Study of prevalence, clinical profile, and predictors of rapid progression in diabetic kidney disease

BACKGROUND

A significant proportion of diabetic kidney disease (DKD) experience a rapid decline in eGFR, leading to end-stage kidney disease (ESKD) within months. This single-centered retrospective cohort study aimed to assess the prevalence, clinical profile, and predictors for rapid progression in type 2 diabetes mellitus (T2DM) patients with DKD.

METHOD

Three hundred fifty-nine T2DM patients with DKD between January 2018 and 2022 were included and those with superimposed non-diabetic kidney disease, chronic kidney disease 5, and < 6 months follow-up were excluded. They were classified as rapid and non-rapid progressors based on the annual eGFR decline of > 5 ml/min/1.73 m2/year. The primary outcome analyzed was the progression to ESKD. The secondary outcomes were the onset of microvascular and macrovascular complications and predictors for rapid progression as well as ESKD.

RESULTS

In a median follow-up of 3.5 years, 61.3% were rapid progressors (mean eGFR decline of 15.4 ml/1.73m2/year) and 38.7% were non-rapid progressors (mean eGFR decline 1.8 ml/1.73m2/year. Among rapid progressors, 61.4% reached ESKD. Severe proteinuria, the presence of retinopathy, and acute kidney injury (AKI) episodes were strong predictors of rapid progression. Cardiovascular disease and diabetic retinopathy (microvascular complications) were significantly higher among rapid progressors and had a mortality rate of 7.2%.

CONCLUSION

The majority of type 2 DKD patients were rapid progressors and two-thirds of them developed ESKD. The prevalence of hypertension, cardiovascular disease, diabetic retinopathy, AKI episodes, and mortality was higher in rapid progressors. Severe proteinuria and diabetic retinopathy were found to be strong predictors for rapid eGFR decline and its progression to ESKD.

Ocular and systemic vascular endothelial growth factor ligand inhibitor use and nephrotoxicity: an update

Tumor growth is intricately linked to the process of angiogenesis, with a key role played by vascular endothelial growth factor (VEGF) and its associated signaling pathways. Notably, these pathways also play a pivotal "housekeeping" role in renal physiology. Over the past decade, the utilization of VEGF signaling inhibitors has seen a substantial rise in the treatment of diverse solid organ tumors, diabetic retinopathy, age-related macular degeneration, and various ocular diseases. However, this increased use of such agents has led to a higher frequency of encountering renal adverse effects in clinical practice. This review comprehensively addresses the incidence, pathophysiological mechanisms, and current evidence concerning renal adverse events associated with systemic and intravitreal antiangiogenic therapies targeting VEGF-A and its receptors (VEGFR) and their associated signaling pathways. Additionally, we briefly explore strategies for mitigating potential risks linked to the use of these agents and effectively managing various renal adverse events, including but not limited to hypertension, proteinuria, renal dysfunction, and electrolyte imbalances.

Role of novel biomarker monocyte chemo-attractant protein-1 in early diagnosis & predicting progression of diabetic kidney disease: A comprehensive review

Diabetic kidney disease (DKD) is the most devastating complication of diabetes mellitus. Identification of patients at the early stages of progression may reduce the disease burden. The limitation of conventional markers such as serum creatinine and proteinuria intensify the need for novel biomarkers. The traditional paradigm of DKD pathogenesis has expanded to the activation of the immune system and inflammatory pathways. Monocyte chemo-attractant protein-1 (MCP-1) is extensively studied, as a key inflammatory mediator that modulates the development of DKD. Recent evidence supports the diagnostic role of MCP-1 in patients with or without proteinuria in DKD, as well as a significant role in the early prediction and risk stratification of DKD. In this review, we will summarize and update present evidence for MCP-1 for diagnostic ability and predicting the progression of DKD.

Uremic pruritus: prevalence, determinants, and its impact on health-related quality of life and sleep in Indian patients undergoing hemodialysis

BACKGROUND

Uremic pruritus has an impact on the quality of life and sleep of hemodialysis patients, but the majority of cases go unreported and untreated unless severe, due to a lack of awareness. The purpose of this study is to determine the prevalence, associated factors, and impact on health-related quality of life (HR-QOL) and sleep in hemodialysis patients.

METHODOLOGY

A single-center observational study of 3 months wherein 120 adults on maintenance hemodialysis were included. Baseline characteristics, dialysis-related factors, and lab parameters influencing uremic pruritus were recorded. Those with uremic pruritus completed "12-item pruritus severity scale (12-PSS)", "SKINDEX10", and "Itch-MOS" questionnaires to evaluate severity, impact on HR-QOL, and sleep respectively.

RESULTS

Sixty seven over one hundred twenty (55.83%) patients had pruritus and majority were mild (40.83%) as per 12-PSS. Those with pruritus (n=67) had a mean age of 56.5±11.3 years, most were males (82%), chronic glomerulonephritis (29.1%) was the commonest cause of end-stage kidney disease, 3 active smokers, and 4 seropositive. 65(97%) patients were on twice-weekly dialysis, 36/67 had <5 years' dialysis vintage and acceptable adequacy. There was no significant association between uremic pruritus and dialysis-related/laboratory parameters. Patients with uremic pruritus demonstrated significantly worse "HR-QOL" (p<0.001) on the "SKINDEX-10", and patients' "Itch-MOS" scores demonstrated a significant decline in sleep quality with increasing pruritus severity (p<0.001).

