Long-term Dialysis Patients Research Articles

Update on Peritoneal Dialysis: Core Curriculum 2016

Update on Peritoneal Dialysis: Core Curriculum 2016

Water and solute transport across the peritoneal membrane.

We review the molecular mechanisms of peritoneal transport and discuss how a better understanding of these mechanisms is relevant for dialysis therapy. Peritoneal dialysis involves diffusion and osmosis through the highly vascularized peritoneal membrane. Computer simulations, expression studies and functional analyses in Aqp1 knockout mice demonstrated the critical role of the water channel aquaporin-1 (AQP1) in water removal during peritoneal dialysis. Pharmacologic regulation of AQP1, either through increased expression or gating, is associated with increased water transport in rodent models of peritoneal dialysis. Water transport is impaired during acute peritonitis, despite unchanged expression of AQP1, resulting from the increased microvascular area that dissipates the osmotic gradient across the membrane. In long-term peritoneal dialysis patients, the fibrotic interstitium also impairs water transport, resulting in ultrafiltration failure. Recent data suggest that stroke and drug intoxications might benefit from peritoneal dialysis and could represent novel applications of peritoneal transport in the future. A better understanding of the regulation of osmotic water transport across the peritoneum offers novel insights into the role of water channels in microvascular endothelia, the functional importance of structural changes in the peritoneal interstitium and the transport of water and solutes across biological membranes in general.

Evaluation of uraemic pruritus in long-term dialysis patients using a modified Chinese scale.

To examine the reliability and validity of a modified Chinese version of the uraemic pruritus scale for measurement of different degrees of itching, as well as to identify the predictors for the severity of uraemic pruritus among long-term dialysis patients. Long-term dialysis patients (n = 110) were recruited for a cross-sectional study from a medical centre in Taiwan. A modified Chinese version of the uraemic pruritus scale was used to evaluate sleep disturbance and the severity, frequency and distribution of itching. Reliability was evaluated using item-total correlations, Cronbach's α, and intra-class correlation. Validity was evaluated by the content validity index, predictive and discriminative validity. Multiple linear regression was used on the predictors for the severity of uraemic pruritus. After optimization for reliability, the scale retained seven items. The Cronbach's α was 0.86, and the results showed that the scale had predictive and discriminative validity. High intact-parathyroid hormone and creatinine clearance rate were important predictors for the severity of uraemic pruritus. The severity of uraemic pruritus was the important predictor for the sleeping disturbance. The modified uraemic pruritus scale can discriminate between patients with a total pruritus score of ≥11 and those with a score of 0 points. The modified Chinese scale is a useful tool for clinically assessing the various degrees of itching among long-term dialysis patients. Our study validates that it could apply to clinical practice in assessment of uraemic pruritus.

Hyperleptinaemia, insulin resistance and survival in peritoneal dialysis patients.

The aim of this study was to clarify the relationship between insulin resistance (IR) and glucose and lipid metabolism in peritoneal dialysis (PD) patients. The study also investigated the prognostic factors for survival in long-term peritoneal dialysis patients. Participants were recruited from July 1 to August 1, 2011, based on selection criteria. Patients were divided into two groups, high (H) and low (L) group according to the median value of homeostasis model assessment of IR (HOMA-IR). Type 2 diabetes mellitus (DM) patients were chosen as positive controls. Clinical, plasma biochemical and metabolic parameters were observed and recorded at the outset and follow-up of this study. Mortality related factors were also detected, and statistical analyses were performed. A total of 157 cases with an average age of 55 ± 15 years were included. There were 26, 66 and 65 cases in the DM, H and L groups, respectively. Younger age, lower body mass index, high sensitive C-reactive protein (hsCRP) level, higher normalized protein catabolic rate (nPCR) were found in the L group compared with the other two groups. HOMA-IR positively correlated with age, leptin and triglyceride levels, and it negatively correlated with BMI. L group had better survival rate than H and DM groups. Dialysis duration, serum leptin level, nPCR and hsCRP were statistically associated with mortality. Insulin resistance may play an important role in the pathophysiology of glucose and lipid metabolism. Dialysis duration, leptin, nPCR and hsCRP may be risk factors for mortality in PD patients.

