Chinese Hemodialysis Patients Research Articles

Intravenous Iron Sucrose in Chinese Hemodialysis Patients with Renal Anemia

Background/Aims: Renal anemia is one of the commonest complications of chronic renal failure. Iron deficiency is the most common factor which affects the efficacy of recombinant human erythropoietin (EPO) therapy. Intravenous (i.v.) iron preparations are commonly used in Western countries, but iron sucrose is seldom used in Chinese patients on maintenance hemodialysis. The aim of the present study was to explore the safety and efficacy of i.v. iron sucrose in Chinese patients on maintenance hemodialysis and to explore the optimal administration frequency. Methods: One hundred and thirty-six patients on maintenance hemodialysis were involved in this randomized, controlled, parallel-group, single-center trial. Seventy patients received i.v. iron sucrose (Venofer®, delivering 100 mg iron) twice a week for 8 weeks, then once a week for another 4 weeks. The other 66 patients received oral (p.o.) ferrous succinate 200 mg t.i.d. for 12 weeks. Levels of serum ferritin (SF), transferrin saturation (TSAT), hemoglobin (Hb) and hematocrit (Hct) were assessed at baseline and then again after 4, 8 and 12 weeks of treatment. Results: There were no differences between i.v. and p.o. groups in terms of sex, age, duration of hemodialysis, dialysis frequency per week, EPO dosage per week, the level of intact parathyroid hormone, serum creatinine, blood urea nitrogen, or hematological parameters at baseline. After 8 and 12 weeks of treatment, mean Hb concentration and Hct were significantly increased in the i.v. group, and were also significantly higher than those in the p.o. group. Levels of SF and TSAT were also significantly increased in the i.v. group, and significantly higher than in the p.o. group. After 8 weeks, the response rate in the i.v. group was 88.6%, which was significantly higher than that in the p.o. group. The mean EPO dose was significantly lower in the i.v. group than the p.o. group. Hb, Hct, SF and TSAT levels were maintained between 8 and 12 weeks in the i.v. group despite the decrease in dose frequency. There were no adverse events related to i.v. iron administration. Twenty-two patients in the p.o. group had adverse gastrointestinal effects. After 12 weeks, the cost of EPO + i.v. iron was significantly higher than the cost of EPO + p.o. iron. Conclusion: Intravenous iron sucrose can effectively increase serum iron parameters and Hb levels in Chinese patients on maintenance hemodialysis and is well tolerated. Infusion of i.v. iron sucrose 100 mg per week can maintain serum iron parameters and Hb levels in Chinese patients on maintenance hemodialysis and can permit reductions in the required dose of EPO. However, the total cost of i.v. iron is relatively high.

The Prevalence of Left Ventricular Hypertrophy in Chinese Hemodialysis Patients Is Higher Than That in Peritoneal Dialysis Patients

Background. Left ventricular hypertrophy (LVH) is common in dialysis patients, and an independent predictor of mortality. While recent studies have shown no differences in mortality between the two most common dialysis modalities, hemodialysis (HD) and peritoneal dialysis (PD), their impact on LVH is controversial. We thus performed cardiac ultrasound studies in prevalent dialysis patients receiving either HD or PD and compared LVH. Methods. We included 48 HD and 62 PD patients receiving treatment for at least three months in our dialysis center. All patients underwent echocardiographic examination and blood pressure measurements immediately following therapy. Volume status was assessed by bioelectrical impedance analysis. Results. There was no baseline difference in demographics or comorbidities between HD and PD patients. As expected, extracellular water (ECW) in post-HD patients was significantly lower than that in pre-HD and PD patients, while cardiac output (CO) and systolic blood pressure (SBP) were higher in pre-HD than that in post-HD or PD patients. There was no significant difference in CO or SBP between post-HD and PD patients. Left ventricular mass index (LVMI) was markedly higher in HD patients as compared to PD patients. Thus, the prevalence of LVH according to the Framingham criteria was 68.8% in HD patients and 45.2% in PD patients. Subgroup analysis showed similar results in the patients who had been on single-modality dialysis for at least two years and in the anuric patients. Finally, in a linear regression model (r2 = 0.364, p < 0.001), SBP, treatment modality (to be in HD), and ECW were all independent predictors of LVMI. Conclusions. In a cross-sectional analysis of prevalent Chinese patients, we found a higher LVMI and a higher prevalence of LVH in HD than in PD patients. As LVMI was associated with high blood pressure and volume overload, we suggest that in these patients, PD may preserve more physiological hemodynamics even during long-term therapy.

