Methicillin-resistant staphylococcus aureus carriage and comorbidity in patients with chronic kidney disease V D stage: a 3-year prospective study

Asymptomatic methicillin-resistant Staphylococcus aureus (MRSA) nasal colonization is a confirmed factor that affects the frequency of comorbid bacterial infections and mortality in patients with end-stage renal disease (ESRD). The aim was to study the frequency of comorbid conditions and their dynamics in ESRD patients depending on their MRSA status. Methods. To prospective cohort study included 265 ESRD patients, 204 of whom were treated by hemodialysis (HD) and 61 by peritoneal dialysis (PD). All recorded comorbidities, their frequency and the dynamics of change, polymorbidity indices, were analyzed depending on whom had MRSA nasal colonization (group 1, n = 92) and without it (group 2, n= 173). The most common cause of ESRD was glomerulonephritis - 161 patients (60.75%). The groups were representative according to gender, age, type of kidney injury and modality of renal replacement therapy (RRT). Results. According to the results of a 3-year study investigation, the patients with MRSA carriage had a statistically significant higher level of comorbid conditions frequencies compared to the patients who had opportunistic pathogenic bacteria carriage, namely: prevalence of coronary artery disease (55.4% vs 30.1%, р=0.0001), heart failure (44.6% vs 25.4%, р=0.0015), secondary hyperparathyroidism (61.9% vs 45.1%, р=0,009), chronic obstructive pulmonary disease (31.5% vs 17.3%, р=0.0082), peripheral vascular disease (39.15 vs 17.9%, р=0.0001). The increase in the modified polymorphism index in patients of Group 1 and Group 2 during the observation period, was 30 % and 5% respectively. One hundred thirty three hospitalization cases were detected during follow-up period: among patients from Group 1- 66 (71.34%) cases, Group 2 - 67 (38.73%); χ² = 26.180, р < 0.0001; RR – 1.8524, 95% ДІ: 1.4760 – 2.3247. Conclusions. Asymptomatic MRSA nasal colonization is a factor that can increase the incidence of coexisting diseases as well as the total number of comorbid conditions in dialysis patients

CARRIAGE OF OPPORTUNISTIC MICROORGANISMS AND SURVIVAL OF PATIENTS WITH CHRONIC KIDNEY DISEASE STAGE 5 D

Despite of significant development of dialysis technology, mortality rates of CKD V D stage patients remain unsatisfactorily high. Next to cardiovascular diseases, infections are seems to be as a major causes of morbidity, hospitalization and mortality in this population. Staphylococcus aureus, especially MRSA, infections are a major cause of morbidity and hospitalization in CKD V D stage patients. Preceding MRSA colonization views as a risk factor for subsequent MRSA infections in future. Aim. The aim of this study was to explore the effects of opportunistic pathogens colonization on survival in patients with CKD VD stage. Materials and methods. This prospective cohort, open-label study included 255patients with CKD V D st. (198 HD and 57 PD patients). Patients were randomized into two groups, depending on the MRSA colonization history: first group (n=66) included patients with identified MRSA colonization and the second group (n=189) included patients with colonization of other opportunistic pathogens. The groups were representative according to gender, age, type of kidney affections and renal replacement therapy (RRT) modality. The endpoint was the total number of deaths. All cases, which took place from 01.08.2011 to 01.08.2016 year, were analyzed. The Kaplan-Meier method was perfomed for evaluation of survival.   Results. The analysis allowed to state that during analyzed period in total were 75 deaths: in the first group ofpatients - 32 (48.5%), and in the second - 43 (22.8%) cases; %2= 14,38, p = 0,000078; RR – 2,131, 95% ffl: 1,484-3,060. The survival rate of patients was significantly lower in the first group, irrespective of RRT modality. The 3-years cumulative proportion surviving was 53% and 79% in the first (MRSApositive) and second groups, respectively; p< 0,001. Conclusion. This study demonstrated that MRSA asymptomatic colonization has a significant negative effect on survival in the patient population with CKD VD stag

