Bone marrow macrophage iron content and sideroblast count in iron- and ESA-naïve patients with CKD-related anemia

BACKGROUND

Since in chronic kidney disease (CKD) iron deficiency anemia (IDA) can coexist with inflammation-induced immobilization of iron in macrophages (anemia of chronic disorders - ACD), we assessed the utility of ferritin, transferrin saturation (TSAT), and hepcidin for differentiation of mixed IDA-ACD from ACD, using bone marrow (BM) examination as reference.

METHODS

This cross-sectional, single-center study analyzed 162 non-dialysis iron and epoietin-naïve CKD patients (52% males, median age 67 years, eGFR 14.2 mL/min 1.73 m², hemoglobin 9.4 g/dL). BM aspiration, serum hepcidin (ELISA), ferritin, TSAT, and C-Reactive protein (CRP) were the main studied parameters.

RESULTS

ACD was seen in 51%, IDA-ACD in 40%, while "pure" IDA in only 9%. In univariate and binomial analyses, IDA-ACD differed from ACD by lower ferritin and TSAT, but not by hepcidin or CRP. Correspondingly, in receiver operating curve analysis, ferritin and TSAT differentiated IDA-ACD from ACD, at cutoffs of 165 ng/mL and 14%, but with moderate precision (sensitivity and specificity of 72%, and 61%, respectively).

CONCLUSION

The mixed pattern IDA-ACD could be more prevalent than estimated in non-dialysis CKD. Ferritin and, to a lesser degree, TSAT are useful in the diagnosis of IDA superimposed on ACD, while hepcidin, although reflecting BM macrophages iron, seems to have limited utility.

Prognostic role of glomerular electron microscopy lesions in IgA nephropathy: "the devil is in the details"

INTRODUCTION

Transmission electron microscopy enables examination of ultrastructural glomerular changes; while this tool has already been applied in IgA nephropathy (IgAN), limited information exists on the prognostic value in this disease. We aimed to systematically investigate ultrastructural lesions and assess their role in predicting the evolution of IgA nephropathy to end-stage kidney disease.

METHODS

A single-center retrospective study was performed on 107 consecutive IgAN patients (median age 42 years, 67% male, estimated glomerular filtration rate 46 mL/min, proteinuria 1.0 g/g) between 2010 and 2015, who were followed-up until end-stage kidney disease, death, or end of study (January 2021). A pathologist evaluated the Mesangial hypercellularity (M), Endocapillary hypercellularity (E), Segmental glomerulosclerosis (S), and Tubular atrophy/interstitial fibrosis-Crescents (C) (MEST-C) score and transmission electron microscopy lesions according to a comprehensive protocol that encompassed all glomerular structures.

RESULTS

Patients were followed up for a median of 7.1 years; 32 (43%) reached end-stage kidney disease. Patients who reached kidney failure had higher comorbidity score, more frequent arterial hypertension, lower estimated glomerular filtration rate, and higher MEST-C score. In terms of transmission electron microscopy lesions, patients who progressed to end-stage kidney disease had more frequent podocyte activation, effacement, and presence of microvilli; more frequent signs of endothelial cell activation and fenestration; higher mesangial cell proliferation. In the univariate Cox proportional hazard regression, higher MEST-C score and lesions detected by transmission electron microscopy in podocytes, endothelial cells, and mesangial cell proliferation were associated with shorter kidney survival time. In the multivariate Cox proportional hazard regression, only higher MEST-C score, presence of podocytes with microvilli, and mesangial cell proliferation were associated with end-stage kidney disease.

CONCLUSION

This study shows that, besides the MEST-C score, the presence of podocytes with microvilli and mesangial cell proliferation are associated with poor kidney survival in IgAN patients, highlighting the prognostic value of lesions detected by transmission electron microscopy.

Budd-Chiari syndrome: An unusual complication of an internal jugular tunneled dialysis catheter

Budd-Chiari syndrome due to the tip of an internal jugular tunneled dialysis catheter malposition in inferior vena cava or hepatic vein is a rare complication. We aimed to present our experience and compare it with the previous reports to highlight the clinical features and the optimal management. A 57-year-old female with history of ANCAp vasculitis, treated by hemodialysis in the last 2 years on a right internal jugular vein tunneled catheter was admitted for pain in the right upper quadrant. A subacute Budd-Chiari syndrome due to catheter malposition was diagnosed. The catheter was removed, and a new tunneled hemodialysis line was inserted in the right internal jugular vein with the tip at the junction of right atrium with superior vena cava. Anticoagulation with apixaban 2.5 mg twice daily was started after catheter replacement and the patient was discharged. At 1 month follow-up the patient had no symptoms, and the ultrasound revealed the absence of the thrombus in the inferior vena cava. Imagining monitoring for malposition after insertion or in a clinical context suggestive for Budd-Chiari syndrome is essential for early diagnosis and treatment. In our case, anticoagulation with apixaban and prompt catheter replacement resulted in Budd-Chiari syndrome resolution.

Nephrotic Syndrome and Statin Therapy: An Outcome Analysis

Background and Objectives: Hypercholesterolemia in patients with nephrotic syndrome (NS) may predispose to cardiovascular events and alter kidney function. We aimed to evaluate statins efficiency in NS patients under immunosuppression using four endpoints: remission rate (RR), end-stage kidney disease (ESKD), major cardiovascular events (MACE), and thrombotic complications (VTE). Materials and Methods: We retrospectively examined the outcome at 24 months after diagnosis of 154 NS patients (age 53 (39–64) years, 64% male, estimated glomerular filtration rate (eGFR) 61.9 (45.2–81.0) mL/min). During the follow-up, the lipid profile was evaluated at 6 months and at 1 and 2 years. Results: The median cholesterol level was 319 mg/dL, and 83% of the patients received statins. Patients without statins (17%) had similar age, body mass index, comorbidities, blood lipids levels, NS severity, and kidney function. The most used statin was simvastatin (41%), followed by rosuvastatin (32%) and atorvastatin (27%). Overall, 79% of the patients reached a form of remission, 5% reached ESKD, 8% suffered MACE, and 11% had VTE. The mean time to VTE was longer in the statin group (22.6 (95%CI 21.7, 23.6) versus 20.0 (95%CI 16.5, 23.5) months, p 0.02). In multivariate analysis, statin therapy was not associated with better RR, kidney survival, or fewer MACE; however, the rate of VTE was lower in patients on statins (HR 2.83 (95%CI 1.02, 7.84)). Conclusions: Statins did not improve the remission rate and did not reduce the risk of MACE or ESKD in non-diabetic nephrotic patients. However, statins seemed to reduce the risk of VTE. Further randomized controlled studies are needed to establish statins’ role in NS management.

MO260: Prognostic Role of Electron Microscopy Lesions in IGA Nephropathy

BACKGROUND AND AIMS

The progression of immunoglobulin A nephropathy (IgAN) is currently assessed using the Oxford MEST-C score, which uses five indicators (mesangial and endocapillary hypercellularity, segmental sclerosis, interstitial fibrosis/tubular atrophy and the presence of crescents). However, little is known about the prognostic role of the glomerular lesions assessed by transmission electron microscopy (EM).

METHOD

We performed a unicentric retrospective study on 107 consecutive IgAN patients {age 42 [interquartile range (IQR) 33–54] years}, 67% male, eGFR 46 (IQR 33.3–65.2) mL/min, proteinuria 1.0 (IQR 0.4–2.1) g/g creatinine)—kidney biopsy-proven—between 2010 and 2015. Patients were followed until end-stage kidney disease (ESKD, dialysis or renal transplantation), death or end of study (January 2021), whichever came first.

For each biopsy specimen, light microscopy, immunofluorescence and EM were routinely performed. One pathologist (GTB) reviewed independently the slides without knowledge of the original biopsy interpretation and assessed for MEST-C score and EM lesions according to the Mayo Clinic/Renal Pathology Society Consensus in podocytes, endothelial cells, mesangium and glomerular basement membrane (Table 1).

RESULTS

Patients were followed for a median of 7.1 (95% CI 6.7–7.5) years. The patients who reached ESKD—32 (43%)—had a higher Charlson comorbidity score [CCS 2 (IQR 2–4) versus 1 (IQR 0–3), P = .01)], arterial hypertension more often [88% versus 64%, P = .01)], lower eGFR [33.7 (IQR 22.4–44.3) versus 56.3 (IQR 39.4–72.5) mL/min, P < .001] and higher MEST-C score [2 (IQR 2–4) versus 1 (IQR 1–2), P < .001]. There were no differences regarding proteinuria, hematuria and treatment.

In terms of EM lesions, patients who experienced ESKD had more frequent podocyte activation (47% versus 27%, P < 0.01), effacement (100% versus 83%, P = .01) and presence of microvilli (69% versus 35%, P = .001); more often endothelial cells activation (47% versus 27%, P = .04) and fenestration (56% versus 29%, P < 0.01); higher mesangial cells proliferation (91% versus 64%, P < .01).

Mean kidney survival time for the entire cohort was 8.2 (95% CI 7.4–8.9) years.

In univariate Cox proportional hazard (CPH) regression higher MEST-C score and EM lesions in podocytes, endothelial cells and mesangial cell proliferation were associated with a shorter kidney survival time (Table 1). However, in the multivariate CPH adjusted for CCS, arterial hypertension, eGFR and treatment, only higher MEST-C score, presence of podocytes with microvilli and mesangial cell proliferation were associated with ESKD (Table 1).

CONCLUSION

To the best of our knowledge, this is the first study to evaluate in depth the prognostic value of EM lesions in IgAN patients in a reasonable large cohort with an appropriate follow-up time. Besides the MEST-C score, we found that the presence of podocytes with microvilli and mesangial cell proliferation are associated with poor kidney survival.

MO226: Is Remission of Hematuria Associated with Kidney Outcome in Biopsy-Proven Primary IGA Nephropathy?

BACKGROUND AND AIMS

Microscopic hematuria, associated with variable proteinuria, is the most common clinical feature of IgA nephropathy (IgAN). However, its role in the disease progression is still controversial. This study aims to assess whether remission of hematuria is associated with kidney outcome in adults with primary IgAN.

METHOD

This retrospective, longitudinal study enrolled 62 adults, out of 214 with biopsy-proven IgAN between 1 January 2008 and 31 December 2017 {age 41 [95% confidence interval (CI) 37–46] years, 73% males, eGFR 41.3 (95% CI 33.1–51) mL/min and proteinuria 1.1 (95% CI 0.9–1.6) g/g} who had at least three assessment visits 3 months apart until 31 May 2018. The median follow-up period was 68 (95% CI 58.6–77.3) months.

Demographic (age, gender), comorbidities, clinical and laboratory data (proteinuria, hematuria and blood pressure) at the time of kidney biopsy and during the follow-up period were retrieved from medical records. Information about therapy was also recorded. The study endpoint was kidney death defined as doubling of serum creatinine or renal replacement therapy (RRT) initiation. Kidney survival was evaluated by Kaplan–Meier method and variables related to kidney outcome by multivariate Cox proportional hazard modeling.

Remission of hematuria was defined as ≤ 5 red blood cells/high power field in at least two samples taken no less than 3 months apart. Subjects were grouped as remission of hematuria (n = 24) and persistent hematuria (n = 38).

RESULTS

There were no differences between the two groups regarding demographic characteristics, comorbidities, kidney function, proteinuria, hematuria or inflammation markers at time of kidney biopsy. During the follow-up period, remission of proteinuria (defined as a > 50% decrease in urinary protein-to-creatinine ratio from baseline) was found in more than half of the group with remission of hematuria but in less than a quarter of group with persistent hematuria (57.1% versus 24.2%; P = .02). However, systolic blood pressure was well controlled (<130 mmHg) in similar proportions (63.6 versus 57.9%, P = .7) and a comparable reduction in mean arterial blood pressure from the baseline was observed [ΔMAP −7.8 (95% confidence interval (CI) −14.1 to −0.45) versus −2.8 (95% CI −9.7–4.9) mmHg; P = .2] in both groups. A high proportion of patients were treated with renin–angiotensin inhibitors (71 versus 61%; P = .5) and almost a third received immunosuppressive therapy (38 versus 34%; P = .8), similarly in the two groups.

During the follow-up, a lower proportion of patients with remission of hematuria reached the composite kidney endpoint (16.7 versus 42.1%, P = .03). In the univariate time-dependent analysis, the kidney survival was numerically better in patients with remission of hematuria [(71.4 (95% CI 64.5–78.2) versus 66.02 (95% CI 54.7–77.2) months; log rank P = .06; Fig. 1A].

However, in the multivariate time-dependent analysis, only the absence of proteinuria remission [OR 0.06 (95%CI 0.008–0.46), P = .007] and a lower baseline eGFR [OR 0.96 (95% CI 0.93–0.98), P = .007] were associated with a poor kidney outcome (chi-squared = 18.5, P < .001) (Fig. 1B).

CONCLUSION

In this cohort of young adults with biopsy-proven primary IgA nephropathy and moderate decline in kidney function, the remission of hematuria for at least 3 months was not associated with kidney outcome.

MO262: Intravenous Cyclophosphamide for High-Risk Primary PLA2R-Positive Membranous Nephropathy

BACKGROUND AND AIMS

The mainstay of treatment for high-risk primary membranous nephropathy (MN) is the cyclic steroid-oral cyclophosphamide (CYC) regimen (modified Ponticelli regimen). However, there has been increasing awareness of serious treatment-related toxicity. Intravenous CYC offers the potential benefit of lower cumulative dose and a lower rate of adverse events. Therefore, we aimed to evaluate the efficacy and safety of intravenous CYC in high-risk primary PLA2R-positive MN.

