The Association of Postprandial Triglyceride Variability with Renal Dysfunction and Microalbuminuria in Patients with Type 2 Diabetic Mellitus: A Retrospective and Observational Study

Objective. We examined whether or not day-to-day variations in lipid profiles, especially triglyceride (TG) variability, were associated with the exacerbation of diabetic kidney disease. Methods. We conducted a retrospective and observational study. First, 527 patients with type 2 diabetes mellitus (DM) who had had their estimated glomerular filtration rate (eGFR) checked every 6 months since 2012 for over 5 years were registered. Variability in postprandial TG was determined using the standard deviation (SD), SD adjusted (Adj-SD) for the number of measurements, and maximum minus minimum difference (MMD) during the first three years of follow-up. The endpoint was a ≥40% decline from baseline in the eGFR, initiation of dialysis or death. Next, 181 patients who had no micro- or macroalbuminuria in February 2013 were selected from among the 527 patients for an analysis. The endpoint was the incidence of microalbuminuria, initiation of dialysis, or death. Results. Among the 527 participants, 110 reached a ≥40% decline from baseline in the eGFR or death. The renal survival was lower in the higher-SD, higher-Adj-SD, and higher-MMD groups than in the lower-SD, lower-Adj-SD, and lower-MMD groups, respectively (log-rank test p = 0.0073 , 0.0059, and 0.0195, respectively). A lower SD, lower Adj-SD, and lower MMD were significantly associated with the renal survival in the adjusted model (hazard ratio, 1.62, 1.66, 1.59; 95% confidence intervals, 1.05-2.53, 1.08-2.58, 1.04-2.47, respectively). Next, among 181 participants, 108 developed microalbuminuria or death. The nonincidence of microalbuminuria was lower in the higher-SD, higher-Adj-SD, and higher-MMD groups than in the lower-SD, lower-Adj-SD, and lower-MMD groups, respectively (log-rank test p = 0.0241 , 0.0352, and 0.0474, respectively). Conclusions. Postprandial TG variability is a novel risk factor for eGFR decline and the incidence of microalbuminuria in patients with type 2 DM.

The role of premorbid transthoracic echocardiogram in identifying adverse clinical outcomes in patients admitted with COVID-19

Background/Introduction The novel coronavirus disease (COVID-19) inpatient mortality rate is approximately 20% in the United States. Reports have described a wide pattern of abnormalities in echocardiograms performed in patients admitted with COVID-19. The role of premorbid transthoracic echocardiogram (TTE) in the prediction of COVID-19 severity and mortality is yet to be fully assessed. Purpose To assess whether a pre-COVID TTE can identify patients at high risk of adverse outcomes who are admitted with COVID-19. Methods All patients who underwent a TTE from one year to one month prior to an index inpatient admission for COVID-19 were retrospectively enrolled across five clinical sites. Demographic information, medical history, and laboratory data were included for analysis. Echocardiograms were analyzed by an observer blinded to clinical data. Linear and logistic regressions were performed to detect the association of variables with death, invasive mechanical ventilation, initiation of dialysis, and a composite of these endpoints during the COVID-19 admission. Outcomes were then adjusted for a risk score using inverse propensity weighting incorporating age, sex, diabetes, hypertension, obstructive sleep apnea, history of atherosclerotic cardiovascular disease, atrial fibrillation, diuretic use, and angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use. Results There were 104 patients (68±15 years old, 49% male, BMI 31.4±9.1kg/m2) who met inclusion criteria (baseline characteristics in Table 1). Mean time from TTE to positive SARS-CoV-2 PCR test was 139±91 days. Twenty-nine (28%) participants died during the index COVID-19 admission. There was no association of pre-COVID echocardiographic measures of systolic ventricular function with any endpoint. Diastolic function, as assessed by LV e', was associated with mortality (Table 2). There were 25 patients (24%) with a normal lateral e' (≥10cm/s); none died. There were 35 (34%) patients with LV e' lateral velocity <8 cm/s, of whom 15 (43%) died. LV e' lateral velocity <8 cm/s was associated with an unadjusted odds ratio of 7.69 (95% confidence interval [CI] 2.26–26.19) for death and 3.25 (95% CI 1.11–9.54) for the composite outcome. The odds ratio for death was 4.76 (95% CI 1.10–20.61) and 3.78 (95% CI 0.98–14.6) for the composite outcome after adjustment for clinical risk factors (Table 2). Conclusion In patients with an echocardiogram prior to COVID-19, impaired diastolic function as represented by an abnormal LV e' lateral velocity was associated with both inpatient COVID-19 mortality and a composite outcome of death, mechanical ventilation, and initiation of dialysis, even after adjustment for multiple co-morbidities and medication use. Knowledge of the pre-COVID TTE results may help clinicians identify patients at higher risk of adverse outcomes during an admission for COVID-19. FUNDunding Acknowledgement Type of funding sources: None.

