Computed Tomography-Assessed Sarcopenia Predicts Mortality in Kidney Transplant Candidates.

OBJECTIVES: Sarcopenia is common in chronic kidney disease and associated with increased mortality. We investigated the prevalence of sarcopenia, defined as low muscle mass by the psoas muscle index, in endstage renal disease patients on waiting lists for kidney transplant and determined its association with prognostic nutritional index, C-reactive protein-toalbumin ratio, cardiovascular events, and mortality. MATERIALS AND METHODS: Our study included 162 patients with end-stage renal disease and 87 agematched healthy controls. We calculated nutritional status as follows: prognostic nutritional index = (10 × albumin [g/dL]) + (0.005 × total lymphocyte count (×103/µL]) and C-reactive protein-to-albumin ratio. We gathered demographic and laboratory data from medical records. RESULTS: Patients with end-stage renal disease had a mean age of 44.7 ± 14.2 years; follow-up time was 3.37 years (range, 0.35-9.60 y). Although patients with endstage renal disease versus controls had higher prevalence of sarcopenia (16.7% vs 3.4%; P = .002) and C-reactive protein-to-albumin ratio (1.47 [range, 0.12-37.10] vs 0.74 [range, 0.21-10.20]; P < .001), prognostic nutritional index was lower (40 [range, 20.4-52.2] vs 44 [range, 36.1-53.0]; P < .001). In patients with end-stage renal disease with and without sarcopenia, prognostic nutritional index (P = .005) was lower and C-reactive protein-to-albumin ratio (P = .041) was higher in those with versus those without sarcopenia. Among 67 patients on waiting lists who received kidney transplants, those without sarcopenia had better 5-year patient survival posttransplant than those with sarcopenia (P = .001). Multivariate regression analysis showed sarcopenia and low prognostic nutritional index were independentrisk factors for mortality among patients with end-stage renal disease. CONCLUSIONS: Sarcopenia was ~5 times more frequent in patients with end-stage renal disease than in healthy controls and was positively correlated with the prognostic nutritional index. Sarcopenia was an independent risk factor for mortality in patients on transplant waiting lists.

Peritoneal calprotectin level in peritoneal dialysis patients.

BACKGROUND: Calprotectin is an important molecule in the initiation and progression of the inflammatory process. Systemic and local intraperitoneal inflammation are distinct processes and consequences in peritoneal dialysis (PD). We aimed to evaluate dialysate calprotectin levels and its associations with peritonitis and dialysis adequacy in PD patients. METHODS: Forty-four PD patients were included in this prospective study. Calprotectin concentration was evaluated in 24-h peritoneal drainage fluid. Patients were followed-up for 1 year, and peritonitis episodes were recorded. Dialysate calprotectin levels were compared to dialysis adequacy parameters and peritonitis frequency. RESULTS: The mean age of patients was 54.9±12.7 years. Median PD duration was 54 (23-76) months. Seventeen patients (38.6%) had previous peritonitis episodes. During follow-up, 15 of 44 patients (34.1%) had peritonitis. The median calprotectin concentration was 79.5 (75.2-86.3) ng/ml. The patients were divided into low and high calprotectin groups according to median value. In the high calprotectin group, BMI was found higher (p = 0.04). There was no significant relationship between calprotectin concentration and peritonitis during follow-up (p = 0.29). However, the patients that have had previous peritonitis had higher calprotectin concentrations (p = 0.02). The patients who had higher erythrocyte sedimentation rate (ESR) levels also had higher calprotectin concentrations (p = 0.01). CONCLUSION: Peritoneal calprotectin concentrations were correlated with higher BMI and ESR, and it was higher in patients with previous peritonitis episodes. To our knowledge, this is the first study to examine the peritoneal calprotectin levels in PD patients. Further studies are needed to determine the use of peritoneal calprotectin as an inflammatory marker in PD.