CONCLUSION

The majority of patients on maintenance hemodialysis experience uremic pruritus. None of the clinical characteristics, dialysis-related factors, and laboratory parameters affected uremic pruritus. Uremic pruritus patients had the worst HR-QOL & their sleep quality significantly declined as pruritus severity escalated.

TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION

Study approval was obtained from Institutional Research Committee and Institutional Ethical Committee (IEC 642/2021). Clinical Trial Registry of India (CTRI) registration (CTRI/2022/01/039143) was also obtained.

Hydroxychloroquine in nephrology: current status and future directions

Hydroxychloroquine is one of the oldest disease-modifying anti-rheumatic drugs in clinical use. The drug interferes with lysosomal activity and antigen presentation, inhibits autophagy, and decreases transcription of pro-inflammatory cytokines. Owing to its immunomodulatory, anti-inflammatory, anti-thrombotic effect, hydroxychloroquine has been an integral part of therapy for systemic lupus erythematosus and lupus nephritis for several decades. The therapeutic versatility of hydroxychloroquine has led to repurposing it for other clinical conditions, with recent studies showing reduction in proteinuria in IgA nephropathy. Research is also underway to investigate the efficacy of hydroxychloroquine in primary membranous nephropathy, Alport's syndrome, systemic vasculitis, anti-GBM disease, acute kidney injury and for cardiovascular risk reduction in chronic kidney disease. Hydroxychloroquine is well-tolerated, inexpensive, and widely available and therefore, should its indications expand in the future, it would certainly be welcomed. However, clinicians should be aware of the risk of irreversible and progressive retinal toxicity and rarely, cardiomyopathy. Monitoring hydroxychloroquine levels in blood appears to be a promising tool to evaluate compliance, individualize the dose and reduce the risk of retinal toxicity, although this is not yet standard clinical practice. In this review, we discuss the existing knowledge regarding the mechanism of action of hydroxychloroquine, its utility in lupus nephritis and other kidney diseases, the main adverse effects and the evidence gaps that need to be addressed in future research. Created with Biorender.com. HCQ, hydroxychloroquine; GBM, glomerular basement membrane; mDC, myeloid dendritic cell; MHC, major histocompatibility complex; TLR, toll-like receptor.

Chronic kidney disease of unknown aetiology: A comprehensive review of a global public health problem

The term chronic kidney disease of unknown aetiology (CKDu) refers to chronic kidney disease (CKD) in the absence of diabetes, long-standing hypertension, glomerulonephritis, obstructive uropathy or other apparent causes. An increasing number of CKDu cases have been reported from Latin America, Sri Lanka, India and others over the last two decades. These regional nephropathies share the following common attributes: (a) they affect low-to-middle income countries with tropical climates, (b) involve predominantly rural agricultural communities, (c) male predilection, (d) absence of significant proteinuria and hypertension, and (e) chronic tubulointerstitial nephritis on kidney biopsy. The current body of literature suggests that CKDu may be caused by heat stress, agrochemicals, contaminated drinking water or heavy metals; however, considerable regional disparities in CKDu research make it difficult to establish a common causal link. In the absence of a definite aetiology, specific preventive and therapeutic interventions are lacking. Improvement of working conditions of farmers and labourers, provision of safe drinking water and changes in agricultural practices are some of the measures that have been implemented; however, there is lack of data to assess their impact on the incidence and progression of CKDu. There is a need for a concerted global effort to address the current knowledge gaps, and to develop effective and sustainable strategies to tackle this devastating disease.

Effect of Febuxostat versus Allopurinol on the Glomerular Filtration Rate and Hyperuricemia in Patients with Chronic Kidney Disease

Hyperuricemia is a risk factor for the progression of chronic kidney disease (CKD). We compared febuxostat versus allopurinol in the progression of CKD and hyperuricemia in 101 patients with Stage 3-4 CKD treated with febuxostat or allopurinol for at least 6 months for hyperuricemia (>7 mg/dL) between January 2012 and December 2016. Baseline characteristics, serum uric acid (SUA), serum creatinine, and estimated glomerular filtration rate (eGFR) at entry and 6 months were compared. The primary outcome was the decline in eGFR and the secondary outcomes were reductions in SUA and adverse events. Fifty-four were in the febuxostat group and 47 were in the allopurinol group. The baseline characteristics were comparable except for age. The mean dose of febuxostat and allopurinol was 43.70 ± 14.5 mg and 108.51 ± 40 mg, respectively. After 6 months, the median rate of decline in eGFR was 1.2 mL/min/1.73 m2 (IQR: 1.2, 5.5) in the febuxostat group and 3.1 mL/min/1.73 m2 (0.6, 6.2) in the allopurinol group, but this was not statistically significant (P = 0.136). The mean reduction in SUA was significantly better (P = 0.004) in the febuxostat group (3.9 ± 1.7 mg/dL) compared with the allopurinol group (2.1 ± 1.0 mg/dL). Both drugs had no serious adverse events. Febuxostat was better at reducing hyperuricemia than allopurinol, but there was no significant difference in the progression of CKD. Large randomized trials and long-term follow-up are necessary to see whether febuxostat has a favorable effect on the progression of CKD.