Length polymorphism in heme oxygenase-1 is associated with arteriovenous fistula patency in hemodialysis patients

Heme oxygenase-1 (HO-1) is a rate-limiting enzyme in heme degradation, producing carbon monoxide (CO), which carries potent antiproliferative and anti-inflammatory effects in the vascular walls. Transcription of the HO-1 gene is regulated by the length polymorphism of dinucleotide guanosine thymine repeat (GT)(n) in the promoter region, which was measured in this study to determine its association with arteriovenous fistula (AVF) failure in Chinese hemodialysis (HD) patients in Taiwan. L allele means (GT)(n)>or=30 and S allele means (GT)n<30. Therefore, there are two L alleles for L/L genotype, one L and one S allele for L/S genotype, and two S alleles for S/S genotype. Among the 603 HD patients who were enrolled in this study, 178 patients had history of AVF failure, while 425 patients did not. Significant associations were found between AVF failure and the following factors (hazard ratio): longer HD duration (1.004 month), lower pump flow (0.993 ml/min), higher dynamic venous pressure (1.010 mmHg), location of AVF on the right side (1.587 vs left side) and upper arm (2.242 vs forearm), and L/L and L/S genotypes of HO-1 (2.040 vs S/S genotype). The proportion of AVF failure increased from 20.3% in S/S genotype and 31.0% in L/S genotype to 35.4% in L/L genotype (P=0.011). Relative incidences were 1/87.6 (1 episode per 87.6 patient-months), 1/129, and 1/224.9 for HD patients with L/L, L/S, and S/S genotypes, respectively (P<0.002). The unassisted patency of AVF at 5 years decreased significantly from 83.8% (124/148) to 75.1% (223/297) and 69% (109/158) in S/S, L/S, and L/L genotypes, respectively (P<0.0001). In comparison with HD patients with S/S genotype, those with L/L genotype had a higher prevalence of coronary artery disease (29.1 vs 14.2%; P=0.005). A longer length polymorphism with (GT)(n) >or=30 in the HO-1 gene was associated with a higher frequency of access failure and a poorer patency of AVF in HD patients. The longer GT repeat in the HO-1 promoter might inhibit gene transcription, and consequently offset the CO-mediated protective effect against vascular injury.

Nutritional and Inflammatory Markers in the Prediction of Mortality in Chinese Hemodialysis Patients

Background/Aims: The prevalence ofcardiovascular disease and mortality rate is relatively low in Chinese dialysis patients. This study aimed to evaluate the predictive value of nutritional and inflammatory markers in Chinese hemodialysis patients. Methods: A total of 158 patients (70 men and 88 women, age 59.9 ± 13.2 years) were studied. Nutritional and inflammatory markers, including subjective global assessment (SGA), insulin-like growth factor-1, albumin, tumor necrosis factor-α, interleukin (IL)-1β, IL-6, serum amyloid A (SAA), and C-reactive protein (CRP), were measured. These patients were followed up until April 2004 (36 months) to determine the incidence and causes of death. Results: SGA (p = 0.001), IL-1β (p = 0.032), SAA (p = 0.031), IL-6 (p = 0.001) and CRP (p < 0.001) were found to be significant predictors of mortality. After adjusting with age, sex, diabetes, coronary artery disease, Kt/V_urea, and duration on dialysis, CRP (odds ratio = 4.58; p = 0.038) and SGA (odds ratio = 6.57; p = 0.004) remained the independent predictors of mortality. The adjusted mortality rate was highest for patients with a high CRP level and malnutrition (assessed by SGA). Conclusions: SGA and CRP levels are the most significant predictors of mortality in Chinese dialysis patients. Chinese dialysis patients with a high CRP level tend to be at higher risk of mortality only if they are malnourished.

