Assessment of Interobserver Reliability of Nephrologist Examination of Urine Sediment.

To access publisher's full text version of this article, please click on the hyperlink in Additional Links field or click on the hyperlink at the top of the page marked DownloadImportance: Urine sediment microscopy is commonly performed during the evaluation of kidney disease. Interobserver reliability of nephrologists' urine sediment examination has not been well studied. Objective: Assess interobserver reliability of the urine sediment examination. Design, setting, and participants: In this diagnostic test study, urine samples were prospectively collected from a convenience sample of adult patients from an academic hospital in the United States undergoing kidney biopsy from July 11, 2018, to March 20, 2019. Digital images and videos of urine sediment findings were captured using a bright-field microscope. These images and videos along with urine dipstick results were incorporated in online surveys and sent to expert nephrologists at 15 US teaching hospitals. They were asked to identify individual sediment findings and the most likely underlying disease process. Exposures: Urine dipstick results and urine sediment images from patients undergoing native kidney biopsy. Main outcomes and measures: Interobserver reliability of urine sediment microscopy findings estimated by overall percent agreement and Fleiss κ coefficients. Secondary outcomes included concordance of diagnoses suspected by nephrologists with corresponding kidney biopsy results. Results: In total, 10 surveys from 10 patients containing 76 study questions on individual features were sent to 21 nephrologists, 14 (67%) of whom completed them all. Their combined 1064 responses were analyzed. Overall percent agreement for casts was an estimated 59% (95% CI, 50%-69%), κ = 0.52 (95% CI, 0.42-0.62). For other sediment findings, overall percent agreement was an estimated 69% (95% CI, 61%-77%), κ = 0.65 (95% CI, 0.56-0.73). The κ estimates ranged from 0.13 (95% CI, 0.10-0.17) for mixed cellular casts to 0.90 (95% CI, 0.87-0.94) for squamous epithelial cells. Conclusions and relevance: In this study, substantial variability occurred in the interpretation of urine sediment findings, even among expert nephrologists. Educational or technological innovations may help improve the urine sediment as a diagnostic tool

Bleeding Complications After Percutaneous Native Kidney Biopsy: Results From the Boston Kidney Biopsy Cohort.

To access publisher's full text version of this article, please click on the hyperlink in Additional Links field or click on the hyperlink at the top of the page marked DownloadBackground: The major risk of kidney biopsy is severe bleeding. Numerous risk factors for bleeding after biopsy have been reported, but findings have been inconsistent. Methods: We retrospectively reviewed medical records of adult patients enrolled in a native kidney biopsy cohort study to identify major bleeding events (red blood cell [RBC] transfusions, invasive procedures, kidney loss, or death). We used logistic and linear regression models to identify characteristics associated with postbiopsy RBC transfusions and decline in hemoglobin within a week after the procedure. Results: Major bleeding events occurred in 28 of 644 (4.3%) patients (28 required an RBC transfusion, 4 underwent angiographic intervention, and 1 had open surgery to control bleeding). No patient lost a kidney or died because of the biopsy. Postbiopsy RBC transfusion risk was driven by the baseline hemoglobin level (odds ratio [OR] 13.6; 95% confidence interval [CI] 5.4-34.1 for hemoglobin <10 vs. ≥10 g/dl). After adjusting for hemoglobin, no other patient characteristics were independently associated with RBC transfusions. Female sex (β = 0.18; 95% CI: 0.04-0.32), estimated glomerular filtration rate (eGFR) <30 ml/min per 1.73 m2 (β = 0.32; 95% CI: 0.14-0.49), and baseline hemoglobin (β = 0.09; 95% CI: 0.05-0.13, per g/dl increase) were independently associated with a larger drop in hemoglobin. Histopathologic lesions were not independently associated with major bleeding after biopsy. Conclusion: Biopsies were generally well tolerated. Baseline hemoglobin was the dominant risk factor for RBC transfusions, but female sex and eGFR <30 ml/min per 1.73 m2 were also associated with a larger decline in hemoglobin after the procedure.United States Department of Health & Human Services National Institutes of Health (NIH) - USA ASN Ben J. Lipps Research Fellowship Gran

Clinical spectrum of coronavirus disease 2019 in Iceland: population based cohort study.

