Gross hematuria after SARS-CoV-2 vaccination: questionnaire survey in Japan

Background Recent clinical reports indicate a correlation between gross hematuria after the coronavirus 2019 (COVID-19) vaccination in patients with glomerulonephritis, especially immunoglobulin A nephropathy (IgAN). Furthermore, healthcare workers in Japan were initially vaccinated with an mRNA vaccine from February 17, 2021, and some of them experienced gross hematuria after receiving the vaccination. Methods We conducted a web-based survey of the councilor members of the Japanese Society of Nephrology (581 members, 382 facilities) to elucidate the relationship between gross hematuria and COVID-19 vaccination. Results In the first survey, 27 cases (female: 22, 81.5%) of gross hematuria were reported after receiving a COVID-19 vaccination. Of them, 19 (70.4%) patients were already diagnosed with IgAN at the occurrence of gross hematuria. Proteinuria appeared in eight of the 14 (57.1%) cases with no proteinuria before vaccination and hematuria in five of the seven (71.4%) cases with no hematuria before vaccination. The second survey revealed that a renal biopsy was performed after vaccination in four cases, all of whom were diagnosed with IgAN. Only one case showed a slightly increased serum creatinine level, and no patients progressed to severe renal dysfunction. Conclusion This study clarified the clinical features of gross hematuria after a COVID-19 vaccination. Because there was no obvious progression to severe renal dysfunction, safety of the COVID-19 vaccination is warranted at least in the protocol of inoculation twice.

Cardio-renal protective effects of SGLT2 inhibitors in patients with type 2 diabetes mellitus and severely impaired renal function

Background Prognostic impact of Sodium-Glucose Cotransporter 2 (SGLT2) inhibitors on cardiovascular and renal outcome was unknown in patients with type-2 diabetes mellitus (DM) and severely impaired renal function. Methods From July 2015 to December 2020, patients with type-2 DM who were taken SGLT2 inhibitors for more than six months were retrospectively screened. Patients with estimated glomerular filtration rate (eGFR) over 60ml/min/1.73m2 were excluded. We divided those patients into two groups by eGFR; less than 45ml/min/1,73m2 were group A and 46–60ml/min/m2 were group B. Randomly selected patients with DM not taking SGLT2 inhibitors and having severe renal dysfunction: eGFR less than 45ml/min/m2 (Group C) were set as controls. The primary outcome was a composite of cardiovascular/renal death, initiation of dialysis, doubling of the serum creatine level, decline in the eGFR more than 30%, nonfatal myocardial infraction, nonfatal stroke, and hospitalization for heart failure. Results Totally 418 patients were enrolled. Median age was 71 years (group A, n=106), 64 years (group B, n=115), and 77 years (group C, n=201) (p<0.001). After median 24 months follow-up, primary endpoints were observed 24.5% in group A, 4.3% in group B, 36.8% in group C (p<0.001). In Kaplan-Meier analysis, significantly lower incidence of primary endpoints were observed in SGLT2 groups (group A and B) than controls (p<0.001, Figure 1). In patients with severe renal dysfunction, taking SGLT2 inhibitors tended to decrease future renal event (Figure 2). The incidence of SGLT2 related adverse events was not different between 2 groups (A and B). Conclusions Even in patients with severe renal dysfunction, SGLT2 inhibitors would have cardio-renal protective effects without drug-related adverse effects. FUNDunding Acknowledgement Type of funding sources: None.

Effectiveness of a new cardiac risk scoring model reclassified by QRS fragmentation as a predictor of postoperative cardiac event in patients with severe renal dysfunction

Background It is difficult to evaluate the risk of patients with severe renal dysfunction before surgery due to various limitations despite high postoperative cardiac events. This study aimed to investigate the value of a newly reclassified Revised Cardiac Risk Index (RCRI) that incorporates QRS fragmentation (fQRS) as a predictor of postoperative cardiac events in patients with severe renal dysfunction. Methods Among the patients with severe renal dysfunction, 256 consecutive patients who underwent both a nuclear stress test and noncardiac surgery were evaluated. We reclassified RCRI as fragmented RCRI (FRCRI) by integrating fQRS on electrocardiography. We defined postoperative major adverse cardiac event (MACE) as a composite of cardiac death, nonfatal myocardial infarction, and pulmonary edema. Results Twenty-eight patients (10.9%) developed postoperative MACE, and this was significantly frequent in patients with myocardial perfusion defect (41.4% vs. 28.0%, p = 0.031). fQRS was observed 84 (32.8%) patients, and it was proven to be an independent predictor of postoperative MACE after adjusting for the RCRI (odds ratio 3.279, 95% confidence interval (CI) 1.419–7.580, p = 0.005). Moreover, fQRS had an incremental prognostic value for the RCRI (chi-square = 7.8, p = 0.005), and to the combination of RCRI and age (chi-square = 9.1, p = 0.003). The area under curve for predicting postoperative MACE significantly increased from 0.612 for RCRI to 0.667 for FRCRI (p = 0.027) and 23 patients (32.4%) originally classified as RCRI 2 were reclassified as FRCRI 3. Conclusions A newly reclassified FRCRI that incorporates fQRS, is a valuable predictor of postoperative MACE in patients with severe renal dysfunction undergoing noncardiac surgery.

