Chronic kidney disease (CKD) is associated with increased risk of fragility fracture but whether this is independent of osteoporosis is unclear.
We conducted a retrospective cross-sectional study of ...1,702 female patients referred for dual-energy X-ray absorptiometry (DXA) scanning (Lunar IDXA) between September 2006 and April 2007. Estimated glomerular filtration rate (eGFR; ml/min/1.73 m(2)) by Modification of Diet in Renal Disease was calculated within 1 year (median interval 4 weeks) of the DXA scan. The independent association of self-reported fracture occurrence with eGFR category was assessed using multivariate logistic regression.
Mean age (SD) was 61.7 (10.8) years; mean eGFR (SD) was 68.8 (12.2). The percentages of subjects with an eGFR of 75-89, 60-74, 30-59 and <30 was 34, 45, 20 and 0.8%, respectively. Forty-seven percent had osteoporosis. Mean T scores for the above eGFR categories were -2.2, -2.3, -2.5 and -3.0, respectively (p trend <0.001). Osteoporosis was significantly associated with eGFR on univariate analysis but not following adjustment for age. The percentage of patients with a fracture (29%) and with multiple prior fractures (3.5%) was higher at lower eGFR (p < 0.001, χ(2) test). The adjusted odds ratios (95% confidence interval) of any prior fracture for eGFR 75-89, 60-74 and 30-59 were 1.0 (reference), 1.2 (0.9-1.6) and 1.4 (1.0-1.9), respectively, adjusting simultaneously for age, T score, risk factors and treatment for osteoporosis.
Moderate CKD is a significant independent predictor of fracture occurrence.
Introduction Experience with the use of patient‐reported outcome measures such as EQ‐5D and the symptom module of the Palliative care Outcome Scale—Renal Version (POS‐S Renal) as mortality prediction ...tools in hemodialysis is limited.
Methods A prospective survival study of people receiving hemodialysis (N = 362). The EQ‐5D and the POS‐S Renal were used to assess symptom burden and self‐rated health (with a self‐rated component). Participants were followed from instrument completion to death or study end. Competing risks survival analysis was used to evaluate associations with time to death, with renal transplant as a competing risk.
Findings 32% (N = 116) of participants died over a median (25th–75th centile) of 2.6 (1.41–3.38) years. Factors most notably associated with mortality adjusted hazard ratio (95%CI) included: lower EQ VAS score 2.7 (1.4, 5.2) P = 0.004 (lowest tertile), higher POS‐S Renal score 2.4 (1.3, 4.3) P = 0.004 (highest tertile), and lower EQ‐5D score 2.6 (1.3, 5.3) P = 0.01 (lowest tertile) as well as the presence of: “problems with mobility?” 2 (1.1, 3.3) P = 0.01, or “problems with usual activities?” 2.1 (1.4, 3.3), P < 0.001. After age adjustment area under the receiver operating curves (AUC) (95%CI) for mortality were: 0.71 (0.62, 0.79) for EQ VAS score, 0.71 (0.63, 0.80) for POS‐S Renal‐S Renal score, and 0.76 (0.68, 0.84) for EQ‐5D score. AUC 95%CI was highest for our fourth model at 0.79 (0.72, 0.86) comprised of individual elements from both instruments and established risk factors.
Discussion EQ VAS scores and predictive models based on combinations of elements from the POS‐S Renal and EQ‐5D instruments may aid in mortality discrimination and possibly in the delivery of supportive care services.
The link between myeloma and thrombosis is well established. Monoclonal gammopathy of undetermined significance (MGUS) has also been associated with an increased risk of thrombosis. It was recently ...demonstrated that patients with myeloma display changes in thromboelastometry that may indicate a prothrombotic state. There is little data with regard to changes in thromboelastography in patients with myeloma or MGUS. The aim of this study was to investigate the differing coagulation profiles of patients of patients with myeloma and MGUS by means of conventional coagulation tests and thromboelastography. Blood was taken by direct venepuncture from patients with myeloma, MGUS and normal controls. Routine coagulation tests were performed in an accredited hospital laboratory. Thromboelastography (TEG
®
) was performed as per the manufacturer’s protocol. Eight patients were recruited in each group. Patients with myeloma had a significantly lower mean haemoglobin level than patients with MGUS or normal controls (
p
< 0.001). Pateints with myeloma had a significantly more prolonged mean prothrombin time than normal controls (
p
= 0.018) but not patients with MGUS. Patients with myeloma had significantly higher median D-dimer levels than normal controls (
p
= 0.025), as did patients with MGUS (
p
= 0.017). Patients with myeloma had a significantly higher mean factor VIII level than normal controls (
p
= 0.009) and there was a non-significant trend towards patients with MGUS having higher factor VIII levels than normal controls (
p
= 0.059). There was no significant difference in thromboelastographic parameters between the three groups. Patients with MGUS appear to have a distinct coagulation profile which is intermediate between patients with myeloma and normal controls.