AGE AND GENDER-SPECIFICS OF CARDIOVASCULAR MORTALITY IN HEMODIALYSIS PATIENTS

Cardiovascular diseases are the leading causes of death in hemodialysis (HD) patients. An analysis of the epidemiological evidence is the basis for the development of the measures and recommendations directed on reducing prevalence of fatal events, including cardiovascular. Aim. The study of cardiovascular mortality in patients who received treatment for renal replacement therapy, based on the demographic and gender characteristics, type of kidney damage and duration of HD treatment. Methods. Cardiovascular mortality causes in 89 patients who received programmed hemodialysis from January 1, 2007 to December 31, 2011 in Kyiv City Scientific and Practical Center of Nephrology and Dialysis were analyzed. Results. Cardiovascular disease was the primary cause of death in the study population (64, 96 %). The annual cardiovascular mortality rate has a significant positive trend in the HD patients. It was ascertained its declining from 10,26% in 2007 to 6,69% in 2011.  About 40% of cardiovascular causes of death occurred during the first 90 days of HD treatment, 73,53% of them were among males. The number of fatality authentically is higher for younger women with non- diabetic renal glomerular lesions and middle-aged patients with diabetes mellitus. CVD, as the cause of death, was significantly more often for males of middle age with the glomerular (diabetic and non-diabetic) diseases and of the elderly - with nonglomerular and non-diabetic glomerular origin. Conclusion. According to the study the series of the regularities of the structure of cardiovascular mortality has been established. The significant association between the sex of the patient and the type of renal disease was identified in each age group

Predictors of cardiovascular disease in peritoneal dialysis patients: A Prospective longitudinal cohort study

The present study aimed to investigate the incidence rate and possible predictors of cardiovascular disease (CVD) in end-stage renal disease (ESRD) patients treated with continuous ambulatory peritoneal dialysis (CAPD). Methods. This prospective longitudinal cohort study included 133 ESRD patients treated with CAPD between 2012 and 2019. The study was conducted in two phases. In the first phase, key patient demographic, clinical, and laboratory data, including the incidence of cardiovascular disease, were collected at baseline. In the second phase, an assessment of potential predictors of CVD in PD patients was performed. Baseline patient characteristics were used as potential predictors in this study. The mean duration of the prospective study was 28.2 ± 7.1 months, corresponding to 249.2 patient-years. Univariate and multivariate Cox proportional hazard regression and ROC analysis were performed to estimate predictors of CVD events. The primary end-point (newly diagnosed cardiovascular disease) was determined at the end of the study. Statistical processing of the results obtained was performed with "MedCalc," version 19.3 (Ostend, Belgium). Results. One hundred and three PD patients were included in the final analysis. During the study period, a significant increase (by 82%) in the frequency of all CVDs was observed (р < 0.0001), more than twice as frequent in heart failure (HF) (р < 0.0001) and atrial fibrillation (AF) (р= 0.0156). The primary endpoint was observed in 49 events: newly diagnosed HF in 21 (20.4%) patients, coronary artery disease in 9 (8.7%) patients, AF in 7 (6.8%) patients, acute myocardial infarction in 5 (4.9%) patients, another coronary heart disease in 7 (6.8%) patients. The incidence rate of CVD and HF was 19.66 and 8.43 per 100 patient-years, respectively. Multivariate Cox regression analysis indicated that hyperhydration (HR=4.2; 95% CI: 2,.2 - 7.3), diabetes mellitus as the primary cause of ESRD (HR=2.5; 95% CI: 1.3 - 4.3), history of MRSA colonization (HR=1.4; 95% CI: 1.2 - 1.7) and age (HR=1.03; 95% CI: 1.004 - 1.05) are independent predictors of all new-onset cardiovascular events in ESRD patients, treated with CAPD. ​A total of 44 patients (42.7%) died during the study period. The incidence rates of all-cause mortality were 17.67 per 100 patient-years. The most common cause of mortality was CVD, accounting for 50.0% of all events (8.82 per 100 patient-years). Conclusions. This prospective longitudinal study demonstrates that treatment with PD is associated with an increased incidence of CVD. Hyperhydration, diabetes mellitus, history of MRSA colonization, and age over 55 years are independent predictors of new-onset CVD in PD patients

