Long-term Hemodialysis Patients Research Articles

Increased cerebral blood flow is correlated with neurocognitive impairment in long-term hemodialysis patients: an arterial spin labeling MRI study.

The purpose of this study was to investigate cerebral blood flow (CBF) changes in hemodialysis patients with arterial spin labeling (ASL) and to correlate these changes with clinical risk factors and neurocognitive function. Thirty-two hemodialysis patients and 35 age-, sex-, and education-matched healthy controls (HCs) were recruited in this prospective study. The Mini-Mental State Examination (MMSE) was performed to evaluate neurocognitive function. Pulsed ASL was performed to measure CBF. Two independent sample t-test was used to explore the CBF difference between the patients and HCs. Multiple stepwise regression was used to investigate the risk factors for CBF in patients. Correlation analysis was used to explore the relationship between the MMSE scores and CBF changes with and without adjusting for anemia status. Compared to HCs, the hemodialysis patients showed significantly increased CBF in some neurocognition-related cerebral regions (all P < 0.001, Bonferroni corrected). Increased CBF in the right opercular and triangular part of the inferior frontal gyrus correlated with the poorer MMSE scores (r = -0.502, P = 0.004; r = -0.423, P = 0.018, FDR corrected) and these correlations still remained after adjusting for anemia status (r = -0.516, P = 0.005; r = -0.439, P = 0.019, FDR corrected). The increased dialysis duration, and decreased hemoglobin, hematocrit, and serum phosphorus were predictive risk factors for increased CBF (P < 0.05). In conclusion, long-term hemodialysis patients had increased CBF, which correlated with neurocognitive impairment, and after adjusting for the effect of anemia, the correlation still remained.

Fibroblast Growth Factor 23 and Mortality Among Prevalent Hemodialysis Patients in the Japan Dialysis Outcomes and Practice Patterns Study

IntroductionElevated fibroblast growth factor 23 (FGF23) levels have been strongly associated with mortality in the predialysis and incident hemodialysis populations, but few studies have examined this relationship in a large cohort of prevalent hemodialysis patients and in particular among persons with high dialysis vintage. To address this, we analyzed data from the Japan Dialysis Outcomes and Practice Patterns Study (J-DOPPS).MethodsWe included 1122 prevalent hemodialysis patients from the J-DOPPS phase 5 (2012–2015) who had FGF23 measurements. We evaluated the association of FGF23 levels with all-cause mortality and cardiovascular composite outcome using Cox regression adjusted for potential confounders.ResultsAt study enrollment, median dialysis vintage was 5.8 years (interquartile range, 2.7–12.4 years) and median FGF23 level was 2113 pg/ml (interquartile range, 583–6880 pg/ml). During 3-year follow-up, 154 of the 1122 participants died. In adjusted analyses, higher FGF23 was associated with a greater hazard of death (hazard ratio per doubling of FGF23, 1.12; 95% confidence interval, 1.03–1.21); however, the association became weaker as the dialysis vintage increased and finally disappeared in the highest tertile (>9.4 years). Similar patterns of effect modification by dialysis vintage were observed for cardiovascular composite outcome and in time-dependent models.ConclusionElevated FGF23 was associated with mortality and cardiovascular events in prevalent hemodialysis patients, but the association was attenuated at longer dialysis vintages. This novel finding suggests that long-term hemodialysis patients may be less susceptible to the detrimental effects of FGF23 or correlated biological processes, and additional studies are needed to gain understanding of these possibilities.

P1109HDX: IS IT A BETTER WAY TO DIALYSE?

