Supportive care in patients with chronic kidney disease refers to the application of palliative medicine principles and practices in nephrology. The main purpose is to reduce suffering by managing symptoms, helping with decision making and providing holistic support to the patient and family/caregiver in clinical, social, spiritual or nutritional distress, with a multidisciplinary team. We present the case of a 92-year-old male patient with chronic kidney disease of unknown etiology since 2004. In 2019, he was referred to our kidney disease supportive care program, presenting a serum creatinine of 5.44 mg/dL (estimated glomerular filtration rate of 9 mL/ min/1.73 m2). During the following three years, the patient lived at home independently, maintained good control of his chronic kidney diseaseassociated symptoms and preserved his functional status. We present this case as a practical example of how to approach an autonomous elderly, chronic kidney disease patient, with few comorbidities, who opted for supportive care.
Background and Aims Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) are systemic autoimmune diseases that involve small- and medium-sized blood vessels. AAV compromises the overall survival of patients, and its kidney involvement can lead to end-stage kidney disease (ESKD). Our aim was to determine whether the serum C3, C-reactive protein (CRP) and ANCA levels could predict kidney survival. Method We retrospectively reviewed patients with AAV and kidney involvement (n = 62) from 2006 to 2022. Demographic, clinical and laboratory data were collected. Patients’ ANCA title were measured by ELISA, and Glomerular Filtration Rate (GFR) was estimate by CKD-EPI equation. ANCA, C3 and CRP were measure at diagnosis, remission, and last follow-up. ANCA was analyzed as continuous and categorical variable. We analyzed factors associated with dialysis dependency at diagnosis and evolution to ESKD. Multivariable adjusted Cox regression analysis was performed for assessing predictive variables associated with dialysis outcome. Results The cohort included 62 total patients, with median age of 69 (63-77) years old, 44% were female, 35.5% (n = 22) presented with alveolar haemorrhage, 82.3% (n = 51) were MPO-ANCA+ and 4 patients had concomitant anti-GBM+. At admission, the median ANCA title was 80.5 UI/mL (36.75- 112.25), C3 was 108.5 mg/dL (90-130.25) and CRP 7.5 mg/dL (2.14-14.34). The GFR was 11.17±11.16 at admission and 24% of patients required dialysis at admission (n = 15). At 3 months 30% (n = 19) required dialysis, 10% at 6 months (n = 6) and 5% at 1 year (n = 3). The median time until dialysis was 488.98 (0-5702) days. Twenty (32.3%) patients died during the study period. The title of ANCA at admission, as categorical variable, did not associate with requirement of kidney replacement therapy during follow-up (p = 0.870) nor as a continuous variable (p = 0.523). Considering C3 and CRP, only low C3 at last follow-up correlates with ESKD (p = 0.028). Median C3 at last follow-up was 91.5 mg/dl (79.5-107) in ESKD patients and 114.5 mg/dl (92-142.75) in patients that do not require dialysis. In the cox regression analysis of kidney survival, C3 levels at last follow-up were significantly associated with a shorter time until dialysis (p = 0.006). In a multivariate analysis, including age and gender, C3 levels at last follow-up lost significance to predict time until ESKD (p = 0.083, model p = 0.005). Initial GFR was not correlated with ANCA title at admission (r = 0.220, p = 0.205) nor as a categorical variable (p = 0.592). At remission, GFR was not correlated with ANCA title (r = 0.383, p = 0.349). Considering factors associated with the need for dialysis at admission, only CRP levels at admission were significantly higher (p = 0.035) in those who required dialysis. ANCA title and C3 at admission did not correlate with dialysis at admission (p = 0.875, p = 0.702). In multivariate analysis, including age and gender, CRP maintain its significancy (p = 0.036, model p = 0.044). Conclusion C3 and CRP levels have been studied as possible factors predicting kidney survival, however, results are not consistent. CRP is a marker of inflammation and C3 represents complement activity, these serologic markers could be important to identify patients at risk for ESKD. In our study CRP levels seems to be related to dialysis requirement at admission. These patients should be followed more closely and carefully to improve kidney survival.
