Day 1 :
Keynote Forum
John Mellas
St. Mary’s Health Center, USA
Keynote: The description of a method to accurately measure creatinine clearance in acute kidney injury
Time : 10:00-10:40
Biography:
John Mellas, MD, has been practicing nephrology for thirty years in St. Louis, Missouri. He is the Senior Partner in the largest nephrology practice in St. Louis. He is also Chairman of the Nephrology Division at St. Mary’s Health Center where he is actively involved in teaching internal medicine trainees. He has developed a method to measure creatinine clearance in acute kidney injury and has been using it in his practice for the last several years. A detailed description of the method was published in Mathematical Biosciences in March 2016, titled, “The Description of a Method to Accurately Measure Creatinine Clearance in Acute Kidney Injury”. His talk will describe the logic behind the derivation of the method with patient examples provided to illustrate its use in the evaluation of the patient with acute kidney injury.
Abstract:
Background: Acute kidney injury (AKI) is a common and serious condition encountered in hospitalized patients. The severity of kidney injury is defined by the RIFLE, AKIN and KDIGO criteria which attempts to establish the degree of renal impairment. The KDIGO guidelines state that the creatinine clearance should be measured whenever possible in AKI and that the serum creatinine concentration and creatinine clearance remain the best clinical indicators of renal function. Neither the RIFLE, AKIN, nor KDIGO criteria estimate actual creatinine clearance. Furthermore, there are no accepted methods for accurately estimating creatinine clearance in AKI.
Study Design: The present study describes a unique method for estimating K in AKI using urine creatinine excretion over an established time interval (E), an estimate of creatinine production over the same time interval (P), and the estimated static glomerular filtration rate (sGFR), at time zero, utilizing the CKD-EPI formula. Using these variables estimated creatinine clearance (Ke)=E/P*sGFR.
Setting & Participants: The method was tested for validity using simulated patients where actual creatinine clearance (Ka) was compared to Ke in several patients, both male and female, and of various ages, body weights and degrees of renal impairment. These measurements were made at several serum creatinine concentrations in an attempt to determine the accuracy of this method in the non-steady state. In addition, E/P and Ke was calculated in hospitalized patients, with AKI, and seen in nephrology consultation by the author. In these patients the accuracy of the method was determined by looking at the following metrics; E/P>1, E/P<1, E=P in an attempt to predict progressive azotemia, recovering azotemia, or stabilization in the level of azotemia respectively. In addition, it was determined whether Ke<10 ml/min agreed with Ka and whether patients with AKI on renal replacement therapy could safely terminate dialysis if Ke was greater than 5 ml/min.
Outcomes & Results: In the simulated patients, there were 96 measurements in 6 different patients where Ka was compared to Ke. The estimated proportion of Ke within 30% of Ka was 0.907 with 95% exact binomial proportion confidence limits. The predictive accuracy of E/P in the study patients was also reported as a proportion and the associated 95% confidence limits: 0.848 (0.800, 0.896) for E/P<1; 0.939 (0.904, 0.974) for E/P>1 and 0.907 (0.841, 0.973) for 0.9
Limitations: This includes the need to measure urine volume accurately. Furthermore, the precision of the method requires accurate estimates of sGFR, while a reasonable measure of P is crucial for estimating Ke.
Conclusions: the present study provides the practitioner with a new tool to estimate real time K in AKI with enough precision to predict the severity of the renal injury, including progression, stabilization, or improvement in azotemia. It is the author’s belief that this simple method improves on RIFLE, AKIN and KDIGO for estimating the degree of renal impairment in AKI and allows a more accurate estimate of K in AKI.
