Impact of Sodium-Glucose Cotransporter-2 Inhibitors in the Management of Chronic Kidney Disease: A Middle East and Africa Perspective

Chronic kidney disease (CKD) is a major public health concern in the Middle East and Africa (MEA) region and a leading cause of death in patients with type 2 diabetes mellitus (T2DM) and hypertension. Early initiation of sodium-glucose cotransporter - 2 inhibitors (SGLT-2i) and proper sequencing with renin-angiotensin-aldosterone system inhibitors (RAASi) in these patients may result in better clinical outcomes due to their cardioprotective properties and complementary mechanisms of action. In this review, we present guideline-based consensus recommendations by experts from the MEA region, as practical algorithms for screening, early detection, nephrology referral, and treatment pathways for CKD management in patients with hypertension and diabetes mellitus. This study will help physicians take timely and appropriate actions to provide better care to patients with CKD or those at high risk of CKD.

Inhibition of Proprotein Convertase Subtilisin/Kexin-9 After Kidney Transplant: Single-Center Experience Among Patients With High Cardiovascular Risk

OBJECTIVES

The benefits of reduction in low-density lipoprotein cholesterol by evolocumab by nearly 60% has not been evaluated among kidney transplant recipients to our knowledge. We assessed the efficacy and safety of evolocumab, a proprotein convertase subtilisin/kexin-9 inhibitor, in reducing lipids and cardiovascular events among kidney transplant recipients in a randomized controlled study.

MATERIALS AND METHODS

Between June 2017 and June 2019, we enrolled 197 kidney transplant recipients with high cardiovascular risk score (>20). Patients who received evolocumab (140 mg/2 weeks) comprised group 1 (n = 98), and patients maintained on statin therapy comprised group 2 (n = 99). We followed patients clinically and with necessary laboratory investigations over 24 months.

RESULTS

The 2 groups had comparable demographic characteristics (P > .05). Before enrollment in the study, smokers were significantly more prevalent in group 1, whereas posttransplant diabetes mellitus was more prevalent in group 2 (P = .033). Moreover, baseline serum creatinine was higher in group 1, whereas immunosuppression was equivalent in both groups (P > .05). We found no significant differences between the 2 groups concerning cardiovascular events, and both graft and patient outcomes were comparable (P > .05). The higher baseline cholesterol in group 1 (5.5 vs 4.7 mmol/L; P < .001) decreased significantly after 3 months and thereafter (P = .031) compared with levels in group 2 and baseline values (P < .001). We reported 2 cases of acute myocardial infarction and 1 atrial fibrillation in group 2.

CONCLUSIONS

Proprotein convertase subtilisin/kexin-9 inhibitors, as an added therapy to statins, are safe and effective in treating hypercholesterolemia after kidney transplant. Evolocumab can minimize cardiovascular events after kidney transplant in patients with high events at baseline. Longer-term trials with larger number of patients are needed to confirm its beneficial effects on cardiovascular complications and patient and graft survival.

Contrast-induced Nephropathy in Kidney Transplant Recipients: A Single-center Experience

INTRODUCTION

Data regarding contrast-induced nephropathy (CIN) in kidney transplant (KT) recipients are scarce despite the distinct risk factors such as the use of immunosuppressive agents, sympathetic denervation, glomerular hyperfiltration, and high prevalence of the cardiovascular disease. This study aimed to determine the prevalence of CIN in KT recipients who received low-osmolality iodine-based contrast material (CM) for radiological assessment.

METHODS

Between 2010 and 2020, 79 of the 3180 KT recipients followed at Hamed Al-Essa organ transplant center received low-osmolality iodine-based contrast for radiological assessment for various indications. Preventive measures including holding metformin, intravenous hydration, sodium bicarbonate and N-acetylcysteine were given before contrast administration. CIN was defined as an increase in serum creatinine of 25% from the baseline within 72 hours.

RESULTS

The enrolled patients were divided into two groups: those who developed CIN (n = 7) and those with no increase in serum creatinine level (n = 72). The mean age of the patients was 52.1 ± 12.3 years; 44 of them were males, and the cause of end-stage kidney disease was mostly diabetic nephropathy. The pre-transplant demographics were comparable between the two groups. Fortyseven cases received contrast for coronary angiography, and 32 received it for a CT scan. The graft function deteriorated in group 1, but no significant difference was found between the two groups at the end of the study.

CONCLUSION

CIN is not uncommon in KT recipients receiving CM, especially with ischemic heart disease. Risk stratification, optimizing hemodynamics, and avoiding potential nephrotoxins are essential before performing CM-enhanced studies in KT recipients.  DOI: 10.52547/ijkd.7165.

MO972: Impact of Inhibition of Pcsk-9 Among Renal Transplant Recipients with High Cardiovascular Risk

BACKGROUND AND AIMS

Monoclonal antibodies inhibiting proprotein convertase subtilisin/Kexin type A(PCSK-9) have emerged as one of the new cholesterol-lowering agents. It is not evaluated among renal transplant recipients despite its favorable safety profile. We aimed to evaluate the safety and efficacy of evolocumab in reducing lipids and cardiovascular events among risky renal transplant recipients. 

