Effect modification of polypharmacy on incident frailty by chronic kidney disease in older adults

BACKGROUND

Frailty and polypharmacy are common conditions in older adults, especially in those with chronic kidney disease (CKD). Therefore, we analyzed the association of polypharmacy and incident frailty and the effect modification by CKD in very old adults.

METHODS

In non-frail individuals within the Berlin Initiative (cohort) Study, polypharmacy (≥ 5 medications) was assessed according to multiple definitions based on the number of regular and on demand prescription and over the counter drugs, as well as vitamins and supplements. CKD was defined as an estimated glomerular filtration rate < 60 mL/min/1.73m2 and/or an albumin-creatinine ratio ≥ 30 mg/g. Incident frailty was assessed at follow-up using Fried criteria. Logistic regression was applied to assess (1) the association of different polypharmacy definitions with incident frailty and (2) effect modification by CKD.

RESULTS

In this cohort study, out of 757 non-frail participants (mean age 82.9 years, 52% female, 74% CKD), 298 (39%) participants reported polypharmacy. Over the observation period of 2.1 years, 105 became frail. Individuals with polypharmacy had 1.96 adjusted odds (95% confidence interval (CI): 1.20-3.19) of becoming frail compared to participants without polypharmacy. The effect of polypharmacy on incident frailty was modified by CKD on the additive scale (relative excess risk due to interaction: 1.56; 95% CI 0.01-3.12).

CONCLUSIONS

This study demonstrates an association of polypharmacy and incident frailty and suggests strong evidence for an effect modification of CKD on polypharmacy and incident frailty. Revision of prescriptions could be a target strategy to prevent frailty occurrence, especially in older adults with CKD.

The Lack of a Standardized Definition of Chronic Dialysis Treatment in German Statutory Health Insurance Claims Data—Effects on Estimated Incidence and Mortality

BACKGROUND

Chronic kidney failure (CKF) is often treated with dialysis, which is invasive and costly and carries major medical risks. The existing studies of patients with CKF requiring dialysis that are based on claims data from German statutory health insurance (SHI) carriers employ varying definitions of this entity, with unclear consequences for the resulting statistical estimates.

METHODS

We carried out a cohort study on four random samples, each consisting of 62 200 persons aged 70 or above, from among the insurees of the SHI AOK Nordost, with one sample for each of the years 2012, 2014, 2016, and 2018. The prevalence, incidence, mortality, and direct health-care costs of CKF requiring dialysis were estimated and compared on the basis of four different definitions from literature and a new definition developed by the authors in reference to billing data.

RESULTS

The different definitions led to variation in 12-month prevalences (range: 0.33-0.61%) and 6-month incidences (0.058-0.100%). The percentage of patients with prior acute kidney injury (AKI) ranged from 27.6% to 61.8%. Among incident patients, three-month survival ranged from 70.2% to 88.1%, and six-month survival from 60.5% to 81.3%. In CKF patients without prior AKI, the survival curves differed less across definitions (80.2-91.8% at three months, 70.7-84.4% at six months). The monthly health-care costs ranged from €6010 to €9606, with marked variability across definitions in the costs of inpatient and outpatient care.

CONCLUSION

The lack of a standardized definition of CKF requiring dialysis in German SHI claims data leads to variability in the estimated case numbers, mortality, and health-care costs. These differences are most probably in part due to the variable inclusion of inpatients who received short-term dialysis after AKI.

Diagnostic Validity of Chronic Kidney Disease in Health Claims Data Over Time: Results from a Cohort of Community-Dwelling Older Adults in Germany

Purpose

The validity of ICD-10 diagnostic codes for chronic kidney disease (CKD) in health claims data has not been sufficiently studied in the general population and over time.

Patients and Methods

We used data from the Berlin Initiative Study (BIS), a prospective longitudinal cohort of community-dwelling individuals aged ≥70 years in Berlin, Germany. With estimated glomerular filtration rate (eGFR) as reference, we assessed the diagnostic validity (sensitivity, specificity, positive [PPV], and negative predictive values [NPV]) of different claims-based ICD-10 codes for CKD stages G3-5 (eGFR <60mL/min/1.73m²: ICD-10 N18.x-N19), G3 (eGFR 30-<60mL/min/1.73m²: N18.3), and G4-5 (eGFR <30mL/min/1.73m²: N18.4-5). We analysed trends over five study visits (2009-2019).

Results

We included data of 2068 participants at baseline (2009-2011) and 870 at follow-up 4 (2018-2019), of whom 784 (38.9%) and 440 (50.6%) had CKD G3-5, respectively. At baseline, sensitivity for CKD in claims data ranged from 0.25 (95%-confidence interval [CI] 0.22-0.28) to 0.51 (95%-CI 0.48-0.55) for G3-5, depending on the included ICD-10 codes, 0.20 (95%-CI 0.18-0.24) for G3, and 0.36 (95%-CI 0.25-0.49) for G4-5. Over the course of 10 years, sensitivity increased by 0.17 to 0.29 in all groups. Specificity, PPVs, and NPVs remained mostly stable over time and ranged from 0.82-0.99, 0.47-0.89, and 0.66-0.98 across all study visits, respectively.

Conclusion

German claims data showed overall agreeable performance in identifying older adults with CKD, while differentiation between stages was limited. Our results suggest increasing sensitivity over time possibly attributable to improved CKD diagnosis and awareness.