Novel biomarkers for prognosticating diabetic kidney disease progression

The global burden of diabetic kidney disease (DKD) is escalating, and it remains as a predominant cause of the end-stage renal disease (ESRD). DKD is associated with increased cardiovascular disease and morbidity in all types of diabetes. Prediction of progression with albuminuria and eGFR is challenging in DKD, especially in non-proteinuric DKD patients. The pathogenesis of DKD is multifactorial characterized by injury to all components of the nephron, whereas albuminuria is an indicator of only glomerular injury. The limits in the diagnostic and prognostic value of urine albumin demonstrate the need for alternative and clinically significant early biomarkers, allowing more targeted and effective diabetic treatment, to reduce the burden of DKD and ESRD. Identification of biomarkers, based on multifactorial pathogenesis of DKD can be the crucial paradigm in the treatment algorithm of DKD patients. This review focuses on the potential biomarkers linked to DKD pathogenesis, particularly with the hope of broadening the diagnostic window to identify patients with different stages of DKD progression.

Frailty in end stage renal disease: Current perspectives

Frailty is common in end stage renal disease (ESRD) and is a marker of poor outcomes. Its prevalence increases as chronic kidney disease (CKD) progresses. There are different measurement tools available to assess frailty in ESRD. The pathogenesis of frailty in ESRD is multifactorial including uraemia and dialysis related factors. In this current review, we discuss the importance of frailty, its pathogenesis, screening methods, prognostic implications and management strategies in context of ESRD.

Hemodialysis catheter-related bloodstream infections: A single-centre experience

Aim and objectives: In hemodialysis patients, catheter-related bloodstream infections (CRBSI) cause significant morbidity and mortality. We analyzed CRBSI incidence, associated factors, and the causative organisms’ spectrum. Methodology: Patients aged ≥18 years either on maintenance hemodialysis or with acute kidney injury having CRBSI (NKF-KDOQI criteria) were included in this prospective observational study and patients with other infections were excluded. Blood, catheter tip culture and antibiogram were analyzed. All patients were initially treated with antibiotics covering both gram-positive and gram-negative pathogens. Results: Of 921 catheters (882 patients) analyzed, 212 (23%) had CRBSI, of which 69(32.5%) and 143(67.5%) had possible CRBSI and probable CRBSI respectively. 131 (61.8%) were <60 years, 133 (62.7%) were males, 177 (83.5%) had diabetes, 141(66.5%) had leukocytosis and 172(81.1%) had positive procalcitonin. 193 (91%) had uncuffed catheters and 162 (76.4%) had jugular catheters. Our study showed that CRBSI incidence was 13.39/1000 catheter days, median catheter days, and median time to CRBSI was 40 and 17.2 days. Gram-positive coagulase-negative staphylococcus aureus (n=31; 44.9%) followed by extended-spectrum beta-lactamase (ESBL) enteric gram-negative organisms (n=30; 43.4%) were common isolates and remaining had fungal etiology (n=8; 11.7%). Conclusion: The incidence of CRBSI was high in our population. In culture-positive cases, gram-positive organisms contributed marginally higher than gram-negative organisms. Coagulase Negative Staphylococcus aureus (CONS) and ESBL enteric gram-negative organisms are the commonest isolates. More than two-thirds of patients with CRBSI had diabetes mellitus and leukocytosis at presentation.

MO769: Utility of Doppler Ultrasonography in the Evaluation of Arteriovenous Fistula, a Nephrologists Perspective

BACKGROUND AND AIMS

An arteriovenous (AV) fistula is preferred for long-term haemodialysis vascular access. AV fistula creation requires adequate arterial and venous anatomy to support its creation and a sufficient time interval to allow the AV fistula to mature prior to its use.  Failure to mature remains a problem highlighting the importance of the perioperative evaluation of the fistula. Ultrasound and colour doppler are a rapid, non-invasive and repeatable tools that can be used for the early diagnosis of vascular complications.

METHOD

A prospective, observational study was conducted at a tertiary hospital in South India. All the patients with arteriovenous fistulas made in the upper limb between the time period of June 2021–August 2021 were included. A preoperative doppler mapping and assessment of the upper lime was done by the nephrology team and two DUS exams in the post-operative period.

