Background: Despite pre-kidney-transplant cardiovascular (CV) assessment being routine care to minimise perioperative risk, the utility of such assessment is not well established. The study reviewed the evaluation and outcome of a standardised CV assessment protocol. Methods: Data were analysed for 231 patients (age 53.4 ± 12.9 years, diabetes 34.6%) referred for kidney transplantation between 1/2/2012-31/12/2014. One hundred forty-three patients were high-risk (age > 60 years, diabetes, CV disease, heart failure, peripheral vascular disease) and offered dobutamine stress echocardiography (DSE); 88 patients were low-risk and offered ECG and echocardiography with/without exercise treadmill test. Results: At the end of follow-up (579 ± 289 days), 35 patients underwent kidney transplantation and 50 were active on the waitlist. There were 24 events (CV or death), none were perioperative. One hundred fifteen patients had DSE with proportionally more events in DSE-positive compared to DSE-negative patients (6/34 vs. 7/81, p = 0.164). In 42 patients who underwent coronary angiography due to a positive DSE or ischaemic heart disease symptoms, 13 (31%) had events, 6 were suspended, 11 removed from waitlist, 3 wait-listed, 1 transplanted and 17 still undergoing assessment. Patients with significant coronary artery disease requiring intervention had poorer event-free survival compared to those without intervention (56% vs. 83% at 2 years, p = 0.044). However, the association became non-significant after correction for CV risk factors (HR = 3.17, p = 0.215). Conclusions: The stratified CV risk assessment protocol using DSE in all high-risk patients was effective in identifying patients with coronary artery disease. The coronary angiograms identified the event-prone patients effectively but coronary interventions were not associated with improved survival.
Background and Aims Clinical practice guidelines recommend an arteriovenous fistula (AVF) as the ideal vascular access for hemodialysis. Autologous AVFs have higher primary, assisted primary and overall survival, associated with lower morbidity and mortality compared to prosthetic AVFs. However, primary failure of AVFs function is not uncommon, above all due to the vascular pathology of patients on hemodialysis (HD). We determined the survival rates in a series of vascular accesses created in a high-resolution hospital. Method Cross-sectional study; We include all AVFs performed during the last 20 years. Demographic variables (age, sex), etiology of CKD and associated comorbidity were collected. We determine the primary, assisted and global survival times. Statistical analysis with SPSS 25.0. Categorical variables are expressed as percentages and are compared using the Chi2 test. Quantitative variables are expressed as mean ± standard deviation and the Mann Whitney Student-T/U was used to compare them. We performed a kaplan-Meier analysis determining primary, assisted and overall survival. Statistical significance for a value of p <0.05. Results 622 AVFs performed in 482 patients were reviewed. 86.8% were autologous. The mean age was 65.4±14 years; 66.6% were male. The most frequent etiologies of CKD were diabetic nephropathy (30.2%), unknown (18%), and glomerulonephritis (16.6%). 91.2% had arterial hypertension (HBP) and diabetes mellitus (DM) 47.9%. 48.7% received antiplatelet therapy and 15.6% anticoagulation prior to the creation of the AVF. 27% presented primary failure. In the survival analysis using the Kaplan Meier test, the mean time to perform angioplasty in dysfunctional AVFs was 14.6±1.37 months and to perform a thrombectomy 17.6±1.31 months. The overall survival of AVFs was 41.9±2 months. When assessing the type of AVF, we observed a longer survival for autologous (31.5±1.8) vs prosthetic (21.8±3.6) (p = 0.03 log Rank 4.73). Conclusion In our study, autologous AVFs have better survival compared to prosthetic ones. Of the AVFs created, primary survival at one year (requiring angioplasty) was 64%, assisted primary survival (requiring thrombectomy) was 42%, and overall survival 24%.
Background and Aims Elderly patients and comorbidity present more frequently deterioration of their cognitive and / or functional capacity, and consequently worse quality of life related to health and the need for help to perform their basic activities. It has been described in the literature that peritoneal dialysis (PD) is a protective factor in the patient's survival against hemodialysis (HD). Quality of life is an important parameter in patients undergoing renal replacement therapy, which influences the choice of dialysis modality. We analyzed and compared the degree of functional dependence of patients on PD versus HD. Method Descriptive and cross-sectional study. A total of 84 patients belonging to the General University Hospital of Ciudad Real were included. Demographic variables (age, sex), associated comorbidity, etiology of CKD, among others, were collected. To assess the degree of dependence, the Barthel index and Lawton and Brody were performed. Statistical analysis with SPSS 25.0. Categorical variables are expressed as percentages and have been compared using the Chi2 test. Quantitative variables are expressed as mean +/- standard deviation, and the T-student was used to compare them. Statistical significance for a value of p <0.05. Results Of the 84 patients, 40.5% received PD and 59.5% HD. 60.7% were male and 39.3% female, with an average age of 60.90 years. 75% were hypertensive, 38.1% diabetic, 61.9% dyslipidemic, 27.4% obese and 61.9% had peripheral vasculopathy. The most frequent causes of CKD were diabetic nephropathy (22.6%), glomerular etiology (21.4%), unfiltered (20.2%) and nephroangiosclerosis (14.3%), among others. The degree of functional dependence according to the Barthel index was 63.1.9% for total independence, 29.8% mild dependence, 4.8% moderate dependence and 1.2% total dependence; and for the Lawton and Brody index, 42.9% total independence, 14.3% mild dependence, 27.4% moderate dependence, 11.9% severe dependence and 3.6% total dependence. When comparing the degree of functional dependence between both dialysis techniques, we observed that patients in PD had a lower degree of functional dependence compared to patients in HD, these differences being statistically significant (Lawton and Brody 73.5% in PD vs. 22% in HD, p <0.001 and Barthel index 85.3% in PD vs 48% in HD, p = 00.4). Conclusion In our experience, the degree of functional dependence in patients in PD is lower compared to patients in HD with less comorbidity, being able to condition the choice of the technique of renal replacement therapy.
