarce. We investigated the association between educational attainment and all-cause mortality, major adverse cardiovascular (CV) events (MACEs), kidney failure requiring dialysis, and CKD etiology.

Methods

Participants (N = 5095, aged 18–74 years) of the ongoing multicenter German Chronic Kidney Disease (GCKD) cohort, enrolled on the basis of an estimated glomerular filtration rate (eGFR) of 30 to 60 ml/min (stages G3, A1–A3) or overt proteinuria (stages G1–G2, A3), were divided into 3 categories according to their educational attainment and were followed for 6.5 years.

Results

Participants with low educational attainment (vs. high) had a higher risk for mortality (hazard ratio [HR] 1.48, 95% CI: 1.16–1.90), MACE (HR 1.37, 95% CI: 1.02–1.83), and kidney failure (HR 1.54, 95% CI: 1.15–2.05). Mediators between low educational attainment and mortality were smoking, CV disease (CVD) at baseline, low income, higher body mass index, and higher serum levels of CRP, high-density lipoprotein cholesterol, uric acid, NGAL, BAP, NT-proBNP, OPN, H-FABP, and urea. Low educational attainment was positively associated with diabetic nephropathy (odds ratio [OR] 1.65, 95% CI: 1.36–2.0) and CKD subsequent to acute kidney injury (OR 1.56, 95% CI: 1.03–2.35), but negatively associated with IgA nephropathy (OR 0.68, 95% CI: 0.52–0.90).

Conclusion

Low educational attainment is associated with adverse outcomes and CKD etiology. Lifestyle habits and biomarkers mediate associations between low educational attainment and mortality. Recognition of the role of educational attainment and the associated health-relevant risk factors is important to optimize the care of patients with CKD and improve prognosis.

Validation of a Novel Predictive Algorithm for Kidney Failure in Patients Suffering from Chronic Kidney Disease: The Prognostic Reasoning System for Chronic Kidney Disease (PROGRES-CKD)

Current equation-based risk stratification algorithms for kidney failure (KF) may have limited applicability in real world settings, where missing information may impede their computation for a large share of patients, hampering one from taking full advantage of the wealth of information collected in electronic health records. To overcome such limitations, we trained and validated the Prognostic Reasoning System for Chronic Kidney Disease (PROGRES-CKD), a novel algorithm predicting end-stage kidney disease (ESKD). PROGRES-CKD is a naïve Bayes classifier predicting ESKD onset within 6 and 24 months in adult, stage 3-to-5 CKD patients. PROGRES-CKD trained on 17,775 CKD patients treated in the Fresenius Medical Care (FMC) NephroCare network. The algorithm was validated in a second independent FMC cohort (n = 6760) and in the German Chronic Kidney Disease (GCKD) study cohort (n = 4058). We contrasted PROGRES-CKD accuracy against the performance of the Kidney Failure Risk Equation (KFRE). Discrimination accuracy in the validation cohorts was excellent for both short-term (stage 4-5 CKD, FMC: AUC = 0.90, 95%CI 0.88-0.91; GCKD: AUC = 0.91, 95% CI 0.86-0.97) and long-term (stage 3-5 CKD, FMC: AUC = 0.85, 95%CI 0.83-0.88; GCKD: AUC = 0.85, 95%CI 0.83-0.88) forecasting horizons. The performance of PROGRES-CKD was non-inferior to KFRE for the 24-month horizon and proved more accurate for the 6-month horizon forecast in both validation cohorts. In the real world setting captured in the FMC validation cohort, PROGRES-CKD was computable for all patients, whereas KFRE could be computed for complete cases only (i.e., 30% and 16% of the cohort in 6- and 24-month horizons). PROGRES-CKD accurately predicts KF onset among CKD patients. Contrary to equation-based scores, PROGRES-CKD extends to patients with incomplete data and allows explicit assessment of prediction robustness in case of missing values. PROGRES-CKD may efficiently assist physicians' prognostic reasoning in real-life applications.

Sensitivity and specificity of strain rate for the early detection of left ventricular dysfunction in breast cancer patients receiving adjuvant treatment with adriamycin with or without trastuzumab

Background

Medical literature states that a global longitudinal strain rate (GLS) &lt;−19% and further reductions in relation with baseline GLS may predict long term left ventricular dysfunction in breast cancer patients receiving adjuvant treatment with Adriamycin (A) with or without trastuzumab (T). However, there is not strong evidence to support the use of this technique in daily clinical practice.

Purpose

To analyze the sensitivity (S) and specificity (Sp) of GLS &lt;−19% or its relative 10, 15 and 20% reduction form baseline, for the early detection of left ventricular dysfunction in breast cancer patients receiving adjuvant treatment with A with or without T.

Methods

Patients were prospectively assessed with a cardiac echoDoppler + GLS at baseline, every 3 months during the first year and every 4 months thereafter. We assessed the S and Sp of GLS &lt;−19% or its relative &gt;10%, &gt;15% and &gt;20% reduction form baseline after treatment with A with or without T as predictors of cardiotoxicity (defined as a &gt;10 percentage points decrease of left ventricular ejection fraction to a value below the lower normal limit with respect to baseline).

Results

136 out of 884 patients (16%) had GLS measured at each visit: 83 patients (60%) and 53 patients (40%) treated with A or A+T respectively. Patients were followed up to 31±6 months. Mean age was 51±12 years. The table shows the baseline characteristics of both groups. 10 out of 83 patients in group A (12%) and 18 out of 53 P in group A+T (34%) developed cardiotoxicity. Baseline left ventricular ejection fraction and GLS were 61±4,7% and −20,18±2,6% in group A, and 58,7±5,8% and −19,5±2,6 post treatment. In this group, GLS S and Sp were 50 and 80%, respectively. In the group A+T, the best GLS cutoff was −19%, with a 60% sensitivity and 78% specificity.

Conclusions

In our non-selected cohort of patients, nor GLS or its percentage reductions along follow up predicted the reduction of left ventricular ejection fraction and the developing of cardiotoxic ventricular dysfunction in breast cancer patients receiving adjuvant treatment with A with or without T. The systematic use of this tool should be further investigated and validated at each center to help establish its usefulness in daily practice.

Funding Acknowledgement

Type of funding sources: None. Baseline characteristics

Low adherence to CKD-specific dietary recommendations associates with impaired kidney function, dyslipidemia, and inflammation

BACKGROUND/OBJECTIVES

A diet following chronic kidney disease (CKD)-specific recommendations is considered essential for optimal management of patients with CKD. However, data on the adherence to these recommendations and its implications for health-relevant biomarkers are lacking. The objectives were to estimate adherence to CKD-specific dietary recommendations, to identify characteristics and lifestyle variables associated with poor adherence, and to investigate the relationship of adherence with biomarkers.

METHODS

In this cross-sectional analysis, average dietary intake was estimated in 3193 participants with moderately severe CKD enrolled into the observational multicenter German CKD study using a food frequency questionnaire. A CKD diet score was developed to assess adherence to CKD-specific dietary recommendations based on intake of sodium, potassium, fiber, protein, sugar, and cholesterol. The associations of dietary adherence with characteristics, lifestyle variables, and biomarker levels were determined.

RESULTS

Logistic regression analysis revealed younger age, higher body mass index, male gender, lower educational attainment, various lifestyle variables (cigarette smoking, infrequent alcohol consumption, low physical activity), and lower estimated glomerular filtrate rate associated with lower adherence to dietary recommendations. Low adherence to dietary recommendations was further associated with dyslipidemia, higher uric acid, and C-reactive protein levels. Associations between low dietary adherence and biomarkers were mostly driven by low intake of fiber and potassium, and high intake of sugar and cholesterol.

