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Outcomes among Hospitalized Chronic Kidney Disease Patients with COVID-19

Khatri, Minesh; Charytan, David M; Parnia, Sam; Petrilli, Christopher M; Michael, Jeffrey; Liu, David; Tatapudi, Vasishta; Jones, Simon; Benstein, Judith; Horwitz, Leora I
ISSN: 2641-7650
CID: 4966642

Decreasing Incidence of AKI in Patients with COVID-19 critical illness in New York City

Charytan, David M; Parnia, Sam; Khatri, Minesh; Petrilli, Christopher M; Jones, Simon; Benstein, Judith; Horwitz, Leora I
Introduction/UNASSIGNED:Reports from the United States suggest that acute kidney injury (AKI) frequently complicates COVID-19, but understanding of AKI risks and outcomes is incomplete. Additionally, whether kidney outcomes have evolved during the course of the pandemic is unknown. Methods/UNASSIGNED:We used electronic records to identify COVID-19 patients with and without AKI admitted to 3 New York Hospitals between March 2 and August 25, 2020. Outcomes included AKI overall and according to admission week, AKI stage, the requirement for new renal replacement therapy (RRT), mortality and recovery of kidney function. Logistic regression was utilized to assess associations of patient characteristics and outcomes. Results/UNASSIGNED:Out of 4732 admissions 1386 (29.3%) patients had AKI. Among those with AKI, 717 (51.7%) had Stage 1, 132 (9.5%) Stage 2, 537 (38.7%) stage 3, and 237 (17.1%) required RRT initiation. In March 536/1648 (32.5%) of patients developed AKI compared with 15/87 (17.2%) in August (P<0.001 for monthly trend) whereas RRT initiation was required in 6.9% and 0% of admission, in March and August respectively. Mortality was higher with than without AKI (51.6% vs 8.6%) and was 71.9% in individuals requiring RRT. However, most patients with AKI who survived hospitalization (77%) recovered to within 0.3 mg/dL of baseline creatinine. Among those surviving to discharge, 62% discontinued RRT. Conclusions/UNASSIGNED:AKI impacts a high proportion of admitted COVID-19 patients and is associated with high mortality, particularly when RRT is required. AKI incidence appears to be decreasing over time and kidney function frequently recovers in those who survive.
PMID: 33558853
ISSN: 2468-0249
CID: 4779502

The association between serum chloride levels and chronic kidney disease progression: a cohort study

Khatri, Minesh; Zitovsky, Joshua; Lee, Dale; Nayyar, Kamal; Fazzari, Melissa; Grant, Candace
BACKGROUND:Limited data suggest serum chloride levels associate with mortality in heart failure, chronic kidney disease (CKD), and pulmonary arterial hypertension. Randomized trials have also shown that administration of crystalloid intravenous fluids with lower chloride concentration may have better renal outcomes. However, chloride has not been studied longitudinally for CKD progression. METHODS:We used a prospective cohort of subjects with stage 3 and 4 CKD recruited from a nephrology clinic at a single medical center. Linear regression, linear regression with generalized estimating equations, and Cox proportional hazards models were created for outcomes of overall change in estimated glomerular filtration rate (eGFR), longitudinal changes in eGFR, and time to > 30% decline in eGFR, respectively. Baseline chloride was modeled continuously and categorically, and models were adjusted for potential confounders. RESULTS:compared to the lowest quartile (p = 0.004). No association between serum chloride and time to 30% decline in eGFR was observed in multivariable analysis (hazard ratio 1.05 per 1 mEq/L increase in serum chloride, p = 0.103). CONCLUSIONS:In CKD patients, higher serum chloride associated with a modestly steeper rate of eGFR decline, and may be a useful biomarker to predict CKD progression. Further studies are needed to determine causality.
PMID: 32375681
ISSN: 1471-2369
CID: 4439312

