A case of non-traumatic rectus sheath hematoma in a post-kidney transplant patient undergoing catheter embolization during anticoagulation treatment for atrial fibrillation

A 65-year-old man, a post living donor kidney transplant patient, was admitted to the intensive care unit (ICU) with a severe bacterial infection. He also tested positive for coronavirus disease and had a cough. On admission, heparin was administered for atrial fibrillation. On the third day of hospitalization, his general condition had recovered, and he was discharged from the ICU to the general ward. On the fourth day of hospitalization, he experienced abdominal pain, and a hard mass was palpated in the left lower abdomen. On the fifth day of hospitalization, contrast-enhanced computed tomography showed an extensive rectus sheath hematoma (RSH) extending from the left lower abdominal wall to the left side of the bladder, with extravasation from a small branch of the left inferior epigastric artery. Heparin was discontinued, and transcatheter arterial embolization was performed to control the bleeding. RSH is a rare disease, and cases of extensive hematoma in post-kidney transplant patients occur even less frequently. Patients taking anticoagulants and those with chronic kidney disease are at high risk for RSH, so physicians should be cognizant of this disease when these patients develop abdominal pain.

Efficacy and Safety of Anti-angiogenic Agents for Cancer Patients With Proteinuria or a History of Proteinuria: A Systematic Review

BACKGROUND/AIM

The safety and efficacy of anti-angiogenic agents in patients with cancer with proteinuria and a history of proteinuria are not well established. This systematic review aimed to answer these questions.

MATERIALS AND METHODS

We searched three electronic databases for articles published until June 18, 2021. The main outcomes used were "death", "renal impairment", and "proteinuria impairment".

RESULTS

After screening 303 references in the PubMed, Cochrane Library, and ICHUSHI-web databases, this review included five studies on renal cell carcinoma (RCC). In patients with metastatic RCC, the hazard ratio of the presence of (or having) proteinuria (1+ or higher) at baseline was 0.82 (0.23-2.97); thus, proteinuria was not significantly associated with the outcome of death. No significant deterioration in kidney function was observed in patients with proteinuria. Although proteinuria at baseline was a significant risk factor for proteinuria progression during and after treatment, most patients maintained grade 1 or 2 proteinuria and continued treatment without dose reduction or discontinuation.

CONCLUSION

While weak evidence suggests that proteinuria at the start of treatment with anti-angiogenic agents might be a risk factor for worsening proteinuria, it was not significantly associated with death or renal impairment.

Changes in antibody titer after four and five doses of the SARS-CoV-2 vaccine in Japanese post-kidney transplant patients

INTRODUCTION

Immunosuppressed patients exhibit low antibody acquisition rates following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination. Kidney transplant recipients previously exhibited low antibody acquisition rates after two vaccine doses, which increased after the third dose. We evaluated antibody titers of Japanese post-kidney transplant patients after the fourth and fifth vaccinations.

METHODS

Antibody titers for SARS-CoV-2 spike protein were measured between 3 weeks and 3 months after the fourth or fifth vaccination.

RESULTS

Increased antibody acquisition rates were observed after the fourth (75.0% antibody-positive) and fifth (81.5% antibody-positive) vaccinations. The antibody-acquired group after the fourth vaccination exhibited a higher body mass index and estimated glomerular filtration rate (eGFR) than the non-acquired group. A higher eGFR was associated with antibody acquisition after the fifth vaccination.

CONCLUSION

In Japanese post-kidney transplant patients, the antibody acquisition rate increased with each vaccine additional dose. Additional vaccinations are recommended to protect against SARS-CoV-2 infection.

Establishment of an adverse effect prevention protocol on plasma exchange using fresh frozen plasma prior to ABO-incompatible living donor kidney transplantation at our hospital

INTRODUCTION

Simple plasma exchange (PE) with fresh-frozen plasma replacement allows antibody removal for ABO-incompatible living donor kidney transplantation, but is associated with a high incidence of allergic reactions. We developed, implemented, and evaluated a protocol for safe preoperative PE.

METHODS

The protocol comprised pretreatment (125 mg methylprednisolone infusion, 400 mg acetaminophen and 30 mg diphenhydramine orally) with a replacement fluid rate < 20 mL/min. Allergic reaction incidence was investigated in controls who underwent ABO-incompatible living donor kidney transplantation between 2016 and March 2020 (group C) and patients who underwent the protocol and procedure between April 2020 and February 2023 (group N).

RESULTS

Ten (group C) and 19 (group N) patients performed 11 and 30 sessions of PE, respectively. Allergic reactions occurred in 81.8% and 36.7% (p = 0.014), respectively, with an odds ratio of the protocol was 0.056 (95% CI 0.0059-0.5380, P = 0.013).

CONCLUSION

Our protocol resulted in a significantly lower incidence of allergic reactions.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Relationship between the lower limit of systolic blood pressure target and kidney function decline in advanced chronic kidney disease: an instrumental variable analysis from the REACH-J CKD cohort study

Intensive antihypertensive treatment decreases cardiovascular disease and mortality risks in chronic kidney disease (CKD), whereas extremely low systolic blood pressure (SBP) is associated with worsening kidney function and poor prognosis. Although the SBP variation is particularly large in patients with CKD, the optimal lower limit of SBP target is unclear. In a nationwide, multicenter cohort study of patients with an estimated glomerular filtration rate (eGFR) < 45 mL/min/1.73 m2, we evaluated the association between the eGFR slopes and the lower limit of SBP target at ≥110 mmHg using a linear mixed-effects model and an instrumental variable method. The instrumental variable was calculated as the facility-level percentage of nephrologists who answered in the survey that their lower limit of SBP target was 110 mmHg or higher. A total of 1320 patients (mean age 70 years; 66% men) were included. The mean eGFR slope ± standard deviation over the four years to baseline was -2.48 ± 2.15 mL/min/1.73 m2/year. The instrumental variable for the lower limit of SBP target at ≥110 mmHg (vs. ≤100 mmHg) was associated with less eGFR decline (coefficient: +1.05 mL/min/1.73 m2/year; 95% confidence interval: 0.33-1.77), while unassociated with a history of cardiovascular disease. The renoprotective effect was particularly larger in the subgroups of the elderly and those with a history of cardiovascular disease. In conclusion, the lower limit of SBP target at 110 mmHg or higher was associated with improved eGFR slope, suggesting the importance of aiming at avoiding excessively low SBP in patients with advanced CKD.