CONCLUSIONS

This study revealed differential characteristics and biomarkers associated with lower adherence to CKD-specific dietary recommendations. Promotion of CKD-specific dietary recommendations may help to mitigate the adverse prognosis in CKD patients.

Glue Embolization of Gastroesophageal Varices during Transjugular Intrahepatic Portosystemic Shunt (TIPS) Improves Survival Compared to Coil-only Embolization-A Single-Center Retrospective Study

PURPOSE

To compare the safety and effectiveness of coil versus glue embolization of gastroesophageal varices during transjugular intrahepatic portosystemic shunt (TIPS) creation.

MATERIALS AND METHODS

In this monocentric retrospective study 104 (males: 67 (64%)) patients receiving TIPS with concomitant embolization of GEV and a minimum follow-up of one year (2008-2017) were included. Primary outcome parameter was overall survival (6 week; 1 year). Six-week overall survival was assessed as a surrogate for treatment failure as proposed by the international Baveno working group. Secondary outcome parameters were development of acute-on-chronic liver failure (ACLF), variceal rebleeding and hepatic encephalopathy (HE). Survival analysis was performed using Kaplan-Meier with log-rank test and adjusted Cox regression analysis.

RESULTS

Indications for TIPS were refractory ascites (n = 33) or variceal bleeding (n = 71). Embolization was performed using glue with or without coils (n = 40) (Group G) or coil-only (n = 64) (Group NG). Overall survival was significantly better in group G (p = 0.022; HR = -3.333). Six-week survival was significantly lower in group NG (p = 0.014; HR = 6.945). Rates of development of ACLF were significantly higher in group NG after 6 months (NG = 14; G = 6; p = 0.039; HR = 3.243). Rebleeding rates (NG = 6; G = 3; p = 0.74) and development of HE (NG = 22; G = 15; p = 0.75) did not differ significantly between groups.

CONCLUSION

Usage of glue in embolization of GEV may improve overall survival, reduce treatment failure and may be preferable over coil embolization alone.

FC 061OSTEOPONTIN AND ITS ASSOCIATION WITH ADVERSE EVENTS IN THE GERMAN CHRONIC KIDNEY DISEASE STUDY

Background and Aims

Osteopontin (OPN) is synthesized in the thick ascending limb of Henle’s loop and in the distal tubule. Numerous studies have shown that OPN mRNA and protein expression is increased in animal models of many different renal diseases, especially glomerular diseases as well as diabetic nephropathy. Here, high OPN expression correlated with proteinuria, reduction of creatinine clearance, fibrosis as well as macrophage and T-cell infiltration. OPN has therefore been suggested to be a promising biomarker for various kidney diseases. Further studies are needed to fully understand its role in kidney (patho-)physiology and its potential as a marker of kidney disease progression and adverse renal events. We therefore evaluated the association of OPN with kidney events and all-cause mortality in a cohort of CKD patients, the German Chronic Kidney Disease (GCKD) study.

Method

OPN was measured from baseline serum samples using the Quantikine Human OPN Immunoassay. Coefficients of variation were &lt;7%. Kidney events included kidney failure treated with kidney replacement therapy (dialysis, transplantation), and death due to discontinuation of dialysis treatment. Another event of interest was all-cause mortality. All events were abstracted from hospital discharge letters and death certificates by trained physicians based on a standardized endpoint catalogue. Cross-sectional regression models (dependent variables: eGFR, logUACR) adjusted for confounding variables (Table 1 legend) were fitted. Multi-variable adjusted Cox proportional hazard regression analyses were conducted. Estimated risks are expressed as cause-specific hazard ratios (HR) for all-cause mortality and kidney events, with death of other causes as the competing event. Sensitivity analyses included evaluation of all models stratified by the three most common causes of kidney disease in GCKD: hypertensive nephropathy, primary glomerular disease, and diabetic nephropathy.

Results

Over 6.5 years of follow-up, 473 kidney events and 582 deaths occurred among 4,950 GCKD patients. Hundred-and-forty-eight deaths and 62 kidney events occurred in 1,143 hypertensive nephropathy patients, 49 deaths and 118 kidney events occurred in 935 primary glomerular nephropathy patients, and 170 deaths and 99 kidney events in diabetic nephropathy patients (Table 1). Overall mean age was 60.1 years (±12.0), with 60.3% men. Median OPN levels were 29.2 ng/mL (IQR 21.2). Cross-sectionally a 10% change in OPN was associated with 0.5% lower eGFR on average (p&lt;0.0001, 95% CI: -6.4 to -4.6) and a 7% change in UACR (p&lt;0.0001, 95% CI: 0.6 to 0.8) overall. Stratified by leading cause of kidney disease, results for eGFR and UACR were of similar direction for all groups (Table 1 A). After adjusting for baseline eGFR and UACR (Table 1 B), higher OPN levels were associated with a higher risk of kidney events overall (HR 1.4, p&lt;0.001, 95% CI 1.1-1.7). For patients with diabetic nephropathy this risk was even higher (HR 2.2, p&lt;0.01, 95% CI 1.4-3.6). Higher OPN levels were also associated with higher risk of all-cause mortality overall (HR 1.5, p&lt;0.0001, 95% CI 1.3-1.8) as well as for diabetic nephropathy patients (HR 1.7, p&lt;0.01, 95% CI 1.2-2.4). HRs for the hypertensive nephropathy and primary glomerular nephropathy groups showed mostly the same effect directions, but did not reach significance after adjustment.

Conclusion

Higher OPN levels were associated with lower eGFR and higher UACR cross-sectionally and significantly associated with a higher risk of renal events and all-cause mortality especially for diabetic nephropathy patients even after adjustment for baseline eGFR, UACR and other confounding factors. These results are supportive of OPN being a potential marker of CKD progression and mortality.

No evidence to support the impact of migration background on treatment response rates and cancer survival: a retrospective matched-pair analysis in Germany

Background

Immigration has taken the central stage in world politics, especially in the developed countries like Germany, where the continuous flow of immigrants has been well documented since 1960s. Strikingly, emerging data suggest that migrant patients have a poorer response to the treatment and lower survival rates in their new host country, raising concerns about health disparities. Herein, we present our investigation on the treatment response rate and cancer survival in German patients with and without an immigrant background that were treated at our comprehensive cancer center in Germany.

Methods

Initially, we considered 8162 cancer patients treated at the Center for Integrated Oncology (CIO), University Hospital Bonn, Germany (April 2002–December 2015) for matched-pair analysis. Subsequently, the German patients with a migration background and those from the native German population were manually identified and catalogued using a highly specific name-based algorithm. The clinical parameters such as demographic characteristics, tumor characteristics, defined staging criteria, and primary therapy were further adjusted. Using these stringent criteria, a total of 422 patients (n = 211, Germans with migration background; n = 211, native German population) were screened to compare for the treatment response and survival rates (i.e., 5-year overall survival, progression-free survival, and time to progression).

Results

Compared to the cohort with migration background, the cohort without migration background was slightly older (54.9 vs. 57.9 years) while having the same sex distribution (54.5% vs. 55.0% female) and longer follow-up time (36.9 vs. 42.6 months). We did not find significant differences in cancer survival (5-year overall survival, P = 0.771) and the response rates (Overall Remission Rate; McNemar’s test, P = 0.346) between both collectives.

