In Stages 3-5 CKD patients, CAC is an independent predictor of both ESKD and mortality at 10 years. Those who developed ESKD at the fastest rate either had the highest CAC score or the worst CKD-MBD derangements.

BACKGROUND Transfusion of 2 units of red blood cells (RBCs) for Hb ≤80 g/L is the prevailing liberal practice for patients undergoing intensive treatment for acute leukemia or hematopoietic transplant across North America. There is little evidence regarding optimal transfusion targets in these highly transfusion‐dependent patient populations. STUDY DESIGN AND METHODS This was a retrospective pre‐post cohort study of consecutive patients admitted to Kingston Health Sciences Center between April through December 2016 (pre) and April through December 2017 (post) for acute leukemia induction chemotherapy or high dose chemotherapy (HDCT) for autologous stem cell transplantation (ASCT). The pre‐cohort was transfused using a liberal threshold (2 units of RBCs for Hb ≤80 g/L) and the post‐cohort using a more restrictive threshold (1 unit RBCs for Hb ≤70 g/L), implemented with a computerized physician order entry form. Primary outcome was number of RBC units transfused per inpatient day. Secondary outcomes included inpatient mortality and select morbidity measures. RESULTS 124 patients underwent 134 treatment courses: 62 courses of induction chemotherapy (pre = 26, post = 36) and 72 courses of HDCT for ASCT (pre = 39, post = 33). There was a significant decrease in median RBC utilization per admission in both patient populations: 10.5 versus 6.7 in the leukemia group (p = 0.01) and 2.0 versus 1.0 in the ASCT group (p = 0.04). This reduction was seen without a difference in inpatient mortality, length of stay, falls, serious bleeds, requirement for ICU, or time to engraftment post ASCT. CONCLUSIONS A restrictive transfusion strategy in patients receiving intensive chemotherapy for acute leukemia or ASCT decreased inpatient RBC usage without increasing adverse inpatient events.

Background: Nutritional status and protein energy wasting (PEW) is prevalent in patients with nondialysis-dependent chronic kidney disease (CKD). The relationship between PEW and long-term development of clinically important outcomes remains to be examined. Objectives:To investigate the relationships between PEW, as measured by Subjective Global Assessment (SGA 1-7), and progression to important clinical outcomes: mortality and/or kidney failure.Design: Prospective cohort design.Participants: One hundred and thirty-nine participants were well-nourished and 37 moderately malnourished patients with CKD 3-5.Measurements: The outcomes were 2, 5, and 10-year progression to kidney failure (dialysis or transplant) or mortality, kidney failure alone, and mortality alone. SGA was determined by a registered renal dietitian. Food frequency questionnaires were used to assess dietary intake. Clinical and laboratory baseline characteristics were collected. Multivariable regression models and Cox models were created to examine the relationship between SGA and outcomes.Results: PEW was associated with the combined outcome of kidney failure or mortality at 2 (p = 0.003), 5 (p = 0.004), but not at 10 (p = 0.73) years. This relationship was primarily driven by the relationship between PEW and kidney failure.In Cox models, the relationship between PEW and kidney failure remained after adjusting for Kidney Failure Risk Equation scores. The multivariable modeling revealed that PEW remained a statistically significant predictor of the combined outcome and ESKD after adjustment for age, estimated glomerular filtration rate (eGFR), sex, albumin-to-creatinine ratio, diabetes, albumin, and protein intake.Conclusions: PEW, determined by the SGA 1-7, is an important prognostic tool.Further research looking at clinically important outcomes are needed to implement nutritional interventions for nondialysis-dependent CKD patients.

Purpose of reviewThe pivotal phase III trials demonstrating efficacy and safety of direct oral anticoagulants (DOACs) in the treatment of venous thromboembolism (VTE) or nonvalvular atrial fibrillation (NVAF) excluded patients with important and common comorbidities, including obesity, advanced chronic kidney disease, cirrhosis, cancer and antiphospholipid antibody syndrome. Despite the lack of large prospective randomized control trials in these patient populations, the use of DOACs has led to a wealth of efficacy and safety data within these groups. Recent findingsRetrospective studies, meta-analyses, national databases and pharmacokinetic data have shed light on the efficacy and safety of DOACs in these patient populations. Although DOACs should be avoided in those with high-risk triple positive antiphospholipid antibody syndrome, advanced cirrhosis, advanced kidney disease and intact gastrointestinal cancers, and used with caution in genitourinary cancers, their use extends beyond the inclusion criteria of the initial randomized control trials. SummaryDOACs have revolutionized anticoagulant management and have become the cornerstone for VTE treatment and stroke prevention in NVAF. The decision to use DOACs must be individualized. Patient preference, underlying comorbidities and informed consent must always be considered when selecting the most appropriate anticoagulant.