Non‐relation of Parathyroid Hormone Gene Polymorphisms to Secondary Hyperparathyroidism in Chinese Hemodialysis Patients

Objective: To investigate the relationship between parathyroid hormone (PTH) gene polymorphisms and secondary hyperparathyroidism in Chinese hemodialysis (HD) patients. Materials and Methods: 210 patients in one HD unit were enrolled as the study group and 203 age‐matched health subjects were enrolled as controls. PTH genotypes were determined by polymerase chain reaction and restricted fragment length polymorphisms (RFLPs) of BstBI and DraII. B and b or D and d were indicated by the presence or absence, respectively, of BstBI and DraII at restriction sites on the PTH gene. Serum iPTH levels and serum total calcium (Sca), phosphate (Sp), bone‐specific alkaline phosphatase (bAlk), and aluminum (Al) levels across different genotypes were compared. Results: When polymorphisms at the BstBI the restriction site were investigated, the patients' BB, Bb, and bb genotype frequencies were 62%, 37%, and 1%, respectively. At the DraII restriction site, the patients' DD, Dd, and dd genotype frequencies were 78%, 17%, and 5%, respectively. No significant differences were found across the three genotypes, BB, Bb, and bb, in serum Sca, Sp, bAlk, Al and iPTH levels. DraII cleavage PTH gene polymorphisms displayed a similar pattern. Patients with BBDD haplotype were not found to have significantly higher serum iPTH levels than those with other haplotypes. Conclusion: Our study appears to indicate that PTH gene polymorphisms do not influence serum iPTH levels in Chinese HD patients.

Health‐Related Quality of Life in Hemodialysis Patients in Taiwan

Background: Health‐related quality of life (HRQOL) is an important outcome of medical treatment effectiveness.Objectives: Thirty‐six item short‐Form (SF‐36) first has been used in hemodialysis (HD) patients in Taiwan.Method: HRQOL was measured by using SF‐36 in 497 HD patients in 5 hospitals.Results: Male sex, age less than 50 years, higher education level (EL), marriage, employed status (EPS), less comorbid medical condition (CMC), and non‐diabetic patients were all predicted a better physical component scale (PCS). Age less than 50 years, BMI greater than 18.5, HEL, EPS, and NDP were all predicted a higher mental component scale (MCS). Scales contributing to a summary measure of physical health, the PCS score, was significantly lower in women (35 ± 12.3) than in men (37.9 ± 12.3). There is no difference in MCS score between women and men. In multivariate analysis, age, CMC, diabetes, serum creatinine (SCr), and erythropoietin responsiveness were significant independent predictors of PCS. Diabetes, EL, SCr, and erythropoietic responsiveness were significant independent predictors of MCS. All of the individual scales, PCS and MCS scores were lower in the Taiwan HD patients than values for the US general population. Each of the individual scales and MCS scores were substantially lower in Taiwan HD group than in the US HD cohort. But the bodily pain of PCS was significantly higher in Taiwan HD group in spite of mean PCS scores for Taiwan HD group and US HD study participants were nearly equal at 36.3 and 36.1, respectively.Conclusion: Physical and mental aspects of quality of life are substantially reduced among Taiwan HD patients, but higher bodily pain tolerance. A number of demographic and clinical characteristics significantly impact on HRQOL in Taiwan HD patients. To our knowledge, this is the first time we demonstrate the HRQOL by using SF‐36 in Chinese HD patients.