Abstract Background and Aims Inadequate dialysis has been linked to reduced quality of life, increased symptom burden and increased risk of cardiovascular illness in patients with chronic kidney disease. This is especially significant in long-term haemodialysis patients who have little to no residual urine output and are thus almost entirely dependent on good quality dialysis to remove toxins and fluid. In most conventional haemodialysis modes middle molecule clearance is inadequate. This in turn plays an important part in causing multiple complications. HDx is a new type of haemodialysis being introduced using Theranova® dialyzer. This claims to have medium cut-off membranes, functioning similar to a kidney, hence providing better clearance of middle molecules, whilst selectively preventing loss of proteins from the body. In order to test the safety and efficacy of HDx using Theranova® we tried it in a cohort of our patients in the form of an audit. Our primary objective was to find out the effect of HDx on quality of life. Secondary objective was to determine whether HDx improves blood biochemistry, with a reduction in medication &amp; transfusion needs. Method Thirty seven Haemodialysis patients were switched from hemodiafiltration to HDx, out of these 3 patients were transplanted, 2 patients died, 1 patient switched back and 7 patients were transferred to satellite units. Audit was continued with the remaining 24 patients. All patients completed an Integrated Palliative Care Outcome Score (IPOS) prior to commencing on HDx and then at six months. Blood parameters including phosphorous, calcium, haemoglobin, Ferritin and CRP were measured monthly and mean values of 6 months before and after HDx initiation were compared. Comparison of erythropoietin, intravenous iron and packed red blood cell transfusion requirements pre and post HDx commencement were also undertaken. Results No obvious adverse effects were noted with use of HDx dialysis. All patients had an improvement in overall IPOS scores after being on HDx for 6 months. Shorter post dialysis symptom recovery times were also noted. 13 patients had a decrease in their erythropoietin requirements, in 2 patients requirement remained the same, 9 patients had increase in their requirement however 3 of these patients had been requiring packed red blood cell transfusion prior to HDx commencement, no longer required transfusion. We found an overall improvement in patients iron infusion need. 11 patients had a dose reduction, with 4 of these patients no longer requiring iron. 9 patients continued to have the same requirements. 4 patients had an increase in iron dose, but 3 of these patients previously being transfusion dependant no longer required regular transfusions. We also noted that with use of HDx clotting risk was reduced and patients who were switched from Evodial (heparin coated dialyzer membranes) to HDx did not have increased circuit clotting. With regards to inflammation we noted no significant changes in CRP, ferritin levels and other blood parameters. Conclusion Looking at our cohort of patients we concluded that HDx is safe to use with no obvious adverse effects. It seems that use of HDx is particularly helpful in improving quality of life in dialysis patients as indicated by improvement in IPOS scores. IPOS is a validated questionnaire to measure symptoms and concerns in patients with advanced illnesses. As life quality is a major concern in dialysis patients, this outcome is of particular significance. HDx was also helpful in reducing the overall burden of transfusions, iron and erythropoietin requirements. This is beneficial in overall patient health and cost burden. Based on the above we found out that HDX was safe and effective in our patient cohort, however large-scale studies will be required for more conclusive evidence.

Quantitative evaluation of superior mesenteric artery calcification in hemodialysis patients undergoing aortic valve replacement.

Postoperative acute mesenteric ischemia (AMI) in the long-term hemodialysis (HD) patients could be a disastrous complication leading to high mortality. The objective is to evaluate the association between the presence of superior mesenteric artery calcification (SMAC) and early and late outcomes after aortic valve replacement (AVR) in HD patients. Between April 2003 and December 2018, the enrolled 46 HD patients (19 women; mean age 72 years) who underwent AVR for severe aortic valve stenosis were retrospectively reviewed. 25 patients (54.3%) who had severe calcifications of superior mesenteric artery (SMA) were defined as the SMAC group, and the calcification extent of SMA was evaluated on preoperative non-contrast CT using Agaston calcium score [calcification area (cm2) × max CT value (HU)]. The operative outcomes were compared with those of the non-SMAC group comprising 21 patients (45.7%). The following factors in SMAC group were statistically higher compared with those of the non-SMAC group: age (73.6 ± 7.2 vs 69.3 ± 7.1 years; p = 0.04), celiac artery calcification (76.4% vs 17.6%; p < 0.001), calcium score of SMA (692.3 ± 300.0 vs 123.5 ± 180.7; p < 0.001), the incidence of AMI (24.0% vs 4.7%; p = 0.001), and hospital mortality (16.0% vs 0%; p = 0.02). In multivariate analysis, the presence of SMAC was significantly associated with AMI (OR 3.8, p = 0.05) and hospital mortality (OR 2.4, p = 0.02). Calcium score of SMA in patients complicated with AMI was significantly higher than those without AMI (815.7 ± 300.5 vs 366.9 ± 351.2; p < 0.01). Quantitative evaluation of SMAC could be a predictive marker of incidence of AMI after AVR in HD patients.

The influence of cardiac valvular calcification on all-cause and cardiovascular mortality in maintenance hemodialysis patients.

