Vedran Premuzic

Complications of Permanent Hemodialysis Catheter Placement; Need for Better Pre-Implantation Algorithm?

There is a correlation between central venous cannulation and the development of central venous stenosis. Minor retrosternal vein lesions can be easily missed. Computerized tomographic (CT) venography is the diagnostic procedure of choice. The aim of this study was to examine the complications after catheter implantation in patients with prior permanent catheter placement and to evaluate present diagnostic procedures performed prior to choosing permanent access site in order to reduce possible complications after catheter placement. Complications of permanent CVC insertion in our department were analyzed between October 2011 and February 2015. We have implanted the Tesio twin catheter system and the Hickman Bard dual lumen catheter. All patients with prior permanent dialysis catheter were evaluated with color doppler, while patients with suspected central venous stenosis (CVS) or thrombosis were evaluated with phlebography or CT venography prior to catheter placement. One hundred and ninety‐eight permanent dialysis catheters were placed (173 Tesio [87.4%] and 25 Hickman [12.6%]) in 163 patients. There were 125 patients (76.7%) with prior temporary catheter and 61 (48.8%) of them had more than one prior permanent catheter (1.92 catheter per person).There were 4/61 (6.5%) patients with catheter‐related complications without prior phlebography and CT venography. Phlebography and CT venography were performed in 30 (24.0%) patients with suspected CVS/thrombosis and with dialysis vintage of 76.23 months (52.78–98.28). Phlebography and CT venography were more sensitive than color doppler in the detection of CVS/thrombosis in patients with prior permanent catheter placements (P < 0.001). Since this diagnostic algorithm was introduced prior to catheter placement there were no catheter insertion‐related complications or dysfunctions (P < 0.001). All our procedures on patients with prior permanent catheters followed preliminary color doppler diagnostics. Nevertheless, in four cases, the vessel obstruction and abnormality led to catheter insertion‐related complications. When phlebography and CT venography was performed before the procedure in patients with prior permanent catheters and one or more CVS or thrombosis, early and late catheter‐related complications were avoided by careful selection of the least injured vein and planning of procedure. When planning a permanent dialysis catheter placement in patients with prior multiple CVC, phlebography and CT venography may be diagnostic procedures of choice for avoidance of early catheter dysfunction and CVC placement complications.

Consequence of Elevated Fibroblast Growth Factor 23 Levels in Acute Kidney Injury, Renal Recovery and Overall Survival in Intensive Care Unit Patients After Major Surgery: FGF23 and Acute Kidney Injury

The main goal of our study was to investigate the role of increased fibroblast growth factor 23 (FGF23) levels on renal recovery and overall survival. We conducted a prospective case‐control cohort study, which included 121 adult cases who developed AKI after major surgical procedures. The subjects were followed‐up until the last enrolled patient survived 180 days or until the time of death. Higher FGF23 levels positively correlated with serum creatinine levels (P < 0.05). Significantly higher number of patients without diuresis and with FGF23 ≤ 709 RU/mL survived when compared to patients without diuresis and with FGF23 ≥ 709 RU/mL (P < 0.001). FGF23 levels >709 RU/mL were a good predictive tool for overall mortality in a 6‐month period (P < 0.05). This is the first study to analyze the impact of FGF23 values on short‐term renal recovery and survival of patients with AKI after major surgery. The FGF23 increase related to AKI especially in more severe stages and in patients without diuresis is an independent risk factor for mortality.

Nonfatal cardiac perforation after central venous catheter insertion

Cardiac tamponade caused by perforation of the cardiac wall is a rare complication related to central venous catheter (CVC) placement. A 71-year-old female with a previous history of moderate aortic stenosis and kidney transplantation was admitted to hospital due to global heart failure and worsening of allograft function. Intensified hemodialysis was commenced through a CVC placed in the right subclavian vein. Chest radiography revealed catheter tip in the right atrium and no signs of pneumothorax. Thorough diagnostics outruled immediate life-threatening conditions, such as myocardial infarction and pulmonary embolism. However, not previously seen, 2 cm thick pericardial effusion without repercussion on the blood flow was visualized during echocardiography, predominantly reclining the free surface of the right atrium, with fibrin scar tissue covering the epicardium – it was the spot of spontaneously recovered cardiac wall perforation. Follow-up echocardiogram performed before the discharge showed regression of the previously found pericardial effusion.