FP745BLOOD PRESSURE CHANGE IN THE TYROSINE-KINASE INHIBITORS TREATMENT OF DIALYSIS PATIENTS WITH RENAL CELL CARCINOMA

Introduction and Aims:Malignant tumor is more frequently occurred and a higher risk of death in dialysis patients than in general population. Especially, dialysis patients with renal cell carcinoma (RCC) have a significantly higher relative risks compared to general population (3.6 to 24.1 SIR). As dialysis period becomes longer, the kidney is replaced by more cysts and it is called acquired cystic disease of the kidney (ACDK). RCC is a grave complication arising from ACDK in long-term dialysis patients. Recently, molecular targeted therapy is recommended for patients with advanced RCC, because that is effective therapy to prevent the progression of RCC and improve their mortality. However, there are few reports about the molecular targeted therapy for dialysis patients with RCC. Furthermore, the rise in blood pressure is one of the adverse effects due to the tyrosine-kinase inhibitors (TKI) treatment, but is not fully understood in dialysis patients. Methods: Among dialysis patients who were admitted in our hospital from 2010 to 2013, those with RCC were enrolled. Of 32 cases, three patients were excluded from the present study. Two patients received only best supportive care because their general condition was too poor to receive an invasive surgery, 1 patient did not have sufficient clinical data because he was treated on an outpatient basis. Finally, we compared clinical characteristics, treatment strategy and blood pressure change over a 1-month period between patients with only surgery (control group, n=16) and those with surgery plus TKI treatment (TKI group, n=13). Their mean age at start of treatment was 61 ± 8 years, 76% were men, and dialysis vintage was 11.9 ± 11.4 years. Eleven of 29 patients were died and the median overall survival time was 65 months. Results: The change of systolic blood pressure before and after treatment tended to be higher in the TKI group compared to the control group (+11.2 mmHg v.s. -3.4 mmHg, respectively, p=0.09). The change of diastolic blood pressure was slightly higher in the TKI group compared to the control group (+6.0 mmHg v.s. -0.8 mmHg, respectively, p=0.11). The number of patients with additional antihypertensive drugs were significantly higher in the TKI group than in the control group (7 patients (54%) v.s. 3 patients (19%), respectively, p<0.05), and dry weight was decreased by 2.6% in the TKI group and 1.3% in the control group (p=0.07). The percentage of patients who need management of hypertension (defined as either the additional antihypertensive drugs or the decrease of dry weight by 3% or more) was 69% in the TKI group and 25% in the control group (p<0.05). Conclusions: Our study showed that TKI treatment was associated with blood pressure elevation especially in dialysis patients. Therefore, we should pay more attention to the change of blood pressure and control it appropriately in these patients.

Nutrition and dietary intake and their association with mortality and hospitalisation in adults with chronic kidney disease treated with haemodialysis: protocol for DIET-HD, a prospective multinational cohort study

IntroductionAdults with end-stage kidney disease (ESKD) treated with haemodialysis experience mortality of between 15% and 20% each year. Effective interventions that improve health outcomes for long-term dialysis patients remain unproven....

Gab1 is essential for membrane translocation, activity and integrity of mTORCs after EGF stimulation in urothelial cell carcinoma.

Urothelial carcinoma is the most common type of malignancy in long-term dialysis patients and kidney transplant recipients in Taiwan. mTORCs (mammalian target of rapamycin complexes) and EGF are important in urothelial carcinoma. To identify the regulation of mTORCs upon EGF stimulation is necessary. mTOR integrates signals from growth factors via mTOR Complex 1 (mTORC1) and mTOR Complex 2 (mTORC2). The mechanism of mTORC1 action has been widely studied; however, the regulation of mTORC2 has not been well studied. Here, we demonstrate that Gab1 is an important upstream regulator in EGF-mediated activation of mTORCs. In our study, we confirm that mTORCs translocate from the cytoplasm to the plasma membrane via the PH domain of Gab1 upon EGF stimulation. Moreover, Gab1 associates with mTORCs. This association stabilizes the integrity of mTORCs and induces mTORC activity. Compared to normal bladder tissue, the expression of Gab1 and activity of mTORCs are elevated in urothelial carcinoma. Collectively, our results suggest that Gab1 is an essential regulator of the EGF-mediated mTORC pathways and may potentially be used as a biomarker for urothelial carcinoma to predict diagnosis and drug response.

