Primary kidney disease modifies the effect of comorbidities on kidney replacement therapy patients’ survival

Background Comorbidities are associated with increased mortality among patients receiving long-term kidney replacement therapy (KRT). However, it is not known whether primary kidney disease modifies the effect of comorbidities on KRT patients’ survival. Methods An incident cohort of all patients (n = 8696) entering chronic KRT in Finland in 2000–2017 was followed until death or end of 2017. All data were obtained from the Finnish Registry for Kidney Diseases. Information on comorbidities (coronary artery disease, peripheral vascular disease, left ventricular hypertrophy, heart failure, cerebrovascular disease, malignancy, obesity, underweight, and hypertension) was collected at the start of KRT. The main outcome measure was relative risk of death according to comorbidities analyzed in six groups of primary kidney disease: type 2 diabetes, type 1 diabetes, glomerulonephritis (GN), polycystic kidney disease (PKD), nephrosclerosis, and other or unknown diagnoses. Kaplan-Meier estimates and Cox regression were used for survival analyses. Results In the multivariable model, heart failure increased the risk of death threefold among PKD and GN patients, whereas in patients with other kidney diagnoses the increased risk was less than twofold. Obesity was associated with worse survival only among GN patients. Presence of three or more comorbidities increased the age- and sex-adjusted relative risk of death 4.5-fold in GN and PKD patients, but the increase was only 2.5-fold in patients in other diagnosis groups. Conclusions Primary kidney disease should be considered when assessing the effect of comorbidities on survival of KRT patients as it varies significantly according to type of primary kidney disease.

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Abstract 15714: Prediction of Sudden Cardiac Death With Automated High-Throughput Analysis of T-Wave Heterogeneity in Standard 12-Lead Electrocardiogram

Circulation ◽

10.1161/circ.130.suppl_2.15714 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Tuomas Kenttä ◽

Bruce D Nearing ◽

Kimmo Porthan ◽

Jani T Tikkanen ◽

Matti Viitasalo ◽

...

Keyword(s):

At Risk ◽

Relative Risk ◽

Sudden Cardiac Death ◽

General Population ◽

Cardiac Death ◽

Left Ventricular ◽

Adjusted Relative Risk ◽

T Wave ◽

Increased Risk ◽

Patients At Risk

Introduction: Noninvasive identification of patients at risk for sudden cardiac death (SCD) remains a major clinical challenge. Abnormal ventricular repolarization is associated with increased risk of lethal ventricular arrhythmias and SCD. Hypothesis: We investigated the hypothesis that spatial repolarization heterogeneity can identify patients at risk for SCD in general population. Methods: Spatial R-, J- and T-wave heterogeneities (RWH, JWH and TWH, respectively) were automatically analyzed with second central moment technique from standard digital 12-lead ECGs in 5618 adults (46% men; age 50.9±12.5 yrs.) who took part in Health 2000 Study, an epidemiological survey representative of the entire Finnish adult population. During average follow-up of 7.7±1.4 years, a total of 72 SCDs occurred. Thresholds of RWH, JWH and TWH were based on optimal cutoff points from ROC curves. Results: Increased RWH, JWH and TWH (Fig.1) in left precordial leads (V4-V6) were univariately associated with SCD (P<0.001, each). When adjusted with clinical risk markers (age, gender, BMI, systolic blood pressure, cholesterol, heart rate, left ventricular hypertrophy, QRS duration, arterial hypertension, diabetes, coronary heart disease and previous myocardial infarction) JWH and TWH remained as independent predictors of SCD. Increased TWH (≥102μV) was associated with a 1.9-fold adjusted relative risk (95% confidence interval [CI]: 1.2 - 3.1; P=0.011) and increased JWH (≥123μV) with a 2.0-fold adjusted relative risk for SCD (95% CI: 1.2 - 3.3; P=0.004). When both TWH and JWH were above threshold, the adjusted relative risk for SCD was 3.2-fold (95% CI: 1.7 - 6.2; P<0.001). When all heterogeneity measures (RWH, JWH and TWH) were above threshold, the risk for SCD was 3.7-fold (95% CI: 1.6 - 8.6; P=0.003). Conclusions: Automated measurement of spatial J- and T-wave heterogeneity enables analysis of high patient volumes and is able to stratify SCD risk in general population.

