Increased mortality after kidney transplantation in mildly frail recipients

Background

Physical Frailty Phenotype (PFP) is the most used frailty instrument among kidney transplant recipients, classifying patients as pre-frail if they have 1–2 criteria and as frail if they have ≥3. However, different definitions of robustness have been used among renal patients, including only those who have 0 criteria, or those with 0–1 criteria. Our aim was to determine the impact of one PFP criterion on transplant outcomes.

Methods

We undertook a retrospective study of 296 kidney transplant recipients who had been evaluated for frailty by PFP at the time of evaluating for transplantation.

Results

Only 30.4% of patients had 0 criteria, and an additional 42.9% showed one PFP criterion. As PFP score increased, a higher percentage of women and cerebrovascular disease were found. Recipients with 0–1 criteria had lower 1-year mortality after transplant than those with ≥2 (1.8% vs 10.1%), but this difference was already present when we only considered those who scored 0 (mortality 1.1%) and 1 (mortality 2.4%) separately. The multivariable analysis confirmed that one PFP criterion was associated to a higher risk of patient death after kidney transplantation [hazard ratio 3.52 (95% confidence interval 1.03–15.9)].

Conclusions

Listed kidney transplant candidates frequently show only one PFP frailty criterion. This has an independent impact on patient survival after transplantation.

COVID-19 in elderly kidney transplant recipients

The SARS-Cov-2 infection disease (COVID-19) pandemic has posed at risk the kidney transplant (KT) population, particularly the elderly recipients. From March 12 until April 4, 2020, we diagnosed COVID-19 in 16 of our 324 KT patients aged ≥65 years old (4.9%). Many of them had had contact with healthcare facilities in the month prior to infection. Median time of symptom onset to admission was 7 days. All presented with fever and all but one with pneumonia. Up to 33% showed renal graft dysfunction. At infection diagnosis, mTOR inhibitors or mycophenolate were withdrawn. Tacrolimus was withdrawn in 70%. The main treatment combination was hydroxychloroquine and azithromycin. A subset of patients was treated with anti-retroviral and tocilizumab. Short-term fatality rate was 50% at a median time since admission of 3 days. Those who died were more frequently obese, frail, and had underlying heart disease. Although a higher respiratory rate was observed at admission in nonsurvivors, symptoms at presentation were similar between both groups. Patients who died were more anemic, lymphopenic, and showed higher D-dimer, C-reactive protein, and IL-6 at their first tests. COVID-19 is frequent among the elderly KT population and associates a very early and high mortality rate.

P0185ROLE OF THE COMPLEMENT SYSTEM IN PROLIFERATIVE LUPUS NEPHRITIS

Background and Aims

Lupus Nephritis (LN) is a serious complication in patients with Systemic Lupus Erythematosus (SLE) which confers a worse prognosis in patients that develop this condition. It is well known that histological lesions correlate poorly with the prognosis of the disease, but little is known about the role of complement proteins deposition in kidney tissue. The aim of this study was to evaluate the effect on renal manifestations of the deposition in renal tissue of C3, as a marker of alternative pathway, C4 as a marker of the classical pathway and C1q representing the lectin pathway.

Method

A retrospective observational study was performed, including native kidney biopsies with a diagnosis of lupus proliferative nephritis (class III/IV) (ISN/RPS 2003). Direct immunofluorescence microscopy was performed in -80ºC frozen sections to evaluate IgA, IgG, IgM, C4d, C1q and C3, and LES activity and chronicity scores were calculated according to NIH disease activity scoring system. The intensity of staining was graded as 0 (no staining), +1 (stainvisible at 40X magnification), +2 (at 20X), +3 (at X10), and +4 (at 2-4X). For statistical purpose we considered weak staining: 0, +1, +2 and strong staining: +3, +4. Patient´s files were retrospectively reviewed and clinical and analytical data were collected using a standardized form.