Keynote Forum
Roger E De Filippo
Children’s Hospital of Los Angeles, USA
Keynote: Injection of amniotic fluid stem cells delays progression of renal fibrosis
Time : 10:40-11:20
Biography:
Roger E De Filippo completed his MD at the Keck School of Medicine, University of Southern California, in 1993. He completed a Pediatric Urology Fellowship in 2003 at Boston Children’s Hospital, Harvard Medical School and did two years of Tissue Engineering research during his fellowship training. He is Chief of Pediatric Urology at Children’s Hospital Los Angeles and Co-Director of the GOFARR Laboratory for Organ Regenerative Research and Cell Therapeutics. He has published close to 50 manuscripts in reputed journals and presently serves on the Editorial Board of the journal Stem Cells Translational Medicine.
Abstract:
Introduction: Alport syndrome (AS) is a hereditary form of chronic kidney disease (CKD) and is also a valuable model for studying progressive renal fibrosis and end stage renal disease (ESRD). Herein, we investigate the therapeutic potential of amniotic fluid stem cells (AFSC), which are not only well established to possess pluripotential characteristics but also demonstrate anti-fibrotic properties that may potentially lead to better therapies for AS and/or other fibrotic diseases of the kidney.
Methods: In this study, we have administered AFSCs in a murine model of AS (Col4a5-/-) before the onset of proteinuria. Mice were sacrificed at 5 days, 1 and 2 month(s) post treatment and kidneys were harvested for molecular and histological analysis. Kidney function was assessed with serum creatinine, BUN as well as proteinuria measurements.
Results: Systemic infusion of AFSC resulted in delayed renal fibrosis and prolonged animal survival, slower progression of glomerulosclerosis and ameliorated kidney function. Treated mice presented lower myofibroblast transformation in the kidney interstitial space, accompanied with down-regulated expression of inflammatory and cytokines such as IL-1, TNFα and TGFβ. Furthermore, AFSC injected mice presented significantly less glomerulosclerosis as much as 2.5 months post stem cell treatment when compared to their untreated siblings. Injected animals exhibited decreased recruitment and activation of M1 type macrophages and an apparent preference towards M2 type macrophages; which are thought to favor tissue remodeling. AFSCs do not differentiate into podocyte-like cells and they do not stimulate the production of collagen IVa5, needed for correct glomerular basement membrane assembly and function. Our investigation supports a mechanism of renal protection through paracrine/endocrine modulation of expression of cytokines promoting fibrosis and macrophage recruitment to the interstitial space. Furthermore, injected mice manifested preservation of the number of podocytes and improved integrity of the glomerular basement membrane. These beneficial effects may be promoted by interference with the renin-angiotensin system by the AFSCs.
Conclusion: In this study, we have shown that AFSCs are capable of slowing down the progression of Alport disease by incurring structural and functional benefits to the kidney. Although injection of AFSC does not entirely reverse kidney disease, taken together, our findings suggest that a single AFSC treatment delays progression of CKD and significantly improves survival in treated AS mice. These cells may present an alternative approach to treat various medical conditions where currently therapeutic options are either limited or inadequate.
- Nephrology | Akute Kidney Injury | Chronic Kidney Diseases
Location: Appia 1 & 2
Session Introduction
Viachaslau Barodka
Johns Hopkins University, USA
Title: Prevention of cardiac surgery associated acute kidney injury by a goal-directed perfusion protocol: A propensity-scored analysis
Biography:
Viachaslau Barodka has completed his MD at Byelrussian State Medical University in 2000. In 2004, he moved to United States and completed his Residency Training in Anesthesiology at Thomas Jefferson University, Philadelphia, PA. In 2009, after completion of the Cardiothoracic Fellowship at The Johns Hopkins University Hospital, Baltimore, USA, he continued his career as an Assistant Professor of Cardiac Anesthesia. He has special expertise in cardiovascular physiology and outcomes after cardiac surgery. He has 25 publications in high impact peer reviewed journals.