Conclusion

Contrary to prior reports, we found no significant differences in cancer survival between German patients with immigrant background and native German patients. Nevertheless, the advanced treatment protocols implemented at our comprehensive cancer center may possibly account for the low variance in outcome. To conduct similar studies with a broader perspective, we propose that certain risk factors (country-of-origin-specific infections, dietary habits, epigenetics for chronic diseases etc.) should be considered, specially in the future studies that will recruit new arrivals from the 2015 German refugee crisis.

Comparison of Repeated Doses of Ivermectin Versus Ivermectin Plus Albendazole for the Treatment of Onchocerciasis: A Randomized, Open-label, Clinical Trial

BACKGROUND

Improved treatment for onchocerciasis is needed to accelerate onchocerciasis elimination in Africa. Aiming to better exploit registered drugs, this study was undertaken to determine whether annual or semiannual treatment with ivermectin (IVM; 200 µg/kg) plus albendazole (ALB; 800 mg single dose) is superior to IVM alone.

METHODS

This trial was performed in Ghana and included 272 participants with microfilariae (MF), who were randomly assigned to 4 treatment arms: (1) IVM annually at 0, 12, and 24 months; (2) IVM semiannually at 0, 6, 12, 18, and 24 months; (3) IVM+ALB annually; or (4) IVM+ALB semiannually. Microfiladermia was determined pretreatment and at 6, 18, and 36 months. The primary outcome was the proportion of fertile and viable female worms in onchocercomata excised at 36 months.

RESULTS

Posttreatment nodule histology showed that 15/135 (11.1%), 22/155 (14.2%), 35/154 (22.7%), and 20/125 (16.0%) living female worms had normal embryogenesis in the IVM annual, IVM semiannual, IVM+ALB annual, and IVM+ALB semiannual groups, respectively (P = .1229). Proportions of dead worms also did not differ between the 4 groups (P = .9198). Proportions of patients without MF at 36 months (1 year after the last treatment) were 35/56 (63%) after annual IVM, 42/59 (71%) after semiannual IVM, 39/64 (61%) after annual IVM+ALB, and 43/53 (81%) after semiannual IVM+ALB.

CONCLUSIONS

The combination treatment of IVM plus ALB was no better than IVM alone for sterilizing, killing adult worms, or achieving sustained MF clearance. However, semiannual treatment was superior to annual treatment for achieving sustained clearance of Onchocerca volvulus MF from the skin (P = .024).

CLINICAL TRIALS REGISTRATION

ISRCTN50035143.

Short-term real-world outcomes following intravitreal brolucizumab for neovascular AMD: SHIFT study

BACKGROUND

Brolucizumab has recently been approved in Europe as a novel treatment for patients with neovascular age-related macular degeneration (nAMD). We report on early experiences with real-world outcomes of switch to brolucizumab therapy in previously anti-vascular endothelial growth factor (anti-VEGF)-treated patients.

METHODS

Patients with recalcitrant nAMD were switched to brolucizumab therapy. Functional and structural parameters 4 weeks after first brolucizumab injection were evaluated including best-corrected visual acuity (BCVA (logMAR)), foveal centre point (FCP (µm)), central subfield retinal thickness (CSRT (µm)) and macular volume (mm³).

RESULTS

Sixty-three eyes of 57 patients with nAMD (52.6% females) with a mean (±SD) age of 79.5±6.7 years were included. Mean change of BCVA was 0.03±0.14 logMAR (p=0.115). Significant reductions were recorded for FCP with a mean (±SD) change of -66.81±72.63 µm, -66.76±60.71 µm for CSRT and -0.27±0.24 mm³ for macular volume (all p<0.001). Intraocular inflammation was observed in seven eyes of seven patients, including one case of retinal vasculitis.

CONCLUSIONS

The results of the SHIFT study indicate that switch to brolucizumab may represent a treatment option in patients with nAMD poorly responsive to other anti-VEGF agents. Further long-term analyses appear prudent to assess efficacy and safety of brolucizumab in a routine clinical setting.

Determinants of Quality of Life in Geographic Atrophy Secondary to Age-Related Macular Degeneration

Purpose

To longitudinally evaluate vision-related quality of life (VRQoL) in geographic atrophy (GA) secondary to age-related macular degeneration (AMD) and define its relation to visual function and structural biomarkers.

Methods

Patients with GA secondary to AMD were recruited in the context of the prospective, non-interventional, natural-history Directional Spread in Geographic-Atrophy study (NCT02051998). Fundus autofluorescence and infrared reflectance images were semi-automatically annotated for GA. Linear mixed-effects models were applied to investigate the association of putative determinants with the National Eye Institute Visual Function Questionnaire 25 (NEI VFQ-25) VRQoL.

Results

A total of 87 patients with a mean age ± SD of 77.07 ± 7.49 years were included in the analysis. At baseline, median (IQR) best-corrected visual acuity (BCVA) was 0.3 (0.51) for the better eye and 0.89 (0.76) for the worse eye; 46% of the patients showed binocular and 25.3% monocular non-central GA. The VRQoL composite score was impaired: 69.96 (24.03). Sixty-six patients with a median of 2 (2) follow-up visits after 1.08 (0.78) years were examined longitudinally.

Conclusions

Vision-related quality of life is significantly impaired in patients with GA secondary to AMD. The cross-sectional and longitudinal association of VRQoL with visual functional and structural biomarkers supports the validity of the NEI VFQ-25 VRQoL.

Myocardial Mapping in Systemic Sarcoidosis: A Comparison of Two Measurement Approaches

PURPOSE

 To investigate if T1 and T2 mapping is able to differentiate between diseased and healthy myocardium in patients with systemic sarcoidosis, and to compare the standard mapping measurement (measurement within the whole myocardium of the midventricular short axis slice, SAX) to a more standardized method measuring relaxation times within the midventricular septum (ConSept).

MATERIALS AND METHODS

 24 patients with biopsy-proven extracardiac sarcoidosis and 17 healthy control subjects were prospectively enrolled in this study and underwent CMR imaging at 1.5 T including native T1 and T2 mapping. Patients were divided into patients with (LGE+) and without (LGE-) cardiac sarcoidosis. T1 and T2 relaxation times were compared between patients and controls. Furthermore, the SAX and the ConSept approach were compared regarding differentiation between healthy and diseased myocardium.

RESULTS

 T1 and T2 relaxation times were significantly longer in all patients compared with controls using both the SAX and the ConSept approach (p < 0.05). However, LGE+ and LGE- patients showed no significant differences in T1 and T2 relaxation times regardless of the measurement approach used (ConSept/SAX) (p > 0.05). Direct comparison of ConSept and SAX T1 mapping showed high conformity in the discrimination between healthy and diseased myocardium (Kappa = 0.844).

CONCLUSION

 T1 and T2 mapping may not only enable noninvasive recognition of cardiac involvement in patients with systemic sarcoidosis but may also serve as a marker for early cardiac involvement of the disease allowing for timely treatment. ConSept T1 mapping represents an equivalent method for tissue characterization in this population compared to the SAX approach. Further studies including follow-up examinations are necessary to confirm these preliminary results.

KEY POINTS

  · Mapping may enable noninvasive recognition of cardiac involvement in patients with systemic sarcoidosis. · Mapping may serve as a marker for early cardiac involvement in patients with systemic sarcoidosis. · The ConSept approach can be used as an alternative measuring method in sarcoidosis patients.

CITATION FORMAT

· Dabir D, Luetkens J, Kuetting D et al. Myocardial Mapping in Systemic Sarcoidosis: A Comparison of Two Measurement Approaches. Fortschr Röntgenstr 2021; 193: 68 - 76.

