High Calcium-phosphate Product Research Articles

Carotid Intima-Media Thickness in Children with Chronic Kidney Disease as an Early Predictor of Cardiovascular Diseases

Aim: Cardiovascular problems are very common in children with chronic kidney disease (CKD). To examine early cardiovascular risk factors, notably carotid intima-media thickness (CIMT) and pulse wave velocity (PWV). Material and Method: Case-control study was conducted in the Department of Pediatric Nephrology Sindh Institute of Urology and Transplantation Karachi from 1stFebruary 2023 to 31st July 2023. Forty two children were enrolled. CIMT and PWV were measured using ultrasonography and pulse wave analysis respectively. The following clinical parameters were also assessed: blood pressure, age, gender, etiology, duration of chronic kidney disease (CKD), estimated glomerular filtration rate (eGFR), serum albumin, calcium-phosphate product, and intact parathyroid hormone (PTH), and vitamin D levels. Results: The average age was 10.2±3.6 years, with a higher proportion of boys in the cases group (69% versus 47.6%, p-value 0.04). Most patients had normal blood pressure (78.6%), and congenital anomalies were the most common CKD etiology (57.1%). Median eGFR was 30.5 ml/min/1.73 m2, with stages 3 and 4 CKD most prevalent. Serum albumin was normal (mean 4.45±0.68), but some cases had a high calcium-phosphate product (7%) and low vitamin D levels (52%). CIMT and PWV did not differ significantly between cases and controls. Echocardiography revealed mild cardiac abnormalities in some cases. Practical implication: Some patients showed minor left ventricular expansion, while others had mildly depressed GLS and decreased LVEF. Further research should focus on longitudinal studies and explore new biomarkers for early cardiovascular risk detection. Conclusion: The various clinical characteristics such as blood pressure, mineral and bone diseases, and cardiac abnormalities are common in children with chronic kidney diseases. There were no significant changes in carotid intima-media thickness and pulse wave velocity between the cases and controls. Keywords: Chronic kidney disease, Carotid intima-media thickness, Cardiovascular disease, Pulse wave velocity

Impact of haemodialysis on cardio-metabolic burden in chronic kidney disease patients - A prospective cohort study

Abstract Background: Maintenance haemodialysis (MHD) is the major form of renal replacement therapy in Nigeria, and may have a significant impact on cardiovascular (CV) and metabolic burden in chronic kidney disease (CKD) patients. Methods: This is a prospective cohort study involving 40 CKD dialysis-naïve end-stage renal disease patients who were assessed at first contact before commencing dialysis and assessments repeated 3 months later while on MHD. Clinical, echocardiographic and biochemical indices were assessed on both occasions. We studied the impact of MHD on CV risk factors such as left ventricular hypertrophy, left ventricular ejection fraction (LVEF), high calcium-phosphate product, hypoalbuminaemia, anaemia and dyslipidaemia. Results: The mean serum calcium-phosphate product, plasma total cholesterol, triglycerides and low-density lipoprotein cholesterol were significantly higher at baseline than at three months; while the mean haemoglobin, serum albumin and plasma high-density lipoprotein were significantly lower at baseline than at 3 months (P < 0.01). There was a significant difference in echocardiographic indices at baseline and at 3 months in CKD patients on MHD. Left ventricular mass and left ventricular mass index were significantly higher at baseline than at 3 months (P < 0.01); while LVEF was significantly lower at baseline than at 3 months (P < 0.01). Conclusions: Our study showed statistically significant improvements in CV risk factors among CKD patients after 3 months on maintenance haemodialysis. Early and effective maintenance haemodialysis reduce CV risk factors in Nigerian CKD patients.

Association between Flow-Mediated Dilation and Skin Perfusion Pressure with Peripheral Artery Disease in Hemodialysis Patients.