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Does sacubitril/valsartan work in acute myocardial infarction? The PARADISE-AMI study

European Heart Journal Supplements ◽

10.1093/eurheartj/suab098 ◽

2021 ◽

Vol 23 (Supplement_E) ◽

pp. E87-E90

Author(s):

Laura Gatto

Keyword(s):

Myocardial Infarction ◽

Heart Failure ◽

Acute Myocardial Infarction ◽

Left Ventricular Dysfunction ◽

Clinical Studies ◽

Ventricular Dysfunction ◽

Left Ventricular ◽

Laboratory Animals ◽

Risk Of Death ◽

Increased Risk

Abstract Patients with acute myocardial infarction (AMI) complicated by left ventricular dysfunction have an increased risk of death and heart failure. Numerous clinical studies have demonstrated the ability of ACE inhibitors in optimizing the outcome in this particular clinical setting. In recent years, the sacubitril/valsartan association has drastically improved the prognosis of patients with heart failure with reduced ejection fraction with a significant decrease in mortality from cardiovascular causes and hospitalizations due to acute heart failure. However, it has not yet been fully clarified whether this pharmacological association may play a role in patients with AMI. Pre-clinical studies have suggested the possibility that sacubitril/valsartan can reduce the size of the infarct scar and prevent the onset of ventricular arrhythmias in laboratory animals in which myocardial infarction was induced. On the other hand, small clinical experiences with patients after myocardial infarction have provided conflicting data. The results of the PARADISE-MI study were recently presented, which enrolled 5661 patients with AMI complicated by pulmonary congestion and left ventricular dysfunction randomized to therapy with ramipril or sacubitril/valsartan and followed up for ∼2 years. Although combination therapy was associated with an ∼10% reduction in the risk of death from cardiovascular causes or an episode of heart failure, this was not enough to achieve statistical significance. However, treatment with sacubitril/valsartan was shown to be more effective than ramipril in preventing recurrence of heart failure after the first one.

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COVID-19-related mortality in kidney transplant and dialysis patients: results of the ERACODA collaboration

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfaa261 ◽

2020 ◽

Vol 35 (11) ◽

pp. 1973-1983 ◽

Cited By ~ 1

Author(s):

Luuk B Hilbrands ◽

Raphaël Duivenvoorden ◽

Priya Vart ◽

Casper F M Franssen ◽

Marc H Hemmelder ◽

...

Keyword(s):

Kidney Transplantation ◽

Replacement Therapy ◽

Kidney Transplant ◽

Clinical Decision Making ◽

Case Fatality ◽

Dialysis Patients ◽

Risk Of Death ◽

Increased Risk ◽

Kidney Replacement Therapy ◽

Related Mortality

Abstract Background. Patients on kidney replacement therapy comprise a vulnerable population and may be at increased risk of death from coronavirus disease 2019 (COVID-19). Currently, only limited data are available on outcomes in this patient population. Methods. We set up the ERACODA (European Renal Association COVID-19 Database) database, which is specifically designed to prospectively collect detailed data on kidney transplant and dialysis patients with COVID-19. For this analysis, patients were included who presented between 1 February and 1 May 2020 and had complete information available on the primary outcome parameter, 28-day mortality. Results. Of the 1073 patients enrolled, 305 (28%) were kidney transplant and 768 (72%) dialysis patients with a mean age of 60 ± 13 and 67 ± 14 years, respectively. The 28-day probability of death was 21.3% [95% confidence interval (95% CI) 14.3–30.2%] in kidney transplant and 25.0% (95% CI 20.2–30.0%) in dialysis patients. Mortality was primarily associated with advanced age in kidney transplant patients, and with age and frailty in dialysis patients. After adjusting for sex, age and frailty, in-hospital mortality did not significantly differ between transplant and dialysis patients [hazard ratio (HR) 0.81, 95% CI 0.59–1.10, P = 0.18]. In the subset of dialysis patients who were a candidate for transplantation (n = 148), 8 patients died within 28 days, as compared with 7 deaths in 23 patients who underwent a kidney transplantation <1 year before presentation (HR adjusted for sex, age and frailty 0.20, 95% CI 0.07–0.56, P < 0.01). Conclusions. The 28-day case-fatality rate is high in patients on kidney replacement therapy with COVID-19 and is primarily driven by the risk factors age and frailty. Furthermore, in the first year after kidney transplantation, patients may be at increased risk of COVID-19-related mortality as compared with dialysis patients on the waiting list for transplantation. This information is important in guiding clinical decision-making, and for informing the public and healthcare authorities on the COVID-19-related mortality risk in kidney transplant and dialysis patients.

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Decline in mortality among hospitalised covid-19 patients in Sweden: a nationwide observational study

10.1101/2020.10.27.20220061 ◽

2020 ◽

Author(s):

Kristoffer Strålin ◽

Erik Wahlström ◽

Sten Walther ◽

Anna M Bennet-Bark ◽

Mona Heurgren ◽

...