METHOD

We retrospectively examined the renal outcome on 1 August 2020 of 40 adult patients [age 57 (interquartile range (IQR) 48–69] years, 70% male, serum creatinine 1.1 (IQR 0.9–1.3) mg/dL) who were diagnosed with MN by kidney biopsy and had positive serum anti-PLA2R ab at diagnosis [median titer 257.3 (IQR 86.4–603.0) RU/mL] during 2016–2019.

We included only patients with first episode MN at high risk according to 2021 KDIGO guideline, and who were followed for at least 6 months.

All patients received CYC at a dose of 600 mg/m2 every 4 weeks for up to 6 months in conjunction with prednisone at a dose of 0.75 mg/kg daily (up to 60 mg/day) with gradual tapering to 0.5 mg/kg/day by 3 months and 0.1 mg/kg/day by 6 months.

The outcomes were as follows: kidney survival defined as kidney replacement therapy (KRT) initiation; partial (proteinuria 0.5–3.5 g/24 h) or complete remission (proteinuria < 0.5 g/24 h and serum albumin ≥ 3.5 g/dL)—whichever came first.

RESULTS

Patients were followed for a median of 26 (95% CI 19.2–32.7) months, and 27 (67%) patients reached a form of remission with complete remission observed in 15 patients (37%) and partial remission in 12 (30%).

Cumulative remission rates were 24% after 6 months, 57% after 12 months and 77% after 24 months. Median time to cumulative remission was 11.0 (95%CI 6.6–15.3) months.

Absence of response was observed in 13 patients (33%), three (8%) of whom started KRT after a mean follow-up of 4.2 (95% CI 3.9–4.5) years.

Patients who did not respond to immunosuppression had more severe nephrotic syndrome [24 h proteinuria 12.5 (IQR 7.9–15.0) versus 6.1 (IQR 4.0–8.7) g/24 h, P = .002; serum albumin 2.1 (IQR 2.0–2.3) versus 2.4 (IQR 2.0–2.8) g/dL, P = .04] at diagnosis, but similar titer of PLA2R ab [417 (IQR 258–690) versus 185.7 (IQR 85–439) RU/mL, P = .2].

In the Cox proportional hazard model, only lower serum albumin [HR 3.9 (95% CI 1.2–12.3), P = .01] was retained as a risk factor for absence of remission, while 24 h proteinuria [HR 1.0 (95% CI 0.9–1.0), P = .6], baseline PLA2R ab titer [HR 1.0 (95% CI 0.9–1.0), P = .7] and kidney biopsy chronicity index [HR 1.0 (95% CI 0.8–1.2), P = .5] were not.

Clinical relapse occurred in 3 of 27 (11%) patients at a mean of 11 months after treatment discontinuation.

During the follow-up period five (13%) patients died. Cardiovascular disease (three patients) and infections (two patients) were the main causes of death; apparently not related to CYC treatment.

Median cumulative dose of CYC was 7.2g. None of the patients required blood transfusions or granulocyte–colony-stimulating factor for the management of myelosuppression. Two patient developed community-acquired pneumonia after the first CYC dose and required hospital admission. When the infection resolved, immunosuppressive treatment was successfully completed.

CONCLUSION

Monthly intravenous CYC pulses in patients with high-risk primary PLA2R-positive MN seems to be an effective and safe alternative for treatment. Also, in these patients, lower serum albumin at diagnosis is an early marker for lack of remission.

MO833: Patient Benefits of Nephrological Follow-Up Before the Initiation of Rrt—An Observational Retrospective Analysis

BACKGROUND AND AIMS

The clinical follow-up of CKD patients by nephrologists before RRT initiation (RRTi) is recommended by the practice guidelines starting with stage 3b CKD [1]. Despite this, the real-life implementation in clinical practice suggests otherwise, based on the paucity of papers reporting on the matter [2, 3].

In Romania, where the representation of the nephrology outpatient care is scarce, partly because of the low number of specialists, the establishment of outpatient clinics attached to dialysis units could be a solution.

The purpose of this analysis is to evaluate, for the first time, if nephrological monitoring through the Diaverum outpatient clinics has benefits for CKD patients.

METHOD

A total of 344 patients from 9 Diaverum clinics have been evaluated (335 haemodialysis, 9 peritoneal dialysis), our present analysis retaining only those starting haemodialysis, of which 118 started RRT in the 3 years between 1 January 2015 and 31 December 2017 and were monitored through the nephrology outpatient and 217 were patients there were not referred to a nephrology unit until RRTi, in the 2 years between 1 July 2016 and 1 July 2018.

Clinical and laboratory data were gathered at RRTi and the follow up was investigated over a period of 3 years for both groups, starting from the end of the inclusion period, using anonymized records from the electronic database of Diaverum.

Collected data were compared using the Pearson test for nominal variables and the Student's t-test and Wilcoxon Mann—Whitney U-tests for continuous variables.

Survival analysis was employed using the Kaplan–Meier estimate and Cox regression models.

RESULTS

The patient groups had similar general characteristics: most were men, >40% being elder (>65 yo), ∼30% had DM and both groups were comprised of subjects with multiple comorbidities (a mean Charlson score of 6).

For patients that were not nephrologically referred, RRT was started in 100% of the cases using a CVC, while AVFs were employed in a majority of those followed through the outpatient clinics.

In both groups, the mean eGFR was similarly <10 mL/min/1/73 m2 but >7 mL/min/1.73 m2 reflecting an alignment to clinical practice guidelines [1].

The median level of haemoglobin and the percentage of those with an optimal level of haemoglobin were higher in the group of monitored patients (9.9 versus 8.4 g/dL, respectively, 42% versus 15%).

The nutrition status faired better in monitored patients: BMI (26 versus 23.3 kg/m2) and serum albumin (3.8 versus 3.5 g/dL).

Serum calcium levels were higher (8.8 versus 8.3 mg/dL) and serum iPTH levels were lower (264 versus 331 pg/mL) in monitored patients, suggesting a better control of CKD-MBD, but serum phosphate was higher (5.7 versus 4.64 mg/dL), possibly reflecting a better nutrition status.

The number of hospital admissions, COVID-19 cases and deaths are hard to compare, given the different observation periods that covered different periods and waves of the COVID-19 pandemic. However, hospital admissions and COVID-19 cases seemed more frequent in those that were not monitored.

The 4 year survival rate was significantly higher (59% versus 51%) in the Kaplan–Meier analysis for those monitored through the outpatient. In the multivariate analysis, statistically significant associations with mortality were observed for diabetic and unmonitored patients.

A major bias in our analysis is the difference between the periods of follow-up, which featured different periods of the COVID-19 pandemic.

CONCLUSION

This is the first observational analysis on a nephrological patient population from Romania, which was followed through outpatient units until the initiation of RRT.

Patient monitoring before RRTi potentially allows: for a better control of the main complications of CKD (anaemia, CKD-MBD), a better preparation for RRTi (a more frequent use of an AVF) and possibly for an improvement in morbidity and mortality, as suggested by previous studies on the benefits of nephrological monitoring before RRTi [4, 5].

MO540: Are the Haematological Markers of Inflammation Predictors of Fibroblast Growth Factor-23 in Non-Dialysis Chronic Kidney Disease?

BACKGROUND AND AIMS

Recently, a growing body of evidence point to the relationships between inflammation and fibroblast growth factor 23 (FGF23) in adults with and without chronic kidney disease (CKD). On the other hand, some haematological indices derived from the complete blood count appear as simple and inexpensive biomarkers of systemic inflammation. Therefore, this study aimed to evaluate the association between the haematological markers of inflammation and FGF23 in non-dialysis CKD.

METHOD

This single centre, cross-sectional study prospectively enrolled 90 subjects with moderate to severe stable CKD [median estimated glomerular filtration rate (eGFR) 25 (95% confidence interval 95% CI 24.9–30.5) mL/min, 46% in stage G3, urinary albumin-to-creatinine ratio (ACR) 221 (95% CI 498–954) mg/g], mostly males (61%), aged 62 (95% CI 57–64) years. Patients on renal replacement therapy (RRT) and those with active malignancies, infectious and inflammatory diseases were excluded.

Demographic, past medical history (CKD vintage and etiology, comorbidities, chronic medications) and laboratory data were collected. Haematological markers of systemic inflammation [red blood cell distribution width (RDW), platelet distribution width (PDW), neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR)] were obtained from the complete blood count. Other measured lab parameters were: c-terminal FGF23 (cFGF23), intact parathyroid hormone (iPTH), serum calcidiol (25OHD), total calcium (tCa), phosphate (PO4), alkaline phosphatase, C-reactive protein, albumin, transferrin, ferritin and transferrin saturation, as markers of mineral metabolism, inflammatory, nutritional and iron status, respectively.

Associations among studied parameters were assessed by Spearman rank test, multivariate linear regression and logistic regression models. Non-parametric variables were log-transformed.

RESULTS

The median cFGF23 was 4.65 (95% CI 7.57–14.4) pg/mL. Subjects in the highest cFGF23 quartile [n = 22, cFGF23 20.8 (95% CI 20.8–40.8) pg/mL] had higher RDW (P = 0.02), iPTH (P < 0.001), PO4 (P = 0.005) and ACR (P = 0.004), but lower tCa (P = 0.04), haemoglobin (P = 0.01) and eGFR (P < 0.001) as compared to those in the lowest quartile [n = 23, cFGF23 0.84 (95% CI 0.71–1.10) pg/mL]. Moreover, they had higher proportions of arterial hypertension (P = 0.01) and previous treatment with intravenous iron (P = 0.03). A trend to higher PLR (P = 0.052), NLR (P = 0.064), and ferritin (P = 0.076) was also observed.

However, beside the expected bivariate correlations with eGFR, ACR, iPTH, tCa and PO4, cFGF23 was further correlated solely with haemoglobin (rs = –0.33, P = 0.002).

In a multivariate linear regression model which explained 34% of the log(cFGF23) variance, log(PLR) (B 1.59, 95% CI 0.14–3.03, P = 0.03) and log(eGFR) (B –1.65, 95% CI –2.51 to –0.80, P < 0.001) were independent predictors. After adjustment for history of arterial hypertension and previous intravenous iron treatment, in a model of logistic regression (Nagelkerke R2 0.57, Chi2 16.7, P = 0.03), log(eGFR) was found as independent predictor of the log(FGF23) [odds ratio (OR) 0.07, 95% CI 0.01–0.36, P = 0.002]. However, RDW was retained in the last step of this model with a borderline significance (OR 4.3, 95% CI 0.98–19.02, P = 0.052).

CONCLUSION

Taken together, our findings suggest that, in addition to the kidney function, RDW and PLR seem to predict cFGF23 in non-inflammed, stable, non-dialysis CKD adults. Thus, one might speculate in favour of the association between chronic inflammatory state and FGF23 metabolism and in support of the revelatory role of some haematological markers of inflammation, a hypothesis that needs further research.

MO586: Low-Protein Diet Supplemented With Ketoanalogues of Essential Amino Acids in Advanced Diabetic Kidney Disease: Safety Issues in Elderly

BACKGROUND AND AIMS

Lately, studies support the role of dietary protein restriction in the management of patients with chronic kidney disease (CKD). Beneficial effects were noticed in ameliorating metabolic disturbances in advanced CKD and optimizing the blood pressure control, thus postponing kidney replacement therapy. However, nutritional safety of low-protein diets (LPDs) remains debatable, especially in elderly.

This prospective unicenter interventional study aimed to assess the effects of LPD in advanced diabetic kidney disease (DKD). We present a sub-analysis of data focusing on the safety in elderly patients.

METHOD

Ninety-two patients with DKD with stable CKD stage 4+, heavy proteinuria (>3 g/g creatininuria), good nutritional status (Subjective Global Assessment—SGA A) and compliant to protein restriction proved during a 3-month run-in phase (21% of the screened population) were enrolled and received conventional LPD (0.6 g mixed protein/kg-day) supplemented with ketoanalogues of essential amino acids (Ketosteril®, Bad Homburg, Germany), 1 tb/10 kg dry ideal body weight per day (sLPD) for 12 months. Efficacy outcomes were the variation of proteinuria (primary outcome) and the variation of estimated glomerular filtration rate, eGFR (secondary outcome). Safety was assessed throughout the study using anthropometric measures (Body Mass Index, BMI), SGA, serum albumin (SAlb). Inflammatory parameters (C-reactive protein, CRP) and the occurrence of adverse reactions were also recorded. Compliance was evaluated using urinary urea from 24-h urine collection to estimate the protein intake (ePI) and the 3-day food diary for energy intake (EnI).

RESULTS

Ninety-two patients [61% males, median age 61 (58–67) years, eGFR 11.7 (11.2–12.2) mL/min/1.73 m², proteinuria 4.8 (4.6–5.2) g/g creatininuria] completed the study. For the whole group, proteinuria decreased with 67% from the baseline to the end of study (EOS), and the rate of decline in eGFR was reduced with 80% compared with the period before enrolment.

Of the total group, 42% (39 patients) were elderly (≥65 years): median age 75 (71–80) years old, 64% males, median eGFR 12.61 (11.16–13.81) mL/min and median proteinuria 5.14 (4.84–5.25) g/g creatininuria. About 21% (19 patients) were late elderly (≥75 years old).

