15-year-change of phenotype and prognosis in non-dialysis CKD patients referred to a nephrology clinic.

PURPOSE: Changes over time of phenotype and prognosis in CKD patients starting nephrology care are undefined. This information is critical to correctly plan and optimize healthcare resources and clinical management in tertiary care. METHODS: We performed a long-term observational cohort study including 2,866 non-dialysis CKD patients newly referred to our nephrology clinic from 2004 to 2018. Three cohorts were constituted based on 5-year calendar intervals (2004-2008, 2009-2013, and 2014-2018). The changes over time of main demographic, clinical and laboratory characteristics were compared among the three cohorts. We also compared between cohorts the risk of renal death (combined endpoint of renal replacement therapy-RRT, or death before RRT) as well as of the single components (RRT or death). RESULTS: Across the three cohorts, we detected a significant increase in the prevalence of age ≥ 75 years (from 22.0 to 28.4%), male gender (from 53.1 to 62.1%), diabetes (from 32.6 to 39.5%), severe proteinuria ≥ 500 mg/24 h (from 46.9 to 52.4%). Mean eGFR at referral declined from 56.8 ± 27.0 to 49.6 ± 26.1 mL/min/1.73m2. Incidence of renal death significantly declined over time (5.36, 3.22 and 4.54/100 pts-year in 2004-2008, 2009-2013 and 2014-2018 cohorts, respectively). As compared with patients referred in 2004-2008, adjusted risk of renal death was lower in patients referred in 2009-2013 (HR 0.49, 95%CI 0.34-0.69) and 2014-2018 (HR 0.61, 95%CI 0.45-0.84). Similar results were obtained for RRT, while mortality did not change over time. CONCLUSIONS: In the last 15 years, phenotype of newly referred CKD patients has remarkably changed with increasing frequency of older patients and more severe disease; however, renal survival improved suggesting greater efficacy of nephrology care.

Prevalence and renal prognosis of left ventricular diastolic dysfunction in non-dialysis chronic kidney disease patients with preserved systolic function.

BACKGROUND: Left ventricular (LV) diastolic dysfunction is common in non-dialysis chronic kidney disease (ND-CKD) patients; however, the prevalence estimated according to the new diagnostic criteria as well as the prognostic role of diastolic dysfunction on CKD progression remain unknown. METHOD: We longitudinally evaluated consecutive ND-CKD patients and preserved systolic function (LV ejection fraction > 50%). According to the recently updated guidelines, LV diastolic dysfunction was assessed by four echocardiographic variables (annular e' velocity, average mitral valve E-wave/e' ratio, left atrial volume index and tricuspid regurgitation). Patients were classified as diastolic dysfunction, indeterminate and normal. Time-dependent estimated glomerular filtration rate (eGFR) change was assessed by mixed-effects regression model. Cumulative incidence of composite renal outcome (eGFR decline > 50% or chronic dialysis) was also estimated. RESULTS: Among 140 patients (age 66.2 ±â€Š14.5 years; 61% males; eGFR 39.8 ±â€Š21.8 ml/min per 1.73m2; 43.6% diabetics), diastolic dysfunction occurred in 22.9%, indeterminate in 45.7% and normal in 31.4%. Prevalence of diastolic dysfunction was much lower than that estimated with older criteria (62.7%). Logistic regression (odds ratio, 95% confidence interval [CI]) showed that diastolic dysfunction was associated with lower eGFR (0.97, 0.94-0.99), older age (1.04, 1.01-1.06) and night-time systolic blood pressure (1.04, 1.00-1.07). Across 1702 eGFR measurements collected during a median follow-up of 4.6 years, eGFR decline (ml/min per 1.73m2; per year) was faster in patients with diastolic dysfunction (-2.12, 95% CI from -2.68 to -1.56) and in the indeterminate (11.2/100 pts per year) as compared to normal (-1.14, 95% CI from -1.64 to -0.63). Incidence of composite renal outcome was significantly higher in diastolic dysfunction (13.8/100 pts/year) than in normal group (3.5/100 pts per year)'. CONCLUSION: In ND-CKD population, LV diastolic dysfunction is less frequent than previously described and acts as independent predictor of CKD progression.

Ferric Carboxymatose in Non-Hemodialysis CKD Patients: A Longitudinal Cohort Study.