Nutritional status and survival of End-Stage Renal Disease patients treated with continuous ambulatory peritoneal dialysis

The objective of the work was to study the survival peculiarities ofend-stage renal disease patients treated with continuous ambulatory peritoneal dialysis (CAPD) depending on the nutritional status and informative markers associated with it. Methods. 105 ESRD patients who received CAPD treatment during 2012 - 2017 years at the Kyiv Scientific and Practical Center of Nephrology and Dialysis, which is the clinical base of the State Institution "Institute of Nephrology National Academy of Medical Sciences of Ukraine" were included in the cohort prospective open study. The survival analysis was carried out both in the studied population as a whole and in groups depending on the nutritional status (NS) indicators defined basing on the calculation of the subjective global assessment (SGA) points: the first group (n = 51) consisted of patients without malnutrition, the second group (n = 30) - patients with a mild degree of malnutrition, the third group (n = 13) - patients with a moderate degree of malnutrition, and the fourth group (n = 11) - patients with a severe degree of malnutrition. The survival analysis was conducted both in the groups in compliance with NS, and depending on the informational markers associated with NS, in particular, albumin, body mass index (BMI), residual renal function (RRF). Survival were calculated using the Kaplan-Meier method, and the difference between survival rates was analyzed using the log-rank test and χ². The starting date of peritoneal dialysis treatment was considered as the starting point of the monitoring. The difference was considered to be accurate at p <0.05. Analyzed cases were included till January 7, 2019. The event risk assessment was carried out with the probability of relative risk (RR) values calculating their confidence intervals (95% CI). Results.Forty-three (40.95%) patients died during the current analysis, 17 patients were switched to the hemodialysis (HD), 4 patients had undergone kidney transplantations. Cardiovascular disease was the leading cause of death (41.9%), the second cause of death by frequency was bacterial infections (20.9%). Longer monitoring periods death rate was significantly higher in patients of group with an average (11/84.6% vs 14/27.45%, p <0.0001; RR - 3.08; 95% CI: 1.8 -5.09)and a mild degree of nutritional disorders (ND) (11/84.6% vs 11/36.7%, p = 0.0018, RR - 2.3, 95% CI: 1.36-3.89) compared with normal NS.Similarly, the percentage of died patients with a severe ND degree was significantly higher than those with a normal nutritional status (7/63.6% vs. 14/27.45%, p = 0.0091, RR - 2.31, 95% CI: 1.23 - 4.35). The cumulative survival during the 1- year amounted to 90% of patients for 3 and 5 years - 64% and 41%, respectively. It was found that the survival rate of PD patients is credibly higher in groups with normal NS ormild ND degree than patients of group with a moderate or severe degree of nutritional disorders (χ2 = 22,9; df = 3; p = 0,00004). The cumulative survival for 1 and 3 years was 97%, 98%, 70%, 81% and 76%, 70%, 24%, 36% in groups of patients without nutritional disorder, with mild nutritional disorders, moderate and severe disorders, respectively. The cumulative survival with serum albumin level 24 kg/m2 was apparently higher than those with an indicatorBMI ≤ 24 kg/m2, and it was in 1 and 3 years 94% vs 86% and 79% vs 47%, respectively (p = 0.00321, log-rank test). Veritable differences have been registered in the cumulative frequencies of survivors depending on RRF value: the survival rate was significantly higher among patients with RRF ≥ 5 ml/min/1.73 m² and significantly lower among patients with RRF <2 ml/min/1.73 m2 (χ² = 17.4; df = 2; p = 0.00016). Conclusions.Thus, our studyfound that serum albumin level, BMI and RRF magnitude are the markers for the survival of ESRD patientstreated with PD. Veritable difference between the survival of patients depending on the nutritional status was stated. Three-year cumulative survival with mild degree of malnutrition group was twice as high as in severe nutritional disorders and it was 70% vs 36% (p <0.001). The relative risk of death from all causes increases by 3.1 and 2.32 times for moderate and severe nutritional disorders patients compared to the patients group with normal NS

Activation of chronic inflammation and comorbidity in end-stage renal disease patients treated with continuous ambulatory peritoneal dialysis.