Capillary leak syndrome: etiologies, pathophysiology, and management

Siddall, Eric; Khatri, Minesh; Radhakrishnan, Jai
In various human diseases, an increase in capillary permeability to proteins leads to the loss of protein-rich fluid from the intravascular to the interstitial space. Although sepsis is the disease most commonly associated with this phenomenon, many other diseases can lead to a "sepsis-like" syndrome with manifestations of diffuse pitting edema, exudative serous cavity effusions, noncardiogenic pulmonary edema, hypotension, and, in some cases, hypovolemic shock with multiple-organ failure. The term capillary leak syndrome has been used to describe this constellation of disease manifestations associated with an increased capillary permeability to proteins. Diseases other than sepsis that can result in capillary leak syndrome include the idiopathic systemic capillary leak syndrome or Clarkson's disease, engraftment syndrome, differentiation syndrome, the ovarian hyperstimulation syndrome, hemophagocytic lymphohistiocytosis, viral hemorrhagic fevers, autoimmune diseases, snakebite envenomation, and ricin poisoning. Drugs including some interleukins, some monoclonal antibodies, and gemcitabine can also cause capillary leak syndrome. Acute kidney injury is commonly seen in all of these diseases. In addition to hypotension, cytokines are likely to be important in the pathophysiology of acute kidney injury in capillary leak syndrome. Fluid management is a critical part of the treatment of capillary leak syndrome; hypovolemia and hypotension can cause organ injury, whereas capillary leakage of administered fluid can worsen organ edema leading to progressive organ injury. The purpose of this article is to discuss the diseases other than sepsis that produce capillary leak and review their collective pathophysiology and treatment.
PMID: 28318633
ISSN: 1523-1755
CID: 3534222

The association between a Mediterranean-style diet and kidney function in the Northern Manhattan Study cohort

Khatri, Minesh; Moon, Yeseon P; Scarmeas, Nikolaos; Gu, Yian; Gardener, Hannah; Cheung, Ken; Wright, Clinton B; Sacco, Ralph L; Nickolas, Thomas L; Elkind, Mitchell S V
BACKGROUND AND OBJECTIVES/OBJECTIVE:Various dietary strategies have been investigated to slow kidney function decline. However, it is unknown whether a Mediterranean diet, which has been associated with improved cardiovascular risk, is associated with change in kidney function. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS/METHODS:This study used the Northern Manhattan Study, a prospective, multiethnic, observational cohort of participants who were stroke free at baseline. Data were collected between 1993 and 2008. Serum creatinine measurements were taken a mean 6.9 years apart. A baseline dietary questionnaire was extrapolated into a previously used 9-point scoring system (MeDi). The primary outcome was incident eGFR<60 ml/min per 1.73 m(2)using the Modification of Diet in Renal Disease formula. A secondary outcome was the upper quartile of annualized eGFR decline (≥ 2.5 ml/min per 1.73 m(2) per year). Conditional logistic regression models adjusted for demographics and baseline vascular risk factors. RESULTS:Mean baseline age was 64 years, with 59% women and 65% Hispanics (N=900); mean baseline eGFR was 83.1 ml/min per 1.73 m(2). Incident eGFR<60 ml/min per 1.73 m(2) developed in 14% . In adjusted models, every 1-point increase in the MeDi score, indicating increasing adherence to a Mediterranean diet, was associated with decreased odds of incident eGFR<60 ml/min per 1.73 m(2) (odds ratio, 0.83; 95% confidence interval, 0.71 to 0.96) and decreased odds of being in the upper quartile of eGFR decline (odds ratio, 0.88; 95% confidence interval, 0.79 to 0.98). CONCLUSIONS:A Mediterranean diet was associated with a reduced incidence of eGFR<60 ml/min per 1.73 m(2) and upper quartile of eGFR decline in a multiethnic cohort.
PMID: 25359387
ISSN: 1555-905x
CID: 3534212