To access publisher's full text version of this article, please click on the hyperlink in Additional Links field or click on the hyperlink at the top of the page marked DownloadObjective: To characterise the symptoms of coronavirus disease 2019 (covid-19). Design: Population based cohort study. Setting: Iceland. Participants: All individuals who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by reverse transcription polymerase chain reaction (RT-PCR) between 17 March and 30 April 2020. Cases were identified by three testing strategies: targeted testing guided by clinical suspicion, open invitation population screening based on self referral, and random population screening. All identified cases were enrolled in a telehealth monitoring service, and symptoms were systematically monitored from diagnosis to recovery. Main outcome measures: Occurrence of one or more of 19 predefined symptoms during follow-up. Results: Among 1564 people positive for SARS-CoV-2, the most common presenting symptoms were myalgia (55%), headache (51%), and non-productive cough (49%). At the time of diagnosis, 83 (5.3%) individuals reported no symptoms, of whom 49 (59%) remained asymptomatic during follow-up. At diagnosis, 216 (14%) and 349 (22%) people did not meet the case definition of the Centers for Disease Control and Prevention and the World Health Organization, respectively. Most (67%) of the SARS-CoV-2-positive patients had mild symptoms throughout the course of their disease. Conclusion: In the setting of broad access to RT-PCR testing, most SARS-CoV-2-positive people were found to have mild symptoms. Fever and dyspnoea were less common than previously reported. A substantial proportion of SARS-CoV-2-positive people did not meet recommended case definitions at the time of diagnosis

The value of pre-transplant coronary angiography findings in kidney transplant candidates at high risk for cardiovascular disease

IntroductionCardiovascular disease is a significant cause of mortality after kidney transplantation. Whether pre-transplant screening for coronary artery disease (CAD) in asymptomatic kidney transplant candidates (KTCs) is beneficial is unclear.MethodsWe conducted a retrospective cohort study evaluating post-transplant cardiovascular events in 192 high-risk KTCs who underwent pre-transplant CAD evaluation. The study aimed to identify risk factors associated with finding severe CAD on pre-transplant angiography, and to assess the relationship between screening strategies and post-transplant cardiovascular events.ResultsAt five years post-transplant, cardiovascular events occurred in 23.9% of subjects. Prior CAD history and left ventricular ejection fraction (LVEF) &lt; 50% were associated with higher odds of finding severe CAD on pre-transplant angiography. Severe CAD on angiography was associated with a higher risk of early cardiovascular events within six months of transplantation. However, coronary intervention in KTCs with severe CAD was not associated with lower rates of post-transplant cardiovascular events.ConclusionPre-transplant coronary angiography to identify severe CAD is of highest yield in KTCs with a history of CAD or an LVEF &lt; 50%. Our findings indicate that the identification of severe CAD in KTCs has prognostic significance for the early post-transplant period. Optimization of medical therapy in these high-risk KTCs may improve post-transplant cardiovascular outcomes