Kidney function estimators for drug dose adjustment of direct oral anticoagulants in older adults with atrial fibrillation

Background

The Cockcroft-Gault equation (CrClC-G) is recommended for dose adjustment of direct oral anticoagulant drugs (DOACs) to kidney function. We aimed to assess whether defining DOAC dose appropriateness according to various kidney function estimators changed the associations between dose appropriateness and adverse events in older adults with atrial fibrillation (AF).

Methods

Participants of the Berlin Initiative Study with AF and treated with DOACs were included. We investigated CrClC-G and estimated glomerular filtration rate (eGFR) using the Chronic Kidney Disease Epidemiology Collaboration and European Kidney Function Consortium equations based on creatinine and/or cystatin C. Marginal structural Cox models yielded confounder-adjusted hazard ratios for the risk of mortality, thromboembolism and bleeding associated with dose status.

Results

A total of 224 patients were included in the analysis (median age 87 years). Using CrClC-G, 154 (69%) had an appropriate dose of DOACs, 52 (23%) were underdosed and 18 (8%) were overdosed. During a 39-month median follow-up period, 109 (14.9/100 person-years) participants died, 25 (3.6/100 person-years) experienced thromboembolism and 60 (9.8/100 person-years) experienced bleeding. Dose status was not associated with mortality and thromboembolism, independent of the equation. Underdose status was associated with a lower risk of bleeding with all the equations compared with the appropriate dose group. In participants with discrepancies in dose status using CrClC-G and eGFR equations, the occurrence of endpoints did not differ between participants having an appropriate dose using CrClC-G or eGFR.

Conclusion

In older adults with AF, the association of DOAC dose status with adverse events did not differ when using CrClC-G or eGFR. Our results suggest that eGFR equations are not inferior to CrClC-G within this context.

Incidence of hospital-acquired acute kidney injury and trajectories of glomerular filtration rate in older adults

BACKGROUND

In older adults, epidemiological data on incidence rates (IR) of hospital-acquired acute kidney injury (AKI) are scarce. Also, little is known about trajectories of kidney function before hospitalization with AKI.

METHODS

We used data from biennial face-to-face study visits from the prospective Berlin Initiative Study (BIS) including community-dwelling participants aged 70+ with repeat estimated glomerular filtration rate (eGFR) based on serum creatinine and cystatin C. Primary outcome was first incident of hospital-acquired AKI assessed through linked insurance claims data. In a nested case-control study, kidney function decline prior to hospitalization with and without AKI was investigated using eGFR trajectories estimated with mixed-effects models adjusted for traditional cardiovascular comorbidities.

RESULTS

Out of 2020 study participants (52.9% women; mean age 80.4 years) without prior AKI, 383 developed a first incident AKI, 1518 were hospitalized without AKI, and 119 were never hospitalized during a median follow-up of 8.8 years. IR per 1000 person years for hospital-acquired AKI was 26.8 (95% confidence interval (CI): 24.1-29.6); higher for men than women (33.9 (29.5-38.7) vs. 21.2 (18.1-24.6)). IR (CI) were lowest for persons aged 70-75 (13.1; 10.0-16.8) and highest for ≥ 90 years (54.6; 40.0-72.9). eGFR trajectories declined more steeply in men and women with AKI compared to men and women without AKI years before hospitalization. These differences in eGFR trajectories remained after adjustment for traditional comorbidities.

CONCLUSION

AKI is a frequent in-hospital complication in individuals aged 70 + showing a striking increase of IR with age. eGFR decline was steeper in elderly patients with AKI compared to elderly patients without AKI years prior to hospitalization emphasising the need for long-term kidney function monitoring pre-admission to improve risk stratification.

[Development of quality indicators for the care of patients with chronic kidney disease : Results of a structured consensus process using the Delphi technique]

BACKGROUND

Chronic kidney disease (CKD) is a common condition, especially in the elderly. In order to prevent progression and complications of the disease, guideline-adherent outpatient care of patients with CKD should be prioritized. Quality indicators (QIs) can be used to measure and evaluate the quality of ambulatory care for patients with CKD. QIs specifically made for evaluating CKD care in Germany are not yet available. The goal of this work was to develop QIs for the quality assessment of outpatient care for patients over the age of 70 with CKD not requiring dialysis.

MATERIALS AND METHODS

QIs were operationalized from the recommendations of the German national guideline for CKD and others were proposed based on a published review of international QIs. The resulting QIs were divided into sets based on routine data (e.g., health insurance billing data) and data collection in practices (chart review). A panel of experts from various disciplines as well as a patient representative evaluated the proposed QIs in a two-stage Delphi process via online survey in October 2021 and January 2022 and a final consensus conference in March 2022. In addition, ranking lists of the most important QIs from each set were created.

RESULTS

An incidence indicator and a prevalence indicator were established; these were not subject to vote. Further, 21 QIs were voted upon by the expert panel. The seven most important QIs in each set (billing data or chart review) were selected. Only one QI was rated by the expert panel as not suitable for additional use in adults under the age of 70 years.

DISCUSSION

The QIs will enable the evaluation of the quality of outpatient care for patients with CKD with the long-term aim of optimizing guideline-adherent outpatient care.

Association of kidney function and albuminuria with frailty worsening and death in very old adults

BACKGROUND AND OBJECTIVES

Studies analysing the association of albuminuria and prevalent frailty in community-dwelling very old adults are scarce and lack information on incident frailty. We investigated the association of kidney function decline and increase of albuminuria with frailty worsening or death in very old adults.

DESIGN

Longitudinal analyses with biennial visits of the Berlin Initiative (cohort) Study and a frailty follow-up of 2.1 years.

SETTING/SUBJECTS

1,076 participants with a mean age of 84.3 (5.6) years of whom 54% were female.