Flow-mediated dilation (FMD) is used to noninvasively assess the health of blood vessels and it has been shown to have a similar predictive ability for cardiovascular disease to traditional risk factors. Skin perfusion pressure (SPP) refers to the blood pressure required to restore capillary or microcirculatory flow after controlled occlusion and the return of flow. SPP has been shown to be an important measurement when making clinical decisions for patients with limb ischemia and to be a predictor of the likelihood of wound healing. Peripheral artery disease is common in hemodialysis (HD) patients. However, little is known about the association between FMD or SPP and peripheral artery disease. The aim of this study was to evaluate the association between FMD and SPP with brachial-ankle pulse wave velocity (baPWV) and ankle-brachial index (ABI) in HD patients in Taiwan, an area with a high rate of ESRD. This study was conducted at a regional hospital in southern Taiwan. ABI and baPWV values were measured using an ABI automated device. FMD and SPP were measured using ultrasound and a microvasculature blood flow monitor, respectively. Eighty patients were enrolled in this study. Compared to the patients with an ABI ≥ 0.95, those with an ABI < 0.95 had lower SPP of the feet (dorsal and plantar portions, both p < 0.001). After multivariable adjustments, low triglycerides (p = 0.033) and high calcium–phosphate product (p = 0.018) were significantly associated with low FMD. Further, low ABI (p = 0.001) and low baPWV (p = 0.036) were significantly associated with low SPP of dorsal portions. Old age (p = 0.005), low high-density lipoprotein cholesterol (p = 0.016), and low ABI (p = 0.002) were significantly associated with low SPP of plantar portions. This study demonstrated an association between FMD and SPP with peripheral artery disease in HD patients. Patients with low ABI and baPWV had a high risk of low SPP of the feet. However, there was no significant correlation between FMD and ABI or baPWV.

Changes in AZGP1 Serum Levels and Correlation With Pulse Wave Velocity After Kidney Transplantation.

Background: Zinc-alpha 2-glycoprotein (AZGP1), a secreted protein with ubiquitous tissue expression, has been controversially linked to the risk of cardiovascular disease. In a cohort of kidney transplant recipients, we measured serum AZGP1 levels after transplantation over a 2 year period and tested for an association with pulse wave velocity as an important parameter indicating future cardiovascular events.Methods: Annual blood sampling and pulse wave velocity measurements were longitudinally performed in 113 kidney transplant recipients. AZGP1 was measured in serum samples using standard ELISA. Association of AZGP1 with pulse wave velocity was longitudinally assessed during follow up of 2 years by mixed longitudinal modeling.Results: AZGP1 serum levels declined significantly after kidney transplantation. This decline was dependent on allograft function as indicated by inverse correlation with eGFR. When corrected for eGFR multivariable analysis revealed an inverse correlation between AZGP1 and pulse wave velocity. This analysis further showed independent associations of older age, higher blood pressure, and higher calcium phosphate product with higher pulse wave velocity.Conclusions: Improved kidney function after transplantation leads to a decline in AZGP1 serum levels. Independent of kidney function and other cardiovascular risk factors lower AZGP1 levels are associated with higher pulse wave velocity in the 2 years after kidney transplantation. These data suggest that AZGP1 might be a potential biomarker for cardiovascular health and a target for improving cardiovascular outcome.

Impact of Dialysis Vintage and Renal Biomarkers on Mortality in Dialysis-Dependent Patients With Critical Limb Ischemia Undergoing Revascularization

