Day 1 :
Keynote Forum
Eleni Theodoropoulou
General Hospital of Athens "Alexandra", Athens, Greece
Keynote: ABO-Incompatible kidney transplantation: Current trends and future perspectives
Biography:
Eleni Theodoropoulou is working in the Department of Nephrology of General Hospital of Athens " Alexandra",Athens Greece as a Consultant Nephrologist. She has been involved in a large field of nephrology both in scientific and education levels.
Abstract:
Kidney transplantation (KTx) is the treatment of choice for well-selected patients with end-stage renal disease (ESRD) as it improves both quality of life and life expectancy (1,2). However, although it is well documented that KTx and particularly pre-emptive KTx, should be considered as optimal regarding patient’s survival, the steadily growing shortage of kidney transplants makes that approach unrealistic. In order to overpass that problem, several strategies have evolved: (i) KTx with “borderline” donors, (ii) KTx with non-heart beating donors, (iii) ABO-incompatible (ABOi) KTx, (iv) KTx across a positive cross-match, (v) kidney paired donation, and (vi)
altruistic donation. The first series of 26 successful ABOi KTx was reported by Alexandre et al in 1987 (3). Recipient’s desensitization included splenectomy, immunosuppression with steroids,
cyclosporine, azathioprine, and anti-thymocyte globulin, as well as donor-derived platelets transfusion. Since 1989, ABOi KTx has been extensively implemented in Japan because of a religious-driven limited deceased organ donation. From there comes the largest published study including 1878 ABOi KTxs performed from 1989 to
2010 (4). Recipient’s desensitization included plasmapheresis (PP) or other apheresis technique, immunosuppression with steroids, calcineurin inhibitors, antimetabolites, antilymphocyte globulin, cyclophosphamide or deoxyspergualin in various combinations, and anticoagulation. Splenectomy had been performed in 98% of the
cases during the earlier era (1989-2000), in the recent era (2001-2010) it has been subsequently substituted by rituximab. Graft survival rates for the first year improved from 82% in the earlier era to 96% in the recent era. Given the promising results been published by the Japanese, similar protocols have been gradually implemented in the USA and Europe since the mid-1990s. The mainstay of all
preconditioning regimens is the removal of preformed isohaemagglutinin antibodies (by PP, double-filtration plasmapheresis, specific and non-specific immunoadsorption) and the prevention of formation of new ones (earlier by splenectomy, later by rituximab, intravenous immunoglobulins).
Graft survival time seems to be equivalent between ABOi and ABO-compatible (ABOc) transplant recipients in various studies (5, 6). In a recent meta-analysis (7) of divergent studies, it was concluded that “ABOi KTx has very good outcomes, albeit inferior to ABOc KTx”, but still better than remaining on dialysis or receiving a deceased donor kidney transplant. Major complications include infections which is the leading cause of death, antibody-mediated rejection and bleeding. The optimal pretransplantation isohaemagglutinin titre is still debatable. It is of note, that blood group A2 is less antigenemic and that minor incompatibility constellations
against A2 antigen have been safely transplanted without desensitization. Nevertheless, a safe pretransplantation isohaemagglutinin titre has been reported as ≤1/8 albeit with deviation depending on the centre, the measurement method used and the acceptable cut-off values. Flow cytometry has been proved to be the most reliable and reproducible technique for measurement of isohaemagglutinin titre (8). The reason why isohaemagglutinins against recipient’s blood type antigens are detected in the peripheral blood soon after KTx but no antibody-antigen reaction is recorded has been attributed to a phenomenon called “accommodation”. So far, the mechanism behind that phenomenon has been remaining elusive and speculative. Today, ABO-i KTx accounts for approximately 30% of all living donor kidney transplantations performed in Japan. Despite the wide implementation as well as the good results, there are still questions to be answered, such as (i) What is the best method to measure the isohaemagglutinin titre? What are the acceptable titres before as well as after desensitization? (ii) What is the most efficacious and safest
procedure for the removal of preformed antibodies? (iii) Is the administration of rituximab mandatory in all cases? (iv) What is the role of intravenous immunoglobulins? Is there a connection to the increased bleeding complications after transplantation? (v) What are the mechanisms of the phenomenon called “accommodation”? (vi) What is the role of newer molecules (eculizumab, abase,F7508) in the prevention of acute humoral rejection?
