Chronic Kidney Disease Stage 5D Research Articles

Estimating the Level of Carbamoylated Plasma Non-High-Density Lipoproteins Using Infrared Spectroscopy

Background: The increased cardiovascular morbidity and mortality observed in chronic kidney disease (CKD) patients can be partly explained by the presence of carbamoylated lipoproteins. Lipid profiles can be determined with infrared spectroscopy. In this paper, the effects of carbamoylation on spectral changes of non-high-density lipoproteins (non-HDL) were studied. Methods: In the present study, fasting serum samples were obtained from 84 CKD patients (CKD stage 3–5: n = 37 and CKD stage 5d (hemodialysis): n = 47) and from 45 healthy subjects. In vitro carbamoylation of serum lipoproteins from healthy subjects was performed using increasing concentrations of potassium cyanate. Lipoprotein-containing pellets were isolated by precipitation of non-HDL. The amount of carbamoylated serum non-HDL was estimated using attenuated total reflectance-Fourier transform infrared (ATR-FTIR) spectroscopy, followed by soft independent modelling by class analogy analysis. Results: Carbamoylation resulted in a small increase of the amide I band (1714–1589 cm−1) of the infrared spectroscopy (IR) spectrum. A significant difference in the amide II/amide I area under the curves (AUC) ratio was observed between healthy subjects and CKD patients, as well as between the two CKD groups (non-dialysis versus hemodialysis patients). Conclusions: ATR-FTIR spectroscopy can be considered as a novel method to detect non-HDL carbamoylation.

Vascular calcification in patients with chronic kidney disease on dialysis in the Kingdom of Saudi Arabia: A cross-sectional study.

The study aimed to provide a unique nationwide data and a valuable update on the current situation of vascular calcification (VC) among chronic kidney disease (CKD) patients in the Kingdom of Saudi Arabia. The study included all patients diagnosed with CKD over a period of one year and six months from September 2015 to February 2017 and underwent dialysis. All analyses were done using IBM-SPSS. Of the 842 enrolled patients, 836 (99.3%) constituted the descriptive population. The mean age of patients was 51.8 ± 15.4 years. A total of 759 (90.8%) patients had cardiovascular risk factors. The prevalence of VC in patients with CKD is 40.8%. In the multivariate analysis, prognostic factors for VC were physical inactivity with odd ratio 2.87 [95% confidence interval (CI): (1.89-4.63), P < 0.01], history of ischemic heart disease 2.34 [95% CI: (1.30-4.22), P < 0.01], dyslipidemia 1.56 [95% CI: (1.01-2.40), P = 0.04], and older age 1.06 [95% CI: (1.05-1.07), P <0.01]. At inclusion, the mean ± standard deviation for high-density lipoprotein cholesterol, low cholesterol, total cholesterol, and triglycerides was 41 ± 30, 79.7 ± 29.9, 144.2 ± 38.5, and 143.4 ± 95.3 mg/dL, respectively. This study reports useful information about the prevalence of VCs in CKD stage 5D in a Middle Eastern country as the Kingdom of Saudi Arabia. Furthermore, it offers information on the predictors or associated factors of a VC in CKD patients.

Clinical profile of tuberculosis in patients with chronic kidney disease: A report from an endemic Country.

The objective is to study the clinical profile of tuberculosis (TB) in chronic kidney disease (CKD). This is retrospective study of CKD patients who were diagnosed to have TB over a period of seven years at a tertiary care hospital. TB was diagnosed in 115 patients with an incidence of 4200/100,000. Mean age of the patients was 46.9 ± 16 years. Sixty-two patients (53.9%) were male. Causes of CKD were diabetic nephropathy and hypertension in 11.3% each, chronic glomerulonephritis in 31.3%, chronic tubulointerstitial nephritis in 39.1%, autosomal dominant polycystic kidney disease, and post-renal transplant CKD in 3.5% each. About 68.7% of patients with TB had advanced CKD stage of 4-5D, whereas 31.3% of patients had early CKD stage 1-3. Twenty percent of patients were on dialysis. Three-fourths of the patients had extrapulmonary TB. Pleuropulmonary (41.8%), kidney and urinary tract (20%), and abdomen and lymph node (13% each) were the most common sites for TB. The main clinical presentation of TB was: fever/pyrexia of unknown origin in 24.3%, constitutional symptoms of anorexia, fever, night sweats, and weight loss in 27.8%, abnormal chest radiograph in 31.2%, ascites/peritonitis in 13.9%, pleural effusion in 25.2%, lymphadenopathy in 20%, and sterile pyuria/hematuria/chronic pyelonephritis in 13%. Microbiological and/or histopathological diagnoses were made in 45.2% and in the other 54.8%, diagnosis of TB was made on clinical grounds. Adverse effects of anti-TB drugs were seen in 9.6% of patients. Ninety-three percent completed the treatment and survived. Eight patients (7%), all in CKD stage 5D, died. The incidence of TB was high among CKD stages 4 and 5 and in those receiving dialysis. Extrapulmonary disease such as pleuropulmonary, renal, peritoneal, and lymph node were the common forms of TB.