Keyword(s):

Relative Risk ◽

Severity Of Illness ◽

Future Research ◽

Adjusted Relative Risk ◽

National Board ◽

Risk Of Death ◽

Hospitalised Patients ◽

Observational Cohort ◽

Relative Risk Of Death ◽

Nationwide Observational Study

ABSTRACTOBJECTIVEIt is important to know if mortality among hospitalised covid-19 patients has changed as the pandemic has progressed. The aim of this study was to describe the dynamics of mortality among patients hospitalised for covid-19 in a nationwide study.DESIGNNationwide observational cohort study of all patients hospitalised in Sweden 1 March to 30 June 2020 with SARS-CoV-2 RNA positivity 14 days before to 5 days after admission, and a discharge code for covid-19.SETTINGAll hospitals in Sweden.PARTICIPANTS15 761 hospitalised patients with covid-19, with data compiled by the Swedish National Board of Health and Welfare.MAIN OUTCOME MEASURESOutcome was 60-day all-cause mortality. Patients were stratified according to month of hospital admission. Poisson regression was used to estimate the relative risk of death by month of admission, adjusting for pre-existing conditions, age, sex, care dependency, and severity of illness (Simplified Acute Physiology, version 3), for patients in intensive care units (ICU).RESULTSThe overall 60-day mortality was 17.8% (95% confidence interval (CI), 17.2% to 18.4%), and it decreased from 24.7% (95% CI, 23.0% to 26.5%) in March to 13.3% (95% CI, 12.1% to 14.7%) in June. Adjusted relative risk (RR) of death was 0.56 (95% CI, 0.51 to 0.63) for June, using March as reference. Corresponding RR for patients not admitted to ICU and those admitted to ICU were 0.60 (95% CI, 0.53 to 0.67) and 0.61 (95% CI, 0.48 to 0.79), respectively. The proportion of patients admitted to ICU decreased from 19.5% (95% CI, 17.9% to 21.0%) in the March cohort to 11.0% (95% CI, 9.9% to 12.2%) in the June cohort.CONCLUSIONSThere was a gradual decline in mortality from March to June 2020 in Swedish hospitalised covid-19 patients, which was independent of pre-existing conditions, age, and sex. Future research is needed to explain the reasons for this decline. The changing covid-19 mortality should be taken into account when management and results of studies from the first pandemic wave are evaluated.

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EVALUATION OF 2-D ECHO FINDINGS IN CHRONIC KIDNEY DISEASE :A CASE STUDY OF 50 END STAGE RENAL DISEASE PATIENTS

10.36106/paripex/9600483 ◽

2020 ◽

pp. 1-2

Author(s):

Ruby Patel ◽

Deepak Baldania ◽

Babulal Bamboria

Keyword(s):

Heart Failure ◽

Chronic Kidney Disease ◽

Kidney Disease ◽

Cardiovascular Mortality ◽

Cardiovascular Events ◽

Left Ventricular ◽

Major Public Health Problem ◽

Cardiac Abnormalities ◽

Increased Risk ◽

Esrd Patients

Chronic kidney disease (CKD) is a major public health problem worldwide with increase in incidence and prevalence. Diabetes and hypertension are the leading cause of CKD worldwide, whereas hypertension is a cause as well as effect of CKD. CKD is a risk factor for cardiovascular events and complications which increase as CKD progress to ESRD [3]. Cardiovascular mortality is 10-20 times more common in ESRD patients on renal replacement therapy as compared to general population. One of the major structural cardiac abnormalities in CKD patients is left ventricular hypertrophy (LVH) and is associated with increased risk for cardiac ischemia, congestive heart failure, as well as a very strong independent predictor for cardiovascular mortality [4]. Majority patients with CKD die due to cardiovascular events before reaching ESRD due to risk factors [5]. Anemia and hypertension are most consistent with heart failure that causes 2/3rd death of all dialysis patients. ESRD patients do have myriads of structural and functional cardiac abnormalities which include LVH, depressed LV function, regional wall motion abnormality, pericardial effusion and valvular calcification.

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Effects of Spironolactone and Chlorthalidone on Cardiovascular Structure and Function in Chronic Kidney Disease

Clinical Journal of the American Society of Nephrology ◽

10.2215/cjn.01930221 ◽

2021 ◽

pp. CJN.01930221

Author(s):

Nicola Edwards ◽

Anna Price ◽

Samir Mehta ◽

Thomas Hiemstra ◽

Amreen Kaur ◽

...