IL-17A is a novel player in dialysis-induced peritoneal damage

The classical view of the immune system has changed by the discovery of novel T-helper (Th) subsets, including Th17 (IL-17A-producing cells). IL-17A participates in immune-mediated glomerulonephritis and more recently in inflammatory pathologies, including experimental renal injury. Peritoneal dialysis patients present chronic inflammation and Th1/Th2 imbalance, but the role of the Th17 response in peritoneal membrane damage has not been investigated. In peritoneal biopsies from dialyzed patients, IL-17A immunostaining was found mainly in inflammatory areas and was absent in the healthy peritoneum. IL-17A-expressing cells included lymphocytes (CD4+ and γδ), neutrophils, and mast cells. Elevated IL-17A effluent concentrations were found in long-term peritoneal dialysis patients. Studies in mice showed that repeated exposure to recombinant IL-17A caused peritoneal inflammation and fibrosis. Moreover, chronic exposure to dialysis fluids resulted in a peritoneal Th17 response, including elevated IL-17A gene and protein production, submesothelial cell infiltration of IL-17A-expressing cells, and upregulation of Th17 differentiation factors and cytokines. IL-17A neutralization diminished experimental peritoneal inflammation and fibrosis caused by chronic exposure to dialysis fluids in mice. Thus, IL-17A is a key player of peritoneum damage and it may be a good candidate for therapeutic intervention in peritoneal dialysis patients.

Adipose tissue-derived mesenchymal stem cells in long-term dialysis patients display downregulation of PCAF expression and poor angiogenesis activation.

We previously demonstrated that mesenchymal stem cells (MSCs) differentiate into functional kidney cells capable of urine and erythropoietin production, indicating that they may be used for kidney regeneration. However, the viability of MSCs from dialysis patients may be affected under uremic conditions. In this study, we isolated MSCs from the adipose tissues of end-stage kidney disease (ESKD) patients undergoing long-term dialysis (KD-MSCs; mean: 72.3 months) and from healthy controls (HC-MSCs) to compare their viability. KD-MSCs and HC-MSCs were assessed for their proliferation potential, senescence, and differentiation capacities into adipocytes, osteoblasts, and chondrocytes. Gene expression of stem cell-specific transcription factors was analyzed by PCR array and confirmed by western blot analysis at the protein level. No significant differences of proliferation potential, senescence, or differentiation capacity were observed between KD-MSCs and HC-MSCs. However, gene and protein expression of p300/CBP-associated factor (PCAF) was significantly suppressed in KD-MSCs. Because PCAF is a histone acetyltransferase that mediates regulation of hypoxia-inducible factor-1α (HIF-1α), we examined the hypoxic response in MSCs. HC-MSCs but not KD-MSCs showed upregulation of PCAF protein expression under hypoxia. Similarly, HIF-1α and vascular endothelial growth factor (VEGF) expression did not increase under hypoxia in KD-MSCs but did so in HC-MSCs. Additionally, a directed in vivo angiogenesis assay revealed a decrease in angiogenesis activation of KD-MSCs. In conclusion, long-term uremia leads to persistent and systematic downregulation of PCAF gene and protein expression and poor angiogenesis activation of MSCs from patients with ESKD. Furthermore, PCAF, HIF-1α, and VEGF expression were not upregulated by hypoxic stimulation of KD-MSCs. These results suggest that the hypoxic response may be blunted in MSCs from ESKD patients.

Multidisciplinary clinical strategies for encapsulating peritoneal sclerosis in peritoneal dialysis: Update from Japan

Peritoneal dialysis is established as a first-line standard renal replacement therapy for end-stage renal disease. However, the development of encapsulating peritoneal sclerosis has been a critical complication among long-term peritoneal dialysis patients. During the past decade, multidisciplinary approaches have been used to suppress encapsulating peritoneal sclerosis. The present article reviews the historical and present status of encapsulating peritoneal sclerosis in Japan.