The aim of the work was to determine the blood serum pro-inflammatory cytokine profile and to study their relationship with comorbidity and mortality in end-stage renal disease (ESRD) patients treated with continuous ambulatory peritoneal dialysis (CAPD). Ninety three ESRD patients treated with CAPD during 2012-2019 were included in the cohort prospective open study. The study was conducted in two stages. At the first stage, the determination of TNF-α and IL-6 levels was conducted and study of comorbidity, its quantitative assessment, baseline clinical and laboratory parameters was made. A modified polymorbidity index (MPI) which determined the quantitative assessment of comorbidity was calculated as the number of diseases per one patient excluding ESRD and its reasons. At the second stage, considering the baseline values of the studied cytokines, a prospective study of the dynamics of the prevalence of comorbid pathology, the value of MPI and mortality rate was carried out. The average duration of prospective follow-up was 26.4±6.8 months. Serum cytokines levels were determined by ELISA. Statistical analysis was performed by using "MedCalc", version 19.1.7. (Ostend, Belgium). Serum levels of TNF-α and IL-6 were significantly higher in PD-patients with 5 or more comorbid diseases. Levels of TNF-α&gt;13.0 pg/ml have a negative effect on the dynamics of prevalence of heart failure (HF) and coronary heart disease (CHD), number of comorbid conditions in CAPD-patients. The proportion of the dead with a level of TNF-α&gt;13.0 pg/ml was by three times higher, and deaths from cardiovascular events are almost by 10 times higher than patients who had a level of TNF-α≤13.0 pg/ml. Serum levels of IL-6&gt;23.4 pg/ml are associated with a significant increase in number of comorbid conditions, prevalence of bacterial infections and overall and infectious mortality. Independent predictors of comorbidity and overall mortality in patients with ESRD who are treated with CAPD are serum levels of TNF-α, IL-6 and albumin. Serum levels of TNF-α and albumin are predictors of fatal cardiovascular events, and serum levels of IL-6 are predictors of fatal infectious events

COMORBIDITY AND SURVIVAL OF PATIENTS WITH CHRONIC KIDNEY DISEAS STAGE 5 D

Annual expansion of dialysis population, high mortality, considerable expenses on specialized medical care are evoked the medical community to research comorbidities, that undoubtedly has an influence on course of chronic kidney disease VD stage (CKD VD st.) and prognosis. Aim. The aim of this study was to investigate the prevalence and structure of comorbid conditions in patients with CKDVD stage, and determinate the relation between comorbidities and survival rate in dialysis population. Materials and methods. It was studied the prevalence and structure of comorbidities among 204 patients with CKD VD st. (125 on hemodialysis [HD], 51 on peritoneal dialysis [PD], and 28 on hemodiafiltration [HDF]). All recorded concomitant diseases with its incidence data and coand polymorbidity indices were analyzed in consideration of renal replacement therapy (RRT). The survival rates were assessed in according with indices of comorbidity by Kaplan - Mayer methodology. Results. The performed analysis was demonstrated that in almost single patient had no mononosologicalpathology. The numbers of concomitant diseases were 3,55, 3,3 и 3,4 3,3per patient on HD, HDF and PD, respectively, without significant relation with RRT modality. In according with the study results the most common comorbid conditions, irrespective from RRT modality, were anaemia (88%), arterial hypertension (86%), and secondary hyperparathyroidism (40%). The proposed modified index of polymorbidities was revealed as the universal marker of survival rate in patients with CKD VD st. Conclusion. Thus the considerable prevalence of comorbid conditions in population ofpatients with CKD VD st. irrespective of RRT modality has significant negative effect on prognosis