METHODS

Partial proportional odds models were used to assess the association of estimated glomerular filtration rate (eGFR) decline and/or albuminuria (albumin creatinine ratio, ACR) with frailty worsening or death.

RESULTS

At frailty baseline, 1,076 participants with an eGFR of 50 (13) ml/min/1.73 m2, 48% being prefrail and 31% frail were included. After median 2.1 years, 960 (90%) participants had valid information on frailty transition: 187 (17.5%) worsened and 111 (10.3%) died. In the multivariable model, the odds of frailty worsening for participants with albuminuria in combination with eGFR <60 ml/min/1.73 m2 were elevated [OR (95% CI): 2.47 (1.41-4.31)] compared to participants without albuminuria and eGFR ≥60 ml/min/1.73 m2 as there was a rapid eGFR decline of ≥3 ml/min/1.73 m2 per year [1.55 (1.04-2.33)] and albuminuria trajectories six years prior [1.53 (1.11-2.10)] to frailty baseline. The odds of death for each exposure were even higher.

CONCLUSIONS

In older adults, advanced stages of CKD and albuminuria alone were associated with 2-fold odds of frailty worsening independent of death.

Polypharmacy and the Change of Self-Rated Health in Community-Dwelling Older Adults

Polypharmacy is associated with poorer self-rated health (SRH). However, whether polypharmacy has an impact on the SRH progression is unknown. This study investigates the association of polypharmacy with SRH change in 1428 participants of the Berlin Initiative Study aged 70 years and older over four years. Polypharmacy was defined as the intake of ≥5 medications. Descriptive statistics of SRH-change categories stratified by polypharmacy status were reported. The association of polypharmacy with being in SRH change categories was assessed using multinomial regression analysis. At baseline, mean age was 79.1 (6.1) years, 54.0% were females, and prevalence of polypharmacy was 47.1%. Participants with polypharmacy were older and had more comorbidities compared to those without polypharmacy. Over four years, five SRH-change categories were identified. After covariate adjustment, individuals with polypharmacy had higher odds of being in the stable moderate category (OR 3.55; 95% CI [2.43-5.20]), stable low category (OR 3.32; 95% CI [1.65-6.70]), decline category (OR 1.87; 95% CI [1.34-2.62]), and improvement category (OR 2.01; [1.33-3.05]) compared to being in the stable high category independent of the number of comorbidities. Reducing polypharmacy could be an impactful strategy to foster favorable SRH progression in old age.

Age and the Course of GFR in Persons Aged 70 and Above

BACKGROUND AND OBJECTIVES

In older adults, data on the age-related course of GFR are scarce, which might lead to misjudgment of the clinical relevance of reduced GFR in old age.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

To describe the course of eGFR in older adults and derive reference values in population-based individuals, we used the longitudinal design of the Berlin Initiative Study (BIS) with a repeated estimation of GFR over a median of 6.1 years of follow-up. In 2069 community-dwelling older individuals (mean inclusion age 80 years, range 70-99), GFR was estimated biennially with the BIS-2 equation, including standardized creatinine and cystatin C levels, sex, and age. We described the crude and adjusted course using a mixed-effects model and analyzed the influence of death on the GFR course applying joint models. GFR slopes were compared using GFR equations on the basis of creatinine and/or cystatin C.

RESULTS

We observed a decreasing, thus nonlinear, eGFR decline with increasing age in a population of old adults. The estimated 1-year slope for ages 75 and 90 diminished for men from -1.67 to -0.99 and for women from -1.52 to -0.97. The modeled mean eGFR for men aged ≥79 and women ≥78 was below 60 ml/min per 1.73 m². Multivariable adjustment attenuated slopes only minimally. Taking death into account by applying joint models did not alter the nonlinear eGFR decline. Using eGFR equations on the basis of creatinine only showed linear slope patterns in contrast to nonlinear patterns for equations including cystatin C.

CONCLUSIONS

The eGFR decline depended on sex and age and changed only marginally after multivariable adjustment but decelerated with increasing age. Equations including cystatin C demonstrated a nonlinear slope challenging the previously assumed linearity of the decline of eGFR in old age.

MO195: Kidney Function and the Risk of Heart Failure Among Older Adults: A Prospective Population-Based Cohort Study

BACKGROUND AND AIMS

Decreased kidney function is an established risk factor of cardiovascular morbidity including heart failure (HF) as well as cardiovascular and all-cause mortality among adults. However, the role of decreased kidney function with regard to these outcomes among old and very old adults remains poorly understood. This is an important knowledge gap given the common decline of kidney function in advanced age, which can affect both healthy individuals and patients with significant morbidity. To this end, we conducted a population-based study to assess whether decreased kidney function is associated with an increased risk of HF, cardiovascular and all-cause mortality in a prospective cohort of community-dwelling older adults.

METHOD

We included participants of the Berlin Initiative Study (BIS), age ≥70 years, with estimated glomerular filtration rate (eGFRBIS2) at baseline (between 2009 and 2011) and information on prior diagnosis of HF. Participants were followed from baseline until the occurrence of one of the study outcomes (see below) or December 2020, the latest date of data availability. Potential confounders included demographic characteristics, anthropometrics (body mass index), lifestyle factors (alcohol consumption, smoking, physical exercise), proxies of socioeconomic status (education, income), medications (major classes of antihypertensive drugs, oral anticoagulants, antiplatelet agents), and comorbidities measured at baseline using face-to-face interviews and administrative healthcare data. The three study outcomes were hospitalization for HF (HHF), cardiovascular death and all-cause mortality. HHF was defined based on inpatient diagnostic codes, and the mortality outcomes were defined based on a combination of administrative healthcare data, death certificates and hospital discharge notes. Cox proportional hazards models estimated hazard ratios (HRs) with 95% confidence intervals (CIs) of the three outcomes associated with decreased kidney function (eGFRBIS2 &lt; 60 mL/min/1.73 m2) compared with retained kidney function (eGFRBIS2 ≥ 60 mL/min/1.73 m2). Analyses were repeated among BIS participants with prior HF.