Control of metabolic predisposition to cardiovascular complications of chronic kidney disease by effervescent calcium magnesium citrate: a feasibility study

AimsCardiovascular (CV) complications are common in chronic kidney disease (CKD). Numerous metabolic disturbances including hyperphosphatemia, high circulating calciprotein particles (CPP), hyperparathyroidism, metabolic acidosis, and magnesium deficiency are associated with, and likely pathogenic for CV complications in CKD. The goal of this feasibility study was to determine whether effervescent calcium magnesium citrate (EffCaMgCit) ameliorates the aforementioned pathogenic intermediates.MethodsNine patients with Stage 3 and nine patients with Stage 5D CKD underwent a randomized crossover study, where they took EffCaMgCit three times daily for 7 days in one phase, and a conventional phosphorus binder calcium acetate (CaAc) three times daily for 7 days in the other phase. Two-hour postprandial blood samples were obtained on the day before and on the 7th day of treatment.ResultsIn Stage 5D CKD, EffCaMgCit significantly increased T50 (half time for conversion of primary to secondary CPP) from baseline by 63% (P = 0.013), coincident with statistically non-significant declines in serum phosphorus by 25% and in saturation of octacalcium phosphate by 35%; CaAc did not change T50. In Stage 3 CKD, neither EffCaMgCit nor CaAc altered T50. With EffCaMgCit, a significant increase in plasma citrate was accompanied by statistically non-significant increase in serum Mg and phosphate. CaAc was without effect in any of these parameters in Stage 3 CKD. In both Stages 3 and 5D, both drugs significantly reduced serum parathyroid hormone. Only EffCaMgCit significantly increased serum bicarbonate by 3 mM (P = 0.015) in Stage 5D.ConclusionsIn Stage 5D, EffCaMgCit inhibited formation of CPP, suppressed PTH, and conferred magnesium and alkali loads. These effects were unique, since they were not observed with CaAc. In Stage 3 CKD, neither of the regimens have any effect. These metabolic changes suggest that EffCaMgCit might be useful in protecting against cardiovascular complications of CKD by ameliorating pathobiologic intermediates.

Elbasvir plus grazoprevir for patients with chronic hepatitis C genotype 1: A multicenter, real-world cohort study focusing on chronic kidney disease

The real-world effectiveness and safety of all-oral direct-acting antivirals (DAAs) for chronic hepatitis C (HCV) infection and chronic kidney disease (CKD) have not been fully elucidated. This study assesses elbasvir (EBR) plus grazoprevir (GZR) for patients with HCV genotype 1 infection in the clinical setting, focusing on CKD stage 3-5D. This multicenter, real-world cohort study consisted of 282 Japanese patients who were treated with EBR (50 mg) plus GZR (100 mg) for a fixed 12-week duration. We evaluated the sustained viral response rate 12 weeks after the end of treatment (SVR12), longitudinal liver and renal parameters, and adverse effects according to the cirrhosis and CKD status. Of those enrolled, 89 (31.6%) were CKD stage 3–5 and 21 (7.4%) were CKD stage 5D (hemodialysis-dependent). The overall and CKD stage 3-5D SVR12 rates in the per protocol populations were 98.6% (272/276) and 98.1% (101/103). High SVR12 rates were observed in almost all groups, except for prior all-oral DAA failure with NS5A resistance-associated substitutions. There was no significant change during treatment or follow-up period in estimated glomerular filtration rate, irrespective of CKD status. In contrast, the serum complement level (C3 and C4) increased, with significance for C3. Serious adverse effects were very rare, both in the groups with normal eGFR and CKD, and discontinuation was required for only six (2.1%) patients. EBR plus GZR for HCV genotype 1 was highly effective with a low rate of adverse effects, regardless of CKD status. In addition, liver parameters and complement levels improved longitudinally.