- Dialysis | Diabetic Nephropathy | Renal Failure | Kidney Stones | Urology | Nephrology | Critical Care | Renal Nursing | Cardiac Renal Failure | Kidney Transplantation
Location: Istanbul, Turkey
Chair
Eleni Chelioti
Eleni Chelioti is working in the General Hospital of Athens "Alexandra", Athens, Greece
Session Introduction
Eleni Chelioti
Tzaneio Prefecture General Hospital of Piraeus, Greece
Title: Estimation of renal function in elderly diabetic patients
Biography:
Eleni Chelioti is working as a Consultant Nephrologist in the Department of Nephrology of General Hospital of Piraeus Tzaneio in Athens,Greece. She has passion in improving the health and well-being in patients with chronic kidney disease.
Abstract:
Kidney function loss in type 2 diabetic patients (T2DM) translates into
a high incidence of chronic kidney disease (CKD) and susceptibility to ischemic or toxic renal insults. In clinical practice indirect methods are used to approximate GFR. The MDRD, Cockcroft-Gault (CG) and the CKD-EPI formulae are the mostfrequently used.
The aim of the study was to assess the accuracy and impact of formula-based for the estimation of renal function in elderly diabetic patients.
Material and methods: A cross sectional study was carried out. The study included elderly patients with T2DM and serum creatinine over the normal range, who attended the outpatient nephrology clinic of our hospital within 2016. Diabetic nephropathy (DN) was classified in 5 stages: stage 1(S1): >90, stage2(S2): 60-89, stage 3(S3): 30-59, stage 4(S4):15-29 and stage 5(S5): <15 ml/min/1.73m 2 . Renal function was estimated using MDRD, CG and CKD-EPI formulaes. Categorical data are presented as absolute and relative frequencies and using the Pearson r test.
Results: 125 patients were included (48%males, mean age 70±11 years). According to the CG equation, the percentage of patients who classified to the 5 stages were: 4% S1, 8% S2, 15% S3, 32% S4 and 41% S5. Using the MDRD and CKD-EPI formulae the percentage of patients did not differ between the 5 stages and were 1,5%, 3%, 12%, 32% and 51,5% respectively. Comparison between CG, CKD-EPI and MDRD equations, revealed a higher percentage (10,6%) of patients to the stage 5 using either CKD-EPI and MDRD. At the same time CG revealed a higher percentage of patients at stage 1, 2 and 3(3%, 4,6% and 3,1% respectively).
The correlation between CG and CKD-EPI and CG and MDRD was statistically significant (r=0,884, p=0,001 and r=0,854, p=0,001 respectively).
Conclusions: Our results show that CG equation overestimated the renal function of elderly diabetic patients in the first 3 stages of DN. On the other hand, CKD-EPI and MDRD seems to have a higher accuracy at estimates the renal function in T2DM elderly patients in different stages of DN and particular to the stage 5, when compared with the CG equation.
Key words: type 2 diabetes mellitus, elderly, estimation renal function, equations, diabetic nephropathy
Modhi Albaz
University of PNU, Saudi Arabia
Title: The risk of stroke using CHA2DS2-VASc score in hemodialysis patients at a tertiary Hospital in Riyadh,Saudi Arabia
Biography:
Modhi Albaz done her graduation in Princess Nourah bint Abdulrahman University, Saudi Arabia.
Abstract:
Introduction: Patients undergoing hemodialysis are at increased risk of stroke. However, less known about the impact of some of the stroke risk factors, and the value of stroke risk scores in determining the risk in those patients. Our main goal is to assess the risk factors for stroke in hemodialysis patients and the use of the new CHA2DS2-VASc score for stroke assessment.
