non-HD Patients Research Articles

Significant differences in lipid profile associated with mace between hemodialysis (HD) and non-HD patients: FU-registry

Significant differences in lipid profile associated with mace between hemodialysis (HD) and non-HD patients: FU-registry

Dyssynergic defecation may play an important role in postoperative Hirschsprung's disease patients with severe persistent constipation: Analysis of a case series

BackgroundAfter surgery for Hirschsprung's disease (HD) the majority of patients have satisfactory clinical outcomes. Nevertheless, a substantial number of patients remain who suffer from severe persistent constipation. Current consensus attributes these complaints to the hallmarks of HD. In non-HD patients a cause for severe constipation is dyssynergic defecation. MethodsRetrospectively, we reviewed the medical records of ten postoperative HD patients with severe persistent constipation who had undergone extensive anorectal function tests to diagnose the reason for the constipation. We analyzed the results of these tests. ResultsDuring the last three years, ten postoperative HD patients with severe persistent constipation were given extensive anorectal function tests. All ten patients were diagnosed with dyssynergic defecation. The ages at the time of diagnosis ranged from 7 to 19years with a median age of 12years. Signs of an enlarged rectum were seen in all ten patients, with a maximum measured value of 845mL. ConclusionsPatients with HD may also suffer from dyssynergic defecation. It is important to consider this possibility when dealing with severe persistent constipation in postoperative HD patients. Viable options for treating dyssynergic defecation are available that could prevent irreversible long-term complications.

Associations between lipid profiles and MACE in hemodialysis patients with percutaneous coronary intervention: From the FU-Registry

BackgroundIt is well known that percutaneous coronary intervention (PCI) in hemodialysis (HD) patients is associated with higher rates of in-stent restenosis and major adverse cardiovascular events (MACE) compared to that in non-HD patients, even if the target value in cholesterol management is achieved. MethodsTo evaluate the factors that are associated with MACE in HD patients, we selected 142 HD patients (164 lesions) without acute coronary syndrome (ACS) from 2148 patients (2568 lesions) who underwent PCI in our database of the FU-Registry [UMIN000005679, Fukuoka University Hospital EC/IRB:10-1-08(09-105)], and compared 52 patients (53 lesions) with MACE [MACE(+)] to 90 patients (111 lesions) without MACE [MACE(−)]. ResultsTotal cholesterol (TC: 150±30mg/dL vs 166±39mg/dL, p<0.05) and high-density lipoprotein cholesterol (HDL-C: 40.1±14.7mg/dL vs 47.8±13.5mg/dL, p<0.01) levels were significantly lower in the MACE(+) group at follow-up. No significant differences were observed in other parameters, including triglyceride, low-density lipoprotein cholesterol (LDL-C; LDL-C/HDL-C ratio, and % changes in HDL-C, non-HDL-C, LDL-C), and hemoglobin A1c (US National Glycohemoglobin Standardization Program) between before and after PCI. TC, LDL-C, and non-HDL-C at the time of PCI and TC, and HDL-C at the 9-month follow-up were negatively correlated with MACE, while body mass index (BMI) [odds ratio (OR): 0.81; 95% confidence interval (CI): 0.68–0.95)], prior coronary artery bypass graft (CABG) (OR: 3.89; 95%CI: 1.29–12.6), and insulin use (OR: 3.17; 95%CI: 1.23–8.55) were strongly correlated with MACE in a multivariate analysis. ConclusionBMI, CABG, and insulin use, but not LDL-C, are independent predictors of MACE in HD patients, suggesting that the application of lipid management for non-HD patients to HD patients at the time of PCI may not necessarily be beneficial for medium-term clinical outcomes.