To investigate the effect of cardiac valve calcification (CVC) on all-cause and cardiovascular mortality in maintenance hemodialysis (MHD) patients. A retrospective cohort study was conducted in 183 long-term hemodialysis patients with complete follow-up data from January 1, 2012, to December 30, 2015. The baseline data between CVC and non-CVC groups were compared. Kaplan-Meier method was used to analyze all-cause and cardiovascular mortality. The effect of CVC on prognosis was analyzed using the Cox proportional hazardregressionmodel and subgroup analysis. Among 183 patients under hemodialysis, 104 (56.8%) were males, with an average age of 56.1 ± 17.0years and 68 (37.2%) were complicated with valvular calcification. The median follow-up period was 30.8months. All-cause and cardiovascular mortality were 50% vs. 14.8% and 25% vs. 7.0% in the CVC and non-CVC groups, respectively (P < 0.05). Kaplan-Meier indicated that differences in all-cause and cardiovascular mortality were statistically significant between the two groups (P < 0.001). Cox regression analysis showed that CVC significantly increased all-cause (hazards ratio [HR] 2.161 [1.083-4.315]) and cardiovascular mortality (3.435 [1.222-9.651]) after adjusting for multiple factors. Meanwhile, CVC also increases the incidence of new-onset cardiovascular events. Subgroup analysis revealed that all-cause and cardiovascular mortality were significantly higher in patients with aortic valve calcification (AVC) than in patients with mitral valve calcification (MVC). Multivariate calibration showed that AVC increased the risk of cardiovascular death (HR 5.486 [1.802-16.702]) (P < 0.05), whereas MVC did not. By further comparing the echocardiographic data of the two groups, the incidence of LVH and pulmonary hypertension in the AVC group was significantly higher than that in the MVC group. Valve calcification increases the risk of all-cause and cardiovascular mortality in MHD patients, also new-onset cardiovascular events, and aortic valve calcification contributes more to the risk of cardiovascular mortality.

Outcomes of the Gore Excluder abdominal aortic aneurysm leg endoprosthesis for treatment of central vein stenosis or occlusion in patients with chronic hemodialysis

ObjectiveCentral venous occlusive disease is a critical complication in long-term hemodialysis patients with arteriovenous (AV) dialysis circuits. The purpose of this retrospective, single-arm cohort study was to evaluate the effectiveness of an abdominal aortic aneurysm (AAA) contralateral leg endoprosthesis to treat symptomatic central venous occlusive diseases in patients with chronic hemodialysis. MethodsA prospective cohort study included 60 patients on hemodialysis presenting with central venous stenosis or occlusion, who were treated with a Gore Excluder AAA contralateral leg stent graft between December 2013 and July 2018. Follow-up angiography was obtained at 3, 6, and 12 months. The outcomes and duration of primary circuit and target site patency were measured from the time of the stent graft implantation to the first reintervention for AV circuit dysfunction and target site restenosis. Secondary patency was calculated from stent graft implantation to the point when AV access was no longer attainable. ResultsCircuit primary patency rate was 54.9% at 1 year of Gore Excluder AAA contralateral leg or iliac extender stent grafts, implanted in 60 hemodialysis patients with central vein occlusive disease. Cumulative target site primary patency rate was 88.3% at 1 year. Secondary patency rate was 95% during follow-up. Patients with concomitant lesions had a significantly higher risk of circuit primary patency dysfunction. ConclusionsTreatment of central vein obstructions in hemodialysis patients with stent grafts has been appealing owing to the tapered shape with a larger diameter and the availability of various lengths.

Collagen I Weakly Interacts with the β-Sheets of β2-Microglobulin and Enhances Conformational Exchange To Induce Amyloid Formation.

Amyloidogenesis is significant in both protein function and pathology. Amyloid formation of folded, globular proteins is commonly initiated by partial or complete unfolding. However, how this unfolding event is triggered for proteins that are otherwise stable in their native environments is not well understood. The accumulation of the immunoglobulin protein β2-microglobulin (β2m) into amyloid plaques in the joints of long-term hemodialysis patients is the hallmark of dialysis-related amyloidosis (DRA). While β2m does not form amyloid unassisted near neutral pH in vitro, the localization of β2m deposits to joint spaces suggests a role for the local extracellular matrix (ECM) proteins, specifically collagens, in promoting amyloid formation. Indeed, collagen and other ECM components have been observed to facilitate β2m amyloid formation, but the large size and anisotropy of the complex, combined with the low affinity of these interactions, have limited atomic-level elucidation of the amyloid-promoting mechanism(s) by these molecules. Using solution NMR approaches that uniquely probe weak interactions in large molecular weight complexes, we are able to map the binding interfaces on β2m for collagen I and detect collagen I-induced μs–ms time-scale dynamics in the β2m backbone. By combining solution NMR relaxation methods and 15N-dark-state exchange saturation transfer experiments, we propose a model in which weak, multimodal collagen I−β2m interactions promote exchange with a minor population of amyloid-competent species to induce fibrillogenesis. The results portray the intimate role of the environment in switching an innocuous protein into an amyloid-competent state, rationalizing the localization of amyloid deposits in DRA.