Lipoprotein(a) Concentration and Risks of Cardiovascular Disease and Diabetes

Publisher's version (útgefin grein)Background: Lipoprotein(a) [Lp(a)] is a causal risk factor for cardiovascular diseases that has no established therapy. The attribute of Lp(a) that affects cardiovascular risk is not established. Low levels of Lp(a) have been associated with type 2 diabetes (T2D). Objectives: This study investigated whether cardiovascular risk is conferred by Lp(a) molar concentration or apolipoprotein(a) [apo(a)] size, and whether the relationship between Lp(a) and T2D risk is causal. Methods: This was a case-control study of 143,087 Icelanders with genetic information, including 17,715 with coronary artery disease (CAD) and 8,734 with T2D. This study used measured and genetically imputed Lp(a) molar concentration, kringle IV type 2 (KIV-2) repeats (which determine apo(a) size), and a splice variant in LPA associated with small apo(a) but low Lp(a) molar concentration to disentangle the relationship between Lp(a) and cardiovascular risk. Loss-of-function homozygotes and other subjects genetically predicted to have low Lp(a) levels were evaluated to assess the relationship between Lp(a) and T2D. Results: Lp(a) molar concentration was associated dose-dependently with CAD risk, peripheral artery disease, aortic valve stenosis, heart failure, and lifespan. Lp(a) molar concentration fully explained the Lp(a) association with CAD, and there was no residual association with apo(a) size. Homozygous carriers of loss-of-function mutations had little or no Lp(a) and increased the risk of T2D. Conclusions: Molar concentration is the attribute of Lp(a) that affects risk of cardiovascular diseases. Low Lp(a) concentration (bottom 10%) increases T2D risk. Pharmacologic reduction of Lp(a) concentration in the 20% of individuals with the greatest concentration down to the population median is predicted to decrease CAD risk without increasing T2D risk.Peer Reviewe

Physical and cognitive impact following SARS-CoV-2 infection in a large population-based case-control study

© 2023. The Author(s).BACKGROUND: Persistent symptoms are common after SARS-CoV-2 infection but correlation with objective measures is unclear. METHODS: We invited all 3098 adults who tested SARS-CoV-2 positive in Iceland before October 2020 to the deCODE Health Study. We compared multiple symptoms and physical measures between 1706 Icelanders with confirmed prior infection (cases) who participated, and 619 contemporary and 13,779 historical controls. Cases participated in the study 5-18 months after infection. RESULTS: Here we report that 41 of 88 symptoms are associated with prior infection, most significantly disturbed smell and taste, memory disturbance, and dyspnea. Measured objectively, cases had poorer smell and taste results, less grip strength, and poorer memory recall. Differences in grip strength and memory recall were small. No other objective measure associated with prior infection including heart rate, blood pressure, postural orthostatic tachycardia, oxygen saturation, exercise tolerance, hearing, and traditional inflammatory, cardiac, liver, and kidney blood biomarkers. There was no evidence of more anxiety or depression among cases. We estimate the prevalence of long Covid to be 7% at a median of 8 months after infection. CONCLUSIONS: We confirm that diverse symptoms are common months after SARS-CoV-2 infection but find few differences between cases and controls in objective parameters measured. These discrepancies between symptoms and physical measures suggest a more complicated contribution to symptoms related to prior infection than is captured with conventional tests. Traditional clinical assessment is not expected to be particularly informative in relating symptoms to a past SARS-CoV-2 infection.Peer reviewe

Replacement of traditional prothrombin time monitoring with the new Fiix prothrombin time increases the efficacy of warfarin without increasing bleeding. A review article

Publisher Copyright: © 2021, The Author(s). Supported by the RANNIS technology development fund (The Icelandic Center for Research, [email protected]). The funding source had no contribution to the scientific work or writing of the text.The antithrombotic effect of vitamin K antagonists (VKA) depends on controlled lowering of the activity of factors (F) II and X whereas reductions in FVII and FIX play little role. PT-INR based monitoring, however, is highly influenced by FVII, which has the shortest half-life of vitamin K-dependent coagulation factors. Hence, variability in the anticoagulant effect of VKA may be partly secondary to an inherent flaw of the traditional monitoring test itself. The Fiix prothrombin time (Fiix-PT) is a novel test that is only sensitive to reductions in FII and FX and is intended to stabilize the VKA effect. Two clinical studies have now demonstrated that when warfarin is monitored with the Fiix-PT based normalized ratio (Fiix-NR) instead of PT-INR, anticoagulation is stabilized and less testing and fewer dose adjustments are needed. Furthermore, the relative risk of thromboembolism was reduced by 50–56% in these studies without an increase in major bleeding.Peer reviewe