Keyword(s):

Blood Pressure ◽

Chronic Kidney Disease ◽

Relative Risk ◽

Kidney Disease ◽

Arterial Stiffness ◽

Left Ventricular Mass ◽

Left Ventricular ◽

Mean Difference ◽

Adjusted Relative Risk ◽

Ventricular Mass

Background and objectives: In a randomized double blind, placebo controlled trial, treatment with spironolactone in early-stage chronic kidney disease, reduced left ventricular mass and arterial stiffness compared to placebo. It is not known if these effects were due to blood pressure reduction or specific vascular and myocardial effects of spironolactone. Design, setting, participants and measurements: A prospective, randomized, open-label, blinded endpoint (PROBE) study conducted in four UK centers (Birmingham, Cambridge, Edinburgh & London) comparing spironolactone 25mg to chlorthalidone 25mg once daily for 40 weeks in 154 participants with non diabetic stage 2 and 3 chronic kidney disease (eGFR 30-89ml/min/1.73m2). The primary endpoint was change in left ventricle mass on cardiac magnetic resonance. Participants were on treatment with an angiotensin converting enzyme inhibitor or angiotensin receptor blocker and had controlled blood pressure (target ≤130/80mmHg). Results: There was no significant difference in left ventricular mass regression; at week 40 the adjusted mean difference for spironolactone compared to chlorthalidone was -3.8g (95% CI - 8.1g, 0.5g), p=0.08. Office and 24-hour ambulatory blood pressures fell in response to both drugs with no significant differences between treatment. Pulse wave velocity was not significantly different between groups; at week 40, the adjusted mean difference for spironolactone compared to chlorthalidone was 0.04m/s (-0.4m/s, 0.5m/s), p=0.9. Hyperkalemia (defined ≥5.4mEq/L) occurred more frequently with spironolactone (12 vs. 2 participants, adjusted relative risk was 5.5 (1.4, 22.1), p=0.02), but there were no cases of severe hyperkalemia (defined ≥6.5mEq/L). A decline in eGFR >30% occurred in 8 participants treated with chlorthalidone compared with 2 participants with spironolactone (adjusted relative risk was 0.2 (0.05, 1.1), p=0.07). Conclusion: Spironolactone was not superior to chlorthalidone in reducing left ventricular mass, blood pressure or arterial stiffness in non-diabetic CKD.

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Physician volume and discontinuation of rituximab during lymphoma treatment.

Journal of Clinical Oncology ◽

10.1200/jco.2017.35.15_suppl.6593 ◽

2017 ◽

Vol 35 (15_suppl) ◽

pp. 6593-6593

Author(s):

Scott F. Huntington ◽

Jessica B. Long ◽

Jessica R. Hoag ◽

Rong Wang ◽

Amer M Zeidan ◽

...

Keyword(s):

Relative Risk ◽

Cox Proportional Hazards Model ◽

Adjusted Relative Risk ◽

Dependent Manner ◽

Early Discontinuation ◽

Risk Of Death ◽

Systemic Treatments ◽

Increased Risk ◽

Provider Volume ◽

The Impact

6593 Background: Despite the high complexity of cancer therapies, studies evaluating provider-level volume and outcomes of systemic treatments are lacking. As rituximab was the first approved monoclonal immunotherapy, and has the potential for severe infusion reactions, we hypothesize that low provider volume is associated with early rituximab discontinuation. Methods: We conducted a retrospective cohort study using Surveillance, Epidemiology, and End Results -Medicare data.Individuals 66+ years old with B cell non-Hodgkin lymphoma (NHL) diagnosed during 2004-2011 and 1+ rituximab claims were included. A provider was assigned to each patient-rituximab initiation using Medicare claims. We used a 12-month lookback from each initiation to categorize provider volume (0, 1-2, or 3+ rituximab initiations) in the prior year. Our primary outcome was early discontinuation, defined as receipt of 1-2 rituximab cycles within 180 days of initiation. We used a modified Poisson regression to account for provider level correlation and estimated the relative risk of early discontinuation in patients with 6+ months of follow up after rituximab initiation. A Cox proportional hazards model was used to measure the impact of discontinuation on overall survival. Results: A total of15,110 patients (median age: 75 years) initiated rituximab with 2,684 providers. The majority (70.4%) initiated rituximab in conjunction with chemotherapy and 1,146 (7.6%) experienced early rituximab discontinuation. Provider experience with rituximab during the previous 12 months was associated with early discontinuation in a dose-dependent manner (adjusted relative risk [aRR]: 1.57, [95% confidence interval [CI]:1.35-1.83], p < .001 for 0 vs 3+ initiations; aRR: 1.19 [95% CI:1.03-1.37], p = .02 for 1-2 vs. 3+ initiations). In addition, rituximab discontinuation was associated with a higher risk of death (adjusted hazard ratio: 1.39 [95% CI:1.28-1.52], p < .001). Conclusions: Lower physician volume is associated with increased risk of early discontinuation in older adults initiating rituximab for NHL. Due to the association between early discontinuation and mortality, physician volume may be an important factor in providing high quality NHL care.

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