P0782PROGNOSTIC IMPACT OF NECK CIRCUMFERENCE ON CARDIVASCULAR OUTCOMES AND MORTALITY IN PATIENTS WITH MODERATE CHRONIC KIDNEY DISEASE: AN ANALYSIS FROM THE GERMAN CHRONIC KIDNEY DISEASE (GCKD) STUDY

Background and Aims

Neck circumference (NC) is an approximator of upper body subcutaneous fat tissue and a marker of obesity. It has been shown to be associated with cardiovascular risk factors and incident chronic kidney disease (CKD). In CKD patients, the impact on cardiovascular events and all cause death has not been fully elucidated yet. The prognostic impact on these outcomes in a representative cohort of adult patients with moderate CKD of Caucasian origin was investigated here.

Method

We used data from the GCKD study, a German multi-centric prospective observational cohort study of 5217 adults with moderate chronic kidney disease, defined as eGFR 30–60 mL/min/1.73 m2 or eGFR &gt;60 mL/min/1.73 m2 and significant proteinuria (albuminuria &gt;300 mg/g creatinine or proteinuria &gt;500 mg/g creatinine). Exclusion criteria were active malignancy, heart failure NYHA class IV, organ transplantation, and non-Caucasian origin. NC was measured repeatedly (annually, except at first year of follow-up) during the study, therefore, the mean value was analyzed. We report data from the 4-year follow-up visit regarding 1) a combined endpoint of non-fatal myocardial infarction, non-fatal stroke, cardiovascular death, and peripheral artery disease event (amputation or revascularization) and 2) all-cause death as another endpoint. Cox proportional hazard regression was used to calculate hazard ratios (HR) with 95% CIs. In univariate analysis, ordinal regression with quintiles of NC was applied.

Results

NC was accrued in 4453 participants and analyzed. NC overall was 40±5 cm (43±4 cm in men and 37±4 cm in women, p&lt;0.001), mean age 60±12 years, 41% were female, 96% had hypertension, 35% were diabetic, 58% had ever smoked, eGFR was 50±18 ml/min/1.73 m (CKD-EPI), BMI 28±6 kg/m, LDL-cholesterol 119±43 mg/dl. Higher quintiles of NC were associated increased risk of the cardiovascular outcome in univariate analysis: highest (44 cm) vs. lowest (36.5 cm), HR 2.34 (1.63–3.36; p&lt;0.001). In multivariable analysis adjusted for age, sex, and BMI, this effect was reduced but still apparent: HR 1.04 (1.01–1.08, p=0.025). Age (HR per year 1.05, 1.04–1.07, p&lt;0.001), and female sex (HR 0.69, 0.50–0.95, p=0.023), showed also significant effects, whereas BMI did not (p=0.831). The effect of higher quintiles of NC on the risk of all-cause death in univariate analysis was even stronger: highest vs. lowest, HR 3.2 (1.72–5.81, p=0.006). However, after adjustment this effect was abolished: HR 0.99 (0.95–1.04; p=0.85). Only age (HR 1.07, 1.04–1.09, p&lt;0.001), and female sex (HR 0.45, 0.27-0.74, p=0.002), remained significant predictors of all-cause death in this model.

Conclusion

In patients with chronic kidney disease, we found higher NC to be associated with increased cardiovascular event risk, but not all-cause death, after adjustment for age, sex and BMI. The risk of cardiovascular outcomes and overall mortality was consistently lower in women. Our analysis supports evidence, that upper body subcutaneous adipose tissue might be an independent contributor to cardiovascular event risk.

Association of Serum Uromodulin with Death, Cardiovascular Events, and Kidney Failure in CKD

BACKGROUND AND OBJECTIVES

Uromodulin is exclusively produced by tubular epithelial cells and released into urine and serum. Higher serum uromodulin has been associated with lower risk for kidney failure in Chinese patients with CKD and with lower risk for mortality in the elderly and in patients undergoing coronary angiography. We hypothesized that lower serum uromodulin is associated with mortality, cardiovascular events, and kidney failure in white patients with CKD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We measured serum uromodulin in 5143 participants enrolled in the German CKD (GCKD) study. The associations of baseline serum uromodulin with all-cause mortality, major adverse cardiovascular events (MACE; a composite of cardiovascular mortality, nonfatal myocardial infarction or stroke, or incident peripheral vascular disease), and kidney failure (dialysis or transplantation) were evaluated using multivariable Cox proportional hazard regression analyses in a cohort study design, adjusting for demographics, eGFR, albuminuria, cardiovascular risk factors, and medication.

RESULTS

The mean age of participants was 60±12 years, 60% were male. Mean serum uromodulin concentration was 98±60 ng/ml, eGFR was 49±18 ml/min per 1.73 m², and 78% had eGFR <60 ml/min per 1.73 m². Participants in lower serum uromodulin quartiles had lower eGFR and higher albuminuria, prevalence of diabetes, hypertension, coronary artery disease, and more frequent history of stroke at baseline. During a follow-up of 4 years, 335 participants died, 417 developed MACE, and 229 developed kidney failure. In multivariable analysis, the highest serum uromodulin quartile was associated with lower hazard for mortality (hazard ratio [HR], 0.57; 95% CI, 0.38 to 0.87), MACE (HR, 0.63; 95% CI, 0.45 to 0.90), and kidney failure (HR, 0.24; 95% CI, 0.10 to 0.55) compared with the lowest quartile.

CONCLUSIONS

Higher serum uromodulin is independently associated with lower risk for mortality, cardiovascular events, and kidney failure in white patients with CKD.

CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER

Deutsches Register für Klinische Studien (DRKS; German national database of clinical studies), DRKS00003971.

Prognostic value of intermediate age-related macular degeneration phenotypes for geographic atrophy progression

BACKGROUND

To characterise early stages of geographic atrophy (GA) development in age-related macular degeneration (AMD) and to determine the prognostic value of structural precursor lesions in eyes with intermediate (i) AMD on the subsequent GA progression.

METHODS

Structural precursor lesions for atrophic areas (lesion size at least 0.5 mm² in fundus autofluorescence images) were retrospectively identified based on multimodal imaging and evaluated for association with the subsequent GA enlargement rates (square-root transformed, sqrt). A linear mixed-effects model was used to account for the hierarchical nature of the data with a Tukey post hoc test to assess the impact of the local precursor on the subsequent GA progression rate.

RESULTS

A total of 39 eyes with GA of 34 patients with a mean age of 74.4±6.7 (±SD) years were included in this study. Five precursor lesions (phenotypes 1-5) preceding GA development were identified: large, sub-retinal pigment epithelial drusen (n=19), reticular pseudodrusen (RPD, n=10), refractile deposits (n=4), pigment epithelial detachment (n=4) and vitelliform lesions (n=2). Precursor lesions exhibited a significant association with the subsequent (sqrt) GA progression rates (p=0.0018) with RPD (phenotype 2) being associated with the fastest GA enlargement (2.29±0.52 (±SE) mm/year.

CONCLUSIONS

The results indicate the prognostic relevance of iAMD phenotyping for subsequent GA progression highlighting the role of structural AMD features across different AMD stages.

Association Between Dietary Patterns and Kidney Function in Patients With Chronic Kidney Disease: A Cross-Sectional Analysis of the German Chronic Kidney Disease Study

OBJECTIVE

In the general population, "healthy" dietary patterns are associated with improved health outcomes, but data on associations between observance of specific dietary patterns and kidney function in patients with chronic kidney disease (CKD) are sparse.