FIXED DOSE COMBINATION THERAPY IS ASSOCIATED WITH BETTER BLOOD PRESSURE CONTROL AND LOWER ALBUMINURIA IN REAL-LIFE COHORT DURING 7 YEARS OF FOLLOW UP. ENAH – CROATIAN RURAL STUDY

Objective: The aim of this study was to analyze differences in blood pressure (BP) control and albuminuria between subjects treated with fixed dose combination (FCD) and those treated with free components in real-life during the 7 years follow up period. Design and method: Out of 1134 subjects (door-to-door enrollment, participation rate 80%) data on 236 (54 men; 182 women; mena age 63.2 years) treated hypertensives (HT) were analyzed at the end of 7 years of follow-up. At enter 136 of them were already treated HT (group A) and 100 were new-diagnosed HT (group B) who had started with antihypertensive therapy from that moment. Local GP were allowed to tailor antihypertensive therapy during the follow up period. At basal and at the end of follow up BP was measured by physicians who were project collaborators (ESH/ESC guidelines; OmronM6); salt intake (spot urine - Kawasaki equation), eGFR (CKD-Epi) and albumin-to-creatinin ration (ACR mg/g;first morning urine sample) were analyzed in central lab. Pregnant women, terminal ill, bed-ridden patients, those with severe disability, mentally ill or suffering from dementia or at least one limb amputated/immobilized were exclided. Results: At the end of follow up BP controll was achieved in 31.6% and 38% of HT (group A and B, respectively). In both groups, there there were no significnat differences in salt intake, BMI, smoking and the number of used drugs between controlled and uncontrolled subjects (p < 0.05). However, in group A significant increase in FDC prescription was observed ih the controlled vs.uncontrolled subjects (22% vs. 5.5%). BP control was associated with lower ACR in group A (14.9 vs.76.3; p < 0.01) and group B (9.1 vs.24.9; p < 0.05). Conclusions: In this real-life cohort after 7 years of follow-up BP controll was ahived with more drugs but only if used as FDC what was associated with better organoprotection i.e.lower ACR. Overall poor BP control and organoprotection could be improved using more FDC.

CHARACTERISTICS OF PATIENTS WITH ATRIAL FIBRILLATION. ESH-FA PROJECT – DATA ON CROATIAN COHORT

Objective: The aim of the study was to analyze clinical characteristics of the consecutive sample of patients with atrial fibrillation (AFib) who were admitted to the UHC Zagreb Cardiology Clinic, part of the ESH Excellence centre of hypertension. This cohort is part of the ESH –FA project. Design and method: Consecutive sample of 201 patients with AFib (115 M, 86 F; averaged age 71.6) was enrolled in period 2014–2016. Data were collected from medical records. BP was measured following the ESH/ESC guidelines. Hypertension (HT) was defined as BP >  = 140/90 mmHg and/or antihypertensive drugs treatment, chronic kidney disease (CKD) was defined as eGFR (CKD Epi < 60 ml/min). Results: Average BP values and heart rate were 133.5/80.2 mmHg, 82.2 bpm, and BMI was 31.1 kg/m2, there were 19.6% and 11.5% smokers and ex-smokers, respectively. CHD, cerebrovascular disease, heart failure, valvular disease, PAD, hypothyreosis, and CKD were established in 52.7%, 17.9%, 49.3%, 29.3%, 13.9%, 14.4% and 52.5%, respectively. Family history for CVD was positive in 43.2% patients. Prevalence of HT was 83.5%, and 63.7% were treated, while 20% were newly diagnosed. Only 30.2% HT had BP < 140/90 mmHg. Most frequently used antihypertensive drugs were beta blockers (67.6%), loopD (54.7%), ACEi (50.7%), potassium-sparingD (22.8%) and thiazide-likeD (17.9%). LoopD were prescribed more frequently in patients with CKD than in non-CKD as well as in HF than in non-HF patients. Hypokalemia was noticed in 18.9% patients and was mostly reported in non-HF patients (41.1%); it was associated with overuse of loopD and underuse of potassium-sparingD. First diagnosed, paroxysmal, permanent and persistent AFib were diagnosed in 5.4%, 33.3%, 51.2% and 10.4%, respectively. CHADVASC > 2 was determined in 78.9%; varfarin and NOAC were administered in 64.4% and 35.6% patients, respectively. In patients treated with varfarin INR > 2 was achieved in only 35.4%. Conclusions: Better BP control and anticoagulation with more frequent use of NOACs is needed. Physicians must be aware of high prevalence of CKD in AFib patients and consequent drug dose adjustments.