RESULTS

Our study cohort included 1466 HF free older adults (mean age 79 years; 55% female). Compared with retained kidney function, decreased kidney function was associated with increased risks of HHF (crude incidence rates per 100/year: 2.7 versus 1.1; adjusted HR, 1.48; 95% CI, 1.06–2.07), cardiovascular death (crude incidence rates per 100/year: 2.7 versus 0.9; adjusted HR, 1.49; 95% CI, 1.06–2.09), and all-cause mortality (crude incidence rates per 100/year: 6.3 versus 2.8; adjusted HR, 1.27; 95% CI, 1.03–1.57). Kaplan-Meier curves for the three study outcomes are shown in Figure 1. Among the 590 older adults with prior HF (mean age 83 years; 54% female), the effect estimates were similar albeit less precise (HHF: HR, 1.32; 95% CI, 0.88–1.98/cardiovascular death: HR, 1.67; 95% CI, 1.06–2.63/all-cause mortality: HR, 1.22; 95% CI, 0.91–1.63).

CONCLUSION

Our population-based study showed that decreased kidney function is associated with increased risks of cardiovascular morbidity and cardiovascular and all-cause mortality among older adults, corroborating findings in younger populations.

MO510: CKD Progression in a Cohort of Older Community-Dwelling Adults– Results From the Berlin Initiative Study (BIS)

BACKGROUND AND AIMS

Data on the estimated glomerular filtration rate (eGFR) over time in older populations are scarce. Identifying patterns of eGFR progression is essential for a better understanding of chronic kidney disease (CKD) in older adults.

METHOD

We used data from the BIS, a community-dwelling cohort of 2069 people aged 70 or older. Participants were recruited between 2009 and 2011. After baseline assessment, four follow-up visits were conducted biennially over a total observation period of 8 years. During all study visits, eGFR and CKD stages based on KIDGO guidelines were assessed using the creatinine and cystatin C-based BIS2 equation (eGFRBIS2). Additionally, we used the creatinine-based EKFC equation (eGFREKFC). In a sub-analysis, we included only non-deceased participants with complete attendance at all study visits and valid eGFR values at all measurements.

RESULTS

At baseline, the mean age was 80.4 years (SD = 6.7), and 52.6 % were females. Prevalence was highest for CKD stage 2 (45.4%) and 3 (49.3%). After 8 years, the prevalence for CKD stages 1 and 2 decreased, whereas stages 3 and 4 showed a consistent upward trend resulting in 18.4%,  72.4% and 8.9% of participants in stages 2, 3 and 4, respectively. Mean eGFRBIS2 decreased from 58.1 (SD = 15.2) to 48.3 (SD = 13.3) mL/min/1.73 m² after 8 years. Mean eGFREKFC showed a similar trend with estimates being slightly higher (60.4 versus 54.2 mL/min/1.73 m2 after 8 years).

Same trends applied to the subgroup with complete attendance (mean age: 77.4 years). However, compared with the total population they showed a higher mean eGFRBIS2 (63.3 versus 58.1 mL/min/1.73 m²) and lower prevalence of CKD stages 3 and 4 (stage 2: 59.4 versus 45.4%; stage 3: 37.1 versus 49.3% stage 4: 1.2 versus 3.6%) at baseline.

CONCLUSION

We found that over the observation period of 8 years, mean eGFRBIS2 decreased by 9.8 mL/min/1.73 m2 resulting in an increasing prevalence of CKD stages 3 and 4 by 23.1 and 5.3%, respectively. This was observed in the total population as well as in the subgroup with complete study attendance.

MO373: How to Decide Whether Creatinine or Cystatin C is More Accurate for Kidney Function Assessment in Older Adults

BACKGROUND AND AIMS

The gold standard for evaluation of kidney function is measured GFR [mGFR] which is challenging to perform in clinical practice. Serum creatinine and cystatin C are used to estimate GFR clinically, but neither is a perfect marker. Within any given individual, the estimated glomerular filtration rate (eGFR) can be widely different when using serum creatinine [eGFRCr] vs. cystatin C [eGFRCys]. We investigated which was closest to mGFR in elderly outpatients when results between these two eGFRs were discrepant.

METHOD

About 657 older ambulatory participants of the population-based Berlin Initiative Study (BIS) had GFR measured by iohexol plasma clearance (mGFR), as well as serum creatinine and cystatin C levels. eGFRCr and eGFRCys were calculated using the 2009 and 2012 CKD-EPI equations, respectively. The cohort was divided into two groups based on which of these eGFR estimates was lowest. Bias (defined as ‘eGFR-mGFR’), imprecision (standard deviation [interquartile range] of bias), as well as proportion within 30% (P30) were calculated.