METHOD

About 195 kidney transplant recipients—with high cardiovascular risk (&gt;20)—were enrolled in this randomized controlled study during the period between 6.2017 and 6.2018. Patients who received statin and evolocumab (140 mg/2 weeks, group 1, n = 97) while those who were maintained on statin alone comprised group 2 (n = 98). They were followed up for 24 months.

RESULTS

The two groups were comparable regarding their demographics (P  &gt; 0.05). Before enrollment in the study, post-transplant complications were comparable apart from a higher prevalence of NODAT in group 2 (P = 0.033). Smokers were significantly more prevalent in group 1. Basal graft function was significantly higher in group 1 despite equivalent regimen of immunosuppression in both groups (P  &gt; 0.05). Clinically two groups were comparable concerning cardiovascular events and both graft and patient outcomes (P  &gt; 0.05). Basal cholesterol was significantly higher in group 1 (5.5 versus 4.7, P  &lt; 0.001) which dropped significantly after 3 months (versus12 months in group 2) and thereafter (P = 0.031). We observed that triglycerides in the two groups were comparable (P  &gt; 0.05) till the end of the study.

CONCLUSION

Evolocumab is a promising add on lipid-lowering agent. In high risk renal transplant, earlier reduction of cholesterol was observed in the add-on evolocumab group but without significant positive cardiovascular impact.

MO297: Acute Kidney Injury Among COVID-19 Positive Patients is Associated With Higher Mortality: Single Center Experience

BACKGROUND AND AIMS

Despite the lungs are the major targets of COVID-19, other organs such as the kidneys are also affected. Renal complications of COVID-19 are not yet well studied. We aimed to study the prevalence of acute kidney injury (AKI) among positive COVID-19 cases that were managed in the intensive care unit (ICU) in a single isolation hospital during the pandemic, and to explore its impact on patient outcome.

METHOD

This retrospective study included 616 patients with COVID-19 who were managed in the ICU in a single isolation hospital in Kuwait during the pandemic, from February to December 2020. AKI was defined according to the serum creatinine criteria in the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. Of the 616 patients, 40.2% developed AKI (group 1, n = 248) and were compared with the patients without AKI (group 2, n = 368).

RESULTS

Most of cases in the two groups were males (73% versus 70.7%), aged (60.8 ± 14 versus 51.7 ± 16 years), respectively. The two groups were comparable regarding chronic kidney disease (2% versus 0.8%) and chronic pulmonary disease. Other factors were significantly predominating among group 1 as diabetes mellitus (63.7 versus 40.5%), hypertension (74.2% versus 40.5%) and ischemic heart disease (26.2% versus 12.5%) (P &lt; .05).

Fever, cough, shortness of breath and dehydration were significantly more frequent presentations among patients of group 1, and had radiological findings that were synchronized with COVID-19 (89.5% versus 50.8%) (P &lt; .05). Moreover, sepsis, volume depletion, shock, arrhythmias and ARDS predominated among the AKI group (P &lt; .05). The number of cases who were managed by therapeutic anticoagulation was significantly higher in AKI patients (89.9% versus 51.9%); also, cases who received supportive vasopressors and convalescent plasma transfusion as well as steroid were significantly higher in the same group (P &lt; .05). Other therapeutic modalities such as antivirals, tocilizumab and hydroxychloroquine were comparable in both groups.

We found that acute respiratory failure requiring mechanical ventilation was significant among the AKI group (66.8% versus 29.4%), and the overall mortality rate was significantly higher in the same group (62.5% versus 32.8%).

CONCLUSION

The prevalence of AKI in patients with COVID-19 was 40.2%, and it was associated with poor prognosis among ICU COVID-19 positive cases.

MO973: Optimization of Erythropoietin Stimulating Agents for Post-Transplant Anemia in Kidney Recipients: Prospective Randomized Controlled Trial

BACKGROUND AND AIMS

Many studies suggested that chronic allograft nephropathy might progress faster in patients with PTA, but whether full correction of anemia improves renal outcomes is unknown. We aimed to assess the impact of full correction of chronic anemia in renal transplant recipients with stable graft function on patient and graft outcome along one year follow-up.

METHOD

We enrolled 247 kidney recipients with stable graft function to be assessed for anemia. Eligible patients were randomized to achieve target hemoglobin between 11:12 g/dL (group 1, n = 183) or 13:15 g/dl (in group 2, n = 64) using erythropoietin receptor stimulating agents (ESA). Monthly clinical and laboratory evaluation of kidney graft function was carried out. Quality of life was assessed at the start and 12 months.