ATRIAL FIBRILLATION AND CHRONIC KIDNEY DISEASE ESH-FA PROJECT- DATA ON CROATIAN COHORT

Objective: Chronic kidney disease (CKD) is well established risk factor for atrial fibrillation (AFib). The aim of the study was to analyze association of CKD and AFib in the consecutive sample of patients with AFib who were admitted to the UHC Zagreb Cardiology Clinic, part of the ESH Excellence centre of hypertension. This cohort is part of the ESH –FA project. Design and method: Consecutive sample of 201 patients with AFib (115 M, 86 F; averaged age 71.6) was enrolled in period 2014–2016. Data were collected from medical records. BP was measured following the ESH/ESC guidelines. Hypertension (HT) was defined as BP equel or greater than 140/90 mmHg and/or antihypertensive drugs treatment, chronic kidney disease (CKD) was defined as eGFR (CKD Epi < 60 ml/min). Results: CKD was diagnosed in 52.2% of patients with AFib, and 13.3% were in CKD stage > 3. CKD patients were older than non-CKD (72.2 vs. 68.3). Coronary heart disease, heart failure and known significant valvular disease were more frequently presented in CKD patients (64.4% vs. 47.2%, p = 0.05; 64.4% vs.44.5%, p = 0.02; 38.9% vs.21.6%, p = 0.02, respectively). Prevalence of HT was higher in CKD patients (92.4% vs. 77.1%; p = 0.02), but there were no differences in control of HT between CKD and non-CKD patients. Permanent and persistent AFib were more frequently diagnosed in CKD, while first diagnosed and paroxysmal AFib were more frequently diagnosed in non-CKD patients (p = 0.003). CKD patients had significantly more CHADVASC > 2 than non-CKD patients (90.2% vs. 70%; p = 0.004). Conclusions: CKD is highly prevalent in patients with AFib and substantial numbers of patients are in advanced CKD stages. Prevalence of HT and CV comorbidity, as well as prevalence of permanent and persistent AFib are much more frequently presented in CKD than in non-CKD patients. Compared to non-CKD patients, CHADVASC was more often above 2 in CKD patients. In general, AFib patients with associated CKD have higher global CV risk as well higher risk for future thromboembolic incidents than non-CKD AFib patients.

The Different Impacts on the Long-Term Survival of Tunneled Internal Jugular Hemodialysis Catheters Based on Tip Position and Laterality

Background/Aims: The aim of this study was to examine the impact of different catheter tip positions on the life of the catheter, dysfunction, infection, and quality of hemodialysis and possible differences between the access site laterality in jugular-tunneled hemodialysis catheters. Methods: Catheters were evaluated for the following parameters: place of insertion, time of insertion, duration of use, and reason for removal. In all patients, the catheter tip position was checked using an X-ray. Results: The mean duration of implanted catheters with the tip placed in the cavo-atrial junction and right atrium was significantly longer. There were no differences in catheter functionality at follow-up or complications based on catheter laterality for each catheter tip position. Conclusion: According to our results, the localization of the catheter tip in superior vena cava still remains the least preferable method. Our results showed that the main factor responsible for better catheter functionality was not laterality but the depth to which the catheter tip is inserted into the body.

[OP.7A.05] TRENDS IN PREVALENCE, TREATMENT AND CONTROL OF HYPERTENSION IN CROATIAN CONTINENTAL RURAL POPULATION - ENAH STUDY

Objective: Overall prevalence of hypertension (HT) in Croatia is high and control of HT is poor. In this study our aim was to analyze trends in prevalence, treatment and control of HT in the same rural population during the 10 years long survey. Design and method: Out of 3056 subjects enrolled in ENAH study, 2361 were eligible for further analysis. All inhabitants older than 18 years of age from this rural area were invited to participate and were examined on a door-to-door basis. Pregnant women, patients with terminal illness who were bed-ridden, patients with severe disability or those who have had at least one limb amputated or immobilized and mentally ill or suffering from dementia were considered ineligible. Participation rate was >70%. Blood pressure (BP) and heart rate (HR) were measured using Omron 6 device following the ESH guidelines. HT was defined as a BP > = 140/90 mmHg, and/or current use of antihypertensive drugs. Treatment of HT was defined as usage of antihypertensive medication at the time of the interview. Control of treated HT was defined as BP < 140/90 mmHg. Villagers were examined in 2005, 2008, 2010 and 2015, and trends of prevalence, treatment and control were analysed. There were no differences in age and gender among various years groups. Results: Prevalence of HT decreased from 2005 to 2010 but still remains very high (64.1% vs. 55.2%; p = 0.04). Prevalence of treated HT significantly increased from 2005 to 2015 (26.8% vs. 68.5%; p = 0.001). Prevalence of controlled HT gradually increased and in 2005, 2008, 2010 and 2015 was 11.%, 14.5%, 15.1% and 17.3%, respectively; p = 0.09). Significant decrease in average systolic BP was observed (p for trend <0.001 for systolic BP). Conclusions: Prevalence of HT in Croatian rural area remains very high. Nowadays, much more HT were treated and there is trend to better control. However, results are still unacceptable. High salt consumption, obesity, poor socioeconomic status and low educational level are the most import causes of such thrashing result.

