The ratio of measured to estimated glomerular filtration rate may be a marker of early mortality and dialysis requirement

Abstract Background It has been suggested that, in patients with CKD stage 5, measured GFR (mGFR), defined as the mean of urea and creatinine clearance, as measured by a 24-h urine collection, is a better measure of renal function than estimated GFR (eGFR), based on the CKD-EPI formula. This could be due to reduced muscle mass in this group. Its use is recommended in the ERBP guidelines. Unplanned dialysis initiation (DI) is associated with increased morbidity, mortality, and reduced modality choice and is generally considered undesirable. We hypothesized that the ratio mGFR/eGFR (M/E) aids prediction of death and DI. Methods All 24-h measurements of urea and creatinine excretion were extracted from the clinical biochemistry databases in Zealand. Data concerning renal diagnosis, comorbidity, biochemistry, medical treatment, mortality and date of DI, were extracted from patient notes, the National Patient Registry and the Danish Nephrology Registry. Patients were included if their eGFR was < 30 ml/min/1.73m2. The last available value for each patient was included. Follow-up was 12 months. Results One thousand two hundred sixty-five patients were included. M/E was median 0.91 ± 0.43. It was highly correlated to previous determinations. It was negatively correlated to eGFR, comorbidity, high age and female sex. It was positively related to albumin and negatively to C-reactive protein. M/E was higher in patients treated with ACE inhibitors and diuretics but no other treatment groups. On a multivariate analysis, M/E was negatively correlated with mortality and combined mortality/DI, but not DI. A post hoc analysis showed a negative correlation to DI at 3 months. For patients with an eGFR 10–15 ml/min/1.73m2, combined mortality and DI at 3 months was for low M/E (< 0.75) 36%, medium (0.75–1.25) 20%, high (> 1.25) 8%. A low M/E predicted increased need for unplanned DI. A supplementary analysis in 519 patients where body surface area values were available, allowing BSA-corrected M/E to be analyzed, revealed similar results. Conclusion A low mGFR/eGFR ratio is associated with comorbidity, malnutrition, and inflammation. It is a marker of early DI, mortality, and unplanned dialysis initiation, independently of eGFR, age and comorbidity. Particular attention paid to patients with a low M/E may lower the incidence of unplanned dialysis requirement.

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Analysis of saccular aneurysms in the Barrow Ruptured Aneurysm Trial

Journal of Neurosurgery ◽

10.3171/2016.9.jns161301 ◽

2018 ◽

Vol 128 (1) ◽

pp. 120-125 ◽

Cited By ~ 24

Author(s):

Robert F. Spetzler ◽

Joseph M. Zabramski ◽

Cameron G. McDougall ◽

Felipe C. Albuquerque ◽

Nancy K. Hills ◽

...

Keyword(s):