No information is available on the efficacy of ferric carboxymaltose (FCM) in real-world CKD patients outside the hemodialysis setting. We prospectively followed 59 non-hemodialysis CKD patients with iron deficient anemia (IDA: hemoglobin <12.0/<13.5 g/dL in women/men and TSAT < 20% and/or ferritin < 100 ng/mL) who were intolerant or non-responders to oral iron. Patients received ferric carboxymaltose (FCM) (single dose of 500 mg) followed by additional doses if iron deficiency persisted. We evaluated efficacy of FCM in terms of increase of hemoglobin, ferritin, and TSAT levels. Direct and indirect costs of FCM were also analyzed in comparison with a hypothetical scenario where same amount of iron as ferric gluconate (FG) was administered intravenously. During the 24 weeks of study, 847 ± 428 mg of FCM per patient were administered. IDA improved after four weeks of FCM and remained stable thereafter. At week-24, mean change (95%CI) from baseline of hemoglobin, ferritin and TSAT were +1.16 g/dL (0.55-1.77), +104 ng/mL (40-168) and +9.5% (5.8-13.2), respectively. These changes were independent from ESA use and clinical setting (non-dialysis CKD, peritoneal dialysis and kidney transplant). Among ESA-treated patients (n = 24), ESA doses significantly decreased by 26% with treatment and stopped either temporarily or persistently in nine patients. FCM, compared to a FG-based scenario, was associated with a cost saving of 288 euros/patient/24 weeks. Saving was the same in ESA users/non-users. Therefore, in non-hemodialysis CKD patients, FCM effectively corrects IDA and allows remarkable cost savings in terms of societal, healthcare and patient perspective.

[Peritoneal dialysis catheter infection with abscess of the abdominal wall in a ADPKD patient].

Infections to the peritoneal catheter are common in Peritoneal Dialysis (PD). We report the clinical case of a 49-year-old male patient in PD, who showed an atypical manifestation of tunnel infection caused by Staphylococcus aureus. The infection was characterized by a little abscess, on the left pararectal abdominal line, 6 cm far from exit-site of the peritoneal catheter. The diagnosis was made using ultrasonography (US), which showed a fistulous communication from subcutaneous cuff to the skin. We treated the infection conservatively by performing cuff-shaving and drainage of the abscess, associated to antibiotic therapy (teicoplanin). Due to the persistence of the infection, we added oral and topical rifampicin, and advanced medication with freez-dried collagen plant impregnated with extended-release gentamicin. The complete resolution of the infection allowed us to avoid removing the catheter.

[Role of Ambulatory Blood Pressure Monitoring (ABPM) in chronic kidney patients: a review].

About 90%of patients with chronic kidney disease (CKD) have arterial hypertension; the main international guidelines recommend maintaining blood pressure (BP) values below 130/80 mmHg to reduce the cardio-renal risk in this population. Twenty-four-hour Ambulatory Blood Pressure Monitoring (ABPM) is the golden standard for the identification of the BP profiles and patterns, as well as for the assessment of the circadian rhythm and BP variability. The correct interpretation of ABPM allows to optimize anti-hypertensive treatment and to reduce cardio-renal risk in CKD patient. In fact, in patients with CKD, the ABPM has a greater role in terms of renal and cardio-vascular prognosis when compared to clinical BP measurements. Patients with ABPM in target present a low cardio-renal risk, regardless of clinical BP values; on the contrary, if the clinical PA is normal and the ABPM not in target, this risk increases significantly. Moreover, in the CKD population, non-dipping is associated with a higher risk of cardiovascular events and end stage renal disease (ESRD), making identifying nocturnal hypertension greatly important. Therefore, ABPM is an instrument of primary importance in the diagnostic and therapeutic work-out of renal patients.

[Infected hepatic cyst in ADPKD patient in peritoneal dialysis].

Renal and hepatic cysts infections are among the most important infectious complications of ADPKD and often require hospitalization. Liver cysts are even more complex than renal cysts and their diagnosis and treatment are quite controversial. We report the case of a 58-year-old patient with ADPKD undergoing peritoneal dialysis treatment. He presented fever and severe asthenia and was diagnosed with a hepatic cyst infection. Given the presence of the peritoneal catheter, and in order to facilitate the targeted treatment of the infection, we administered antibiotics (ceftazidime and teicoplanin) in the bags used for peritoneal dialysis exchanges for 4 weeks, obtaining the complete disappearance of symptoms and laboratory and ultrasound alterations. Intraperitoneal antibiotics administration in the treatment of infected hepatic cysts represents an effective and safe therapeutic alternative, never described in literature so far.