Chapter 3: Management of kidney injury caused by cancer drug therapy, from clinical practice guidelines for the management of kidney injury during anticancer drug therapy 2022

Cisplatin should be administered with diuretics and Magnesium supplementation under adequate hydration to avoid renal impairment. Patients should be evaluated for eGFR (estimated glomerular filtration rate) during the treatment with pemetrexed, as kidney injury has been reported. Pemetrexed should be administered with caution in patients with a CCr (creatinine clearance) < 45 mL/min. Mesna is used to prevent hemorrhagic cystitis in patients receiving ifosfamide. Febuxostat is effective in avoiding hyperuricemia induced by TLS (tumor lysis syndrome). Preventative rasburicase is recommended in high-risk cases of TLS. Thrombotic microangiopathy could be triggered by anticancer drugs and there is no evidence of efficacy of plasma exchange therapy. When proteinuria occurs during treatment with anti-angiogenic agents or multi-kinase inhibitors, dose reductions or interruptions based on grading should be considered. Grade 3 proteinuria and renal dysfunction require urgent intervention, including drug interruption or withdrawal, and referral to a nephrologist should be considered. The first-line drugs used for blood pressure elevation due to anti-angiogenic agents are ACE (angiotensin-converting enzyme) inhibitors and ARBs (angiotensin receptor blockers). The protein binding of drugs and their pharmacokinetics are considerably altered in patients with hypoalbuminemia. The clearance of rituximab is increased in patients with proteinuria, and the correlation with urinary IgG suggests similar pharmacokinetic changes when using other antibody drugs. AIN (acute interstitial nephritis) is the most common cause of ICI (immune checkpoint inhibitor)-related kidney injury that is often treated with steroids. The need for renal biopsy in patients with kidney injury that occurs during treatment with ICI remains controversial.

A retrospective database analysis of erythropoiesis-stimulating agent treatment patterns and associated healthcare resource use in patients with non-dialysis-dependent chronic kidney disease-related anaemia in Japan

AIM

This study was conducted to evaluate clinical characteristics, treatment patterns, and healthcare resource use (HCRU) for patients in Japan with non-dialysis-dependent chronic kidney disease (CKD) and anaemia.

METHODS

This retrospective, longitudinal, epidemiological database extraction study used the JMDC Claims Database, comprising ~9.4 million unique beneficiaries. The observation period for anaemia and erythropoiesis-stimulating agent (ESA)/iron treatment was 1 January 2015 to 31 December 2018, and for HCRU and costs was 1 April 2016 to 31 March 2018. The non-dialysis-dependent CKD anaemia population, and the ESA treatment, iron treatment, and no-treatment cohorts were evaluated. Patient characteristics, treatment patterns, and outcomes were summarised descriptively.

RESULTS

The non-dialysis-dependent CKD anaemia population included 5908 patients (7.9%), with 464 patients in the ESA treatment cohort, 809 patients (13.7%) in the iron treatment cohort (13.7%), and 4405 (74.6%) patients in the no-treatment cohort. The prevalence of patients prescribed an antihypertensive, antidiabetic, and/or antihyperlipidaemic medication generally increased with increasing baseline CKD stage. Proportions of no treatment for anaemia decreased while ESA treatment increased with increasing CKD stage; ESA treatment increased with decreasing baseline haemoglobin levels. Patients in the ESA treatment cohort generally had more frequent events associated with HCRU and higher costs from HCRU-associated activities (e.g., inpatient and outpatient care, pharmacy).

CONCLUSION

As CKD severity increased, anaemia management changed from iron use or no treatment to ESA use; however, anaemia may be undertreated across all CKD stages. ESA-treated patients incurred greater HCRU-associated costs relative to other patients with non-dialysis-dependent CKD anaemia in Japan.

Prognostic factors of IgA nephropathy presenting with mild proteinuria at the time of diagnosis (a multicenter cohort study)

BACKGROUND

Clinical factors affecting renal prognosis in patients with immunoglobulin A nephropathy (IgAN) and low urinary protein excretion (U-Prot) remain unclear. This study evaluated such factors in patients with clinical grade I (CG-I) IgAN with U-Prot < 0.5 g/day.

METHODS

This secondary analysis of a previous retrospective study included 394 patients with CG-I IgAN. The primary outcome was the first occurrence of a 1.5-fold increase in serum creatinine levels from baseline. Factors related to renal prognosis were examined using univariate and multivariate Cox regression analyses. CG-I was divided into C-Grade Ia (CG-Ia) (n = 330) with baseline eGFR ≥ 60 ml/min/1.73 m², and C-Grade Ib (CG-Ib) (n = 64) with baseline eGFR < 60 ml/min/1.73 m². Outcome incidence was compared between conservative and aggressive therapy (corticosteroids and/or tonsillectomy) groups.

RESULTS

Overall outcome incidence was significantly higher in CG-Ib than in CG-Ia; the cumulative incidence was significantly higher in CG-Ib (hazard ratio, 9.67; 95% confidence interval, 2.90-32.23). Older age, higher IgA levels, eGFR < 60 mL/min/1.73 m², lower eGFR at baseline were independent prognostic factors for CG-I. Older age, lower eGFR, higher IgA levels at baseline, and U-Prot remission at 1-year post-diagnosis were independent prognostic factors for CG-Ib. Aggressive therapy tended to suppress the cumulative outcome incidence compared with conservative therapy in CG-Ib (p = 0.087).

CONCLUSION

An eGFR < 60 mL/min/1.73 m² is a significant predictor of renal prognosis in patients with IgAN and U-Prot < 0.5 g/day.

Serum and plasma levels of Ba, but not those of soluble C5b-9, might be affected by renal function in chronic kidney disease patients

BACKGROUND

During the last few decades, pathogenic mechanisms associated with uncontrolled activation of the complement (C) system and development of anti-C agents have been closely investigated in the field of nephrology. The usefulness of some C products such as C5a and sC5b-9 for diagnostic and prognostic purposes remains controversial. On the other hand, decreased renal function is being observed in many patients with or without nephritis as a background factor in progressively aging societies. We therefore investigated whether renal function influenced the evaluation of various complement components and activation products.

METHODS

To investigate the influence of renal function on evaluations of C3, C4, CH50, Ba, C5a and sC5b-9, 40 patients were retrospectively chosen from among 844 patients without active glomerulonephritis from 2009 to 2016. We measured plasma and serum levels of C3, C4, CH50, Ba, C5a and sC5b-9 using enzyme-linked immunosorbent assays and compared the findings with inulin clearance (Cin) as a marker of preserved renal function.

RESULTS

Both plasma and serum levels of Ba correlated significantly with Cin, but other values did not. Compared with patients with Cin ≥ 60 or ≥ 30 mL/min/1.73 m², plasma and serum levels of Ba were increased in patients with Cin decreased to < 60 or < 30 mL/min/1.73 m², but levels of C5a and sC5b-9 were not.

CONCLUSION

The influence of renal function might need to be considered when evaluating Ba, but not C5a and sC5b-9, in plasma and serum samples from chronic kidney disease patients.