Factors associated with nutritional status in peritoneal dialysis patients

The aim of our study was to examine the relationship between nutritional status (NS) in patients undergoing continuous ambulatory peritoneal dialysis (CAPD) and dialysis-related factors.Methods. 105 patients who were treated by CAPD were included in this observational study. To assess the NS we determined the level of serum albumin, body mass index (BMI) and subjective global assessment (SGA). The study was carried out in two stages. At the first stage of the work PD patients’ nutrition status was examined. For further analysis, the patients were divided into four groups according to the condition of the NS: the first group (n = 54) consisted of patients without disturbance of nutrition, the second (n = 27) with mild nutrition disorders, the third (n = 13) - with an average degree and the fourth (n = 11) with a severe degree of malnutrition. At the second stage of the work specialty of the nutritional status and residual renal function, frequency of PD-peritonitis, transport characteristics of the peritoneum were studied.Results. Nutritional disorders were observed in 54 (51.4 %) patients. A mild malnutrition was diagnosed in 28.7 % of patients, medium and severe in 12,38 % and 10,48% of patients, respectively. Parameters of NS, except BMI, were higher in patients without nutrition disorders (ND) comparing with the patients who had it. RRF was higher in patients without ND; but anuria was observed practically in all patients with severe ND. We receive direct relationship between the level of serum albumin and RRF (r = 0.53; p <0,001), and SGA and RRF (r = 0.52; p <0,001). Number of PD – peritonitis was lower in patients with normal NS and the highest in patients with severe ND. Strong correlation between the level of serum albumin, SGA, and the frequency and duration of peritonitis was established (r = - 0.59; p<0,001 and r = - 0.59; p <0,001 respectively). High transport characteristic of peritoneum was associated with lower degree of serum albumin and SGA (p <0,001). There was no relationship established between SGA, serum albumin, BMI, age, duration of CAPD treatment, gender, and main nosology.Conclusions: Thus, ND were diagnosed in more than 50% of the examined patients. ND were associated with reduce of RRF, frequency and duration of PD-peritonitis, high transport characteristics of the peritoneum. There was no correlation between level of serum albumin, SGA and gender, duration of CAPD, main nosology and age. BMI did not have correlation with any parameters. The received data testify the necessity of constant monitoring of laboratory and functional parameters of the nutrition status

Pneumonia in patients with chronic kidney disease V D stage: pathogenetic aspects of complex therapy and outcomes

Abstract.The aim of our study was to increase the effectiveness of treatment of comorbid pneumonia in patients with CKD VD stage. Materials and Methods. 73 patients with CKD VD st. (59 on HD and 14 on PD) with mild to moderate comorbid pneumonia who received renal replacement therapy (RRT) during 2013-2016 were included in the observational prospective open-label randomized trial. Patients were randomized into two groups: group 1 (n = 42) included patients who in addition to the conventional therapy of pneumonia received medication «Lipin» as a complex therapy; group 2 included patients (n = 31) who received only basic (traditional) therapy. The groups were representative by the main demographic, social and clinical-laboratory findings, severity of pneumonia, duration and modality of RRT. The primary endpoints were death from any cause and episodes of rehospitalization. The overall assessment of the clinical efficacy of the therapy was based on a comparison of the duration of hospitalization, antibiotic therapy, intoxication syndrome, and regression of X-ray changes. Survival in observation groups was determined by the Kaplan-Meier method. Analyzed cases were included to October 31, 2018. The markers of oxidative stress (OS) were determined in 29 patients of group 1 and 14 patients of group 2 before treatment and after 14 days while treatment of  pneumonia was started. Results. The analysis demonstrated that during a 1-year period a 17 (25,76%) episodes of rehospitalization were recorded: 11 causes (35.5%) in group 1 and 6 (14.3%) in group 2 (χ² = 4.486, p = 0.035). In total, 29 deaths were recorded during the study period: 10 (23.8%) cases in group 1, and 19 (61.3%) - in group 2 (χ² = 8.957, p = 0.003, RR - 2.574, 95% CI: 1.400-4.733). The three- and five-year cumulative survival rates were 83% vs. 21% and 59% vs. 21%, in the group 1 and group 2, respectively (p = 0.00003). It was stated that the duration of hospitalization, antibiotic therapy, intoxication syndrome and X-ray regression were significantly lower in group 1 compared with group 2 (p <0.05). The comparative analysis of dynamics in the groups shows that increasing the treatment effectiveness at complex therapy background accompanied by a significant positive dynamics of OS markers (p <0,05). Conclusions Thus, the results of this study demonstrated the effectiveness of complex method of pneumonia treatment in patients with CKD stage 5D including Lipin medication compared traditional therapy. There is a significant difference in patient survival depending on the proposed and generally accepted treatment