In elderly, proteinuria significantly decreased: 1.51 (0.98–1.75) versus 5.14 (4.84–5.26) g/g creatininuria, i.e. by 70% of the baseline value. eGFR also significantly decreased: 10.73 (9.87–11.68) versus 12.61 (11.16–13.81) mL/min. To note, the rate of decline in kidney function was 0.1 versus 0.5 mL/min-month before enrolment, i.e. 5 times slower. The nutritional status was improved: BMI decreased [25.58 (24.68–26.98) versus 27.08 (25.47–28.11) kg/m² at baseline] and the percentage of overweighted subjects declined (56.4 versus 76.9%), while SGA did not change during the study. SAlb was also stable: 4.19 (4.03–4.30) versus 3.90 (3.86–3.99) mg/dL. The inflammatory status was significantly ameliorated: CRP decreased, 8 (7–9) versus 14 (12–15) at baseline mg/L. Thus, by the EOS the percentage of patients with inflammation (CRP ≥ 10 mg/L) significantly decreased: 23.1 versus 92.3% at baseline. The ePI and EnI were very close to recommendations and remained stable during the study: 0.64 (0.63–0.67) versus 0.68 (0.65–0.69) g/kg-day for ePI and 31.30 (28.50–33.00) versus 31.16 (30.16–32.56) kcal/kg-day for EnI at EOS versus baseline, respectively. In a binary regression analysis, lower levels of CRP were associated with sLPD, lower proteinuria and higher SAlb (P < 0.0001, Negelkerke R Square test 58%, Hosmer & Lemeshow test 0.11). No adverse reactions were noted.

CONCLUSION

In elderly patients with advanced DKD, low protein diet supplemented with ketoanalogues of essential amino acids seems to be effective in reducing the decline in eGFR and proteinuria, while being also nutritionally safe.

MO493: Covid-19 Among Romanian HAemodialysis Patients: Risk Factors and Outcomes. Data From the Romanian Renal Registry

BACKGROUND AND AIMS

During the COVID-19 pandemic, patients on maintenance heamodialysis (HD) are vulnerable due to their comorbidities, uremia-impaired immunity and limited physical distancing. We aimed to evaluate the risk factors and outcomes of SARS-CoV-2 infection in HD patients in our country.

METHOD

All HD patients enrolled in the national COVID-19 screening programme between 1 September 2020 and 28 February 2021, were included in this retrospective 6-month cohort study, with outcomes ascertained through 28 February 2021.

We excluded patients under 18 years who received a preemptive kidney graft, recovered kidney function or were lost to follow-up during the first 90 days of HD.

Screening for COVID-19 infection was performed by RT-PCR on nasopharyngeal swabs, every 14 days or at staff indication.

SARS-CoV-2 infection severity was defined as mild, moderate, severe and critical as previously described.

We aimed to evaluate the risk factors for COVID-19 as well as for all-causes of death within 90 days of COVID-19.

RESULTS

A total of 15 401 patients on maintenance HD were included. The median age was 64 years, and two-thirds were >60 years old; 57% were male. Glomerular, diabetic kidney and tubulo-interstitial diseases were the main causes of CKD (18, 11 and 10%, respectively).

During the 6-months, 5386 patients (35%) were COVID-19 positive. Compared with negative patients, they had longer vintages, were more often treated by public dialysis providers and had a higher mortality.

Patients in the first 90 days of HD treated by public providers were more prone to SARS-CoV-2 infection in the multivariate logistic regression analysis (Table 1A).

A total of 15% of the COVID-19 patients died; those with the critical SARS-CoV-2 infection had the lowest survival of 8%, followed by those with severe (35%), medium (72%) and asymptomatic (89%) (Fig. 1).

COVID-19 patients >70 years, of male sex, in the first 90 days of HD, with diabetic kidney disease, and from a public unit had higher mortality. Moreover, the same risk factors were retained in the multivariate Cox proportional hazard model (Table 1B).

CONCLUSION

The COVID-19 pandemic has had a substantial effect on mortality in HD patients affected by SARS-CoV-2 in Romania, especially those elderly and diabetic, with severe and critical clinical forms.

MO579: The Long-Term Efficacy and Safety of Low-Protein Diets in Non-Diabetic Patients with Advanced CKD: Focus on Elderly

BACKGROUND AND AIMS

Current data suggest the benefits of protein restriction in the management of advanced chronic kidney disease (CKD), improving metabolic abnormalities, optimizing blood pressure control and allowing to postpone kidney replacement therapy (KRT). However, feasibility, safety and even the long-term benefits of low protein diets (LPDs) are questioned, especially in elderly.

This study aimed to compare the long-term efficacy and safety of two types of LPDs in elderly non-diabetic patients with advanced CKD.

METHOD

Long-term follow-up (FU) data from a prospective randomized controlled single-center trial (RCT) on 207 CKD stage 4 + non-diabetic patients are presented. The RCT compared the effects of vegetarian very low protein diet supplemented with keoanalogues of essential amino acids (sVLPD, vegetable proteins 0.3 g/kg-day plus, Ketosteril®, Bad Homburg, Germany, 1 tb/5 kg bw-day) with conventional LPD (mixed proteins 0.6g/kg-day) for 15 months (Garneata L et al. JASN. 2016; doi:10.1681/ASN.2 015 040 369). The composite endpoint was the need of KRT or the patients’ death. The census point was either the occurrence of primary endpoint or 31 July 2018.

We are presenting a sub-analysis focusing on elderly patients (>65 years old). Safety was assessed throughout the study by anthropometric measures, Subjective Global Assessment (SGA), serum levels of albumin (SAlb) and C-reactive protein (CRP). Davies Comorbidity score was also registered during the follow-up.

RESULTS

Two hundred patients who ended the RCT were enrolled in the FU. All of them voluntarily continued the prescribed intervention. Data analysis showed sVLPD to be superior to LPD on long-term with respect to the primary endpoint, preserving the nutritional status (published data).

Of the 200 subjects, 36 (18%) were elderly, 15 on LPD and 21 on sVLPD.

At 31 July 2018, more than 10 years after the end of RCT, 70% of the elderly patients were alive with no statistically significant difference between groups (81 versus 43.3%, P = 0.08 in sVLPD and LPD, respectively).

The median follow-up was significantly higher in the sVLPD group: 116 (106–123) versus 97 (49–115) months.

The need for KRT during FU was significantly lower in patients on sVLPD: 43 versus 100%. The time until KRT was similar between groups: 32 (7–54) versus 35 (6–131) months, sVLPD and LPD, respectively.

There were no significant differences between sVLPD and LPD at the end of FU (EOFU) in the nutritional status assessed by SGA and SAlb [4.41 (4.14–4.56) versus 4.31 (3.90–4.35) g/dL]. At the EOFU, CRP was significantly lower in the sVLPD group: 7 (4–9) versus 10.5 (7–16) mg/L. Davies Comorbidity Score increased during the FU in both groups, with no difference: 3 (1–3) versus 3 (3–5), sVLPD and LPD, respectively. Kaplan–Meier analysis showed better survival rates in the sVLPD group, both for the patient (10-year survival 78 versus 53% in sVLPD and LPD, respectively) and for kidney (10-year survival 82 versus 20% in sVLPD and LPD, respectively). Cox regression analysis of data showed SGA A and the sVLPD to be associated with better patients’ survival, while only sVLPD was associated with better kidneys’ survival.

CONCLUSION

Both types of protein-restricted diets proved feasible and safe on long-term in elderly. Vegetarian very low protein diet supplemented with ketoanalogues was associated with better patients and kidneys survival as compared with low protein diet in elderly non-diabetic patients.

Negative anti-phospholipase A2 receptor antibody status at three months predicts remission in primary membranous nephropathy

Background

The value of anti-phospholipase A2 receptor antibody (anti-PLA2R ab) monitoring at 3 months after diagnosis in membranous nephropathy (MN) remains uncertain.

Methods

We retrospectively examined the outcome on 1 August 2020 of 59 adult patients (age 54 (44, 68) years, 69% male, SCr 1.0 (0.9, 1.3) mg/dL) diagnosed with MN (kidney biopsy, positive serum anti-PLA2R ab). The outcomes were: kidney survival; partial and/or complete remission.

Results

Most of the studied patients (97%) received immunosuppression, cyclophosphamide regimens were the most frequent (87%), followed by cyclosporine (10%). The median time to remission was 12.0 months and the cumulative remission rates were 34% at 6, 54% at 12, and 73% at 24 months. Forty (69%) patients had negative anti-PLA2R ab at 3 months, they had similar age, serum creatinine, albumin, proteinuria, and treatment with the group with positive ab at 3 months. In the Cox proportional hazard model, three months anti-PLA2R ab negativization (HR 0.4 (95%CI 0.1, 0.9)) was an independent predictor for remission, while baseline hypoalbuminemia (HR 3.0 (95%CI 1.5, 5.7)) was associated with absence of remission. Six (10%) patients died, mostly due to cardiovascular disease and infections. A total of five (9%) patients started dialysis. Mean kidney survival time was 50.3 months and there was no survival difference in relation to baseline anti-PLA2R ab titer (p .09) or 3 months negativization (p .8).

Conclusions

Three months anti-PLA2R ab negativization seems to be a late predictor of remission, and lower serum albumin at diagnosis is an early marker for remission absence. Abbreviations: anti-P LA2R ab, anti-phospholipase A2 receptor antibody; eGFR, estimated glomerular filtration rate; ESKD, end stage kidney disease; MN, membranous nephropathy; NELL-1, neural epidermal growth factor-like 1 protein; RAAS: renin–angiotensin–aldosterone system; RBC: red blood cells; RRT, renal replacement therapy; T HSD7A, thrombospondin type-1 domain containing 7A

Anti-phospholipase A2 receptor antibody screening in nephrotic syndrome may identify a distinct subset of patients with primary membranous nephropathy

PURPOSE

We sought to investigate the utility of anti-PLA2R antibody as a non-invasive screening method for the diagnosis of primary MN in patients with nephrotic syndrome (NS).

METHODS

All consecutive patients with NS admitted in our department, between 01.01.2015 and 31.12.2019 were screened for anti-PLA2R antibodies by an ELISA assay (EUROIMMUN, Lübeck, DE). A positive anti-PLA2R serology was defined as an ELISA value over 2 RU/ml. Subsequently, all patients underwent kidney biopsy to confirm the histological diagnosis.

RESULTS

Of the 203 patients with NS, we identified 67 patients with "high" titer of anti-PLA2R antibodies (> 20 RU/ml) and 47 patients with "intermediate" titer (2-20 RU/ml). In the entire cohort, the area under the curve (AUC) was 0.83 (95% CI 0.78-0.89; p < 0.001). With a cutoff of 20 RU/ml, the anti-PLA2R antibodies had a 64% sensitivity (95% CI 53-73%) and 94% specificity (95% CI 88-97%) to discriminate MN from other causes of NS. In addition, the PPV and NPV were 91% (95% CI 82-95%) and 75% (95% CI 69-79%). When analyzing the posttest effect, we identified a LR+ of 11.56 (95% CI 5.2-25.2) and LR- of 0.38 (95% CI 0.29-0.5). The overall accuracy of the test was 80.3% (95% CI 74-85%) and the diagnostic odds ratio was 30.42. When performing subgroup analysis, we identified that in younger patients, in those with preserved renal function or with negative workup for secondary causes, the diagnostic performance of anti-PLA2R antibodies was improved, the sensitivity increasing to 68-71%, the PPV to 93-95% and the LR+ to 12.23-15.4.

CONCLUSION

Serum anti-PLA2R antibody screening in patients with NS is a useful method for the diagnosis of primary MN. In younger patients (less than 60 years old) who have a preserved renal function and a negative workup for secondary causes of NS, a positive anti-PLA2R test highly predicts a diagnosis of primary MN.

Hydroxychloroquine in IgA nephropathy: a systematic review

Background

Hydroxychloroquine (HCQ) has recently been reported to be a promising and safe anti-proteinuric agent for IgA nephropathy (IgAN) patients. In the present systematic review, we aimed to summarize the evidence concerning the benefits and risks of HCQ therapy in IgAN.

Methods

Electronic databases were searched for randomized, cohort, or case-control studies with IgAN biopsy-proven patients comparing the effects of HCQ with angiotensin-converting enzyme inhibitors/angiotensin receptor blockers or immunosuppression on proteinuria reduction.

Results

Five studies, one randomized and three observational, involving a total of 504 patients, were eligible for inclusion. Overall, there was a tendency of HCQ treatment to reduce proteinuria. In the studies where the control arm was supportive therapy, HCQ significantly reduced proteinuria at 6 months. However, in the studies that compared HCQ to immunosuppressive therapy, we found no difference in proteinuria reduction. HCQ had no impact on eGFR.

Conclusion

HCQ seems to be an efficient alternative therapy for patients with IgAN who insufficiently respond to conventional therapy. However, ethnically diverse randomized controlled studies with long-term follow-up are needed.

Long-Term Intravenous Iron Therapy and Morbidity in Hemodialysis Patients

Objective: The aim of this study was to describe long-term intravenous iron therapy-associated morbidity in hemodialysis patients from a single Hemodialysis Center. Material and methods: We conducted an observational retrospective cohort study from 01 January to 31 December 2015. Two hundred and twenty prevalent patients on maintenance hemodialysis therapy for at least 12 months (mean age 53±13 years, 56% males, median hemodialysis vintage 5 (1-26) years) were included. Diabetic nephropathy as primary kidney disease, pregnancy and incomplete data records regarding study aims were exclusion criteria. We compared the frequency, duration and causes of hospitalizations in iron sucrose-treated versus gender and age-matched iron non-treated patients. Differences between groups were assessed using Chi-square and Kruskal-Wallis H tests. A p value μ0.05 was considered statistically significant. Results: From the entire cohort, 68% were iron-treated. One in five patients were treated with higher doses (400 mg monthly), and lower doses were used (100-200 mg monthly) in 80% of patients. There were no differences regarding the rates of admission between the two groups (56/100 patient-years in the iron sucrose-treated vs. 50/100 patient-years in the iron-untreated group, p=0.1). Still, the hospitalization rate significantly increased with the administered iron dose (0.4 vs. 0.7 vs. 0.8/100 patient-years for 100 mg vs. 200 mg vs. 400 mg monthly, respectively, p=0.006). Hospitalization rates due to infectious and cardiovascular diseases were similar for both groups (12/100 patient-years vs. 5.7/100 patient-years, p=0.3 and 11.3/100 patient-years vs. 4.3/100 patient-years, p=0.2, respectively). Conclusion: Higher doses of intravenous iron sucrose appear to be associated with an elevated risk of hospitalization. Nonetheless, long-term intravenous iron therapy seems to have a limited influence in terms of specific cause of morbidity in non-diabetic hemodialysis patients.