Enhanced expression of hemoglobin scavenger receptor and heme oxygenase-1 is associated with aortic valve stenosis in patients undergoing hemodialysis

A high prevalence and a rapid progression of aortic valve stenosis (AS) in patients undergoing hemodialysis (HD) has been reported. In these circumstances, intraleaflet hemorrhage of aortic valve may be related to the development of AS in HD patients. We immunohistochemically examined the relationship among intraleaflet hemorrhage, neovascularization, hemoglobin scavenger receptor (CD163), and heme oxygenase-1 (HO-1) using surgically resected aortic valve specimens from AS patients undergoing HD. The study population consisted of 26 HD patients and 25 non-HD patients with severe AS who had undergone aortic valve replacement. Frozen aortic valve samples surgically obtained from AS patients were stained immunohistochemically with antibodies against smooth muscle cells, macrophages, glycophorin-A (a protein specific to erythrocyte membranes), CD31, CD163, and HO-1. Morphometric analysis demonstrated that the CD163-positive macrophage score, the number of CD31-positive microvessels, and the percentage of glycophorin-A and HO-1-positive area were significantly higher in HD patients than in non-HD patients (CD163-positive macrophage score, P < 0.0001; CD31-positive microvessels, P < 0.0001; glycophorin-A, P < 0.0001; HO-1, P < 0.0001). Double immunostaining for CD163 or HO-1 and macrophages revealed that the majority of CD163- or HO-1-positive cells were macrophages. Furthermore, CD163-positive macrophage score was positively correlated with glycophorin-A, HO-1-positive area, and the number of CD31-positive microvessels (glycophorin-A, R = 0.66, P < 0.0001; HO-1, R = 0.50, P < 0.0005; microvessels, R = 0.38, P < 0.01). These findings suggest a positive association among intraleaflet hemorrhage, neovascularization, and enhanced expression of CD163 and HO-1 as a response to intraleaflet hemorrhage in stenotic aortic valves in AS patients undergoing HD.

Clinical Presentation and Outcomes of Cardiovascular Implantable Electronic Device Infections in Hemodialysis Patients

Infection is a serious complication of cardiovascular implantable electronic device (CIED) implantation. Kidney failure is as an independent risk factor for CIED infection and associated mortality. The presence of multiple comorbid conditions may contribute to varied clinical presentations and poor outcomes in hemodialysis (HD)-dependent patients with cardiac device infection. Case series. CIED infections in HD patients (n=17) and non-HD patients (n=398) at Mayo Clinic in Rochester, MN, between 1991 and2008. Surgical management and death. Clinical presentations, microbial organisms. Of 415 patients admitted with CIED infection, 17 (4%) were receiving maintenance HD therapy. Among those on HD therapy, mean age was 72±15 (SD) years, 59% were women, and 53% had a central venous catheter for dialysis access. All 17 patients receiving HD therapy presented with CIED-associated bloodstream infection and 41% of these had infected vegetations on CIED leads or cardiac valves. A majority (82%) were managed with complete device removal and almost half (43%) received a replacement device when bloodstream infection cleared. Device infection was associated with significant short-term mortality in HD patients and 90-day survival was only 76% in this group of patients. Smaller sample size, majority white cohort, observational study. CIED infection in patients receiving HD usually is associated with bloodstream infection and frequently is complicated with device-related endocarditis. Despite complete device removal in the majority of HD patients with infection, mortality remains high.

Efficacy and safety of radiofrequency catheter ablation for atrial fibrillation in chronic hemodialysis patients

Radiofrequency catheter ablation (RFCA) is increasingly performed for the treatment of atrial fibrillation (AF), but it is problematic because the use of anti-arrhythmic agents is largely restricted in patients undergoing hemodialysis (HD) therapy. However, little is known about the long-term clinical outcomes of AF after RFCA in HD patients. Between 2002 and 2008, 16 HD patients (age: 63.8 ± 7.4 years, 75.0% men) underwent RFCA for AF at the Toyota Kosei Hospital. We investigated the long-term results and mortality of RFCA for AF in HD patients and compared them with those of 111 non-HD patients (age: 58.6 ± 10.0 years, 78.3% male) who received the same procedures. During the follow-up (64.3 ± 25.4 months in HD patients, 70.5 ± 20.2 months in non-HD patients) after the initial RFCA procedure, sinus rhythm was restored in 4 HD patients (25%) and in 45 non-HD patients (40.5%). Multiple procedures were performed in 12 HD patients and in 57 non-HD patients. After the final procedure, 13 HD patients (81.3%) and 92 non-HD patients (82.9%) were free of atrial arrhythmia and symptoms. Of importance, Kaplan-Meier analysis did not demonstrate any significant differences in the atrial arrhythmia-free rate after the last procedure between HD patients and the control group matched after propensity-score analysis despite higher all-cause mortality in HD patients than in non-HD patients. During 5-years of follow-up, the use of multiple RFCA procedures for AF in patients undergoing HD was favorable, whereas the use of a single procedure was disappointing. Multiple RFCA procedures can be an efficient approach to the treatment of AF in HD patients.