Immobilization-induced hypercalcemia in a patient with renal failure

Summary Immobilization-induced hypercalcemia is an uncommon cause of elevated calcium which is usually diagnosed following extensive systemic workup and exclusion of more common etiologies. Previously reported cases have largely described this phenomenon in adolescents and young adults a few weeks to months after the initial onset of immobilization. Metabolic workup tends to demonstrate hypercalcemia, hypercalciuria, and eventual osteoporosis. While the exact mechanism remains largely unclear, a dysregulation between bone resorption and formation is central to the pathogenesis of this disease. Decreased mechanical loading from prolonged bedrest tends to increase osteoclast induced bone resorption while promoting osteocytes to secrete proteins such as sclerostin to reduce osteoblast mediated bone formation. We describe the case of an 18-year-old male who was admitted following intraabdominal trauma. He underwent extensive abdominal surgery including nephrectomy resulting in initiation of dialysis. After 6 months of hospitalization, the patient gradually began developing uptrending calcium levels. Imaging and laboratory workup were unremarkable for any PTH-mediated process, malignancy, thyroid disorder, adrenal disorder, or infection. Workup did reveal significant elevated bone turnover markers which in combination with the clinical history led the physicians to arrive at the diagnosis of immobilization induced hypercalcemia. In order to prevent decreased rates of bone loss, the patient was administered denosumab for treatment. Hypocalcemia followed treatment expectedly and was repleted with supplementation via the patient’s total parenteral nutrition. Learning points Immobilization-induced hypercalcemia should remain as a differential diagnosis of patients with prolonged hospitalizations with hypercalcemia. Extensive workup of common etiologies of hypercalcemia should be considered prior to arriving at this diagnosis. Denosumab, while off-label for this usage, offers an effective treatment option for immobilization-induced hypercalcemia though it carries a risk of hypocalcemia especially among patients with renal disease.

The Role of Patiromer in Delaying the Onset of Renal Replacement Therapy in Patients with Advanced Renal Failure

Patients with chronic kidney disease (CKD) are at an increased risk of developing hyperkalemia, which can be potentially life threatening. Hyperkalemia is frequently encountered with renin-angiotensin-aldosterone system inhibitor (RAASi) therapy use in patients with CKD and often results in the underdosing or discontinuation of these drugs. RAASi therapy has been proven to delay the progression of CKD, ameliorate proteinuria, and reduce the overall risk of cardiovascular morbidity and mortality. Patiromer is a sodium-free, potassium-binding polymer used for the treatment of hyperkalemia. We present a case series of four patients with Stage 4 or 5 CKD in whom the initiation of dialysis was delayed with the use of patiromer. For one patient, dialysis was delayed by 18 months, whereas the remaining three patients, in whom hyperkalemia was one of the main complications, remain dialysis independent to date.

Predictive value of the conditions for the optimal dialysis initiation (Meta-analysis of observational studies)

BACKGROUND. The survival of dialysis patients remains unsatisfactory. A number of observational studies have shown that the conditions of initiation of dialysis can influence long-term outcomes, including mortality.THE AIM. To compare the mortality of patients under predefined conditions of optimal (planned) and suboptimal (unplanned) dialysis initiation.METHODS. Using the MEDLINE and EMBASE databases from inception to June 2020, we conducted a systematic search for studies that examined the overall mortality of patients who met or did not meet the predefined conditions for an “optimal” start of renal replacement therapy (RRT): planned vs. unplanned onset; initiation of substitution therapy on permanent access vs. temporary; with priorobservation of the nephrologist vs. without it. As a result of a systematic search, subsequent analysis and selection of publica tions, 8 studies were included in the meta-analysis (total number of incident patients was 22755; 13680 patients met the conditions of the optimal dialysis start).RESULTS. All-cause mortality among patients with the conditions of suboptimal dialysis start was higher than in those with the optimal start (34.4 % vs. 46.6 %, p<0,001) with the increase in the relative risk (RR) of fatal outcome by 35.1 % (95 % confidence interval (CI) 30.8 %-39.4 %, p<0.0001). Estimated number of patients needed to start dialysis in the optimal conditions to prevent 1 death was 8 (95 % CI 7-9).CONCLUSION. The meta-analysis demonstrated the relationship between the urgent initiation of RRT, the use of temporary access for dialysis, and the lack of timely prior follow-up by a nephrologist with an increase in mortality. Prevention of dialysis initiation in these suboptimal conditions in real-world clinical practice can be an effective tool for improving patient-centered outcomes.