Ruptured Aneurysm ◽

Modified Rankin Scale ◽

Clinical Trial Registration ◽

Treatment Groups ◽

Significant Difference ◽

Initial Hospitalization ◽

Intent To Treat ◽

Post Hoc ◽

Saccular Aneurysms

OBJECTIVEThe Barrow Ruptured Aneurysm Trial (BRAT) is a prospective, randomized trial in which treatment with clipping was compared to treatment with coil embolization. Patients were randomized to treatment on presentation with any nontraumatic subarachnoid hemorrhage (SAH). Because all other randomized trials comparing these 2 types of treatments have been limited to saccular aneurysms, the authors analyzed the current BRAT data for this subgroup of lesions.METHODSThe primary BRAT analysis included all sources of SAH: nonaneurysmal lesions; saccular, blister, fusiform, and dissecting aneurysms; and SAHs from an aneurysm associated with either an arteriovenous malformation or a fistula. In this post hoc review, the outcomes for the subgroup of patients with saccular aneurysms were further analyzed by type of treatment. The extent of aneurysm obliteration was adjudicated by an independent neuroradiologist not involved in treatment.RESULTSOf the 471 patients enrolled in the BRAT, 362 (77%) had an SAH from a saccular aneurysm. Patients with saccular aneurysms were assigned equally to the clipping and the coiling cohorts (181 each). In each cohort, 3 patients died before treatment and 178 were treated. Of the 178 clip-assigned patients with saccular aneurysms, 1 (1%) was crossed over to coiling, and 64 (36%) of the 178 coil-assigned patients were crossed over to clipping. There was no statistically significant difference in poor outcome (modified Rankin Scale score > 2) between these 2 treatment arms at any recorded time point during 6 years of follow-up. After the initial hospitalization, 1 of 241 (0.4%) clipped saccular aneurysms and 21 of 115 (18%) coiled saccular aneurysms required retreatment (p < 0.001). At the 6-year follow-up, 95% (95/100) of the clipped aneurysms were completely obliterated, compared with 40% (16/40) of the coiled aneurysms (p < 0.001). There was no difference in morbidity between the 2 treatment groups (p = 0.10).CONCLUSIONSIn the subgroup of patients with saccular aneurysms enrolled in the BRAT, there was no significant difference between modified Rankin Scale outcomes at any follow-up time in patients with saccular aneurysms assigned to clipping compared with those assigned to coiling (intent-to-treat analysis). At the 6-year follow-up evaluation, rates of retreatment and complete aneurysm obliteration significantly favored patients who underwent clipping compared with those who underwent coiling.Clinical trial registration no.: NCT01593267 (clinicaltrials.gov)

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FC 053RATIO OF MEASURED GFR TO ESTIMATED GFR MAY PREDICT EARLY DEATH AND REQUIREMENT FOR DIALYSIS

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfab130.001 ◽

2021 ◽

Vol 36 (Supplement_1) ◽

Author(s):

James G Heaf ◽

Rafal Yahya ◽

Morten Dahl

Keyword(s):

Creatinine Clearance ◽

Medical Treatment ◽

Early Death ◽

Dialysis Initiation ◽

Estimated Gfr ◽

Ckd Stage ◽

Mortality Incidence ◽

End Stage ◽

Unplanned Dialysis ◽

Measured Gfr

Abstract Background and Aims It has been suggested that, in patients with CKD stage 5, measured GFR (mGFR), defined as the mean of urea and creatinine clearance as measured by a 24-hour urine collection, is a better measure of renal function than estimated GFR (eGFR), based on the CKD-EPI formula. This could be due to reduced muscle mass in this group. Its use is recommended in the ERBP guidelines. Unplanned dialysis initiation (UDI) is associated with increased morbidity, mortality, and reduced modality choice. It is generally considered undesirable. We hypothesized that the ratio mGFR/eGFR (R) aids prediction of death and end stage kidney disease (ESKD), as defined by permanent dialysis requirement or transplantation. Method All 24-hour measurements of urea and creatinine excretion were extracted from the clinical biochemistry databases in Zealand. Data concerning renal diagnosis, comorbidity, biochemistry, medical treatment, mortality and date of ESKD, were extracted from patient notes, the National Patient Registry and the Danish Nephrology Registry. Patients were included if their eGFR was <30 ml/min/1.73m2. The last available value for each patient was included. Results 1265 patients were included. In 519, body surface area (BSA) was available, and the corrected ratio (RBSA) could be calculated. The urea clearance was 49 ±24% of creatinine clearance. R was median 0.88 (IQR 0.63-1.15), RBSA 0.87 (0.68-1.06). R was not related to eGFR. Comorbidity was associated with lower R, e.g. atherosclerosis (0.90 ±0.41 vs. 0.97 ±0.49*), heart failure (0.80 ±0.37 vs. 0.95 ±0.44*), pulmonary disease (0.80 ±0.37 vs. 0.94 ±0.44***), hepatic disease (0.67 ±0.41 vs. 0.92 ±0.43***), but not diabetes mellitus. It was related to albumin (r=0.24***), C-reactive protein (-0.22***) and biochemical markers of uraemia, e.g. bicarbonate (-0.19***). Medical treatment data was available in 137 patients. R was higher in patients treated with ACE inhibitors (1.20 ±0.50 vs. 1.01 ±0.36*) and diuretics (1.09 ±0.40 vs. 0.94 ±0.35*), but no other treatment groups. Patients were grouped as high R (H, >1.25), medium (M, 0.75-1.25) or low (L, <0.75). R was not associated with prognosis at one year, but L patients had a significantly higher ESKD and mortality incidence at 3 months. For patients with eGFR 10-15 ml/min/1.73m2, ESKD incidence was L 22%, M 15%, H 5%, mortality 19, 5, and 2% respectively. Similar findings were seen in other groups, e.g. eGFR 15-20 ml/min/1.73m2: ESKD 11, 2, and 0%; death 11, 5, and 1%. UDI was higher for L patients. For patients with eGFR 10-15 ml/min/1.73m2, UDI occurred in L: 47%, M:27%, H:25%. For patients with eGFR 10-15 ml/min/1.73m2 the figures were 51, 38 and 12% respectively. Findings for the subgroup of patients with RBSA measurements were similar. *:p<0.05; **:p<001;***:p<0.001 Conclusion A low mGFR/eGFR ratio is associated with comorbidity, malnutrition, inflammation and biochemical uraemia. It a marker of early ESKD, death and unplanned dialysis initiation, independently of eGFR. Particular attention paid to patients with a low R may lower the incidence of unplanned dialysis requirement.