Calretinin and microtubule-associated protein-2 (MAP-2) immunohistochemistry in the diagnosis of Hirschsprung's disease

Background/PurposeIdentifying ganglion cells by rectal suction biopsy is a basic diagnostic tool for the diagnosis of Hirschsprung's disease (HD). However, the difficult interpretation of conventionally processed slides often necessitates ancillary staining methods. The aim of this study was to evaluate the usefulness of calretinin and microtubule-associated protein-2 (MAP-2) immunohistochemistry in the diagnosis of HD. MethodsWe analyzed 52 rectal suction biopsy specimens (37 from 15 HD patients and 15 from 7 non-HD patients) for ganglion cells with calretinin and MAP-2 immunohistochemistry. We also analyzed full-thickness, frozen biopsy samples obtained from 15 HD patients who underwent surgery utilizing calretinin and MAP-2 immunohistochemistry. ResultsBoth calretinin and MAP-2 positively stained ganglion cells in the submucosal plexus of the ganglionic bowel but not aganglionic bowel. Calretinin usually stained ganglion cell cytoplasm and nuclei more intensely than MAP-2, which only stained cytoplasm. No nerve fiber staining in the submucosal layer was observed for either antibody. In 21.1% (11/52) of samples, calretinin and MAP-2 staining found ganglion cells which were reported not to have ganglion cells in the original surgical pathology reports. Immunohistochemical staining for calretinin using paraffin-embedded tissue sections after cryostat sections clearly demonstrated decreased staining intensity compared to MAP-2. ConclusionCalretinin and MAP-2 are useful diagnostic markers for diagnosing HD in rectal suction biopsies. These complementary methods could ameliorate the diagnostic difficulties associated with HD.

The impact of haemodialysis on the outcomes of catheter ablation in patients with paroxysmal atrial fibrillation

The outcomes of catheter ablation (CA) in patients with paroxysmal atrial fibrillation (PAF) who are undergoing haemodialysis (HD) have not been fully elucidated. This study aimed to determine the impact of HD on CA outcome in these patients. We examined 1364 consecutive PAF patients (mean age, 61 ± 10 years) who underwent CA, including 32 (2.3%) patients undergoing HD. The patients undergoing HD had a significantly lower body mass index (P < 0.0001), higher CHADS2 score (P = 0.006), and higher prevalence of structural heart disease (P < 0.0001), hypertension (P = 0.002), and congestive heart failure (P = 0.02). Echocardiography indicated a larger left atrial diameter (P < 0.0001) and left ventricular diameter (P = 0.0002) in the HD patients. Haemodialysis was a significant predictor of AF recurrence (hazard ratio 2.56; 95% confidence interval 1.56-4.03; P = 0.0004) in the overall population. Sinus rhythm maintenance rates in the HD patients at 1, 3, and 5 years were 42.3, 37.6, and 19.7%, respectively, after the first procedure, and 64.7, 54.9, and 47.1%, respectively, after the final procedure (median, 2; range, 1-2 procedures); these rates were significantly lower than those in the non-HD patients (P < 0.0001). The 5-year survival rate was 78.1% in the HD patients. Haemodialysis was significantly associated with AF recurrence after CA for PAF. However, an ∼50% success rate for sinus rhythm maintenance without antiarrhythmic drug therapy in HD patients suggested that CA could be an option for the treatment of AF.

Impacts of TCF7L2 gene polymorphisms on the susceptibility of hepatogenous diabetes and hepatocellular carcinoma in cirrhotic patients