Clinical Phenotypes and Predictors of Remission in Primary Membranous Nephropathy

(1) Background: We sought to investigate the clinical outcome and to identify the independent predictors of clinical remission in a prospectively followed cohort of patients with primary membranous nephropathy (pMN). (2) Methods: We conducted a prospective, observational, non-interventional study that included 65 consecutive patients diagnosed with pMN between January 2015 and December 2019 at our department and followed for at least 24 months. The primary outcomes evaluated during the follow-up period were the occurrence of immunological and clinical remission (either complete or partial remission). Univariate and multivariate Cox proportional hazard regression analyses were performed to identify independent predictors of clinical remission. (3) Results: In the study cohort, 13 patients had a PLA2R-negative pMN, while, of those with PLA2R-associated pMN, 27 patients had a low anti-PLA2R antibody titer (<200 RU/mL), and 25 patients had a high anti-PLA2R antibody titer at baseline (≥200 RU/mL). The clinical outcome was better in patients with PLA2R-negative pMN compared to patients with PLA2R-positive pMN. These patients had a higher percentage of complete remissions (46.2%, compared to 33.3% in those with low anti-PLA2R antibody titer or 24% in those with high anti-PLA2R antibody titer), a faster decline of 24 h proteinuria and lower time to complete remission. In multivariate Cox regression analysis, patients with PLA2R-negative pMN had a 3.1-fold and a 2.87-fold higher chance for achieving a complete or partial remission compared to patients with high anti-PLA2R antibody titer or to all PLA2R-positive patients, respectively. Additionally, patients with a baseline 24 h proteinuria of less than 8 g/day and with an immunological remission at 24 months had a 2.4-fold (HR, 2.4; 95%CI, 1.19-4.8) and a 2.2-fold (HR, 2.26; 95%CI, 1.05-4.87), respectively, higher chance of achieving a clinical response. By contrary, renal function at diagnosis, type of therapeutic intervention or anti-PLA2R antibody titer did not predict the occurrence of clinical remission. (4) Conclusions: We identified a different clinical phenotype between PLA2R-positive and PLA2R-negative pMN. Additionally, we have shown that baseline proteinuria seems to be a more important predictor of clinical outcome than anti-PLA2R-ab titer.

MO580HYPOPROTEIC DIET SUPPLEMENTED WITH KETOANALOGUES IN PATIENTS WITH ADVANCED DIABETIC KIDNEY DISEASE – EFFECTS ON MINERAL BONE DISORDERS

Background and Aims

Dietary protein restriction is rediscussed as mainstay approach in advanced Chronic Kidney Disease (CKD), both in diabetics and non-diabetics to defer renal replacement therapy (RRT), mainly by better metabolic control; improvements in mineral bone disorders (MBD) were also suggested, but less studied in Diabetic Kidney Disease (DKD).

An unicentric prospective interventional trial aimed to assess the effects of ketoanalogue-supplemented low protein diet (sLPD) on proteinuria and CKD progression (data already presented). The parameters of MBD were also evaluated.

Method

Adult diabetic patients (452) with stable CKD stage 4+, proteinuria&gt;3g/g creatininuria and SGA A were enrolled in a run-in phase (3 mo), with LPD (0.6g/kg dry ideal bw). Those who proved adherent (92, 64% males, median age 55.7 yrs, 65% on insulin) received sLPD (Ketosteril®, 1 tablet/10kg) for 12mo. Monitoring and treatment followed the Best Practice Guidelines.

The primary endpoint was proteinuria during intervention as compared to pre-enrolment. Serum levels of calcium, phosphates and iPTH were considered to assess MBD. Nutrition, inflammation (SGA, BMI, serum albumin, CRP) and compliance were safety parameters.

Results

In patients with advanced DKD and severe proteinuria, sLPD was associated with a 69 (63; 82) % reduction in proteinuria (data presented).

Significant amelioration in MBD was noted: serum levels of calcium and phosphates were significantly ameliorated at the end of the study as compared to enrolment - 4.3 (4.2-4.9) vs 3.2 (3.1-3.5) mg/dL and 5.4 (4.9-6.1) vs 8.2 (7.8-8.9) mg/dL, respectively. Serum iPTH significantly decreased: 185 (168-212) vs 375 (354-585) pg/mL. The need for calcium supplementation decreased: 6.5 (6.0-6.7) vs 7.0 (6.8-7.3) g/day. Vitamin D was required by only 35% vs 65% of patients.

Nutritional status was preserved and dietary compliance was very good throughout the study.

Conclusion

In patients with advanced DKD ketoanalogue supplemented low protein diet seems to be effective and safe as part of MBD management.

MO560IS SERUM ERYTHROPOIETIN CORRELATED WITH IRON METABOLISM AND INFLAMMATION IN NON-DIALYSIS CHRONIC KIDNEY DISEASE PATIENTS WITH ANEMIA?

Background and Aims

Both the relative erythropoietin (Epo) deficiency and its relationship with serum hemoglobin (Hb) are widely postulated in chronic kidney disease (CKD), but the influence of chronic inflammation and iron status on serum Epo levels is still a matter of debate, with yet divergent reported results. Therefore, we aimed to assess the determinants of serum Epo in non-dialysis CKD patients.

Method

Fifty-two adults with CKD and anemia (defined as Hb &lt;12g/dL), in stable clinical condition, never treated with erythropoiesis-stimulating agents (ESA) entered this cross-sectional, single-center study. Diabetes mellitus, active infectious and inflammatory diseases, malignancy, anemia of other causes than CKD, current immunosuppressive therapy, iron supplementation and blood transfusions in the previous six months were exclusion criteria. The subjects were mostly men (56%), elderly (two thirds over 60 years), with advanced CKD [71% in CKD stages G4-G5, median estimated glomerular filtration rate – eGFR 14.5 (95%CI 16 to 25) mL/min], moderate anemia [Hb 9.8 (95%CI 9.2 to 9.9) g/dL], and mild to moderate inflammation [C-reactive protein 6 (95%CI 9.2 to 18.4) mg/L].

Serum Epo was assessed by ELISA (Abcam® 119522). Complete blood count, reticulocyte index, peripheral blood smear, bone marrow aspiration (Perls’ stain), serum ferritin, and transferrin saturation, were used to investigate anemia and iron metabolism. Parameters of kidney disease (CKD etiology, eGFR and proteinuria), demographic data (age, gender), C-reactive protein, serum albumin, and serum hepcidin-25 (Hep-25, Bachem® commercial ELISA kit) were also analyzed.

Results

The median serum Epo of the whole cohort was 4.8 (95%CI 5.1 to 9.9) mU/mL. According to median Epo, subjects were clustered in Group 1 (below median, G1) and Group 2 (above median, G2). Estimated GFR and serum Hep-25 were lower in G1 than in G2 [10.6 (95%CI 9.7 to 20.8) vs. 26 (95%CI 19.1 to 32.8) mL/min, p=0.004, and 62.6 (95%CI 51.0 to 85.1) vs. 95.4 (95%CI 77.0 to 108.5) ng/mL, p=0.03, respectively]. All the other investigated parameters were similar in the two groups.

In bivariate analysis (Spearman rank correlation), serum Epo was positively associated only with eGFR (rs=0.40, p=0.003). Marginal associations with the percentage of bone marrow sideroblasts, as marker of the iron available for erythropoiesis (rs=0.25, p=0.08), erythrocyte mean corpuscular hemoglobin concentration (rs=−0.26, p=0.07), and reticulocyte index (rs=0.24, p=0.09) were observed. Conversely, serum Epo was not related to hemoglobin, indices of iron stores (e.g. serum ferritin and iron content in bone marrow macrophages), inflammation and nutritional status (e.g. C-reactive protein and serum albumin).

In a model of multiple linear regression which explained 14% of serum Epo variation, eGFR was the only determinant: Beta 0.14 (95%CI 0.05 to 0.23), p=0.004. Also, a binary logistic multiple regression model predicting serum Epo lower or higher than the median retained the eGFR as an independent predictor, while serum hepcidin showed only borderline significance:

Conclusion

Kidney function is the main determinant of endogenous erythropoietin level in moderately anemic patients with advanced CKD, ESA or iron naive, while serum hepcidin-25 seems to exert a limited influence.

MO285CLINICAL PRESENTATION OF IGA NEPHROPATHY AND LONG-TERM RENAL OUTCOME

Background and Aims

There is a wide range of clinical presentation of IgA nephropathy (IgAN), from asymptomatic microscopic hematuria to rapidly progressive glomerulonephritis. However, there is little epidemiologic data on the relationship between the clinical pattern at diagnosis and long-term renal outcome.

Method

We performed a unicentric retrospective study on 299 consecutive IgAN patients (age 43 [35-56] years, 71% male, eGFR 42.1 [25.2-62.8] mL/min, proteinuria 1.3 [0.6-2.6] g/g creatinine) - kidney biopsy proven - between 2010-2017. Patients were followed until composite endpoint (doubling of serum creatinine, ESKD (dialysis or renal transplant) or death, whichever came first) or end of study (May 2018).

Results

Patients were followed for a mean of 41 (95%CI 38, 44) months, and 80 (27%) patients experienced the composite endpoint.

The most frequent clinical presentation at diagnosis regardless of age was nephritic syndrome (68%), followed by asymptomatic urinary abnormalities (AUA) (19%), macroscopic hematuria (15%), acute kidney injury (AKI) (14%) and nephrotic syndrome (10%).

The clinical pattern varied in frequency with age: macroscopic hematuria had a bimodal distribution in the 20- and 60-years groups, AKI was more frequent in the 50 to70 years groups, AUA was more often present in the 30 to 50 years groups (Figure 1).

Mean renal survival time for the entire cohort was 70 (95%CI 65, 75) months; patients with AKI (40 (95%CI 27, 54) vs 75 (95%CI 69, 80) months, p&lt;0.001), nephrotic syndrome (42 (95%CI 26, 57) vs 73 (95%CI 67,78 months, p&lt;0.001)) at diagnosis had significantly shorter renal survival time.

In multivariate Cox regression analysis adjusted for IgAN progression factors, presence of nephritic syndrome at diagnosis was associated with good renal outcome, while clinical presentation as AKI or nephrotic syndrome were associated with poor renal survival (Table 1).

Conclusion

Although AKI and nephrotic syndrome are uncommon in IgAN at diagnosis, their presence seems to be associated with poor renal survival.

MO562ACUTE IMPACT OF A SINGLE HIGH DOSE OF FERRIC CARBOXYMALTOSE ON ENDOTHELIAL FUNCTION IN CKD NON-DIALYSIS PATIENTS

Background and Aims

Anemia is highly prevalent in CKD, and most frequently is caused by iron deficiency. Intravenous iron therapy is often and efficiently used, even in non-dialysis CKD patients. Still, experimental data suggested that intravenous iron could alter endothelial function, rising concerns related to the possible cardiovascular long-term effects. In this regard, we clinically assessed the acute impact of a high dose of iron ferric carboxymaltose (FCM), a commonly used iron formulation, on endothelial function in CKD iron-naive non-dialysis patients.

Method

In this prospective crossover single center study, forty CKD iron-deficient non-dialysis patients [median age 66.5 (56;73) years, 62% female, median estimated glomerular filtration rate 24 (11;36) mL/min, 78% in the very high-risk category according to KDIGO, 90% with hypertension and 40% with diabetes mellitus] were included. The study was approved by Ethics Committee of the UMF “Carol Davila” Bucharest. Pregnancy and breast feeding, anemia of other cause, history of erythropoietin therapy, high-degree inflammation, active malignancies, glomerulonephritis or liver diseases, immunosuppressive therapy, hemoglobin &lt;7g/dl, ferritin &gt; 500 ng/ml and/or transferrin saturation &gt; 50%, baseline flow mediated dilatation (FMD) &lt; 7%, antioxidant supplements and active smoking were exclusion criteria. The effect on endothelial function was clinically assessed by comparing FMD at 15 minutes before and 15 minutes after 2 infusions: first, the comparator (250 mL 0.9% saline), and 24 hours apart, FCM (1000 mg in 250 mL 0.9% saline). FMD was measured using a Doppler ultrasound system according to guidelines recommendations. Wilcoxon paired test was used to test the post- and pre-infusion differences.

Results

Flow mediated vasodilatation and blood pressure at baseline was similar before each intervention. Neither comparator nor FCM infusion had any effect on acute changes in systolic and diastolic blood pressure. Arterial reactivity was not acutely affected after FCM [ΔFCM 0.01 (-0.35;0.15) versus saline solution 0.001 (-0.4;0.5), p=0.9].

Conclusion

A single high dose of ferric carboxymaltose did not acutely impaired endothelial function evaluated by flow mediated vasodilatation, in a CKD non-dialysis cohort.