MO609PREVALENCE OF MALNUTRITION AND INFLAMMATION IN NONDIALYZED PATIENTS WITH CHRONIC KIDNEY DISEASE: A CLINICAL STUDY

Background and Aims The prevalence of chronic kidney disease (CKD) in India varies from 0.16–0.78%. The reported incidence of malnutrition in CKD patients is 37–84%. There is a paucity of data on the quantification of malnutrition and inflammation in undialyzed patients of CKD from north east of India. This study analyzed the prevalence and causes of malnutrition and inflammation in patients with CKD before the initiation of dialysis treatment. Method This study was conducted from May 2017 to May 2019 in the department of nephrology Guahati medical college hospital. Assessment of nutritional and inflammatory status was carried out in patients with CKD before initiation of dialysis. Serum albumin; body mass index (BMI); triceps skin fold thickness (TST); mid-arm muscle circumference (MAMC); and subjective global assessment (SGA) scoring were used for assessment of nutritional parameters. Serum C-reactive protein; serum albumin and serum ferritin level were used to assess the inflammatory status in these patients. Results A total of 528 (male:female= 359:169) patients with CKD participated in this study. Diabetic Nephropathy (35%) was the most common; followed by; hypertension (23%) and chronic glomerulonephritis (20 %). The evidence of malnutrition was noted in 344 (65%). The mean age of patients with malnutrition was 52.8±12.45 years with a male predominance (68%). On the basis of SGA score; malnutrition was noted in 344 patients (mild moderate [36%]; severe; [30%]); remaining (34%) were well nourished. Thus; evidence of Malnutrition was noted in 65% of patients with CKD.). Serum total protein & albumin were higher in the non-malnourished patients in comparison to malnourished (5.83±1.0 vs 5.31±1.12 p&lt;0.05; 3.65±0.7 vs 2.62±0.74) The inflammatory markers (serum ferritin & C reactive protein) were elevated significantly in patients with malnutrition in comparison to those without malnutrition (308.15±60.18 mg/dL vs. 251.64±63.14 mg/dL; p &lt; 0.001; 77% vs. 50%; p &lt; 0.01). Conclusion Malnutrition and inflammation are common in patients with CKD before the commencement of dialysis. This indicates that an emphasis should be placed on the assessment and prevention or correction of malnutrition and inflammatory burden in these patients with CKD.

MO887THE IMPACT OF A MULTI-DISCIPLINARY CLINIC ON THE OUTCOMES OF INCIDENT DIALYSIS PATIENTS IN A REGIONAL HOSPITAL IN SINGAPORE

Background and Aims Institution of a pre-dialysis programme has been shown to improve the outcome of the chronic kidney disease (CKD) patients approaching end stage renal disease (ESRD). A renal multidisciplinary clinic (MDC) aimed at reducing unprepared dialysis initiation is known to reduce morbidity in such patients and reduce the risks of complications once the patient initiates dialysis. The design of this service is of paramount importance to ensure efficient delivery and to achieve optimal utilization of the resources. The number of patients requiring urgent initiation of dialysis is alarmingly high in Singapore as compared to elective initiation, and our hospital was no exception when we started the renal service in 2018. Patients with unplanned initiation of RRT either because of lack of referral/late referral, infrequent follow up with the nephrologist or because of other factors such as inadequate knowledge of disease trajectory, or poor compliance to medications, tended to have worse outcomes. Method We recruited the patient who initiated dialysis between July 2018 to July 2020 in our Quality Improvement (QI) project. In the MDC group, the patient will be reviewed by a dedicated team of nephrologists, renal coordinators (RC) and medical social workers (MSW) and comprises of 2 mutually exclusive components: low clearance clinic (LCC) and transitional care clinic (TCC). In the MDC, nephrologist takes a lead role for the patient’s overall medical assessment and treatment. Renal coordinator provides the CKD and dialysis education to empower patient to make the correct RRT choice. MSW provides psychosocial support and financial counselling. The LCC became operational from 07th September 2018 while the TCC was initiated on 12th July 2019. CKD patients who are deemed likely to need RRT in the coming one year by the primary nephrologist are scheduled to attend LCC. Upon initiation of haemodialysis, all patients are referred to the TCC in the first month of their discharge. In the conventional group, we recruited the patient who have not attended MDC before or after dialysis initiation. Retrospectively, their data including baseline demographic and morbidity parameters were collected in the MDC group and conventional group. Morbidity outcome like definitive dialysis access, needs of intensive care unit (ICU) admissions, complications like catheter related blood stream infections (CRBSI) and other infections, stroke and myocardial infarction (MI) were analysed. Results There are 130 patients initiated on RRT between July 2018 to July 2020. The percentage of patient started dialysis with a definitive access was greater in the MDC group (25%) as compared to the conventional group (9%) (p=0.03). Although statistically not significant, the incidence of intensive care unit (ICU) admission was also lower in the MDC group (10%) than the conventional group (31%) (p=0.06). After initiation of dialysis, the patients in the MDC group had lower rates of CRBSI (5.6%) than the conventional group (14%) (p=0.17). These patients also had lower rates of other infections and major adverse cardiovascular outcomes (13% in MDC group versus 37% in conventional group) (p=002). The rate of recurrent admission, defined as frequent admissions up to 3 times per year, was lower as well in the MDC group (13%) as compared to the conventional group (35%) (p=0.003). Conclusion This QI project has demonstrated the benefit of MDC in improving the lives of the incident dialysis patients. Moving forward, we aim to continue to evolve this clinic in order to match the changing needs of our patients, with a view to increase its uptake, and to increase the percentage of patients having elective starts with a definitive dialysis access to at least 65% as per target set in NKF-KDOQI 2009 guidelines, in order to help them achieve the maximum benefit out of this endeavour.