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Dental health assessed using panoramic radiograph and adverse events in chronic kidney disease stage 4–5 patients transitioning to dialysis and transplantation–A prospective cohort study

PLoS ONE ◽

10.1371/journal.pone.0258055 ◽

2021 ◽

Vol 16 (9) ◽

pp. e0258055

Author(s):

Mikko J. Järvisalo ◽

Viljami Jokihaka ◽

Markus Hakamäki ◽

Roosa Lankinen ◽

Heidi Helin ◽

...

Keyword(s):

Chronic Kidney Disease ◽

Oral Health ◽

Kidney Disease ◽

Dental Health ◽

C Reactive Protein ◽

Reactive Protein ◽

Stage 4 ◽

Ckd Stage ◽

Maintenance Dialysis

Background and aims Oral health could potentially be a modifiable risk factor for adverse outcomes in chronic kidney disease (CKD) patients transitioning from predialysis treatment to maintenance dialysis and transplantation. We aimed to study the association between an index of radiographically assessed oral health, Panoramic Tomographic Index (PTI), and cardiovascular and all-cause mortality, major adverse cardiovascular events (MACEs) and episodes of bacteremia and laboratory measurements during a three-year prospective follow-up in CKD stage 4–5 patients not on maintenance dialysis at baseline. Methods Altogether 190 CKD stage 4–5 patients without maintenance dialysis attended panoramic dental radiographs in the beginning of the study. The patients were followed up for three years or until death. MACEs and episodes of bacteremia were recorded during follow-up. Laboratory sampling for C-reactive protein and leukocytes was repeated tri-monthly. Results PTI was not associated with baseline laboratory parameters or C-reactive protein or leukocytes examined as repeated measures through the 3-year follow-up. During follow-up, 22 patients had at least one episode of bacteremia, but only 2 of the bacteremias were considered to be of oral origin. PTI was not associated with incident bacteremia during follow-up. Thirty-six patients died during follow-up including 17 patients due to cardiovascular causes. During follow-up 42 patients were observed with a MACE. PTI was independently associated with all-cause (HR 1.074 95% CI 1.029–1.122, p = 0.001) and cardiovascular (HR 1.105, 95% CI 1.057–1.157, p<0.0001) mortality, as well as, incident MACEs (HR 1.071 95% CI 1.031–1.113, p = 0.0004) in the multivariable Cox models adjusted for age and kidney transplantation or CKD treatment modality during follow-up. Conclusions Radiographically assessed dental health is independently associated with all-cause and cardiovascular mortality and MACEs but not with the incidence of bacteremia in CKD stage 4–5 patients transitioning to maintenance dialysis and renal transplantation during follow-up.

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Bezlotoxumab Is Associated With a Reduction in Cumulative Inpatient-Days: Analysis of the Hospitalization Data From the MODIFY I and II Clinical Trials

Open Forum Infectious Diseases ◽

10.1093/ofid/ofy218 ◽

2018 ◽

Vol 5 (11) ◽

Cited By ~ 1

Author(s):

Anirban Basu ◽

Vimalanand S Prabhu ◽

Mary Beth Dorr ◽

Yoav Golan ◽

Erik R Dubberke ◽

...