Abstract:
We sought to determine whether a goal-directed perfusion protocol (GDPP) could reduce the incidence of acute kidney injury (AKI) following cardiac surgery. Based on available literature, we identified goals to achieve during cardiopulmonary bypass (including maintenance of oxygen delivery above 300 mL O2/min/m2 body surface area, and reduction in vasopressor use) which were combined into the GDPP. GDPP patients were matched to controls that underwent cardiac surgery between 2010-2015 using propensity scoring across 15 variables. The primary and secondary outcomes were the incidence of AKI and the mean rise in serum creatinine within the first 72 hours following cardiac surgery. We utilized GDPP in 88 patients, and matched these to 88 control patients who were similar across all variables including mean age (61 years in controls vs. 64 in GDPP patients, p=0.12) and preoperative glomerular filtration rate (90 vs. 83, p=0.34). Controls received more phenylephrine on cardiopulmonary bypass (mean 2.1 vs. 1.4 mg, p<0.001) and had lower nadir oxygen delivery (mean 241 vs. 301 mL O2/min/m2, p<0.001). The AKI incidence was 23.9% in controls and 9.1% in GDPP patients (p=0.008); incidences of AKI stage 1, 2, and 3 were 19.3%, 3.4% and 1.1% in controls, and 5.7%, 3.4%, and 0% in GDPP patients. Control patients exhibited a larger mean percent increase in creatinine from baseline (35% vs. 16%, p<0.001). GDPP appears effective in reducing AKI incidence following cardiac surgery. A randomized trial is needed to confirm these findings.
Vinod C Tawar
Kwantlen Medical Clinic, USA
Title: Stage III & IV renal dysfunction & significant restoration to normal EGFR by novel ace inhibitors: A retrospective study
Biography:
Vinod C Tawar has earned BSc Hons. and BSc Tech. Pharmaceuticals from University of Bombay. He was offered a Teaching Assistantship at the School of Pharmacy, University of Manitoba, Canada, where he achieved a Post-graduate (MSc) degree in Pharmacology followed by working as a Toxicologist at a university hospital in Winnipeg for a duration of 10 years. In due course, he developed a toxicology laboratory for patient management and forensic purposes. This later became a reference laboratory for the Province of Manitoba. In 1981, he decided to study medicine and graduated Medicine in 1985. Subsequently, he joined Douglas Hospital Research Centre at McGill University as a Psychiatry Research Consultant with participation in projects on depression, Alzheimer’s disease, alcoholism and schizophrenia. Here he had co-authored many research papers. After 5 years, he was offered a two year Residency Position for licensure in general practice. Currently, he has been in an office based group family medicine practice for 16 years. Eight years ago, he has completed Post-graduate studies in Family Medicine for the specialty while working. During his practice, he had conducted research on depression, hypertension, GERD and asthma. At present, he has maintained his interest on nephropathy and challenging tasks of medicine.
Abstract:
This study has been based on the improvements observed in predominantly diabetic patients with EGFR falling below normal, leading to stage III and stage IV renal damage. The study consisted of a review of 82 patients’ clinical records. Approximately 27% of the patients had demonstrated falling EGFR and were started on perindopril 8 mg or trandolopril 2–4 mg per day. The duration of treatment needed to restore to normal EGFR varied from 8 to 16 weeks depending on the extent of dysfunction (EGFR>40). The population consisted of male and female patients mainly of South Asian origin. Perindopril has shown to be beneficial in patients with EGFR of over 40 and trandolopril 4 mg dose has been useful in patients with stage IV cases. The findings have encouraged me to initiate diabetic patients with the above mentioned ACEI for prevention of renal dysfunction.
Boris Ajdinovic
Military Medical Academy, Serbia
Title: Diuretic 99mTc DTPA renography in assessment of renal function and drainage in infants with antenatally detected hydronephrosis
Biography:
Abstract:
Background: Controversy about the postnatal management of infants with antenatally detected hydronephrosis (ANH) still exists. We report the results of diuretic 99mTc DTPA renography on 30 infants presenting with an antenatal diagnosis of unilateral renal pelvic dilatation.