Incidence and causes of in-hospital mortality in cardiac device-related infections

Introduction Cardiac device-related infections (CDRI) are associated with increased in-hospital mortality despite effective treatment by transvenous lead extraction (TLE) and antibiotic therapy. Data on mortality and causes of death are scarce and predictors of mortality are not well defined. Purpose To analyse the incidence and causes of mortality in CDRI and identify predictors of mortality in a large single centre experience. Methods All patients undergoing TLE for CDRI in our department between May 2012 and January 2020 were included in a prospective registry. Patient characteristics, procedural and follow-up data were collected and analysed. A Kaplan-Meier analysis was used to analyse the influence of different infection types on mortality. Univariate and multivariate cox regression analysis was applied to identify risk factors for mortality. Results Among 561 consecutive patients (72±12 years; 77% male) treated for CDRI (51.2% systemic and 48.8% localized infection), 61 patients (10.9%) died during the index hospitalization. The most frequent cause of death was severe systemic infection or sepsis in 38 patients (6.8%), followed by end-stage heart failure (9; 1.6%), respiratory insufficiency (3; 0.5%), ventricular arrhythmias (3; 0.5%), asystole (2; 0.4%), pulmonary embolism (2; 0.4%), acute enteric ischemia (2; 0.4%), mechanical ileus (1; 0.2%), and unwitnessed sudden death (1; 0.2%). Patients who died had significantly more often systemic infections (p<0.001), positive blood cultures (p<0.001), severe renal dysfunction (GFR <30ml/min; p<0.001), heart failure with reduced ejection fraction (HFrEF; p=0.001), and diabetes (p=0.004). Kaplan-Meier survival analysis showed a significantly higher mortality in patients with systemic CDRI as compared to localized infection (log-rank p<0.001). Several factors were predictors of mortality in univariate analysis: systemic infection (HR 4.64, 95% CI 2.18–9.84; p<0.001), GFR <30 ml/min (HR 4.27, 95% CI 2.57–7.09; p<0.001), vegetation in TOE (HR 3.68, 95% CI 1.78–7.43; p<0.001), positive blood cultures (HR 2.52, 95% CI 1.46–4.37; p=0.001), diabetes (HR 1.89, 95% CI 1.12–3.18; p=0.018), HFrEF (HR 1.83, 95% CI 1.09–3.05; p=0.021), tricuspid regurgitation (HR 1.79, 95% CI 1.21–2.65, p=0.004), and days from hospital admission to explant (HR 1.04, 95% CI 1.02–1.06; p<0.001). Multivariate analysis revealed severe renal dysfunction (HR 2.71, 95% CI 1.47–5.00; p=0.001) and days from hospital admission to TLE (HR 1.029, 95% CI 1.004–1.055, p=0.021) as independent predictors of in-hospital mortality. Conclusion In-hospital mortality in CDRI is particularly high in patients with severe systemic infection and sepsis despite state-of the-art treatment. Delayed TLE is associated with an increased in-hospital mortality. Therefore, TLE should be performed early in the course of CDRI, particularly in patients with severe systemic infection. Funding Acknowledgement Type of funding source: None

P0438PREDICTORS OF TREATMENT RESPONSE AND LONG-TERM OUTCOME IN PATIENTS WITH PAUCI-IMMUNE GLOMERULONEPHRITIS AND SEVERE RENAL DYSFUNCTION AT DIAGNOSIS

