MO977: Circulating CD14++CD16+MONocytes, NK Cells and LYMPHOcyte Subsets Correlate with Conventional and Novel Deformation Related Indices of Left Ventricular Function in Kidney Transplant Recipients with no Established Cardiovascular Disease

BACKGROUND AND AIMS

Kidney transplant recipients (KTRs) carry a significant burden of cardiovascular disease (CVD), despite improvement of patterns of left ventricular (LV) remodeling following kidney transplantation. Kidney allograft dysfunction and the immunosuppressed milieu play a major adverse role in myocardial structural changes in asymptomatic KTRs. An intricate relationship exists between immune system responses with heart failure syndromes, manifesting among others with aberrant activity and counts of proinflammatory CD16+monocytes, of natural killer (NK) cells and T regulatory cells (Tregs). The associations of immune cell subpopulations with subclinical markers of CVD remain to be determined in KTRs. The aim of our study was to investigate potential correlations between blood levels of specific immune cells subsets with conventional and novel deformation related indices of LV function in KTRs.

METHOD

31 stable KTRs (mean age 58 ± 9.28 years, 67% males, 13% diabetics) without established CVD were enrolled. Control population included 17 chronic kidney disease (CKD) stage 3 patients without history of CVD. Additional exclusion criteria were history of malignancy, autoimmune disease and active or chronic infections. The peripheral blood immune cell subsets CD14++CD16-, CD14++CD16+and CD14+CD16++ absolute values and percentages out of total monocytes and NK cells (CD3+CD16+56+), CD3-CD19+B lymphocytes, CD3+CD4+T cells, CD3+CD8+T cells and Tregs (CD4+CD25+FoxP3+) absolute values and percentages out of total lymphocytes were measured by flow cytometry. Simultaneously, conventional (left atrial volume index (LAVI), LV mass index (LVMI), E/E’) and novel 2D speckle tracking (2DST) echocardiographic indices of LV function [global longitudinal strain (GLS), global circumferential strain (GCS), global radial strain (GRS), TWIST AND UNTWIST] were assessed.

RESULTS

KTRs had a mean eGFR of 58 ± 18 mL/min/1.73 m2 (CKD-EPI) and mean 24-h proteinuria (PER) 707 ± -1185 mg/24 h. Total lymphocytes, B-cells, T-cells and CD8+T cells counts correlated positively with eGFR (P  < 0.05). Increased non-classical CD14+CD16++ monocytes were associated with proteinuria levels (P  < 0.01) whereas an inverse correlation was observed between the percentage of classical CD14++CD16- monocytes with PER (P < 0.05). When compared with CKD patients, KTRs displayed higher CD14++CD16- and lower CD14+CD16++ monocytes counts, a lower percentage of NK cells and T cells and lower Tregs (significant differences presented in Table 1). Regarding classical indices of LV function, increased total monocytes were associated with elevated LAVI (P  < 0.05), whereas an increased percentage of the intermediate CD14++CD16+monocytes correlated positively with an increased E/E’ value. Increased NK cells were associated with more negative GCS values (P  < 0.05). No significant correlations were observed between the rest immune cells with the classical or novel LV dysfunction indices.

CONCLUSION

Alterations of immune cells subsets correlate with subclinical markers of LV dysfunction in KTRs with no established CVD. Future research is required to evaluate the role of immune subpopulations as tools to identify KTRs who are at the highest risk for complications and guide interventions.

MO946: Factors Associated With Changes in Health-Related Quality of Life (Hrqol) in A Greek Cohort of Kidney Transplant Recipients: A Prospective Study

BACKGROUND AND AIMS

Kidney transplantation is recognized as the treatment of choice for patients with End Stage Kidney Disease (ESKD). Improvement in short term patient and graft survival of kidney transplant recipients (KTRs), has shifted interest to the long-term outcomes and Health-Related Quality of Life (HRQoL) estimation is closely related. Thus, reliable evaluation of HRQoL with disease-specific questionnaires is of great importance. The aim of our study was to assess prospectively possible changes in HRQoL during follow up period and to identify associated factors that might affect these changes.