RESULTS

More females were found in group 1 (68.9%) versus (50%) in group 2 (P = 0.007), and the original disease was chronic glomerulonephritis (37.5%) followed by diabetic nephropathy (DN) (15.7%) in group 2; but DN patients predominate in group 1(P = 0.005). The studied groups were comparable regarding pretransplant comorbidities. Most patients received thymoglobulin as induction and most of them were maintained on cyclosporine. We did not find any significant difference between the two groups concerning posttransplant diabetes, BK viremia or malignancies (P  &gt; 0.05); however, better graft function was observed in group 2 at 6 months (P  &lt; 0.05). We found that required ESA doses were significantly higher in patients of group 1 from the sixth month. Group 1 showed higher mean blood pressure (P = 0.003) while group 2 showed higher mean albumin (P  &lt; 0.05). Graft outcome was comparable in both groups (P = 0.125), but mortality cases were significantly higher in group 1 (16 cases, 8.7%) (P = 0.005).

CONCLUSION

Full correction of PTA in renal transplant recipients had no positive impact on graft outcome but it was associated with better patient survival possibly due improved cardiovascular risk.

MO1001THE OUTCOME OF PLASMA CELL-RICH ACUTE REJECTION IN KIDNEY TRANSPLANTATION, IS IT REALLY POOR?

Background and Aims

The outcome of Plasma cell-rich acute rejection (PCAR) in kidney transplant is reported to be poor. However, PCAR which can be associated with any type of rejection, may not be considered as independent morphological prognostic feature. Different treatment modalities were prescribed with variable responses. We report here four cases of PCAR and describe their presentations, type of rejection, associated conditions and treatment outcome.

Method

Out of 1920 kidney transplant recipients under follow up in our centre from 1996 till 2019, four patients were reported to have PCAR according to 2007 Banff classification. They were re-evaluated based on 2015 Banff classification. The treatment protocol was tailored according to the type of rejection and associated conditions.

Results

The four patients, aged 28, 44, 46 and 54 years, had live unrelated renal transplant done somewhere abroad with no data about donor HLA typing. Two of them were females. One had high PRA and she was positive for HBsAg. One patient received induction immunosuppression with basiliximab. They all received prednisolone, mycophenolate and cyclosporine as the maintenance immunosuppression and had immediate graft function. Rejection happened between 23 to 180 months post-transplant. Two patients had acute T-cell mediated Banff 1A rejections with features consistent with early membranous nephropathy. One had acute T-cell mediated rejection Banff 1B and the fourth had borderline T-cell mediated rejection with morphological changes suggestive of chronic active antibody mediated rejection (AMR). Plasma cells constituted 10 to 30% of the interstitial infiltration. All patients received solumedrol pulse. Both patients with features of membranous nephropathy received rituximab and one of them had additionally IVIG. The patient with AMR received plasma exchange and IVIG. However, she did not receive rituximab as she was positive for HBsAg. All patients responded well to treatment and the mean improvement in eGFR was 12.8%, 24.9%, 40.3% and 39.1% at 1-, 3-, 6- and 12-months post treatment. Repeat kidney biopsy at 3 to 12 weeks post treatment showed resolution of plasma cell infiltration in all patients.

Conclusion

Outcome of PCAR management was favourable among our patients irrespective of the type of rejection and associated conditions.

Successful Management of Late-Onset Cytomegalovirus-Induced Hemophagocytic Lymphohistiocytosis in Kidney Transplant Recipient After Coronary Artery Bypass Graft Surgery

Hemophagocytic syndrome combines febrile hepatosplenomegaly, pancytopenia, hypofibrinemia, and hepatic dysfunction. It is characterized by bone marrow and organ infiltration of activated, nonmalignant macrophages that phagocytize blood cells. It is rare among renal transplant recipients. Here, we present the successful management of late-onset cytomegalovirusinduced hemophagocytic lymphohistiocytosis in a kidney transplant recipient after coronary artery bypass graft surgery. In 2012, our patient had end-stage kidney disease due to diabetic nephropathy and underwent related living-donor renal transplant. He was also hypertensive and hyperuricemic and had heart ischemia for which percutaneous coronary intervention for triple vessel disease was performed before transplant. In March 2017, he underwent successful aortic valve replacement and coronary artery bypass graft surgery; however, the patient had persistent thrombocytopenia. Heparin-induced thrombocytopenia was negative. His bone marrow showed hemophagocytosis possibly due to cytomegalovirus. Moreover, antiglycoprotein IIb/IIIA autoantibodies were positive. A positron emission tomography scan was negative for malignancy. He started treatment for cytomegalovirus with modifi cation of his immunosuppressive regimen (pulse steroid). Antiplatelet therapy was held and only resu med if platelet count exceeded 30000/L. Moreover, he received intravenous immunoglobulin and romiplostim treatment with partial response. Throughout treatment, he had stable kidney graft function with improving platelet count. A multi disciplinary approach is needed to treat patients with hemophagocytic syndrome, especially renal transplant recipients. Late-onset cytomegalovirus is an important cause for this syndrome.