Aim: Aim of this study was to assess the renal function determined by the pattern of drainage and split renal function (SRF) on diuretic renography and to correlate these findings with antero-posterior pelvic diameter (APD) estimated by ultrasonography.
Methods: Thirty infants with 60 renal units (RU) (25 boys and 5 girls, median age 6.0 months, range 2–24) who presented with unilateral hydronephrosis on ultrasound in newborn period underwent DTPA diuretic renal scintigraphy (F+15 protocol). We classified hydronephrosis into 3 groups according to APD: Mild (APD 5–9.9 mm) in 5/60 RU, moderate (APD 10–14.9 mm) in 10/60 RU and severe (APD≥15 mm) in 17/60 RU. The postnatal associated clinical diagnosis were pelviureteric junction obstruction (PUJ), simple hydronephrosis, megaureter, vesicoureteral reflux (VUR) and posterior urethrae valves in 11, 10, 6, 2 and 1 infant respectively. Images and Tmax/2 after diuretic stimulation on the background subtracted renographic curves were used as the criteria for classifying the drainage as 1) good 2) partial and 3) poor or no drainage. SRF was calculated with integral method.
Results: Good drainage was shown in 36/60, partial drainage in 13/60 and poor or no drainage in 11/60 RU. In infants with severe ANH (APD≥15 mm), obstruction was not excluded in 1/17 RU (94.1%); and in infants with mild to moderate ANH, obstruction excluded in 13/15 RU (86.7%); p<0, 001. Split renal function (SRF) >40% was observed in 55/60 RU, with no RU showing SRF less than 23.5%.
Conclusion: Although ANH is mostly benign condition and has favorable outcome, it can also cause a significant morbidity. Diuretic renography in antenatally detected hydronephrosis should be a useful tool in postnatal follow up, especially in differentiating nonobstructive form hydronephrosis from obstructive. In the presence of partial or no drainage, the SRF may not be significantly impaired. Finding of poor renal emptying is significantly more common among children with increasing renal pelvis APD.
Nina Dunne
University of Brighton, UK
Title: A meta-analysis of sodium profiling techniques and the impact on intradialytic hypotension
Biography:
Nina Dunne obtained a scholarship to undertake a PhD from The University of Manchester, UK. Her research focus is centered on Pediatric Dialysis. She is currently a Senior Lecturer in Child Health at The University of Brighton, UK.
Abstract:
Hemodialysis has improved in recent years; however, despite such improvements, intra-dialytic hypotensive episodes still persist which can lead to a reduction in the overall effectiveness of the treatment. Profiling sodium levels during dialysis can improve vascular refilling and therefore may prevent hypotensive events. A number of profiling methods exist and this meta-analysis is set out to examine the effectiveness of these methods. A review and meta-analysis analytical framework was used to assess the effectiveness of hemodialysis sodium profiling techniques. Stata 11.2 (Stata Corp) was used to analyze the data. Actual numbers of hypotensive events were pooled between studies. Analysis of subgroups was performed on sodium profile type. The data were further investigated using meta-regression. Publication bias was also tested. Stepwise profiling was shown to be statistically significantly effective in reducing intradialytic hypotensive episodes. Results demonstrated that linear sodium profiling was not effective in reducing hypotensive events during dialysis. This review has shown that using stepwise profiling is more effective at reducing intra-dialytic symptoms than other profiling methods. There was no evidence that linear profiling method was any more effective than conventional dialysis and in fact the results showed the reverse.
Joanne Reid
Queen’s University Belfast, UK
Title: Establishing a clinical phenotype for cachexia in chronic kidney disease
Biography:
Joanne Reid’s predominate area of research is aligned with the MRC framework and focuses on cachexia. The quality of her research and its knowledge translation is evidenced by research outputs. She has received a Royal College of Nursing, Nurse of the Year Research Award for her competitively funded work on cachexia which has informed national guidelines, for example Royal College of Nursing end of life guidelines. She is an Associate Editor of BMC Palliative Care, and has been an invited guest Editor for Healthcare.