METHOD

We used the Greek version of the translated and adapted by our team disease-specific instrument Kidney Transplant Questionnaire 25 (KTQ-25) and the Greek SF-36 were administered in a cohort of KTRs during their routine visit in the transplant outpatient clinic twice, at study entry and after one year. Sociodemographic and medical information were also collected at both time points. Inclusion criteria were, aged ≥18-year-old, time since transplant ≥1 year, functioning transplant. All participants provided written informed consent.

RESULTS

A total of 84 KTRs (59 males; mean age 53.5 ± 10.7; mean e-GFR 47.7 ± 15.1 mL/min/1.73 m2; average time since transplantation 55.7 ± 48.3 months) included in the study at the first time point, while 74 KTRs (88.1%) remained for the second assessment (3 died, 4 denied and 4 changed transplant unit). The majority of KTRs were married (73.8%), with children (77.4%), non-smokers (81.6%) and retired (60.7%). The 45.8% had family monthly income ≤ 1000€. In 62%, hemodialysis was the modality before transplantation and 59.52% had received graft from deceased donor. Immunosuppressive treatment was 84.34% corticosteroids, 54.22% Tacrolimus, 40.96% Cyclosporine, 91.75% MMF and 3.61% Azathioprine. The observed SF-36 scores in all dimensions both time-points were similar without significant changes. Also, no significant changes found between the two time-points at all 5 dimensions and total score of the KTQ-25. A multivariate regression analysis for the 5 dimensions of the KTQ-25 at the second time-point was done. Showed that variables significantly associated with Physical Symptoms dimension was age (P = 0.021) directly and Osteoporosis (P = 0.025) inversely. In regression analysis of Fatigue dimension, variables that remained significant were female sex (P = 0.046) and higher serum cholesterols’ levels (P = 0.012). Uncertainty/Fear dimension was significantly worse in KTRs with history of cardiovascular disease (P = 0.032). Appearance dimension was significantly and positively correlated with female sex and negative with age and history of cardiovascular disease (P = 0.018, P = 0.043 and P = 0.041, respectively). No significantly correlation found for Emotions dimension. Total KTQ-25 score was significantly correlated with female sex (P = 0.024), while history of cardiovascular disease had a negative impact on the score (P = 0.013).

CONCLUSION

In this one-year prospective study of the HRQoL of KTRs, no statistically significant changes were found in the scores of KTQ-25 and SF-36 instruments. Age, sex, osteoporosis, serum cholesterols’ levels and history of cardiovascular disease are some of the factors that might affect prospectively HRQoL of KTRs.

MO898: Comparison of Quality of Life and Bio-Psychosocial Burden in Family Caregivers Between Dialysis Patients and Kidney Transplant Recipients

BACKGROUND AND AIMS

Chronic kidney disease (CKD) is considered as a high-stress disease for patients, because of severe morbidity, chronicity and its life-long treatment often requiring dedicated family care. Caregivers’ burden is considered a multidimensional bio-psychosocial reaction of great importance both for caregivers’ and CKD patients’ Quality of Life (QoL). Kidney transplantation (KT) has been shown to improve patient's QoL, however the effect of KT on family's burden in comparison with dialysis has not been sufficiently studied. Aim of this cross-sectional, multicentre, observational study was to estimate and compare the QoL and burden between family caregivers of dialysis patients versus KT recipients (KTRs).

METHOD

We included 138 caregivers of dialysis patients and 33 of KTRs. We assessed caregivers’ QoL with SF-36 questionnaire and bio-psychosocial burden with Zarit Burden Interview scale (ZBI).

RESULTS

Mean age of caregivers did not differ between the two groups (56y dialysis versus 58y KTRs). The majority of KTRs (57.6%) and dialysis patients’ caregivers (68.1%) were women of whom 73% and 52% were spouses, respectively. Educational level and financial status did not differ between the two groups of caregivers. The results of the SF-36 and ZBI are comparatively presented in the Table 1.