RESULTS

Mean (±SD) age was 78 (±6) years, eGFRCys was 59 (±23), mean eGFRCr was 64 (±20) and mGFR was 55 (±20) mL/min/1.73 m2. Mean (±SD) body mass index was 28 (4) kg/m2 58% were men, and 26% had diabetes mellitus. Two-thirds of participants (448/657 = 68%) had eGFRCys &lt; eGFRCr. Regardless of which group participants were in, the lower of the two eGFR estimates was the one less biased compared to mGFR. Among those in whom eGFRCr ≤ eGFRCys, 80% (=168/209) had eGFRCr closer to mGFR than eGFRCys; among those in whom eGFRCys &lt; eGFRCr, 74% (=333/448) had eGFRCys closer to mGFR than eGFRCr (Figure). P30 was 86% for eGFRCr when it was the lower estimate, and was 90% for eGFRCys when it was the lower estimate (Table).

CONCLUSION

In a population of community-dwelling older adults, the lower value between eGFRCys and eGFRCr was closest to mGFR in 76% of participants.

Control of blood pressure in older patients with heart failure and the risk of mortality: a population-based prospective cohort study

BACKGROUND

treatment goals for blood pressure (BP) lowering in older patients with heart failure (HF) are unclear.

OBJECTIVE

to assess whether BP control < 140/90 mmHg is associated with a decreased risk of mortality in older HF patients.

DESIGN

population-based prospective cohort study.

SETTING/SUBJECTS

participants of the Berlin Initiative Study, a prospective cohort of community-dwelling older adults launched in 2009. Clinical information was obtained in face-to-face interviews and linked to administrative healthcare data.

METHODS

Cox proportional hazards models estimated adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) of cardiovascular death and all-cause mortality associated with normalised BP (systolic BP < 140 mmHg and diastolic BP < 90 mmHg) compared with non-normalised BP (systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg) in HF patients. The primary analysis considered only baseline BP ('time-fixed'); an additional analysis updated BP during follow-up ('time-dependent').

RESULTS

at baseline, 544 patients were diagnosed with HF and treated with antihypertensive drugs (mean age 82.8 years; 45.4% female). During a median follow-up of 7.5 years and compared with non-normalised BP, normalised BP was associated with similar risks of cardiovascular death (HR, 1.24; 95% CI, 0.84-1.85) and all-cause mortality (HR, 1.16; 95% CI, 0.89-1.51) in the time-fixed analysis but with increased risks of cardiovascular death (HR, 1.79; 95% CI, 1.23-2.61) and all-cause mortality (HR, 1.48; 95% CI, 1.15-1.90) in the time-dependent analysis.

CONCLUSIONS

BP control < 140/90 mmHg was not associated with a decreased risk of mortality in older HF patients. The increased risk in the time-dependent analysis requires further corroboration.

FC 046INCIDENCE OF NOSOCOMIAL ACUTE KIDNEY INJURY (AKI) IN A COHORT OF COMMUNITY-DWELLING OLDER ADULTS OVER 8 YEARS OF OBSERVATION

Background and Aims

Acute kidney injury (AKI) is amongst the most common in-hospital complications especially in old age. Epidemiological data on incidence rates (IR) of nosocomial AKI in individuals aged 70+ years, stratified by age, gender and pre-existing diseases are scarce because older adults are usually underrepresented in clinical research.

Method

We used data from the Berlin Initiative Study (BIS), a longitudinal, population-based cohort of adults aged ≥70 with biennial follow-up visits (including blood and urine tests) in combination with claims data from the AOK Nordost insurance fund to complement information on diagnoses and in-hospital procedures (based on ICD-10 and OPS coding). Nosocomial AKI was defined as documented in-hospital diagnosis (ICD-10: N17.xx) excluding cases with AKI as admission diagnosis. Incidence rates (IR) and 95% confidence intervals (CI) of the first nosocomial AKI were calculated with the number of incident cases during observation divided by the total person-years of follow-up, for AKI cases truncated at the first incidence of nosocomial AKI. IR are reported by age strata, sex and preexisting diseases (diabetes, arterial hypertension, atrial fibrillation, heart failure, angina pectoris, peripheral artery disease and impaired kidney function).

Results

In 2020 individuals (mean age 80.5 years; 52.6% women), 383 developed nosocomial AKI over the median [IQR] follow up time of 8.8 [5.9-9.3] years (Fig.1). The IR of nosocomial AKI was 26.8 (95%CI 24.1-29.6) per 1000 person years among all patients, with higher IR in men compared to women, and - when stratified by age - lowest IR in age category 70-75 versus the highest IR in age category of ≥ 90 years (Fig.1).

Conclusion

Nosocomial AKI is an in-hospital complication common in older adults with IRs rising continuously with age above the age of 70 years. IR of AKI are considerably higher in patients with cardiovascular comorbidities. A better understanding of the patient population at risk is of great clinical relevance when aiming to improve prevention strategies.

Kidney Function as Risk Factor and Predictor of Cardiovascular Outcomes and Mortality Among Older Adults

RATIONALE & OBJECTIVE

Estimated glomerular filtration rate (eGFR) and urinary albumin-creatinine ratio (UACR) are associated with cardiovascular events in the general population but their utility among older adults is unclear. We investigated the associations of eGFR and UACR with stroke, myocardial infarction (MI), and death among older adults.

STUDY DESIGN

Population-based cohort study.

SETTING & PARTICIPANTS

1,581 participants (aged≥70 years) in the Berlin Initiative Study (BIS) without prior stroke or MI.

EXPOSURES & PREDICTORS

Serum creatinine- and cystatin C-based eGFR, UACR categories, and measured GFR (n=436).

OUTCOMES

Stroke, MI, and all-cause mortality.

ANALYTICAL APPROACH

HRs and 95% CIs derived from multivariable-adjusted Cox proportional hazards models for association analyses. Net reclassification improvement (NRI) and C statistic differences comparing the predictive benefit of kidney measures with a traditional cardiovascular risk model.