SEPTIC EMBOLI CAUSING PNEUMOTHORAX WITH FISTULIZATION TO THE RIGHT BREAST

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Bullous lung disease may either be idiopathic or secondary to environmental factors, and has been associated with IV drug users and HIV infection (1). Treatment of bullous lung disease depends on severity of dyspnea, ranging from smoking cessation to bullectomy. If left untreated, it may result in a secondary spontaneous pneumothorax (SSP). Here we present a patient that developed free air in her right breast from a ruptured bullae. CASE PRESENTATION: A 50 year old female with past medical history of anoxic brain injury secondary to cardiac arrest, chronic ventilator dependence, heroin abuse, endocarditis, septic pulmonary emboli, and breast augmentation presented to the ED with altered mental status and suspected seizures. In addition to altered mentation, her physical examination revealed a marked discordance in breast size, with an enlarged right breast. She was tachycardic, normotensive, and afebrile. CT chest revealed large areas of bronchiectasis, large bulla bilaterally, and right-sided pneumothorax with fistulization to the right breast. CT surgery was consulted and the patient underwent right thoracotomy with decortication of the right lung, along with breast implant removal and closure of the communicating fistula. Chest tube was placed until the pneumothorax resolved. DISCUSSION: The most common complications of giant bullae include pneumothorax, bronchogenic carcinoma, and fluid collection. SSP is a well-known complication and tube thoracostomy is often required for management. Due to the aggressive nature of the complications, management is directed towards prevention. This constitutes pleurodesis using mechanical abraision and bullectomy (usually when a bulla size is greater than 50% of the hemithorax). Though bullae have been associated with cigarette smoking, primary lung disease, and IV drug users, SSP is rarely seen with septic emboli and bacteremia (2). In our case, it was further complicated by a fistula formation and development of large amount of free air in the right breast. CONCLUSIONS: Bullae lung disease is a benign condition that may result in severe complications. Chronic large bullae should be evaluated frequently. This case highlights the various etiologies of bullae formation and we believe clinicians ought to include include pneumothorax and bronchopleural-subcutaneous fistulization as a differential when other causes are unexplainable. Reference #1: Martinez, F. Evaluation and medical management of giant bullae. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com (Accessed on March 15, 2019.) Reference #2: Okabe M, Kasai K, Yokoo T. Pneumothorax Secondary to Septic Pulmonary Emboli in a Long-term Hemodialysis Patient with Psoas Abscess. Intern Med. 2017;56(23):3243-3247. DISCLOSURES: No relevant relationships by Niaz Memon, source=Web Response no disclosure on file for Daniel Murphy; No relevant relationships by Yi Xiong, source=Web Response

Association of plasma macrophage colony-stimulating factor with cardiovascular morbidity and all-cause mortality in chronic hemodialysis patients

BackgroundCardiovascular disease (CVD) events are the main cause of death in long-term hemodialysis (HD) patients. Macrophage colony- stimulating factor (M-CSF) is actively involved in the formation of atherosclerosis and causes plaque instability, thrombosis and the development of acute coronary syndromes. However, little information is available on the role of M-CSF in HD patients. We aimed to investigate the association between plasma M-CSF levels and CVD events as well as all-cause mortality in patients undergoing long-term HD.MethodsFifty two HD patients and 8 healthy controls were recruited in this study. HD patients were followed up from September 2014 to May 2017. The primary end point was CVD event, the secondary outcome was death from any cause. Patients were divided into two groups with low and high M-CSF levels based on the optimal cut-off value determined by the ROC curve. Cox regression analyses were used to assess the predictive value of plasma M-CSF for CVD events and all-cause mortality in HD patients. We tested the levels of plasma M-CSF and other inflammatory cytokines in surviving HD patients using ELISA or CBA kit.ResultsThe average plasma level of M-CSF in 52 patients was approximately twice that of healthy controls (992.4 vs. 427.2 pg/mL; p < 0.05). During 32 months of follow-up, 26 patients (50.0%) had at least one CVD event and 8 patients (15.4%) died. The mean plasma M-CSF concentration increased in survivors after follow-up compared to that detected at baseline (1277.8 ± 693.3 vs. 997.2 ± 417.4 pg/mL; p < 0.05). Multivariate Cox regression analysis showed that plasma M-CSF is an independent risk factor for CVD events in HD patients (p < 0.05). In the Cox regression model after adjusting for gender and age, high M-CSF levels were related to an increased risk of all-cause death (p < 0.05). We also found that M-CSF levels were positively correlated with IL-6 and IL-18 levels (both p < 0.05), which are the major pathogentic cytokines that contribute to HD-related CVD events.ConclusionM-CSF is a prognostic factor for CVD events and all-cause mortality in HD patients.