Results

64 native kidney biopsies from 56 patients with a diagnosis of lupus proliferative nephritis were included, basal characteristics are described in attached Table. Activity index was significantly higher in biopsies showing strong intensity C3 staining compared to biopsies showing weak intensity C3 staining [(n=25) 10±1 vs (n=13) 5±1; p=0.002 respectively], alb/creat was significantly higher in patients in whom biopsy showed strong intensity C3 staining, compared to biopsies showing weak intensity C3 staining [(n=10) 1964.4±585.2 mg/gr vs (n=6) 823.6±58 mg/gr; p<0.001, respectively], prot/creat was significantly higher in biopsies that showed strong C3 staining intensity [(n=27) 2302.5±325 mg/gr vs (n=12) 1287.7±235 mg/gr, p<0.005, respectively], haematuria at NL diagnosis was more frequently in patients whose biopsy showed strong intensity C3 staining (n=21, 80.8%), compared to biopsies showing weak intensity C3 staining (n=5, 19.5%, p<0.001); most of the patients without haematuria at diagnosis showed a weak intensity C3 staining or not C3 staining (n=13, 62%). Endocapillary proliferation was significantly higher in biopsies showing strong intensity C3 staining (90.9% vs 9.1%, p<0.001).Time to proteinuria response is higher in patients showing strong intensity C4d stainingcompared with biopsies showing weak intensity C4d staining (15.2±2.4 vs 6.4±1.8 months; p=0.001), time to haematuria response is higher inbiopsies showing strong intensity C4d staining (19.5±5.5 vs 7.5±2.3 months, p=0.003). Time to proteinuria response is higher in patients showing strong intensity C1q stainingcompared to biopsies showing weak intensity C1q staining (14.0±9 vs 3.3±2.6 months, p <0.001).

Conclusion

Our results suggest that complement system is activated in kidney tissue of proliferative LN patients; C3 staining is associated with clinical, analytical and histological data related to acute lupus activity, whereas C4d and C1q staining are related with long-term outcomes like treatment response. Further studies are needed to elucidate the role of complement system in LN.

P0442RELATED FACTORS IN THE DEVELOPMENT OF LUPUS NEPHRITIS IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Background and Aims

Lupus Nephritis (LN) is a severe complication of Systemic Lupus Erytemathosus (SLE). This is the main reason why identifying predisposing factors to differentiate patients at risk of developing LN is so important.

Method

Retrospective study of patients with SLE diagnosed between years 2008-2018 in our center. Demographic, clinical and analytical data have been collected.

Results

We included 171 patients, 48 (28%) with diagnose of LN. Age at diagnose of SLE was 39,51 ± 15,40 years, being more frequent in women 151 (87,5%). Time of follow-up since SLE diagnose until development of LN was of 3 ± 5, 3 years. Respectful to the LN classification we found: 4 (8%) class I LN, 6 (12.5%) class II LN, 15 (31.2%) class III LN, 19 (39.5%) class IV LN and 4 (8%) class V LN. At diagnose of SLE, the following variables, where related to developing LN: CH50 [HR: 1,039; CI (95%): 1,004-1,064; p=0,024], C3 [HR: 1,029; CI (95%): 1,016-1,042; p<0,001, titer of Anti- DNACrithidia [HR: 4,364; CI(95%): 1,26-15,064; p=0,02], AntiSM [HR: 4,634, CI (95%) 1,76-12,17, p=0,002], ACA IgG [HR: 7,5; CI (95%): 2,3 -24,449; p=0,001] and Lupus anticoagulant [HR: 4,97; CI (95%): 1,591-15,533; p=0,006]. Treatment with hidroxicloroquine is a protective factor against developing LN [HR: 0,17; CI (95%): 0,063-0,511; p=0.001]. At diagnose of LN, complement factors and titer of anti-DNA crithidia show a positive correlation when compared to the initial determinations: C3 [r= 0,605 (p<0,001]); C1q [r= 0,861 (p=0,006)]; CH50 [r= 0,981 (p<0,001), anti- DNACrithidia [r= 0,529 (p<0,001)], anti-Sm [r=0.8, )p=0.001)].

Conclusion

Consumption of complement factors, high titers of anti-DNAcrithidia, Anti-SM, ACA IgG and Lupus anticoagulant are related to a future LN development at SLE diagnose. Moreover, we see an increase of their titer once we diagnose LN. Otherwise, treatment with hidroxicloroquine seems to be a protective factor.

P0294WHEN DO WE HAVE TO SUSPECT THAT A PREECLAMPSIA MASKS A GLOMERULOPATHY?

Background and Aims

Between the 2-8% of pregnancies suffer preeclampsia (PE). In the literature, there have been reported cases of glomerulopathy debuted by pregnancy (GDP) which are initially missdiagnosed as PE. These cases are unusual and not well-defined. We aimed to evaluate clinical and analytical factors that allow us to suspect that a PE masks a GDP.

Method

Retrospective study that included pregnant patients with a postpartum histological diagnosis of glomerulopathy who had been missdiagnosed as PE during pregnancy. We compared them with patients who suffered PE with full recovery after childbirth. We evaluate demographic variables of pregnant women and newborns, clinical variables related to pregnancy and childbirth, blood pressure (BP) and analytical variables before pregnancy and postpartum (serum creatinine (sCrea), estimated glomerular filtration rate by CKD-EPI equation (eGFR), serum uric acid (sUA), ratio of urine protein to creatinine (UPCR)).