Baclofen Toxicity in a Chronic Kidney Disease Stage 5D Patient

The toxicity of Baclofen is extremely unusual. However, its predominant renal clearance makes its vulnerable in patients with impaired renal function. Clinical manifestations may begin as early as 2-3 days after starting the drug, even with a smaller dosage.A 73-year-old man with end-stage renal disease on maintenance hemodialysis was admitted to our emergency department with progressive confusion, hallucination and a generalized decrease in muscular tone. There was no significant metabolic or infectious etiology that could have clarified his condition. A thorough laboratory and imaging workup was negative too. A detailed history of his medication revealed that he had recently been prescribed baclofen for neck muscular spasm (10mg twice daily). He was then diagnosed with baclofen toxicity and was treated with intensive hemodialysis. During his admission, few sessions of hemodialysis on consecutive days, eventually produced expected clinical improvement and a complete return to his previous baseline mental status.Nepalese Medical Journal, vol.1, No. 1, 2018, page: 54-56

Assessment of Infection Control Knowledge Among Hemodialysis Patients in Kasr Al-Ainy Hospitals

Abstract Background: Chronic Kidney Disease (CKD) is considered a public health issue. End-Stage Renal Disease (ESRD) is the form of CKD in which life can be sustained by dialysis or transplantation. In Egypt ESRD is one of the main health problems. Patients receiving Hemodialysis (HD) are at risk of acquiring infections as Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV). As Devices used in dialysis units create an access site, Patients should be educated on how to keep the access site clean and dry and to recognize and report any signs and symptoms of infection immediately.Aim of the Study: This study was conducted to assess the baseline knowledge in Infection Control (IC) among chronic HD patients and to detect rate of seroconversion from hepatitis B & hepatitis C negative to positive among them.Subjects and Methods: A cross sectional study design was conducted in the HD units at Kasr AlAiny hospitals. Patients with CKD stage 5D on regular HD participated in the study [two HD units are present in Kasr Al-Ainy Hospitals; 60 patients in unit (1) and 50 patients in unit (2)]. Results: Regarding the IC knowledge of the HD patients, the median total score was 6/10 (4-10) in unit (1) and 6/10 (2-10) in unit (2). Regarding rate of seroconversion from HCV negative to HCV positive; in unit (1) one patient out of 65 was seroconverted in 2015. In unit (2); one patient out of 22 was seroconverted in 2014, one patient out of 28 was seroconverted in 2015, and one patient out of 30 was serocon-verted in 2016.Conclusion: IC knowledge of chronic HD patients was generally low regarding the BSIs that they are at risk for, how to protect themselves and the IC practices that nurses should follow with them.

