Background Increasing prevalence in type 2 diabetes mellitus (T2DM) have influenced in an increasing prevalence of chronic kidney disease (CKD). Little is known about the influence of non-alcoholic fatty liver disease (NAFLD) on progression of CKD. The aim of this study was to analyse the role of NAFLD and its severity in the progression of renal function in patients with T2DM. Methods Retrospective and observational study, including patients with T2DM and estimated glomerular filtration rate (eGFR) >30 ml/min/1,73m2. NAFLD was defined with presence of compatible ultrasonography and/or presence of fibrosis using NAFLD score. Patients were classified in three groups according to the NAFLD score; group 1 <-1.85, group 2 -1.85 to 0.18, and group 3 > 0.18. Results A total of 102 patients were included (67.6% males, median age 59 [53-64] years), with median time of T2DM evolution was 70 [39-131] months. Group 3 had lower eGFR (84.8 ± 40.4 vs 71.4 ± 30.6 ml/min/1.73m2; p = 0.03) and higher proteinuria at baseline (0.56 ± 0.77 vs 1.59 ± 2.70 g/24h; p = 0.05). After a follow-up time of 75.8 ± 23.9 months, group 3 had a significant decrease in eGFR (66.6 ± 33.3 vs 36.8 ± 23.1 ml/min/1.73m2; p = <0.01), and higher risk of CKD progression (OR 7.50; CI 95% 2.76-20.35; p = <0.001) defined as decrease in > 50% eGFR. Conclusions The presence of NAFLD with high-risk fibrosis confers higher risk of CKD progression in patients with T2DM. Therefore, NAFLD should be a risk factor evaluated in these patients to optimise treatment.
Renal insufficiency in necrotizing vasculitis is usually the result of parenchymal damage. A case of polyarteritis nodosa presenting obstructive nephropathy with bilateral ureteric stenosis is reported. The role of the concurrent crescentic glomerulonephritis in the mechanism of renal failure is discussed.
Background and Aims Overhydration (OH) is an independent predictor of mortality on hemodialysis (HD). The gold standard to assess OH is BCM monitor from Fresenius®, however BCM is a hospital hold device limiting its use. New smart scales have emerged as household devices reporting daily body composition data. Objective To determine if Renpho ES-CS20M® could be useful on a 52 HD patient to estimate body composition data. Method 72 body composition assessments (BCA) during mid-week HD session were performed. Each BCA included: (1) Predialysis Renpho measurement, (2) Predialysis BCM monitor measurement, (3) Postdialysis Renpho measurement. To track the fluid balance during the HD session: (1) we recorded ultrafiltration, (2) food or fluid intake was not allowed, and (3) none of the HD patients urinated during the HD session. If any intravenous fluids were needed during the HD session, we subtracted them off from UF. Results Data from 52 HD patients were studied (age 58.8 ± 16.8 years, 56.9 % males, 14.7% diabetics), with a mean pre-HD weight of 70.0 ± 13. 4 Kg, overhydration of 1.7 ± 1.5 L and urea distribution volume of 31.7 ± 5.7 L. The mean ultrafiltration during HD session was -1.8 ± 0.9 L. Renpho estimated a Pre – HD hydration of 34.25 ± 6.02 Kg vs 33.4 ± 5.7 Kg by BCM, showing a good concordance between methods (ICC 0.788 [0.67-0.86], B -0.58, p <0.01). Renpho poorly estimated pre – HD lean tissue mass at 45.4 ± 6.9 Kg compared with 33.8 ± 8.0 Kg by BCM. Although Renpho was able to provide a moderate concordant estimation of fat tissue mass (33.8 ± 8.0 % with Renpho vs 34.7 ± 9.6%), the bias proportion was unacceptable. Post- HD hydration by Renpho was not able to reproduce the ultrafiltracion achieved during the HD session (pre-HD 34.25 ± 6.02 Kg vs post-HD 34.08 ± 6.00 Kg). Conclusion Renpho has a proportional bias estimating predialysis hydration compared with BCM monitor, but is not able to assess changes produced with ultrafiltration or other parameters of body composition (as lean or fat tissue mass). Although smart scales are unacurate to assess body composition on HD patients, they could be useful on the follow up of them changing the accuracy for frequency.
