Renal anaemia : The role of haemoglobin control in patients with chronic kidney disease

Copyright: Copyright 2011 Elsevier B.V., All rights reserved.Chronic kidney disease (CKD) is a significant and prevalent health problem in the world. Anaemia is one of the most common manifestations in patients with CKD. The correction of anaemia with erythropoietin normalises haemoglobin level and improves quality of life. Many aspects of the impact of anaemia treatment with erythropoiesis-stimulating agents on the progression of CKD remain unresolved and disputable. The present study is a retrospective chart review of 1654 outpatients with CKD. The data were collected from the Centre of Nephrology between 1 January 2002 and 31 December 2006. The aims of the study were to assess the causes of CKD; the prevalence of anaemia based on the current guidelines for anaemia management in CKD (Kidney Disease Dialysis Outcomes Quality Initiative; K/DOQI); to evaluate haemoglobin (Hb), systolic and diastolic blood pressure (SBP and DBP), glomerular filtration rate (GFR) at the first referral to a nephrologist and at the start of renal replacement therapy (RRT). The most common causes of CKD were arterial hypertension (17.2%), chronic glomerulonephritis (17.2%), chronic intersticial nephritis (13.3%), and diabetes (12.8%). Twenty-three percent of end-stage renal disease (ESRD) patients had diabetes mellitus. At the first visit in the renal department, 16% of the patients had an advanced degree of CKD (GFR <30 ml/min). The proportion of patients under an observation in the kidney centre for a period of six months and more was only 34% (554 of 1654). Hypertension was recorded in 72% of study subjects. The blood pressure (BP) values in patients at the first visit (n = 1633) vs. at the start of RRT (n = 154) were: mean SBP 147.4 ± 24.8 mm Hg vs. 152.2 ± 23.0 mm Hg (P < 0.05); mean DBP 88.8 ± 13.6 mm Hg vs. 88.4 ± 12.0 mm Hg (P 0.05). Anaemia was recorded in 41% of study subjects, estimated using K/DOQI recommendations. The prevalence of anaemia was increased from 30.2% to 44.8% of study patients with a rise of BP (from normal BP to hypertension; P < 0.05). The mean Hb level at the start of RRT was 9.8 ± 2.1 g/dl. Only 18% of patients with renal anaemia had used erythropoiesis-stimulating agents before RRT (28 of 155). Anaemia is the prevalent condition at moderate degrees of CKD. The severity of anaemia in the CKD population is determined by evidence of diabetes, cardiovascular disease, and renal function. Anaemia may often be unrecognised or untreated.publishersversionPeer reviewe

Anti-Biofilm Effect of Bacteriophages and Antibiotics against Uropathogenic Escherichia coli

Publisher Copyright: © 2022 by the authors.Escherichia coli is a common cause of biofilm-associated urinary tract infections. Bacteria inside the biofilm are more resistant to antibiotics. Six E. coli strains isolated from patients with urinary tract infections were screened for biofilm-forming capability and antimicrobial susceptibility. Two of the most significant biofilm-producing strains were selected for minimal inhibitory concentration and minimal biofilm eradication concentration in vitro testing using amoxicillin-clavulanic acid, ciprofloxacin, and three commercial bacteriophage cocktails (Pyobacteriophag, Ses, and Intesti). In case of a low phage effect, an adaptation procedure was performed. Although the biofilms formed by strain 021UR were resistant to amoxicillin-clavulanic acid and ciprofloxacin, the three phage cocktails were able to reduce biofilm formation. In contrast, phages did not affect the 01206UR strain against planktonic and biofilm-forming cells. After Pyobacteriophag adaptation, the effect improved, and, regardless of the concentration, the adapted phage cocktail could destroy both planktonic cells and the biofilm of strain 01206UR. Bacteriophages capable of killing bacteria in biofilms can be used as an alternative to antibiotics. However, each case should be considered individually due to the lack of clinical trials for phage therapy. Antimicrobial and phage susceptibility should be determined in biofilm models before treatment to achieve the desired anti-biofilm effect.publishersversionPeer reviewe

Sars-COV-2 Vaccination DID Not Affect the Clinical Course of IGA Nephropathy in Latvian Adult Cohort