BackgroundHepatogenous diabetes (HD) occurs as a complication of cirrhosis. Whether genetic factors, rather than only liver damage, play roles in the development of HD is unknown. TCF7L2 gene has been reported to be associated with type 2 diabetes and also cancer risks. We aim to evaluate the impact of TCF7L2 gene on the susceptibility of HD and hepatocellular carcinoma (HCC) in a Chinese Han population. Patients and methodsA total of 367 adult liver transplant candidates with liver cirrhosis were included. Fifteen tag single nucleotide polymorphisms (SNPs) were selected from HapMap CHB database with a minor allele frequency of >0.2 and r2 of >0.8. Another three SNPs were also chosen because of their close association with type 2 diabetes in East Asian. ResultsPatients with HD presented significantly poorer liver function, higher incidence of cirrhotic complications and higher insulin resistance compared with non-HD patients. Three SNPs were differentially distributed between HD patients and non-HD patients. In multivariate logistic analysis, TCF7L2 rs290487 and rs6585194 polymorphisms were independently associated with HD after adjustment of clinical factors. The TCF7L2 rs290487 C/C variant homozygote showed much higher insulin resistance and significantly increased HD risk comparing with T/T and T/C genotypes, while the genetic variant of rs6585194 was protectively against HD. Three SNPs (rs290481, rs290487 and rs290489) located near the 3′ end of TCF7L2 gene were associated with HCC risk with marginal significance. Patients carrying G-C-A haplotype had a significantly higher HCC risk than those with A-T-G. ConclusionsTCF7L2 polymorphisms were associated with HD and maybe cancer risk as well. Further studies with large samples are needed to verify these results.

Characteristics of the Small Bowel Lesions Detected by Capsule Endoscopy in Patients with Chronic Kidney Disease

Obscure gastrointestinal bleeding (OGIB) is one of the common complications in patients with chronic kidney disease (CKD), especially those who are on maintenance hemodialysis (HD). However, little is known about the characteristics of the small-bowel lesions in these patients, or of the factors that could predict the presence of such lesions. Therefore we enrolled a total of 42 CKD patients (including 19 HD patients and 23 non-HD patients), and compared the incidence of the small-bowel lesions among two groups. Furthermore, to identify predictive factors for the presence of small-bowel lesions, we performed multivariate logistic-regression-analyses. The incidence of small-bowel vascular lesions was significantly higher in CKD patients than in age-and-sex matched non-CKD patients (P < 0.001). On the other hand, there was any significant difference of the incidence of small-bowel lesions between HD and non-HD patients. In CKD patients, past history of blood transfusion (OR 5.66; 95% CI 1.10–29.1, P = 0.04) was identified as an independent predictor of the presence of vascular lesions, and history of low-dose aspirin use (OR 6.00; 95% CI 1.13–31.9, P = 0.04) was identified as that of erosive/ulcerated lesions. This indicated that proactive CE examination would be clinically meaningful for these patients.