Prediction of subclinical left ventricular dysfunction by speckle-tracking echocardiography in patients with anti-neutrophil cytoplasmic antibody--associated vasculitis.

Objectives: This study aims to evaluate left ventricular functions using speckle-tracking echocardiography (STE) in patients with anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). Patients and methods: Between June 2018 and July 2019, a total of 31 AAV patients (17 males, 14 females; median age: 53 years; range, 47 to 62 years) and 21 healthy controls (11 males, 10 females; median age: 56 years; range, 46 to 60 years) were included in the study. Clinical and biochemical characteristics of all participants were recorded. All participants underwent conventional and two-dimensional STE. The receiver operating characteristic (ROC) curve analysis was performed to determine the cut-off value of serum N-terminal prohormone of brain natriuretic peptide (NT-pro-BNP) that predicted subclinical left ventricular dysfunction. The Spearman correlation analysis was used to determine the correlation between left ventricular global longitudinal strain (LV-GLS) and NT-pro-BNP. Results: The LV-GLS was lower in AAV patients (19.3% vs. 21.7%, respectively; p=0.014). NT-pro-BNP was negatively correlated with LV-GLS (p=0.005, r=0.401). Conclusion: Subclinical left ventricular dysfunction can be detected by STE in patients with AAV who have free of clinically overt cardiovascular disease. The LV-GLS is negatively correlated with serum NT-pro-BNP levels.

Favipiravir Use in Kidney Transplant Recipients with COVID-19: A Single-Center Experience.

OBJECTIVES: Kidney transplant recipients are among the high-risk groups for severe COVID-19. To date, no specific antiviral agent has proved uniformly effective against SARS-CoV-2. Favipiravir, the recommended drug by the Turkish Ministry of Health, was uniformly supplied to all patients diagnosed with COVID-19 by a positive nasopharyngeal swab polymerase chain reaction test. The aim of our study was to retrospectively compare our kidney transplant recipients treated with favipiravir who developed COVID-19 infection versus those not treated with favipiravir during the clinical course of the disease, with a special emphasis on the occurrence of side effects and adverse events. MATERIALS AND METHODS: We included 37 consecutive kidney transplant recipients with a median age of 46 years (62.2% women). Recipients included 8 with deceased donors and 29 with living related donors; median posttransplant survival was 8.0 years (IQR, 5.5-12.5 years). RESULTS: Twenty-six patients (70.3%) received favipiravir, and 11 (29.7%) did not. There were no statistically significant differences between the groups for baseline demographic characteristics and clinical and laboratory data, except that the favipiravir-treated patients were older and had a higher requirement of oxygen treatment. There were no statistically significant differences between the 2 groups for the course and outcome of COVID-19 infection with regard to adverse side effects/events associated with favipiravir. Laboratory data at baseline, day 7, and day 30 were also comparable between the groups. CONCLUSIONS: Although the efficacy of favipiravir for treatment of COVID-19 infection remains controversial, favipiravir is safe for kidney transplant recipients.

Prognostic nutritional index is a predictor of mortality in elderly patients with chronic kidney disease.

PURPOSE: Prognostic nutritional index (PNI), a composite indicator of inflammation and nutritional status, has recently been recognized as an independent prognostic marker for chronic kidney disease (CKD). We aimed to investigate PNI and its relationship with mortality in elderly patients with CKD. METHODS: Three hundred and fifty-nine patients over the age of 80 years with stage 3-4 CKD were enrolled in this retrospective study. PNI was used to assess the nutritional status of the patients. Patients were divided into two different groups as deceased and survived and as low PNI (< 39) and high PNI (≥ 39) according to median value of PNI. RESULTS: The mean age of the patients was 85.7 ± 3.7 years. One hundred and ninety-five (54.3%) patients died during follow-up. Multivariate analysis revealed that male gender, PNI, proteinuria, and diabetes mellitus (DM) were independent predictors of mortality in elderly patients with CKD. When patients with low PNI were compared to those with high PNI, initiation of dialysis and mortality rate were significantly higher whereas albumin, hemoglobin and lymphocyte count were lower. Pearson correlation analysis showed that PNI was significantly correlated with albumin (r = 1.000, p < 0.001), hemoglobin (r = 0.340, p < 0.001) and eGFR (r = 0.123, p = 0.020). Hemoglobin was an independent predictor of PNI in multivariate analysis. CONCLUSION: In this study, we observed that PNI was significantly associated with mortality over the age of 80 years in patients with CKD and can be used to monitor nutritional status in this patient population.