Keyword(s):

Risk Factors ◽

Resource Use ◽

Hospital Readmission ◽

Treatment Groups ◽

Recurrent Clostridium Difficile Infection ◽

Trial Analysis ◽

Inpatient Settings ◽

The Mean ◽

Post Hoc

Abstract Background Patients with recurrent Clostridium difficile infection (rCDI) are more likely to have a hospital readmission and spend increased time in inpatient settings compared with patients with primary CDI. MODIFY I and II demonstrated that bezlotoxumab significantly reduced rCDI vs placebo. A post hoc within-trial analysis assessed whether bezlotoxumab was associated with a reduction in cumulative inpatient-days. Methods Data were pooled from the MODIFY trials to estimate the cumulative hospitalized days summed over the 84-day follow-up period. We adjusted inpatient use data from pooled MODIFY I and II for survival and censoring to estimate 84-day cumulative inpatient-days, overall and for subgroups. Treatment effects were obtained using recycled predictions based on trial protocol and rCDI risk, and 95% confidence intervals were obtained using 1000 bootstrap replicates. Results Mean cumulative inpatient-days were greater in the placebo arm (14.1 days) vs the bezlotoxumab arm (12.1 days) in the overall population. The mean difference between treatment groups was 2.1 days (95% confidence interval, –0.4 to –3.7). This was consistent in participants with risk factors for rCDI: age ≥65 years, compromised immunity, severe CDI, prior CDI, and ribotype 027/078/244 infection. As the number of risk factors increased, bezlotoxumab resulted in greater reductions in the number of inpatient-days compared with placebo (difference: –1.2 days, –2.3 days, –2.5 days, and –3.0 days for 0, 1, 2, and ≥3 risk factors, respectively). Conclusions Bezlotoxumab was associated with a reduction in cumulative inpatient-days, suggesting that treatment with bezlotoxumab may substantially reduce rCDI-associated health care resource use. Trial registrations. MODIFY I (MK-3415A-001, NCT01241552) and II (MK-3415A-002, NCT01513239)

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The effect of parathyroidectomy compared to non-surgical surveillance on kidney function in primary hyperparathyroidism: a nationwide historic cohort study

BMC Endocrine Disorders ◽

10.1186/s12902-021-00918-z ◽

2022 ◽

Vol 22 (1) ◽

Author(s):

Josephine Matzen ◽

Lise Sofie Bislev ◽

Tanja Sikjær ◽

Lars Rolighed ◽

Mette Friberg Hitz ◽

...

Keyword(s):

Cohort Study ◽

Primary Hyperparathyroidism ◽

Kidney Function ◽

Estimated Glomerular Filtration Rate ◽

National Patient Registry ◽

Severe Hypercalcemia ◽

Lower Egfr ◽

National Patient ◽

Historic Cohort

Abstract Background Patients with primary hyperparathyroidism (pHPT) and impaired kidney function (estimated glomerular filtration rate (eGFR) < 60 mL/min) are offered parathyroidectomy (PTX) to protect them from further complications. Surprisingly, two recent uncontrolled cohort studies have suggested a further decrease in kidney function following PTX. We aimed to examine the effects of PTX compared to non-surgical surveillance on kidney function in pHPT patients. Methods Historic cohort study. From the Danish National Patient Registry (NPR) and major medical biochemistry laboratories in Denmark, we identified 3585 patients with biochemically confirmed pHPT among whom n = 1977 (55%) were treated with PTX (PTX-group) whereas n = 1608 (45%) were followed without surgery (non-PTX group). Baseline was defined as time of diagnosis and kidney function was re-assessed 9–15 months after PTX (PTX group) or 9–15 months after diagnosis (non-PTX group). Results At follow-up, eGFR had decreased significantly in the PTX- compared to the non-PTX-group (median − 4% vs. − 1%, p < 0.01). Stratification by baseline eGFR showed that the decrease was significant for those with a baseline eGFR value of 80–89 and > 90 mL/min, but not for those with lower eGFR values. Findings did not differ between patients with mild compared to moderate/severe hypercalcemia. However, after mutual adjustments, we identified baseline levels of calcium, PTH, and eGFR as well as age and treatment (PTX vs. no-PTX) as independent predictors for changes in kidney function. Conclusion Compared to non-surgical surveillance, PTX is associated with a small but significant decrease in kidney function in pHPT patients with an initial normal kidney function.