BACKGROUND AND AIMS: The current strategy to fight against the COVID-19 pandemic involves active patient vaccination. Patients with renal and autoimmune diseases are in high risk for severe COVID-19 infection [1]. Therefore they should be prioritized for vaccination. Immunoglobulin A nephropathy (IgAN) is one of the most common primary glomerulonephritis triggered by mucous membrane alteration; however, there is a discussion about vaccination-caused IgA flare [2]. The immunological nature of IgAN and misleading information in public sources leaves patients skeptical about whether to get vaccinated [3]. The study aimed to investigate the impact of SARS-CoV-2 vaccination on the clinical course of IgA nephropathy. METHOD: Adult patients treated in Pauls Stradins Clinical University Hospital with morphologically proven IgAN were included in the study. Patients with secondary IgAN were excluded. Evaluation of clinical and laboratory markers was performed on inclusion visit and on the second visit 6 months later. SARS-CoV-2 vaccination type and status were noted on both visits. Estimated GFR was calculated with CKD-EPI creatinine-cystatin equation. IBM SPSS Statistics version 27 and Microsoft Excel 10 were used for data analysis. RESULTS: The study involved 54 patients, 36 were unvaccinated and 18 were fully vaccinated. A significant difference between the two groups was observed by baseline proteinuria. Other differences were not observed. Fourteen patients were vaccinated with mRNA vaccine, 13 with Comirnaty and 1 with Spikevax, and four patients were vaccinated with Vaxzevria vector vaccine. The differences between the two groups are shown in Table 1. During study period, two patients had COVID-19 infection; a patient in the vaccinated group had COVID-19 prior to vaccination. CONCLUSION: SARS-CoV-2 vaccination did not affect the clinical course of IgA nephropathy. Our study results indicate that SARS-CoV-2 vaccination in IgA nephropathy patients was safe regarding renal function and disease activity markers. (Table Presented).publishersversionPeer reviewe

Successful Bacteriophage-Antibiotic Combination Therapy against Multidrug-Resistant Pseudomonas aeruginosa Left Ventricular Assist Device Driveline Infection

Publisher Copyright: © 2023 by the authors.There is considerable interest in the use of bacteriophages (phages) to treat Pseudomonas aeruginosa infections associated with left ventricular assist devices (LVADs). These infections are often challenging to manage due to high rates of multidrug resistance and biofilm formation, which could potentially be overcome with the use of phages. We report a case of a 54-year-old man with relapsing multidrug-resistant P. aeruginosa LVAD driveline infection, who was treated with a combination of two lytic antipseudomonal phages administered intravenously and locally. Treatment was combined with LVAD driveline repositioning and systemic antibiotic administration, resulting in a successful outcome with clinical cure and eradication of the targeted bacteria. However, laboratory in vitro models showed that phages alone could not eradicate biofilms but could prevent biofilm formation. Phage-resistant bacterial strains evolved in biofilm models and showed decreased susceptibility to the phages used. Further studies are needed to understand the complexity of phage resistance and the interaction of phages and antibiotics. Our results indicate that the combination of phages, antibiotics, and surgical intervention can have great potential in treating LVAD-associated infections. More than 21 months post-treatment, our patient remains cured of the infection.publishersversionPeer reviewe

First-year mortality in incident dialysis patients : results of the Peridialysis study

Funding Information: We thank all physicians and other staff members who participated in this study. Baxter Novum is the result of a grant from Baxter Healthcare to Karolinska Institutet. Thanks to Sara Denguir for data collection assistance. Funding Information: The project was supported by an unrestricted grant from Baxter Healthcare, Deerfield, Illinois, USA, grant number 05253284. The funder had no role in study design; collection, analysis and interpretation of data; writing the report; or the decision to submit the report for publication. Publisher Copyright: © 2022, The Author(s).BACKGROUND: Controversy surrounds which factors are important for predicting early mortality after dialysis initiation (DI). We investigated associations of predialysis course and circumstances affecting planning and execution of DI with mortality following DI. METHODS: Among 1580 patients participating in the Peridialysis study, a study of causes and timing of DI, we registered features of predialysis course, clinical and biochemical data at DI, incidence of unplanned suboptimal DI, contraindications to peritoneal dialysis (PD) or hemodialysis (HD), and modality preference, actual choice, and cause of modality choice. Patients were followed for 12 months or until transplantation. A flexible parametric model was used to identify independent factors associated with all-cause mortality. RESULTS: First-year mortality was 19.33%. Independent factors predicting death were high age, comorbidity, clinical contraindications to PD or HD, suboptimal DI, high eGFR, low serum albumin, hyperphosphatemia, high C-reactive protein, signs of overhydration and cerebral symptoms at DI. Among 1061 (67.2%) patients who could select dialysis modality based on personal choice, 654 (61.6%) chose PD, 368 (34.7%) center HD and 39 (3.7%) home HD. The 12-months survival did not differ significantly between patients receiving PD and in-center HD. CONCLUSIONS: First-year mortality in incident dialysis patients was in addition to high age and comorbidity, associated with clinical contraindications to PD or HD, clinical symptoms, hyperphosphatemia, inflammation, and suboptimal DI. In patients with a "free" choice of dialysis modality based on their personal preferences, PD and in-center HD led to broadly similar short-term outcomes.publishersversionPeer reviewe