Venous Thromboembolism in Patients With Myeloma Crowley, Maeve P.; Eustace, Joseph A.; O’Shea, Susan I. ...
Clinical and applied thrombosis/hemostasis,
09/2014, Letnik:
20, Številka:
6
Journal Article
Recenzirano
Myeloma has a well-described association with venous thromboembolism (VTE). There are few dedicated studies investigating the incidence and risk factors. Many assessment scores have been suggested to ...estimate the risk of VTE in patients with cancer but these have been validated in solid organ tumors. The records of patients with myeloma attending a university hospital between January 2007 and December 2012 were reviewed to investigate the incidence of VTE and the associated risk factors. In all, 217 patients with a mean (standard deviation) age at diagnosis of 65 (12) years were included. Of 217 patients, 12% had an episode of VTE, 69% received at least 1 immunomodulatory agent, and 95% had low or intermediate risk of VTE according to the Khorana score. Venous thromboembolism was a frequent occurrence in this cohort. Patients had many risk factors for VTE but no one was predictive. As myeloma outcomes continue to improve, a dedicated prospective study is warranted to investigate the most appropriate thromboprophylaxis strategy.
The prevalence of chronic kidney disease (CKD) using available estimating equations with the Republic of Ireland is unknown.
A randomly selected population based cross-sectional study of 1,098 adults ...aged 45 years and older was conducted using data from the 2007 Survey of Lifestyle, Attitudes and Nutrition (SLÁN). Estimated Glomerular Filtration Rate (eGFR) was calculated from a single IDMS aligned serum creatinine using the CKD-EPI and the MDRD equations, and albumin to creatinine ratio was based on a single random urine sample.
The sample clinical characteristics and demography was similar to middle and older age adults in the general Irish population, though with an underrepresentation of subjects >75 years and of males. All results are based on subjects with available blood and urine samples. Applying weighting to obtain survey based population estimates, using Irish population census data, the estimated weighted prevalence of CKD-EPI eGFR<60 mL/min/1.73m2 was 11.6%, (95% confidence interval; 9.0, 14.2%), 12.0% ( 9.0, 14.2%) of men and 11.2% (7.3, 15.2%) of women. Unweighted prevalence estimates were similar at 11.8% (9.9, 13.8%). Albuminuria increased with lower CKD-EPI eGFR category. 10.1% of all subjects had albuminuria and an eGFR≥60 mL/min/1.73 m2 giving an overall weighted estimated prevalence of National Kidney Foundation (NKF) defined CKD 21.3% (18.0, 24.6%), with the unadjusted estimate of 21.9% (19.5, 24.4%). MDRD related estimates for eGFR <60 mL/min/1.73 m2, and NFK defined CKD were higher than CKD-EPI and differences were greater in younger and female subjects.
CKD is highly prevalent in middle and older aged adults within the Republic of Ireland. In this population, there is poor agreement between CKD-EPI and MDRD equations especially at higher GFRs. CKD is associated with lower educational status and poor self rated health.
Cohort study of the treatment of severe HIV-associated nephropathy with corticosteroids.
Human immunodeficiency virus-associated nephropathy (HIVAN) results in rapidly progressive azotemia. The ...effectiveness and safety of corticosteroids in the treatment of HIVAN, however, remains controversial.
We conducted a retrospective cohort study of patients with biopsy-proven HIVAN and progressive azotemia who were eligible for corticosteroid treatment and who had no clinical or histologic evidence of an alternative cause of acute renal failure. Selected patients were treated with 60 mg of prednisone for one month, followed by a several-month taper.