MO270PROGNOSTIC ROLE OF ANTI-PHOSPHOLIPASE A2 RECEPTOR ANTIBODY NEGATIVIZATION AT THREE MONTHS IN MEMBRANOUS NEPHROPATHY

Background and Aims

The predictive value of anti-phospholipase A2 receptor antibody (anti-PLA2R ab) levels at three-months from diagnosis in patients with membranous nephropathy (MN) is not proven.

Method

We retrospectively examined the renal outcome on 1 August 2020 of 59 adult patients (age 54 (44, 68) years, 69% male, serum creatinine 1.0 (0.9, 1.3) mg/dL) who were diagnosed with MN by kidney biopsy and had positive serum anti-PLA2R ab during 2016-2019.

The outcomes were: kidney survival defined as renal replacement therapy (RRT) initiation; partial (proteinuria 0.5 to 3.5g/24h) or complete remission (proteinuria &lt;0.5g/24h and serum albumin ≥3.5g/dL) - whichever came first.

Variables related to renal outcome were further evaluated in univariate and multivariate Cox proportional hazard (CPH) models.

Results

Forty (69%) patients had negative anti-PLA2R ab at 3 months; there were no differences regarding age, serum creatinine, serum albumin, proteinuria and treatment when compared to the group with positive ab at 3 months.

Fifty-seven (97%) patients received immunosuppressive treatment, cyclophosphamide-based regimens were the most frequent (87%), followed by cyclosporine (10%).

Overall, 64% of the patients reached a form of remission. Cumulative remission rates were 34% after 6 months, 54% after 12 months, 68% after 18 months and 73% after 24 months. Only five patients (9%) relapsed during the study period. Median time to cumulative remission was 12.0 (95%CI 8.2, 15.7) months.

In the CPH models, negativization of the anti-PLA2R antibodies at three months was an independent predictor for remission, however lower serum albumin was also retained as a risk factor for absence of remission (Table 1).

During the follow up period 6 (10%) patients died. Cardiovascular disease and infections were the main causes of death. A total of 5 (9%) patients started RRT during the study period. The mean renal survival time was 50.3 (95%CI 46.5, 54.0) months. We found no difference in renal survival regarding anti-PLA2R Ab titer or negativization.

Conclusion

Negativization of anti-PLA2R antibodies in the first three months from diagnosis was a predictor for remission in patients with membranous nephropathy.

MO278IMMUNOSUPPRESSIVE THERAPY VERSUS SUPPORTIVE CARE IN IGA NEPHROPATHY PATIENTS WITH STAGE 3 AND 4 CHRONIC KIDNEY DISEASE

Background and Aims

The use of immunosuppressive therapy for IgA nephropathy (IgAN) patients with stage 3 or 4 chronic kidney disease (CKD) is controversial.

Method

We performed a monocentric retrospective study on 83 consecutive IgAN patients (age 41 [33-56] years, 72% male, eGFR 36.1 [25.4-47.5] mL/min) with stage 3 or 4 CKD and proteinuria ≥ 0.75g/day who received uncontrolled supportive care (Supp) (n=36), corticosteroids (CS) (n=14) or CS combined with monthly pulses of cyclophosphamide (CS+CFM) (n=33) between 2010-2017. Patients were followed until composite endpoint (doubling of serum creatinine, ESKD (dialysis or renal transplant) or death, whichever came first) or end of study (May 2018).

Results

Patients were followed for a median of 29 (95%CI 25.2, 32.7) months, and 12 (15%) patients experienced the composite endpoint.

There were no differences between the three studied groups regarding age (Supp 46 [33.5-61.0] vs CS 40 [33-47] vs CS+CFM 41 [34-48] years), eGFR (Supp 37.7 [27.5-49.2] vs CS 40.3 [32.5-54.6] vs CS+CFM 31.5 [22.7-44.3] mL/min), proteinuria (Supp 1.9 [1.4-3.5] vs CS 1.3 [1.0-1.7] vs CS+CFM 1.7 [1.1-2.9] g/g creatinine), MESTC score (Supp 2.5 [1.5-4.0] vs CS 2 [0-2] vs CS+CFM 3 [2-3]), hypertension (Supp 94% vs CS 86% vs CS+CFM 94%) and therapy with renal angiotensin system inhibitors (Supp 83% vs CS 64% vs CS+CFM 67%).

Mean renal survival time for the entire cohort was 81.0 (95%CI 73.1, 89.0) months; we found similar renal survival time between the three groups (Supp 79.0 (95%CI 66.5, 91.6) vs CS 69.3 (95%CI 47.7, 91.0) vs CS+CFM 73.7 (95%CI 66.0, 81.4) months, p=0.4).

In univariate and multivariate Cox regression analysis adjusted for IgAN progression factors, immunosuppressive therapy was not associated with better renal survival when compared to supportive therapy (Table 1).

Conclusion

Within the limitation of a retrospective study, we found no benefit from immunosuppressive therapy in patients with IgAN with stage 3 and 4 CKD as compared to supportive care.

MO300PHOSPHOLIPASE A2 RECEPTOR ANTIBODY SCREENING IN NEPHROTIC SYNDROME MAY IDENTIFY A DISTINCT SUBSET OF PATIENTS WITH PRIMARY MEMBRANOUS NEPHROPATHY

Background and Aims

Primary membranous nephropathy (MN) is a glomerulus-specific autoimmune disorder caused by anti-phospholipase A2 receptor (anti-PLA2R) antibodies in 70-80% of cases. We sought to investigate the utility of anti-PLA2R antibody as a non-invasive screening method for the diagnosis of primary MN in patients with nephrotic syndrome (NS).

Method

A total of 203 consecutive patients with NS admitted in the Nephrology Department of Fundeni Clinical Institute, Bucharest, Romania, between January 2015 and December 2019 were screened for anti-PLA2R antibodies by an ELISA assay (Euroimmun, Lubeck, DE). A positive anti-PLA2R serology was defined as an ELISA value over 2 RU/ml. Subsequently, all patients underwent kidney biopsy to confirm the histological diagnosis.

Results

Of the 203 patients with NS, 113 (55.7%) patients tested negative for anti-PLA2R antibodies, while 23 (11.3%) and 67 (33%) patients had an anti-PLA2R antibody titer of 2-20 RU/ml and &gt;20 RU/ml, respectively. Mean age and serum creatinine of the entire cohort were 53 ± 13 years and 1.84 ± 1.63 mg/dl, respectively, while median 24-h proteinuria was 6.8 g/day (IQR: 4.8 – 10.6). Thirty patients (14.7%) were identified to have a potential secondary cause of NS. Ninety-five patients (46.8%) had a histological diagnosis of MN, while 108 patients were diagnosed with other glomerular disorders. In patients with anti-PLA2R antibody titer &gt; 20 RU/ml, the most frequent histological diagnosis was MN (n=61, 91%) with 6 patients having other glomerular patterns of injury (two FSGS, one minimal-change disease, one membrano-proliferative glomerulonephritis, one diabetic nephropathy and one postinfectious glomerulonephritis) (Figure 1). Of patients with intermediate anti-PLA2R antibody titer (2-20 RU/ml), 39% had MN and 61% had other glomerular disorders (Figure 1). Eighteen patients with MN had a positive work-up for secondary causes, eight patients (44%) having an anti-PLA2R antibody titer &gt; 20 RU/ml. Additionally, patients with anti-PLA2R antibody titer &gt; 20 RU/ml had a lower serum creatinine (1.5 ± 0.89 mg/dl) than patients with intermediate titer (1.89 ± 1.21 mg/dl) and those with negative titer (2.03 ± 1.98 mg/dl) (Figure 2). When analyzing the diagnostic performance of anti-PLA2R antibodies in the entire cohort we identified an AUC of 0.83 (95%CI, 0.78-0.89; p&lt;0.001), the cut-off titer of 20 RU/ml having a sensibility, specificity, positive predictive value (PPV) and negative predictive value of 65%, 94%, 91% and 75%, respectively. The accuracy of anti-PLA2R antibodies for non-invasive diagnosis of primary MN was improved in the subgroup of patients that were younger than 60 years (AUC=0.88; 95%CI, 0.82-0.95; p&lt;0.001, with a PPV and NPV of 91% and 80%), had an estimated glomerular filtration rate over 60 ml/min (AUC=0.85; 95%CI, 0.77-0.93; p&lt;0.001, with a PPV and NPV of 95% and 69%) or had a negative work-up for secondary causes of NS (AUC=0.88; 95%CI, 0.82-0.93; p&lt;0.001, with a PPV and NPV of 93% and 80%).

Conclusion

Serum anti-PLA2R antibody screening in patients with NS is a useful method for the diagnosis of primary MN. In younger patients (less than 60 years-old) that have a preserved renal function and a negative work-up for secondary causes a positive anti-PLA2R antibody test highly predicts a diagnosis of primary MN.

MO293NEUTROPHIL-TO-LYMPHOCYTE RATIO AND OUTCOME IN CRESCENTIC GLOMERULONEPHRITIS

Background and Aims

Crescent formation is a nonspecific response to severe injury to the glomerular capillary wall, which may be seen with any form of inflammatory glomerulopathy. Despite improved therapeutic interventions, patients with crescentic glomerulonephritis (CGN) still have a severe kidney prognosis and high mortality. Since neutrophil-to-lymphocyte ratio (NLR) is an inflammatory marker linked to worse outcomes in patients with malignancies, chronic kidney disease, myocardial infarction, and other clinical settings, we aimed to assess if NLR can predict kidney outcome and mortality in subjects with CGN.

Method

Eighty-four adults with biopsy-proven CGN between 1st Jan. 2008 and 31st Dec. 2017 [age 56 (95%CI 53 to 59) years, 50% males, eGFR 9.3 (95%CI 7.8-12.7) mL/min] were retrospectively enrolled in this single-centre study. Subjects were followed for a median of 31 (95%CI 6 to 56) months, until 31st May 2018. Seven subjects with inadequate biopsy sample and insufficient data were excluded. Demographic (age, gender), clinical and laboratory data at the time of biopsy were obtained from medical records. Kaplan-Meier method was used to evaluate kidney and patient survival. Variables related to kidney outcome were evaluated in a multivariate Cox proportional hazard (CPH) model.

According to median NLR value (4.3, 95%CI 3.5 to 5.2) subjects were clustered in low NLR group (≤4.3; n=38 pts.) and high NLR group (&gt;4.3; n=38 pts.). The primary endpoints were time to renal replacement therapy (RRT) initiation and all-cause mortality.

Results

The most common CGN subtype was pauci-immune GN (76.3%; i.e. myeloperoxidase-ANCA vasculitis - 48.7%, PR3-ANCA vasculitis - 15.8% and ANCA-negative vasculitis - 11.8%) followed by. anti-GBM antibody and immune complex related GN, with similar frequencies (11.8% each). According to kidney biopsy (KB) findings, half of the subjects had fibro-cellular crescents (55.3%), while cellular and fibrous crescents were found in 35.5% and 9.2%, respectively. Almost all subjects received corticosteroids (97.4%) and 82.9% received cyclophosphamide.

Baseline eGFR was lower in the high-NLR group (8.5 vs. 11.6 mL/min, p=0.04), but no other differences in laboratory findings at baseline between the two groups were found. In bivariate analysis, NLR was negatively associated with serum albumin (rs=-0.26, p=0.02). NLR was not associated with other inflammation markers, Charlson comorbidity score, nor with the type of crescents at KB.

During the follow-up period 53.9% started RRT and 19.7% died. There were no differences regarding mortality between the two groups.

The mean kidney survival time was 47.6 (95%CI 33.5, 61.7) months. Kidney survival at 12, 24, 48 and 60 months were 44, 41, 38, and 33% respectively. In univariate time-dependent analysis (Figure) patients with low-NLR (68.95%CI 48 to 88 months) had better kidney survival than those with high-NLR (25, 95%CI 13 to 38 months; log rank p=0.004). Moreover, the kidney survival advantage remained (OR 1.06, 95%CI 1.002 to 1.16) after adjusting for eGFR, proteinuria, C reactive protein, immunosuppressive treatment and CGN etiology. Lower eGFR-ul was also associated with poor kidney survival (OR 0.96, 95%CI 0.88 to 0.97).

Conclusion

In adults with biopsy-proven crescentic glomerulonephritis and advanced kidney function decline, a higher neutrophil-to-lymphocyte ratio seems to predict worse kidney survival, but not the risk of mortality.

IgA nephropathy with serum ANCA positivity: case series and literature review

The co-occurrence of IgA nephropathy (IgAN) and positive anti-neutrophil cytoplasmic autoantibodies (ANCA) serology is uncommon. In the present case series and literature review, we aimed to clarify the impact of ANCA on pathogenesis, clinical and histopathology presentation, and outcome in IgAN patients. We report four patients with an overlap lesion of IgAN-ANCA positive. Also, we performed a narrative review of all biopsy-proven published case series. Only 1.2% patients had ANCA in our 330-biopsy-proven IgAN cohort. We compared our data with previous reports-6 case series and 3 small retrospective studies-a total of 103 patients. All patients but one had eGFR below 15 mL/min at diagnosis. Besides rapidly decreasing eGFR, all presented with proteinuria around 1.5 g/day and dysmorphic microhematuria, suggesting glomerular inflammation. Systemic symptoms suggestive for ANCA vasculitis were seen in half of our patients, but only one patient had hemorrhagic alveolitis. Patients from our cohort responded to the intensive immunosuppressive regimens used in ANCA-positive vasculitis with renal involvement. However, in the follow-up, one patient had a relapse followed by septic shock related to immunosuppression and one patient started hemodialysis. In the review, we found that IgAN-ANCA -positive patients are characterized by vasculitis-like lesions and clinically by a rapidly progressive decline in kidney function, which was reversed by an aggressive induction immunosuppressive protocol used in ANCA vasculitis. Checking ANCA serology seems useful in patients with rapidly progressive IgAN for therapeutic and prognostic reasons.

