Rates of AKI Lower with TAVR versus SAVR
Nephrology Dialysis Transplantation. doi.org/10.1093/ndt/gfy097
In randomized trials, rates of acute kidney injury are lower with transcatheter aortic valve replacement (TAVR) compared with surgical aortic valve replacement (SAVR). There are limited nationally representative real-world data on the comparative rates of AKI for TAVR versus SAVR and predictors and prognostic implications of AKI after aortic valve replacement (AVR).
Nilay Kumar, MD, and Neetika Garg, MD, conducted an analysis to compare rates of AKI and dialysis requiring AKI (AKI-D) in TAVR versus SAVR; the researchers also sought to identify predictors of AKI and prognostic implications of AKI in patients undergoing TAVR or SAVR.
The analysis included 8004 unweighted TAVR procedures and 29,355 unweighted SAVR procedures representing the entirety of procedures nationwide. Mean age of all patients undergoing AVR was 70.9 years and 42.3% were female. In a propensity-matched cohort of 4889 pairs of TAVR and SAVR procedures, there was an association between TAVR and significantly lower rates of AKI (odds ratio [OR], 0.73; 95% confidence interval [CI], 0.66-0.80; P<.001) and AKI-D (OR, 0.69; 95% CI, 0.50-0.96; P=.03) compared with SAVR.
There was an association between AKI and significantly higher rates of in-hospital mortality with both TAVR (OR, 7.16; 95% CI, 5.52-9.29; P<.001) and SAVR (OR, 9.43; 95% CI, 7.71-11.55; P<.001).
“In a large propensity-matched cohort of TAVR and SAVR procedures, TAVR was associated with significantly lower rates of AKI and AKI-D compared with SAVR. AKI and AKI-D are predictors of poor in-hospital outcomes in TAVR as well as SAVR,” the researchers concluded.
CHRONIC KIDNEY DISEASE
CKD Associated with Complications after Pancreatectomy Regardless of Stage
Journal of Gastrointestinal Surgery. doi:10.1007/s11605-018-3743-8
Patients with severe chronic kidney disease (CKD) undergoing pancreatectomy are at increased risk for adverse outcomes; however, the impact of milder CKD on this patient population is unclear. Further, there are some data suggesting that, due to physiologic changes associated with aging, CKD may be over diagnosed in patients >65 years of age. Derrick Antoniak, MD, and colleagues conducted a study designed to examine outcomes in older patients with mild CKD undergoing pancreatectomy for malignancy.
The study cohort included 16,173 patients who underwent pancreatectomy from 2005 to 2014. Mean age was 66 years (range, 18-90), median preoperative creatinine was 0.80 mg/dL, and median preoperative estimated glomerular filtration rate was 86.36 mL/min/1.73 m2. Three percent of the patients died and 23% experienced a major complication.
In results of adjusted analyses, there was an association between increased risk for major complications and CKD stage 2 (adjusted odds ratio [aOR], 1.24; 95% confidence interval [CI], 1.10-1.40); CKD stage 3a (aOR, 1.50; 95% CI, 1.24-1.82); CKD stage 3b (aOR, 1.56; 95% CI, 1.19-2.06); and CKD stage 4 (aOR, 2.17; 95% CI, 1.25-3.76). CKD stage 4 was also associated with increased mortality (aOR, 2.68; 95% CI, 1.10-6.56). There was no association with age and the relationship between CKD and either outcome.
“CKD of any stage was associated with an increased risk of postoperative major complication, and severe CKD was associated with increased mortality among patients undergoing pancreatectomy for malignancy. These associations were not diminished in elderly patients. Our findings could inform preoperative counseling and decision-making,” the researchers said.
Diabetic Nephropathy and Altered Expression of WFS1 and NOTCH2 Genes
Diabetes Research and Clinical Practice. doi.org/10.1016/j.diabres.2018.03.053
In light of the increase in the incidence of type 2 diabetes mellitus (T2DM) and the importance of early diagnosis and management of complications associated with T2DM, particularly diabetic nephropathy, there has been increased interest in the genetic factors that affect the risk of T2DM and related nephropathy. Sahar A. Sharaf, MD, and colleagues conducted a study designed to examine the expression of the genes KCNJ11, ABCC8, JAZF1, WFS1, PPARG, NOTCH2, and EXOSC4 in peripheral blood in patients with T2DM. The study cohort included 30 patients with T2DM without complications, 30 patients with diabetic nephropathy, and 40 healthy controls. Gene expression was studied using quantitative real time polymerase chain reaction array.