Dialysis patients’ caregivers had worse QoL compared with KTRs caregivers. There was a statistically significant difference in general health, bodily pain and social functioning role among KTRs versus dialysis caregivers. Dialysis caregivers showed a significantly higher burden in 3 sub-dimensions of ZBI (personal strain, role strain, relational deprivation) compared with KTRs caregivers. Moreover, the burden of KTRs caregivers found to be inverse correlated with educational level (P = 0.01), while in dialysis caregivers, older age, female gender and low income were directly associated with burden (P < 0.001, P = 0.019 and P = 0.005, respectively).

CONCLUSION

The caregivers of dialysis patients showed worse QoL and significantly higher burden compared with KTRs caregivers. Further studies of larger size will probably shed light to the potential benefits of ΚΤ in patients’ caregivers and families. Currently, implementation of programs for psychological support in high burdened caregivers of kidney disease patients’ could be of help.

MO710: Longitudinal Effects of Different Biocompatible Peritoneal Solutions on Membrane Function

BACKGROUND AND AIMS

Peritoneal biocompatible dialysates (low GDPs, neutral pH) seem to sustain more steady peritoneal membrane characteristics compared to conventional ones. However, various brand biocompatible dialysates have different composition (e.g. in lactate concentration) and there is no published study comparing their effects on membrane characteristics in long peritoneal dialysis (PD). Our PD unit has been using solely two brands of biocompatible dialysates (Balance, Fresenius© and Physioneal, Baxter©) since 2000. The aim of our study was to compare longitudinal data on peritoneal membrane function between these two different brand solutions

METHOD

Membrane characteristics were assessed by uni-peritoneal equilibration test (uni-PET, a combination of modified and mini PET), which is performed at least annually on every patient. Patients with no less than two PETs were included. We estimated dialysate to plasma (D/P) creatinine, ultrafiltration (UF) at 4 h, sodium seiving expressed as Dip/DPNa = [(dialysate sodium time 0/plasma sodium)–(dialysate sodium time 1 h/plasma sodium)], sodium removal (in 1 h) and free water transport (FWT). We collected clinical and lab data of the patients too.

RESULTS

A total of 85 patients (age 61.1 ± 15.1 years) were included—38 patients on Balance and 47 on Physioneal. The main characteristics of the patients are shown in Τable 1. Baseline membrane characteristics presented no differences between the two groups (D/Pcre 0.75 ± 0.125 versus 0.745 ± 0.11, P = 0.71—UF 660 ± 285 mL versus 651 ± 252 mL, P = 0.86—DipDPNA 0.05 ± 0.03 versus 0.047 ± 0.046 P = 0.54—sodium removal 30 (15.7, 42.3) mEq versus 38 (17.3, 46)mEq, P = 0.31—FWT 149 ± 85 mL versus 140 ± 109 mL, P = 0.69).

The patients were followed up for a median of 36 months (range 2.4–143). A total of 219 PETs were performed. Analysis for repeated PET tests was performed by using generalized linear regression models. The membrane characteristics (D/Pcre, Dip/DPNa, FWT and UF) of both groups remained stable longitudinally and overall no differences between the two different solutions were observed (Fig. 1). Only at the fourth year of follow-up, patients on Balance solutions had lower D/Pcre compared to Physioneal (0.62 versus 0.72, P = 0.003).

CONCLUSION

Different biocompatible solutions had no differences on peritoneal membrane characteristics longitudinally.

Hypothermic Machine Perfusion of Kidney Transplant: A Mini-Review

Most kidney grafts are marginal and from deceased donors, which yield worse clinical outcomes. Hypothermic machine perfusion has created a paradigm shift in kidney preservation. This mini-review summarizes the main points of hypothermic machine perfusion of kidney transplants that should be known by any physician and surgeon involved with kidney transplantation. Specifically, this review explains a proposed mechanism of action of hypothermic machine perfusion of kidney transplants. This review also describes the clinical effectiveness of hypothermic machine perfusion and explains how to evaluate and predict graft functionality according to machine parameters and perfusate biomarkers. Finally, treatment options and the most recent studies on oxygenated hypothermic machine perfusion are mentioned.