Sclerostin levels predict cardiovascular mortality in long-term hemodialysis patients: A prospective observational cohort study.

Sclerostin is a protein which is involved in bone metabolism and probably also in vessel wall function. This prospective observational cohort study evaluated the prognostic significance of sclerostin in hemodialysis (HD) patients. In total, 106 HD patients and 25 healthy controls participated in the study. HD patients were prospectively followed up for five years. Sclerostin was measured in serum using standard ELISA kits by Biomedica. Sclerostin concentrations in serum were higher in HD patients compared to the controls (89.2±40.3 pmol/l vs. 32.8±13.0 pmol/l, p<0.001). Sclerostin levels were significant for cardiovascular mortality but not for overall mortality and mortality due to infection. A higher cardiovascular risk was connected to sclerostin concentrations above the median (>84 pmol/l), HR (95 % CI): 2.577 (1.0002-10.207), p=0.04. When sclerostin was evaluated together with residual diuresis in Kaplan-Meier analysis the worst prognosis due to cardiovascular events was observed in the group with high sclerostin and zero residual diuresis compared to all other patients (p=0.007). In summary, serum sclerostin levels in HD patients were increased when compared to healthy subjects. High sclerostin levels were demonstrated as a risk factor for cardiovascular mortality. Further studies are required to clarify the pathophysiological mechanisms of sclerostin action in patients with renal failure before therapeutic measures can be established.

MON-132 PERCUTANEOUS TRANSHEPATIC TUNNELLED CATHETER FOR HAEMODIALYSIS: A SINGLE CENTRE EXPERIENCE

Obtaining vascular access for dialysis can be challenging in long-term haemodialysis patients who have exhausted all traditional access sites as a result of multiple catheter placements. Transhepatic dialysis catheter insertion is potentially life-saving for those with access failure. This study aims at evaluating the functionality and safety of transhepatic venous catheters in haemodialysis patients. Eight patients (3 male and 5 female, aged 59+/-17 years ) had transhepatic tunnelled dialysis catheters inserted in our haemodialysis unit in the past 3 years. The insertion method, type of catheter use, functional duration of catheters, maximum blood flow rate achieved, catheter complications and reasons for catheter removal were evaluated retrospectively. A total of eleven transhepatic catheters were placed in eight patients between January 2016 and November 2018. All the patients were on long term dialysis, with a mean dialysis vintage of 160 months. Most patients started with peritoneal dialysis, and switched to haemodialysis after peritoneal failure. The average heamodialysis duration was 85 months (range 14-144 months). Nine catheters were placed successfully (9/11, 82% technical success). Catheter insertion failed due to development of subphenic haematoma in 1 patient and the negotiation of the catheter into the proper venous position was unsuccessful in the other. One catheter was placed under general anaesthesia while the rest were done under local anaesthesia. RetrO® Long-Term Hemodialysis Catheter (BARD Access Systems) was used in 10 out of 11 of the procedures, and Permcath™ (Medtronic) was used in 1 case. Seven of the 9 functional catheters were placed in the portal vein while the remaining 2 were placed in the hepatic vein. The functional duration of transhepatic catheters ranges from 32 to 551 days, with a mean of 298 days. Of the 9 catheters, 2 were still in use at the end of the study (2/9, 22.2%). One patient died with a functional catheter. Six of the catheters were removed(6/9, 66.6%) . Arteriovenous fistular was created in 1 patient, while 3 catheters were removed due to catheter thrombosis (3/9, 33.3%). Two patients were noted to have catheter dislodgement into the pleural cavity (2/9, 22.2%), both presented with shock and haemothorax. Poor blood flow was the most common complication during the use of transhepatic catheters. Catheter revision was required in 2 cases. The maximum blood flow rate achieved for each catheter ranged from 150ml/minute to 250ml/minute, with a mean rate of 186ml/minute. The maximum blood flow rate was below 200ml/minute in 4 of the catheters (4/9,44.4%). Bleeding at the catheter site necessitating hospital admission occurred in 3 cases (3/9, 33.3%), catheter exit site infection occurred in 2 (2/9, 22.2%), but there were no catheter related sepsis. For patients who have exhausted access options for dialysis, transhepatic catheter placement is an alternative with potentially good long-term functionality. However, limitations in blood flow rate, and the high thrombosis rate with the need for high level of maintenance to preserve patency should be noted. Furthermore, physicians need to be cautious about potentially life-threatening complications such as catheter dislodgement.