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Risk of hypersensitivity pneumonitis and interstitial lung diseases among pigeon breeders

European Respiratory Journal ◽

10.1183/13993003.00376-2016 ◽

2016 ◽

Vol 48 (3) ◽

pp. 818-825 ◽

Cited By ~ 11

Author(s):

Christine Cramer ◽

Vivi Schlünssen ◽

Elisabeth Bendstrup ◽

Zara Ann Stokholm ◽

Jesper Medom Vestergaard ◽

...

Keyword(s):

Lung Diseases ◽

Hypersensitivity Pneumonitis ◽

Cox Regression ◽

Interstitial Lung Diseases ◽

Protective Measures ◽

National Patient Registry ◽

Hazard Ratios ◽

Increased Risk ◽

National Patient

We studied the risk of hypersensitivity pneumonitis and other interstitial lung diseases (ILDs) among pigeon breeders.This is a retrospective follow-up study from 1980 to 2013 of 6920 pigeon breeders identified in the records of the Danish Racing Pigeon Association. They were compared with 276 800 individually matched referents randomly drawn from the Danish population. Hospital based diagnoses of hypersensitivity pneumonitis and other ILDs were identified in the National Patient Registry 1977–2013. Stratified Cox regression analyses estimated the hazard ratios (HR) of hypersensitivity pneumonitis and other ILDs adjusted for occupation, residence and redeemed prescription of medication with ILDs as a possible side-effect. Subjects were censored at death, emigration or a diagnosis of connective tissue disease.The overall incidence rate of ILD was 77.4 per 100 000 person-years among the pigeon breeders and 50.0 among the referents. This difference corresponded to an adjusted HR of 1.56 (95% CI 1.26–1.94). The adjusted HRs of hypersensitivity pneumonitis and other ILDs for pigeon breeders were 14.36 (95% CI 8.10–25.44) and 1.33 (95% CI 1.05–1.69), respectively.This study shows an increased risk of ILD among pigeon breeders compared with the referent population. Protective measures are recommended even though ILD leading to hospital contact remains rare among pigeon breeders.

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Efficacy of ustekinumab in biologic-naïve patients with psoriatic arthritis by prior treatment exposure and disease duration: data from PSUMMIT 1 and PSUMMIT 2

RMD Open ◽

10.1136/rmdopen-2019-000990 ◽

2019 ◽

Vol 5 (2) ◽

pp. e000990 ◽

Cited By ~ 3

Author(s):

Iain B McInnes ◽

Soumya D Chakravarty ◽

Isabel Apaolaza ◽

Shelly Kafka ◽

Elizabeth C Hsia ◽

...

Keyword(s):