Assessment of Antibody-Titer Changes after Second and Third Severe Acute Respiratory Syndrome Coronavirus 2 mRNA Vaccination in Japanese Post-Kidney-Transplant Patients

Post-renal-transplant patients have a relatively low antibody-acquisition rate following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) mRNA vaccination. In this study, antibody titers were measured 5−6 months and 3 weeks to 3 months after the second and third SARS-CoV-2 mRNA vaccinations, respectively. Post-renal-transplant patients visiting our hospital who had received three SARS-CoV-2 mRNA vaccine doses were included in the study. SARS-CoV-2 immunoglobulin G antibody titers were measured three times: between 3 weeks and 3 months after the second vaccination, 5−6 months after the second vaccination, and between 3 weeks and 3 months after the third vaccination. A total of 62 (40 men and 22 women) were included, 44 of whom (71.0%) were antibody positive after their third vaccination. On comparing the antibody-acquired and antibody-non-acquired groups, body mass index (BMI, odds ratio [OR]: 1.44, 95% confidence interval [CI]: 1.07−1.93, p < 0.05) and the estimated glomerular filtration rate (eGFR, OR: 1.14, 95% CI: 1.06−1.24, p < 0.01) were associated with antibody acquisition. Therefore, in Japanese post-kidney-transplant patients, increases in the antibody-acquisition rate and absolute antibody titer after the third vaccination were observed, with BMI and eGFR associated with the antibody-acquisition rate.

Antibody response to double SARS-CoV-2 mRNA vaccination in Japanese kidney transplant recipients

Immunocompromised patients, especially those who undergo kidney transplantation, have lower antibody levels following SARS-CoV-2 mRNA vaccination. The situation of transplant treatment, such as transplant source and immunosuppressive drugs, is different in Japan than that in other countries. Therefore, it is necessary to clarify whether antibody acquisition rates differ between Japan and other countries. This retrospective study included patients with post-kidney transplant who were attending at the Nagoya University Hospital. The anti-SARS-CoV-2 IgG antibody titers were measured between 3 weeks and 3 months after vaccination. Seventy-three patients (45 men and 28 women) were included. Of these, 23 (31.5%) showed antibody presence, and the rates of antibody acquisition were very low than those in the control group (100.0% vs. 31.5%, P < 0.05). Antibody acquisition rates were associated with body mass index (odds ratio [OR]: 1.21, 95% confidence interval [CI]: 1.04-1.39, P < 0.05) and the duration between transplantation and vaccination (OR: 1.01, 95% CI: 1.00-1.02, P < 0.05). The immunosuppressive drugs used were: prednisolone in all cases, tacrolimus in 89.0%, cyclosporine in 9.6%, and mofetil mycophenolate in 97.3%. None of the patients were excluded from receiving two doses of the vaccine due to adverse effects. The study indicated that vaccination-induced antibody acquisition rates against SARS-CoV-2 were extremely low in Japanese patients who underwent post-kidney transplantation. Thus, despite two doses of vaccination, it is necessary to closely monitor infection control in such patients.

Effect of body mass index on the association between alcohol consumption and the development of chronic kidney disease

The influence of body mass or metabolic capacity on the association between alcohol consumption and lower risks of developing chronic kidney disease (CKD) is not fully elucidated. We examined whether the body mass index (BMI) affects the association between drinking alcohol and CKD. We defined CKD as an estimated glomerular filtration rate decline < 60 mL/min/1.73 m² and/or positive proteinuria (≥ 1+). Participants were 11,175 Japanese individuals aged 40–74 years without baseline CKD who underwent annual health checkups. Daily alcohol consumption at baseline was estimated using a questionnaire, and the participants were categorized as “infrequent (occasionally, rarely or never),” “light (< 20 g/day),” “moderate (20–39 g/day),” and “heavy (≥ 40 g/day).” Over a median 5-year observation period, 936 participants developed CKD. Compared with infrequent drinkers, light drinkers were associated with low CKD risks; adjusted hazard ratios (95% confidence intervals) were 0.81 (0.69–0.95). Stratified by BMI (kg/m²), moderate drinkers in the low (< 18.5), normal (18.5–24.9), and high (≥ 25.0) BMI groups had adjusted hazard ratios (95% confidence intervals) of 3.44 (1.60–7.42), 0.75 (0.58–0.98), and 0.63 (0.39–1.04), respectively. Taken together, the association between alcohol consumption and CKD incidence was not the same in all the individuals, and individual tolerance must be considered.

The effectiveness of strict low-density lipoprotein cholesterol management in secondary prevention of Japanese patients

Background

In Japanese guidelines, target value of low-density lipoprotein cholesterol (LDL-C) &lt;100mg/dL is recommended as standard management for secondary prevention of coronary artery disease. On the other hand, the guidelines also state that LDL-C targeting &lt;70mg/dL should be considered in high-risk patients. However, the effectiveness of strict LDL-C management in the prevention of long-term coronary event recurrence in Japanese patients remains unclear.

Purpose

The purpose of the present study was to evaluate whether the strict management of LDL-C targeting &lt;70 mg/dL was effective to prevent recurrence of acute coronary syndrome (ACS) than standard management in patients with previous percutaneous coronary intervention (PCI).

Methods

From January 2007 to August 2020, we performed coronary angiography in 359 patients with previous PCI who were suspected of having signs of recurrent cardiac ischemia. Patients were stratified into three groups according to achieved LDL-C value; &lt;70mg/dL (n=57), 70 to &lt;100mg/dL (n=135) and ≥100mg/dL (n=167). In addition, patients who had previous ACS and/or diabetes mellitus were defined as high-risk group, and sub-analysis by their achieved LDL-C values was performed in high-risk group and non-high-risk group. Endpoint was recurrence of ACS. Moreover, risk factors associated with recurrent-ACS were examined in patients with LDL-C &lt;100 mg/dL.

Results

After follow-up (median 6.1 years), 99 patients (28%) had recurrent-ACS. Recurrent-ACS was significantly lower in patients with LDL-C &lt;70mg/dL than LDL-C 70 to &lt;100mg/dL and LDL-C ≥100mg/dL (p&lt;0.01 and p&lt;0.001, respectively). In sub-analysis, high-risk group with LDL-C &lt;70 mg/dL had lower incidence of recurrent-ACS than LDL-C 70 to &lt;100 mg/dL (p=0.03). Similar tendency was found in non-high-risk group (p=0.08). There was no difference of recurrent-ACS between high-risk group and non-high-risk group in patients with LDL-C &lt;70mg/dL (p=0.41). Moreover, in patients with achieved LDL-C &lt;100mg/dL (n=192), multivariate analysis identified that LDL-C (HR: 1.032, p&lt;0.01) and HbA1c (HR: 1.330, p&lt;0.01) were independent predictors of recurrent-ACS. In these patients, whether or not they were in the high-risk group was not a significant predictor (p=0.61).

Conclusions

Strict management of LDL-C targeting &lt;70 mg/dL should be considered for a wider range of Japanese patients as well as for Westerners to prevent recurrence of ACS in secondary prevention.