OF PHOTOPHERESIS IN KIDNEY TRANSPLANTATION

Aim– to perform a comparative study of the long-term results of the combined use of extracorporeal photochemotherapy (photopheresis) and drug immunosuppression and standard immunosuppressive therapy in patients after kidney transplantation.Materials and methods. An open cohort randomized study was conducted, including 60 patients with chronic kidney disease stage 5D. All patients underwent single-group cadaveric kidney transplantation. Patients were randomly divided into two groups. All transplants were paired, the fi rst kidney transplant was received by the patient of the main group, the second – by comparison group. 30 patients of the main group received standard protocol of immunosuppression and 10–15 sessions of photopheresis during the fi rst six months after transplantation. All patients of the comparison group received standard immunosuppressive therapy only. End points: primary – graft loss, surrogate – the number of acute rejection episodes and infectious complications, the dynamics of creatinine blood concentration, the glomerular fi ltration rate and daily proteinuria, the dynamics of tacrolimus C0 blood concentration. To study the mechanism of photopheresis action in the late postoperative period, we evaluated the immunological parameters: subpopulation of naive T-cells (CD3+CD4+CD45RO–CD28+), the level of CD28 molecule expression (MFI) on these cells and also – subpopulation of T-regulatory cells (CD3+CD4+CD25 (Hi)CD127–).Results.The use of photopheresis leads to the graft function improvement in the late postoperative period: the creatinine concentration (p = 0.017) in the blood and daily proteinuria (p = 0.011) were lower in patients of the main group, the glomerular fi ltration rate was higher (p = 0.027). The incidence rate ratio (IRR) of rejection in the main group was signifi cantly lower than in the comparison group: 0.2509 (95% CI 0.05386, 0.9167), p = 0.0358. The risk of graft loss was also lower in the main group: IRR 0.2782 (95% CI 0.07562, 0.8657), p = 0.026, as well as the risk of infectious complications: IRR 0.3888 (95% CI 0.2754; 0, 5445), p &lt; 0.0001. Survival rate of transplants was higher in the main group (Log Rank p = 0.009; Breslow p = 0.005). The use of photopheresis made it possible to reduce the concentration of tacrolimus in the late postoperative period (p = 0.0017) without increasing the risk of graft rejection. The photopheresis tolerogenic effect in the late postoperative period may be due to an increase in the population of T-regulatory cells with the CD3+CD4+CD25(Hi)+CD127– phenotype compared to the patients which received only standard immunosuppressive therapy (p = 0.024).Conclusion.The preventive use of photopheresis contributes to improvement of the kidney transplantation long-term outcomes. Further studies are needed to study the mechanisms of photopheresis action and markers of partial immunological tolerance to the allograft.

Menopause in CKD

Most women with dialysis-dependent chronic kidney disease (CKD) stage 5 (CKD stage 5D) are in the postmenopausal age group. Early menopause is reported for all CKD stages (stages 3-5D). The traditional definition of menopause is not applicable in CKD stage 5(D) because menses can resume with hormone replacement therapy or kidney transplantation. Treatment of vasomotor symptoms continues to be the primary indication for hormone replacement therapy, with no dosing studies done specifically for CKD or kidney transplantation populations. Similarly, the risk for cardiovascular disease and osteoporosis in menopause is well described in healthy women, but the role that menopause plays in accelerating the risk further in CKD/kidney transplantation is yet to be explored. Lack of data and specific guidance on management make the long-term effects of menopause one of the most under-recognized and neglected patient problems in clinical nephrology. The efficacy and side effects of widely available therapeutic options in healthy women for menopause-related clinical manifestations, be it hormone replacement therapy for vasomotor symptoms or antiresorptive agents for osteoporosis, are to be tested in kidney transplantation and CKD populations. Longitudinal clinical trials are in need to define menopause in CKD and determine the role that CKD plays in menopause transition and menopause on CKD manifestations.

Clinical Practices and Therapeutic Management of Mineral and Bone Disorders in Chronic Kidney Disease 4, 5 and 5D: The OCEANOS Study in Iran

Background: The aim of this study was to evaluate the management of mineral and bone disorders (MBD) in patients with chronic kidney disease (CKD) in Iran and the extent to which KDIGO goals were met. Methods: This multi-centre observational studywasconductedonpatients withCKDstages 4, 5, and5D. Data were collectedfroma total of 209patients withnosurgical or medical conditions that precluded their participation. This study assessed the frequency of measurements, serum levels of phosphorus (P), calcium (Ca), and parathyroid hormone (PTH), the achievement of the targets recommended by the 2009 KDIGO guidelines, and the presence of vascular/valvular calcification. Results: The KDIGO targets for P, Ca, and iPTH, were achieved in 47, 51, and 18 of the patients with stage 4 + 5 and in 63, 50, and 44 of the patients with stage 5D, respectively. The serum PTH level of 18 of the patients with CKD stage 4 + 5 was within the recommended range, while it was higher than the recommended level in other patients. Among patients with CKD stage 5D, the serum PTH level was within, below, and above the recommended range in 44, 39, and 17 of the patients, respectively. The frequency of the measurement of the blood levels of Ca, P, and PTH were based on the 2009 KDIGO guidelines in 88 of patients. Forty-six percent of cases were screened for vascular/valvular calcification, 30 of whom had calcification at least in one site. Conclusions: The current status is far from the targets recommended by the current guidelines in the management of CKD-MBD. © 2017, Nephro-Urology Monthly.