METHODS

Dietary intake was evaluated using food frequency questionnaires in patients with moderately severe CKD under nephrology care enrolled into the observational multicenter German CKD study. The Dietary Approaches to Stop Hypertension (DASH) diet score, Mediterranean diet score, and German Food Pyramid Index (GFPI) were calculated and their association with estimated glomerular filtration rate (eGFR) and albuminuria was assessed by multivariable linear regression analysis, adjusted for gender, age, body mass index, energy intake, smoking status, alcohol intake, education, high-density lipoprotein-cholesterol (HDL- cholesterol), low-density lipoprotein-cholesterol (LDL-cholesterol), hypertension, and diabetes mellitus.

RESULTS

A total of 2,813 patients (41% women; age 60.1 ± 11.6 years) were included in the analysis. High DASH diet score and GFPI were associated with lower systolic blood pressure and lower intake of antihypertensive medication, higher HDL, and lower uric acid levels. Mediterranean-style diet was associated with lower prevalence of diabetes mellitus. Higher DASH and Mediterranean diet scores were associated with higher eGFR (β-coefficient = 1.226, P < .001; β-coefficient = 0.932, P = .007, respectively). In contrast, GFPI was not associated with eGFR. For the individual components of the dietary patterns, higher intake of nuts and legumes, cereals, fish, and polyunsaturated fats was associated with higher eGFR and higher intake of dairy, composed of low- and whole-fat dairy, was associated with lower eGFR. No association was found between dietary patterns and albuminuria.

CONCLUSION

Higher observance of the DASH or Mediterranean diet, but not German food pyramid recommendations, was associated with higher eGFR among patients with CKD. Improving dietary habits may offer an opportunity to better control comorbidities and kidney function decline in patients with CKD.

Spectrum and dosing of urate-lowering drugs in a large cohort of chronic kidney disease patients and their effect on serum urate levels: a cross-sectional analysis from the German Chronic Kidney Disease study

Background

Despite a plethora of studies on the effect of urate-lowering therapy (ULT) in patients with chronic kidney disease (CKD), current guidelines on the treatment of hyperuricaemia and gout vary, especially concerning the need for dose adjustment of allopurinol, whose main metabolite is accumulating with declining renal function. Data on allopurinol dosing and its relationship to renal function, co-medication and sex and the resulting urate level in large cohorts are missing.

Methods

We studied a subgroup of 2378 patients of the German Chronic Kidney Disease (GCKD) study to determine prescription patterns of ULT among CKD patients under nephrological care and the relationship of ULT dose to urate levels. Prescription and dosing of ULT were manually abstracted from the patient’s paper charts at the baseline visit, in which all currently used medications and their dosing were recorded.

Results

In this cohort, 39.6% were women, the mean estimated glomerular filtration rate (eGFR) was 51.3 ± 19.3 mL/min/1.73 m² and the mean age was 59.0 ± 12.4 years. Of the 2378 examined patients, 666 (28.0%) received ULT. The dose of ULT was available for 572 patients. The main ULT agent was allopurinol (94.4%), followed by febuxostat (2.9%) and benzbromarone (2.6%). Of the 540 patients who used allopurinol with a reported daily dose, 480 had an eGFR <60 mL/min/1.73 m² and 320 had an eGFR <45 mL/min/1.73 m², 31.5% of the latter (n = 101) received a dose >150 mg/day, the recommended maximal dose for this level of eGFR. The prescribed dose was not related to eGFR: the median eGFR for patients taking 100, 150 and 300 mg/day was 40 [interquartile range (IQR) 32–49], 43 (34–52) and 42 (35–54) mL/min/1.73 m², respectively. Patients with lower doses of allopurinol had higher serum urate levels than patients with higher (than recommended) allopurinol doses. Sex, alcohol intake, eGFR, use of diuretics and treatment with allopurinol were independent determinants of serum urate levels in multivariate regression analysis.

Conclusions

The most frequently used drug to lower serum urate levels in this CKD cohort was allopurinol. Even in patients regularly seen by nephrologists, the dose of allopurinol is often not adjusted to the current eGFR. Patients with higher ULT doses achieved better control of their serum urate levels. Lowering of serum urate in CKD patients requires balancing potential adverse effects of allopurinol with suboptimal control of serum urate levels.

Assessment of Exudative Activity of Choroidal Neovascularization in Age-Related Macular Degeneration by OCT Angiography

PURPOSE

Based on exudative activity, choroidal neovascularization (CNV) in age-related macular degeneration (AMD) can be classified as "active" aCNV, pretherapied "silent" sCNV (i.e., a treatment-free interval >12 weeks), or treatment-naïve "quiescent" qCNV. We evaluated the qualitative and quantitative optical coherence tomography angiography (OCTA) features of these CNV subgroups.

METHODS

The presence of small-caliber vessels, peripheral arcades, and a -perilesional OCTA signal attenuation as well as values for vessel length, density, and branching index were evaluated for each CNV network in a 6 × 6 mm OCTA scan pattern.

RESULTS

Fifty-one eyes of 51 patients with AMD (age 75.9 ± 7.5 years; 20 males [39.2%]) were included. The qCNV subgroup (n = 8) showed the highest prevalence of qualitative and quantitative values for OCTA activity criteria, reaching significance with regard to small-caliber vessels (p = 0.003), peripheral arcades (p = 0.039), vessel length (p = 0.020), and branching index (p < 0.001) when compared to the aCNV (n = 32) and sCNV (n = 11) subgroups. Qualitative criteria were inversely associated with the number of previous anti-VEGF injections (each p < 0.03), while quantitative metrics also suggested lower values.

CONCLUSIONS

These findings suggest that OCTA may be supportive in the phenotypical differentiation of CNV lesions secondary to AMD, while the assessed structural changes appeared to be more indicative of previously administered anti-VEGF therapy than current exudative activity.

Prognostic Value of Retinal Layers in Comparison with Other Risk Factors for Conversion of Intermediate Age-related Macular Degeneration

PURPOSE

To analyze longitudinal thickness changes of retinal layers in comparison with established risk factors in eyes with age-related macular degeneration (AMD) with regard to their prognostic value for conversion into advanced AMD stages.

DESIGN

Prospective, longitudinal natural history study.

PARTICIPANTS

Ninety-one eyes of 91 patients with AMD (73.3±7.3 years; 62 female patients [50.4%]) of the Molecular Diagnostic of Age-related Macular Degeneration (MODIAMD) study without exudative or nonexudative late-stage AMD in the study eye at baseline.

METHODS

At each annual follow-up visit, all subjects underwent ophthalmic examination with assessment of best-corrected visual acuity (BCVA) and retinal imaging, including spectral-domain OCT (SD-OCT), over a study period of 6 years.

PURPOSE

To analyze longitudinal thickness changes of retinal layers in comparison with established risk factors in eyes with age-related macular degeneration (AMD) with regard to their prognostic value for conversion into advanced AMD stages.

MAIN OUTCOME MEASURES

Qualitative structural AMD features and SD-OCT-based quantitative thickness changes of different retinal layers, such as the retinal pigment epithelium-drusen complex (RPEDC), were assessed by multimodal imaging. Their prognostic relevance regarding disease conversion was determined using Cox regression (cloglog link function).

RESULTS

In the multivariable analysis, the presence of focal hyperpigmentation, almost reaching statistical significance, showed the strongest effect regarding the development of nonexudative late-stage AMD (hazard ratio [HR], 5.88; 95% confidence interval [CI], 0.69-50.2; P = 0.052) followed by the presence of refractile drusen (HR, 4.82; 95% CI, 1.33-17.44; P = 0.0164). A thickening of the RPEDC was the only assessed retinal layer that exhibited a significant effect on the development of nonexudative advanced AMD (HR, 1.03; 95% CI, 1.0-1.07; P = 0.0393), whereas no association was observable for the other retinal layers. Neither qualitative nor quantitative markers were significant predictors for the development of exudative late-stage AMD (P > 0.05).