Purpose: Revascularization of both endovascular therapy (EVT) and surgical reconstruction improve clinical outcomes of patients with critical limb ischemia (CLI); however, treatment of dialysis-dependent patients with CLI is still challenging. This study aimed to investigate the impact of dialysis-related parameters on the risk of mortality in dialysis-dependent patients undergoing revascularization for CLI. Materials and Methods: We retrospectively identified 274 dialysis-dependent patients with CLI (196 males; mean age 71 years), who underwent revascularization, from the clinical database of the surgical reconstruction vs peripheral intervention in patients with critical limb ischemia (SPINACH) study, which was a prospective, multicenter, observational study. Of these patients, 175 patients underwent EVT and 99 patients received surgical reconstruction. The current study evaluated the impact of dialysis vintage and renal biomarkers on the mortality rate of dialysis-dependent patients with CLI undergoing revascularization. Results: During a mean follow-up period of 1.7 ± 1.1 years, 147 deaths were observed. The 3-year overall survival rate and its standard error were estimated to be 40.5% ± 8.1% using the Kaplan-Meier method. A Cox proportional hazard analysis revealed that dialysis vintage ≥4 years, serum creatinine levels <4.7 mg/dL, serum urea nitrogen ≥88 mg/dL, and calcium-phosphate product ≥62.6 mg2/dL2 were independent risk factors for mortality after adjustment for the detailed mortality risk score developed in the SPINACH study. Adding these parameters to the original mortality risk score slightly, but not significantly, increased the area under the time-dependent receiver operating characteristics curve from 0.74 (95% CI, 0.67 to 0.81) to 0.77 (0.71 to 0.84) (p=0.084), whereas continuous net reclassification improvement reached 0.75 (0.12 to 0.90) (p=0.027). Conclusion: We found that long dialysis vintage, low serum creatinine, high serum urea nitrogen, and high calcium-phosphate product were independently associated with the increased risk of mortality in dialysis-dependent patients with CLI undergoing revascularization.

Factors Related to the Presence of Anemia in Patients with Chronic Kidney Disease in Hemodialysis

Introduction: The prevalence of anemia in Chronic Kidney Disease (CKD) is high. However, little is known about the factors related to anemia in patients with chronic Hemodialysis (HD) in Mexico. Material and Methods: A cross-sectional study was conducted in adult patients with CKD undergoing HD in the northern area of Mexico City treated at the Mexican Institute of Social Security. Hemoglobin (Hb) and Hematocrit (Htc) levels, as well as clinical and biochemical factors associated with anemia, were evaluated. Results: Data was collected from 747 patients, obtaining a mean hemoglobin of 9.7 g/dl (IQR 8.4-10.9 g/dl). The group was divided into two using Hb &lt;10.0 g/dl and &gt;10.0 g/dl as cutoff limits. Fifty six percent of the patients had hemoglobin =10.0 g/dl. Hb level &lt;10.0 g/dl were associated with DM (OR 1.49, IC 95% 1.06-2.10, p=0.001), hyperphosphatemia (OR 1.69, IC 95% 1.21-2.28, p=0.001), high calcium-phosphate product (OR 1.43, IC 95% 1.01-2.03, p=0.040) and iron deficiency (OR 1.95, IC 95% 1.38-2.75, p=0.001). Glomerulopathies (OR 0.44, IC 95% 0.22-0.90, p=0.026), female gender (OR 0.55, IC 95% 0.40-0.074, p=0.001) and erythropoietin administration (OR 0.57, IC 95% 0.39-0.82, p=0.002) were associated with hemoglobin ≥10 g/dl. Conclusion: The factors associated with Hb &lt;10.0 g/dl were mineral-bone metabolism disorders and iron deficiency. The periodic evaluation of qualityof- care indicators of HD treatment, such anemia, are necessary to detect improvement opportunities.

Patterns and Predictors of Left Ventricular Hypertrophy in Nigerians with Chronic Kidney Disease