Background and Aims End stage kidney disease (ESKD) treatment choice may be very difficult mainly for elderly patients. Dialysis can be burdensome for the frail patients, offering more aggressive procedures and less quality of life. Conservative Care (CC) may shorten life in a fit patient. This study aimed to describe our elderly patients' choices when it comes to CKD treatment options and reflect about them. Method We designed a single center retrospective observational, cross-sectional study regarding patients (pts) over 80 years old (yo) who attend the appointment of ESKD treatment modalities between July 2015 and and December 2021, since a Conservative Care Program is available in our hospital. Results During these 6,5 years, 113 pts over 80 yo were attended. Mean age was 85 yo (range 80–103). 66% were male and mean charlson comorbidity index (CMI) was 7 (sd ± 1,2). Mean seric creatinine was 3,69 mg/dl (sd 0,99; range 1,8-7,0). Mean estimated glomerular filtration rate was 17,41 (sd ±4,12) and 14,64 (sd ± 7,6) ml/min per 1.73 m2 when calculated with BIS1 and CKD-EPI equation, respectively. Two patients were already on a regular program of dialysis. Regarding CKD etiology, 31,9% was from multifactorial origin, 27,4% was from undetermined origin, 10,6% was hypertensive, 8% was diabetic, 6,2% was from chronic pyelonephritis and 9,7% was in the context of cardiorenal syndrome. Regarding treatment options, 54% chose hemodialysis, 38,9% chose conservative care (CC), 2,7% chose peritoneal dialysis and 2,7% refused any treatment. We also observed a significant increase in the CC during these 6.5 years of study. Of those who chose hemodialysis, 22,95% (n = 14) died before starting on a regular program of dialysis, 62,3% (n = 38) actually started on a regular program and 14,75% (n = 9) still maintain follow-up in nephrology appointment. Regarding those who died before starting on dialysis treatment, the mean time between choosing dialysis and death was 1,36 years (range 115 days to 5,46 years, median 1,36 years), and between starting on a regular program and death was 1,38 year (range 11 days to 4,9 years). The main cause of death was unknown (66%) (by lack of data), followed by infectious cause (26,6%). Considering those who chose CC, 31,8% (n = 14) died before starting the regular follow up, 54,5% (n = 24) are on a regular program of follow up, and 4,5% (n = 2) lately decided for dialysis. Regarding those who died before CC, the mean time between choosing it and death was approximately 1 year (range 29 days to 3,4 years), and between starting on a regular follow up and death was 0,68 years (range 14 days to 1,7 years). We didn’t find any statistical significance between CMI and the ESRD modality chosen (p = 0.709) or the occurrence of death (p = 0,496). Conclusion Even considering the poor prognosis and the high mortality rate, the majority of patients over 80 years old still chose dialysis over conservative kidney treatment. In our cohort, there was no survival benefit from those who choose dialysis instead of CC. CC should be offered as an alternative treatment to all the patients who may not benefit from dialysis. It is important to find tools who help us to guide patients in the best suitable choice in regard to ESKD treatments.
Background and aims Despite therapeutic advances, anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV) carry poor renal and survival outcomes. Prognostic elements are needed to guide treatment. Several studies explored determinants of AAV outcomes, but predictive factors are not well established. Poor prognosis factors have been lower glomerular filtration rate, lower serum C3, C3 deposition on immunofluorescence (IF), and recently platelet count below 250 × 109/L. Histopathological lesions have also been related to renal outcomes. In this study we aim to correlate serum immune and inflammatory biomarkers with renal histological lesions’ severity. Methods We retrospectively analysed histopathological findings of adults with biopsy-proven AAV renal involvement through Berden's histopathological classification (BHC) classes, Brix's renal risk score (BRS), interstitial fibrosis and tubular atrophy (IFTA) and crescentic glomeruli percentages (%), C3 positive IF and presence of interstitial hemorrhage (IH). Patients’ ANCA titer (ANCAd) measured by ELISA, serum C3 and C-reactive protein (CRP) were documented at diagnosis. ANCA titer was also registered at last follow-up date (ANCAf). Univariate statistical analysis was used to correlate every biomarker with every histologic variable mentioned. C3 and CRP were used as continuous variables and ANCA titers as continuous and categorical variables. As a continuous variable, ANCA titers above laboratorial detection were not considered (i.e. >134). Seronegative AAV were not considered for titer analysis. BRS was considered as continuous variable for its score and as categorical for its risk group. Multivariate analysis was used to identify independent predictors renal biopsy findings. Results We included 46 patients with biopsy-proven AAV kidney involvement from January 2006 to January 2023, 65.2% male (n = 30), median age 66.5 (60.75-74.5), 78.3% (36) MPO, 15.2% (7) PR3 and 6.5% (3) seronegative; and 6.5% (3) had concomitant anti-GBM+ (all MPO). Categorization by ANCAd revealed 7.7% (3) 0-19 UI/mL, 7.7% (3) 20-39, 