RESULTS

During a median follow-up of 8.2 years, 193 strokes, 125 MIs, and 531 deaths occurred. Independent of UACR, when GFR was estimated using the creatinine- and cystatin C-based BIS equation, eGFR of 45 to 59mL/min/1.73m² (vs eGFR>60mL/min/1.73m²) was associated with stroke (HR, 2.23; 95% CI, 1.55-3.21) but not MI or all-cause mortality. For those with eGFR<45mL/min/1.73m², the HRs were 1.99 (95% CI, 1.23-3.20) for stroke, 1.38 (95% CI, 0.81-2.36) for MI, and 1.57 (95% CI, 1.20-2.06) for mortality. Compared with UACR<30mg/g, UACR of 30 to 300mg/g was not associated with stroke (HR, 0.91; 95% CI, 0.63-1.33) but was associated with MI (HR, 1.65; 95% CI, 1.09-2.51) and all-cause mortality (HR, 1.63; 95% CI, 1.34-1.98). Prediction analysis for stroke showed significant positive NRI for eGFR calculated using the cystatin C-based Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation and the creatinine- and cystatin C-based BIS and Full Age Spectrum equations. UACR demonstrated significant positive NRIs for MI and mortality.

LIMITATIONS

eGFR and UACR categorization based on single assessments; lack of cause-specific death data.

CONCLUSIONS

eGFR of 45 to 59mL/min/1.73m² without albuminuria was associated with stroke but not MI or all-cause mortality in older adults. In contrast, UACR of 30 to 300mg/g was associated with MI and all-cause mortality but not with stroke. Furthermore, cystatin C-based eGFR improved risk prediction for stroke in this cohort of older adults.

P0154BLOOD PRESSURE CONTROL IN ELDERLY PATIENTS WITH HEART FAILURE AND MORTALITY RISK: A POPULATION-BASED PROSPECTIVE COHORT STUDY

Background and Aims

Current guidelines on the management of heart failure (HF) recommend control of blood pressure (BP) in elderly patients. However, the exact treatment goals in this vulnerable population are unclear. Thus, our population-based prospective cohort study aimed to assess whether BP values &lt;140/90 mmHg are associated with a decreased risk of cardiovascular (CV) death and all-cause mortality in HF patients ≥70 years.

Method

The study included participants of the Berlin Initiative Study (BIS), all ≥70 years, who were treated with antihypertensive drugs and had a diagnosis of HF (ICD-10 codes: I11.0, I13.0, I13.2, I50.x) at baseline. The study period was from 2009 to 2017. Demographics, lifestyle factors, medications, and comorbidities were assessed in face-to-face interviews and from linked administrative healthcare data. Outcomes were adjudicated using death certificates and hospital discharge notes. Cox proportional hazards models yielded crude and adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) of CV death and all-cause mortality associated with normalized BP (systolic BP &lt;140 mmHg and diastolic BP &lt;90 mmHg) compared with non-normalized BP (systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg) in patients with HF. In sensitivity analyses we restricted to high-risk HF patients (≥80 years or with previous CV events). We also repeated the analyses in patients without HF to assess a potential effect modification.

Results

Among 1623 BIS participants treated with antihypertensive drugs at baseline, 544 (33.5%) had a diagnosis of HF. Of those, 255 (46.9%) showed normalized BP and 289 (53.1%) had non-normalized values. Mean age (standard deviation [SD]) was 82.8 (6.8) years (45.4% female). Selected patient characteristics are shown in the Table. Median (interquartile range) duration of follow-up was 6.7 (4.1-7.3) years. Compared with non-normalized BP, normalized BP was associated with a numerically increased risk of CV death (HR, 1.40; 95% CI, 0.90-2.17) and all-cause mortality (HR, 1.28; 95% CI, 0.96-1.71) in patients with HF. The associations were more pronounced or reached statistical significance when restricting to HF patients ≥80 years (CV death: HR, 1.54; 95% CI, 0.94-2.53 / all-cause mortality: HR, 1.56; 95% CI, 1.11-2.18) or HF patients with previous CV events (CV death: HR, 1.65; 95% CI, 0.83-3.29 / all-cause mortality: HR, 1.33; 95% CI, 0.85-2.07) (Figure). The effect estimates in patients without HF were comparable to those with HF (CV death: HR, 1.18; 95% CI, 0.78-1.78; p for interaction, 0.695 / all-cause mortality: HR, 1.20; 95% CI, 0.93-1.54; p for interaction, 0.604).

Conclusion

Our study suggests that normalized BP does not decrease the risk of CV death or all-cause mortality in elderly patients with HF and it could even increase the risk especially in high-risk subgroups. Thus, individualized benefit-risk assessment is required for the pharmacotherapy of HF in this vulnerable population.

Correction: Performance of risk prediction scores for cardiovascular mortality in older persons: External validation of the SCORE OP and appraisal

[This corrects the article DOI: 10.1371/journal.pone.0231097.].

Self-reported medication in community-dwelling older adults in Germany: results from the Berlin Initiative Study

Background

Older adults have the highest drug utilization due to multimorbidity. Although the number of people over age 70 is expected to double within the next decades, population-based data on their medication patterns are scarce especially in combination with polypharmacy and potentially inappropriate medication (PIM). Our objective was to analyse the frequency of polypharmacy, pattern of prescription (PD) and over-the-counter (OTC) drug usage, and PIMs according to age and gender in a population-based cohort of very old adults in Germany.