Background: Chronic kidney disease (CKD) impacts hugely on cardiovascular morbidity and mortality. Nigerian data on patterns and predictors of left ventricular hypertrophy (LVH) in persons living with CKD are scarce. The objective of the study is to describe the patterns and predictors of LVH in Nigerians with CKD. Methods: Recruitment and clinical assessment of adult Nigerians with CKD were done using standard procedures. Statistical analysis was done using appropriate statistical software. Results: Fifty-seven participants were involved in this study. Concentric and eccentric LVH occurred in 50% and 25% of the predialysis CKD patients, respectively, while 24% and 36% of the maintenance dialysis CKD patients had concentric and eccentric LVH, respectively. LVH patterns in dialysis-naive individuals were not significantly different from LVH patterns in persons on dialysis. The significant predictors of LVH in study participants were proteinuria, anemia, hypoalbuminemia, estimated glomerular filtration rate &lt;30 mL/1.73 m2/min, and hypertensive nephrosclerosis. High calcium-phosphate product was a significant predictor of LVH in only participants on dialysis. Conclusion: This study showed no significant difference in LVH patterns among predialysis and maintenance dialysis CKD patients. Indices of deteriorating renal function were significant predictors of LVH in both categories of CKD patients. Early screening and treatment of significant risk factors of LVH are required in reducing CVD burden among CKD patients.

Prevalence of Cardiovascular Risk Factors among Chronic Kidney Disease Patients Undergoing Hemodialysis in a Tertiary Care Center, Kathmandu, Nepal

The risk of cardiovascular disease is higher in chronic kidney disease patients compared to the general population and its impact is higher in developing countries compared to the developed countries. With this background in mind, we aimed to evaluate the prevalence of different cardiovascular risk factors in patients on maintenance hemodialysis in a tertiary care center. Chronic kidney disease patients aged 18 years and above who were under maintenance hemodialysis in the hemodialysis unit of Nepal Medical College were included in the study. Pre-dialysis venous blood samples from the participants were collected and analyzed for serum calcium, phosphorus, total protein, albumin and hemoglobin. Calcium phosphate product was calculated. Out of 100 study participants, 52% were male and 48% were female. Age-wise distribution showed 38% of the participants were below 40 years. The mean age of the participants was 45.86 ± 14.4 years. Ninety-three percent had hypertension and 29% had diabetes mellitus. Hypocalcemia was present in 80%, hyperphosphatemia was seen among 81% and high calcium phosphate product was present in 33% of the participants. Low hemoglobin (&lt; 10gm/dL) was found in 86%. The cardiovascular risk trend in the Nepalese chronic kidney disease population is fairly different compared to the western population. Participants were younger. Prevalence of hypertension and diabetes was high. The high prevalence of anemia might be due to unaffordability of the participants for regular erythropoietin therapy. Inadequately managed hyperphosphatemia despite the widespread use of phosphorus binders, is still a major clinical challenge in patients on hemodialysis.

Calcium phosphate product level as a predictor for arteriovenous fistula re-operations in patients with chronic renal failure.

There is an increased calcium phosphate product level causing the formation of calcification in the arterial wall and thus decreased quality of fistula in patients with chronic renal failure. The purpose of our study is to verify the relationship between arteriovenous fistula re-operation and high calcium phosphate product level. Seventy-nine consecutive patients with chronic renal failure between April 2016 and February 2018 were included in the study. Patients having calcium phosphate product level ≥50mg2/dl2 were defined as group 1, whereas those having <50mg2/dl2 were defined as group 2. Primary outcome of interest was the need for re-operation during the follow-up and to determine the risk factors for re-operation. To determine independent predictors for re-operation, multivariate logistic regression model was used. The rates of redo and tredo operation were significantly higher in group 1 compared to group 2 ( p = 0.01 and 0.04). In multivariate analysis, phosphate (OR: 1.84, 95% CI: 1.00-3.40, p = 0.05) and triglyceride (OR: 1.01, 95% CI: 1.00-1.02, p = 0.04) levels for redo operation and calcium phosphate product level (OR: 1.11, 95% CI: 1.01-1.22, p = 0.03) for tredo operation were found to be independent predictors. High calcium phosphate product level leads to increased risk of arteriovenous fistula re-operation by causing arterial stiffness in this patient group. Additionally, these re-operations place additional burden on morbidity and cost efficacy. Thus, we recommend keeping the calcium phosphate product level at the optimal level in these patients to avoid both the risk of arteriovenous fistula re-operation and the other cardiovascular problems.