장기혈액투석 환자의 가족특성, 가족지지, 가족기능 및 환자역할행위 이행

Purpose: The purpose of this study was to examine the role of family to the compliance of patient role behavior in long-term hemodialysis patients. Methods: In this descriptive correlational design, 103 participants recruited from 3 hemodialysis clinics at D city. They completed the self-reported questionnaire including family characteristics, family support, family function, and compliance of patient role behavior. All participants have family and are undergoing regular hemodialysis more than 1 year. Results: Among patient

An Analysis of Medication Adherence and Patient Preference in Long-term Stable Maintenance Hemodialysis Patients in Japan.

Objective This follow-up survey report describes medication adherence and patient preferences, beliefs, and expectations of maintenance hemodialysis treatment in Japan. Methods This patient-reported questionnaire-based survey was conducted in six regions in Japan from September 2016 to November 2016. Patients The questionnaire was provided to 700 patients (50-79 years old) on maintenance hemodialysis for >3 years who were members of the Japan Association of Kidney Disease Patients. Patients were randomly selected by a stratified sampling method based on patient distribution observed from the Japanese Society for Dialysis Therapy Renal Data Registry. Results A total of 524 (74.9%) complete patient questionnaires were evaluated; the mean (SD) age was 66.6 (7.2) years (men, 63.4%) with a dialysis vintage of 16.9 (9.1) years. Adherence was high for all types of medications: between 76.7% for phosphate binders and 95.7% for antidiabetic medications. The most common reason for a missed dose was forgetting to take medication [52.5% (117/223)]. Patient preference for oral medication was as low as 0.9% (1/110), 9% (31/345), and 2.9% (2/69) for patients who felt mental burden, felt no mental burden, and neither, respectively, with their current treatment regimen. In addition, 37.8% (198/524) of patients responded that the elimination of 1 medication (1 tablet) would reduce their mental burden. Conclusion The results of this survey show that overall medication adherence is high in Japanese patients on maintenance hemodialysis. While many patients perceive an absence of mental burden, they still prefer to avoid oral medication when possible.

Extracellular matrix components modulate different stages in β2-microglobulin amyloid formation

Amyloid deposition of WT human β2-microglobulin (WT-hβ2m) in the joints of long-term hemodialysis patients is the hallmark of dialysis-related amyloidosis. In vitro, WT-hβ2m does not form amyloid fibrils at physiological pH and temperature unless co-solvents or other reagents are added. Therefore, understanding how fibril formation is initiated and maintained in the joint space is important for elucidating WT-hβ2m aggregation and dialysis-related amyloidosis onset. Here, we investigated the roles of collagen I and the commonly administered anticoagulant, low-molecular-weight (LMW) heparin, in the initiation and subsequent aggregation phases of WT-hβ2m in physiologically relevant conditions. Using thioflavin T fluorescence to study the kinetics of amyloid formation, we analyzed how these two agents affect specific stages of WT-hβ2m assembly. Our results revealed that LMW-heparin strongly promotes WT-hβ2m fibrillogenesis during all stages of aggregation. However, collagen I affected WT-hβ2m amyloid formation in contrasting ways: decreasing the lag time of fibril formation in the presence of LMW-heparin and slowing the rate at higher concentrations. We found that in self-seeded reactions, interaction of collagen I with WT-hβ2m amyloid fibrils attenuates surface-mediated growth of WT-hβ2m fibrils, demonstrating a key role of secondary nucleation in WT-hβ2m amyloid formation. Interestingly, collagen I fibrils did not suppress surface-mediated assembly of WT-hβ2m monomers when cross-seeded with fibrils formed from the N-terminally truncated variant ΔN6-hβ2m. Together, these results provide detailed insights into how collagen I and LMW-heparin impact different stages in the aggregation of WT-hβ2m into amyloid, which lead to dramatic effects on the time course of assembly.