Suboptimal dialysis initiation is associated with comorbidities and uraemia progression rate but not with estimated glomerular filtration rate

Publisher Copyright: © 2020 The Author(s) 2020. Published by Oxford University Press on behalf of ERA-EDTA.Background: Despite early referral of uraemic patients to nephrological care, suboptimal dialysis initiation (SDI) remains a common problem associated with increased morbimortality. We hypothesized that SDI is related to pre-dialysis care. Methods: In the 'Peridialysis' study, time and reasons for dialysis initiation (DI), clinical and biochemical data and centre characteristics were registered during the pre- and peri-dialytic period for 1583 end-stage kidney disease patients starting dialysis over a 3-year period at 15 nephrology departments in the Nordic and Baltic countries to identify factors associated with SDI. Results: SDI occurred in 42%. Risk factors for SDI were late referral, cachexia, comorbidity (particularly cardiovascular), hypoalbuminaemia and rapid uraemia progression. Patients with polycystic renal disease had a lower incidence of SDI. High urea and C-reactive protein levels, acidosis and other electrolyte disorders were markers of SDI, independently of estimated glomerular filtration rate (eGFR). SDI patients had higher eGFR than non-SDI patients during the pre-dialysis period, but lower eGFR at DI. eGFR as such did not predict SDI. Patients with comorbidities had higher eGFR at DI. Centre practice and policy did not associate with the incidence of SDI. Conclusions: SDI occurred in 42% of all DIs. SDI was associated with hypoalbuminaemia, comorbidity and rate of eGFR loss, but not with the degree of renal failure as assessed by eGFR.Peer reviewe

Why do physicians prescribe dialysis? A prospective questionnaire study

IntroductionThe incidence of unplanned dialysis initiation (DI) with consequent increased comorbidity, mortality and reduced modality choice remains high, but the optimal timing of dialysis initiation (DI) remains controversial, and there is a lack of studies of specific reasons for DI. We investigated why and when physicians prescribe dialysis and hypothesized that physician motivation for DI is an independent factor which may have clinical consequences.MethodsIn the Peridialysis study, an ongoing multicenter prospective study assessing the causes and timing of DI and consequences of unplanned dialysis, physicians in 11 hospitals were asked to describe their primary, secondary and further reasons for prescribing DI. The stated reasons for DI were analyzed in relation to clinical and biochemical data at DI, and characteristics of physicians.ResultsIn 446 patients (median age 67 years; 38% females; diabetes 25.6%), DI was prescribed by 84 doctors who stated 23 different primary reasons for DI. The primary indication was clinical in 63% and biochemical in 37%; 23% started for life-threatening conditions. Reduced renal function accounted for only 19% of primary reasons for DI but was a primary or contributing reason in 69%. The eGFR at DI was 7.2 ±3.4 ml/min/1.73 m2, but varied according to comorbidity and cause of DI. Patients with cachexia, anorexia and pulmonary stasis (34% with heart failure) had the highest eGFR (8.2–9.8 ml/min/1.73 m2), and those with edema, “low GFR”, and acidosis, the lowest (4.6–6.1 ml/min/1.73 m2). Patients with multiple comorbidity including diabetes started at a high eGFR (8.7 ml/min/1.73 m2). Physician experience played a role in dialysis prescription. Non-specialists were more likely to prescribe dialysis for life-threatening conditions, while older and more experienced physicians were more likely to start dialysis for clinical reasons, and at a lower eGFR. Female doctors started dialysis at a higher eGFR than males (8.0 vs. 7.1 ml/min/1.73 m2).ConclusionsDI was prescribed mainly based on clinical reasons in accordance with current recommendations while low renal function accounted for only 19% of primary reasons for DI. There are considerable differences in physicians´ stated motivations for DI, related to their age, clinical experience and interpretation of biochemical variables. These differences may be an independent factor in the clinical treatment of patients, with consequences for the risk of unplanned DI.</div

Suboptimal dialysis initiation is associated with comorbidities and uraemia progression rate but not with estimated glomerular filtration rate