A Prospective Study of Pulmonary Hypertension in Patients with Chronic Kidney Disease: A New and Pernicious Complication.

Pulmonary hypertension (PH) is a recently recognized complication of chronic kidney disease (CKD), especially in end-stage renal disease. It has prevalence estimates of 30%–50% and is an independent predictor of increased mortality in CKD patients. The aim of this study is to analyze the prevalence of PH in patients with CKD, its severity in different stages of CKD, and risk factors for it. One hundred and eight patients with CKD treated at Karnataka Institute of Medical Sciences, Hubli, Karnataka, between January 1, 2014, and June 30, 2015, were selected. Clinical evaluation and relevant investigations including echocardiography were done. Follow-up echocardiography was done at 3 and 6 months and assessed. The mean age of studied population was 43.53 ± 14.63 years. Sex ratio was 2.72:1 (male:female). PH was present in 47 of 108 (43.5%) cases at beginning, 41 of 83 (491.4%) at 3 months, and 32 of 64 (50%) at 6 months. The prevalence and severity of PH increased with progression of CKD stage, although not statistically significant. Heart failure with reduced ejection fraction and heart failure with preserved EF were significantly higher among PH group compared to non-PH group (P < 0.01). Mean hemoglobin in PH group was significantly lower, compared to non-PH group (P < 0.01). Mean interdialytic weight gain and central venous pressure were higher among PH group than non-PH group. Higher calcium phosphate product ≥50 was more prevalent in PH group than in non-PH group. The majority of them had moderate PH at the beginning of the study which remained same, despite being on hemodialysis. PH is a common complication in CKD patients with prevalence of 43.5%–50%. Left-sided heart failure, anemia, fluid retention, and increased calcium phosphate product are the risk factors for developing PH.

HYPERPHOSPHATEMIA IN END STAGE RENAL DISEASE: PREVALENCE AND PATIENTS CHARACTERISTICS OF MULTIETHNIC POPULATION OF UNITED ARAB EMIRATES

Objective: Hyperphosphatemia is significantly associated with increased mortality among end stage renal disease (ESRD) patients on hemodialysis. There is paucity of data on hyperphosphatemia in ESRD patients of the multiethnic population of United Arab Emirates (UAE). The study aimed to investigate the prevalence and characteristics of hyperphosphatemia in ESRD patients of the multiethnic population of UAE undergoing maintenance hemodialysis.Methods: Adults ESRD patients undergoing maintenance hemodialysis for more than six months at the study site were included. Demographic, clinical and biological data of the patients were collected. Patient characteristics were compared as per the serum phosphate level, between patients with or without hyperphosphatemia. Univariate and multivariate logistic regression analyses were carried out to identify the predictors of hyperphosphatemia.Results: Hyperphosphatemia was present in 73.8% of the study population, while 31.3% presented with high calcium-phosphate product. Univariate logistic analysis revealed that hyperphosphatemia was inversely correlated with age, hemoglobin, serum calcium, and hypertensive nephropathy as cause of renal disease, and positively correlated with female gender, expatriate status, body mass index (BMI), higher number of comorbidities, calcium-phosphate product and parathyroid hormone (PTH). Multivariate logistic regression model revealed that only age, BMI, hemoglobin and PTH independently correlated with hyperphosphatemia.Conclusion: We report a high prevalence of hyperphosphatemia in multiethnic study population undergoing maintenance hemodialysis at a secondary care hospital in UAE. In this study population, only age, BMI, hemoglobin and PTH were identified as independent predictors of hyperphosphatemia.

Impact of deteriorated calcium-phosphate homeostasis on amputation-free survival after endovascular revascularization in patients with critical limb ischemia on hemodialysis.