Low-salt low-protein diet and blood pressure control in patients with advanced diabetic kidney disease and heavy proteinuria

PURPOSE

To assess the associations between effects of low salt, low protein diet supplemented with keto-analogues (sLPD)-on salt intake, blood pressure (BP) and cardiovascular events (CVEs) in patients with advanced diabetic kidney disease (DKD) and heavy proteinuria.

METHODS

Prospective, single-center study (total duration of 15 months), enrolling 92 patients with advanced DKD (median eGFR 11.7 ml/min) and heavy proteinuria (median 4.8 g/g creatininuria). The intervention consisted in a low salt-low protein (0.6 g/kg-day) diet (sLPD) under intensive nutritional counselling, and adjustment of antihypertensive therapy. The endpoints of this sub-analysis were a salt intake ≤ 5 g/day, a mean blood pressure (MAP) ≤ 97 mmHg, corresponding to KDIGO target of 130/80 mmHg, and the rate of CVEs.

RESULTS

Salt intake decreased with 2.5 g/day and the proportion of patients reaching the salt intake endpoint increased with 58%. A salt intake ≤ 5 g/day was associated with a reduced MAP, BMI, proteinuria, fractional excretion of sodium, and eGFR, suggesting a salt-related volume contraction but was not related to protein intake. Mean arterial pressure decreased with 13 mmHg. MAP ≤ 97 mmHg was associated with lower proteinuria, salt, and protein intake, but the contribution of salt intake cannot be differentiated from that of protein intake. CVEs occurred in 20% of patients and were independently related to a lower age and MAP, and increased comorbidities. eGFR only minimally declined and no renal adverse events were noted. sLPD was nutritionally safe.

CONCLUSIONS

The multifactorial personalized intervention allowed a stable MAP reduction to KDIGO recommended levels (≤ 97 mmHg), related to the decrease in salt and protein intake. However, BP lower than 130/80 mmHg increased the cardiovascular but not the renal risk in heavy proteinuric patients with advanced DKD.

TRIAL REGISTRATION NUMBER

0341507433: NCT03415074. Registered 02/02/2015 in US National Library of Medicine, ClinicalTrials.gov (NCT).

Protein convertase subtilisin/kexin type 9 biology in nephrotic syndrome: implications for use as therapy

Low-density lipoprotein cholesterol (LDL-C) levels almost constantly increased in patients with nephrotic syndrome (NS). Protein convertase subtilisin/kexin type 9 (PCSK9) [accelerates LDL-receptor (LDL-R) degradation] is overexpressed by liver cells in NS. Their levels, correlated inversely to LDL-R expression and directly to LDL-C, seem to play a central role in hypercholesterolaemia in NS. Hypersynthesis resulting from sterol regulatory element-binding protein dysfunction, hyperactivity induced by c-inhibitor of apoptosis protein expressed in response to stimulation by tumour necrosis factor-α produced by damaged podocytes and hypo-clearance are the main possible mechanisms. Increased LDL-C may damage all kidney cell populations (podocytes, mesangial and tubular cells) in a similar manner. Intracellular cholesterol accumulation produces oxidative stress, foam cell formation and apoptosis, all favoured by local inflammation. The cumulative effect of cellular lesions is worsened proteinuria and kidney function loss. Accordingly, NS patients should be considered high risk and treated by lowering LDL-C. However, there is still not enough evidence determining whether lipid-lowering agents are helpful in managing dyslipidaemia in NS. Based on good efficacy and safety proved in the general population, therapeutic modulation of PCSK9 via antibody therapy might be a reasonable solution. This article explores the established and forthcoming evidence implicating PCSK9 in LDL-C dysregulation in NS.

Is There a Role for IgA/C3 Ratio in IgA Nephropathy Prognosis? An Outcome Analysis on An European Population

INTRODUCTION

Serum immunoglobulin A (IgA)/C3 ratio has been reported as a predictor of histological lesions and prognosis in asian patients with IgA nephropathy (IgAN). Since its validity in other populations is unclear, we aimed to evaluate the relationship between IgA/C3 ratio and renal outcome in Caucasian European patients with biopsy-proven IgAN.

METHODS

We conducted a retrospective, observational study on 95 patients with primary IgAN patients diagnosed between 2010 to 2017 (70% male, age 41 (34 to 49) years, eGFR 39.4 (25.2 to 56.5) mL/ min, proteinuria 1.7 (0.8 to 3.0) g/g). The primary study composite end-point was doubling of serum creatinine, ESRD (dialysis or renal transplant) or death, whichever came first.

RESULTS

Median follow-up was 30 (95% CI: 27.5 to 32.4) months; 11% developed ESRD, 10% experienced serum creatinine doubling, and 1% died. The endpoint was reached by 21% of the patients. They had lower eGFR, higher proteinuria and hematuria, and lower serum albumin. The distribution in Oxford classes was alike. The AUROC for IgA/C3 ratio was 0.60 (95% CI: 0.45 to 0.74) and generated an optimal cut-off of 2.91 (sensitivity 68%, specificity 55%). The mean event-free survival of the whole cohort was 5.2 (95% CI: 4.7 to 5.8) years. Patients with IgA/C3 ratio < 2.9 had a tendency to better renal survival (P > .05). In Cox proportional hazard ratio model, the independent predictors of a poorer eventfree survival were higher serum creatinine, higher proteinuria and increased IgA/C3 ratio, while renin angiotensin system inhibitors predicted better outcome.

CONCLUSION

Our study reports evidence that supports IgA/C3 ratio as a reasonable predictor of IgAN prognosis in European patients.

Results from the ERA-EDTA Registry indicate a high mortality due to COVID-19 in dialysis patients and kidney transplant recipients across Europe

The aim of this study was to investigate 28-day mortality after COVID-19 diagnosis in the European kidney replacement therapy population. In addition, we determined the role of patient characteristics, treatment factors, and country on mortality risk with the use of ERA-EDTA Registry data on patients receiving kidney replacement therapy in Europe from February 1, 2020, to April 30, 2020. Additional data on all patients with a diagnosis of COVID-19 were collected from 7 European countries encompassing 4298 patients. COVID-19-attributable mortality was calculated using propensity score-matched historic control data and after 28 days of follow-up was 20.0% (95% confidence interval 18.7%-21.4%) in 3285 patients receiving dialysis and 19.9% (17.5%-22.5%) in 1013 recipients of a transplant. We identified differences in COVID-19 mortality across countries, and an increased mortality risk in older patients receiving kidney replacement therapy and male patients receiving dialysis. In recipients of kidney transplants ≥75 years of age, 44.3% (35.7%-53.9%) did not survive COVID-19. Mortality risk was 1.28 (1.02-1.60) times higher in transplant recipients compared with matched dialysis patients. Thus, the pandemic has had a substantial effect on mortality in patients receiving kidney replacement therapy, a highly vulnerable population due to underlying chronic kidney disease and a high prevalence of multimorbidity.

Adult-onset minimal change disease: the significance of histological chronic changes for clinical presentation and outcome

INTRODUCTION

Data on pathologic features with prognostic utility in adults with minimal change disease (MCD) are limited. We assessed the relationship between histologic chronic changes and clinical presentation and outcomes.

METHODS

The consecutive records of 79 patients with MCD and minimum of 6 months follow-up were retrospectively reviewed. Kidney survival was the primary endpoint (doubling serum creatinine or dialysis initiation). Secondary endpoints were time to remission and relapse. Total chronicity score was the sum of glomerulosclerosis (0-3), interstitial fibrosis (0-3), tubular atrophy (0-3), and arteriolosclerosis (0/1).

RESULTS

The median renal chronicity score was 1; 77% had minimal (0-1), 18% mild (2-4), and 5% moderate (5-7) chronicity. Fifty percent had a null score; they were younger, had higher eGFR, similar proteinuria, better renal survival, and lower mortality. Mean kidney survival time was 5.7 (95% CI 5.2-6.2) years; 89% reached a form of remission at a median of 8 weeks; 31% relapsed at a mean of 26 months. Chronic changes severity predicted both relapses and kidney survival, each one-point increase in score raised with 27% the risk of relapse and with 31% the risk of dialysis initiation. Acute kidney injury (AKI) was present in 42% of the patients; they had more often mesangial proliferation, interstitial inflammation, tubular atrophy, arteriosclerosis, podocyte villous hypertrophy, and higher chronicity score.

CONCLUSION

Standardized grading of chronicity was a predictor of kidney survival and disease relapse and was related to AKI. Older patients with severe nephrotic syndrome and with increased chronicity score could represent a high-risk category.

P0279DIABETIC KIDNEY DISEASE VERSUS CHRONIC KIDNEY DISEASE IN ADULTS WITHOUT DIABETES MELLITUS: A RENAL SURVIVAL ANALYSIS

Background and Aims

Diabetic kidney disease (DKD) is the most common cause of end-stage renal disease, but the decline in kidney function varies considerably between chronic kidney diseases (CKD), and determinants of renal function loss, early in the course of the disease, are still a matter of debate.

Method

We retrospectively examined the renal outcome at 31 July 2017 of 309 CKD patients (age 59.1 (50.1-68.6) years; 60% male; eGFR 32.7 (21.7-44.8) mL/min) admitted in our hospital during January 2007-December 2012 with a median follow up time of 7.2 (95%CI, 6.8-7.6) years. Only patients who had at least 3 admissions and who were alive during the study period were included. CKD was defined as the presence of an eGFR &lt;60ml/min/1.73m2 or the presence of albuminuria &gt;30mg/g creatinine for more than 3 months. The primary endpoint was renal survival defined as renal replacement therapy (RRT) initiation. Factors affecting renal survival were evaluated in a Cox proportional hazard model.

Results

DKD (24%), glomerular (GN, 24%), tubulo-interstitial (TIN, 27%) and vascular nephropathies (VN, 25%) were the causes of CKD. Patients with DKD (66.8 (56.5-72.2) years) and VN (68.5 (59.7-76.2) years) were older than those with GN (50.3 (37.4-59.0) years) and TIN (55.6 (45.8-61.8) years). Moreover, the highest cardiovascular comorbidity score was found in patients with VN and DKD (p&lt;0.001). Median eGFR decline was -1.23 ( -3.39 – 0.35) mL/min/year; 29% of the patients had CKD progression of &gt;3mL/min/year and 14% had rapid progression (&gt;5mL/min/year). Patients with GN had the lowest eGFR (26.8 (19.1-38.9) versus DKD 36.2 (23.4-47.7), VN 34.9 (22.4-51.0), TIN 32.4 (21.8-44.8) mL/min, p&lt;0.001), the fastest eGFR decline (-3.1 versus DKD -1.9, VN -1, TIN -1,2 mL/min/year, p 0.5) and the highest proteinuria (2.7 versus DKD 1.4, VN 0.4, TIN 0.6 g/24h, p&lt;0.001). During follow up, 29% of the studied patients started RRT; mean renal survival time for the entire cohort was 7.4 (95%CI, 7.0-7.8) years. CKD cause (versus DKD p=0.04, Figure 1), lower eGFR (HR 0.89 (95%CI, 0.85-0.93)), elevated albuminuria (HR 1.4 (95%CI, 1.2-1.7)), higher total serum cholesterol (HR 1.00 (95%CI, 1.00-1.01)) and elevated mean arterial blood pressure (HR 1.03 (95%CI, 1.00-1.06)) were associated with RRT initiation in the Cox regression model.

Conclusion

Patients with DKD and VN had similar poorer renal survival as compared with GN and TIN. Earlier referral to the diabetic renal clinic and intensive management of the modifiable risk factors (albuminuria, hypercholesterolemia, hypertention) are necessary to retard progression of CKD and, subsequently, prolong renal survival.

P0113STANDARDIZED GRADING OF CHRONIC CHANGES IN MINIMAL CHANGE DISEASE: A VALIDATION STUDY IN NATIVE KIDNEY BIOPSY SPECIMENS

Background and Aims

Recently, a group of pathologists and nephrologists devised a simple scoring system for chronic changes based on the grading of glomerulosclerosis (GS), tubular atrophy (TA), interstitial fibrosis (IF) and arteriosclerosis (AS). We aimed to validate for the first time this score in patients with minimal change disease.

Method

We included 79 adult patients (age 50.3 (46.3, 54.3) years, 57% male, eGFR 54.7 (44.2, 63.5) mL/min) with biopsy proven MCD between 2010-2015 who were followed up until January 1, 2017. The extent of GS, TA and AS was scored from 0 to 3, 0 to 3 and 0 to 1, respectively. The scores were then added (total renal chronicity score) to grade the overall severity of the chronic lesions into minimal (0–1 total score), mild (2–4 total score), moderate (5–7 total score) and severe (&gt;8 total score). The outcomes were: patient survival; kidney survival defined as doubling of serum creatinine or ESRD; partial (proteinuria 0.3 to 3.5g/24h) or complete remission (proteinuria &lt;0.3g/24h) - whichever came first. Variables related to renal outcome were further evaluated in a multivariate Cox proportional hazard (CPH) model.