Abstract:
Cachexia contributes to increased morbidity and premature mortality in persons with chronic illnesses including cancer, cardiac failure and chronic kidney disease. It is a multifactorial syndrome which currently lacks a clear definition in a renal population. This presentation will present a study outline which aims to determine the clinical phenotype of cachexia specific to individuals with CKD and is scheduled to start in autumn, 2016. This is a longitudinal study which will run over 2 years. All adult hemodialysis patients who attend the Northern Ireland Regional Nephrology Unit (NIRNU), who have a confirmed diagnosis of stage 5 CKD (estimated GFR<15 mL/min/1.73 m2) will be eligible for inclusion into this study to determine if they experience (and to what degree) the known characteristics associated with cachexia. Patients will be monitored for 1 year (or time till death if <1 year). The NIRNU provides care to approximately 250 stage 5 CKD hemodialysis patients per annum. The recruitment window for this study is approximately 7 months, with a potential patient population of 145. Potential patients will be identified via inpatient wards and outpatient units at NIRNU. We are proposing to study all patients. Data collection measures (bloods plus validated tools to determine QoL, fatigue and anorexia; lean muscle mass and muscle strength) will be collected at routine hemodialysis appointments. The patients recruited will be followed for 1 year to ascertain the percentage that develops known characteristics of cachexia and to what degree they experience these characteristics.
Hariharan Munganda
Asian Institute of Medical Sciences, India
Title: A prospective observational study on prevalence of hepatitis C virus infection and its risk factors in chronic kidney disease patients on hemodialysis at a tertiary care center in Delhi NCR, India
Biography:
Hariharan Munganda is pursuing his DNB Medicine Post-graduate degree after his MBBS. He has participated in national and international conferences. He has published papers in reputed national and international journals and has been serving as a research student in Nephrology Department of reputed hospital in Delhi NCR, India.
Abstract:
Introduction: Chronic renal disease patients on hemodialysis are at increased risk of infection by hepatitis C virus (HCV). Subjects undergoing treatment in dialysis centers without nephrologists and improper viral marker screening, dialysis at more than one center and no separate dialysis machine for HCV+ve patients and unscreened blood transfusion are at risk of cross contamination. Thus, there is a need to screen these subjects for prevalence of HCV seropositivity and study the impact of HCV positivity on clinical course of the disease.
Aim: Aim of or study was to assess prevalence of HCV positivity in CKD on hemodialysis subjects; and also to assess various characteristics of HCV positive subjects and compare them with HCV negative CKD subjects.
Methodology: In our Asian tertiary care hospital, dialysis unit a total of 100 CKD subjects were recruited for the study and after informed written consent, further detailed history, socioeconomic and clinical parameters including dialysis related parameters were analyzed and compared between the Hepatitis C seropositive and seronegative subjects. Hepatitis C positivity was assessed using chemiluminescence.
Result: Prevalence of seropositivity was found to be 16% in CKD subjects. Only 2% of the subjects have acquired HCV from our hospital while 14% have acquired HCV infection from other sources.
Conclusion: High prevalence of HCV infection exists in CKD subjects. Facilities for separate dialyzer under expert supervision from nephrologists are strictly recommended to contain the HCV infection.
Aldjia Leila Azouaou
Parnet Hussein Dey Algiers-CHU, Algeria
Title: Incessant research of target weight
Biography:
L Azouaou is a Teacher Assistant of Nephrology in College of Medicine of Algiers. She is a Graduate of the University of the Sorbonne in Paris in Nephropathology IUD, and Founder of the genetic study of SNCR in Algeria. She participated actively in several nephrology congresses in the world.