Assessment of peritoneal thickness using CT in relation to dialysis adequacy in peritoneal dialysis patients.

Studies assessing peritoneal thickness by CT in peritoneal dialysis (PD) patients are lacking. In this study, we aimed to investigate the association between peritoneal thickness as measured by CT and dialysis adequacy with peritoneal membrane characteristics in PD patients. Ninety-four PD patients were enrolled. Peritoneal thickness was measured by CT. Patients with and without a decrease in Kt/V of at least 0.3 over time were classified as Group 1 and Group 2, respectively. An increase of 0.1 unit of dialysate/plasma (D/P) creatinine over time were considered significant. The relationship between peritoneal membrane thickness, change in Kt/V, and peritoneal membrane characteristics were investigated. There were 31 (33.0%) patients in Group 1. The duration of PD (86.0 ± 64.1 vs. 59.6 ± 45.2 months, p: 0.023), peritoneal thickness (1.02 ± 0.37 vs. 0.87 ± 0.21 mm, p: 0.015), peritoneal calcification (7 [22.6%] vs. 3 [4.8%] patients, p: 0.013], increased D/P creatinine ratio (14 [45.2%] vs. 14 [22.2%] patients, p: 0.031) and CRP (13.9 ± 11.2 vs. 7.1 ± 4.8 mg/L, p: 0.045) were significantly higher in Group 1, whereas albumin (3.6 ± 0.5 vs. 3.8 ± 0.6 g/dL, p: 0.047) and parathyroid hormone (355.2 ± 260.2 vs. 532.1 ± 332.9 ng/L, p: 0.015) levels were significantly lower. Peritoneal thickness was significantly correlated with duration of PD (r: 0.775, p < 0.001) and CRP (r: 0.282, p: 0.006). Regression analysis showed that peritoneal thickness (Exp (B) [95% CI]: 0.029 [0.003-0.253], p: 0.001) was independent predictor of decreased Kt/V in PD patients. In conclusion, prolonged PD duration and increased peritoneal thickness are associated with a decrease in Kt/V over time. CT may be an alternative and noninvasive method instead of peritoneal biopsy for determining the structural changes of the peritoneal membrane .

The association between perceived stress with sleep quality, insomnia, anxiety and depression in kidney transplant recipients during Covid-19 pandemic.