RESULTS

In our study, a total of 134 patients were evaluated with a mean age of 51.89 ± 13.7 years. The total number of males in the study was 115 (85.8%). The aetiology of end-stage renal disease (ESRD) was predominantly nondiabetic in origin seen in 56.7% of the patients. Ischaemic heart disease was seen in 36 patients. There were 116 brachiocephalic,18 radiocephalic AV fistulas in our group of patients. The overall success rate of the fistula was 79.9%. The average vein diameter in patients with successful AV fistula was 3.03 ± 1.05 mm and was 2.25 ± 0.9 mm in those who had a failed fistula. The average blood flow measurement in the proximal artery supplying the fistula was 479.42 ± 113.1 mL/min in the immediate post-op period and 1055.88 ± 227.6 mL/min at 6 weeks. There was a significant difference (P&lt;0.05) in the blood flow measurement between those who achieved primary patency versus those with failure to mature.

CONCLUSION

It is essential for a practicing nephrologist to be acquainted with the technique of doppler to assess AV fistula to assess for maturity and to see for.

MO173: Clinical Profile of Plasma Cell Dyscrasias and Their Renal Outcomes

BACKGROUND AND AIMS

The involvement of kidney in plasma cell dyscrasias is widespread, often referred to as myeloma kidney. At the time of presentation, nearly 50% of patients have renal involvement which is associated with higher mortality [1, 2]. Multiple myeloma is more common in African Americans, with male predilection and median age about 65–70 years [3]. Two major causes of renal insufficiency are light chain cast nephropathy and hyperkalcaemia [4]. Flow cytometry plays an important role in diagnosis of plasma cell dyscrasias. Myeloma cells infrequently express CD19 and variable CD45 in contrast to normal plasma cells. Approximately 70% of myeloma cells will express CD56, which is typically negative in normal plasma cells and in plasma cell leukaemia [5]. Studies addressing the relation of flow cytometry parameters with respect to prognosis and outcome in plasma cell dyscrasias are sparse in Asian population. Hence, this research was conducted to study the clinical profile and correlation of flow cytometry parameters with renal outcomes in patients with plasma cell dyscrasias.

METHOD

All consecutive patients, aged above 18 years and diagnosed with plasma cell dyscrasias from January 2016 to June 2021 were included.

RESULTS

Of 165 patients, 115 were males (69.7%), with mean age 58.2 ± 6.4 years. Pallor was seen in 126 (76.4%), bone pains in 90 (54.5%), lytic lesions in 63 (38.2%) and fractures in 37 (22.4%) patients. Severe anaemia (&lt;7 g/ dL) was seen in 35 (21.2%) patients. At presentation, deranged renal parameters with eGFR &lt; 60 mL/min/1.73 m2 were seen in 89 (53.9%) patients, of which 55 (61.8%) patients progressed to chronic kidney disease and 8 (8.9%) patients were continued on maintenance hemodialysis. Nephrotic syndrome presentation was seen in 26 (15.8%) patients. Infections were seen in 65 (39.4%) patients, of which most common infections were respiratory (25, 38.5%), blood stream (18, 27.7%) and urinary tract (12, 18.5%) infections. Serum free light chains were more than 800 mg/L in 71 patients, of them high kappa and lambda levels are seen in 41 (24.8%), and 30 (18.2%) patients, respectively. Most common immunoglobulin seen was IgG (63.6%), followed by IgA (15.8%) and IgE (2.4%). Flow cytometry parameters are shown in Table 1.

Remission was attained with chemotherapy in 139 patients (64.3%), and bone marrow transplantation was done in 27 patients (16.4%). Relapse of disease was seen in 31 patients (18.8%) and worsening of renal parameters at relapse was seen in 15 (48.4%) patients. A total of 35 (21.2%) patients expired. Correlation of flow cytometry parameters with renal outcomes showed presence of CD56 with worse renal outcomes (P = .032), and presence of CD117 with favourable renal outcomes (P = .003) with statistical significance. Presence of CD56 and CD138 had increased risk of mortality with significant P value (P = .04, P = .01, respectively).

CONCLUSION

Flow cytometry parameters may play a role in predicting the prognosis and renal outcomes in patients of plasma cell dyscrasias. Our study showed presence of CD56 with worse renal outcome and mortality, while CD117 presence with favourable renal outcome.

Table 1. Flow cytometry parameters in patients with plasma cell dyscrasias CD markers (n = 165) Present Absent CD19 21/165 (12.7%) 144/165 (87.3%) CD38 53/165 (32.1%) 112/165 (67.9%) CD45 46/165 (27.9%) 119/165 (73.9%) CD56 134/165 (81.2%) 31/165 (18.8%) CD117 86/165 (52.1%) 79/165 (48.9%) CD138 46/165 (27.9%) 119/165 (73.9%) KAPPA 93/165 (56.4%) 72/165 (44.6%) LAMBDA 71/165 (43%) 94/165 (57%)

MO471: Adverse Drug Reactions and Drug–Drug Interaction in Chronic Kidney Disease With Tuberculosis

BACKGROUND AND AIMS

The risk of developing tuberculosis (TB) is 10–25% in chronic kidney disease (CKD) patients. TB in CKD patients may have a mortality of 16–37%. Standard treatment with four drugs (Isoniazid, Rifampin, Pyrazinamide and Ethambutol) predisposes to side effects, drug interactions and incomplete adherence in this population. We studied adverse drug reactions and potential drug–drug interactions in CKD patients with TB.