Invited Commentary

The population prevalence of patients receiving hemodialysis (HD) due to end stage renal disease is progressively increasing, and cardiovascular complications have been identified as the most common cause of death in these patients [1U.S. Renal Data System2011 Atlas of CKD and ESRD.http://www.usrds.org/atlas.aspxGoogle Scholar]. As a consequence, cardiac operations on HD patients are becoming more common. Traditionally, the results of myocardial revascularization in these patients have been poor because of advanced coronary disease and complications from the underlying condition. Indeed, guidelines from the European Society of Cardiology on myocardial revascularization suggest accounting for the general condition of the HD patient and life expectancy when considering a revascularization strategy [2Kolh P. Wijns W. Danchin N. et al.Guidelines on myocardial revascularization.Eur J Cardiothorac Surg. 2010; 38: S1-S52Crossref PubMed Scopus (316) Google Scholar]. The article by Takami and colleagues provides important new data on predictors of early and late outcomes after coronary artery bypass grafting (CABG) in HD patients [3Takami Y. Tajima K. Kato W. et al.Predictors for early and late outcomes after coronary artery bypass grafting in hemodialysis patients.Ann Thorac Surg. 2012; 94: 1940-1946Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar]. In their retrospective analysis of 152 HD patients, the authors found a significant reduction in hospital mortality with the introduction of an off-pump coronary artery bypass (OPCAB) in 2003. Early mortality decreased from 15.3% in the pre-OPCAB era to 6.3% afterward. Crude mortality in these patients is still significantly higher that in the general CABG population, but the improvement associated with the introduction of OPCAB in their experience was noteworthy. The effect of off-pump CABG on renal function in non-HD patients remains controversial [4Lamy A. Devereaux P.J. Prabhakaran D. et al.Off-pup or on-pump coronary artery bypass grafting at 30 days.N Eng J Med. 2012; 366: 1489-1497Crossref PubMed Scopus (530) Google Scholar, 5Elmistekawy E. Chan V. Bourke M.E. et al.Off-pump coronary artery bypass grafting does not preserve renal function better than on-pump coronary artery bypass grafting: results of a case-matched study.J Thorac Cardiovasc Surg. 2012; 143: 85-92Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar], but OPCAB may confer a clear benefit in the specific subgroup of HD patients. One may speculate as to the possible mechanisms leading to this association, with OPCAB potentially resulting in less manipulations of the aorta, a lower need for transfusion, volume replacement and hemodilution, and therefore fewer strokes, a shorter duration of mechanical ventilation, and a lower incidence of infections. Another important finding of this study was that the long-term survival of HD patients who underwent CABG appeared equivalent to that of HD patients who did not undergo myocardial revascularization. Thus, despite the high early mortality, CABG effectively returns HD patients to their life expectancy curve. Although indication bias in selecting patients was likely in Takami's study, this finding carries important implications for the patient and clinician when considering HD patients for coronary surgery. External validation by further studies will be needed to confirm whether OPCAB is indeed the optimal strategy for myocardial revascularization in HD patients. Moreover, future studies may consider the role of minimally invasive procedures such as minimally invasive cardiac surgery-CABG in further reducing surgical trauma [6McGinn Jr, J.T. Usman S. Lapierre H. Pothula V.R. Mesana T.G. Ruel M. Minimally invasive coronary artery bypass grafting: dual-center experience in 450 consecutive patients.Circulation. 2009; 120: S78-S84Crossref PubMed Scopus (139) Google Scholar], considering that mediastinitis is the most common fatal complication in HD patients after conventional surgery [7Liu J.Y. Birkmeyer J.O. Sanders J.H. et al.Risk of morbidity and mortality in dyalisis patients undergoing coronary artery bypass surgery.Circulation. 2000; 102: 2973-2977Crossref PubMed Scopus (192) Google Scholar]. Predictors for Early and Late Outcomes After Coronary Artery Bypass Grafting in Hemodialysis PatientsThe Annals of Thoracic SurgeryVol. 94Issue 6PreviewMarkedly higher hospital and long-term mortality after coronary artery bypass grafting (CABG) have been reported in hemodialysis (HD)-dependent patients. We tried to identify the predictors for short-term and long-term outcomes after CABG, which have not been well studied. Full-Text PDF

Clinical manifestations of acute appendicitis in hemodialysis patients

Acute appendicitis has been suggested to be more aggravated in hemodialysis (HD) patients in comparison to non-HD patients but only scanty evidence demonstrates the conditions. A retrospective cohort study was done for HD and non-HD patients with a discharge diagnosis of acute appendicitis in a single medical center. Patients with acute appendicitis on HD (n = 11), and non-HD (n = 40) were enrolled. The patients in the HD group, demonstrated older age, less leukocytosis, shorter preoperative diagnostic delay, but with no improvement of perforation rate and poor prognosis such as longer hospital stay and higher morbidity rate in comparison to the non-HD group. The differences between the HD and non-HD group still existed even with an age- and gender-matched non-HD group. A higher C-reactive protein level was a helpful index in early diagnosis and predicting the possibility of perforation. Hyponatremia was an important prognostic factor associated with a longer preoperative delay, longer hospital stay and higher morbidity rate in the HD group. The diagnosis of AA in HD patients was earlier than in non-HD patients. HD patients with AA had atypical presentations and a poor prognosis especially those that presented with hyponatremia and a perforated appendicitis. Higher C-reactive protein was associated with the development of perforated appendicitis in HD patients.