Acute kidney injury is associated with increased hospital mortality after stroke

Khatri, Minesh; Himmelfarb, Jonathan; Adams, Derk; Becker, Kyra; Longstreth, W T; Tirschwell, David L
BACKGROUND:Acute kidney injury (AKI) is common and is associated with poor clinical outcomes. Information about the incidence of AKI and its effect on stroke outcomes is limited. METHODS:Data were analyzed from a registry of subjects with ischemic stroke and intracerebral hemorrhage (ICH) hospitalized at a single academic medical center. Admission creatinine was considered to be the baseline. AKI was defined as a creatinine increase during hospitalization of 0.3 mg/dL or a percentage increase of at least 50% from baseline. Multivariate logistic regression models were created for both stroke types, with hospital mortality as the outcome. Covariates included gender, race, age, admission creatinine, National Institutes of Health Stroke Scale score at admission, the performance of a contrast-enhanced computed tomographic scan of the head and neck, and medical comorbidities. RESULTS:There were 528 cases of ischemic stroke with 70 deaths (13%), and 829 cases of ICH with 268 deaths (32%). The mean age was 64 years; 56% of patients were men and 71% were white. AKI complicated 14% of ischemic stroke and 21% of ICH hospitalizations. In multivariate analysis stratified by stroke type, AKI was associated with increased hospital mortality from ischemic stroke (odds ratio [OR] 3.08; 95% confidence interval [CI] 1.49-6.35) but not ICH (OR 0.82; 95% CI 0.50-1.35), except for those surviving at least 2 days (OR 2.11; 95% CI 1.18-3.77). CONCLUSIONS:AKI occurs frequently after stroke and is associated with increased hospital mortality. Additional studies are needed to establish if the association is causal and if measures to prevent AKI would result in decreased mortality.
PMID: 22818389
ISSN: 1532-8511
CID: 3534202

A prospective study of frailty in nephrology-referred patients with CKD

Roshanravan, Baback; Khatri, Minesh; Robinson-Cohen, Cassianne; Levin, Greg; Patel, Kushang V; de Boer, Ian H; Seliger, Stephen; Ruzinski, John; Himmelfarb, Jonathan; Kestenbaum, Bryan
BACKGROUND:Frailty is a construct developed to characterize a state of reduced functional capacity in older adults. However, there are limited data describing the prevalence or consequences of frailty in middle-aged patients with chronic kidney disease (CKD). STUDY DESIGN/METHODS:Observational study. SETTING & PARTICIPANTS/METHODS:336 non-dialysis-dependent patients with stages 1-4 CKD with estimated glomerular filtration rate (eGFR) <90 mL/min/1.73 m(2) (by the CKD-EPI [CKD Epidemiology Collaboration] serum creatinine-based equation) or evidence of microalbuminuria enrolled in the Seattle Kidney Study, a clinic-based cohort study. Findings were compared with community-dwelling older adults in the Cardiovascular Health Study. OUTCOME/RESULTS:Prevalence and determinants of frailty in addition to its association with the combined outcome of all-cause mortality or renal replacement therapy. MEASUREMENTS/METHODS:We defined frailty according to established criteria as 3 or more of the following characteristics: slow gait, weakness, unintentional weight loss, exhaustion, and low physical activity. We estimated kidney function using serum cystatin C concentrations (eGFR(cys)) to minimize confounding due to relationships of serum creatinine levels with muscle mass and frailty. RESULTS:The mean age of the study population was 59 years and mean eGFR(cys) was 51 mL/min/1.73 m(2). The prevalence of frailty (14.0%) was twice that of the much older non-CKD reference population (P < 0.01). The most common frailty components were physical inactivity and exhaustion. After adjustment including diabetes, eGFR(cys) categories of <30 and 30-44 mL/min/1.73 m(2) were associated with a 2.8- (95% CI, 1.3-6.3) and 2.1 (95% CI, 1.0-4.7)-fold greater prevalence of frailty compared with GFR(cys) ≥60 mL/min/1.73 m(2). There were 63 events during a median 987 days of follow-up. After adjustment, the frailty phenotype was associated with an estimated 2.5 (95% CI, 1.4-4.4)-fold greater risk of death or dialysis therapy. LIMITATIONS/CONCLUSIONS:Cross-sectional study design obscures inference regarding temporal relationships between CKD and frailty. CONCLUSIONS:Frailty is relatively common in middle-aged patients with CKD and is associated with lower eGFR(cys) and increased risk of death or dialysis therapy.
PMID: 22770927
ISSN: 1523-6838
CID: 3534192