Longitudinal Assessment of Electrolyte Disorders in a Cohort of Chronic Stable Kidney Transplant Recipients

BACKGROUND

Kidney transplantation is complicated by various electrolyte disturbances with variable reported prevalence and incidence and of multifactorial pathogenesis. The aim of our study was the retrospective longitudinal assessment of the serum electrolytes in a cohort of stable kidney transplant recipients (KTRs) and the possible associated parameters, including graft function and medications.

METHODS

We included 93 stable KTRs under follow-up in our hospital's kidney transplant unit. Serum magnesium, calcium, phosphorus, potassium, sodium, and urine sodium levels were recorded retrospectively during 3 consecutive years. In addition, comorbidities, biochemical parameters, medications, and graft function (estimated glomerular filtration rate (eGFR) using the Chronic Kidney Disease Epidemiology Collaboration equation and 24-hour urinary protein [uTpr]) were recorded.

RESULTS

Mean age at baseline was 51 ± 11 years; 64 KTRs were men (68.8%), 17 (18.3%) had diabetes, 79 (85%) had hypertension, and 11 (11.8%) had cardiovascular disease. Mean eGFR and uTpr (mg/24 h) at study initiation were 47.1 ± 13.5 mL/min/1.73 m² and 369.4 ± 404.2 mg/24 h, respectively. Hypomagnesemia was the most common disturbance observed in 21.7% of KTRs. Patients with hypomagnesemia displayed higher parathyroid hormone levels and more frequently had diabetes. Hypophosphatemia was recorded in 9.7% of KTRs during the first year. Hyperkalemia, hypokalemia, and hypercalcemia were rare (<5%). Mean serum and urine sodium concentration remained stable during the study, whereas urinary sodium levels showed a positive correlation with uTpr (P < .05).

CONCLUSIONS

In our cohort of KTRs, there were no significant electrolyte disorders, either in terms of frequency or severity, with hypomagnesemia being the most prevalent disturbance. The identification of potential associated risk factors and clinical data correlations are pivotal for the development of individualized and evidence-based therapeutic approach and decisions.

Survival of Peritoneal Membrane Function on Biocompatible Dialysis Solutions in a Peritoneal Dialysis Cohort Assessed by a Novel Test

Background: Longitudinal surveillance of peritoneal membrane function is crucial in defining patients with a risk of ultrafiltration failure. Long PD is associated with increased low molecular weight solute transport and decreased ultrafiltration and free water transport. Classic PET test only provides information about low molecular solute transport, and the vast majority of longitudinal studies are based on this test and include patients using conventional dialysates. Our aim was to prospectively analyze longitudinal data on peritoneal function in patients on biocompatible solutions using a novel test. Methods: Membrane function data were collected based on uni-PET (a combination of modified and mini PET). A total of 85 patients (age 61.1 ± 15.1 years) with at least one test/year were included. Results: The median follow up was 36 months (21.3, 67.2). A total of 219 PETs were performed. One-way repeated measures ANOVA showed that there were no statistically significant differences over time in ultrafiltration, free water transport, ultrafiltration through small pores, sodium removal, D/D0 and D/PCre in repeated PET-tests. Twenty-three tests revealed ultrafiltration failure in 16 (18.8%) patients. Those patients were longer on PD, had higher D/P creatinine ratios, lower ultrafiltration at one hour with lower free water transport and higher urine volume at baseline. Multivariate analysis revealed that the variation of ultrafiltration over repeated PET-tests independently correlated only with D/Pcreatinine, free water transport and ultrafiltration through small pores. Conclusions. Uni-PET is a combination of two tests that provides more information on the function of the membrane compared with PET. Our study on a PD cohort using only biocompatible solutions revealed that function membrane parameters remained stable over a long time. Ultrafiltration failure was correlated with increased D/P creatinine and decreased free water transport and ultrafiltration through small pores.