METHOD

Consecutive patients with CKD and TB attending tertiary care hospitals in South India were included over a period of 12 months. CKD was diagnosed based on estimated GFR using CKD EPI and TB using standard methodology. Data on demographic details and adverse drug reactions were collected from case records. Potential drug–drug interactions were checked using Micromedex Drug-Reax® (Truven Health Analytics, Greenwood Village, Colorado, USA). Statistical analysis was done using SPSS version 20.

RESULTS

Of 1300 TB patients, 59 had CKD. The demographic details are as per Table 1.

CONCLUSION

In CKD with TB, adverse drug reactions were seen in 45.5% and potential drug–drug interactions were seen mostly with rifampin (28.81% in CKD).

"Comparison of creatinine based glomerular filtration rate estimation equations in voluntary Indian kidney donors: A single centre study"

Aim: In transplantation, accurate donor glomerular filtration rate (GFR) estimation is crucial. While various creatinine based equations are in use, none are validated in Indians, thus this study was conducted to judge accuracy of creatinine based GFR estimation equations and urinary creatinine clearance. Methods: A single-centre, observational and retrospective study at a tertiary care hospital. Adult voluntary donors GFR measured (mGFR) by Tc‑99m DTPA were included. Primary outcome was performance of estimated GFR (eGFR) by Cockcroft-Gault's formula corrected for body surface area (CG-BSA), Modification of diet in renal disease (MDRD) 4/6 and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI); Secondary outcome was performance of 24 hour urinary creatinine clearance (Cr Cl). Results: 102 kidney donors were analysed with mean age of 45.89 ± 9.98 years and 85.3% females. Mean ± SD mGFR by Tc‑99m DTPA was 82.11 ± 14.32 ml/min/1.73m2. Mean ± SD eGFR (ml/min/1.73m2) by CG-BSA was 99.68 ± 23.71, by MDRD-4 was 98.25 ± 28.61, by MDRD-6 was 93.66 ± 19.44 and by CKD-EPI was 111.14 ± 31.61. Lowest bias (2.3), highest precision (16.23) and accuracy (97.1%) was with MDRD-6; 24-hour urinary Cr Cl highly overestimated GFR (158.27 ml/min/1.73 m2) with highest bias, lowest precision and accuracy. Conclusion: Among the equations, MDRD-6 was the most precise and accurate with 24 hour urinary creatinine clearance being the least reliable. This study highlights the need for a correction factor or a new GFR estimation equation and not to consider urinary Cr Cl to assess donor GFR.

Measurement of Blood Pressure in Chronic Kidney Disease: Time to Change Our Clinical Practice - A Comprehensive Review

Chronic kidney disease (CKD) is extremely common all over the world and is strongly linked to cardiovascular disease (CVD). The great majority of CKD patients have hypertension, which raises the risk of cardiovascular disease (CVD), end-stage kidney disease, and mortality. Controlling hypertension in patients with CKD is critical in our clinical practice since it slows the course of the disease and lowers the risk of CVD. As a result, accurate blood pressure (BP) monitoring is crucial for CKD diagnosis and therapy. Three important guidelines on BP thresholds and targets for antihypertensive medication therapy have been published in the recent decade emphasizing the way we measure BP. For both office BP and out-of-office BP measuring techniques, their clinical importance in the management of hypertension has been well defined. Although BP measurement is widely disseminated and routinely performed in most clinical settings, it remains unstandardized, and practitioners frequently fail to follow the basic recommendations to avoid measurement errors. This may lead to misdiagnosis and wrong management of hypertension, especially in CKD patients. Here, we review presently available all BP measuring techniques and their use in clinical practice and the recommendations from various guidelines and research gaps emphasizing CKD patients.

Risk Factors of Pulmonary Hypertension in Patients on Hemodialysis: A Single Center Study

Introduction

Pulmonary hypertension (PH) is an underestimated cardiovascular consequence and a mortality predictor in patients on hemodialysis (HD). Thus, we studied its prevalence, risk factors, association with inflammation/oxidative stress, and cardiac changes in HD patients.

Methods

This was a single-center cross-sectional observational study conducted at a tertiary care hospital. Patients aged >18 years on hemodialysis for at least three months were included and divided into those with and without PH; patients with secondary causes for PH were excluded. Clinical characteristics, HD-related factors, lab parameters (C-reactive protein and malondialdehyde with thiol assay were used as markers of inflammation and oxidative stress, respectively), and echocardiography details were compared. PH was defined as a mean pulmonary artery pressure of >25 mmHg at rest, and it was further divided as mild (25–40 mmHg), moderate (40–60 mmHg), and severe (>60 mmHg).

Results

Of 52 patients, 28 patients had PH (mild 24, moderate 4, and none had severe PH) with prevalence of 54%. No difference was found in clinical characteristics, dialysis-related factors, biochemical parameters including inflammation (C-reactive protein; p=0.76), or oxidative stress (thiol; p=0.36 and MDA; p=0.46) between the groups. When compared to individuals without PH, HD patients with PH exhibited significantly more mitral regurgitation (p=0.002).