Randomized controlled trial of cholecalciferol supplementation in chronic kidney disease patients with hypovitaminosis D

Hypovitaminosis D is common in chronic kidney disease (CKD). Effects of 25-hydroxyvitamin D replenishment in CKD are not well described. An 8-week randomized, placebo-controlled, double-blind parallel intervention study was conducted in haemodialysis (HD) and non-HD CKD patients. Treatment consisted of 40,000 IU of cholecalciferol orally per week. Plasma 25-hydroxyvitamin D (25-OHD), plasma 1,25-dihydroxyvitamin D (1,25-diOHD), plasma parathyroid hormone (PTH), serum phosphate, ionized serum calcium and serum fibroblast growth factor 23 (FGF-23) were analysed. We also investigated biomarkers related to cardiovascular disease (plasma D-dimer, plasma fibrinogen, plasma von Willebrand factor antigen and activity, plasma interleukin 6, plasma C-reactive protein, blood pressure, aortic augmentation index, aortic pulse wave velocity and 24-h urinary protein loss). Objective and subjective health variables were assessed (muscle function tests, visual analogue scores and Health Assessment Questionnaire). Fifty-two CKD patients with 25-OHD <50 nmol/L at screening were included. Cholecalciferol supplementation led to a significant increase to a median of 155 nmol/L 25-OHD (interquartile range 137-173 nmol/L) in treated patients (n = 25, P < 0.001). In non-HD patients, we saw a significant increase in 1,25-diOHD (n = 13, P < 0.01) and a lowering of PTH (n = 13, P < 0.001). This was not observed in HD patients. Cholecalciferol supplementation caused a significant increase in serum calcium and FGF-23. 25-OHD replenishment was effectively obtained with the employed cholecalciferol dosing. In non-HD patients, it had favourable effects on 1,25-diOHD and PTH. Vitamin D-supplemented patients must be monitored for hypercalcaemia. The present study could not identify significant pleiotropic effects of 25-OHD replenishment.

INCREASED EXPRESSION AND PLASMA LEVELS OF NEOPTERIN ARE CLOSELY RELATED TO AORTIC VALVE STENOSIS IN PATIENTS WITH HEMODIALYSIS

Aortic valve stenosis (AS) occurs with increased frequency in hemodialysis (HD) patients and could contribute to the excess cardiovascular mortality. However, little is known about differences in progression of the AS process between HD and non-HD patients. Neopterin, a by-product of the guanosine

Coronary Artery Bypass Grafting in Hemodialysis-Dependent Patients

Perioperative risk during coronary artery bypass grafting (CABG) is reportedly high in patients with chronic renal disease. We aimed to determine postoperative mortality and morbidity and identify the perioperative risk factors of mortality during CABG in hemodialysis (HD)-dependent patients. From the Japan Adult Cardiovascular Surgery Database, we compared 1,300 HD-dependent chronic renal failure patients with 18,387 non-HD patients who all underwent isolated CABG between January 2005 and December 2008. The operative mortality and mortality, including major morbidity, was 4.8% vs. 1.4% and 23.1% vs. 13.7% in the HD and non-HD groups, respectively. Preoperative predictors of operative mortality included age, chronic obstructive pulmonary disease, peripheral arterial disease, congestive heart failure, arrhythmia, preoperative inotropic agent requirement, New York Heart Association class IV, urgent or emergency operation, poor left ventricular function, aortic valve regurgitation (>2), and mitral valve regurgitation (>3). Postoperative predictors of operative mortality included stroke, infection, prolonged ventilation, pneumonia, heart block, and gastrointestinal complications. Compared with non-HD patients, CABG in HD patients was associated with high mortality and morbidity rates. An appropriate surgical strategy and careful perioperative assessment and management for prevention of respiratory and gastrointestinal complications might contribute to improved clinical outcomes after CABG in these patients.

Evaluation of lipid parameters and bioindices in patients with different stages of chronic renal failure