Methods

Cross-sectional baseline data of the Berlin Initiative Study, a prospective cohort study of community-dwelling adults aged ≥70 years with a standardized interview including demographics, lifestyle variables, co-morbidities, and medication assessment were analysed. Medication data were coded using the Anatomical Therapeutic Chemical (ATC) classification. Age- and sex-standardized descriptive analysis of polypharmacy (≥5 drugs, PD and OTC vs. PD only and regular and on demand drugs vs regular only), medication frequency and distribution, including PIMs, was performed by age (</≥80) and gender.

Results

Of 2069 participants with an average age of 79.5 years, 97% (95%CI [96%;98%]) took at least one drug and on average 6.2 drugs (SD = 3.5) with about 40 to 66% fulfilling the criteria of polypharmacy depending on the definition. Regarding drug type more female participants took a combination of PD and OTC (male: 68%, 95%CI [65%;72%]); female: 78%, 95%CI [76%;80%]). Most frequently used were drugs for cardiovascular diseases (85%, 95%CI [83%;86%]). Medication frequency increased among participants aged ≥80 years, especially for cardiovascular drugs, antithrombotics, psychoanaleptics and dietary supplements. Among the top ten prescription drugs were mainly cardiovascular drugs including lipid-lowering agents (simvastatin), beta-blockers (metoprolol, bisoprolol) and ACE inhibitors (ramipril). The most common OTC drug was acetylsalicylic acid (35%; 95%CI [33%;37%])). Dose-independent PIM were identified for 15% of the participants.

Conclusions

Polypharmacy was excessive in older adults, with not only PD but also OTC drugs contributing to the high point prevalence. The medication patterns reflected the treatment of chronic diseases in this age group. There was even an increase in medication frequency between below and above 80 years especially for drugs of cardiovascular diseases, antithrombotic medication, psychoanaleptics, and dietary supplements.

Photochemical mechanism of DEACM uncaging: a combined time-resolved spectroscopic and computational study

Combined spectroscopic and computational studies elucidate excited-state photocleavage in DEACM cages, explaining vastly different time scales for different leaving groups.

Control of blood pressure and risk of mortality in a cohort of older adults: the Berlin Initiative Study

Aims

To assess whether blood pressure (BP) values below 140/90 mmHg during antihypertensive treatment are associated with a decreased risk of all-cause mortality in community-dwelling older adults.

Methods and results

Within the Berlin Initiative Study, we assembled a cohort of patients ≥70 years treated with antihypertensive drugs at baseline (November 2009–June 2011). End of prospective follow-up was December 2016. Cox proportional hazards models yielded adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of all-cause mortality associated with normalized BP [systolic BP (SBP) <140 mmHg and diastolic BP (DBP) <90 mmHg] compared with non-normalized BP (SBP ≥140 mmHg or DBP ≥90 mmHg) overall and after stratification by age or previous cardiovascular events. Among 1628 patients (mean age 81 years) on antihypertensive drugs, 636 exhibited normalized BP. During 8853 person-years of follow-up, 469 patients died. Compared with non-normalized BP, normalized BP was associated with an increased risk of all-cause mortality (incidence rates: 60.3 vs. 48.5 per 1000/year; HR 1.26; 95% CI 1.04–1.54). Increased risks were observed in patients ≥80 years (102.2 vs. 77.5 per 1000/year; HR 1.40; 95% CI 1.12–1.74) and with previous cardiovascular events (98.3 vs. 63.6 per 1000/year; HR 1.61; 95% CI 1.14–2.27) but not in patients aged 70–79 years (22.6 vs. 22.7 per 1000/year; HR 0.83; 95% CI 0.54–1.27) or without previous cardiovascular events (45.2 vs. 44.4 per 1000/year; HR 1.16, 95% CI 0.90–1.48).

Conclusion

Blood pressure values below 140/90 mmHg during antihypertensive treatment may be associated with an increased risk of mortality in octogenarians or elderly patients with previous cardiovascular events.

Picosecond activation of the DEACM photocage unravelled by VIS-pump-IR-probe spectroscopy

The light-induced ultrafast uncaging process of the [7-(diethylamino)coumarin-4-yl]methyl (DEACM) cage is measured by time-resolved visible-pump-infrared-probe spectroscopy, and supported by steady-state absorption spectroscopy in the visible and infrared spectral regions. Understanding the uncaging process is important because its favorable properties make DEACM an interesting case for chemical and biological applications. It has a convenient absorption in the visible spectral range, and is relatively easily modified to carry leaving groups (LGs) such as nucleotides, substrates or inhibitors, which are inactive when bound and active when released. Previous work suggested a lower limit for the uncaging rate, which places it among the fastest available cages. Here, we determine the photodissociation directly to occur on the picosecond time scale by monitoring the appearance of the released LG in the infrared spectral region. In the present study, azide (N₃) is chosen as an LG to monitor photodissociation because its vibrational mode is spectrally isolated (hence easy to follow) and its absorption wavenumber is sensitive to local structural rearrangements. The uncaging process is recorded up to 3 nanoseconds and compared to the collected steady-state spectra. The free LG appears on a picosecond time scale, rendering this one of the fastest known cages. No evidence is found for a tight-ion pair (TIP) preceding the free LG. The uncaging mechanism is found to be slowed down upon the addition of water to acetonitrile.

Prevalence of reduced kidney function and albuminuria in older adults: the Berlin Initiative Study

Background

Although CKD is said to increase among older adults, epidemiologic data on kidney function in people ≥70 years of age are scarce. The Berlin Initiative Study (BIS) aims to fill this gap by evaluating the CKD burden in older adults.