Comparison of multipotency and molecular profile of MSCs between CKD and healthy rats

We previously showed that mesenchymal stem cells (MSCs) can differentiate into a functional miniature kidney, suggesting that MSCs may be a cell source for kidney regeneration. However, MSCs from long-term dialysis patients, which have been exposed to uremic toxin, can exhibit reduced viability. Therefore, the aim of this study was to examine the gene expression profiles and differentiation capabilities of bone marrow- and adipose-derived MSCs from chronic kidney disease (CKD) model rats. CKD was induced in rats by adenine feeding, and then MSCs were isolated from bone marrow (BMSCs) and adipose tissue (ASCs). After confirming MSC surface marker expression, comprehensive gene expression profiles were obtained by RT-PCR array. MSCs were differentiated into adipocytes, osteoblasts, and chondrocytes, and histological and/or functional assays were performed. Tgfb3 expression was up-regulated, while Bmp6, Gdf15, Mmp2, and Vegfa were down-regulated in CKD-ASCs compared with Control-ASCs. There were no significant differences in the gene expression of stemness markers, and the morphology of cells that underwent adipogenesis, osteogenesis, and chondrogenesis, or GPDH activity between CKD and control groups. Comparing BMSCs with ASCs, gene expression of Bglap, Bmp4, Igf1, Itgax, Pparg, Ptprc, and Tnf were up-regulated, while Col1a1, Mmp2, Sox9, and Vegfa were down-regulated in both CKD and control groups. Uremic toxin in CKD rats had a small effect on the gene expression and differentiation of MSCs. However, long-term exposure to uremic toxin and the differences in gene expression of MSCs derived from bone marrow or adipose tissue may affect renal regeneration.

Permanent catheters for hemodialysis is not ideal but sometimes considered a necessity: a prospective study

BackgroundIt is not always easy to achieve an adequate arterio venous fistula in long-term dialysis patients; hence, permanent cuffed tunneled central venous catheters represent necessity in some ESRD patients like those with advanced age and/ or comorbid conditions.PurposeTo report the technique and the results of the permanent tunneled catheters as a vascular access .Patients and methodsThis report describe the technique and the results of the permanent tunneled catheters as a vascular access for hemodialysis at Mansoura University Hospitals. Catheter was inserted by seldinger percutaneous technique with the use of radioscopic guidance by an experienced vascular surgeon.ResultsThe study included 33 patients for whom 38 catheters were inserted (17 males,16 females), nine of whom were hypotensive, with a mean age of 48,9 years.The cumulative primary patency rate at 1 year was 52.6% and at 2 years, 21.05%. Complications developed including ,tunnel haematoma, thrombosis, and infection.ConclusionPermanent cuffed, tunneled catheters play a larger role, particularly among those in whom finding a vascular access can be challenging.

Influence of Continuous Dietary Guidances for Long-term Dialysis Patients on Clinical Indices

Influence of Continuous Dietary Guidances for Long-term Dialysis Patients on Clinical Indices

Bimaxillary Full Arch Fixed Dental Implant Supported Treatment for a Patient With Renal Failure and Secondary Hyperparathyroidism and Osteodystrophy

A long-term dialysis patient with end-stage renal disease (ESRD) also referred to as chronic kidney disease (CKD) due to IgA nephropathy complicated by severe secondary hyperparathyroidism and renal osteodystrophy was successfully treated with dental implant-supported fixed prostheses. Phosphate binders, vitamin D, calcium cinacalcet calcimimetic therapy, and dialysis 3 times weekly had been instituted with standard divalent ion serum assessments. Successful control of the patient's secondary hyperparathyroidism was achieved. Long and wide diameter implants were used with an anterior guidance occlusion scheme to reduce the per-square-millimeter off-axial implant force delivered to the bone. Patients with ESRD and renal osteodystrophy may be successfully surgically and prosthetically treated with long wide dental implants supporting fixed full arch splinted dental prostheses with an appropriate occlusal scheme.

Accumulation of advanced glycation end products and beta 2-microglobulin in fibrotic thickening of the peritoneum in long-term peritoneal dialysis patients