Background and Aims Clinical practice guidelines recommend an arteriovenous fistula (AVF) as the preferred vascular access for hemodialysis and are associated with a lower incidence of morbidity and mortality. However, primary vascular access (AV) failure is not uncommon. Low-grade inflammation is present in ERCT. We identify the inflammatory parameters that influence the primary permeability of vascular access for hemodialysis. Method Cross-sectional study; We include all the AVs performed in the HGUCR. We evaluate the initial operation after the creation of the AV. Demographic variables (age, sex), aetiology of CKD and associated comorbidity were collected. Statistical analysis with SPSS 25.0. Categorical variables are expressed as percentages and are compared using the Chi2 Test. Quantitative variables are expressed as mean ± standard deviation and the t-student was used to compare them. We performed a multivariate analysis to determine those factors involved in the primary failure of the VA. Statistical significance for a value of p <0.05. Results 600 VA performed on 466 patients were reviewed between October 2009 and December 2019. 492 autologous VA (86.8%) and 75 prosthetic VA (13.2%) were performed. The mean age of the patients was 65.3 ± 14.2 years and 66.2% were male. The most frequent etiology of CKD was diabetic nephropathy (29.9%), followed by non-affiliated (18%) and glomerulonephritis (16.5%). 90.8% of the patients had arterial hypertension (HT), diabetes mellitus (DM) 48%. 77.2% of AV presented primary permeability. In the univariate analysis using Chi2 and T student, statistical age (p = 0.017), HT (p = 0.002), statin treatment (p = 0.002), antiplatelet therapy (p = 0.001), low ferritin levels (p = 0.011) and PCR (p = 0.019). When performing a multivariate analysis, the high CRP figures (OR: 0.64 95% CI 0.42-0.98 p = 0.043) and ferritinemia (OR: 1.04 95% CI 1.01-1.06 p = 0.013) are predictive factors of primary AV failure. Conclusion In our study, high CRP decreases the probability of primary functioning of AVFs by 36% and elevated ferritin levels are predictors of primary failure after adjusting for age and sex in the multivariate model.
Background and Aims Management of ANCA-Associated Vasculitis (AAV) is in constant update. The aim of the study is to describe our experience as a territorial reference center with this systemic disease and to analyze which factors have a significant influence on the development of end-stage renal disease (ESRD). Method Retrospective observational study. All the patients who developed AAV in our center between 2010 and 2019 were included. Demographic variables (age, sex), renal function, other vasculitis related symptoms, induction and maintenance therapy, response degree and follow-up were collected. Categorical variables are expressed as percentages and compared using Chi2 test. Quantitative variables are expressed as mean ± standard deviation and compared using Mann-Whitney U test. Cox regression was performed to determine independent predictors of ESRD. Kaplan-Meier was used to estimate ESRD-free survival. Statistical significance for a value of p< 0,05. Statistical analysis was performed with SPSS 25.0. Results 45 patients were analyzed, with an average age of 70 ± 11 years. 62.2% were men. Mean time of follow-up 36 ± 31.6 months. 37.8% presented c-ANCA autoantibodies and 57.8% p-ANCA. Mean baseline serum creatinine level was 5.51 ± 3.65 mg/dl and proteinuria 2.82 ± 2.48 g/24h. 77.8% received cyclophosphamide as induction immunosuppressive treatment whereas 13.3% rituximab. 50% received azathioprine, 36.1% mycophenolate and 13.9% rituximab as maintenance treatment. 37.8% patients underwent plasma exchange therapy and 44.4% hemodialysis. Complete remission was achieved by 13.3% of patients, while 57.8% partial remission. 28.9% had absence of remission. 28.9% achieved ESRD. ESRD was associated with undergoing hemodialysis (69.2% vs 30.8% p=0.033), to the type of response (complete 7.7% vs partial 23.1% vs no response 69.2%), baseline creatinine level (8.36 ± 5.44 vs 4.35 ± 1.64 mg/dl p=0.011), creatinine 6 months after induction treatment (4.3 ± 2.05 vs 2.04 ± 0.77 mg/dl p=0.001) and at the end of follow-up (6.33 ± 2.47 mg/dl vs 2.2 ± 1.29 mg/dl p=0.001) and also to baseline proteinuria (4.21 ± 3.12 vs 2.25 ± 1.96 p=0.003), proteinuria 6 months after induction treatment (1.4 ± 1.46 vs 0.58 ± 0.73 g/24h p=0.014) and at the end of follow-up (2.48 ± 1.9 vs 1.12 ± 1.64 p=0.001). Logistic regression only showed end of follow up serum creatinine level as an independent risk factor of ESRD (OR3.74 IC 95% 1.01-13.75 p=0.047). ESRD-free survival chance after 5 of follow-up was 67%. Conclusion Only serum creatinine level at the end of follow-up could be found as an associated factor with ESRD. Greater number of patients would be needed in order to obtain other factors leading to ESRD in patients with AAV.
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