CONCLUSIONS

The results indicate that the development of both exudative and nonexudative AMD is associated with distinct prognostic features. However, compared with the assessment of qualitative AMD features, the quantification of retinal layers on average across the central retina had less prognostic impact. Further studies are needed to identify and validate robust biomarkers in early AMD stages.

Patterns of medication use and the burden of polypharmacy in patients with chronic kidney disease: the German Chronic Kidney Disease study

Background

Patients with chronic kidney disease (CKD) bear a substantial burden of comorbidities leading to the prescription of multiple drugs and a risk of polypharmacy. However, data on medication use in this population are scarce.

Methods

A total of 5217 adults with an estimated glomerular filtration rate (eGFR) between 30 and 60 mL/min/1.73 m² or an eGFR ≥60 mL/min/1.73m² and overt proteinuria (>500 mg/day) were studied. Self-reported data on current medication use were assessed at baseline (2010-12) and after 4 years of follow-up (FU). Prevalence and risk factors associated with polypharmacy (defined as the regular use of five or more drugs per day) as well as initiation or termination of polypharmacy were evaluated using multivariable logistic regression.

Results

The prevalence of polypharmacy at baseline and FU was almost 80%, ranging from 62% in patients with CKD Stage G1 to 86% in those with CKD Stage G3b. The median number of different medications taken per day was eight (range 0-27). β-blockers, angiotensin-converting enzyme inhibitors and statins were most frequently used. Increasing CKD G stage, age and body mass index, diabetes mellitus, cardiovascular disease and a history of smoking were significantly associated with both the prevalence of polypharmacy and its maintenance during FU. Diabetes mellitus was also significantly associated with the initiation of polypharmacy [odds ratio (OR) 2.46, (95% confidence interval 1.36-4.45); P = 0.003].

Conclusion

Medication burden in CKD patients is high. Further research appears warranted to address the implications of polypharmacy, risks of drug interactions and strategies for risk reduction in this vulnerable patient population.

Epicardial fat, cardiovascular risk factors and calcifications in patients with chronic kidney disease

Background

Epicardial adipose tissue (EAT) exerts cardiopathogenic effects, but the independent association between EAT and cardiovascular (CV) calcification in patients with chronic kidney disease (CKD) remains controversial. We therefore assessed the association between EAT, CV risk factors and CV calcifications.

Methods

257 patients with CKD Stage 3 and/or overt proteinuria underwent quantification of EAT, coronary artery calcification and aortic valve calcification by computed tomography. Framingham and American College of Cardiology and American Heart Association (ACC-AHA) 10-year CV event risk scores were calculated for each patient.

Results

Using multivariable regression analysis, higher EAT was significantly associated with the majority of investigated risk factors {higher age: odds ratio [OR] 1.05/year [95% confidence interval (CI) 1.02-1.08]; male sex: OR 4.03 [95% CI 2.22-7.31]; higher BMI: OR 1.28/kg/m² [95% CI 1.20-1.37]; former smoking: OR 1.84 [95% CI 1.07-3.17]; lower high-density lipoprotein cholesterol: OR 0.98/mg/dL [95% CI 0.96-1.00] and lower estimated glomerular filtration rate: OR 0.98/mL/min/1.73 m² [95% CI 0.97-0.99]; all P < 0.05} and was not associated with diabetes mellitus, hypertensive nephropathy, total cholesterol and albuminuria. EAT was positively associated with higher ACC-AHA and Framingham risk scores. EAT correlated with coronary artery calcification and aortic valve calcification [Spearman ρ = 0.388 (95% CI 0.287-0.532) and r _rb = 0.409 (95% CI 0.310-0.556), respectively], but these correlations were dependent on CV risk factors.

Conclusions

The increase of EAT can be explained by individual CV risk factors and kidney function and correlates with 10-year risk for CV event scores, suggesting that EAT is a modifiable risk factor in patients with CKD. Although EAT correlates with CV calcifications, these relations depend on CV risk factors.

Local Progression Kinetics of Geographic Atrophy in Age-Related Macular Degeneration Are Associated With Atrophy Border Morphology

Purpose

To assess the impact of distinct atrophy border characteristics based on spectral-domain optical coherence tomography (SD-OCT) imaging on local atrophy progression.

Methods

Patients with geographic atrophy (GA) secondary to AMD were recruited in the context of the Longitudinal Fundus Autofluorescence in Age-related Macular Degeneration and Directional Spread in Geographic Atrophy studies (NCT00393692, NCT02051998). Horizontal and vertical SD-OCT scans were acquired at sequential visits using a device allowing for anatomically accurate registration of follow-up to baseline scans. For quantification of local atrophy progression, the lateral spread of GA (LSGA) was measured. Further, border types were independently graded. Comparison of LSGA between the different border types was performed using linear mixed-effects models.

Results

Seventy-two eyes of 49 patients (27 female) aged 74.0 years (Inter quartile range [IQR], 68.1-79.0) were included into this analysis. A total of 258 border sections were analyzed longitudinally over a median period of 1.2 years (IQR, 0.9-1.6). At baseline, 17.1% borders were classified as 'regular', 47.7% as 'irregular', and 35.3% as 'splitting'. Sixty-two percent of the eyes exhibited more than one border type. LSGA was slowest in 'regular' borders (62.85 ± 25.29 μm/y), followed by 'irregular' borders (91.15 ± 15.05 μm/y) and fastest in 'splitting' borders (183.15 ± 18.17 μm/y). Differences between the 'splitting' and each other border type were statistically significant (P < 0.001).

Conclusions

The results indicate that SD-OCT-based assessment of local GA border morphology can serve as a predictor for local atrophy progression. These observations help to better understand the natural history and potential pathogenetic factors of GA development and progression.

Correction: Blood pressure control in chronic kidney disease: A cross-sectional analysis from the German Chronic Kidney Disease (GCKD) study

[This corrects the article DOI: 10.1371/journal.pone.0202604.].

Stereoscopic Vision in Macular Telangiectasia Type 2

PURPOSE

To investigate stereoscopic vision in patients with macular telangiectasia (MacTel) type 2 and correlate paracentral sensitivity loss to reduced stereoscopic function.

METHODS

In a prospective single-center study, 50 patients with MacTel type 2 and 25 age-matched controls were investigated. Stereoscopic function was evaluated with Lang I, Titmus, and TNO tests. Sensitivity of the central 16° was tested using fundus-controlled perimetry (microperimetry). Functional loss was quantified as depth, size, and localization of scotomata.

RESULTS

Both the Titmus and the TNO test revealed significantly reduced stereoscopic vision in patients compared to controls (p < 0.0001 for both). This applied even to patients with only relative or monocular paracentral scotoma. A strong correlation was observed for reduced stereoscopic vision with horizontal scotoma size and with the distance of scotomata from the foveal center.

CONCLUSIONS

The results indicate that stereoscopic vision is impaired early in patients with MacTel type 2. A paracentral sensitivity loss, even if mild and limited to one eye, may considerably interfere with stereoscopic function despite normal visual acuity. Projection of paracentral scotomata within the patient's central visual field plays an important role in stereoscopic vision and should be considered when interpreting stereoscopic test results.