Background and Aims Secondary Hyperparathyroidism (SHPT) is a complication of chronic kidney disease (CKD). Etelcalcetide is the first intravenous calcimimetic authorized for the treatment of SHPT in haemodialysis (HD). It has proven to be effective in lowering parathyroid hormone (PTH), with an acceptable and comparable safety profile. The aim of this descriptive study was to evaluate the results of using etelcalcetide in patients on HD with SHPT. Method Thirty patients on HD received etelcalcetide were enrolled (figure 1). The minimum observation period was 6 months. Fifteen (50%) were previously with cinacalcet (group 1) and 15 (50%) received etelcalcetide at onset (group 2). We analyzed change of serum iPTH, calcium (Ca) and phosphorus (P) in both cohorts; as well as the dosage of calcium carbonate, non-calcium (phosphate binders) and / or vitamin D analogs. The presence of adverse effects were also recorded. Results Thirty patients on HD received etelcalcetide were enrolled (figure 1). The minimum observation period was 6 months. Fifteen (50%) were previously with cinacalcet (group 1) and 15 (50%) received etelcalcetide at onset (group 2). We analyzed change of serum iPTH, calcium (Ca) and phosphorus (P) in both cohorts; as well as the dosage of calcium carbonate, non-calcium (phosphate binders) and / or vitamin D analogs. The presence of adverse effects were also recorded. In global, serum iPTH levels were significantly decreased during therapy compared to baseline levels. When comparing both groups, we found a significant decrease of Ca, P and iPTH in group 2. However, we only found significant decrease of Ca in group 1 (figure 2). When we analyzed the reducton of PTH >30% in both groups, we observed that 46.6% of patients treated with etecalcetide compared to 33.3% of patients treated with cinacalcet, achieved this reduction in PTH. The dosage of calcium binders (33.3% pretreatment vs 56.7% at the end of follow-up, p 0.054), non-calcium binders (40% pretreatment vs 63.3% at the end of follow-up, p 0.02) and vitamin D analogues (56,7% pretreatment vs 66,7% at the end of follow-up, p 0,3) were increased when etelcalcetide treatment was started. No changes were made in dialysate calcium concentration. Six patients, presented hypocalcemia (Ca < 7.5 mEq/l). Conclusion In our cohort, etelcalcetide has shown to be effective in reducing serum iPTH. In addition, etecalcetide was noninferior to cinacalcet reducing PTH>30%. An increase in the use of vitamin D analogues, calcium binders and non-calcium binders has been observed, probably due to the hypocalcemia.
BACKGROUND AND AIMS Decreased bone mineral density in patients undergoing haemodialysis (HD) is related to the development of fractures that lead to increased morbimortality. There is limited evidence on fracture risk factors that would allow to identify patients at risk to prompt early treatment. In this context, FRAX® (Fracture Risk Assessment scale, which is freely available online at https://www.sheffield.ac.uk/FRAX/tool.aspx?country=4) scale aids in the risk prediction (as a percentage over a 10-year span) of both major and hip osteoporotic fractures in specific populations, including patients with chronic kidney disease (CKD) [1]. However, the evidence of its utility in HD patients is scarce [2]. The aim of our study is to identify patients on HD with increased risk of fractures based on FRAX® scale, blood-test and densitometric parameters. Also, we aim to demonstrate a correlation between a higher risk of fractures as assessed by FRAX® scale and densitometry-established osteoporosis. METHOD This is a single-centre retrospective study including patients undergoing periodic intermittent haemodiafiltration. Data regarding clinical and blood-test parameters were collected. FRAX® scale was used to estimate the risk of hip and major fractures. Patients were divided accordingly into high and low fracture risk, with a threshold set at a 10-year 3% risk of hip fracture and 10% for other major fractures, according to definitions for the general population given by FRIDEX (Fracture RIsk factors and bone DEnsitometry type central dual X-ray) and FROCAT cohorts[3]. The relationship between clinical, blood-test parameters and the degree of osteopaenia and osteoporosis was evaluated. Osteopaenia was defined as a T-score between −1 and −2.5 in femoral neck densitometry. Osteoporosis was established as a T-score lower than −2.5. Qualitative parameters were analysed using Fisher's exact test, whilst Mann–Whitney U test was employed in the analysis of quantitative parameters. RESULTS A total of 54 patients (59.26% male) with a median age of 60 years [interquartile range (IQR), 50–72.25] were recruited. Six low intensity fractures were observed (11.1%), five of them occurred in high-risk-FRAX-scale-classified patients (P 0.095). The observed median FRAX score for our sample was 7.35% (IQR, 4.97–13.25) for major fractures and 1.70% (IQR, 0.78–6.13) for hip fractures. Patients with a higher risk of major fracture, according to FRAX® scale (>7.5%), were older (P < 0.001) and had been on renal replacement therapy (RRT) for a longer period of time (P 0.008). Furthermore, a significantly higher proportion of patients with prior kidney transplantation (0.012) and osteoporosis (0.002) was found in this group. No differences were observed in blood-test parameters, KtV and dialysate composition between low and high-risk patients. Densitometry was performed in 26 patients (48.14%). In this subset, osteopaenia was observed in 14 patients (53.84%) and osteoporosis in 11 (42.31%). Patients with osteoporosis had a higher FRAX score for major fracture (21%, IQR 11.50–26.50; P 0.001) and hip fracture (7.80%, IQR 5.75–14.50; P < 0.001). No correlation was found between prior kidney transplantation or exposure to steroids and densitometry-established osteoporosis. CONCLUSIONS Despite not being validated yet in Spain, our results demonstrate that FRAX® scale significantly correlates with the degree of osteoporosis in patients undergoing HD, representing an effective tool for the identification of patients at high risk of suffering fractures, prompting early prevention and management.