Psoriatic Arthritis ◽

Disease Duration ◽

Prior Treatment ◽

Subcutaneous Injections ◽

Treatment Groups ◽

Reactive Protein ◽

American College Of Rheumatology ◽

Factor Inhibitor ◽

Inflammatory Drugs ◽

Post Hoc

ObjectiveTo evaluate the efficacy of ustekinumab by prior treatment exposure and disease duration in tumour necrosis factor inhibitor (TNF)-naïve patients with psoriatic arthritis (PsA) in the PSUMMIT 1 and PSUMMIT 2 studies.MethodsIn the phase 3, randomised, placebo-controlled PSUMMIT 1 and PSUMMIT 2 studies, adults with active PsA for ≥6 months despite conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and/or non-steroidal anti-inflammatory drugs (NSAIDs) (PSUMMIT 1) or csDMARDs, NSAIDs and/or anti-TNF agents (PSUMMIT 2) were enrolled. Patients were randomised to subcutaneous injections of placebo, ustekinumab 45 mg or ustekinumab 90 mg at weeks 0 and 4 and every 12 weeks. Efficacy was assessed at week 24 using the American College of Rheumatology criteria and 28-joint count disease activity score using C reactive protein (DAS28-CRP); radiographical progression, enthesitis, and dactylitis were also assessed in this post hoc analysis.ResultsA total of 747 patients were included; all 747 were TNF-naïve, of which, 179 were methotrexate-naïve and TNF-naïve, and 146 were all csDMARD-naïve and TNF-naïve. At week 24, greater proportions of ustekinumab-treated patients had ≥20%/50%/70% improvement in American College of Rheumatology criteria (ACR20/ACR50/ACR70) responses, DAS28-CRP response and DAS28-CRP remission versus placebo in all three prior-treatment populations, with similar differences between treatment groups. Greater proportions of ustekinumab-treated patients also had complete resolution of enthesitis and dactylitis at week 24 across the three prior-treatment populations. Mean changes from baseline in total van der Heijde-Sharp Score at week 24 were generally smaller for ustekinumab-treated patients versus placebo but were statistically significant only in the full TNF-naïve population. Response rates for ACR20/ACR50/ACR70 were similar for TNF-naïve patients with PsA durations of <1 year, ≥1 to <3 years, and ≥3 years.ConclusionUstekinumab-treated patients demonstrated greater clinical response at week 24 compared with placebo regardless of prior treatment exposure and PsA disease duration.

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Medication safety in pregnancy – Results from the MoBa study

Norsk Epidemiologi ◽

10.5324/nje.v24i1-2.1818 ◽

2014 ◽

Vol 24 (1-2) ◽

Cited By ~ 1

Author(s):

Hedvig Nordeng ◽

Eivind Ystrom ◽

Malin Eberhard-Gran

Keyword(s):

Medication Safety ◽

Comparison Group ◽

Over The Counter ◽

National Patient Registry ◽

Mother And Child ◽

National Patient ◽

Long Term Follow Up ◽

In Pregnancy

This article summarizes the results of several of our studies on medication safety in pregnancy based on the Norwegian Mother and Child Cohort Study (MoBa). Medications investigated include antidepressants, NSAIDs, codeine, triptans, paracetamol and certain herbals. A major advantage of these studies is that MoBa has information on prescribed medications, over-the-counter medications and herbal medications. Moreover, MoBa enables the possibility of including a disease comparison group, and long-term follow-up into childhood. The size of MoBa enables designs like the sibling-design, which offers important advantages over studies comparing unrelated individuals. The possibility of linking MoBa to nationwide registries like the NorPD and the National Patient Registry enables validation of medication exposures and childhood diagnosis. Pharmacoepidemiological studies are vital to our understanding of the safety of medications in pregnancy, but great care must be taken in the analysis and interpretation of observational data to avoid problems of confounding and bias.

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The Danish Multiple Sclerosis Registry: a 50-year follow-up

Multiple Sclerosis Journal ◽

10.1177/135245859900500418 ◽

1999 ◽

Vol 5 (4) ◽

pp. 293-296 ◽

Cited By ~ 70

Author(s):

Nils Koch-Henriksen

Keyword(s):

Multiple Sclerosis ◽

Nationwide Survey ◽

Epidemiological Studies ◽

Population Based ◽

National Patient Registry ◽

New Information ◽

Central Population ◽

Average Annual Incidence ◽

National Patient

The Danish Multiple Sclerosis Registry was established in 1948 in continuation with a nationwide survey of the prevalence of Multiple Sclerosis (MS) in Denmark. The register has since collected information on MS patients from all Danish departments of neurology, practising neurologists, MS rehabilitation centres, the National Patient Registry, the Danish MS Society, and departments of neuropathology. The registry is linked with the Danish Central Population Registry. The completeness has been estimated at more than 90%. All cases are reclassified by two neurologists as to diagnosis and year of onset. 12 070 cases with a confirmed diagnosis of MS are kept in the databases. They were prevalent in 1949 or have had onset in the period 1948-1993. The registry is continuously updated with new information on registered cases and new cases. The crude average annual incidence rate 1980-89 was 4.99/105; the prevalence rate was 112/105 by 1 January 1990. Cross-linking with other registers have enabled analytical prospective epidemiological studies, and the registry has provided population based unbiassed samples of patients for a number of clinical studies.