Funding Acknowledgement

Type of funding sources: None. Probability of freedom from ACS

High urinary glucose is associated with improved renal prognosis in patients with diabetes mellitus

AIMS/INTRODUCTION

The relationship between renal function and urinary glucose is poorly understood in diabetes patients who are not using sodium-glucose cotransporter 2 inhibitors. This study aimed to investigate the association of urinary glucose excretion with renal function prognosis in such patients.

MATERIALS AND METHODS

This retrospective cohort study included 1,172 patients with type 1 or 2 diabetes mellitus. Patients were recruited and data were collected between 1 January 2007 and 31 December 2011; follow-up data were collected until 30 June 2015. The primary outcome was set as a 30% decline in estimated glomerular filtration rate relative to baseline. The relationship between this outcome and urinary glucose was investigated using Cox proportional hazards model. For analysis, patients were categorized into two groups: urinary glucose <5 g/day or ≥5 g/day. Interaction terms were analyzed.

RESULTS

Multivariate analysis showed that the prognosis of renal function was significantly better in patients with high urinary glucose (≥5 g/day; adjusted hazard ratio 0.58, 95% confidence interval 0.35-0.96; P = 0.034). Significant interactions were observed between high urinary glucose and male sex (hazard ratio 0.33, 95% confidence interval 0.14-0.74; P = 0.007), and between high urinary glucose and longer duration of diabetes (≥10 years; hazard ratio 0.25, 95% confidence interval 0.11-0.58; P = 0.001).

CONCLUSIONS

The present study suggests that high urinary glucose is associated with prognosis in diabetes patients not taking sodium-glucose cotransporter 2 inhibitors. Measurement of 24-h urinary glucose excretion might have clinical utility for predicting renal prognosis.

MO509DOSE-RESPONSE RELATIONSHIP BETWEEN ALCOHOL CONSUMPTION AND THE RISK OF DEVELOPING CKD: RETROSPECTIVE COHORT STUDY

Background and Aims

Drinking habits are one of the most important modifiable lifestyle factors to prevent the development of chronic kidney disease (CKD). Previous studies showed that it was inversely associated with the risk of developing CKD, but the dose-response relationship between alcohol consumption and the development of CKD is still controversial. In the present study, we aimed to examine whether the amount of alcohol consumed at one time is associated with new onset of CKD in general population.

Method

Study subjects were 11,162 Japanese aged 45 to 74 years, with an estimated glomerular filtration rate ≥60 mL/min/1.73m2, no proteinuria, no past history of cardiovascular disease, COPD or liver disease. The drinking status was obtained by self-administered questionnaires. We categorized the study subjects into four groups based on the amount of alcohol consumption: &lt;20g/time of ethanol equivalent (lowest); 20-40g/time (low intermediate); 40-60g/time (high intermediate); &gt;60g/time (highest). We set non-drinkers as a reference category. The primary outcome was the incidence of CKD, defined as 25% reduction of eGFR and to less than 60 mL/min/1.73 m2 and/or a dipstick urinalysis score of 1+ or greater (equivalent to ≥30 mg/dL) during the follow up period. We employed Cox proportional hazards regression models to examine the dose-response relationship between baseline alcohol consumption and the risk of CKD. Trend tests were performed using Cox proportional hazards regression models that treated alcohol consumption as a continuous linear term.

Results

Lowest and low intermediate groups were significantly associated with a decreased risk of CKD (hazard ratio [HR] 0.84; 95% confidence interval [CI], and 0.71–0.99; HR 0.79; 95% CI, 0.66–0.96, respectively) compared to non-drinkers. High intermediate group was associated with a decreased risk of CKD (HR 0.92; 95% CI, 0.70–1.21), and highest group was associated with an increased risk of CKD (HR 1.28; 95% CI, 0.84–1.95), but these associations did not reach statistical significance. There was no dose-response relationship between baseline alcohol consumption and risk of CKD (P-trend = 0.30).

Conclusion

A J-shape association was observed between self-reported alcohol intake and the incidence of CKD. Moderate alcohol consumption at one time may help reduce the risk of CKD.

The efficacy of synthetic pseudo-ceramide for dry and rough lips

OBJECTIVE

Lips can easily become dry and rough, one reason being the characteristics of their ceramide (CER) profile. Lips have lower levels of total ceramides, higher percentages of CER[NS] and CER[AS], and lower percentages of CER[NP] and CER[NH] than skin in other regions of the body. The purpose of this study was to clarify the effects of synthetic pseudo‐ceramide (pCer; Cetyl‐PG hydroxyethyl palmitamide) to improve the dryness and roughness of the lips of healthy subjects in a formulation that exclude an occlusive effect.

METHODS

Thirty‐one Japanese female subjects with normal skin (age range 21–37 years; mean 28.6) were enrolled in this study. A four‐week continuous use test was conducted using samples with or without 0.5% or 2.0% pCer. The degree of lip roughness was scored, and values of capacitance, transepidermal water loss (TEWL) and lip surface elasticity were measured. Endogenous CER profiles and absorption levels of pCer in the stratum corneum (SC) were analysed in tape‐stripped skin specimens.

RESULTS

Treatment with the pCer‐2.0% sample significantly improved the visual roughness score after 2 and 4 weeks compared to 0 weeks and compared to the Blank. Moreover, an improvement in TEWL was observed after 4 weeks of treatment with the pCer‐2.0% sample. CER[NP] showed a significant increase in pCer‐2.0% treated lips after 4 weeks compared to the Blank. Both pCer‐0.5% and pCer‐2.0% were significantly absorbed after 2 weeks compared with the Blank.

CONCLUSION

The effect of the synthetic pseudo‐ceramide pCer to improve the roughness of lips was shown excluding the effect of occlusiveness derived from the formulation for the first time. Since the improvement of TEWL and absorption of pCer was observed, we concluded that pCer was first absorbed in rough lip areas, improved the ceramide profile and consequently restored the barrier function.

Nephrotic syndrome with focal segmental glomerular lesions unclassified by Columbia classification; Pathology and clinical implication

Background

The Columbia classification is widely used for diagnosis of focal segmental glomerulosclerosis (FSGS). In practice, we occasionally encounter segmental glomerular lesions unclassified as Columbia classification. We analyzed the clinical implication of unclassified segmental lesions comparing with Columbia-classified FSGS.

Methods

A retrospective cohort study from 13 local hospitals in Japan. From 172 biopsy cases diagnosed with FSGS or minimal change disease (MCD)/FSGS spectrum with unclassified segmental lesions, adult patients with nephrotic syndrome who received immunosuppressive therapies were included. The cases are classified by pathology, i.e., typical FSGS lesions sufficiently classified into subgroups of Columbia classification: collapsing (COL), tip (TIP), cellular (CEL), perihilar (PH), and not otherwise specified (NOS), and unclassified by the Columbia classification into three subgroups: “endothelial damage,”; “simple attachment,”; and “minor cellular lesion,”. The response to immunosuppressive treatment and 30% decline of eGFR were compared.