Characteristics of pathological alterations in long-term peritoneal dialysis (PD) are thickening of submesothelial compact (SMC) zone, small-vessel vasculopathy, and loss of mesothelial cells. Bioincompatible PD fluid plays crucial roles in peritoneal injury. Encapsulating peritoneal sclerosis (EPS), a rare and serious complication, occurred in patients on long-term PD or frequent peritonitis episodes, and ~50 % of EPS developed after PD cessation. We hypothesized that PD-related peritoneal injury factors induced by bioincompatible PD fluid accumulated in the peritoneum and might induce EPS. We therefore examined the accumulation of advanced glycation end products (AGE) and beta 2-microglobulin (β2M) in peritoneum and evaluated the relationship between their accumulation, clinical parameters, and outcome after PD cessation. Forty-five parietal peritoneal specimens were obtained from 28 PD patients, 14 uremic patients, and three patients with normal kidney function. The peritoneal equilibration test was used for peritoneal function. AGE- and β2M-expressing areas were found in vascular walls, perivascular areas, and the deep layer of the SMC in short-term PD patients and extended over the entire SMC in long-term patients. Peritonitis and prolonged PD treatment aggravated peritoneal thickening and the proportion of AGE-expressing areas. The proportion of β2M-expressing areas was increased in long-term PD patients. Thickening of the SMC and the proportions of AGE- and β2M-expressing areas were not related to ascites or EPS after PD withdrawal. It appears that the increased proportion of AGE and β2M deposition induced by long-term exposure of PD fluid may be a marker of peritoneal injury.

Risk of Stroke in Long-term Dialysis Patients Compared With the General Population

Patients undergoing maintenance dialysis are at increased risk of stroke. We performed a nationwide retrospective cohort study to determine the risks for ischemic stroke and hemorrhagic stroke among incident hemodialysis (HD) and peritoneal dialysis (PD) patients in comparison to a reference group in Taiwan. Data for 74,192 HD patients, 5,974 PD patients, and 669,773 nondialysis individualswho were older than 18 years and had no history of stroke or cancer were retrieved from the National Health Insurance Research Database for 1998-2009. Patient demographics, comorbid conditions. First hospitalization for stroke, defined as a diagnosis at discharge (either primary or 1 of 4 secondary diagnoses) of ischemic or hemorrhagic stroke using International Classification of Diseases, Ninth Revision, Clinical Modification codes. HD and PD patients had higher incidences of hospitalized ischemic stroke (102.6 and 100.1/10,000 person-years) and hemorrhagic stroke (74.7 and 59.4/10,000 person-years) in comparison to the age- and sex-matched reference cohort (42.4 and 13.0/10,000 person-years, respectively). In addition to HD and PD therapy, older age, male sex, diabetes, and hypertension were found to be independent risk factors for both ischemic and hemorrhagic strokes. Using the HD group as the comparison group, we found that PD patients had a lower risk of hemorrhagic stroke (HR, 0.75; 95% CI, 0.58-0.96), and there was no significant difference in risks of ischemic stroke between PD and HD patients after adjusting for all potential confounders and competing risk of death, and matched by propensity scores. This was a retrospective study, and some important variables were not available. Patients undergoing dialysis are at elevated risk of stroke. Patients undergoing PD appear to be less likely to develop hemorrhagic stroke than those undergoing HD. Comprehensive control of hypertension and diabetes is necessary when delivering dialysis treatment.

Surgical Treatment of dialysis-associated spondylosis

【Objective】The purposes of this study were to classify the lesions of dialysis-associated spondylosis and evaluate the results of surgical treatment. 【Subjects and methods】The subjects were 87 patients (43 men and 44 women) who underwent surgery. These patients were studied in terms of lesion classification, surgical method, duration of dialysis, duration of surgery, intraoperative blood loss, and postoperative complications. 【Results】Among patients with cervical spine involvement, 13 had destructive spondyloarthropathy (DSA), 29 had amyloid deposition, and 8 had a dens axis lesion. Among patients with lumbar spine involvement, 20 had DSA, and 17 had amyloid deposition. With regard to 6 patients with a dens axis lesion involving atlantoaxial subluxation, each had posterior fusion (PF) of the occiput to the upper cervical spine. With regard to the patients with lumbar DSA, 10 patients had posterolateral fusion (PLF), 8 patients had posterior lumbar interbody fusion (PLIF) and 2 patients had laminectomy. The duration of dialysis in cases of a dens axis lesion varied between 25 and 35 years, with the mean duration being 28.9 years. 【Conclusions】All patients who underwent surgery for dens axis lesions were long-term dialysis patients who had been on dialysis for 25 years. Lumbar spine DSA was treated with PLIF in patients with lateral slipping and marked instability, with laminectomy in patients with a narrowed intervertebral disk space and no instability. ACTA MEDICA NAGASAKIENSIA 56: 5－11, 2011

Impact of advanced dialysis technology on the prevalence of dialysis‐related amyloidosis in long‐term maintenance dialysis patients