Cardiovascular morbidity and mortality are markedly increased in chronic renal failure (CRF). The aim of this study was to evaluate lipid parameters and bioindices in patients with different stages of CRF. In 46 hemodialysed (HD), 50 CRF patients with II, III and IV stage of CRF (non-HD) and 48 control subjects triglycerides (TG), total cholesterol (C), HDL-C, urea, creatinine, creatinuria (standard biochemical methods), apolipoprotein (apo) AI, apo B, lipoprotein(a), cystatin C (immunoturbidimetric method) were evaluated, and LDL-C, non-HDL-C, LDLC/HDL-C, non-HDL-/HDL-C, TG/HDL-C, and new bioindices, LTI (lipid tetrad index), logLTI, LPI (lipid pentad index), logLPI, AIP (atherogenic index of plasma), and creatinine clearance were calculated. There were significant differences in the levels of TG, HDL-C, LDL-C, non-HDL-C, total C and apo A-I between the HD and non-HD patients, and the HD patients and the controls. LTI and LPI were significantly higher in the HD and non-HD patients compared to the controls (p < 0.05), without a good separation by the Box-Whisker plots. The values of TG/HDL-C ratio and AIP were significantly higher in the HD and nonHD-patients compared to the controls (p < 0.05), and significantly higher in the HD compared to non-HD patients (p < 0.05). AIP > 0.11 was found in 71.7% of the HD, 56% of non-HD and 31.3% of the controls. Among lipid parameters and indices, AIP and TG/HDL-C ratio are most suitable for evaluation of lipid disturbances in different stages of CRF. In addition to, non-HDL-/HDL-C, and apoB/A-I ratios, apo A-I, HDL-C and TG are important markers in HD patients. Non-HDL-C is not a suitable marker. LTI and LPI need to be further investigated.

Cholesterol Metabolism in Patients With Hemodialysis in the Presence or Absence of Coronary Artery Disease

Little is known about the interrelationship between the lipid profile, cholesterol metabolism, and coronary risk factors in patients with hemodialysis (HD) in the presence or absence of coronary artery disease (CAD). Ninety-five patients with HD were selected (HD group). Fifty-eight age-, gender-, and body mass index (BMI)-matched patients who had at least 1 cardiovascular risk factor were selected as a non-HD group. Total cholesterol (TC), triglyceride, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), non-HDL-C, and the ratio of LDL-C to HDL-C (L/H) in the HD group were significantly lower than those in the non-HD group. All markers of cholesterol absorption (campesterol/TC, sitosterol/TC, and cholestanol/TC) and the ratio of campesterol to lathosterol in the HD group were significantly higher. In addition, in the HD group, L/H was negatively correlated with lathosterol/TC, campesterol/TC, sitosterol/TC, and cholestanol/TC. Finally, CAD was significantly associated with lathosterol/TC (P=0.028), which was positively associated with BMI in the HD group, whereas CAD was significantly associated only with hypertension (P=0.020) in the non-HD group. HD patients showed lower cholesterol concentrations than non-HD patients, and, as compensation, their cholesterol absorption might be accelerated. However, higher cholesterol synthesis, which was correlated with higher BMI, might be an independent predictor for the presence of CAD in HD patients.

Sirolimus-Eluting Stent vs. Everolimus-Eluting Stent for Coronary Intervention in Patients on Chronic Hemodialysis

Even in the drug-eluting stent era, adverse cardiac events, including restenosis after percutaneous coronary intervention (PCI), have been more frequently seen in patients on hemodialysis (HD) than in non-HD patients. The objective of this study was to compare the sirolimus-eluting stent (SES) and everolimus-eluting stent (EES) for prevention of adverse cardiac events, including restenosis, in HD patients. A total of 100 consecutive patients on HD who underwent PCI were enrolled and randomly assigned to receive SES or EES. Although there was no difference between the 2 groups in baseline patient and lesion characteristics, the angiographic restenosis rate at 8-month follow-up was 21.2% in the SES group and 8.7% in the EES group (P = 0.041). Significant differences were also seen in % diameter stenosis (%DS), minimal lumen diameter, and late lumen loss at 8-month follow-up (P = 0.0024, P = 0.0040, and P = 0.033, respectively). During the 1-year follow-up, major adverse cardiac events occurred in 11 (22.0%) patients in the SES group and in 5 (10.0%) patients in the EES group (P = 0.10). The use of EES was as safe as that of SES. Moreover, EES significantly prevented restenosis in patients on maintenance HD compared with SES.