Association of serum soluble receptor for advanced glycation end-products with subclinical cerebrovascular disease: the Northern Manhattan Study (NOMAS)

Hudson, Barry I; Moon, Yeseon Park; Kalea, Anastasia Z; Khatri, Minesh; Marquez, Chensy; Schmidt, Ann Marie; Paik, Myunghee C; Yoshita, Mitsuhiro; Sacco, Ralph L; DeCarli, Charles; Wright, Clinton B; Elkind, Mitchell S V
OBJECTIVE: Serum levels of the soluble receptor for advanced glycation end-products (sRAGE) have been associated with risk of cardiovascular disease. We hypothesized that sRAGE levels are associated with subclinical cerebrovascular disease in an ethnically diverse population. METHODS: Clinically stroke-free participants in the multi-ethnic Northern Manhattan Study (NOMAS) underwent brain MRI to quantify subclinical brain infarcts (SBI) and white matter hyperintensity volume (WMHV) (n = 1102). Serum levels of sRAGE were measured by ELISA. Logistic and multiple linear regression were employed to estimate associations of sRAGE with SBI and WMHV, after adjusting for demographics and vascular risk factors. RESULTS: Median sRAGE levels were significantly lower in Hispanics (891.9 pg/ml; n = 708) and non-Hispanic blacks (757.4 pg/ml; n = 197) than in non-Hispanic whites (1120.5 pg/ml; n = 170), and these differences remained after adjusting for other risk factors. Interactions were observed by race-ethnicity between sRAGE levels and MRI measurements, including for SBI in Hispanics (p = 0.04) and WMHV among blacks (p = 0.03). In Hispanics, increasing sRAGE levels were associated with a lower odds of SBI, with those in the upper sRAGE quartile displaying a 50% lower odds of SBI after adjusting for sociodemographic and vascular risk factors (p = 0.05). Among blacks, those in the upper quartile of sRAGE had a similarly reduced increased risk of SBI (p = 0.06) and greater WMHV (p = 0.04). CONCLUSION: Compared to whites, Hispanics and blacks have significantly lower sRAGE levels, and these levels were associated with more subclinical brain disease. Taken together, these findings suggest sRAGE levels may be significantly influence by ethnicity. Further studies of sRAGE and stroke risk, particularly in minorities, are warranted.
PMID: 21316677
ISSN: 0021-9150
CID: 778852

Acute Kidney Injury Is Associated with Hospital Mortality after Acute Ischemic Stroke, but Not Intracerebral Hemorrhage [Meeting Abstract]

Khatri, Minesh; Adams, Derk; Becker, Ayra; Logar, Christine; Longstreth, W. T.; Tirschwell, David
ISSN: 0028-3878
CID: 3534112

Serum Levels of Soluble Receptor for Advanced Glycation End-Products Are Associated with Subclinical Cerebrovascular Disease among Hispanics and Blacks [Meeting Abstract]

Hudson, Barry I.; Moon, Yeseon Park; Kalea, Anastasia Z.; Khatri, Minesh; Marquez, Chensy; Schmidt, Ann Marie; Paik, Myunghee C.; Sacco, Ralph L.; DeCarli, Charles; Wright, Clinton B.; Elkind, Mitchell S. V.
ISSN: 0028-3878
CID: 3534102