Patients on hemodialysis (HD) have abnormalities of calcium-phosphate (CaP) homeostasis and high CaP product contributes to atherosclerosis pathogenesis and adverse events. Patients on HD with critical limb ischemia (CLI) are at risk for major amputation and death because of advanced systemic atherosclerotic disease. The aim of this study was to evaluate the relationship between CaP product and amputation-free survival (AFS) in CLI after endovascular treatment (EVT). We retrospectively analyzed 221 CLI patients on HD. In Kaplan-Meier analysis, AFS was significantly lower in patients with CaP product ⩾ 55 mg(2)/dL(2) compared to those with CaP product <55 mg(2)/dL(2) (54.3% vs 78.5%, p = 0.002). However, neither serum phosphate nor calcium levels were individually associated with AFS. In multivariate analysis, CaP product ⩾ 55 mg(2)/dL(2) was an independent predictor for AFS in CLI patients on HD (hazard ratio, 3.03; 95% confidence interval, 1.78-5.15; p-value < 0.001). We concluded abnormal CaP homeostasis was associated with lower AFS after EVT in CLI patients on HD, and can serve for their risk stratification.

Come gestire l'ipertensione arteriosa in emodialisi?

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Dealing with hypertension in hemodialysis patients

Hypertension is a well-known cardiovascular risk factor also for hemodialysis patients. Despite being common in this patient population, hypertension is often difficult to diagnose and poorly controlled.Blood pressure variability (BPV) is a new parameter and a predictor of poor outcomes in the general population. A recent observational study in over 11,000 hemodialysis patients showed that high BPV is associated with an increased risk of all-cause mortality, cardiovascular mortality, and first cardiovascular event. High BPV is associated with female gender, black race, obesity, diabetes and/or cardiovascular disease, hemoglobin levels less than 10 g/dL, high calcium-phosphate product, and use of three or more anti-hypertensive drugs.Today, the management of hypertension in hemodialysis patients requires more and more care, not only from the diagnostic point of view, but also in prognosis and therapy, especially regarding the non-pharmacological approach.

Low serum fetuin A levels and incident stroke in patients with maintenance haemodialysis

Fetuin A, a predictor of mortality in dialysis patients, is associated with vascular calcification and atherosclerosis in haemodialysis (HD) patients. Whether it predicts stroke remains unknown. This study aimed to investigate the association between fetuin A and incident stoke in maintenance HD patients. This is a prospective observational study. 238 prevalent HD patients (127 women and 111 men; mean age, 60 ± 12 years) were followed up for the occurrence of stroke for 55 months. Baseline circulating fetuin A levels, biochemical data and other markers of inflammation were measured. The major outcome was the occurrence of incident ischaemic or haemorrhagic stroke. Thirty one patients had incident strokes; an incidence of 38·4/1000 patient-years (95% confidence interval (CI) 36·5-39·8/1000 patient-years) on follow-up. Patients in the lowest tertile of fetuin A concentration had highest risk to have incident stroke (P < 0·001, log-rank test). By Cox proportional-hazards regression, patients with higher fetuin A levels experienced lower incidence of stroke, hazard ratio (HR) of 0·89 (95% CI, 0·84-0·96), while those with higher mean arterial blood pressure had an HR of 1·19 (95% CI, 1·07-1·34) and those with higher calcium phosphate product (CaxP) had an HR of 1·39 (95% CI, 1·1-1·73) for having strokes. For patients without previous history of diabetes and cerebrovascular disease, fetuin A deficiency also predicts the occurrence of incident stroke. Fetuin A deficiency is associated with a higher risk of incident stroke among prevalent HD patients.