IJU this issue

Mototsugu Oya M.D., Associate Editor In this issue, I would like to focus on “degenerative” and “regenerative” medicine. The degenerative issue is renal cell carcimoma (RCC) arising in end-stage kidneys. Whether RCC arising in patients under hemodialysis (HD) is the same as or different from non-HD RCC in terms of oncogenesis is an important issue to be resolved. The most important molecule related to RCC oncogenesis is von Hippel-Lindau disease tumor suppressor gene. The mutation of the gene is observed both in sporadic non-HD patients and HD patients. In contrast, in pathological aspects, RCC arising in HD patients occasionally have different types of cancer tissues (described by Tickoo SK et al. cited #25 in Takagi's paper). This suggests a distinctly different oncogenic pathway. The most different feature, I believe, is that HD-related RCC are multifocal in contrast to the non-HD, which is single (unifocal). Multifocal tumors can arise in susceptible, pre-oncogenic tissues. For example, liver cancer arises from hepatitis virus-infected tissues that are susceptible to cancer. Takagi et al. described the clinical characteristics of RCC in HD patients in a single institution. They showed that bilateral occurrence did not influence the likelihood of death from cancer, suggesting de novo primary events rather than the metastases of the contralateral primary. Interestingly, a longer duration before surgery was an unfavorable prognosis. This suggests that the accumulation of molecular alteration in end-stage kidneys is related to progression of the cancer as well as the initiation. Molecular pathogenesis needs to be elucidated in this malignant phenotype of long HD-associated RCC. Venous extension or tumor thrombus is a feature of RCC that is rarely observed in other cancers. The 7th edition of UICC changed the T3 classification. The cephalad extent of the tumor was divided into three parts, namely, renal vein, inferior vena cava (IVC) below the diaphragm and IVC above the diaphragm, and assigned T3a, T3b and T3c. Nagata et al. assessed the revision of UICC using the clinical data in their institution retrospectively. Their Kaplan–Meier curves were clearly separated accordingly. They concluded that the new classification could be valid in Japan. T category in RCC is complex, as compared with other cancers. For example, T factor in bladder cancer is simply the extent of the invasion. In determining the T of RCC, tumor size, perinephric invasion, adrenal invasion and venous involvement should be evaluated. The 7th edition of UICC is not perfect. Based on accumulating publications, T factor might be changed in the future. Regenerative medicine is one of the main topics at present. Obinata et al. used a unique cell transplantation system named adipocyte-derived dedifferentiated fat (DFAT) cells to treat stress urinary incontinence (SUI) in a rat model. DFAT cells are easily isolated from a small amount (approximately 1 g) of subcutaneous adipose tissue and differentiated to smooth muscle-like cells by adding transforming growth factor-β1. A cross-section of the urethra showed a marked difference in terms of the thickness of the muscle layers in the DFAT-injected rats. As mentioned in the Editorial Comment by Pastor-Navarro, this injured model is not a permanent model. SUI is a permanent injury as a result of labor during childbirth. She mentioned a need for a permanent injury model to validate the results. I believe DFAT is easy and can be applicable to clinical use. However, several issues should be clarified. How and how long are the dedifferentiated muscle-like cells maintained in the tissues? How is the injected DFAT distributed and how about the injured muscle cells? An easy method that is replicable by other researchers can survive in regenerative medicine. To explore an easy way is a short cut to clinical use. None declared.

Rectal culture screening for vancomycin-resistant enterococcus in chronic haemodialysis patients: false-negative rates and duration of colonisation

Infection or colonisation with vancomycin-resistant enterococci (VRE) is common in chronic haemodialysis (HD) patients. However, there is limited information on the duration of VRE colonisation or on the reliability of consecutive negative rectal cultures to determine the clearance of VRE in chronic HD patients. Chronic HD patients from whom VRE was isolated were examined retrospectively. Rectal cultures were collected more than three times, at least one week apart, between 1 June 2003 and 1 March 2010. The results of the sequential VRE cultures and patients' data were analysed. Among 812 patients from whom VRE was isolated, 89 were chronic HD patients and 92 had three consecutive negative cultures. It took 60.7 ± 183.9 and 111.4 ± 155.4 days to collect three consecutive negative cultures in the 83 non-chronic haemodialysis patients and nine chronic HD patients, respectively (P = 0.011). The independent risk factors for more than three negative sequential rectal cultures were glycopeptide usage [odds ratio (OR): 2.155; P = 0.003] and length of hospital stay (OR: 1.009; P = 0.001). After three consecutive negative rectal cultures, two of six chronic HD patients and 10 of 36 non-HD patients were culture positive again. In conclusion, a significant proportion of patients colonised with VRE cannot be detected by three-weekly rectal cultures, and the duration of VRE colonisation in chronic haemodialysis patients tends to be prolonged. These results may be contributing to the continued increase in the prevalence of VRE.