Conclusion

Hemodialysis patients have a high prevalence of PH. PH was significantly associated with the presence of mitral regurgitation on echocardiography. Our study did not find differences in traditional risk factors, HD-related factors, and inflammation/oxidative markers between the groups with and without PH.

Hypertensive emergency and seizures during haemodialysis

Intracranial abscesses are uncommon, serious and life-threatening infections. A brain abscess is caused by inflammation and collection of infected material, coming from local or remote infectious sources. Patients with chronic kidney disease on dialysis are prone to invasive bacterial infections like methicillin-resistant Staphylococcus aureus (MRSA) especially in the presence of central venous catheters or arteriovenous grafts. However, intracranial abscess formation due to MRSA is rare. Here, we present a case of MRSA brain abscess with an atypical clinical presentation in the absence of traditional risk factors.Intracranial abscesses are uncommon, serious, and life-threatening infections. A Brain abscess is caused by inflammation and collection of infected material, coming from local or remote infectious sources. Patients with chronic kidney disease on dialysis are prone to invasive bacterial infections like methicillin-resistant staphylococcus aureus (MRSA) especially in the presence of central venous catheters or arterio-venous grafts. However intracranial abscess formation due to MRSA is rare. Here we present a case of MRSA brain abscess with an atypical clinical presentation in the absence of traditional risk factors. A 46-year-old male with chronic kidney disease (CKD) secondary to chronic glomerulonephritis, on haemodialysis for 4 years through a left brachio-cephalic AVF developed an episode of generalised tonic-clonic seizures lasting 2 min during his scheduled dialysis session. He reported no complaints before entry to the dialysis. On clinical examination, he was drowsy with the absence of any focal motor deficits. His blood pressure was recorded to be 200/120 mm Hg. He was managed in the intensive care unit with mechanical ventilation, intravenous nitroglycerine for blood pressure control, levetiracetam for seizures and empirical vancomycin. Radiological evaluation showed a brain abscess in the midline involving bosth basi-frontal lobes. After medical optimization, the abscess was drained surgically, and the pus cultured. As culture grew Methicillin Resistant Staphylococcus aureus, he was treated with intravenous vancomycin for 6 weeks. On follow up, the abscess had resolved and the patient recovered without any neurological deficits.

Sodium-glucose cotransporter-2 inhibitors and non-steroidal mineralocorticoid receptor antagonists: Ushering in a new era of nephroprotection beyond renin-angiotensin system blockade

The therapeutic options for preventing or slowing the progression of chronic kidney disease (CKD) have been thus far limited. While angiotensin converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs) are, without a doubt, safe and effective drugs, a significant proportion of patients with CKD still progress to end-stage kidney disease. After decades of negative trials, nephrologists have finally found cause for optimism with the introduction of sodium-glucose cotransporter-2 (SGLT2) inhibitors and non-steroidal mineralocorticoid receptor antagonists (MRAs). Recent trials such as EMPA-REG OUTCOME and CREDENCE have provided evidence of the renal benefits of SGLT2 inhibitors, which have now found widespread acceptance as first-line agents for diabetic CKD, in addition to ACEi/ARBs. Considering results from the DAPA-CKD study, it is expected that their use will soon be expanded to other causes of albuminuric CKD as well, although confirmation from further trials, such as the EMPA-KIDNEY study is awaited. Likewise, although the role of mineralocorticoid receptor overactivation in CKD progression has been known for decades, it is only now with the FIDELIO-DKD study that we have evidence of benefits of MRAs on hard renal endpoints, specifically in patients with diabetic CKD. While further research is ongoing, given the evidence of synergism between the three drug classes, it is foreseeable that a combination of two or more of these drugs may soon become the standard of care for CKD, regardless of underlying aetiology. This review describes pathophysiologic mechanisms, current evidence and future perspectives on the use of SGLT2 inhibitors and novel MRAs in CKD.

Intradialytic hypertension prevalence and predictive factors: A single centre study

Introduction: Intradialytic hypertension (IDH) is associated with significant vascular and cardiac adverse outcomes. Objectives: This study was performed to know the prevalence and factors predicting IDH. Patients and Methods: A single-center cross-sectional observational study at a tertiary care hospital. After ethics committee approval and informed consent, all patients over 18 years on twice weekly hemodialysis were included, those on peritoneal dialysis and acute kidney injury excluded. Primary outcome was prevalence of IDH based on three definitions and secondary outcome was predictive factors. IDH was defined as ≥10 mm Hg surge in systolic blood pressure (SBP) between pre-and postdialysis in 4 of 6 successive sessions or >15 mm Hg rise in mean arterial pressure (MAP) between start and end of dialysis or symptomatic rise in blood pressure requiring intervention. SBP and MAP were measured on standardized monitors before, hourly and 30 minutes post dialysis. Results: Of 136 patients, prevalence of intra-dialytic hypertension was 78/136 (57%), 33/136 (24%), 15/136 (11%) based on systolic rise, rise in MAP and symptomatic rise in BP respectively. Among those with systolic rise, diabetes mellitus (P= 0.03), undernourishment (P=0.03), inter-dialytic weight gain >3 kg (P< 0.001) and dialysis vintage > 3 years (P< 0.001) were significantly associated with IDH. Conclusion: IDH prevalence varied from 11 to 57% with different definitions. Diabetes mellitus, under nutrition, inter-dialytic weight gain >3 kg and dialysis vintage >3 years predicted IDH.