Methods: Single center, retrospective cohort study of 336 patients undergoing hemodialysis from June 24, 2018, to September 6, 2018, were recruited. Baseline demographics, clinical, and laboratory data were collected. We calculated the CHA2DS2-VASc score for stroke assessment in all patients and categorized them into high, moderate and low risk patients according to CHA2DS2-VASc score and subcategorized them into two groups Atrial fibrillation (AFib) and NonAtrial fibrillation (Non AFib) patients
Results: 336 patients were included in our study, The majority of patients were at high risk with a CHA2DS2-VASc score mean of 2.9+ 1.5, although history of stroke was observed only in 15 patients (4.46%). According to CHA2DS2- VASc score, 280 patients were at high risk, 172 (51.19%) were high-risk patients on treatment (anticoagulant or antiplatelet) and 108(32.14%) patients were high risk patients not on treatment 48 were at moderate risk (14.28%) and 8 were at low risk (2.38 %). Patients were divided into subgroups as non-AFib and AFib. In non-AFib patients 320 (95.23%), high-risk patients 103 (32.18%) were not treated; high-risk patients with treatment are 162 (50.62%), moderate patients were 47 (14.68%), 8(2.5%) was in low risk. AFib patients were 16 with a mean CHA2DS2-VASc score of 4.4+1.1. Patients with AFib were all at high risk except 1 was at moderate risk (6.25%). There were 11 (68.75%) patients on treatment and 5 (31.25%) patients not on treatment. The risk factors for stroke that were statistically significant in increasing score risk for all patients were: age > 65 (95% CI, -2.04– -1.29; p = 0.000), being female (95% CI, -1.36– - 0.68; p = 0.000) hypertension (95% CI, -2.59– -1.37; p = 0.000), diabetes (95% CI, -2.10– -1.50; p = 0.000), CVD (95% CI, -2.07– -1.24; p=0.000), history of stroke or TIA (95% CI, -3.70– -2.03; p = 0.000), CHF or LVEF (95% CI, -2.28– - 0.91; p = 0.000).
Conclusions: The risk of stroke in hemodialysis patients is significant according to the use of CHA2DS2-VASc score in Non-AFib hemodialysis patients shows supportive evidence of increased risk of stroke in those patients, which suggest the importance of close monitoring of patients with stroke risk factors by the nephrologist and the stroke team which will lead to the initiation of early prophylaxis in those patients.
Dewi Gathmyr
Dr Esnawan Antariksa Air Force Hospital , Indonesia
Title: Rupture pseudoaneurysms in chronic kidney disease patient related to dialysis access:A case report
Biography:
Dewi Gathmyr has completed her Post-graduation in Nephrology of Internal Medicine Department, University of Indonesia. She is the Head of The Internal Medicine Clinic Lakespra Saryanto Jakarta and also Commander of The Health Unit Air Force Headquarters Jakarta.
Abstract:
Introduction: The number of patients with end-stage renal disease have steadily increased and got some improvements in hemodialysis techniques which have led to extended life expectancy. Pseudoaneurysms incidents were documented to be 2% to 10% of dialysis access grafts. It caused 0.4-1.6% of deaths in US Haemodialysis (HD) patients. 52% were caused by access infection skin integrity of AVF/AVG. We have reported a case of aneurysms rupture in the AVF left arm, instead of using CDL in hemodialysis patients.
Case Report: A 42 years old man presented with swelling, pain and bleeding did not stop from the left arm cimino lump. Bleeding occurred because of an attached wound to the gauze that was installed to cover the abrasions on the lump. Haemodialysis has been used in cimino on the left arm for 8 years. However, cimino is not used anymore since we use lumps instead. HD access was used to the CDL tunnel on the right neck. It was a history of high blood pressure since 12 years ago and arrhythmia since 1 year ago, as well as fatigue
and dyspnoe while conducting activities. In physical examination, a patient has an anemia; jugular venous pressure was increased, systolic murmur and cardiomegaly. There was a swelling 3×2 cm and skin ulcer in the left antebrachial region. A murmur was detected on auscultation. Doppler examination was revealed a feature in consistent with pseudoaneurysms. Patients were diagnosed as rupture pseudoaneurysms, chronic kidney
disease stage-V on HD. Management, elective surgery was performed pro repair rupture pseudoaneurysms, Amlodipine, Valsartan, Clonidine, Bisoprolol, folic acid, B12, low salt diet 1700 kcal, protein 1.3 g/kg/d, HD two times a week, heparin to be canceled.