MO951ASSESSMENT OF HEALTH-RELATED QUALITY OF LIFE (HRQOL) IN A GREEK COHORT OF KIDNEY TRANSPLANT RECIPIENTS WITH THE KIDNEY TRANSPLANT QUESTIONNAIRE (KTQ-25)

Background and Aims

Kidney transplantation is recognized as the treatment of choice for patients with End Stage Kidney Disease (ESKD). Improvement in short term patient and graft survival of kidney transplant recipients (KTRs), has shifted interest to the long-term outcomes and Health-Related Quality of Life (HRQoL) estimation is closely related. Thus, reliable evaluation of HRQoL with disease specific questionnaires is of great importance. The aim of this study was to assess the HRQoL in adult KTRs of our Transplant Unit with Kidney Transplant Questionnaire 25 (KTQ-25) and the 36-item Short Form Health Survey (SF-36).

Method

The Greek version of the recently translated and adapted by our team disease specific instrument KTQ-25 and the Greek SF-36 were administered in KTRs during their routine visit in the transplant outpatient clinic. Patients who met the eligibility criteria (time since transplant≥1 year, aged≥18 year old, functioning transplant) were included after providing written informed consent.

Results

A total of 84 KTRs (59 males; mean age 53.45±10.72; mean e-GFR 47.69±15.07; average time since transplantation 55.68±48.26 months) completed the two questionnaires. The scores in each dimension of KTQ-25 were: Physical Symptoms 3.98±1.60, Fatigue 5.30±1.36, Uncertainty/Fear 5.16±1.33, Appearance 6.31±0.94, Emotions 5.03±1.07 and Total Score 5.20±0.87. The mean SF-36 Physical Component Score (PCS) and Mental Component Score (MCS) scores were 47.98±8.70 and 46.94±9.70 respectively. Fatigue (p=0.009), Uncertainty/Fear (p=0.008) and Total Score (p&lt;0.001) were better in male sex. Physical Symptoms (p=0.013) was better in KTRs with children than those with no children. There was positive correlation of e-GFR with Fatigue (p 0.002), Uncertainty/Fear (p=0.034) and Total Score (p=0.017). Hgb was positive correlated with Fatigue (p&lt;0.001), Uncertainty/Fear (p&lt;0.001), Emotions (p=0.031) and Total Score (p&lt;0.001). KTRs who were receiving EPO for anemia had worse scores in all dimension of KTQ-25 (Physical Symptoms p=0.001; Fatigue p=0.001; Uncertainty/Fear p=0.021; Emotions p=0.010; Total Score p=0.002) except Appearance. Appearance was negative correlated with Weight (p=0.001) and BMI (p=0.001). Total number of daily taken pills was also significantly negative correlated with Fatigue (p=0.006) and Total Score (p=0.007). No differences found between different immunosuppressive therapies.

Conclusion

In our cohort of Greek adults KTRs maximum KTQ-25 score was obtained in Appearance dimension and the minimum in Physical Symptoms dimension. Fatigue, Uncertainty/Fear dimensions and Total Score were better for male sex and for KTRs with higher e-GFR and Hgb levels. Physical Symptoms score was better only for KTRs having children. Overweight and high BMI negatively affected A dimension. This is the first study to use a specific-disease tool for evaluating HRQoL in Greek KTRs and among our significant results is that better graft function is significantly correlated with better HRQoL.