Cardiac complications of secondary hyperparathyroidism in chronic hemodialysis patients

To evaluate the effects of intact parathormone (iPTH) on left ventricular function using transthoracic echocardiography on chronic hemodialysis (HD) patients with secondary hyperparathyroidism. In HD patients, mortality is high and is frequently due to cardiac complications. Secondary hyperparathyroidism, high levels of phosphate (PO_4), and high calcium phosphate product (Ca × PO_4) are related to cardiac complications. Materials and methods: We examined 20 patients with normal iPTH levels (Group 1) and 20 patients with high iPTH levels (Group 2). Intact parathormone levels were measured in serum with a Coat-A-Count kit (Diagnostic Products Corporation, Los Angeles, CA, USA) using an immunoradiometric assay. The normal level of iPTH was 0.8-5.2 pmol/L. In patients with end-stage renal disease, iPTH levels should be 1.5 to 3 times higher than the normal range in order to maintain the bone mass; thus, patients with iPTH levels 4 or more times higher than the normal range (PTH >- 20.8 pmol/L) were defined as Group 2 while patients who had normal iPTH levels were defined as Group 1. Results: In both groups, Doppler parameters indicated diastolic dysfunction. However, mitral annular E velocity was lower in Group 2 than in Group 1 (6.1 ± 1.1 cm/s and 7.5 ± 1.6 cm/s, respectively; P = 0.034). It is well known that left ventricular hypertrophy (LVH) increases mortality rates. Left ventricle mass index and relative wall thickness are parameters reflecting LVH, and both were higher in Group 2 (294.4 ± 103.0 g/m² and 53.5 ± 11.7%) when compared with Group 1 (179.2 ± 104.2 g/m² and 41.8 ± 8.9%). These differences were found to be statistically significant (P < 0.001). Conclusion: This study demonstrates that high levels of iPTH contribute to diastolic dysfunction and LVH in hemodialysis patients.

Quantitative Ultrasound of the Calcaneus in Hemodialysis Patients

The aim of this study was to investigate the bone status of hemodialysis patients and identify factors that have influence on bone quality. Four hundred eighty-nine subjects (213 males and 276 females) on maintenance hemodialysis and 696 healthy subjects (309 men, 387 women) were enrolled in this study. Speed of sound (SOS), broadband ultrasound attenuation (BUA) and quantitative ultrasound index (QUI) were assessed by quantitative ultrasound (QUS) at the right calcaneus in both groups. Serum levels of intact parathyroid (iPTH), total alkaline phosphatase (ALP), calcium and phosphate were measured to determine their influence on bone status in hemodialysis patients. All QUS parameters were significantly lower in hemodialysis patients than in controls ( p < 0.0001). Stepwise multiple linear regression analysis in male patients indicated that age, weight, calcium-phosphate product and ALP were significant predictors of QUS parameters (adjusted R 2 = 0.15 in SOS; adjusted R 2 = 0.17 in BUA and QUI). In female patients, same findings including number of parity were observed in SOS only (adjusted R 2 = 0.25 in SOS). In postmenopausal patients, the duration of menopause was significant negatively correlated with all QUS parameters ( p < 0.01). In conclusion, patients on maintenance hemodialysis had additional risk of bone loss. Advanced age, low body weight, high calcium-phosphate product and high ALP level were important risk factors for deterioration of bone quality. (E-mail: tcchu@mx.nthu.edu.tw)

Analysis of risk factors for mortality of incident patients commencing dialysis in East Yorkshire, UK