Bone mineral density and bone metabolism biochemical markers in patients with chronic kidney disease at the hemodialysis treatment

Introduction: Chronic kidney disease (CKD) is associated with bone and mineral metabolism disorders.Objectives: This investigation studied the bone mineral density (BMD) and bone metabolism biochemical markers in patients with CKD at the hemodialysis treatment among a group of Iranian hemodialysis patients. We also sought to test the possible association of risk factors and biochemical parameters with BMD.Patients and Methods: In this cross sectional study, 77 patients with CKD stage 5D at the hemodialysis treatment. BMD was measured by dual-energy X-ray absorptiometry (DXA) at the anteroposterior lumbar spine (LS) (L1-L4) and left proximal femur. Biochemical markers, including calcium (Ca), phosphorus (P), intact parathyroid hormone (iPTH), serum specific alkaline phosphatase (ALP) and 25-hydroxy-vitamin D (25(OH)D) were measured to assess BMD loss.Results: Around two (2.6%) patients had normal levels of 25(OH) D (mean levels 17.67 ± 11.66 nmol/l). We found a reduction of BMD in comparison with age and gender-matched normal population values at the femoral neck (FN) (T-score = -1.92 ± 1.29), at the total hip (TH) (T-score = -1.79 ± 1.25) and at the lumbar spine (LS) (T-score = -1.55 ± 1.84). The prevalence of T-scores ≤ -2.5 SD was 28.6%, 35.1% and 13.0% according to LS, FN and three bone sites T scores respectively. BMD negatively correlated: with age at the proximal femur, with serum ALP at the lumbar spine and with age of menopause at the femoral neck.Conclusion: Patients with end-stage renal disease at the hemodialysis treatment had a high prevalence of osteoporosis in the general population. Bone mineral density at the all bone sites was below the expected average for gender and age.

Oral Anticoagulants to Prevent Stroke in Nonvalvular Atrial Fibrillation in Patients With CKD Stage 5D: An NKF-KDOQI Controversies Report

Stroke risk may be more than 3-fold higher among patients with chronic kidney disease stage 5D (CKD-5D) compared to the general population, with the highest stroke rates noted among those 85 years and older. Atrial fibrillation (AF), a strong risk factor for stroke, is the most common arrhythmia and affects >7% of the population with CKD-5D. Warfarin use is widely acknowledged as an important intervention for stroke prevention with nonvalvular AF in the general population. However, use of oral anticoagulants for stroke prevention in patients with CKD-5D and nonvalvular AF continues to be debated by the nephrology community. In this National Kidney Foundation-Kidney Disease Outcomes Quality Initiative (NKF-KDOQI) controversies report, we discuss the existing observational studies that examine warfarin use and associated stroke and bleeding risks in adults with CKD-5D and AF. Non-vitamin K-dependent oral anticoagulants and their potential use for stroke prevention in patients with CKD-5D and nonvalvular AF are also discussed. Data from randomized clinical trials are urgently needed to determine the benefits and risks of oral anticoagulant use for stroke prevention in the setting of AF among patients with CKD-5D.

The role of calcium and non calcium-based phosphate binders in chronic kidney disease.

Rising levels of serum phosphate occur late in the course of chronic kidney disease (CKD) and have been easy targets for nephrologists to treat using phosphate binding drugs, as well as fertile ground for the pharmaceutical industry, for meta-analysis and for the earnest pontifications of guideline writers. Unfortunately, the evidence does little to support this focus, which might be better applied to earlier, adaptive hormonal changes, and to phosphate balance rather than serum phosphate levels. Nevertheless, phosphate binders are ubiquitously prescribed to patients on dialysis, and often prescribed to patients with earlier stages of CKD; for which there is no evidence of benefit and some evidence that calcium-based binders (CBBs) and possibly non-CBBs may cause more harm than placebo. For patients on dialysis, observational studies suggest that phosphate binder use may reduce mortality. Meta-analyses report reduced hypercalcaemia for non-CBBs versus CBBs, and compared with CBBs sevelamer has been reported to significantly reduce vascular calcification progression and, in some but not all studies, overall mortality. However, limitations include study heterogeneity. For patients on dialysis, CBBs appear to have no advantages over the non-CBBs, apart from lower cost. In general, it seems prudent to avoid prescribing calcium-based drugs to patients who are pre-dialysis, and to use non-CBBs preferentially in CKD stage 5D. Current draft Kidney Disease Improving Global Outcomes guidelines suggest that CBB dosage be minimized in CKD stages 3 to 5D.