Results

Thirty patients were included in the study ,10 patients with a postpartum histological diagnosis of glomerulopathy who had been diagnosed as PE during the pregnancy and 20 patients with a diagnosis of PE without GDP, baseline characteristics are described in attached table. Glomerulopathy was diagnosis through renal biopsy, main indication of renal biopsy was the persistence of proteinuria and/or sediment abnormalities after 4 months of childbirth. The diagnoses were: IgA nephropathy (3, 33.3%), focal and segmental hyalinosis (2, 22.2%), X-linked Alport syndrome (2, 22.2%), diabetic nephropathy (1, 11.1%), lupus nephritis (1, 11.1%) and chronic interstitial nephropathy (1, 11.1%).

Pregnant women with GDP showed higher prevalence of smoking habit and major value of sCrea and sUA (figure). Regarding to pregnancy factors, patients with GDP had significant higher prevalence of primiparous gestation (100% vs 40%, p=0.002), twin gestation (20% vs 0%, p=0.03), premature newborn (50% vs 15%, p=0.01) and higher weight gain during pregnancy (13.9±5.8 vs 9.5±3.6 kg, p=0.01). Furthermore, in the postpartum data we objected a higher value of systolic/diastolic BP (145.6±10.3 / 89.4±12.1 vs 128.5±10.0 / 80.0±6.3 mmHg, p<0.05), sCrea (0.83±0.3 vs 0.54±0.2 mg/dl, p=0.02), sUA (5.8±1.3 vs 3.4±0.8 mg/dl, p<0.001) and UPCR (3046 [613-4179] vs 802 [281-948] mg/g, p=0.05) in patient with NPD.

Conclusion

Our results suggest that clinical and analytical variables in pregnancy and post-partum allow clinicians suspect a glomerulopathy in the setting of PE. Patients diagnosed as PE who develop GDP had higher prevalence of smoking habit, primiparous gestation, twin gestation and premature newborns. In addition, they also have higher weight gain during pregnancy, worse renal function and major sUA before pregnancy and after childbirth, and major UPCR and BP after childbirth; compared with patients with PE and full recovery after childbirth.

Renal safety outcomes of spironolactone in patients with resistant hypertension

INTRODUCTION

Resistant hypertension (RH) is a significant health problem with complex management. The aim of this study was to evaluate the risks and benefits of adding spironolactone to treat RH.

MATERIAL AND METHODS

In total, 216 patients with RH in whom spironolactone (12.5-25mg daily) was added as an antihypertensive were evaluated. One-hundred and twenty-five (125) were analysed retrospectively and 91 prospectively. Blood pressure (BP) and laboratory parameters (serum creatinine [sCrea], estimated glomerular filtration rate [eGFR] and serum potassium [sK]) were analysed at baseline and at 3-6-12 months after introducing spironolactone.

RESULTS

A change of systolic/diastolic BP (mean±standard deviation) of -10.9±2.7/-4.3±1.6mmHg at 3 months and -13.6±2.8/-6.0±1.6mmHg at 12 months; p<0.001 was observed. These values were confirmed with ambulatory-BP monitoring at 12 months. At 3 months, an increase in sCrea of 0.10±0.04mg/dl, a decrease in eGFR of -5.4±1.9ml/min/1.73m² and an increase in sK of 0.3±0.1mmol/l; p<0.001 was observed for all cases. These changes were maintained after 12 months. There were no significant differences in changes of BP, sCrea, eGFR and sK between 3 and 12 months. Results of the retrospective and prospective cohorts separately were superimposable. In the prospective cohort, spironolactone was withdrawn in 9 patients (9.9%) because of adverse effects.

CONCLUSIONS

After 3 months with spironolactone, a decrease in BP associated with a decrease in the eGFR and an increase in sCrea and sK was observed. These changes were maintained at 12 months. Spironolactone is an effective and safe treatment for RH in patients with baseline eGFR ≥30ml/min/1.73m².

Central blood pressure in morbid obesity and after bariatric surgery

Various mechanisms are related to arterial hypertension in obesity. Central blood pressure (BP) seems to correlate more than peripheral BP with future cardiovascular risk. Bariatric surgery is an effective method to reduce BP along with weight loss in patients with morbid obesity. The study of the relationship between weight modification after bariatric surgery and ambulatory BP measurement, not only peripheral BP, but also central BP, could provide information regarding the mechanisms of organic damage associated with elevated BP in obesity. In this review we analyze the available evidence regarding the association between central BP with obesity and its modifications after bariatric surgery.