Prevalence and progression of CRF in Iceland: a population-based study

To access publisher full text version of this article. Please click on the hyperlink in Additional Links fieldBACKGROUND: The prevalence of end-stage renal disease (ESRD) is lower in Europe than in the United States. The purpose of this study was to examine whether this difference results from a lower prevalence or slower progression of chronic renal failure (CRF) in a European cohort. METHODS: We studied 18,912 subjects (9,773 women, 9,139 men) aged 33 to 81 years who participated in the Reykjavik Study between 1967 and 1991. Subjects with serum creatinine (SCr) levels of 1.7 mg/dL (150 micromol/L) or greater were considered to have CRF. We determined the crude prevalence of CRF, as well as age-standardized prevalence for 5-year age groups, in individuals aged 30 to 79 years. Progression of CRF was defined as a decrease in estimated glomerular filtration rate greater than 1 mL/min/1.73 m2/y. RESULTS: Of 49 individuals who had an SCr of 1.7 mg/dL (150 micromol/L) or greater at entry, 41 individuals (26 men, 15 women) had a persistent elevation in SCr levels. Thirty-four individuals had mild CRF (SCr, 1.7 to 2.8 mg/dL [150 to 250 micromol/L]), 6 individuals had moderate CRF (SCr, 2.8 to 5.6 mg/dL [250 to 500 micromol/L]), and 1 individual had ESRD. The crude prevalence of CRF was 0.22% (220/100,000); 0.15% among women and 0.28% among men. The age-standardized prevalence was 0.23% (95% confidence interval [CI], 0.04 to 0.42) for women and 0.42% (95% CI, 0.18 to 0.66) for men. Eighty-five percent of patients with CRF were 50 years or older. Twenty-seven subjects had progressive renal failure, 17 of whom progressed to ESRD during a median of 7 years (range, 3 to 21 years). CONCLUSION: The prevalence of CRF is markedly lower in Iceland than in the United States. Furthermore, 27% of subjects did not show progression of their renal failure. These factors may explain in part the difference in ESRD prevalence between European countries and the United States

Ignoring instead of chasing after coagulation factor VII during warfarin management: an interrupted time series study.

To access publisher's full text version of this article click on the hyperlink belowDuring warfarin management, variability in prothrombin time-based international normalized ratio (PT-INR) is caused, in part, by clinically inconsequential fluctuations in factor VII (FVII). The new factor II and X (Fiix)-prothrombin time (Fiix-PT) and Fiix-normalized ratio (Fiix-NR), unlike PT-INR, are only affected by reduced FII and FX. We assessed the incidence of thromboembolism (TE) and major bleeding (MB) in all 2667 patients on maintenance-phase warfarin managed at our anticoagulation management service during 30 months; 12 months prior to and 18 months after replacing PT-INR monitoring with Fiix-NR monitoring. Months 13 to 18 were predefined as transitional months. Using 2-segmented regression, a breakpoint in the monthly incidence of TE became evident 6 months after test replacement, that was followed by a 56% reduction in incidence (from 2.82% to 1.23% per patient-year; P = .019). Three-segmented regression did not find any significant trend in TE incidence (slope, +0.03) prior to test replacement; however, during months 13 to 18 and 19 to 30, the incidence of TE decreased gradually (slope, -0.12; R2 = 0.20; P = .007). The incidence of MB (2.79% per patient-year) did not differ. Incidence comparison during the 12-month Fiix and PT periods confirmed a statistically significant reduction (55-62%) in TE. Fiix monitoring reduced testing, dose adjustments, and normalized ratio variability and prolonged testing intervals and time in range. We conclude that ignoring FVII during Fiix-NR monitoring in real-world practice stabilizes the anticoagulant effect of warfarin and associates with a major reduction in TEs without increasing bleeding.Icelandic Research Fund/Technology Development Fun