Compared with patients with no T2DM-related complications, those with diabetic nephropathy had higher expression of NOTCH2 and lower expression of KCNJ11, JAZF1, WFS1, and PPARG genes. KCNJ11, JAZF1, WFS1, PPARG, and EXOSC4 expression showed significant negative correlation with microalbumin; NOTCH2 expression had significantly positive correlation with microalbumin.
There was significant negative correlation between expression of WFS1 and hemoglobin A1c (HbA1c); there was no significant correlation between expression of NOTCH2, KCNJ11, JAZF1, PPARG, and EXOSC4 and HbA1c. Risk ratio of the expression of the studied genes demonstrated that WFS1 and NOTCH2 had the highest risk ratio (30) and the highest sensitivity and specificity in relation to diabetic nephropathy; they were the best predictors among the included genes at a cut off value of ≤0.861 for WFS1 and ≥0.678 for NOTCH2.
In conclusion, the researchers said, “Altered expression of WFS1 and NOTCH2 genes may play a role in pathogenesis and development of diabetic nephropathy in patients with T2DM. These results may contribute in early identification and management of diabetic nephropathy.”
National Survey Results Revealed
Nephrology Nursing Journal. 2018; 45(2):117-140.
Beth T. Ulrich, EdD, RN, FACHE, FAAN, and Tamara M. Kear, PhD, RN, CNS, CNN, reported results of a research survey they conducted for the American Nephrology Nurses Association in collaboration with Nephrology News & Issues. The survey was conducted in January 2018 and was designed to provide a comprehensive national assessment of the overall health and safety of nephrology nurses as well as an overview of nephrology nurses’ work environments.
Survey respondents included more than 1000 nephrology nurses working in nephrology settings nationwide. Most of the respondents (94%) said they were satisfied with their nursing career; 91% said they would recommend nursing to others, while the majority also indicated they would recommend nephrology nursing as a career.
When asked about areas of concern, respondents included staffing, exposure to hazards, long hours of work, and discrimination. Approximately 40% of respondents said they planned to leave their current position within 12 to 36 months, but added that higher salary and benefits would cause them to reconsider.
The survey also revealed areas of opportunities for improvements in nephrology nurse work environments, including staffing, optimizing the knowledge and skills of registered nurses, and mental and physical health.
Effects of Oral Nutritional Supplements in Patients on Hemodialysis
Journal of Renal Nutrition. doi.org/10.1053/j.jrn.2017.10.002
In dialysis-dependent end-stage renal disease (ESRD) patients, protein-energy wasting is common and strongly associated with mortality and adverse outcomes. Intradialytic oral nutritional supplements (ONS) reduced the risk of mortality in that patient population. There are few data available on the associations between ONS and other outcomes. Debbie Benner, MA, RD, CSR, and colleagues conducted a retrospective evaluation of a pilot program that provided ONS to patients at a large dialysis organization in the United States. The evaluation aimed to examine the associations between the administration of ONS and clinical and nutritional outcomes.
The evaluation compared patients receiving ONS (n=3374) with matched controls (n=3374) with serum albumin ≤3.5 g/dL. The controls were identified from facilities not participating in the ONS program. Electronic medical records were used to extract data on death, missed dialysis treatments, hospitalizations, serum albumin, normalized protein catabolic rate, and postdialysis body weight.
Among patients in the ONS program, compared with controls, there was a 69% reduction in deaths (hazard ratio [HR], 0.31; 95% confidence interval [CI], 0.25-0.39; P<.001) and 33% fewer missed dialysis treatments (incidence rate ratio, 0.77; 95% CI, 0.73-0.82; P<.001). Results regarding nutritional markers were mixed: serum albumin was lower and normalized protein catabolic rate values and postdialysis body weights were higher among patients in the ONS program compared with the control group during follow-up.
In conclusion, the researchers said, “Our evaluation confirmed the beneficial effects of ONS in reducing mortality and improving some indices of nutritional status for hypoalbuminemic hemodialysis patients. We also report the novel finding that ONS can reduce the number of missed dialysis treatments. These results support the use of intradialytic ONS as an effective intervention to improve the outcomes in hemodialysis patients with low serum albumin.”
Sarcopenia and Nutritional Status in Hemodialysis Patients
Journal of Renal Nutrition. doi.0rg/10.1053/j.jrn.2017.12.003
A study led by Juliana Giglio, MS, sought to determine whether there is an association with diminished muscle mass, diminished muscle, or both (sarcopenia) and worse nutritional status, poor quality of life, and hard outcomes including hospitalization and mortality among elderly patients on maintenance hemodialysis. The multicenter observational longitudinal study included 170 patients on maintenance hemodialysis from six dialysis centers. Mean age of participants was 70 years and 65% were male.