Comprehensive Conservative Care in End-Stage Kidney Disease

In patients with end-stage kidney disease (ESKD), when there maybe situations where dialysis does not offer benefits in terms of survival or health-related quality of life, dialysis should not be viewed as the default therapy. Such patients can be offered comprehensive conservative care as an alternative to dialysis. Conservative (nondialytic) management of ESKD includes careful attention to fluid balance, treatment of anemia, correction of acidosis and hyperkalemia, blood pressure, and calcium/phosphorus metabolism management and dietary modification. Individualized symptom management and supportive care are crucial to maximize the quality of life. We propose that model of comprehensive conservative care in ESKD should manage both diseases as well as provide supportive care. Facilitating implementation of comprehensive conservative care requires coordination between nephrology and palliative care at patient, professional, administrative, and social levels to maximize benefit with the motto to improve the overall quality of life.

MO229PROFILE OF TUBERCULOSIS AND ITS MANAGEMENT IN CHRONIC KIDNEY DISEASE

Background and Aims

Estimates of Tuberculosis(TB) burden indicate an estimated incidence and mortality of 199 and 32 respectively per 100000 in our country. Risk factors for acquiring TB disease include HIV infection, Diabetes Mellitus, Tobacco consumption and undernutrition. We retrospectively studied profile of TB in Chronic Kidney disease(CKD) in our population.

Method

Retrospective case record based study of consecutive TB patients visiting a Tertiary care hospital attached to a Medical College diagnosed by standard methods to demonstrate TB bacilli in sputum or affected tissue. CKD was diagnosed based on estimated Glomerular filtration rate less than 60 ml/min/m2 for at least three months. Pattern of TB and adverse drug effects were studied. Statistical analysis was done on SPSS version 20

Results

Over ten months, of 746 TB patients seen, 41(5.4%) had CKD, Stage 3b,4 and 5 in 7/41(17.1%), 11(26.8%), 23(56.1%) respectively. Among CKD 24(58.5%) had Diabetes Mellitus, 1(2.4%) HIV and 37(90.2%) hypertension. Pattern of TB is shown in table 1. Adverse drug reactions were significantly higher in CKD 24/41(54.5% vs 17% in non CKD, P &lt; 0.05). Mortality in CKD was 3/41(7.3%) and not significantly higher on multivariable analysis than in those without CKD.

Conclusion

In this retrospective survey of TB patients CKD constituted 5.4%, was associated with more adverse drug reactions but did not impact on mortality. Pulmonary TB was the common pattern in CKD.

P1310STUDY OF RISK FACTORS AND PREVALENCE OF PULMONARY HYPERTENSION IN CKD 5D PATIENTS ON HEMODIALYSIS

Background and Aims

Pulmonary hypertension (PH) in chronic kidney disease stage 5D (CKD5D) patients on haemodialysis (HD) is associated with increased morbidity and mortality. We studied the risk factors and prevalence of PH in patients on HD at our centre. We also studied its association with oxidative stress and markers of inflammation.

Method

After ethics committee clearance, we conducted a cross-sectional study on CKD5D patients at our centre from June 2016 to May 2017. Patients on maintenance HD for at least 3 months were included. Demographic, clinical, biochemical and trans-thoracic echocardiography details were collected. PH was defined as estimated mean pulmonary artery pressure (mPAP) greater than 25 mm Hg at rest. PH was further categorized into mild (mPAP b/w 25-40mmHg), moderate (mPAP b/w 40-60mmHg) and severe PH (mPAP &gt; 60mmHg). Serum thiol and C Reactive protein (CRP) were studied as markers of oxidative stress and inflammation respectively. Data was analysed using SPSS version 16.

Results

Out of 52 patients, 28 (54%) had PH. Twenty four out of these patients had mild PH (Figure 1). None had severe PH. The baseline characteristics of patients with and without PH are shown in Figure 2. No clinical or biochemical factors (p&gt;0.05) were found as significant risk factors in our study. CRP (p-0.76) (inflammatory marker) and Thiol levels (p-0.36) (oxidative stress marker) did not had any relationship with occurrence of PH. (Table 1).

Conclusion

CKD 5D patients on HD have high prevalence of PH. There were no identifiable risk factors. The prevalence of PH was not influenced by dialysis vintage, ultrafiltration, paratharmone levels, presence of co-morbidities, oxidative stress or inflammation.