Dietary and fluid compliance in Chinese hemodialysis patients

The current cross-sectional study examined dietary and fluid compliance behaviors in Chinese hemodialysis (HD) patients and identified variables related to compliance. Sixty-two chronic HD patients participated and information was obtained about their knowledge of dietary and fluid restrictions related to dialysis, health beliefs, personal and medical characteristics, and self-reported compliance. In addition, serum levels of potassium (K) and phosphate (PO 4) and interdialytic daily weight gain were retrieved from the medical records. Dietary and fluid compliance was observed in only 35.5% and 40.3% of the patients, respectively. No direct relationship was observed between dietary knowledge and any compliance measures. ‘Perceived barriers’ was the only variable of the health belief model that showed associations with the compliance measures, implying that patients who perceived less barriers in following the dietary instructions showed better compliance. Residual urine output volume was positively correlated with the level of fluid compliance. Patients with more hours on HD per week were found to be more fluid noncompliant. Working patients and those whose diet was prepared by someone else in the family were also more likely to be noncompliant. Health professionals should be aware of the factors behind noncompliance in HD patients and assist them in making life-style changes. Patient education with family involvement, identification of at-risk patients for noncompliance and assisting patients to identify and manage difficulties with life-style changes related to HD are important elements in promoting compliance.

Psychosocial correlates of fluid compliance among Chinese haemodialysis patients.

The present study was designed to determine the psychosocial correlates of fluid compliance among patients receiving haemodialysis at two Hong Kong renal dialysis centres. There has been little consistency in the findings of correlations among any psychosocial variables and compliance behaviour. There is a need to further study these variables in an attempt to predict haemodialysis patient compliance to fluid restriction. Ninety-two Chinese haemodialysis patients completed the Center for Epidemiological Studies Depression Scale (CES-D), The Multidimensional Health Locus of Control Form C Scale (MHLC), the Social Support Questionnaire, Short Form Scale (SSQ6) and a self-designed socio-demographic questionnaire. Daily interdialytic weight gain (DIWG) measure was used as an indicator of fluid compliance. The prevalence of compliance behaviour of Chinese haemodialysis patients was higher than that reported in western studies. There were significant negative correlations found between DIWG and total score on internal health locus of control and social support satisfaction score. However, internal health locus of control did not predict a significant portion of the DIWG variance. Significant predictors of DIWG included satisfaction with social support, comorbidity and monthly family income. Satisfaction with social support was the largest predictor of DIWG. The present findings suggest that assessing family income, comorbidity, and satisfaction with social support may be useful in identifying haemodialysis patients potentially at risk for difficulties in compliance with fluid restriction.

Psychological characteristics in maintenance hemodialysis patients

Objective To investigate the psychological characteristics in maintenance hemodialysis (MHD) patients. Methods Ninety-two MHD patients from six dialysis centers were studied. Three psychological rating scales were used: Symptom Check List 90 Rating (SCL-90-R), Multidimensional Health Locus of Control (MHLC), and Eysenck Personality Questionnaire (EPQ). Quality of life assessment specific for end-stage renal disease (ESRD) was also included in the survey. The results were compared with data from hemodialysis (HD) centers in the United States and Canada. Results Of the MHD patients, 39.1% had at least one elevated score of psychological symptoms. Compared with patients in the United States, the overall psychological disturbance, particularly with anxiety, was significantly higher in Chinese patients (p < 0.01). As in the United States, Chinese HD patients showed higher scores for the “powerful others” of Health Locus of Control than normal individuals (p < 0.01). However “chance externality” of Health Locus of Control was not significantly elevated in our patients. There was a significant correlation between emotional instability and psychological symptoms in SCL-90-R (p < 0.01). Chance externality was found significantly correlated with the SCL-90-R dimensions (p < 0.01). Education (in years) was found inversely correlated with chance externality dimension. The results also showed that our HD patients had a higher prevalence of somatopathic symptoms than Canadian patients (p < 0.01). The objective quality of life was lower in Chinese than Canadian patients, but the overall life satisfaction scores were similar. Conclusion Chinese HD patients had more psychological disturbance and a lower quality of life than the American and Canadian patients. Attention to psychological characteristics could result in better somatic and psychological health of dialysis patients and improved quality of life.