Results

Among 48 eligible cases, all were Japanese, 34 were typical FSGS; 13 TIP, 15 CEL, 6 NOS, and no COL or PH cases. Fourteen were unclassified cases: endothelial damage (n = 6), simple attachment (n = 5), and minor cellular lesion (n = 3). The median age of overall patients was 60 years old and the median of eGFR and urinary protein creatinine ratio was 51.5 mL/min/1.73m² and 7.35, respectively. They received similar therapeutic regimen. Kaplan-Meier analysis revealed no significant difference in treatment response between typical FSGS and unclassified cases. Evaluating among the subgroups, endothelial damage, simple attachment and minor cellular lesion showed similar treatment response to TIP or CEL. No significant difference was also observed in the 30% decline of eGFR.

Conclusions

Japanese adult patients with nephrotic syndrome showing unclassified segmental lesions as Columbia classification may be equivalent clinical impact as Columbia classification of FSGS.

Effectiveness of more strict managements after achievement of standard target value of low-density lipoprotein cholesterol in secondary prevention of Japanese patients

Background

In secondary prevention of coronary artery disease, target value of low-density lipoprotein cholesterol (LDL-C) &lt;100 mg/dL is recommended as standard management in Japanese guideline. The guideline also stated that strict management of LDL-C targeting &lt;70 mg/dL is considered in some high risk patients. However, in Japanese patients, effectiveness of more strict management of LDL-C lowering therapy for prevention of long-term cardiovascular events remains unclear.

Purpose

The purpose of the present study was to evaluate whether the strict management of LDL-C targeting &lt;70 mg/dL was effective to prevent recurrence of long-term coronary events than standard management in patients with previous percutaneous coronary intervention (PCI).

Methods

We investigated 344 patients with previous PCI who underwent late coronary angiography to examine recurrence of cardiac ischemia beyond the early phase of restenosis from January 2007 to August 2019. Patients were stratified into three groups according to achieved LDL-C value; LDL-C &lt;70mg/dL (n=53), 70 to &lt;100mg/dL (n=130) and ≥100mg/dL (n=161). Endpoints of this study were recurrence of cardiac ischemia presenting as acute coronary syndrome (recurrence-ACS) and any late coronary revascularization.

Results

During average 7.1 years follow-up, 200 patients (58%) underwent any late coronary revascularization. In 94 of those patients, recurrence-ACS was observed. The incidence of recurrence-ACS was significantly lower in patients with achieved LDL-C &lt;70mg/dL than in those with LDL-C 70 to &lt;100mg/dL and LDL-C ≥100mg/dL (p=0.009 and p=0.001, respectively), however, there was no difference between patients with LDL-C 70 to &lt;100mg/dL and LDL-C ≥100mg/dL (p=0.140). Any late revascularization was significantly lower in patients with achieved LDL-C &lt;70mg/dL and in those with LDL-C 70 to &lt;100mg/dL than in those with LDL-C ≥100mg/dL (p=0.002 and p&lt;0.001, respectively), however, no difference was found between patients with LDL-C &lt;70mg/dL and LDL-C 70 to &lt;100mg/dL (p=0.119). Moreover, in patients with achieved LDL-C &lt;100mg/dL (n=183), multivariate analysis identified that LDL-C (HR 1.035, p=0.007) and HbA1c (HR 1.338, p=0.001) were independent predictors of recurrence-ACS. In contrast, only using statins (HR 0.461, p=0.009) was an independent predictor of recurrence-ACS in patients with achieved LDL-C ≥100mg/dL.

Conclusions

LDL-C was the important residual risk of recurrence-ACS even after recommended standard LDL-C lowering management had been achieved. More strict management of LDL-C targeting to &lt;70mg/dL should be considered to prevent recurrence-ACS for wider range of Japanese patients in secondary prevention.

Incidence of late coronary events

Funding Acknowledgement

Type of funding source: None

Impact of old age on the association between in-center extended-hours hemodialysis and mortality in patients on incident hemodialysis

With the global problem of aging, it has become more difficult to improve the prognosis of older dialysis patients. Extended-hours hemodialysis offers longer treatment time compared to conventional hemodialysis regimen and provides favorable metabolic status, hemodynamic stability, and increased dietary intake. Despite prior studies reporting that in-center extended-hours hemodialysis can reduce the mortality rate, the treatment impact on elderly patients remains unclear. Therefore, we examined the association between extended-hours hemodialysis compared to conventional hemodialysis and all-cause mortality. Survival analyses using Cox proportional hazard model with multivariable adjustments and propensity-score based method were performed to compare mortality risk between 198 consecutive patients who started in-center extended-hours hemodialysis (Extended-HD) and 1407 consecutive patients who initiated conventional hemodialysis. The median age was 67.1 years in the Extended-HD group and 70.7 years in the conventional hemodialysis group. Extended-HD was associated with lower all-cause mortality in overall patients and the subgroup >70 years (adjusted hazard ratios of 0.60 [95% CI, 0.39–0.91] and 0.35 [95% CI, 0.18–0.69], respectively). There was a significant interaction between age >70 years and Extended-HD. In conclusion, extended-hours hemodialysis was associated with a lower mortality rate, especially in elderly patients.

P0744CLINICAL IMPACT OF SERUM INDOXYL SULPHATE MEASURED BY NEW ENZYMATIC METHOD IN PATIENTS WITH CHRONIC KIDNEY DISEASE

Background and Aims

Uremic toxins have been highlighted as serious risk factors for deterioration of renal function and onset/progression of cardiovascular diseases (CVD). Serum level of indoxyl sulphate (IS), a major uremic toxin, was demonstrated its significant association with vascular disease and mortality in a cohort of chronic kidney disease (CKD) patients, however, IS has not been available in clinical setting due to time consuming and expensive measurement cost. Recently epoch-making IS measurement method applicable for general auto analyzer has been developed, which could explore new therapeutic avenue in CKD from the view point of uremic toxin management.

In this study, clinical utility of new enzymatic IS measurement method was analyzed in association with renal function and CVD among CKD patients.

Method

Subjects were consecutive 150 CKD patients in Nagoya University Hospital whose serum samples were collected between 2009 and 2014. Serum IS levels were measured by “NIPRO” reagent and analyzed with eGFR, CVD events and renal outcomes defined by 30% decrease in eGFR.