Determination of retinoic acid and its significance in long-term hemodialysis patients

Determination of retinoic acid and its significance in long-term hemodialysis patients

Inferior outcome of rotator cuff repair in chronic hemodialytic patients

BackgroundRepair of rotator cuff tears has yielded excellent functional outcomes in recent decades; however, poor outcomes and dissatisfaction have been noted in specific groups. Spontaneous tendon rupture has been reported in patients receiving long-term hemodialysis owing to alteration of tendon structure, which might impede functional recovery after rotator cuff repair. The purpose of the present study was to compare the clinical outcomes between hemodialysis and non-hemodialysis patients after rotator cuff repair.MethodsWe retrospectively reviewed patients who underwent mini-open rotator cuff repair from Jan 2013 to Jan 2017. A total of 14 patients under chronic hemodialysis (HD) were matched to non-hemodialysis (NHD) patients at a 1:2 ratio according to age, gender, tear size, severity of fatty infiltration and history of diabetes. Pre- and post-operative functional outcome was assessed using the simple shoulder test (SST), American Shoulder and Elbow Surgeons (ASES), Shoulder Rating Scale of the University of California at Los Angeles (UCLA) and visual analog scale (VAS) scores. Clinical functional outcome at the last follow-up was adopted for comparison of the HD and NHD groups.ResultsA total of 42 patients were enrolled in this comparative study, with a mean age of 66.64 ± 1.68 years in the HD group and 65.71 ± 5.40 years in the NHD group. At the final clinical assessment, the post-operative functional outcome was significantly improved in both groups (p < 0.001). However, the functional outcome of the HD group was significantly inferior to that of the NHD group in terms of the SST score (6.50 ± 2.24 vs 9.39 ± 1.87, p < 0.001), ASES score (63.17 ± 15.93 vs 86.96 ± 11.43, p < 0.001), UCLA score (20.14 ± 7.71 vs 29.82 ± 5.08, p < 0.001) and VAS score (3.00 ± 0.96 vs 1.21 ± 1.03, p < 0.001).ConclusionThe improvement of pain and functional improvement of long-term hemodialysis patients were inferior to those of patients without hemodialysis after mini-open rotator cuff repair.

Quality of Life of Long-Term Hemodialysis Patients

The outcome of chronic kidney disease (CKD) is frequently development of end-stage kidney failure that requires program hemodialysis (PHD). Increase of the longevity of long-term PHD patients is associated with continuous somatic and psychic stress for the patient, which might adversely affect the quality of life (QoL) of an end-stage CKD patient.Purpose: to determine the influence of age and dialysis duration on the QoL of end-stage CKD patients receiving PHD.Materials and methods. 50 patients receiving PHD (23 men and 27 women), aged 31 to 79 years, were examined. The mean age was 56.72±11.26 years. The PHD duration ranged between 1 month to 20 years, the average figure being 5.26±4.82 years. The control group included 50 healthy subjects of comparable gender and age. The QoL evaluation data were gathered through survey using the Russian version of SF-36 Questionnaire (Short Form Medical Outcomes Study), validated by the Institute of Clinical and Pharmacological Studies (Saint Petersburg) and analysis of case records.Results. As regards the scales of physical health, a decrease of the QoL of PHD patients was found as follows: РF-physical functioning (54.1±25.6 vs. 85.0±21.4), RP-role functioning related to physical condition (38.5±35.4 vs. 74.5±29.7), Pbodily pain (64.7±32.1 vs. 70.5±24.8), GH-general health condition (51.3±15.9 vs. 65.1±21.7). A trend towards inter-group difference was also discovered as regards the scales of vitality (VT) (53.7±19.5 vs. 61.0±19.4), social functioning (SF) (72.5±18.0 vs. 79.5±23.5). Multiple regression analysis established inverse relationship between the patient’s physical health component (PH) and age (rs=-0.317, P&lt;0.05).Conclusion. In PHD patients, the physical health component is the one that suffers most of all, namely: physical functioning, role functioning related to physical condition, pain intensity, and general health condition. The tendency to statistic differences is observed for the scales of vitality and social functioning of the mental health component. Increase of the age and dialysis duration affect adversely the physical health whereas render no influence on the mental health.