NUTRITIONAL DISTURBANCES IN PATIENTS WITH CHRONIC KIDNEY DISEAS STAGE WHO ARE TREATED BY PERITONEAL DIALYSIS AND ITS RELATIONSHIPS WITH HYDRATION STATUS

The aim of the study was to estimate the nutritional status of patients with chronic kidney disease who are treated by CAPD, the prevalence of its disorders according to functional methods. To study the relationship between nutritional status and hydration. Materials and Methods: During the observational one-stage study, 105 patients with CKD 5D stage who were treated by CAPD were included. To assess the NS, serum albumin and body mass index were determined, functional methods were used, namely, SGA and dietary diary analysis. The status of hydration was assessed by clinical examination and bioimpedance analysis. The study was carried out in two stages. At the first, the definition of laboratory and functional indicators of the National Assembly, assessment of the balance of water sectors was carried out. At the second stage, for further analysis, the patients were divided into four groups according to the condition of the NS, determined on the basis of the SGA: the first group (n = 54) consisted of patients without disturbance of nutrition, the second (n = 27) with mild disruption of nutrition, the third (n = 13) — with an average degree, and the fourth (n = 11) - with a severe degree of malnutrition. Results: Weight loss and subcutaneous fat mass for the past 6 months were detected in 43.8% and 37.14% of patients, respectively. Gastrointestinal disorders and loss of muscle mass were detected in 58.1% and 74.3% of patients, respectively. According to the SGA, nutritional disorders were detected in 51 (48.6%) patients. An easy degree of malnutrition was diagnosed in 25.71% of patients, medium and severe — in 12.38% and 10.48% of patients, respectively. For compare of the data obtained from the survey on the composition of water sectors with reference values allows one to assert the presence of hyperhydration in the examined population. A statistically significant difference is achieved by the volume of extracellular fluid, the volume of circulating blood and plasma. These parameters significantly increase depending on the degree of disturbance of the NS (p <0.001). A direct, reliable correlation was obtained between the SGA and serum albumin level (r = 0.74, p <0.0001), BMI (r = 0.55, p <0.0001) and the inverse volume of extracellular fluid (r = -0, 71; p <0.0001). Peripheral edema as a sign of hyperhydration was detected in 31 patients, the significant majority of whom belonged to the third (10 / 37.03% versus 11 / 84.6%, x2 = 7.965, р = 0.005) and the fourth (10/ 37.03 % against 10 /90,9%, yf = 9,098, р = 0,003) to the group. Daily protein intake, also, was significantly lower in patients of the third and fourth groups (p <0.001). Conclusions: Thus, the normal nutritional status was determined in more than 50% of the patients examined. The level of hydration in patients with nutritional disorders is higher than in patients with normal nutritional status. The received data testify to the necessity of constant monitoring of laboratory and functional indices of NS, expediency of routine use of bioimpedance analysis for hydration estimation