Results

Minimal chronic lesions were found in 77%, mild in 18% and moderate in 5% of the studied patients. Fifty percent had a null score of chronicity; they were younger (44 (29-53) versus 62 (44-66) years, p&lt;0.001), had higher eGFR (65.0 (42.1-83.2) versus 43.4 (25.8-63.9) mL/min, p&lt;0.01) but similar proteinuria (4.8 (1.9-8.2) versus 4.5 (1.1-6.7) g/g, p=0.3). Patients with a score higher than one had higher mortality (18% versus 0%, p&lt;0.001) and started RRT more often (15% versus 0%, p=0.01). There were no differences regarding the presentation as acute kidney injury, and in reaching complete or partial remission. Moreover, there were no clinical or pathology features that predicted remission. 17% of the patients reached the composite endpoint of kidney survival; mean kidney survival time was 5.7 (5.2, 6.3) years. In the CPH analysis the only independent predictors of decreased renal survival were elevated chronicity score (HR 1.56 (95%CI 1.14-2.14), p&lt;0.01), lower serum albumin (HR 0.27 (95%CI 0.08-0.88), p=0.03) and the presence of hypertension (HR 0.18 (95%CI 0.03-0.93), p=0.04).

Conclusion

To the best of our knowledge, this is the first study to validate the standardized grading of chronic changes as an independent predictor of renal survival in patients with minimal change disease.

P0861THE RELATIONSHIP BETWEEN HEPCIDIN-25 AND BONE MARROW IRON IN ANEMIC, NON-DIALYSIS, CHRONIC KIDNEY DISEASE PATIENTS

Background and Aims

Hepcidin-25 (Hep25) is a key known regulator of iron metabolism and its interactions with inflammation, iron stores and erythropoietic activity were involved in the pathogenesis of chronic kidney disease (CKD)-associated anemia. Therefore, our aim was to assess the determinants of serum Hep25 level in non-dialysis CKD patients.

Method

In this cross-sectional, single-center study, 52 subjects (56% men, 65±13 years) with CKD [estimated glomerular filtration rate, eGFR 14.5 (95%CI 16 to 25) mL/min] and anemia [hemoglobin, Hb 9.8 (95%CI 9.2 to 9.9) g/dL], not treated with erythropoiesis-stimulating agents (ESA) or iron in the previous 6 months, were enrolled. Patients with anemia of other causes than CKD, active infectious and inflammatory diseases, malignancy, severe hyperparathyroidism, transfusions during the last 3 months, and immunosuppressive therapy were excluded.

The iron status was evaluated using both peripheral and central parameters. The iron stores were assessed by serum ferritin (Fer) and iron content in bone marrow macrophages (iMf, measured quantitively on a scale from 0 to 6). The iron available for erythropoiesis was assessed by transferrin saturation (TSAT) and the percentage of sideroblasts (%Sb). Anemia was further evaluated by a peripheral blood smear, erythrocytes indices and reticulocyte index.

Serum Hep25 and erythropoietin (Epo) were assessed by ELISA (Bachem®, and Abcam® 119522, respectively). C-reactive protein (CRP), albumin, and parameters of kidney disease (eGFR, proteinuria) were also measured.

Mann-Whitney, Kruskal-Wallis, Chi2 tests, Spearman bivariate correlation and multiple linear regression were used for statistical analysis.

Results

The median serum Hep25 of the whole cohort was 82.1 (95%CI 68.7 to 92.1) ng/mL. According to median Hep25, subjects were clustered in Group 1 (below median - G1) and Group 2 (above median - G2).

%Sb and reticulocyte index had higher levels in G2 than in G1 [9 (95%CI 5 to 14) vs. 5 (95%CI 4 to 7) %, p=0.003 and 0.55 (95%CI 0.39 to 0.77) vs. 0.41 (95%CI 0.32 to 0.58), p=0.05, respectively], while the proportions of subjects with iMf suggestive for iron deficiency or iron overload were similar in G2 and G1 (38% vs. 50%, p=0.40, and 26% vs. 23%, p= 0.75, respectively). Peripheral blood smear, peripheral iron indices and all the other studied parameters were also alike.

In bivariate analysis, Hep25 was positively associated both with indices of iron stores, i.e. Fer (rs = 0.30, p=0.03) and iMf (rs = 0.34, p=0.01) and indices of iron available for erythropoiesis, i.e. %Sb (rs = 0.55, p&lt;0.001) and (marginally) with TSAT (rs = 0.26, p=0.06). Meanwhile, Hep25 was not related to serum Epo, CKD parameters or inflammation markers.

In a multivariate linear regression model that explained 28% of Hep25 variation, the percentage of bone marrow sideroblasts, i.e. the tissue iron available for erythropoiesis, was the only independent determinant of Hep25:

Variables entered in the first step: reticulocyte index, percentage of medullary sideroblasts (%Sb), iron content in the bone marrow macrophages (iMf), serum ferritin, and transferrin saturation

Conclusion

In stable patients with advanced CKD, not treated with ESA or iron, with low to moderate inflammation, serum hepcidin was related only to bone marrow iron available for erythropoiesis, suggesting that in this clinical setting the need of iron for erythropoiesis prevails over inflammation in regulation of hepcidin synthesis.

P0426HISTOLOGICAL PREDICTORS OF RENAL PROGNOSIS IN LUPUS NEPHRITIS: WHICH COMPARTMENT MAKES THE DIFFERENCE?

Background and Aims

Lupus nephritis (LN) encompasses a spectrum of glomerular, tubulointerstitial, and vascular lesions; we aimed to evaluate which compartment injury has renal prognostic value.

Method

We retrospectively examined the renal outcome at 31 December 2015 of 66 patients (age 36 [28-52] years; 76% female; eGFR at baseline 60.8 [24.4-78.1] mL/min) who were diagnosed with lupus nephritis by kidney biopsy during 2010-2015. Data regarding the clinical presentation, renal function, histology (presence/absence of lesions - Table 1; ISN/RPS classification) and treatment were retrieved from the electronic patients’ files. We used a composite endpoint in the survival analysis (Cox proportional hazard models, CPH): renal replacement therapy initiation, doubling of serum creatinine and death, whichever came first.

Results

Nephrotic syndrome was the most frequent form of presentation (42%), followed by nephritic (24%) and nephrotic-nephritic (15%). Most of the patients received immunosuppression treatment (97%, 70% cyclophosphamide regimen). Twenty-five patients (38%) reached the composite endpoint. They were older, male more often, had higher mean arterial pressure (MAP), lower serum albumin, decreased eGFR and higher proteinuria. Moreover, they were in class IV LN and had glomerulosclerosis more frequently. Median renal survival for the entire cohort was 4.4 (95%CI, 2.3-6.5) years. In the multivariatle CPH for the histological predictors, only ISN/RPS classification and tubular atrophy were associated with renal survival (Table 1). In a CPH that included clinical, histological and treatment variables, only lower eGFR (0.97 (95%CI, 0.95-0.99)), MAP (1.03 (95%CI, 1.00-1.06)) and tubular atrophy (4.52 (95%CI, 1.50-13.55)) remained as independent predictors of renal survival.

Conclusion

Tubular atrophy seems to be an important prognostic sign in LN; therefore, greater importance should be given to the tubulointerstitial compartment evaluation.

P0929LOW PROTEIN DIET, BLOOD PRESSURE CONTROL AND NATRIURESIS IN PATIENTS WITH ADVANCED DIABETIC KIDNEY DISEASE AND HEAVY PROTEINURIA

Background and Aims

Recent data suggest the possibility to optimize blood pressure control by low protein diet (LPD) in patients with diabetic kidney disease (DKD). We aimed to assess the effects of a low protein diet (LPD) supplemented with keto-analogues on urinary sodium excretion and blood pressure control.

Method

Prospective, uni-center study with a total duration of 15 months.The study was conducted in a tertiary Nephrology Clinic and included a total of 92 diabetic patients with advanced CKD (eGFR &lt; 30 mL/min) and heavy proteinuria (&gt; 3 g/g creatininuria). Intervention consisted in a LPD (0.6 g/kg-day) supplemented with keto-analogues of essential amino acids with nutritional counselling and adjustment of antihypertensive therapy.

The primary efficacy parameter was proteinuria during intervention as compared to pre-enrolment. Blood pressure (BP), urinary sodium excretion, eGFR and blood glucose control were secondary end-points.

Results

Mean arterial pressure (MAP) decreased from baseline (Bs) to end of study (EOS) with -11 (-17 to -7) mmHg despite a reduction with 22% of patients needing antihypertensive medication. Independent predictors of a lower than median MAP (90mmHg) were a lower protein intake (HR 0.00 (0.00; 0.04; p=0.002), treatment with furosemide (HR 1.06 [1.06; 3.85]; p=0.03) but not with angiotensin-aldosterone system inhibitors (RAASi) [HR 0.17 (0.17; 0.90); p=0.03)] and was not influenced by natriuresis.

Natriuresis decreased from 130 (121-135) to 80 (71-86) mmol/day (p&lt;0.0001). A lower than median natriuresis (100mmol/day) was directly related to proteinuria [HR 0.0003 (0.00; 0.004); p=&lt;0.0001], eGFR [HR 0.0001 (0.00; 0.14); p=0.01] and to diuretic therapy [0.21 (0.05; 0.83); p=0.03] but not to protein intake.

Cardiovascular events were observed in 20% of patients and their occurrence was related to a lower MAP [0.97 (0.95; 0.99}; p=0.001]. No renal adverse were noted and the diet was nutritionally safe.

Conclusion

A low protein diet supplemented with ketoanalogues of essential amino acids on top of anti-hypertensive therapy (mostly loop diuretics) allows for a good control of blood pressure, unrelated to natriuresis in heavy proteinuric patients with advanced DKD.

P0433AGE-RELATED DIFFERENCES IN THE SPECTRUM OF BIOPSY-PROVEN GLOMERULONEPHRITIS

Background and Aims

The proportion of geriatric population is increasing globally and age-related changes, as kidney ageing and decline in immunocompetence, might interfere with frequency of various glomerulopathies (GP). Thus, it is conceivable that the spectrum of biopsy-proven GP varies across different age categories. Accordingly, we aimed to describe age-related variation in clinical presentation and the in prevalence of GP diagnosed by kidney biopsy (KB) in adults.

Method

This retrospective study enrolled 1254 subjects selected from the KB database of a large tertiary academic Nephrology center (which provides specialized care for the south-eastern part of our country), over a ten-year span (01.01.2008-31.12.2017). Inclusion criteria were age &gt;18 years, native kidney biopsy, availability of data from light, immunofluorescence, and electron microscopy, and a histologic diagnosis of GP. Repeated biopsies and inadequate tissue samples were excluded. Demographic (age, gender), clinical and laboratory data at the time of biopsy were extracted from medical records for all the selected subjects.

To investigate the possible influence of age on the spectrum of biopsy-proven GP, the cohort was divided into 4 categories: young adults (18 to 30 years, n=156), adults (31 to 64 years, n=868), elderly (65 to 74 years, n=176) and very elderly (≥75 years, n=54), and the collected data were compared by non-parametric methods (Mann-Whitney, Chi2 and Fisher exact tests).

Results

The nephrotic syndrome was the most common presentation form in all age groups but had a higher prevalence in very elderly (62%) and elderly (55%) as compared to adults (37%, p=0.01) and young adults (41%, p&lt;0.001). In the groups below age of 65, the chronic nephritic syndrome was the second most common indication for KB (31% and 28%, respectively), followed by chronic renal failure in adults (13%) and acute nephritic syndrome in young adults (10%).

Lupus nephritis (LN) and IgA nephropathy (IgAN) were the most commonly diagnosed GP in young adults (22% each), followed by minimal change disease (MCD, 14%), membranous nephropathy (MN, 8%), focal and segmental glomerulosclerosis (FSGS, 8%), and thin basement membrane disease (6%). In adults, the most common GP were: IgAN (23%), MN (15%), diabetic nephropathy (DN, 11%) and MCD (10 %).

Conversely, in both the elderly and the very elderly, the most common biopsy-proven GP was MN (26% each). Elderly had renal amyloidosis as the second most prevalent histological diagnosis (17%), followed by DN (11%), and by IgAN and MCD (≈10% each). Crescentic glomerulonephritis (CGN) occurred in 7.5% of the elderly, but it was the second pathology (17%) in subjects aged 75+ years, followed by MCD (15%) and DN (13%). IgAN and amyloidosis were identified in about 5% of this group.

It appears that the prevalence of both clinical presentation and histologically diagnosed GP showed some similarities between the first two and, respectively, last two age categories.

Conclusion

Biopsy-proven GP have different frequencies depending on the patient’s age, with some pathologies predominantly found at older ages (such as membranous nephropathy, amyloidosis and crescentic GN) or, on the contrary, typical for young adults (lupus nephritis and IgAN). These differences account for the distinct clinical presentations at the time of KB.

P0422RED BLOOD CELL DISTRIBUTION WIDTH AND OUTCOME IN SUBJECTS WITH BIOPSY-PROVEN GLOMERULOPATHIES WITHOUT ANEMIA

Background and Aims

Red blood cell distribution width (RDW) is a marker of anisocytosis and is mainly modified in anemia. However, elevated RDW has recently been reported to predict cardiovascular risk, was correlated with disease activity in inflammatory conditions such as systemic lupus erythematosus, rheumatoid arthritis and, not the least, was associated with increased risk of end stage kidney disease and proteinuria in chronic kidney disease (CKD) subjects. The current study aims to assess if RDW is an independent predictor for renal replacement therapy (RRT) and mortality in subjects with glomerulopathies (GP).

Method

This retrospective, single-center study, included 467 subjects with hemoglobin &gt;12 g/dL at presentation, who were histologically diagnosed with primary and secondary glomerulopathies between 1st Jan. 2008 and 31st Dec. 2017 and who were followed for a mean of 52.8 (95%CI 50.7-55) months, until 31st May 2018. Subjects with inadequate biopsy sample were excluded. Those who deceased until the end of the follow-up were not included in the kidney survival analysis. Predictors of mortality were assessed by logistic regression. Kaplan-Meier method was used to evaluate kidney survival.