BACKGROUND: The psychological distress and sleep problems caused by current Covid-19 outbreak is not well known in kidney transplant recipients. In this study, we aimed to investigate the association between perceived stress with sleep quality, insomnia, anxiety, depression and kidney function in kidney transplant recipients during the Covid-19 pandemic. MATERIAL AND METHODS: A hundred-six kidney transplant recipients were enrolled. Questionnaire of "Socio-demographics", "Perceived Stress Scale (PSS)", "Pittsburgh Sleep Quality Index (PSQI)", "Insomnia Severity Index (ISI)" and "Hospital Anxiety Depression Scale (HADS)" are performed. The laboratory data is recorded. The perceived stress related to Covid-19 pandemic and its associations were investigated. RESULTS: The mean age of patients was 44.2±13.3 years, and 65 of the patients (61.3%) were men. Forty-nine (46.2%) of the patients had high-perceived stress; 51 (48.1%) of the patients had poor sleep quality, 40 (37.7%) of the patients had insomnia, 25 (23.6%) of the patients had anxiety and 47 (44.3%) of the patients had depression. The patients having a history of Covid-19 infection in own or closed relatives (9.09±4.17 vs 6.49±4.16, p:0.014) and the patients who have a rejection episode any of time (8.24±5.16 vs 6.37±3.57, p:0.033) have had significantly higher anxiety scores, when they compared to others. The high PSS were positively correlated with PSQI, ISI, HAD-A and HAD-D. Regression analyses revealed that high-perceived stress is an independent predictor of anxiety and depression. There was not significant difference between kidney function with PSS, PSQI, ISI, HAD-A and HAD-D. CONCLUSIONS: High PSS is positively correlated with poor sleep quality and insomnia and also an independent predictor of anxiety and depression in kidney transplant recipients during the outbreak of Covid-19. As the pandemic is still spreading worldwide quickly early identification and intervention of sleep disturbances and psychiatric disorders are essential to protect graft function with high compliance to treatment in transplantation patients.

Chronic kidney disease progression in aged patients.

PURPOSE: Chronic kidney disease (CKD) is a major morbidity, and its prevalence increases with age. However, there appears to be some confusion about the prognosis of CKD in aged patients, because, it has its own characteristics different from youngers. In this study, we investigated the progression of CKD and related factors in aged patients. METHODS: This was a retrospective study including 334 patients over 80 years of age that were diagnosed with stage 3-4 CKD at our CKD clinic. CKD progression was assessed as an annual decline in the estimated glomerular filtration rate (eGFR). Comorbidities were globally categorized with the Charlson comorbidity index (CCI), but diabetes mellitus, hypertension, and cardiac morbidities were evaluated separately. Patients were grouped as either 'progression to end-stage renal disease (ESRD)' or 'others'. RESULTS: During the follow-up period, 191 (57.2%) patients exhibited progression; the annual median eGFR declined by 0.8 ml/min/1.73 m2. Only 27 (8.1%) of these patients progressed to ESRD. In univariant and multivariate models, respectively, progressing to ESRD was significantly associated with cardiac comorbidities (p < 0.001, p < 0.001), proteinuria (p < 0.001, p = 0.03), and the baseline eGFR value (p < 0.001, p < 0.001). CONCLUSION: In aged patients, CKD progressed slowly, but particularly high initial creatinine levels and proteinuria could be indicator of progression. In addition, cardiac comorbidities may facilitate progression to ESRD.

Potential Causes and Implications of Low Target Therapeutic Ratio in Warfarin-Treated Patients for Thrombosis Prophylaxis: A Single-Center Experience.

Time in therapeutic range (TTR) of international normalized ratio is crucial for the safety and efficacy of anticoagulation with warfarin and it is influenced by many factors. There are limited data about the quality of warfarin therapy and its effects on clinical outcomes in Turkey. The aim of this study is to demonstrate the quality of anticoagulant therapy with warfarin and evaluate the parameters that affect the quality of warfarin therapy. A total of 170 patients with atrial fibrillation (AF; mean age: 62.2 ± 13.3; 69.2% female) treated with warfarin were included in this study. The mean follow-up period was 20 ± 8.4 months. The mean TTR levels of all patients were found to be 54.2% ± 21.4%. The TTR levels were similar in patients with valvular AF (VAF) and nonvalvular AF (NVAF). Logistic regression analysis revealed that elderly, heart failure (HF), and renal dysfunction were independent predictors of lower TTR. There were no significant differences between the VAF and NVAF subgroups regarding the incidence of mortality, stroke, and myocardial infarction. Cox regression analysis revealed that HF, coronary artery disease, and renal dysfunction were independent predictors of clinical outcomes in addition to lower TTR. Our results provide data regarding the quality of anticoagulation with warfarin from a single tertiary center in Istanbul, Turkey. The questions remain in seeking quality improvement in anticoagulation.