ASSESSMENT OF THE FUNCTIONAL ACTIVITY OF PLATELETS IN CHRONIC KIDNEY DISEASE STAGE 5D

Rationale: Thromboembolic complications in patients on hemodialysis have a significant impact on the duration and quality of life. Aim: To study the functional status of platelets in chronic kidney disease stage 5D (CKD-5D). Materials and methods: We examined 61 patients with CKD-5D. The duration of renal replacement therapy was 133 (74 to 177) months. The functional activity of platelets was evaluated in the adenosine diphosphate and adrenaline tests. Results: The functional activity of platelets in the adenosine diphosphate test was reduced in 35 (57.4%) of patients and unchanged in 26 (42.6%) patients. The functional activity of platelets in the adrenaline test was reduced in 38 (62.3%), normal in 8 (13.1%) and increased in 15 (24.6%) patients. Conclusion: In our study, only the adrenaline test was able to identify hyperactivity of platelets. We believe therefore, that the test with adrenaline is preferred for the study of the functional activity of platelets in CKD-5D.

Serum phosphorus adds to value of serum parathyroid hormone for assessment of bone turnover in renal osteodystrophy.

It is well-established that parathyroid hormone (PTH) correlates with the level of bone turnover in patients with chronic kidney disease stage 5D (CKD-5D). Hyperphosphatemia is a well-established complication of end-stage renal disease and is usually attributed to dietary intake. This study evaluates the relationship between serum phosphorus levels and bone turnover in patients with CKD-5D. 93 patients with CKD-5D from the Kentucky Bone Registry who had sequentially undergone anterior iliac bone biopsies were reviewed. Undecalcified bone sections were qualitatively assessed for turnover and placed into a group with low turnover and a group with non-low (normal/high) turnover. Results of PTH and phosphorus concentrations in blood drawn at the time of biopsies were compared between the groups. PTH and phosphorus levels were significantly higher in the non-low turnover group compared to the low turnover group. Cutoff levels for PTH and phosphorus were tested for predictive power of bone turnover. Both PTH and phosphorus correlated with turnover. Adding serum phosphorus to serum PTH enhanced predictive power of PTH for low turnover. The vast majority of patients with serum phosphorus levels ≥ 6.0 mg/dL had non-low turnover, while the majority of those with low turnover had phosphorus values < 6.0 mg/dL. Classification and regression-tree analysis showed that elevated serum phosphorus (> 6.2 mg/dL) in patients with PTH < 440 pg/mL was helpful in diagnosing nonlow turnover in this range of PTH. In patients with PTH ranges of 440 - 814 pg/mL, serum phosphorus levels > 4.55 mg/dL ruled out low turnover bone disease. This suggests that not only dietary intake but also bone affects serum phosphorus levels.