Blood pressure control in chronic kidney disease: A cross-sectional analysis from the German Chronic Kidney Disease (GCKD) study

We assessed the prevalence, awareness, treatment and control of hypertension in patients with moderate chronic kidney disease (CKD) under nephrological care in Germany. In the German Chronic Kidney Disease (GCKD) study, 5217 patients under nephrology specialist care were enrolled from 2010 to 2012 in a prospective observational cohort study. Inclusion criteria were an estimated glomerular filtration rate (eGFR) of 30-60 mL/min/1.73 m2 or overt proteinuria in the presence of an eGFR>60 mL/min/1.73 m2. Office blood pressure was measured by trained study personnel in a standardized way and hypertension awareness and medication were assessed during standardized interviews. Blood pressure was considered as controlled if systolic < 140 and diastolic < 90 mmHg. In 5183 patients in whom measurements were available, mean blood pressure was 139.5 ± 20.4 / 79.3 ± 11.8 mmHg; 4985 (96.2%) of the patients were hypertensive. Awareness and treatment rates were > 90%. However, only 2456 (49.3%) of the hypertensive patients had controlled blood pressure. About half (51.0%) of the patients with uncontrolled blood pressure met criteria for resistant hypertension. Factors associated with better odds for controlled blood pressure in multivariate analyses included younger age, female sex, higher income, low or absent proteinuria, and use of certain classes of antihypertensive medication. We conclude that blood pressure control of CKD patients remains challenging even in the setting of nephrology specialist care, despite high rates of awareness and medication use.

Diagnostic Value of Cardiac Magnetic Resonance Strain Analysis for Detection of Cardiac Sarcoidosis

PURPOSE

The aim of this study was to investigate the diagnostic value of cardiac magnetic resonance (CMR)-derived strain parameters in patients with sarcoidosis, and to compare results to standard CMR markers of sarcoidosis (edema/T2 ratio, early gadolinium enhancement, late gadolinium enhancement) for prediction of disease outcome.

MATERIALS AND METHODS

61 patients with biopsy-proven sarcoidosis underwent CMR examination. According to CMR results, patients were divided into two different groups: patients with (CMR+; n = 23) and without (CMR-; n = 38) findings consistent with cardiac sarcoidosis. In addition, a group of healthy age-matched volunteers (controls; n = 22) served as controls. Left ventricular functional parameters as well as left ventricular longitudinal and circumferential strain were evaluated in all three groups.

RESULTS

Compared to controls, global longitudinal strain (GLS) was significantly impaired in patients with sarcoidosis, irrespective of cardiac involvement. No significant differences in GLS could be revealed between CMR+ and CMR- patients. Circumferential strain parameters were significantly impaired in CMR+ patients in comparison to CMR- patients and controls, while no significant differences could be revealed between CMR- patients and controls. GLS was significantly lower in patients with a negative outcome compared to controls. Compared to the rest of the CMR+ and CMR- patients, the GLS in patients with a negative outcome was further reduced but did not reach statistical significance.

CONCLUSION

GLS is the only strain parameter detecting left ventricular functional impairment in sarcoidosis patients with otherwise unsuspicious CMR and controls. GLS is further reduced in patients with a negative outcome. Thus, GLS may have the potential to serve as a marker for early cardiac involvement in sarcoidosis.

KEY POINTS

· GLS is significantly impaired in sarcoidosis patients with an otherwise inconspicuous CMR, compared to controls. · GLS is reduced in patients with a negative outcome. · GLS may serve as a marker for early cardiac involvement in sarcoidosis.

CITATION FORMAT

· Dabir D, Meyer D, Kuetting D et al. Diagnostic Value of Cardiac Magnetic Resonance Strain Analysis for Detection of Cardiac Sarcoidosis. Fortschr Röntgenstr 2018; 190: 712 - 721.

Influence of factor XIII activity on post-operative transfusion in congenital cardiac surgery-A retrospective analysis

Objectives

Coagulation factor XIII (FXIII) plays a key role in fibrin clot stabilization—an essential process for wound healing following cardiothoracic surgery. However, FXIII deficiency as a risk for post-operative bleeding in pediatric cardiac surgery involving cardiopulmonary bypass (CPB) for congenital heart disease (CHD) is controversially discussed. Thus, as primary outcome measures, we analyzed the association of pre-operative FXIII activity and post-operative chest tube drainage (CTD) loss with transfusion requirements post-operatively. Secondary outcomes included the influence of cyanosis and sex on transfusion.

Methods

Our retrospective analysis (2009–2010) encompassed a single center series of 76 cardio-surgical cases with CPB (0–17 years, mean age 5.61 years) that were post-operatively admitted to our pediatric intensive care unit (PICU). The observational period was 48 hours after cardiac surgery. Blood cell counts and coagulation status, including FXIII activity were routinely performed pre- and post-operatively. The administered amount of blood products and volume expanders was recorded electronically, along with the amount of CTD loss. Uni- and multivariate logistic regression analysis was performed to calculate the associations (odds ratios) of variables with post-operative transfusion needs.

Results

FXIII activities remained stable following CPB surgery. There was no association of pre- and post-operative FXIII activities and transfusion of blood products or volume expanders in the first 48 hours after surgery. Similarly, FXIII showed no association with CTD loss. Cyanosis and female sex were associated with transfusion rates.

Conclusions

Although essentially involved in wound healing and clotting after surgery, FXIII activity does not serve as a valid predictor of post-operative transfusion need.

Cardiovascular magnetic resonance assessment of acute cardiovascular effects of voluntary apnoea in elite divers

BACKGROUND

Prolonged breath holding results in hypoxemia and hypercapnia. Compensatory mechanisms help maintain adequate oxygen supply to hypoxia sensitive organs, but burden the cardiovascular system. The aim was to investigate human compensatory mechanisms and their effects on the cardiovascular system with regard to cardiac function and morphology, blood flow redistribution, serum biomarkers of the adrenergic system and myocardial injury markers following prolonged apnoea.

METHODS

Seventeen elite apnoea divers performed maximal breath-hold during cardiovascular magnetic resonance imaging (CMR). Two breath-hold sessions were performed to assess (1) cardiac function, myocardial tissue properties and (2) blood flow. In between CMR sessions, a head MRI was performed for the assessment of signs of silent brain ischemia. Urine and blood samples were analysed prior to and up to 4 h after the first breath-hold.

RESULTS

Mean breath-hold time was 297 ± 52 s. Left ventricular (LV) end-systolic, end-diastolic, and stroke volume increased significantly (p < 0.05). Peripheral oxygen saturation, LV ejection fraction, LV fractional shortening, and heart rate decreased significantly (p < 0.05). Blood distribution was diverted to cerebral regions with no significant changes in the descending aorta. Catecholamine levels, high-sensitivity cardiac troponin, and NT-pro-BNP levels increased significantly, but did not reach pathological levels.

CONCLUSION

Compensatory effects of prolonged apnoea substantially burden the cardiovascular system. CMR tissue characterisation did not reveal acute myocardial injury, indicating that the resulting cardiovascular stress does not exceed compensatory physiological limits in healthy subjects. However, these compensatory mechanisms could overly tax those limits in subjects with pre-existing cardiac disease. For divers interested in competetive apnoea diving, a comprehensive medical exam with a special focus on the cardiovascular system may be warranted.

TRIAL REGISTRATION

This prospective single-centre study was approved by the institutional ethics committee review board. It was retrospectively registered under ClinicalTrials.gov (Trial registration: NCT02280226 . Registered 29 October 2014).