Abstract:
Introduction: The regulation of blood pressure is very difficult in hemodialysis patients. High blood pressure (hypertension) in hemodialysis was mainly due to a surplus of extracellular volume and increased peripheral resistance that result. Scribner described early in the non-drug treatment of this common complication by sodium diet and ultrafiltration. The correction of hypertension in hemodialysis is done by the dry weight method. The dry weight of the estimation error in chronic hemodialysis patients affects their morbidity and mortality. The aim of our study is to compare the results of estimating "Subjective" dry weight by the clinic with the results of impedance, ultrasound of the inferior vena cava and BNP testing in order identify risk factors for clinical estimation error of the dry weight.
Materials & Methods: This is a prospective study conducted in the hemodialysis center Nafisa Hamoud CHU Parnet of Algiers on 67 chronic hemodialysis patients. The estimate of the water status of patients was assessed by the three above-mentioned methods. We used the BCM (Body Composition Monitor) immediately before the dialysis session, excess post-dialysis fluid was calculated by a formula validated (excess of normal volume by BCM is -1,1 L to + 1.1 L). Serum BNP (B-type natriuretic peptide) was measured before and after dialysis and the calculation of the vein diameter lower cellar. We compared the target weight goal determined by these methods and the subjective target weight. The gap between the two was significant weight when it was greater than 1 kg.
Results: The median age of patients was 40±5 years, and a man sex ratio/woman of 0.84, average BMI of 21±3.5 kg/m2. Les values ​​measured by the various techniques used, drop significantly after the session hemodialysis. We objectified a significant correlation between the results of the impedance, the BNP and the index of the maximum and minimum VCI. 41.5% of our patients have excess volume (hydration), while 49% were within the normal range or with normal hydrated and 8% were dehydrated. We corrected the dry weight of the patients according to the weight determined by the 3 methods, and after two months there has been a balancing of the hydration status of patients and their blood pressures.
Discussion: Determining the "Dry Weight" of patients with ESRD by clinical evidence is not sufficiently reproducible. Our results demonstrate that the clinical evaluation of the dry weight is correlated with dry weight of values ​​estimated by BCM, BNP assay and the IVC diameter.
Conclusion: This study is among the few studies that used the three above-mentioned methods for assessing hydration status of chronic hemodialysis to show a good correlation between these three methods. The existence of a gap between the subjective and objective target weight suggests the incessant need for a coupling between the various techniques evaluated on a strategy adapted to the characteristics of each patient.
Marsida Duli
Ministry of Health, Albania
Title: Health policies on dialysis and chronic kidney disease: The benefits of the Albanian patients
Biography:
Marsida Duli is Advisor at Ministry of Health in Tirana, Albania. She is Nephrologist by her profession and is currently pursuing PhD at the Medical University of Tirana. She received her Master of Science in Health Services Management from University of Siena in Italy. She lectured at public and private universities where she chaired the Department of Public Health in Medicine Faculty. She has published regularly in national and international scientific journals on topics like nephrology, dialysis, health policies, Albanian health system and health services management.
Abstract:
Chronic kidney disease (SRK) increasingly constitutes a global public health problem of the importance of first-hand. In Albania the problem is practically unknown by the population, yet little-known and widely underestimated by doctors and by the government policy makers and public health authorities. Currently in Albania, chronic renal diseases have an increased incidence and prevalence, as well as a clear trend towards the terminal stage, towards renal replacement therapy. The dialysis service is provided by the public sector and the inability to provide this service in public hospitals of all those patients is increasing in number. Since 2007, half of them take it in private hospitals, where the state reimburses the bill for this service in the private sector. With recent developments in Albanian health policies, the development of health service packages for free, the dialysis service is offered to patients due to public-private partnership, from the private sector, even closer to home. This form of financing health services offers, flexibility for patients to be diagnosed and in need to be treated with dialysis, a continuous medication and without fail. Other challenges are still Albanian nephrology primary, secondary and tertiary prevention. The end result is intended to reduce morbidity and mortality from renal diseases, and improve the quality of health care provided to patients on dialysis.