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MO183TELEMEDICINE AS A MODALITY OF HEALTH CARE DELIVERY FOR PATIENTS WITH SEVERE CHRONIC KIDNEY DISEASE DURING COVID-19 PANDEMIC

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfab092.0061 ◽

2021 ◽

Vol 36 (Supplement_1) ◽

Author(s):

Gaetano Alfano ◽

Francesco Fontana ◽

Cristina Bosica ◽

Annachiara Ferrari ◽

Giacomo Mori ◽

...

Keyword(s):

Chronic Kidney Disease ◽

Kidney Disease ◽

Care Delivery ◽

Dialysis Initiation ◽

Ambulatory Setting ◽

Ambulatory Activity ◽

Ckd Stage ◽

Severe Chronic Kidney Disease ◽

Late Referral

Abstract Background and Aims Telemedicine is a new modality of care delivery. Over the last months, it has been used to deliver health care to outpatients with chronic kidney disease (CKD) during COVID-19 pandemic. However, experience of telemedicine in patients with severe CKD is scarce and there are not reassuring data about its efficacy in improving patients’ outcome. To evaluate the efficacy and the outcome profile of telemedicine in people with severe CKD, we reviewed all data of outpatients with severe kidney impairment who underwent nephrological evaluation during the first wave of this pandemic. In particular, outcomes of the ambulatory activity (urgent-start dialysis, late referral and modalities of dialysis initiation) were compared to 2019 ambulatory activity. Method Outpatients with severe chronic kidney disease included in the ambulatory program called “Pre-Dialysis Program were enrolled in a retrospective study. We reviewed all electronic charts of patients who underwent nephrological follow-up from 9th March to June 21st, 2020 (15 weeks in total) at the University Hospital of Modena, Italy. Extension of the observation period to 30th September 2020 allowed us to determine the long-term effects of telemedicine on the rate of urgent-star dialysis, late referral, and modalities of dialysis initiation. Results During 15 weeks of follow-up, 186 nephrological visits were performed (Table) They were subdivided into telemedicine visits (56.5%) and in-person visits (43.5%). Overall, mean age of patients was 71.7±13.1 years with a prevalence of male (60.2%). Patients who received telemedicine visits had a statistically significant lower sCr (3.7±1.2 vs 4.5±1.5 mg/dl; P=0.0001) and higher eGFR level (14.7±6.02 vs 12.16±5.8 ml/min; P=0.002) than patients followed in the ambulatory setting. A high prevalence of patients with CKD stage 5 was monitored by in-person visits (P=0.0001). Patients followed by telemedicine had a clinical profile including a lower weight (P=0.007) and better control of metabolic acidosis (P=0.039) than the counterpart. Changes in domiciliary therapy occurred more frequently in patients monitored in the ambulatory setting (P=0.036). Statistically significant differences were encountered in the prescription of diuretics (P=0.002), sodium bicarbonate (P=0.043), antihypertensive drugs (P=0.001) and uric acid-lowering agents (P=0.046). During the 15-week period in 2019, 214 visits were performed (+13% compared to 2020). The vast majority of these visits were conducted in the hospital setting (210 out of 214; 98.2%). The severity of CKD was similar between patients, without statistically significant difference in the rate of patients in CKD stage III (P=0.7), stage IV (0.388) and stage V (P=0.593). Implementation of telemedicine to in-person visits during COVID-19 pandemic did not change the outcomes of patients. Short-term follow-up showed a similar rate in urgent-start dialysis (P=0.361), late referral (P=1), and HD (P=0.875) or PD initiation (P=0.661). Similar results were seen also at the end of the extended follow-up. Conclusion Implementation of telemedicine has been fundamental to maintain a high level of care in CKD patients during the COVID-19 pandemic. Telemedicine services in combination with in-person visits have contributed to the delivery of clinical monitoring in a group of patients with severe and progressive CKD. No differences have been identified in terms of rate of unplanned dialysis, late referral, and modality of dialysis initiation.

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