FEATURES OF REGULATION OF ERYTHROPOIESIS IN PATIENTS WITH CHRONIC KIDNEY DISEASE STAGE 5D

The aim: to study features of the cytokine profile in patients with chronic kidney disease receiving treatment by programmed hemodialysis. Materials and methods: the study included 100 patients aged 53,4 ± 15,8 years with chronic kidney disease stage 5D, receiving hemodialysis. All patients were performed a detailed interview to clarify the clinical and anamnestic data, features of pharmacotherapy, physical examination, and complex laboratory research, which included hemogram, biochemical analysis of blood to definition of parameters of kidney function, protein, electrolytes, minerals and iron metabolism, determining the level of interleukin-3 and interleukin-6. Results: anemia was found in 89% of patients, had a normocytic normochromic character with elements of anisocytosis. The most severe anemia was associated with a lower dose of erythropoietin and iron, used in the last month. Interleukin-3 averaged 32,8 ± 8,3 pg / ml, minimum 15 pg / ml, maximum 56 pg / ml, which exceeded reference limits. When comparing the levels of interleukin-3 and erythropoietin dose differing vectors of these parameters in patients with anemia of varying severity were indicated. The correlations between the level of interleukin-3 and the fluctuation of the dose of erythropoietin in the last year (r = 0,54; p = 0,01) in patients with mild anemia, and the level of soluble transferrin receptor (r = 0, 84; p = 0,04) in patients with severe anemia were found. The level of interleukin-6 was also higher than the reference values and amounted to 64,6 ± 8,7 pg / ml, the lowest — 36,0 pg / ml, the most — 86,0 pg / ml. The patients with a high risk of systemic inflammation on the scale of Glasgow Prognostic Score had lower levels of interleukin-6. Conclusions: high levels of interleukin-3 and interleukin-6 were revealed in all patients identified. Inverse relationship of interleukin-3 and dose of erythropoietin in depend of severity of anemia was shown. The high risk of systemic inflammation associated with a lower concentration of interleukin-6, which does not allow its use as a universal marker of inflammation in patients with chronic kidney disease receiving hemodialysis.

Prevalence and severity of disordered mineral metabolism in patients with chronic kidney disease: A study from a tertiary care hospital in India.

Background:Disordered mineral metabolism is common complications of chronic kidney disease (CKD). However, there are limited data on the pattern of these disturbances in Indian CKD population.Materials and Methods:This was a prospective observational study of CKD-mineral and bone disorder (CKD-MBD) over a period of 3 years. The biochemical markers of CKD-MBD, namely, calcium, phosphorus, alkaline phosphatase, intact parathyroid hormone (iPTH), and 25-hydoxyvitamin Vitamin D3 (25OHD), were measured in newly diagnosed CKD Stage 3–5 and prevalent CKD Stage 5D adult patients.Results:A total of 462 patients of CKD Stage 3–5D were studied. The frequency of various biochemical abnormalities was hypocalcemia (23.8%), hypercalcemia (5.4%), hypophosphatemia (2.8%), hyperphosphatemia (55.4%), raised alkaline phosphatase (56.9%), secondary hyperparathyroidism (82.7%), and hypoparathyroidism (1.5%). 25OHD was done in 335 (72.5%) patients and 90.4% were found to have Vitamin D deficiency. About 70.6% of the patients had iPTH levels were above kidney disease outcomes quality initiative (KDOQI) target range. Nondiabetic CKD as compared to diabetic CKD had a higher alkaline phosphatase (P = 0.016), a higher iPTH (P = 0.001) a higher proportion of patients with iPTH above KDOQI target range (P = 0.09), and an elevated alkaline phosphatase (P = 0.004). The 25OHD levels were suggestive of severe Vitamin D deficiency in 33.7%, Vitamin D deficiency in 45.4%, and Vitamin D insufficiency in 11.3% patients. There was a significant positive correlation between iPTH with alkaline phosphatase (r = 0.572, P = 0.001), creatinine (r = 0.424, P = 0.001), and phosphorus (r = 0.241, P = 0.001) and a significant negative correlation with hemoglobin (r = −0.325, 0.001), age (r = −0.169, P = 0.002), and 25OHD (r = −0.126, P = 0.021). On multivariate logistic regression analysis, an elevated alkaline phosphatase was a significant predictor of hyperparathyroidism (odds ratio 9.7, 95% confidence interval 4.9–19.2, P = 0.001).Conclusions:There was a high prevalence of CKD-MBD in Indian CKD patients. CKD-MBD is more common and more severe and has an early onset as compared to the western populations.

High-Density Lipoprotein Subfractions and Their Oxidized Subfraction Particles in Patients with Chronic Kidney Disease.