Twenty-one eligible patients were identified. Thirteen subjects had received corticosteroid treatment, whereas eight had not. The mean serum creatinine was 6.2 and 6.8 mg/dL, respectively (P > 0.05). The relative risk (95% CI) for progressive azotemia with corticosteroid treatment at three months was 0.20 (0.05, 0.76, P < 0.05). This association remained significant despite adjustment in separate logistical regression analyses for baseline creatinine, 24-hour proteinuria, CD4 count, history of intravenous drug use, hepatitis B, and hepatitis C. In an additional logistic regression model, using backward stepwise selection of the previously mentioned covariates, only corticosteroid treatment (P = 0.02) and baseline serum creatinine (P = 0.10) were retained within the model. In the corticosteroid-treated group, the mean level of proteinuria decreased by 5.5 g/24 hour (P = 0.01). On long-term follow-up, there was no significant difference in the incidence of hospitalizations (1 per 2.1 vs. 1 per 2.3 patient months) or of serious infections (1 per 2.6 vs. 1 per 2.3 patient months), but there was a significantly longer duration of hospitalization in the corticosteroid-treated group (3.2 vs. 2 days per patient month). At six months, only one of the non–corticosteroid-treated patients but seven of the corticosteroid-treated group continued to have independent renal function (P = 0.06). Three of the corticosteroid-treated group continued to have independent function at two years of follow-up.
A limited course of corticosteroid therapy in selected patients was beneficial and safe. Further research is required for the role of corticosteroids in the treatment of HIVAN.
The occurrence of vascular stiffness in the setting of the nephrotic syndrome and the influence of serum phosphate on this association is unknown.
A retrospective study of 42 prevalent, adult ...nephrotic patients who underwent carotid-femoral pulse wave velocity (PWV) measurement, a median of 24 months after kidney biopsy. Elevated PWV was determined using published age-specific reference ranges. The association, statistical significance and independence of serum phosphate with spot urine protein-creatinine ratio (PCR) and the association of phosphate with PWV was examined.
Mean PCR was 5.5 g/g and mean eGFR (CKD-EPI) was 70 mL/min/1.73 m2. Serum phosphate was statistically significantly associated with severity of nephrotic syndrome independently of eGFR and age. Median (intra-quartile range) PWV was 7 m/s (4-11), with a linear trend for higher PWV across tertile of average serum phosphate over follow-up, P<.001. Twenty subjects (48%) had elevated age-specific PWV, which on logistic regression was statistically significantly associated with mean serum phosphate, OR (95% CI) per 0.1 mmol/L: 2.7 (1.5, 4.9), P = .001, which in separate analyses was independent of eGFR and other laboratory data.
In this cohort of patients with the nephrotic syndrome serum phosphate was commonly elevated, despite well preserved eGFR, which was significantly and independently associated with elevated PWV over follow-up.
Despite limitations of routine methods, Clinical Practice Guidelines support the assessment of bone mineral density (BMD) and vascular calcification in renal transplant recipients. Changes in fat ...mass also occur post-transplantation, although they are traditionally difficult to measure accurately. We report the feasibility, convenience and accuracy of measuring the above 3 parameters using a novel CT protocol.
We conducted a cross-sectional study of 64 first renal allograft recipients (eGFR > 30 ml/min/1.73 m(2)). Quantitative CT (QCT) BMD analysis was conducted using CT lumbar spine (GE Medical Systems Lightspeed VCT & Mindways QCT Pro Bone Mineral Densitometry System Version 4.2.3) to calculate spinal volumetric BMD and compared with standard DXA calculated areal BMD at the spine, hip and distal forearm. Abdominal aortic calcification was assessed by semi-quantitative Aortic Calcification Index (ACI) method and compared with lateral lumbar x-ray Kappuila score and pulse wave velocity (PWV). Visceral and subcutaneous adipose tissue volume (Osirix 16 Ver 3.7.1) was compared with BMI.
Participants were 61 % male, had a mean age of 47 years, median ESKD duration of 5.4 years and a mean eGFR of 54 ml/min. iDXA median T-score at proximal femur was -1.2 and at lumbar spine was -0.2. Median QCT Trabecular T-score at lumbar spine was -1.2. The percent of subjects with a T-score of < 2.5 by site and method was DXA Proximal Femur: 7 %, DXA distal radius: 17 %, DXA spine: 9 %, QCT (American College of Radiology cutoffs): 9 %. CT derived ACI correlated with PWV (r = 0.29, p = 0.02), pulse wave pressure (r = 0.51, p < 0.001), QCT Trabecular (-0.31, p = 0.01) and cortical volumetric BMD and history of cardiovascular events (Mann-Whitney U, p = 0.02). Both visceral and subcutaneous adipose tissue correlated with BMI (r = 0.63 & 0.64, p < 0.001).
Single CT scan triple assessment of BMD, vascular calcification and body composition is an efficient, accurate and convenient method of risk factor monitoring post renal transplantation.
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