Patients were stratified in two groups according to the median RDW value: low RDW group (RDW≤15%; n=342) and high RDW group (RDW&gt;15%; n=125). RRT initiation and all-cause mortality were the primary endpoints of the study.

Results

Subjects with high RDW were older [53 (95%CI 48-56) vs. 45 (95%CI 43-47) years; p=0.03], had more frequent cerebrovascular disease (9.7% vs. 2.7%; p=0.003), congestive heart failure (8.1% vs. 1.8%; p=0.002), connective tissue disease (11.3% vs. 3%; p=0.001) and non-hematologic neoplasia (4.8% vs. 0.9%, p=0.01). Furthermore, they had more severe inflammation as suggested by higher erythrocyte sedimentation rate [54.5 (95%CI 43-60) vs. 35 (95%CI 30-40) mm/hour; p=0.002], fibrinogen [630 (95%CI 562-701) vs. 540 (95%CI 514-585 mg/dL; p=0.02], and C reactive protein [3 (95%CI 2-4) vs. 2 (95%CI 2-3); p=0.03], had lower hemoglobin [13.7 (95%CI 13.4-14) vs. 14.1 (95%CI 13.9-14.4) g/dL); p=0.008], and higher proteinuria [4.2 (95%CI 3.1-5.2) vs. 2.4 (95%CI 2.1-2.8) g/g creatinine; p=0.002]. However, the kidney function between the two groups was similar (56.5 vs. 55 ml/min MDRD; p=0.1).

Secondary GP were more frequent encountered in high RDW group (42.4% vs. 18.1%; p&lt;0.001), especially amyloidosis (19.2% vs. 4.7%; p&lt;0.001) and lupus nephritis (9.6% vs. 3.5%; p=0.01).

During the follow-up period, in high RDW group 26.4% of the subjects died, compared to 11.4% from the other group (p&lt;0.001). In a multivariate logistic regression model, RDW was an independent predictor for mortality [OR 1.5 (95%CI 1.2-15); p=0.007]. Other independent predictors were older age [OR 1.06 (95%CI 1.03-1.08); p&lt;0.001], presence of cerebrovascular disease [OR 3.31 (95%C I1.01-10.8); p=0.04], lower serum albumin [OR 0.48 (95%CI 0.43-0.70), p&lt;0.001] and higher serum creatinine [OR 1.29 (95%CI 1.06-1.57); p&lt;0.001]. There was no difference regarding the frequency of RRT initiation between groups (18% in high RDW group vs. 11% in low RDW group; p=0.07) and the time to kidney death was similar [79.7 (95%CI 72.8-86.6) vs. 87.8 (95%CI 84-91.6) months; log rank p=0.1].

Conclusion

In non-anemic subjects with biopsy-proven glomerular disease, a higher RDW seems associated with a higher risk of mortality, but not with kidney survival. In addition, RDW above 15% might point out to a secondary GP, like amyloidosis and lupus nephritis.

The Success Story of Peritoneal Dialysis in Romania: Analysis of Differences in Mortality by Dialysis Modality and Influence of Risk Factors in a National Cohort

Background

This report describes the status of renal replacement therapy (RRT), particularly continuous ambulatory peritoneal dialysis (CAPD), in Romania (a country with previously limited facilities), outlines the fast development rate of CAPD, and presents national changes in a European context.

Methods

Trends in the development of RRT were analyzed in 2003 on a national basis using annual center questionnaires from 1995 to 2003. Survival data and prognostic risk factors were calculated retrospectively from a representative sample of 2284 patients starting RRT between 1 January 1995 and 31 December 2001 (44% of the total RRT population investigated).

Results

The annual rate of increase in the number of RRT patients (11%) was supported mainly by an exponential development of the CAPD population (+600%); the hemodialysis (HD) growth rate was stable (+33%) and renal transplantation had a marginal contribution. The characteristics of both HD and PD incident patients changed according to current European epidemiology (increasing age and prevalence of diabetes and nephroangiosclerosis). There were significant differences between PD and HD incident populations, PD patients being significantly older and having a higher prevalence of diabetic nephropathy and baseline comorbidities, probably reflecting different inclusion policies. The estimated overall survival of RRT patients in Romania was 90.6% at 1 year [confidence interval (CI) 89.4 – 91.8] and 62.2% at 5 years (CI 59.4 – 65.0). The initial treatment modality did not significantly influence patients’ survival. There was no difference in unadjusted technique survival during the first 2 years; afterwards, there was a clear advantage for HD, with more patients being transferred from PD to HD. Several factors seemed to significantly and negatively influence PD patients’ survival (Cox regression analysis): male gender, lack of predialysis erythropoietin treatment, and initial comorbidities. Stratified analysis to discover the influence of these factors on patients’ survival revealed that HD was associated with an increased risk of death in the younger nondiabetic end-stage renal disease population, regardless of other coexisting comorbid conditions. However, in older patients (>65 years) and in diabetics, regardless of the presence or absence of associated comorbid conditions, there was no significant difference in death rates between HD and PD patients.

Conclusions

We report an impressive quantitative and qualitative development of CAPD in one of the rapidly growing Central and Eastern Europe countries. CAPD should be the method of choice for young nondiabetic end-stage renal disease patients. Improvement in predialysis nephrologic care and in transplantation rates is required to further ensure the ultimate success of the Romanian PD program.

Consensus statement on the assessment of comorbidities in people living with HIV in Romania

Introduction

The life expectancy of HIV-infected patients has been increased by highly effective therapies. People living with HIV (PLWH) in Romania are exposed to age-related comorbidities occurring earlier than in uninfected individuals. Multidisciplinary care is required to maintain the general health and quality of life in these patients. Currently, the communication among different specialties needs to be enhanced and formalized.

Methods

A panel consisting of 8 Romanian experts in infectious diseases, cardio-metabolic, bone, and kidney diseases and psychology met in May 2019 in Bucharest Romania to discuss the need to evaluate and monitor the most prevalent comorbidities in PLWH. The meeting resulted in practical guidance on the management of several non-infectious associated diseases. The algorithms were endorsed by the Society for Infectious Diseases and HIV/AIDS, Romania.

Results

The consensus statement offers practical guidance on how to assess and monitor associated diseases in adult PLWH. The recommendations are grouped for each cluster of comorbidities and are based on international guidelines and clinical experience, including landmarks for referral of PLWH to cardiology, endocrinology, nephrology specialist or clinical psychologist for additional investigations and adequate treatment. Specific indications for diagnosis or treatment were beyond the scope of this consensus.

Conclusions

Screening for associated diseases and adequate management are required to maintain the overall health status of PLWH. When implemented in clinical practice, the recommended algorithms should be used in addition to diagnosis and treatment guidelines and protocols. The infectious diseases specialist plays a key role in coordinating the overall treatment strategy and working within the multidisciplinary team.

Intrarenal resistive index conundrum: systemic atherosclerosis versus renal arteriolosclerosis

Background: We aimed to evaluate the relationship between biopsy-proven kidney lesions, subclinical markers of atherosclerosis and intrarenal resistive index (RRI) in chronic kidney disease (CKD) patients.

Methods: This cross-sectional, single-center study prospectively enrolled 44 consecutive CKD patients (57% male gender, 54.1 (95%CI, 49.7–58.6) years, median eGFR 28.1 (15.0–47.7) mL/min) diagnosed by renal biopsy during 6 months in our clinic. RRI, carotid intima-media thickness (IMT), Kauppila score for abdominal aortic calcification (AACs) were assessed. Traditional and nontraditional atheroscleosis risk factors were also evaluated.

Results: Most of the patients had a diagnosis of glomerular nephropathy, with IgA nephropathy and diabetic nephropathy being the most frequent. RRI increased proportionally with CKD stages. Patients with RRI >0.7 (39%) were older, had diabetic and vascular nephropathies more frequently, higher mean arterial blood pressure, increased systemic atherosclerosis burden (IMT and AACs), higher percentage of global glomerulosclerois, GBM thickness, arteriolosclerosis and interstitial fibrosis/tubular atrophy. RRI directly correlated with age (rs = 0.55, p < 0.001) and with all the studied atherosclerosis markers (clinical atherosclerosis score rs = 0.50, p = 0.02; AACs rs = 0.50, p < 0.01; IMT rs = 0.34, p = 0.02). Also, global glomerulosclerosis (rs = 0.31, p = 0.03) and interstitial fibrosis/tubular atrophy (rs = 0.35, p = 0.01) were directly correlated with RRI. In multivariable adjusted binomial logistic regression models, only arteriolosclerosis was retained as independent predictor of RRI >0.7.

Conclusion: The analysis of RRI may be useful in the evaluation of the general vascular condition of the patient with CKD, supplying information about both microvascular and macrovascular impairment. Moreover, RRI correlates well with renal histopathologic characteristics, particularly with arteriolosclerosis.

Has The Time Arrived to Refine The Indications of Immunosuppressive Therapy and Prognosis in IgA Nephropathy?

Immunoglobulin A nephropathy (IgAN) is the most frequent glomerular disease worldwide and a leading cause of end-stage renal disease. Particularly challenging to the clinician is the early identification of patients at high risk of progression, an estimation of the decline in renal function, and the selection of only those that would benefit from additional immunosuppressive therapies. Nevertheless, the pathway to a better prognostication and to the development of targeted therapies in IgAN has been paved by recent understanding of the genetic and molecular basis of this disease. Merging the data from the Oxford Classification validation studies and prospective treatment studies has suggested that a disease-stratifying algorithm would be appropriate for disease management, although it awaits validation in a prospective setting. The emergence of potential noninvasive biomarkers may assist traditional markers (proteinuria, hematuria) in monitoring disease activity and treatment response. The recent landmark trials of IgAN treatment (STOP-IgAN and TESTING trials) have suggested that the risks associated with immunosuppressive therapy outweigh the benefits, which may shift the treatment paradigm of this disease. While awaiting the approval of the first therapies for IgAN, more targeted and less toxic immunotherapies are warranted. Accordingly, the targeting of complement activation, the modulation of mucosal immunity, the antagonism of B-cell activating factors, and proteasomal inhibition are currently being evaluated in pilot studies for IgAN treatment.

"Associated" or "Secondary" IgA nephropathy? An outcome analysis

BACKGROUND

Whether differences in outcome between primary (pIgAN) and secondary IgA nephropathy (sIgAN) exist is uncertain.

METHODS

We conducted a retrospective, observational study that included all histologically diagnosed IgAN patients between 2010-2017 (N = 306), 248 with pIgAN and 58 with sIgAN. To obtain samples with similar risk of progression, sIgAN patients were grouped as liver disease and autoimmune/viral disease and propensity score matched to corresponding pIgAN samples. Univariate (Kaplan Meier) and multivariate time-dependent (Cox modelling) analyses were performed to identify predictors of the composite end-point (doubling of serum creatinine, end-stage kidney disease or death).

RESULTS

Of the whole cohort, 20% had sIgAN (6% alcoholic cirrhosis, 6% autoimmune disease and 8% viral infections). sIgAN patients were older, had more comorbidities, lower proteinuria and higher haematuria, but similar distribution in MESTC lesions and eGFR as those with pIgAN. They reached the end-point in similar proportions with those with pIgAN (43 vs. 30%; p = 0.09) but their mortality was higher (19 vs. 3%; p<0.0001). Both in unmatched (HR 0.80, 95%CI 0.42-1.52; p = 0.5) and matched samples (log-rank test: liver disease-IgAN vs. pIgAN, p = 0.1; autoimmune/viral-IgAN vs. pIgAN, p = 0.3), sIgAN was not predictive for end-point. In analyses restricted only to sIgAN, those with viral infections (HR, 10.98; 95% CI, 1.12-107.41; p = 0.03) and lower eGFR (HR, 0.94; 95%CI, 0.89-0.98; p = 0.007) had a worse prognosis. Immunosuppression did not influence outcome.

CONCLUSIONS

The differences in MESTC score and outcome between pIgAN and sIgAN seems to be minimal, suggesting that "associated" describes better than "secondary" the relationship among the two. Immunosuppression did not to influence outcome of sIgAN.

Histologic predictors of renal outcome in diabetic nephropathy: Beyond renal pathology society classification

The prognostic utility of histologic features in patients with diabetic nephropathy (DN) classified according to the Renal Pathology Society (RPS) classification is controversial. Therefore, we aimed to evaluate the relationship between histologic changes and renal outcome in DN patients.We examined the renal outcome at November 30, 2017 of 74 adult patients (median age of 54.6 years, 69% male, 81% diabetes mellitus (DM) type 2, estimated GFR (eGFR) 29.6 mL/min) with biopsy proven DN between 2010 and 2015. The primary endpoint was renal replacement therapy (RRT) initiation.Half of the patients progressed to end stage renal disease (ESRD) during follow-up; they had lower eGFR, increased proteinuria, hematuria and serum cholesterol. Regarding the pathologic features, they were more frequently in class III and IV, had higher interstitial fibrosis and tubular atrophy score (IFTA), increased interstitial inflammation, more frequent arteriolar hyalinosis and higher glomerular basement membrane (GBM) thickness. The mean kidney survival time was 2.7 (95%CI 2.1, 3.3) years. In univariate time-dependent analyses, higher RPS DN class, increased IFTA, the presence of arteriolar hyalinosis and arteriosclerosis were associated with RRT initiation.In the fully adjusted model, the clinical characteristics associated with poor renal survival were longer duration of DM, lower eGFR, increased proteinuria and higher hematuria and the only pathologic lesions to remain significant were the GBM thickness and the IFTA.In conclusion, in this European cohort, the severity of glomerular lesions evaluated with the RPS DN classification had limited utility in predicting RRT initiation. However, IFTA and GBM thickness were significantly associated with renal survival.