EFEKTIFITAS PROGRESSIVE MUSCLE RELAXATION (PMR) DAN RELAXATION BREATHING EXERCISE (RBE) TERHADAP TINGKAT FATIGUE DAN SELFCARE PASIEN GGK

Chronic kidney failure is a progressive and irreversible kidney disorder to maintain fluid and electrolyte balance and metabolism, with treatment given by hemodialysis. Long-term hemodialysis patients can cause fatigue in the patient's inability to fulfill selfcare needs. The intervention is in the form of non-pharmacological therapy in the form of relaxation. The purpose of this study was to determine the effectiveness of progressive muscle relaxation and relaxation breathing exercise on the level of fatigue and self care of patients with chronic renal failure. With the design of Randomized Clinical Trial (RCT) pre and post group three test, a sample of 30 respondents. Data collection tools are the Piper Fatigue Scale (PFS) questionnaire (Cronbach alpha = 0.646) and Fatigue Selfcare Management (Cronbach alpha = 0.930). The results showed that PMR intervention had different levels of fatigue (pvalue = 0,000) while selfcare (pvalue = 0.017) had no difference, in the RBE intervention there were differences in fatigue levels (pvalue = 0,000) while selfcare (pvalue = 0.048) had no difference, at PMR + RBE interventions have different levels of fatigue (pvalue = 0,000) and selfcare (pvalue = 0,000). PMR and RBE interventions are more effective to reduce fatigue and improve selfcare, so that it can be recommended for patients undergoing hemodialysis Keywords : fatigue, selfcare, progressive muscle relaxation, relaxation breathing exercise .

A cardiac magnetic resonance imaging study of long-term and incident hemodialysis patients.

The cardiovascular morphology and function in long-term survivors of hemodialysis are not well described. Single-center cross-sectional study nested within a prospective cohort study of 15 long-term (> 7.5years) and 15 matched incident (< 6months) hemodialysis patients with 15 external matched controls. Evaluations included heart structure, function and fibrosis (myocardial longitudinal relaxation time, native T1), and aortic dimensions and elasticity, using cardiovascular magnetic resonance (CMR). Coronary artery calcification (CAC) scores were evaluated from computed tomography (CT). Incident hemodialysis patients had significantly increased left ventricular mass, greater aortic dimensions and reduced aortic distensibility compared to long-term survivors, whereas the CAC score was significantly higher in long-term than incident patients, median (95% CI) 1127 (10-3861) vs 14 (0-268). Both incident and long-term hemodialysis groups had significantly higher native T1 values compared to controls, mean (95% CI) 1300ms (1273-1326), 1274ms (1243-1305) versus 1224ms (1202-1246), respectively, suggesting interstitial fibrosis or edema. Compared to controls, both hemodialysis groups also had significantly lower left ventricular ejection fraction: 48.7% (43.6-53.9), 54.0% (48.3-59.7) versus 62.2% (58.0-66.4) and longitudinal strain: 14.0% (11.7-16.2), 15.2% (12.7-17.7) versus 19.6% (17.8-21.5). Incident hemodialysis patients had larger left ventricular mass and unfavorable aortic structure and function compared to long-term survivors, despite a lower CAC burden. Long-term survivors, despite normal ventricular mass and volumes, had signs of fibrosis or edema, given their significantly increased native T1 values.

Recurrent tertiary hyperparathyroidism due to supernumerary parathyroid glands in a patient receiving long-term hemodialysis: a case report

BackgroundRenal hyperparathyroidism is a common complication of chronic kidney disease (CKD) or end-stage renal disease (ESRD) characterized by elevated parathyroid hormone levels secondary to derangements in the homeostasis of calcium, phosphate, and vitamin D. Rapid correction of severe and prolonged hyperparathyroidism by surgical parathyroidectomy in long-term hemodialysis patients occasionally causes hungry bone syndrome. These patients then exhibit severe and long-lasting secondary or tertiary hyperparathyroidism with high bone turnover.Case presentationWe report a case of recurrent tertiary hyperparathyroidism after total parathyroidectomy due to supernumerary parathyroid gland in a patient with long-term hemodialysis. Supplementation with intravenous calcium, oral calcium, and vitamin D immediately after patient surgery helps to prevent and treat hungry bone syndrome.ConclusionsWe should prompt a search for the supernumerary parathyroid glands in ESRD patients, who have recurrent or persistent hyperparathyroidism after total parathyroidectomy. ESRD patients are more likely to develop hungry bone syndrome after parathyroidectomy. Prevention and treatment of hungry bone syndrome may be required after ectopic parathyroidectomy in clinical practice.