Chronic kidney disease (CKD) may lead to reduced concentrations of high-density lipoprotein (HDL) and its subfractions (HDL2 and HDL3), and damage them via inflammation and oxidative stress. The present study aimed to determine the contribution of such changes to cardiovascular disease (CVD) in patients with CKD. The levels of total cholesterol, low-density lipoprotein cholesterol, HDL-C, HDL2, HDL3, apolipoproteins, malondialdehyde-modified LDL (MDA-LDL), oxidized (ox) HDL, oxHDL2, and oxHDL3 were measured in blood samples from patients with CKD (stages 2-5, n=86) who were not on dialysis and from patients undergoing hemodialysis (CKD stage 5D, n=25). The patients were followed up for 28±9 months after baseline examinations and CVD events were recorded. The levels of HDL3 and ApoA1 in HDL3 fraction decreased according to CKD severity, whereas those of HDL2 and ApoA1 in HDL2 fraction did not differ. The levels of oxHDL were similar across CKD stages. The levels of oxHDL3 and MDA-LDL were decreased, whereas those of oxHDL2 increased according to CKD severity. Multivariate analyses using the Cox proportional hazards model selected high levels of oxHDL and its subfractions, and those adjusted with HDL-C and HDL subfractions or ApoA1 in HDL fractions respectively, compared with HDL-C and HDL subfractions or ApoA1 in HDL fractions alone as independent risk factors for CVD events. The levels of HDL subfractions and their oxidized subfraction particles differed among patients with CKD. The increasing levels of oxHDL subfractions might cause a high frequency of CVD events in such patients.

Phosphate Binders and Clinical Outcomes in Patients with Stage 5D Chronic Kidney Disease.

Knowledge informing the prescription and the choice of phosphate binders in end stage kidney disease (ESKD) patients has a weak evidentiary base. To date, no placebo-controlled trial based on meaningful clinical endpoints (death, cardiovascular events, bone fractures) has been performed to test the efficacy of these drugs. By the same token, we still lack solid proof that noncalcium binders afford better clinical outcomes as compared with calcium-based binders. Without proper trials, clinical decisions about the treatment of hyperphosphatemia rest on experience and contingent clinical judgment. The use of huge doses of calcium-based binders typically prescribed in the nineties now appears unwarranted. The relationship between phosphate and the risk of death is U shaped and moderate hyperphosphatemia carries just a mild-to-moderate risk excess and may not be seen as a compelling indication for the prescription of phosphate binders. Placebo-controlled randomized clinical trials assessing whether non-calcium and calcium-based binders reduce the risk of death and cardiovascular disease events in ESKD patients remain a public health priority.

1. Persistent elevation of BHCG-levels in a patient with stage 5D Chronic Kidney Disease

Introduction and aim: A 24 year old female with Stage 5D chronic kidney disease (CKD) presents with persistent positive BHCG levels. BHCG elevation causes include pregnancy, pituitary production, hydatidiform mole, persistent trophoblast disease, malignancies and false positive hCG. Variants of the hCG molecule has been identified and includes sulfated hCG, hyperglycosylated hCG, hCG free β-subunit and hyperglycosylated hCG free β-subunit. Different hCG fractions are generated depending on the disease process. Isolated cases of falsely raised BHCG in both men and women with CKD have been reported. Origin of hCG has been attributed to pituitary production, coupled with CKD impairing metabolism and clearance of hCG.Methodology: Samples were tested by the NHLS Universitas Academic Laboratory using the Cobas e 601 analyzer (Roche) for intact human chorionic gonadotropin and the β-subunit. This immunoassay detects the holo-hormone, nicked forms of hCG, β-core fragment and free β-subunit. A qualitative urine test, detecting total hCG was negative, while a laboratory urine analysis had a positive result. Analysis on different instruments and serial dilutions excluded assay interference from human antimouse antibodies (HAMA), heterophilic antibodies or a high dose hook effect. Imaging studies including magnetic resonance imaging (MRI) brain, pelvis, computed tomography (CT) chest and pelvic ultra sound was performed. Diagnostic laparoscopy was refused by the patient due to her ongoing peritoneal dialysis.Results: Serial BHCG results show persistent elevation. Imaging studies yielded no explanation to HCG production.Conclusion: Elevated BHCG could be attributed to a tumour of gestational or non-gestational origin, failed pregnancy, familial elevated hCG, reduced clearance and degradation of hCG in CKD or changes of hCG associated with CKD. Immunoassay interference should be considered when patient results and clinical presentation differs. False positive test results may subject patients to unnecessary investigation and it may prevent patients from qualifying for organ transplantation.