7.7% (3) 40-59, 20.5% (8) 60-99, 12.8% (5) 100-134 and 43.6% >134. According to BHC, biopsies were: 17.4% (8) global sclerotic, 28.3% (13) mixed, 39.1% (18) crescentic, and 15.2% (7) focal. According to BRS, 2.2% (1) had low risk, 28.3% (13) medium risk and 58.7% (27) high risk of ESKD. 5 biopsies had incomplete information for a score result. Median BRS was 9 – high risk. IF C3 was positive 28.3% (16) biopsies, and IH in 10.9% (5). Median % IFTA was 40% and median %crescentic was 33%. In univariate analysis, ANCAd did not correlate to BHC class both as continuous and categorical variable (p = 0.477 and p = 0.685 respectively), nor to %IFTA (p = 0.935, p = 0.938), nor %crescents (p = 0.975, p = 0.938), nor C3 IF staining (p = 0.690, p = 0.344), nor IH presence (p = 0.773, p = 0.897), nor to BRS risk groups (p = 0.339, p = 0.584). ANCAd titer did not correlate to BRS score value (p = 0.072, r = 0.372), both as continous variables. However, ANCAf did correlate to BRS´s risk groups (p = 0.037), with ANCAf values higher in the high-risk compared to the medium-risk group (p = 0.016). In multivariate analysis including age and gender, ANCAf persists as a predictor of BRS´s risk groups (p<0.001, model p<0.001). C3 levels at diagnosis did not have statistically significant correlation with neither histological finding: BHC class (p = 0.282), BRS score (p = 0.683), % IFTA (p = 0.753), % crescents (p = 0.989), C3 on IF (p = 0.472) and IH (p = 0.773). No significant correlation was seen when considering CRP at diagnosis: BHC class (p = 0.162), BRS (p = 0.276), %IFTA (p = 0.343), %crescents (p = 0.071), C3 on IF (p = 0.657) and IH (p = 0.951). Conclusions ANCA titer at diagnosis, serum C3 and CRP did not correlate with histological severity and chronicity lesions in our population. Nonetheless, larger cohorts, systematization of biopsy findings and studies on newer biomarkers might bring helpful information to expected prognosis and initial therapeutic approaches. A positive correlation between ANCA levels at the last follow-up date and medium and high-risk BRS groups on initial biopsy might be further explored in larger studies.
Background and Aims Frailty is a clinical syndrome characterized by a state of increased vulnerability and risk of adverse outcomes following a stress, which exerts a heavy economic and social burden. The identification of this syndrome is done throught validated tools. Although frailty is associated with advanced age, certain conditions that produce age-like changes can lead to a state of frailty at younger ages. The presence of multiple comorbidities increases frailty risk. Also, low levels of albumin, even in the normal range, have been related to greater frailty and its levels have been used to assess frailty. Chronic kidney disease is associated with higher prevalence of frailty. However, little has been reported about frailty prevalence in peritoneal dialysis population. Our aim was to access the prevalence of frail and vulnerable PD patients using the Edmonton Frailty Scale (EFS) and to identify prediction factors. Method In a retrospective cohort study, we assessed frailty in PD patients from 2 center in Portugal by a validated frailty score (Edmonton Frailty Scale-EFS). We also collected information that could contribute to frailty in these patients. Linear and logistic regressions were used to access frailty predictors. Receiver operating characteristics (ROC) curve was used to access accuracy of those predictors. Results We included 74 PD patients, 51,5% male, mean age 53,9 ± 15,1 years, median body max index 25,2 ± 4,3 Kg/m2. Median CCI was 4 [interquartile range (IQR) of 3]. Fifty-three patients (71,6%) were classified as robust (non-frail), 11 as vulnerable, and 10 as frail (8 mildly and 2 moderate). Patients were divided into two groups: A group included robust (non-frail) patients; B group included vulnerable and frail ones. Age, sex distribution, IMC, diabetes mellitus prevalence, variables related to PD (efficacy, vintage, modality and complications), and levels of hemoglobin, phosphorus, potassium and C-reactive protein were similar between the groups. Non frail patients presented significantly higher albumin levels and lower CCI (p-value < 0,05). A linear regression was performed to ascertain the effects of CCI and albumin: CCI was an independent predictor for frailty/vulnerability, accessed by EFS (for each point in CCI, there was an increase of 0,5 points in EFS). Albumin did not show a significant effect defining frailty in our sample. ROC curve showed a high accuracy for CCI to identify frail/ vulnerable patients (AUC 0,817). Conclusion In our sample, CCI was an independent factor for frailty/vulnerability classified through EFS. In fact, it had a high accuracy to identify those patients, with a high sensibility. This means that CCI could be used as an acceptable screening test. However, the prevalence of frail/vulnerable patients was low in our sample. A larger one will allow to determine confirm if certain comorbidities, such as diabetes mellitus, or variables related to dialysis technique, are correlated with frailty. Furthermore, a larger sample would be essential to confirm whether albumin is, after all, a good predictor of frailty in the PD population, which was not confirmed in this work.
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