Methods

The BIS is a prospective population-based cohort study whose participants are members of Germany's biggest insurance company. This cross-sectional analysis (i) gives a detailed baseline characterization of the participants, (ii) analyses the representativeness of the cohort's disease profile, (iii) assesses GFR and albuminuria levels across age categories, (iv) associates cardiovascular risk factors with GFR as well as albuminuria and (v) compares means of GFR values according to different estimating equations with measured GFR.

Results

A total of 2069 participants (52.6% female, mean age 80.4 years) were enrolled: 26.1% were diabetic, 78.8% were on antihypertensive medication, 8.7% had experienced a stroke, 14% a myocardial infarction, 22.6% had cancer, 17.8% were anaemic and 26.5% were obese. The distribution of comorbidities in the BIS cohort was very similar to that in the insurance 'source population'. Creatinine and cystatin C as well as the albumin:creatinine ratio (ACR) increased with increasing age. After multivariate adjustments, reduced GFR and elevated ACR were associated with most cardiovascular risk factors. The prevalence of a GFR <60 mL/min/1.73 m 2 ranged from 38 to 62% depending on the estimation equation used.

Conclusions

The BIS is a very well-characterized, representative cohort of older adults. Participants with an ACR ≥30 had significantly higher odds for most cardiovascular risk factors compared with an ACR <30 mg/g. Kidney function declined and ACR rose with increasing age.

Beta Trace Protein does not outperform Creatinine and Cystatin C in estimating Glomerular Filtration Rate in Older Adults

Despite intense research the optimal endogenous biomarker for glomerular filtration rate (GFR) estimation has not been identified yet. We analyzed if ß-trace protein (BTP) improved GFR estimation in elderly. 566 participants aged 70+ from the population-based Berlin Initiative Study were included in a cross-sectional validation study. BTP, standardized creatinine and cystatin C were measured in participants with iohexol clearance measurement as gold standard method for measured GFR (mGFR). In a double logarithmic linear model prediction of mGFR by BTP was assessed. Analyses with BTP only and combined with creatinine and cystatin C were performed. Additionally, performance of GFR estimating equations was compared to mGFR. We found that the combination of all three biomarkers showed the best prediction of mGFR (r² = 0.83), whereat the combination of creatinine and cystatin C provided only minimally diverging results (r² = 0.82). Single usage of BTP showed worst prediction (r² = 0.67) within models with only one biomarker. Subgroup analyses (arterial hypertension, diabetes, body mass index ≤23 and >30) demonstrated a slight additional benefit of including BTP into the prediction model for diabetic, hypertensive and lean patients. Among BTP-containing GFR equations the Inker BTP-based equation showed superior performance. Especially the use of cystatin C renders the addition of BTP unnecessary.

Eukaryotic initiation factor 2alpha phosphorylation is required for B-cell maturation and function in mice

BACKGROUND

The control of translation initiation is a crucial component in the regulation of gene expression. The eukaryotic initiation factor 2α (eIF2α) mediates binding of the initiator transfer-messenger-RNA to the AUG initiation codon, and thus controls a rate-limiting step in translation initiation. Phosphorylation of eIF2α at serine 51 is linked to cellular stress response and attenuates translation initiation. The biochemistry of translation inhibition mediated by eIF2α phosphorylation is well characterized, yet the physiological importance in hematopoiesis remains only partially known.

DESIGN AND METHODS

Using hematopoietic stem cells carrying a non-phosphorylatable mutant form of eIF2α (eIF2αAA), we examined the efficiency of reconstitution in wild-type and B-cell-deficient microMT C57BL/6 recipients in two independent models.

RESULTS

We provide evidence that phosphorylation-deficient eIF2α mutant hematopoietic stem cells may repopulate lethally irradiated mice but have a defect in the development and maintenance of newly formed B cells in the bone marrow and of naïve follicular B cells in the periphery. The mature B-cell compartment is markedly reduced in bone marrow, spleen and peripheral blood, and B-cell receptor-mediated proliferation in vitro and serum immunoglobulin secretion in vivo are impaired.

CONCLUSIONS

The data suggest that regulation of translation through eIF2α phosphorylation is dispensable in hematopoietic reconstitution but essential during late B-cell development.

Double-stranded RNA pattern and partial sequence data indicate plant virus infection associated with the ringspot disease of European mountain ash (Sorbus aucuparia L.)

Double-stranded RNA (dsRNA) has been extracted from tissue of European mountain ash trees (Sorbus aucuparia L.) showing typical ringspot and mottling symptoms on leaves and a gradual decay in general. A characteristic dsRNA pattern was found in leaf samples of symptomatic mountain ash trees from various stands in Germany. Bands of dsRNA molecules of approximately 7 kb, 2.3 kb, 1.5 kb, and 1.3 kb, respectively, were repeatedly detected. By random primed reverse transcription cDNA was synthesised from dsRNA and amplified by degenerate oligonucleotide primed PCR. After TA cloning, the cDNA clones obtained were screened with an enhanced-chemiluminescence-labelled dsRNA probe. Positive clones were further analysed by using them as hybridisation probes in Northern blots of total plant RNA and in Southern hybridisation with genomic DNA from Sorbus aucuparia leaves. From cDNA clones that were found to be specific for dsRNA in Northern analysis, primers were deduced for 5'-RACE analyses and further cloning. Finally, a cDNA fragment of 3,737 bp was obtained, which showed homology to viral proteins, particularly to the RNA-dependent RNA polymerase of members of the family Bunyaviridae, but without high similarity to a known genus. The dsRNA pattern and the sequence information strongly indicate a virus associated with the mountain ash ringspot disease. The putative virus remains still unidentified.