Sarcopenia is defined by the European Working Group on Sarcopenia in Older People as the presence of both low muscle mass by appendicular skeletal + low muscle function by handgrip strength. The current study assessed participants’ clinical and nutritional status and quality of life at baseline. Hospitalization and mortality were recorded during 36 months of follow-up.
Reduced muscle mass was seen in 64% of the patients, 52% had reduced muscle strength, and 37% had sarcopenia. Compared with patients without sarcopenia, those with sarcopenia were older, were more likely to be men, and had worse clinical and nutritional conditions. There was a strong association between reduced muscle mass and poor nutritional status, and low muscle strength was associated with worse quality of life domains.
In multivariate Cox analyses adjusted by age, sex, dialysis vintage, and diabetes mellitus, there was an association between low muscle strength alone and sarcopenia and higher rates of hospitalization. Sarcopenia was also a predictor of mortality.
The researchers said, “In conclusion, in this sample, comprised of elderly patients on maintenance hemodialysis, sarcopenia was associated with worse nutritional and clinical conditions and was a predictor of hospitalization and mortality.”
Prophylaxis with Direct-Acting Antivirals Safe and Effective in Transplantation Recipients
Annals of Internal Medicine. doi:10.7326/M17-2871
The mortality rate among patients with end-stage kidney disease on dialysis is high. With the efficacy and safety of treatments for hepatitis C virus (HCV), discarded kidneys from donors infected with HCV may be a neglected public health resource.
Christine M. Durand, MD, and colleagues recently conducted an open-label nonrandomized trial designed to assess the tolerability and feasibility of using direct-acting antivirals (DAAs) as prophylaxis prior to and following kidney transplantation from HVC-infected donors to non–HVC-infected recipients (HCV D+/R– transplantation). Merck Sharp & Dohme Corp. was the primary funding source for the trial.
The study cohort included 10 HCV D+/R– kidney transplant candidates >50 years of age with no available living donors. The intervention consisted of transplantation of kidneys from deceased donors 13 to 50 years of age with positive HCV RNA and HCV antibody test results. All recipients received 100 mg grazoprevir (GZR) and 50 mg elbasvir (EBR) immediately prior to transplantation. Patients receiving kidneys from donors with genotype 1 infection continued receiving GZR and EBR for 12 weeks following transplantation; patients receiving kidneys from donors with genotype 2 or 3 infection had 400 mg sofosbuvir added to GZR and EBR for 12 weeks of triple therapy.
The primary safety outcome was the incidence of adverse events related to the GZR-EBR regimen. The primary efficacy outcome was the proportion of recipients with an HCV RNA level below the lower limit of quantification 12 weeks following prophylaxis.
There were no treatment-related adverse events among the 10 HCV D+/R– transplant recipients. There was no HCV RNA detected in any recipient 12 weeks after treatment.
“Pre- and post-transplantation HCV treatment was safe and prevented chronic HCV infection in HCV D+/R– transplant recipients. If confirmed in larger studies, this strategy should markedly expand organ options and reduce mortality for kidney transplant candidates without HCV infection,” the researchers said.
Predicting Post-Transplant Infections in Pediatric Recipients
Pediatric Nephrology. doi:10.1007/s00467-018-3951-1
There have been more than 10,000 pediatric transplants in children with end-stage renal disease in the United States, with survival rates of >80% at 10 years post-transplant. However, infection is a significant cause of morbidity in pediatric recipients of kidney transplantation. According to Felicia Scaggs Huang, MD, and colleagues, screening potential organ donors and recipients is key in identifying and mitigating risks of infection in transplant recipients.
The researchers note that, despite the unique risks of each patient, it is possible to predict the timing of many infections post-transplant.
In post-transplant infections within 30 days of the procedure, bacterial and fungal pathogens predominate with donor-derived events and nosocomial infections. In the intermediate period after transplantation (31-180 days), latent infections from donor organs such as Epstein-Barr virus and cytomegalovirus develop. Late infections, defined as occurring >180 days after transplantation, may be due to latent pathogens or community-acquired organisms.
“Approaching an infectious evaluation in a pediatric kidney recipient requires finesse to diagnose and treat this vulnerable population in a timely manner,” the researchers said. In this article, they highlight the most relevant and common infections including clinical manifestations, risk factors, diagnostic techniques, and treatment options.