Dialysis-related amyloidosis (DRA) is a unique type of amyloidosis (beta-2 microglobulin) predominantly in end-stage renal disease. Its clinical manifestations add to increased morbidity and reduced quality of life. There seems to be a relative risk reduction in DRA manifestations when hemodialysis (HD) patients are treated with advanced HD technology, but changes of the course of DRA are uncertain. The aim of our investigation was to evaluate the prevalence and severity of carpal tunnel syndrome (CTS) in long-term dialysis patients receiving either conventional or high-flux, online-produced ultrapure dialysis fluid. The cross-sectional study included 147 HD patients (at least 10 years). The definitive diagnosis of CTS was made histologically or by the coexistence of CTS with other radiological DRA manifestations (bone cysts, arthropathies). The two HD patient groups did not differ significantly in age at start of HD, gender, major co-morbid diseases, anuria, and dialysis vintage. The conventional HD group had significantly higher circulating beta-2 microglobulin and C-reactive protein (CRP) levels. The prevalence of DRA was 68% for the conventional HD group and 28% for the advanced HD group. Duration of dialysis treatment was the only significant risk factor for the development of clinical DRA manifestations in both study groups, but CTS, bone cysts, or arthropathies occurred significantly earlier in conventional HD patients. The prevalence and severity of DRA have decreased with advances in dialysis technology during the last two decades, although its occurrence is simply delayed.

Soluble Tie2 fusion protein decreases peritoneal angiogenesis in uremic rats

Angiogenesis is considered to be one of the most common mechanisms leading to ultrafiltration failure (UFF) in long-term peritoneal dialysis (PD) patients. The angiopoietin (Ang)/Tie system was found to play a role in the initiation of pathological neoangiogenesis and is also involved in peritoneal angiogenesis caused by peritoneal fluid. This aim of this study was to investigate the effects of the soluble Tie2 fusion protein (sTie2/Fc) on peritoneal angiogenesis in PD-treated uremic rats. The rats were divided into 6 groups: normal, sham surgery, uremic rats without PD, uremic PD-treated rats, uremic rats treated with PD and sTie2/Fc (0.25µg/100g) and uremic rats treated with PD and sTie2/Fc (0.5µg/100g). PD rats were treated once a day for 28days prior to testing. Real-time polymerase chain reaction (RT-PCR) or tissue immunohistochemical staining was used to detect Ang-2 mRNA or protein expression in the peritoneal tissues of each group. The microvessel density (MVD) of the peritoneum was detected and quantified by immunohistochemical staining using the anti-CD34 antibody. Compared with the control group, Ang-2 mRNA and protein expression was significantly upregulated in the uremic and PD groups (P<0.05). MVD in the experimental group increased compared with the control group. sTie2/Fc treatment decreased the levels of Ang-2 mRNA and protein expression (P<0.05) in a dose-dependent manner and decreased PD-induced MVD in the peritoneum. In conclusion, angiogenesis of the peritoneum induced by PD was inhibited using sTie2/Fc in a uremic rat model.

Zinc Supplementation Alters Plasma Aluminum and Selenium Status of Patients Undergoing Dialysis: A Pilot Study

End stage renal disease patients undergoing long-term dialysis are at risk for abnormal concentrations of certain essential and non-essential trace metals and high oxidative stress. We evaluated the effects of zinc (Zn) supplementation on plasma aluminum (Al) and selenium (Se) concentrations and oxidative stress in chronic dialysis patients. Zn-deficient patients receiving continuous ambulatory peritoneal dialysis or hemodialysis were divided into two groups according to plasma Al concentrations (HA group, Al > 50 μg/L; and MA group, Al > 30 to ≤ 50 μg/L). All patients received daily oral Zn supplements for two months. Age- and gender-matched healthy individuals did not receive Zn supplement. Clinical variables were assessed before, at one month, and after the supplementation period. Compared with healthy subjects, patients had significantly lower baseline plasma Se concentrations and higher oxidative stress status. After two-month Zn treatment, these patients had higher plasma Zn and Se concentrations, reduced plasma Al concentrations and oxidative stress. Furthermore, increased plasma Zn concentrations were related to the concentrations of Al, Se, oxidative product malondialdehyde (MDA), and antioxidant enzyme superoxide dismutase activities. In conclusion, Zn supplementation ameliorates abnormally high plasma Al concentrations and oxidative stress and improves Se status in long-term dialysis patients.