Polarization and Distribution of Tumor-Associated Macrophages and COX-2 Expression in Basal Cell Carcinoma of the Ocular Adnexae

PURPOSE

Basal cell carcinoma (BCC) is a locally invasive skin tumor which can be subdivided into a circumscribed nodular and an invasive fibrosing subtype. There is increasing evidence that macrophages play an important role in interacting between tumor cells and their microenvironment, thereby affecting not only the invasive potential but also the patients' prognosis. Thus, we wanted to compare these two BCC variants with regard to tumor-related inflammation, COX-2 expression, distribution, and polarization of tumor-associated macrophages.

MATERIAL AND METHODS

30 BCCs (nodular: n = 15; fibrosing: n = 15) of the ocular adnexae were investigated by histopathology and immunohistochemistry. The grade of inflammation was evaluated on hematoxylin and eosin stains (score: 0-3). Immunohistochemical stains for CD68 (macrophages), Ki67 (proliferative activity), and COX-2 as well as immunofluorescence stains for CD68 and CD163 (to distinguish M1 and M2 macrophage subtypes) were performed. SPSS was used for statistical analysis.

RESULTS

Fibrosing BCCs were predominantly located on the lower lid, while nodular BCCs showed a broader distribution (p = 0.013). The fibrosing BCC subtype was associated with a higher degree of inflammation (p < 0.001) and revealed a higher COX-2 immunoreactivity than nodular BCC (p = 0.012). COX-2-positive cells were predominantly located on the infiltrating edge of the tumor. Macrophage polarization was balanced regarding M1 and M2 macrophage subtypes. There was no difference in macrophage number (p = 0.389) or polarization (p = 0.161) between nodular and fibrosing BCC.

CONCLUSIONS

The findings indicate that COX-2 represents a factor for invasion of BCC. Macrophage polarization did not play a major role for aggressive behavior. However, other inflammatory components than tumor-associated macrophages seem to be involved in tissue destruction and thereby an invading growth pattern since fibrosing BCC revealed a significantly more intense inflammatory reaction in the surrounding tissue.

Effects of repetitive prolonged breath-hold in elite divers on myocardial fibrosis and cerebral morphology

BACKGROUND

Prolonged apnea by breath-hold (BH) divers leads to hypoxemia and compensatory mechanisms of the cardiovascular system (i.e. increase of total peripheral resistance, increase of systolic blood-pressure, left-ventricular enlargement) to maintain oxygen supply to oxygen sensitive organs such as the brain. All these changes may result in structural myocardial or subclinical brain alterations. Therefore, the aim of this study was to investigate mid-term effects of repetitive prolonged apnea using cardiac magnetic resonance imaging (CMR) and magnetic resonance imaging of the brain.

MATERIALS AND METHODS

17 elite BH divers (15 males) were investigated at baseline, from whom 9 (7 males) were investigated again at follow-up one year later. CMR included functional imaging and tissue characterization using T1- and T2-mapping as well as late gadolinium enhancement. Results were compared intra-individually and with 50 age matched controls.

RESULTS

Mean BH time were 297 ± 52 s (entire cohort) and 315 ± 56 s (sub-cohort) at initial, and 334 ± 104 s at follow-up examination. Apnea resulted in a progressive increase of the left ventricle and impaired function, whichfully resolved after cessation of apnea. At rest, no dilation of the left ventricle was notable (LV-EDV: 106.7 ± 28.8 ml; LV-EDV/BSA: 52.2 ± 12.7 ml/m²). Compared to controls, the apnea group showed significantly lower volumes (LV-EDV: 106.7 ± 28.8 ml vs. 140.9 ± 36.3 ml, p = .008; LV-EDV/BSA: 52.2 ± 12.7 ml/m² vs. 73.7 ± 12.8 ml/m²). In contrast, LV-EF showed no significant differences between both groups (61.0 ± 7.0% vs. 60.9 ± 3.6%). T1- and T2-mapping revealed no significant differences, neither intra-individually nor in comparison with age matched controls. (T1 pre-contrast: 974.1 ± 12.9 ms vs. 969.4 ± 29.0 ms, p = .2; T1 post-contrast: 368.9 ± 38.5 ms vs. 966.7 ± 40.5 ms, p = .4; ECV: 29.2 ± 1.5% vs. 29.8 ± 1.6%, p = .3; T2. 52 ± 2 ms vs. 52 ± 3 ms; p = .4). Except for one old embolic lesion no structural changes were found in brain imaging.

CONCLUSION

Although, prolonged apnea leads to impressive adaptions of the cardiovascular system (i.e. dilation of the left ventricle) and hypertension due to peripheral vasoconstriction no mid-term morphological changes could be observed in both, the myocardium and the brain. BH divers are suitable as a model to investigate acute physiological changes of prolonged apnea and hypoxemia, but not as a model for chronic alterations.

Abstract P6-09-09: Meta-analysis of ESR1 mutation prevalence in metastatic breast cancer

Introduction: ESR1 mutations were described for the first time in 1996 when different tyrosine 537 mutations were found to confer constitutive activation of the receptor, describing this region as a key factor in the ligand regulation of ER transcriptional activity. However, due to the low prevalence of this mutation in primary breast tumors its clinical significance maintained unknown. With the advent of large scale genomic analysis, a new understanding of breast cancer molecular characteristics has gained relevance. The low prevalence of ESR1 mutations in primary breast cancer has been confirmed but mutations in metastatic ER-positive breast cancers has been proved to be a completely different scenario. Nevertheless, information regarding real prevalence of ESR1 mutation in metastatic breast cancer is not known as selection of patients and molecular technique used are heterogeneous.

Sources: Search was carried by corresponding clinical oncologists of the Breast Cancer Unit of Alexander Fleming Institute. In March 2017, key words “ESR1 mutations”, “Estrogen receptor mutations” and “Breast cancer” were used as search strategy for the present meta-analysis in PubMed. Furthermore, abstracts from congress presentations were analyzed and hand searching from reference list of obtained articles was executed. Online search retrieved 60 articles published, 3 abstracts related were found and 3 further studies were detected by hand search. Articles were excluded if they only included primary tumors and not metastatic cases and if they were undertaken before 2000 due to important technical differences of mutation detection, including finally 23 cohorts.

Study Selection: Studies considered were prospective or retrospective cohorts of metastatic breast cancer patients with mutation analysis of tissue or circulating DNA. A data form was used by the primary reviewer to extract equivalent information from each article. Information extracted included population sampled, prevalence estimates, clinical characteristics of cohort, sample analyzed and technical procedure for mutation detection. A second reviewer blinded to the primary reviewer's decisions checked the article selection and data extraction. Any differences of opinion were discussed, and a third reviewer was available to arbitrate any issues.

Meta-analysis was undertaken using a random-effects model conducted using the metaprop function in Meta package of R studio Version 1.0.136 (© 2009-2016 RStudio, Inc.). PRISMA guidelines were followed in conducting and reporting the results.

Results and Discussion: Results show a prevalence of ESR1 mutation of 24% (CI95% 19-30%) in the 3607 patients included. Nevertheless, important heterogeneity (I2 =90%) is observed due to great differences in the articles published of this topic. This heterogeneity is attributed to the type of cohorts presented, the selection of patients, the technique used and type of sample studied, but another source of heterogeneity must be present as it still persists after grouping studies according to this variables. The importance of this analysis resides in the fact that it is the most complete information of the prevalence of this mutation that may have future importance in therapeutic decisions in metastatic breast cancer.

Citation Format: Mandó P, Rizzo MM, Perez de la Puente C, Costanzo MV, Nervo A, Nadal J, Colo F, Loza CM, Loza J, Fabiano V, Ponce C, Chacon R. Meta-analysis of ESR1 mutation prevalence in metastatic breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-09-09.