Results

Characteristics of patients were 69 ± 10 years old, 29% female, eGFR: 44 ± 20 mL/min/1.73m2 (∼G3a: 43％, G3b: 29％, G4: 24％, Ｇ5: 4％), proteinuria 2.8 ± 3. 5ｇ/ｇCr (A1: 29％, A2: 29％, A3: 42％), HTN: 83％, and DM: 39％. Serum IS levels (μmol/L) were 10.5 ± 7.5 (∼G3a: 1.8 ± 0.6, G3b: 2.1 ± 0.6, G4: 15.8 ± 8.1, Ｇ5: 22.9 ± 13.5), and strongly correlated with eGFR (r =0.518, P&lt;0.001). Among IS low (&lt;6), middle and high (≥12) tertiles, significantly different factors were age, eGFR, Hb, iPTH and LDL-C. In multiple logistic regression analysis, only eGFR was significant associating factor with IS tertiles. IS levels in 2 patients prescribed AST-120 (Kremezin) were 8.1 and 10.3, which seems to be very low in comparison to their eGFR of 13.8 and 13.7. During observation period of 5.1 ± 1.0 years, 59 renal outcomes and 9 CVD events were observed. Kaplan-Meier survival curve analysis free from renal outcomes revealed better tendency in IS low group (p= 0.0617 in log-rank test). According to IS levels adjusted by eGFR, only 1 out of 9 CVD events occurred in low IS/eGFR tertile group.

Conclusion

Serum IS levels could be measured in new enzymatic method. Strong correlation between IS and eGFR was demonstrated, and AST-120 might be effective to improve IS. In renal and CVD outcome analysis, more sample size is needed for further study.

Short-Term Steroid Regimen for Adult Steroid-Sensitive Minimal Change Disease

BACKGROUND

In pediatric patients with steroid-sensitive nephrotic syndrome, recent trials have revealed that a 2-month, short-term steroid regimen is not inferior to an extended steroid course. However, the optimal duration of initial steroid therapy for adult steroid-sensitive minimal change disease (MCD) remains unclear.

OBJECTIVES

The aim of present study was to evaluate the effectiveness of a 2-month, short-term steroid regimen in the treatment of adult steroid-sensitive MCD patients.

METHOD

This was a prospective observational study. Adult patients with steroid-sensitive MCD (n = 35) who were initiated on a short-term steroid regimen between January 2015 and June 2016 were included. The details of the regimen are as follows: (1) prednisolone was administered at an initial dose of 0.8-1.0 mg/kg/day and continued for 4-6 weeks and (2) dosage was reduced to 0.5-0.6 mg/kg/alternate day and continued for 4 weeks. Control patients (n = 140), who were treated using conventional steroid administration, were selected from our previous adult MCD cohort. All patients fulfilled the following criteria: biopsy-proven MCD, age ≥20 years, first episode of nephrotic syndrome, and attainment of complete remission within 4 weeks. The following parameters of patients who received short-term treatment regimen and control patients were compared: any relapse and frequent relapse, adverse events caused by steroid treatment and cumulative steroid dose.

RESULTS

Throughout the observation period (median: 17.3 months), 24 (68.6%) patients in the short-term group developed at least one relapse. The short-term regimen showed earlier occurrence of any relapse than the conventional regimen (adjusted hazard ratio [aHR] 2.45; 95% CI 1.51-3.97; p < 0.001), but there was no difference in frequent relapse (aHR 1.31; 95% CI 0.43-3.99; p = 0.63). None of the patients showed any symptoms of adrenal insufficiency after discontinuation of corticosteroids. The cumulative steroid dose during the observational period was significantly lower in the short-term group than in the conventional group.

CONCLUSIONS

The short-term steroid regimen may represent an effective treatment option that ensures lower steroid exposure when treating adult steroid-sensitive MCD patients.

Circulating levels of CD34+ cells predict long-term cardiovascular outcomes in patients on maintenance hemodialysis

CD34+ cells maintain vascular homeostasis and predict cardiovascular outcomes. We previously evaluated the association of CD34+ cells with cardiovascular disease (CVD) events over 23 months, but long-term CVD outcomes in relation to levels of CD34+ cells in patients on maintenance hemodialysis are unclear. Herein, we analyzed the long-term predictive potential levels of CD34+ cells for CVD outcomes and all-cause mortality. Between March 2005 and May 2005, we enrolled 215 patients on maintenance hemodialysis at Nagoya Kyoritsu Hospital and followed them up to 12.8 years. According to the CD34+ cell counts, patients were classified into the lowest, medium, and highest tertiles. Levels of CD34+ cells were analyzed in association with four-point major adverse CV events (MACEs), CVD death, and all-cause mortality. In univariate analysis age, smoking habit, lower geriatric nutrition risk index, lower calcium × phosphate product, and lower intact parathyroid hormone were significantly associated with the lowest tertile. Whereas, in multivariate analysis, age and smoking habit were significantly associated with the lowest tertile. Among 139 (64.7%) patients who died during a mean follow-up period of 8.0 years, 39 (28.1%) patients died from CVD. Patients in the lowest tertile had a significantly lower survival rate than those in the medium and highest tertiles (p ≤ 0.001). Using multivariable analyses, the lowest tertile was significantly associated with four-point MACEs (hazard ratio 1.80, p = 0.023) and CVD death (hazard ratio 2.50, p = 0.011). In conclusion, our long-term observational study revealed that a low level of CD34+ cells in the circulation predicts CVD outcomes among patients on maintenance hemodialysis.

Very low frequency component of heart rate variability as a marker for therapeutic efficacy in patients with obstructive sleep apnea: Preliminary study

Background:

Although positive airway pressure (PAP) therapy is effective for treating obstructive sleep apnea (OSA), some patients with severe OSA are intolerable to this treatment, which may lead to an increase in the mortality and morbidity of cardiovascular diseases. We investigated the relationship between heart rate variability (HRV) and sleep parameters during natural sleep and treatment of patients with OSA.

Materials and Methods:

This was the cross-sectional observation study. Patients were 17 males with severe OSA who were unable to accept continuous PAP. Standard polysomnography was performed for two consecutive nights, i.e., during natural sleep and following night with bilevel PAP (BiPAP) treatment. Time-dependent responses of the amplitudes of low frequency (LF), very low frequency (VLF), and high frequency components of HRV were assessed with the technique of complex demodulation.

Results:

Apnea–hypopnea index, oxygen desaturation time, and percentage of stage 1 sleep were significantly reduced, whereas the percentages of rapid eye movement and stages 3 + 4 sleep were increased, by BiPAP treatment. Therapy also reduced the amplitudes of VLF and LF components of HRV. Difference in amplitudes of VLF during natural sleep and treatment with BiPAP was significantly correlated with difference in percentages of stage 1 and stages 3 + 4 sleep.

Conclusion:

Therapy-induced amelioration of OSA and sleep quality was accompanied by decrease in the amplitudes of VLF components of HRV. The VLF component may thus reflect physiological changes in both autonomic activity and sleep structure and serve as an objective marker for therapeutic efficacy in patients with severe OSA.

Association Between Tonsillectomy and Outcomes in Patients With Immunoglobulin A Nephropathy

IMPORTANCE

Immunoglobulin A nephropathy is a major cause of end-stage renal disease worldwide; previous methods of medical management, including use of renin-angiotensin system inhibitors and corticosteroids, remain unproven in clinical trials.