Background Despite early referral of uraemic patients to nephrological care, suboptimal dialysis initiation (SDI) remains a common problem associated with increased morbimortality. We hypothesized that SDI is related to pre-dialysis care.Methods In the 'Peridialysis' study, time and reasons for dialysis initiation (DI), clinical and biochemical data and centre characteristics were registered during the pre- and peri-dialytic period for 1583 end-stage kidney disease patients starting dialysis over a 3-year period at 15 nephrology departments in the Nordic and Baltic countries to identify factors associated with SDI.Results SDI occurred in 42%. Risk factors for SDI were late referral, cachexia, comorbidity (particularly cardiovascular), hypoalbuminaemia and rapid uraemia progression. Patients with polycystic renal disease had a lower incidence of SDI. High urea and C-reactive protein levels, acidosis and other electrolyte disorders were markers of SDI, independently of estimated glomerular filtration rate (eGFR). SDI patients had higher eGFR than non-SDI patients during the pre-dialysis period, but lower eGFR at DI. eGFR as such did not predict SDI. Patients with comorbidities had higher eGFR at DI. Centre practice and policy did not associate with the incidence of SDI.Conclusions SDI occurred in 42% of all DIs. SDI was associated with hypoalbuminaemia, comorbidity and rate of eGFR loss, but not with the degree of renal failure as assessed by eGFR.</p

Choice of dialysis modality among patients initiating dialysis: results of the Peridialysis study

Background.In patients with end-stage kidney disease (ESKD), home dialysis offers socio-economic and health benefits compared with in-centre dialysis but is generally underutilized. We hypothesized that the pre-dialysis course and institutional factors affect the choice of dialysis modality after dialysis initiation (DI).Methods.The Peridialysis study is a multinational, multicentre prospective observational study assessing the causes and timing of DI and consequences of suboptimal DI. Clinical and biochemical data, details of the pre-dialytic course, reasons for DI and causes of the choice of dialysis modality were registered.Results.Among 1587 included patients, 516 (32.5%) were judged unsuitable for home dialysis due to contraindications [384 ( 24.2%)] or no assessment [106 (6.7%); mainly due to late referral and/or suboptimal DI] or death [26 (1.6%)]. Older age, comorbidity, late referral, suboptimal DI, acute illness and rapid loss of renal function associated with unsuitability. Of the remaining 1071 patients, 700 (65.4%) chose peritoneal dialysis (61.7%) or home haemodialysis (HD; 3.6%), while 371 (34.6%) chose in-centre HD. Somatic differences between patients choosing home dialysis and in-centre dialysis were minor; factors linked to the choice of in-centre dialysis were late referral, suboptimal DI, acute illness and absence of a 'home dialysis first' institutional policy.Conclusions.Given a personal choice with shared decision making, 65.4% of ESKD patients choose home dialysis. Our data indicate that the incidence of home dialysis potentially could be further increased to reduce the incidence of late referral and unplanned DI and, in acutely ill patients, by implementing an educational programme after improvement of their clinical condition.</p

First-year mortality in incident dialysis patients: results of the Peridialysis study

Background: Controversy surrounds which factors are important for predicting early mortality after dialysis initiation (DI). We investigated associations of predialysis course and circumstances affecting planning and execution of DI with mortality following DI.Methods: Among 1580 patients participating in the Peridialysis study, a study of causes and timing of DI, we registered features of predialysis course, clinical and biochemical data at DI, incidence of unplanned suboptimal DI, contraindications to peritoneal dialysis (PD) or hemodialysis (HD), and modality preference, actual choice, and cause of modality choice. Patients were followed for 12 months or until transplantation. A flexible parametric model was used to identify independent factors associated with all-cause mortality.Results: First-year mortality was 19.33%. Independent factors predicting death were high age, comorbidity, clinical contraindications to PD or HD, suboptimal DI, high eGFR, low serum albumin, hyperphosphatemia, high C-reactive protein, signs of overhydration and cerebral symptoms at DI. Among 1061 (67.2%) patients who could select dialysis modality based on personal choice, 654 (61.6%) chose PD, 368 (34.7%) center HD and 39 (3.7%) home HD. The 12-months survival did not differ significantly between patients receiving PD and in-center HD.Conclusions: First-year mortality in incident dialysis patients was in addition to high age and comorbidity, associated with clinical contraindications to PD or HD, clinical symptoms, hyperphosphatemia, inflammation, and suboptimal DI. In patients with a"free"choice of dialysis modality based on their personal preferences, PD and in-center HD led to broadly similar short-term outcomes.</p