The change in the demographics and the presence of multiple risk factors and co-morbidities in UK patients starting dialysis may lead to poor survival on dialysis. Many of these risk factors are present in the pre-dialysis period allowing a potential window of opportunity to intervene with risk modification measures. To examine various potential factors that may predict early and overall mortality. We carried out an observational prospective study of a cohort of incident patients starting dialysis in a UK centre. Univariate analysis of factors and co-morbidities potentially affecting survival on dialysis were analysed to potential predictors. Factors affecting 1 year mortality were analysed using the t-test, the Mann-Whitney U-test or the chi-square test as appropriate. Mortality over the 5-year follow-up period was analysed using the Kaplan-Meier method. Ninety-four patients [predominantly Caucasian (98%)], of mean age 63 years (15.6) (56% > 65 years) with a slight male preponderance were studied. Vascular disease (39%) and sepsis (33%) accounted for most of the deaths and a significant proportion of mortality was seen in the first year (56%). Patients with early mortality were older (68 vs. 61 years, P = 0.05) with lower haemoglobin (8.4 vs. 9.4 g/dl, P = 0.01) at the start of dialysis, commenced dialysis with a lower eGFR (5.4 vs. 6.5 ml/min/1.73 m(2), P = 0.06) and had more peripheral vascular disease (PVD) (39% mortality in patients with PVD vs. 18.5% in those without PVD, P = 0.04). Diabetes mellitus, high calcium phosphate product, older age and presence of vascular co-morbidities including ischaemic heart disease and peripheral vascular disease were associated with overall mortality over the 5-year follow-up period. In this study, elevated calcium phosphate product and diabetes mellitus in addition to the presence of vascular disease were associated with poor survival. Patients with low haemoglobin and lower first pre-dialysis eGFR suffered higher early mortality. These potentially modifiable factors that could be identified in the pre-dialysis stage provide a valuable opportunity for intervention.

Hemodialysis headache

The aim of this study was to evaluate and analyze the incidence and features of headaches in patients undergoing hemodialysis. In this prospective study 318 patients, 119 women and 199 men, undergoing chronic HD in four hemodialysis centers in Serbia, were questioned about their problems with headaches using a questionary designed according to the diagnostic criteria of the International Headache Classification of Headache Disorders (ICHD) from 2004. Patients were distributed in two groups according to the presence of hemodialysis headaches (HDH). The groups were compared regarding sex, age, duration of HD, primary diseases that lead to ESRD, arterial systolic and diastolic blood pressure (BP) and serum levels of hemoglobin, urea nitrogen, creatinine, sodium, potassium, calcium, phosphates, albumin, glucose and calcium-phosphate product. We also analyzed features of HDH. The results were statistically compared. Patients with HDH had significantly lower serum glucose, but higher serum phosphates and albumin than patients without headaches. Furthermore, HDH patients had higher calcium phosphate product and systolic blood pressure than non-HDH patients. Out of 318 patients included in the study, 21 (6.6%) patients had HDH. According to our results, HDH appeared more frequently in men, during the 3rd hour of HD in more than a half of the patients and lasted less then 4 h in the majority of HDH patients. In the majority of patients HDH was bilateral, non-pulsating, without associated symptoms and it appeared mostly during HD. Personal history was negative for primary headaches in all patients with HDH. We believe that the results of our investigation of more than 300 HD patients pointed to some biochemical changes, possibly implicated by pathophysiology of HDH and disclose some specific HDH features that might contribute to a better understanding of this secondary headache disorder.

Unusual Case of Calciphylaxis Associated with Primary Hyperparathyroidism without Coexistent Renal Failure

To report a case of calciphylaxis in a patient with primary hyperparathyroidism without coexistent renal failure. The clinical, laboratory, and radiographic details of this case are reviewed, and the pathogenesis of calciphylaxis and the associated prognosis are discussed. A 52-year-old woman had progressive fatigue, cachexia, severe osteoporosis, and necrotizing skin lesions. Her serum calcium level was 16 mg/dL, serum phosphorus level was 2.13 mg/dL, and parathyroid hormone level was 2,257 pg/mL (reference range, 15 to 65). On physical examination, gangrenous skin lesions with black crusts were noted on her legs, abdomen, and gluteal region. A mass lesion was detected in the parathyroid region by both ultrasonography and a parathyroid scan. The patient underwent a bilateral neck exploration, and a parathyroid adenoma measuring 3.5 by 1.5 by 1.2 cm was found on pathologic examination. After the operation, biochemical findings normalized, and the skin lesions progressively improved. Severe primary hyperparathyroidism may be a factor leading to calciphylaxis, even in the absence of renal failure and a high calcium-phosphate product. This potentially life-threatening condition should not be left untreated if the levels of serum calcium and parathyroid hormone are severely elevated.