Background and Aims Severe kidney involvement represents a frequent clinical scenario for patients with pauci-immune (PI) vasculitis. We aimed to explore the factors, which are associated with prognosis, in short and long term, following administration of appropriate immunosuppressive therapy. Method Patients were included if they had biopsy proven PI glomerulonephritis (GN) with estimated GFR<20 ml/min/1.73 m2 or dialysis requirement at presentation, received standard immunosuppression and were followed for a minimum period of one year. We recorded clinical, laboratory and histopathological parameters at diagnosis, at 3 months, at 1 year and at the end of follow up. Outcomes of interest included response to treatment, end stage kidney disease (ESKD), and death. Treatment response was defined by the ability to come off dialysis with an eGFR>20 ml/min/1.73 m2 with no signs of vasculitis. Histopathological evaluation included arteriosclerosis, % of normal glomeruli, activity index, chronicity index. Results A total of 83 patients, with a mean age of 59.6 (15.05) years were included. There were, 45 males (54.2%). After 3 months, 59 patients (71.1%) had responded to immunosuppressive therapy, 16 (19.3%) were dialysis depended, 5(6.02%) died and 2 were lost in follow up. By the end of the 1st year, 59 patients (71.1%) achieved remission, 16(19.3%) ended up in ESKD and 6(7.4%) died. Factors which were associated with treatment response included MPO-ANCA positivity [odds ratio OR:3.9, 95%CI (1.13-13.37) p=0.03], eGFR>10ml/min/1.73m2 at presentation [OR:2.5, 95% CI(0.86-7.30), p=0.009], normal glomeruli >10% [OR:3.8, 95%CI (1.24-12.1), p=0.02], and chronicity index more than 6 [OR:6.2, 95% CI(1.77-22.4), p=0.004]. Risk factors associated with ESKD included non-response to immunosuppressive therapy [Relative Risk RR:0.05, 95%CI (0.01-0.2) p<0.0001)], normal glomeruli<10% in the diagnostic biopsy [RR: 2.9, 95% CI (1.38-6.32), p=0.005] and age>75 years [RR:3.2, 95% CI (0.9-10.6) p=0.055]. Two of the 6 deaths were disease related. Conclusion A significant proportion of patients with PI-GN, who presented with severe renal dysfunction, responded to immunosuppressive therapy and recovered renal function approximately 3 months after initiation of therapy. The most important risk factors for ESKD were age>75 years, <10% normal glomeruli in the diagnostic kidney biopsy and non-response to immunosuppressive therapy.

Abstract WP457: Safety and Effect of Medium-Chain Triglycerides Oil to Prevent Deterioration of Nutritional Status in Acute Stroke Patients With Severe Renal Dysfunction

Introduction: When nutritional status in acute stroke patients with renal dysfunction is deteriorated, it is difficult to prevent further deterioration and improve nutritional status, because protein-enriched diet probably causes deterioration of renal function. Hypothesis: Medium-chain triglycerides (MCT) oil composed of caprylic acid (C8) and capric acid (C10) may safely prevent further deterioration and improve nutritional status in acute stroke patients with severe renal dysfunction, because medium-chain fatty acids do not deteriorate renal function. Methods: We included acute stroke patients who 1) were admitted between August 2016 and December 2018, 2) presented creatinine (Cre) of more than 1.5 mg/dl on admission, 3) underwent blood examination on admission, the 3rd day and 7th day, 4) presented prealbumin of less than 20 mg/dl on the 3rd day and 4) who took daily 15g of MCT from the 3rd to the 6th day. We evaluated patients’ features, albumin (Alb), PreAlb, high-sensitivity C-reactive protein (hs-CRP) and Cre on admission, 3rd day and the 7th day. Results: Thirteen patients met our inclusive criteria and were analyzed. The median age, body mass index, Cre, creatinine clearance (Ccr), blood glucose (BG), hs-CRP, Alb and PreAlb were 86 years, 23.2 kg/m2, 1.93 mg/dl, 19.2 mL/min, 117 mg/dl, 0.433 mg/dl, 3.6 g/dl and 17.3 mg/dl. Their Ccr was less than 15 mL/min in 4 (30.8%) of 13 patients, 15 or more and less than 30 mL/min in 7 (53.8%) of 13 patients and 30 or more and less than 40 mL/min in 2 patients (15.4%). Eleven patients received enteral feeding and two patients ate food orally. Their median calorie intake was 1,000 kcal/day except MCT supplementation. On the 3rd day, their median Alb and PreAlb levels decreased to 2.7 mg/dl (p<0.001) and 10.8 mg/dl (p<0.01), respectively, their median hs-CRP increased to 4.01 mg/dl (p<0.01) and Cre was 2.0 mg/dl (ns). On the 7th day following MCT supplementation, their median Alb was 2.7 mg/dl (ns) and median PreAlb increased to 12.2 g/dl (ns), their median hs-CRP decreased to 2.379 mg/dl (ns) and Cre decreased to 1.79 mg/dl (p<0.05). Conclusion: Four-days MCT supplementation of 15g per day probably prevented further deterioration of nutritional status, attenuated inflammation early and had no adverse effect on renal function.