Discussion: Pseudoaneurysms incident was documented to be 2% to 10% of dialysis access graft. In this case, there was infection in the wound above psuedoaneurysm, co-morbid that cannot be excluded as a risk factor. Repeated puncture of the graft may results in pseudoaneurysms. Usage of large needles or poor and traumatic puncture techniques can cause the formation of pseudoaneurysms in the vascular graft. Diagnose of pseudoaneurysms was confirmed by Doppler examination for our patient. Progressive enlargement of
pseudoaneurysms can interfere with needle cannulation or lead to secondary complications including breakdown of the overlying skin, spontaneous bleeding and rupture. Anti-coagulant is limited and elective surgery is performed. In conclusion, pseudoaneurysms are uncommon, recognizable and preventable case.
Adele Shayanrad
Novatis Teb Company, Iran
Title: Role of chemical parameters on quality of water treatmnet for hemodialysis and clinical evaluation results
Biography:
Adele Shayanrad has completed his Master of Science from Semnan University, Iran in Medical Engineering. She is currently working as a Lecturer at Islamic Azad University and University of Applied Science and Technology and also as a Quality Assurance Manager at Novatis Teb. She has published more than 6 papers in reputed conference.
Abstract:
Water quality is one of the most important aspects of ensuring a safe delivery of hemodialysis.Contamination by metals and microbiological agents in hemodialysis water can cause clinical intercurrences in hemodialysis patients. Evaluating and assuring minimum levels of contamination from metals and microorganisms in hemodialysis water can improve patient safety. Water treatment plays a vital role in the delivery of safe and effective Hemodialysis (HD). As every chemical water contamination has the potential to pose clinical problems for the dialysis patient, such water should undergo proper treatment. The objective of the study was to determine the chemical quality of samples of water in a seven hemodialysis units in Iran. This study was to assess hemodialysis water quality in an output of reverse osmosis device on hemodialysis unit which is a product of Novatis Teb Company. Clinical evaluation has been done according to the MEDDEV.2.7.1. For visualization and also analysis of data, Minitab software is used, 49 samples is chosen from 2016 September to 2018 December. On this evaluation, chemical parameter that has important effect on quality of water is visualized. The result of analysis in Minitab software shows that all chemical parameters in reverse osmosis device (NOVA RO 1000) are on allowable range according to ANSI/AAMI RD62:2001 standard. On Novatis Teb reverse osmosis device designing; there is no residual risk during the evaluation of 49 samples. No adverse event and clinical intercurrences reported from hospitals.
Sultan Al Dalbhi
Price Sultan Military Medical City, Saudi Arabia
Title: Incidence of stroke among diabetic nephropathy patients: A meta-analysis
Biography:
Sultan Al Dalbhi is currently working in Prince Sultan Military Medical City, Saudi Arabia in the Department of Nephrology
Abstract:
Background and objectives: The association of microvascular complications (diabetic nephropathy) with the stroke is limited because it will require huge sample size of diabetic population with nephropathy and long follow-up period to see the association or development incidence of stroke among these patients. So,we conducted out this meta-analysis of the existing studies to find out the incidence/ risk of stroke among diabetic nephropathy patients and, to find out what amount of extra risk of stroke is associated with diabetic nephropathy patients as compared to diabetic patients without nephropathy.
Methodology: We searched the existing databases from the year 1995 to August 2018 by using the MeSH terms. All cohort, cross sectional studies were searched for, fulfilling the inclusion criteria and as per operational definitions. The quality assessment criterion for quality of studies was already predefined.
Results: Seven studies were found to be eligible for inclusion in the meta-analysis. It was found that the hazards or risk of stroke development among diabetic patients was 3.25 times higher in patients with nephropathy as compared to patients without nephropathy. The pooled hazards ratio of 1.46 (95% CI=0.81-2.60) and of 1.65 (95% CI=0.53-5.11) among diabetic patients with microalbuminuria and macroalbuminuria respectively.
Conclusion: Diabetic Nephropathy patients has a higher incidence and risk of stroke compared to diabetic patients without nephropathy.
Biography:
Adele Shayanrad has completed his Master of Science from Semnan University, Iran in Medical Engineering. She is currently working as a Lecturer at Islamic Azad University and University of Applied Science and Technology and also as a Quality Assurance Manager at Novatis Teb. She has published more than 6 papers in reputed conference.