OBJECTIVE

To investigate the possible association between tonsillectomy and outcomes in patients with IgA nephropathy.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included 1065 patients with IgA nephropathy enrolled between 2002 and 2004 and divided into 2 groups, those who underwent tonsillectomy and those who did not. Initial treatments (renin-angiotensin system inhibitors or corticosteroids) within 1 year after renal biopsy were also evaluated. A 1:1 propensity score matching was performed to account for between-group differences and 153 matched pairs were obtained. Follow-up concluded January 31, 2014. Analysis was conducted between September 11, 2017, and July 31, 2018.

EXPOSURE

Tonsillectomy.

MAIN OUTCOMES AND MEASURES

The primary outcome was the first occurrence of a 1.5-fold increase in serum creatinine level from baseline or dialysis initiation. Secondary outcomes included additional therapy with renin-angiotensin system inhibitors or corticosteroids initiated 1 year after renal biopsy and adverse events.

RESULTS

In 1065 patients (49.8% women; median [interquartile range] age, 35 [25-52] years), the mean (SD) estimated glomerular filtration rate was 76.6 (28.9) mL/min/1.73 m2 and the median (interquartile range) proteinuria was 0.68 (0.29-1.30) g per day. In all, 252 patients (23.7%) underwent tonsillectomy within 1 year after renal biopsy and 813 patients (76.3%) did not undergo tonsillectomy. The primary outcome was reached by 129 patients (12.1%) during a median (interquartile range) follow-up of 5.8 (1.9-8.5) years. In matching analysis, tonsillectomy was associated with primary outcome reduction (hazard ratio, 0.34; 95% CI, 0.13-0.77; P = .009). In subgroup analyses, benefit associated with tonsillectomy was not modified by baseline characteristic differences. Those undergoing tonsillectomy required fewer additional therapies 1 year following renal biopsy (adjusted hazard ratio, 0.37; 95% CI, 0.20-0.63; P < .001) without increased risks for adverse events, except transient tonsillectomy-related complications.

CONCLUSIONS AND RELEVANCE

This study found that tonsillectomy was associated with a lower risk of renal outcomes in patients with IgA nephropathy. The potential role of tonsillectomy should be considered for preventing end-stage renal disease in patients with IgA nephropathy.

Clinical impact of endocapillary proliferation with modified cutoff points in IgA nephropathy patients

Predictive values of mesangial proliferation (M), endocapillary proliferation (E), segmental glomerulosclerosis (S), and crescents (C) among 19 validation studies of the Oxford Classification of IgA nephropathy (IgAN) were discrepant, especially in Asian patients. These validation studies indicate that cutoffs of MESC score in the Oxford Classification may not be generalizable. Thus, we aimed to improve the clinical value of MESC scores by modifying the cutoff points. A total of 104 patients with IgAN were diagnosed from 2001 to 2012 vai renal biopsy and retrospectively evaluated at Nagoya University Hospital. The cutoff point for modified (M´E´S´C´) was determined using the receiver operating characteristic curve in association with renal outcome in the training cohort. Clinical values of the Oxford MESTC vs M´E´S´C´ cutoff points were analyzed using Kaplan-Meier and Cox regression in association with poor renal outcome in the validation and the entire cohort. Of 104 patients, 12.5% reached poor renal outcome over a median of 6.25 [4.16–9.61] years of follow-up. The modified cutoffs were defined as ≥40%, ≥10%, ≥20%, and ≥5% in the glomeruli for M´E´S´, and C´ respectively. In univariate analysis, E´, S ´, and T were significantly associated with poor renal outcome, whereas Oxford MESC, M´, and C´ in the training and validation cohort were not associated with poor renal outcome. Using multivariate analysis in the presence of estimated glomerular filtration rate (eGFR), only E´ was a significant predictive factor for poor renal outcome. The E´ with modified cutoff point of 10% significantly improved predictive value for poor renal outcome in IgAN. Therefore, the clinical value of modified cutoff points for M´E´S´C´ scores should be validated with various cohort studies in different regions.

Prognostic value of left ventricular dyssynchrony evaluated by gated myocardial perfusion imaging in patients with chronic kidney disease and normal perfusion defect scores

BACKGROUND

This study aimed to investigate whether indices of left ventricular (LV) dyssynchrony by gated myocardial perfusion SPECT (GMPS) could be useful to predict prognosis in chronic kidney disease (CKD) patients with normal perfusion defect scores.

METHODS

One hundred and sixty-seven CKD patients with normal perfusion defect scores on adenosine-stress 201Tl GMPS and no previous history of overt heart diseases were enrolled. Phase standard deviation (PSD) and bandwidth (BW) were automatically calculated from GMPS. The major adverse cardiac events (MACEs) for a mean of 560 days were defined as sudden cardiac death, fatal arrhythmias, and acute coronary syndrome requiring urgent coronary revascularization. Patients were divided into two groups according to the presence or absence of MACEs.

RESULTS

The MACEs occurred in 12 patients (7.1%). Patients who experienced MACEs showed significantly higher PSD and wider BW than those who did not. In the Kaplan-Meier event-free survival analysis, cardiac event rate was significantly higher in the high-PSD and wide-BW group (n = 81) than in the low-PSD and narrow-BW group (n = 71) (P = .002). The multivariate regression analysis revealed that the PSD was associated with MACEs (odds ratio 1.33, 95% confidence interval 1.05-1.69, P = .01).

CONCLUSION

The LV dyssynchrony indices from GMPS may be novel prognostic predictors in CKD patients with normal perfusion defect scores.

Assessment of abdominal aortic calcification by computed tomography for prediction of latent left ventricular stiffness and future cardiovascular risk in pre-dialysis patients with chronic kidney disease: A single center cross-sectional study

Introduction: There is general interest in finding clinical markers for left ventricular diastolic dysfunction (LVDD), a major cause of cardiorenal syndrome leading to heart failure in chronic kidney disease (CKD) patients. The aim was to assess the utility of computed tomography (CT)-based abdominal aortic calcification (AAC) for the prediction of LVDD and prognosis of asymptomatic pre-dialysis CKD patients. Materials and methods: We prospectively evaluated 218 pre-dialysis CKD patients [median estimated glomerular filtration rate (eGFR); 40.9 mL/min/1.73m²]. Non-contrast CT scan and echocardiography were performed to determine the aortic calcification index (ACI) as a semi-quantitative measure of AAC. Results: The median ACI was 11.4. AAC and LVDD were diagnosed in 193 patients (89%) and 75 patients (34%), respectively. Using receiver operating characteristic curve analysis for the estimation of LVDD, ACI of 20 showed optimal sensitivity (52.0%) and specificity (62.8 %) (AUC = 0.664, p < .001). High ACI group included more patients with LVDD-related factors, such as old age, hypertension, diabetes, and more severe CKD. LVDD was significantly more common in patients with high ACI group [39 (50%) and 36 (26%), respectively, p<0.001]. Multivariate analysis showed that ACI correlated significantly with E/A (β=-0.993, p=0.003), E/e' (β=0.077, p<0.001), and cardio-ankle vascular index (β=0.209, p=0.001). Correspondingly, E/e' correlated with logBNP and log(ACI+1), and increased proportionately and significantly with the quartiles of ACI values. Cox proportional hazard models showed that ACI was an independent predictor of CV outcome (hazard ratio 1.03, 95% confidence interval 1.00-1.06, p=0.029). Conclusion: The results would suggest the usefulness of AAC assessment by CT to predict latent LVDD and future CV risk in asymptomatic pre-dialysis CKD patients.