[PP.03.05] SERUM URIC ACID IS NOT ASSOCIATED WITH ALBUMINURIA IN PREHYPERTENSION AND NEWLY DIAGNOSED HYPERTENSION

Objective: Elevated serum uric acid(SUA) even asymptomatic was found to be associated with blood pressure(BP), hypertension(HT), cardiovascular and chronic kidney disease. It was reported that xantin oxidase inhibitors(XOi) could in animals reverse glomerular hypertension and hypertrophy caused with hyperuricemia and in hyperuremic humans decrease microalbuminuria(MA). However, the question still remain whether elevated SUA is cause. marker, or just epiphenomen of renal impairment. Our aim was to analyze association of SUA with MA in prehypertensives(PHT) and newly diagnosed, untreated hypertensives(HT). Design and method: Out of 954 subjects enrolled in ENAH follow-up study, 371 (137 m, 234 w) were eligible for further analysis 100 with optimal, 72 with normal BP, 70 with PHT (high normal BP), and 129 with newly diagnosed HT. Exclusion criteria were treatment with antihypertensive drugs and XOi, diabetes, pregnancy, eGFR<60 ml/min, CV or cerebrovascular incident, chronic terminal diseases, dementia, immobility and missing data. BP was measured using Omron 6 device following the ESH guidelines. Fasting blood was analysed for SUA, glucose, lipids, serum creatinine, hsCRP. HOMA index was used to calculate insulin resistance and MDRD formula to estimate GFR. Albumin to creatinine ratio (ACR) was determined from the first morning spot urine. Results: In the whole group there is trend of lower ACR regarding SUA (1st vs. 2nd vs. 3rd tercile 5.78 vs. 5.11 vs. 4.65; p = 0.002). 78.3% subjects in the highest tertile of SUA were in the lowest tertile of ACR. Correlation of SUA and ACR was significantly negative (r = −0.21; p < 0.01), but after adjustment for age, gender, waist circumference, systolic BP, FBG, alpha1/CR significance was lost (beta = −0.09; p = 0.89). In the subgroup of PHT and HT SUA was also negatively correlated (r = −0.14; p = 0.02) but again the association was not significant after adjustment (beta = −0.10; p = 0.28). Trend of ACR across of SUA tertiles was the same as in the whole group (p = 0.02). Conclusions: In PHT and newly diagnosed, untreated HT, SUA is not associated with MA. Even more, our observation on negative association of SUA with MA might rise a provocative question whether in early phase of cardiorenal continuum elevated SUA, having antioxidative properties, might be even protective.

METABOLIC SYNDROME AND EARLY KIDNEY DAMAGE IN RURAL POPULATION: PP.34.388

Objective: To analyze prevalence of metabolic syndrome (MS) in early phases of chronic kidney disease (CKD) and effect of its components on early renal impairment. Design and Method: In this survey 1003 farmers from continental, rural part of Croatia were enrolled (386 men; 617 women; average age 52(30-95); females were older(Mann-Whitney test:z=3,6;p < 0,001). After extended questionnaire and clinical exam, fasting blood was drawn and second morning urine sample was collected (for microalbuminuria (MA) and alpha1 microglobulinuria (α1MG). Blood pressure (BP) was measured following the ESH/ESC guidelinies, metabolic syndrome (MS) was defined according to the NCEP ATP III recommendations. Subjects were classified into the CKD stages groups according to the KDOQI classification. Results: In general rural population prevalence of MS was 22,6% (30% men, 70% women; p = 0,045). Prevalence of MS was significantly higher in subjects with CKD stage 3 as compared to the CKD stage 1 (χ2 = 4;p = 0,045) as well as in subjects with MA compared to those with normal values (χ2 = 5,85;p = 0,016), while there was no difference between subjects with elevated and normal values of α1MG (χ2 = 0,19;p = 0,662). We observed significant difference between stages CKD 1 and 3 in BP (χ2 = 15,6;p < 0,001), waist circumference (WC) (χ2 = 26,8;p < 0,001), fasting blood glucose (FBG) (χ2 = 22;p < 0,001), triglycerdies (TG) (χ2 = 7,4;p = 0,024) and HDL level (χ2 = 0,621;p < 0,001). Significant differences in BP, FBG, WC and TG were observed between subjects with MA in comparison with normal values (χ2 = 8,1;p = 0,004; χ2 = 23,2;p < 0,001; χ2 = 6,85;p = 0,009; χ2 = 9,0;p = 0,003, respectively). Multivariate age-adjusted OR for development of MA was significant for FBG and TG (OR 2(1,43–2,8);p < 0,001; OR 1,59(1,02–2,5);p = 0,043, respectively). Only systolic BP was significantly associated with α1MG(χ2 = 2,59;p < 0,001) with multivariate age-adjusted OR for development of α1MG of 1,52 (1,01–2,28);p = 0,043. Conclusions: Prevalence of MS and its components increase with CKD stage. MS, and especially FBG and TG are risk factors for MA while systolic BP is a risk factor for proximal tubule damage i.e. α1MG.