Observe the Unexpected: A Strange History of Bioprosthesis in a Patient in Dialytic Treatment

A 73-year-old male with a history of right nephrectomy due to cancer in 1996 was referred to our hospital for dyspnea and acute chest pain. In May 2007, the Shelhigh® No-React® valved bioconduit was implanted using the Bentall-De Bono procedure due to the finding of severe aortic valve insufficiency and acute type A aortic dissection. Nine months after discharge, he was placed on chronic renal dialysis. The patient’s condition was followed carefully after being placed on dialysis, and now, thirteen years later the implanted aortic valve is still moving freely without signs of calcification.

A Case of Liver Failure Due to Dabigatran Treated with Venovenous Hemodiafiltration and Idarucizumab

Dabigatran etexilate, a direct thrombin inhibitor, was recently introduced in clinical use to prevent thromboembolic events in patients with risk factors (such as non-valvular atrial fibrillation or deep vein thrombosis). Dabigatran is not recommended in patients with creatinine clearance below 30 mL/min. More than 85% of the drug is eliminated by the renal route while the remaining part via the enteral route. Acute renal failure can result in an unexpected increase in serum levels of Dabigatran. In elderly, renal dysfunction, co-morbidity, and concomitant intake of different drugs could make the dosage of Dabigatran challenging. We present a case of an elderly man who suffered a severe accidental dabigatran intoxication with acute liver toxicity recovered after dialytic treatment and Idarucizumab.

TO014COMPARISON BETWEEN HIGH FLUX-HD AND OL-HDF ON SURVIVAL AND ADEQUACY: TEN YEARS EXPERIENCE

Background and Aims Four RCTs have been published that compared on-line HDF (Ol-HDF) with HD. However, to date, an indisputable answer in determining whether patients treated with Ol-HDF had a better survival than those treated with high-flux HD (Hf-HD) has not been reached. The aim of our study was to retrospectively evaluate the impact of the dialysis modality (Hf-HD, Ol-HDF or acetate-free biofiltration AFB) on patient survival and dialysis adequacy. Methods We retrospectively evaluated all the incident patients that started dialysis due to uremia from 01-01-2008 to 31-12-2018 at the U.O. Nephrology ASST Spedali Civili of Brescia. Exclusion criteria were: duration of dialysis treatment less than 3 months, and previous dialytic treatment or kidney transplantation. The dialysis modality performed (Hf-HD vs Ol-HDF), the modality of infusion (pre-dilution or post-dilution) and mean total convective volume (replacement fluid volume + ultrafiltration) during last year’s dialysis session in Ol-HDF were analyzed for each patient. Results During observation 677 patients started HD treatment. 70 patients were excluded due to less than 3 months HD treatment. 607 patients (male 390, 64%) were analyzed. 467 pts (77%) were treated with Hf-HD, 103 pts (17%) with Ol-HDF, 36 pts (6%) with AFB. Median duration of HD treatment was 2.6 years (IQR 1.3; 4.7). Ol-HDF was performed in post-dilution mode in 60% of cases (total convective volume 25±4 L); pre-dilution mode was used in 40% of the cases (total convective volume 51±18 L). Patients in the Ol-HDF group were significantly younger than those in Hf-HD and AFB groups (respectively 59±15 years vs 71±15 vs 78±9, p <0.05), and had less diabetes, hypertension and ischemic heart disease (p<0.05) while presenting similar prevalence of cirrhosis (p=0.93) and peripheral vascular disease (p=0.09). Adequacy indices were similar between groups (eKt/V 1.39±0.02 vs 1.41±0.01 vs 1.44±0.04, p=0.47) as well as the protein intake (PCRn 0.92±0.01 vs 0.93±0.01 vs 0.90±0.03 g/Kg/d, p=0.69) and residual renal function (1.5±0.3 vs 1.6±0.1 vs 0.8±0.4 ml/min, p=0.20). Patients on Ol-HDF more frequently had an AV fistula (71% vs 58% vs 59%, p<0.05). At the end of follow-up, 12% of patients had undergone kidney transplantation, 42% continued dialytic treatment while 43% died. Univariate analysis showed a better survival for Ol-HDF patients (Figure 1) (p <0.05). This benefit was confirmed in multivariate analysis (Figure 2) showing that older age, cirrhosis and ischemic heart disease negatively affect survival, while a high protein intake, use of an AV fistula and Ol-HDF (HR 0.43[0.30-0.61]) are protective. Conclusions The use of Ol-HDF is associated with better survival compared to Hf-HD. This is confirmed after adjustment for demographic and comorbidities of the patients, characterizing Ol-HDF as an independent predictor of better survival.

P1527SURVIVAL COMPARISON:HEMODIALYSIS VS PERITONEAL DIALYSIS: TEN YEARS OBSERVATIONAL STUDY

Background and Aims Survival comparison between peritoneal dialysis (PD) and hemodialysis (HD) is still controversial. While some retrospective studies have shown better survival in PD, particularly in the first year, others have not identified this difference. The only RCT published so far showed a 3-year mortality rate similar between two groups. However, the number of patients was too small to provide sufficient statistical power to identify any survival differences between the two dialysis techniques. Aim of this study was to compare HD and PD in term of survival rate and factors possibly involved in a ten-years observational study. Method We retrospectively evaluated all the incident patients that started a dialytic treatment, either HD or PD, due to uremia from 01-01-2008 to 31-12-2018 at the U.O. Nephrology ASST Spedali Civili of Brescia. Exclusion criteria were: duration of dialysis treatment less than 3 months, and previous dialytic treatment or kidney transplantation. For each patient anthropometric, clinical-anamnestic data and comorbidities at dialysis start were recorded. Results One thousand and six patients were identified. 130 patients were excluded due to dialysis treatment less than 3 months. A total 876 patients were analyzed. 77% of patients started dialysis on HD while 23% chose PD. Age was significantly higher in HD patients (69±15 vs 65±16 years; p<0.05). No differences were found in the incidence of: ischemic heart disease (HD 24%, PD 25%, p=0.90), diabetes (32% vs 32%, p=0.83), cancer (20% vs 17%, p=0.37), cardiac arrhythmia (20% vs 25%, p=0.08) and peripheral vascular disease (25% vs 25%, p=0.89). An increased incidence of COPD (HD 17% vs PD 8%, p<0.05) and hypertension (73% vs 87%, p<0.05) was present in PD patients. During follow-up, 17% of patients treated with PD shifted to HD due to catheter malfunction, recurrent infections, insufficient dialytic adequacy or ultrafiltration failure. Kidney transplants were performed more frequently in PD patients (HD 12%; PD 24%, p<0.05). At an intention to treat analysis of the data, univariate analysis showed better survival in PD patients (p<0.05, Figure 1). This difference was not confirmed at multivariate analysis (Figure 2), where age, cardiac arrhythmia, cirrhosis, diabetes and peripheral vascular disease were independently associated with an increased risk of mortality. No independent influence on mortality of the dialysis treatment modality was found. Conclusion This ten years observational study shows that HD and PD are similar in term of patient survival. Age and comorbidities seem to play the most important role in patient survival.