Clinical impact of endocapillary proliferation according to the Oxford classification among adults with Henoch-Schönlein purpura nephritis: a multicenter retrospective cohort study

Background

Henoch-Schönlein purpura nephritis (HSPN) is a form of small vessel vasculitis associated with purpura and IgA deposition in the glomeruli. The International Study of Kidney Disease in Children (ISKDC) classification predicts renal prognosis in children with HSPN, but not in adults. Additionally, it is not well known whether the Oxford classification 2016 and/or the Japanese Histologic classification (JHC) are associated with renal outcome. Herein, we investigated the relationship between pathological characteristics and renal outcome among adult patients with HSPN.

Methods

A multicenter retrospective cohort study was conducted in adult patients with HSPN who underwent renal biopsy between 2004 and 2014. Two nephrologists classified each patient according to the Oxford classification 2016, JHC, and the ISKDC classification. Renal outcome was defined by a 30% decline in the eGFR and/or end-stage kidney disease.

Results

We enrolled 74 adult patients with HSPN (mean age, 47.8 ± 17.4 years; mean eGFR, 76.4 ± 25.8 ml/min/1.73 m²; median proteinuria, 1.40 [IQR: 0.70–2.38] g/day). During a mean follow-up period of 68.0 ± 33.0 months, fourteen patients (18.9%) reached the renal outcome, and all 14 had received immunosuppressive therapy. The log-rank test revealed that event-free renal survival was significantly shorter in patients with endocapillary proliferation (E1) according to the Oxford classification than in those with E0 (p = 0.0072). However, the JHC, ISKDC classification and other Oxford lesions could not demonstrate a significant difference in event-free renal survival. In a multivariate Cox model adjusted for clinical and pathological factors, age (HR, 1.57; 95% CI, 1.12–2.21) and E lesion (HR, 6.71; 95% CI, 1.06–42.7) were independent risk factors for renal outcome.

Conclusions

Endocapillary proliferation is significantly associated with renal outcome in adult patients with HSPN, including those receiving immunosuppressive therapy. Other Oxford classification lesions, JHC, and ISKDC classification were not associated with renal outcome.

Electronic supplementary material

The online version of this article (10.1186/s12882-018-1009-z) contains supplementary material, which is available to authorized users.

Treatment patterns and steroid dose for adult minimal change disease relapses: A retrospective cohort study

Background

In patients with adult minimal change disease (MCD), proteinuria relapse is a problem to solve. However, the optimal relapse treatment regimen remains unclear regarding steroid dose. We described the treatment pattern of adult MCD patients and evaluated the appropriate steroid dose for relapse treatment.

Methods

This retrospective multicenter cohort study included 192 patients with adult biopsy-proven MCD from 14 hospitals in Japan. The prescription pattern of immunosuppressive drugs in relapse was reviewed. To assess the association between steroid dose used for relapse and subsequent outcomes, data of patients with tapered prednisolone (PSL) dosage to <10 mg/day before the first relapse in whom the dose was subsequently increased to ≥10 mg/day were extracted and assigned to the High-PSL or Low-PSL groups, based on the median dose of 20 mg/day. Multivariate Cox proportional hazard model and propensity score analysis with multiple imputations were conducted to compare their clinical course.

Results

During a median observation period of 37.6 months, 186/192 (96.9%) patients achieved complete remission (CR) and 100 (52.1%) relapsed. The median urinary protein level at the first relapse was 3.12 g/gCr or g/day. The proportion of non-steroidal immunosuppressant use increased with relapses; cyclosporine was the most common. No significant differences were found in the second relapse, frequent relapses, or adverse events between High-PSL (n = 34) and Low-PSL (n = 36) groups. A multivariate Cox proportional hazard model revealed that the hazard ratios adjusted with propensity score for the second relapse were 0.94 (High-PSL vs. Low-PSL; 95% confidence interval, 0.42–2.10; P = 0.88) and 0.82 (PSL dose per 10 mg/day; 95% confidence interval, 0.58–1.16; P = 0.25).

Conclusions

Among patients in CR with PSL dose <10 mg/day, higher steroid dose (PSL >20 mg/day) was not associated with favorable outcomes after the first relapse as compared to lower dose (10–20 mg/day).

Existing creatinine-based equations overestimate glomerular filtration rate in Indians

BACKGROUND

Accurate estimation of glomerular filtration rate (GFR) is important for diagnosis and risk stratification in chronic kidney disease and for selection of living donors. Ethnic differences have required correction factors in the originally developed creatinine-based GFR estimation equations for populations around the world. Existing equations have not been validated in the vegetarian Indian population. We examined the performance of creatinine and cystatin-based GFR estimating equations in Indians.

METHODS

GFR was measured by urinary clearance of inulin. Serum creatinine was measured using IDMS-traceable Jaffe's and enzymatic assays, and cystatin C by colloidal gold immunoassay. Dietary protein intake was calculated by measuring urinary nitrogen appearance. Bias, precision and accuracy were calculated for the eGFR equations.

RESULTS

A total of 130 participants (63 healthy kidney donors and 67 with CKD) were studied. About 50% were vegetarians, and the remainder ate meat 3.8 times every month. The average creatinine excretion were 14.7 mg/kg/day (95% CI: 13.5 to 15.9 mg/kg/day) and 12.4 mg/kg/day (95% CI: 11.2 to 13.6 mg/kg/day) in males and females, respectively. The average daily protein intake was 46.1 g/day (95% CI: 43.2 to 48.8 g/day). The mean mGFR in the study population was 51.66 ± 31.68 ml/min/1.73m2. All creatinine-based eGFR equations overestimated GFR (p < 0.01 for each creatinine based eGFR equation). However, eGFR by CKD-EPICys was not significantly different from mGFR (p = 0.38). The CKD-EPICys exhibited lowest bias [mean bias: -3.53 ± 14.70 ml/min/1.73m2 (95% CI: -0.608 to -0.98)] and highest accuracy (P30: 74.6%). The GFR in the healthy population was 79.44 ± 20.19 (range: 41.90-134.50) ml/min/1.73m2.

CONCLUSION

Existing creatinine-based GFR estimating equations overestimate GFR in Indians. An appropriately powered study is needed to develop either a correction factor or a new equation for accurate assessment of kidney function in the Indian population.