P0833SYMPTOM BURDEN IN CHRONIC KIDNEY DISEASE : A CASE FOR STARTING KIDNEY SUPPORTIVE CARE CLINIC

Background and Aims

Chronic Kidney Disease(CKD) is associated with a huge symptom burden which increases with progression and leads to depreciation in Quality of life both directly and indirectly through effects on functional status, health perception, and feelings of subjective well-being. Dialysis therapy does not completely improve symptoms. We studied supportive care needs of patients with CKD through assessment of symptoms using translated version of Integrated Palliative Care Outcome Scale (IPOS- Renal) in a single tertiary health setting.

Method

Patients with chronic Kidney disease having creatinine clearance less than 60 ml/min/m2 were surveyed using IPOS Renal modified translated to vernacular language by forward- backward method. Translated version was approved by independent translator. Symptoms were classified into domains and analyzed using descriptive statistics. Scores were compared for those on maintenance hemodialysis with predialysis CKD patients.

Results

Of 184 patients, 128(69.6%) were receiving twice weekly hemodialysis, mean age was 52 years (range 20-82 year), 140(76%) were male. Average duration of dialysis was 4 years, 87 (46.9%) reported pain of which 39/87(45%) had moderate to severe pain. Other symptoms over past one week were dyspnea in 59(33.6%), Fatigue in 117(69.4%), Nausea in 53(33.6%), Vomiting in 36(20.9%), Anorexia in 90(42.4%), Constipation in 50(35.3%), Dry mouth/soreness in 62(36.4%), increased drowsiness in 63(46.6%), poor mobility in 87(55.8%), Itching in 69(39.3%), Disturbed sleep in 83(48.6%), Restless leg in75(43.6%), Skin related problems in 47(28.6%). Five patients reported presence of other severe symptoms. In Psychosocial domain 138(79.8%) patients and 126(72.8 %) family members expressed anxiety related to their disease or treatment of which one third had persistent anxiety, 140(81.6%) felt depressed and among them 58(42%) felt it most of the time or always and 145(88.6%) felt that they were not at peace, 59(35%) felt they did not have enough information about their disease and treatment and 79(47%) reported that they had unaddressed financial or personal problems, 124(77.2 %) felt they had to spend significant amount of time in healthcare facility. Patients on dialysis had significantly higher symptoms burden and Psychosocial needs.

Conclusion

CKD patients face high physical and psychosocial burden which is unaddressed in present clinical care and increases with stage. Tools such as iPOS renal are required to assess need of supportive care in CKD. Kidney supportive care clinic may be required to address this unmet need.

P0574IS PERIPROCEDURAL BLOOD LOSS FOLLOWING PERCUTANEOUS CORONARY INTERVENTION A RISK FACTOR FOR CONTRAST-INDUCED ACUTE KIDNEY INJURY ?

Background and Aims

Contrast-induced acute kidney injury (CI-AKI) is a significant concern with the use of intraarterial contrast agents, especially in percutaneous coronary interventions (PCI) in which higher contrast volumes are used. Presence of anemia is a risk factor for CI-AKI and is a component of various risk-prediction models. However, the impact of periprocedural hemoglobin (Hb) drop following PCI on CI-AKI is not known, despite the fact that significant blood loss is fairly common in patients undergoing PCI. The aim of this study was to examine whether periprocedural Hb drop is a risk factor for development of CI-AKI following PCI.

Method

This was a single-center, retrospective study of patients admitted for elective or primary PCI at our center between January 2015 and December 2018. Patients with baseline eGFR &lt;15mL/min/1.73m2 were excluded. CI-AKI was defined as per the KDIGO 2012 guidelines as an increase in serum creatinine by at least 0.3 mg/dl, or 1.5-1.9 times the baseline values within 48 hours after administration of contrast media. Periprocedural Hb drop was defined as fall in Hb by at least 1g/dL below baseline values within 48 hours following PCI.

Results

A total of 6418 patients were included. Baseline characteristics of the study population are shown in table 1. Overall incidence of CI-AKI in our study was 7.6% (n=490), of which 3.9% (n=19) required dialysis. Higher incidence of CI-AKI was seen in those with baseline eGFR &lt; 60 ml/min/1.73m2 (16.4%) and a pre-procedural Mehran score &gt;11 (33%). Peri-PCI Hb drop was seen in 49.9% (n=3203), with a drop &gt;2g/dL in 18.5% (n=1185). On multivariate logistic regression analysis (Table 2), it was found that periprocedural Hb drop &gt;2g/dL was independently associated with CI-AKI (OR 1.49, 95% CI 1.18-1.88, P=0.001). Furthermore, in those with periprocedural blood loss, the risk of CI-AKI was increased by 1.3 times for each 1g/dL drop in Hb (OR 1.30, 95% CI 1.14-1.49, P&lt;0.001). Additionally, apart from traditional risk factors, hypertension was independently associated with development of CI-AKI (Table 2).

Conclusion

Periprocedural blood loss was associated with a higher risk of CI-AKI after PCI. Moreover, risk of CI-AKI increased with increasing severity of blood loss. Whether measures to minimize blood loss, like using a transradial approach, staging complex procedures and close monitoring of anticoagulation/antiplatelet regimens, will help reduce risk of CI-AKI needs to be studied.