Background and Aims Vascular endothelial growth factor inhibitors (anti-VEGF) have been shown to be effective in the treatment of macular degeneration and diabetic macular edema. It is known that systemic administration of these drugs can produce adverse renal effects, such as decreased glomerular filtration rate (eFGR), proteinuria, hypertension or thrombotic microangiopathy. However, there is little information about it when the administration is intravitreal. The aim of this study was analyzed the effect of anti-VEGF drugs on renal function and proteinuria. Method Observational and prospective study on diabetic patients, which were divided into two groups: non-cronic kidney disease (CKD) (group 1) and CKD (group 2). We analyzed clinical and analytical variables during follow-up. Results We included 45 diabetic patients (55.6% males) with a median age of 75 (50-91) years. Forty one patients (91.1%) were hypertensive and thirty three (73.3%) were CKD patients. Twenty six (57.8%) received bevazicumab, while the rest (42.2%) received ranibizumab, with a median dose of 6 (1-22). The median follow-up was 25 (9-94) months. The evolution of eFGR and albuminuria are described in Figure 1, where it stands out the increase in albuminuria in group 2. Regarding the drug type, there were no differences. Within the CKD group, one patient presented two episodes of decompensation of heart failure after the administration of an anti-VEGF drug, and two required the initiation of renal replacement therapy. Conclusion Based on the results of our cohort, we believe that it would be advisable to establish a closer monitoring in diabetic patients who are administered an intravitreal anti-VEGF drug, with determination of renal function as well as albuminuria to establish an early diagnosis of possible complications.
Background and Aims Changes on body composition have an impact on the survival of haemodialysis (HD) patients. The aim of the study was to determine the impact of the reduction of physical activity due to COVID19 lockdown on body composition in HD patients. Method Retrospective and observational study including 149 HD patients. Nutritional and Bioimpedance spectroscopy (BIS) data were recorded before and after COVID19 lockdown (mean of 148 ± 20 days between determinations). Results Over the 49 days of COVID19 lockdown, we observed a decrease in normohydrated weight (NHW) of 1.01 ± 3.59 kg mainly secondary to a reduction on total body water (TBW) 0.95 ± 3.78 L (extracellular water 0.45 ± 1.58 L and intracellular water 0.41 ± 2.36 L). There was also a small loss on lean tissue index (LTI) of 0.28 ± 2.42 kg/m2, with an increase of fat tissue index (FTI) 0f 0.02 ± 2.82 kg/m2. Twenty-three patients presented COVID19 infection, of which 21 required admission (median of 10 [4-16] days). Patients who presented COVID19 were older (70.7 ± 12.0 vs 64.9 ± 16.6 years, NS) with higher Charlson index (7.48 ± 2.77 vs 6.33 ± 2.65, p = 0.07). Patients with COVID19 infection presented a greater loss on LTI (-1.18 ± 3.15 bs -0.16 ± 2.30 kg/m2; p = 0.22), FTI (-0.41 ± 3.38 vs 0.06 ± 2.74 kg/m2; p = 0.54); BMI (-1.49 ± 2.14 vs -0.25 ± 0.96 kg/m2; p = < 0.01) and NHW (-4.00 ± 6.33 vs -0.62 ± 2.90 kg; p = < 0.01) compared to patients without COVID19 infection. The length of hospitalization was associated with greater loss of BMI and NHW, resulting, therefore, in overhydration. There also had lower serum phosphorus (3.6 ± 0.8 vs 5.2 ± 0.8 mg/dl; p = 0.01) and serum albumin (3.5 ± 0.4 vs 4.0 ± 0.1 g/dl; p = 0.01). Seven patients died during hospitalization. Deceased patients were older (78.4 ± 6.6 vs 67.4 ± 12.4 years; p = 0.01), presented higher comorbidity (estimated by Charlson index 10.0 [8.0-11.0] vs 6.5 [4.3-8.0]; p = 0.02) and were more overhydrated (3.4 ± 3.6 vs 1.9 ± 1.9; p = 0.34). Although not statistically different, they had lower LTI (10.4 ± 2.1 vs 12.0 ± 3.4 kg/m2; p = 0.18) and lower serum albumin (3.4 ± 0.6 vs 3.9 ± 0.4 g/dl; p = 0.08) compared to survivors. Patients who survived COVID19 infection had longer hospitalization (57% were discharged between twelfth and forty third day; mean hospitalization 14.6 ± 11.5 days). Deceased patients died within the first 12 days of hospitalization (6.8 ± 4.1 days). Conclusion COVID19 lockdown induced a weight reduction on HD patients due to decrease in total body water. COVID19 infection increased this reduction, inducing greater loss on lean and fat tissue composition. Moreover, COVID19 impact on body composition was magnified with the length of hospitalization.
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