In Surgical Colon Cancer Patients Extended-Duration Thromboprophylaxis (30 days) with the Highest Dose of Tinzaparin (4,500 IU s.c./q.d.) Normalizes the Postoperative VEGF Levels

Background/Purpose: In colon cancer (CC) patients preoperative (pre-op) levels of VEGF-A₁₆₅ (VEGF) is a strong predictor for disease recurrence. Elevated postoperative (post-op) VEGF levels could have undesirable effects by enhancing tumor growth and metastasis formation. It has been suggested that thromboprophylaxis with a Low Molecular Weight Heparin (LMWH) in surgical cancer patients, further to thromboembolic protection, may exert some anti-neoplastic properties, as well. The aim of our study was to assess the potential impact of the LMWH Tinzaparin (Innohep® - Leo Pharma, Copenhagen, Denmark), given at different doses and for different perioperative (peri-op) periods, upon the post-op variability of serum VEGF levels in surgical CC patients. Methods: A total of 54 consecutive CC patients who underwent a curative resection were randomized in four groups according to their peri-op thromboprophylaxis scheme, which was based on administrating Tinzaparin in different doses and at different periods, as follows: group I: 3,500 IU for 10 days, group II: 3,500 IU for 30 days, group III: 4,500 IU for 10 days and group IV: 4,500 IU for 30 days. Serum VEGF concentrations were evaluated on the pre-op day (Day 0) and on the 10^th and 30^th post-op days (Day 10 and Day 30, respectively). For statistical analyses the mixed design ANOVA was used. P < 0.05 was considered significant. Results: On Day 0, VEGF didn't differ between groups I, II, III and IV (p>0.05, for every comparison). On Day 10, VEGF was increased in all groups. Between Day 10 and Day 30, VEGF remained stable in groups I (p=0.031) and II (p=1.000) and increased significantly in group III (p=0.005). On the contrary, VEGF decreased significantly in group IV (p<0.001). The most remarkable finding was observed when we compared VEGF between Day 0 and Day 30: while in groups I, II and III, VEGF remained significantly higher compared to Day 0 (p<0.001, p=0.041 and p<0.001, respectively), on the contrary, in group IV (extended-duration with the highest dose of 4,500 IU of tinzaparin) it was comparable to Day 0 (p=1.000). Conclusions: In surgical CC patients only the recommended thromboprophylaxis scheme with the highest prophylactic dose of Tinzaparin (4,500 IU) for extended-duration (30 days) normalizes VEGF levels at the end of the first post-op month by reducing them to the pre-op levels.

Subtotal gastrectomy for diffused hemorrhagic gastritis induced by radiation, following liver resection for hilar cholangiocarcinoma. A case report

INTRODUCTION

A rare case of hemorrhagic gastritis induced by radiation is presented, which was resistant to conservative treatment and required subtotal gastrectomy.

PRESENTATION OF CASE

A 56-year-old male was initially undergone right hepatectomy, resection of the extrahepatic biliary tree, hilar lymph node dissection and hepatico-jejunostomy due to advanced hilar cholangiocarcinoma. Because of the extent of the disease, chemo-radiotherapy was administered. The patient received a total radiotherapy dose of 57.6Gy in 32 sessions. Unfortunately, diffused hemorrhagic gastritis induced by radiation was developed, which was resistant to conservative treatment (endoscopic hemostasis, transfusion). A subtotal gastrectomy was performed. The patient is in good condition 45 months after the liver resection, but with local recurrence.

CONCLUSION

In resistant situations to conservative treatment and recurred bleeding of diffused hemorrhagic gastritis induced by radiation, surgical management may have a role.

Ectopic thyroid carcinoma. Case report

INTRODUCTION

Ectopic thyroid tissue can be found in many sites, including the tongue, thyroglossal duct, mediastinum, trachea, lung, aorta and abdomen. Ectopic thyroid tissue may also be involved in the same processes as normal, orthotopic thyroid gland. These processes include tumors, inflammation and hyperplasia. The appearance of such tissue in rare locations may lead to diagnostic and therapeutic dilemmas.

CASE REPORT

We report a rare case of ectopic thyroglossal thyroid carcinoma in a 63-year-old Caucasian male with a normal orthotopic thyroid gland.

CONCLUSION

Although 99% of thyroid cancers develop within the thyroid itself, in rare cases a carcinoma can arise in ectopic thyroid tissue located in the neck or in other areas of the body. Though rare, the possibility of an ectopic thyroid carcinoma must always be considered by the surgeon in cases of a pathological mass in the neck.