Parameters In Hemodialysis Patients Research Articles

Effect of an intradialytic protein-rich meal intake in nutritional and body composition parameters on hemodialysis patients

Protein intake is a key point to maintain an adequate nutritional status in hemodialysis (HD) patients. There are some studies that confirm the positive influence of intradialytic oral nutritional supplementation in several nutritional parameters in HD patients. The aim of this study was to evaluate the effect of an intradialytic protein rich meal in nutritional and body composition parameters on HD patients. This was a 6-months single center non-randomized study with 99 patients in HD from one Nephrocare dialysis unit in Portugal. Patients in the intervention group (IG) presented one albumin value≤3.8g/dL in the two measurements prior to the beginning of the study. The IG ate a protein rich meal during each treatment. The control group (CG) continued to eat their usual snack brought from home. Albumin, nPCR, potassium, phosphorus, C-reactive protein (CRP), dry weight and body composition were measured at baseline and at the end of the study. Patient's mean age was 69.9±12.9 years and HD vintage, 60.0±50.5 months. Both groups were similar at the start of the study, except in albumin (p=0.019). After the intervention, protein intake increased in the IG (p=0.001). Albumin decreased in both groups but this difference was higher and only statistically significant in the CG (p=0.039). Regarding body composition, in the CG, the fat tissue index (FTI) (p=0.022) and the lean tissue index (LTI) (p=0.003) diminished after the 6 months of the follow-up. However, in the IG the LTI value also reduced (p=0.008) but FTI increased (p=<0.001) at the end of the study. There were no statistically significant differences on dry weight, potassium, phosphorus, and CRP. Apart from the effect on protein intake, the importance of this study relies on the positive changes in regard to patient's body composition obtained after 6 months of an intradialytic intake of a protein rich meal during the HD treatment. This type of intervention can contribute to ameliorate patient's nutritional status without a negative effect on other parameters.

Relationship between serum apelin and cardiac parameters in hemodialysis patients

Objectives The aim of this work was to study the apelin level in hemodialysis (HD) patients and assess its association with cardiac parameters among these patients. Background Mortality in end-stage renal disease (ESRD) patients on maintenance HD is higher by several folds compared with that in the general population, and up to 50% of deaths in these patients are caused by cardiovascular diseases. Apelin, which is a recently discovered active peptide, has a broad range of physiological and pathological actions. Patients and methods A total of 80 nondiabetic end-stage renal failure patients on regular HD, in addition to 20 apparently healthy individuals as the control group, were studied. Lipid profile, serum apelin level, and echocardiography were measured in all patients. Results Serum apelin is highly significantly lower in ESRD patients on maintenance HD compared with that in the control group (P ≤ 0.001). Serum apelin was significantly positively correlated with left ventricular end-systolic dimension (r = 0.290, P = 0.038), left ventricular end-diastolic dimension (r = 0.30, P = 0.021), interventricular septum (r = 0.295, P = 0.036), right ventricle (r = 0.271, P = 0.042), left atrium (r = 0.357, P = 0.014), and aorta (r = 0.339, P = 0.023) in ESRD patients. Conclusion The apelin level was highly significantly lower in HD patients and it was significantly positively correlated with echocardiographic parameters. Thus it might be involved in the pathophysiology of cardiovascular disease in ESRD.

Correlations between Plasma Levels of Anionic Uremic Toxins and Clinical Parameters in Hemodialysis Patients.

When the kidney is seriously impaired, various uremic toxins (UTs) accumulate in the body, often exerting unfavorable effects on physiological functions and drug pharmacokinetics. To prevent this, it is important to determine plasma UT levels accurately in chronic kidney disease patients. Although attempts to predict plasma UT levels using biomarkers have been made, the correlation between UT levels and the markers is not yet fully understood. In this study, we assessed the correlations among plasma levels of indoxyl sulfate (IS), indoleacetic acid (IA), and 3-carboxy-4-methyl-5-propyl-2-furanpropionic acid (CMPF) in 20 hemodialysis patients and evaluated the relationship between the plasma levels of UTs and clinical parameters, such as serum creatinine (Scr), blood urea nitrogen, and estimated glomerular filtration rate (eGFR), with special focus on IS. There were no correlations among the plasma levels of the three UTs before and immediately after hemodialysis. However, a significant correlation was observed between plasma IS levels and Scr before hemodialysis (r=0.643, p=0.002), with the correlation becoming much stronger when using the data obtained immediately after hemodialysis (r=0.744, p<0.001). Further, plasma IS levels showed a significant negative correlation with eGFR (r=-0.558, p=0.011). However, no correlations were observed for IA or CMPF. The results obtained from this study suggest that plasma IS levels can be predicted from Scr values, although the precise mechanism behind the correlation remains to be clarified.

Classification of anemia in hemodialysis patients in relation to vascular access and its correlation with hepcidin and ferritin

Background: Anemia is very common in patients with chronic kidney disease, and becoming almost universal in end stage renal disease, where dialysis or renal transplantation becoming the treatment of choice. High levels of hepcidin appear to accompany reduced renal function and serum ferritin may also be elevated.Objectives: To classify anemia in hemodialysis patients and to display the correlations between the types of anemia and inflammatory parameters like hepcidin and ferritin according to vascular access of hemodialysis.Patients and methods: This case-control study was conducted at Al-Hayat center for hemodialysis, and included 60 adult patients on hemodialysis. Also 20 healthy individuals were recruited as control group. Measurement of hemoglobin, erythrocyte sedimentation rate, transferrin saturation percentage, serum ferritin, C-reactive protein and hepcidin were done. Anemic patients were classified into; anemia of chronic disorder, iron deficiency anemia, combined, and others. Patients were also divided into two groups depending on their vascular access of hemodialysis.Results: Anemia of chronic diseases was the most frequent anemia (45%) among the patients followed by combined anemia of chronic diseases/iron deficiency anemia then iron deficiency and other causes. No significant difference was observed between types of anemia and inflammatory parameters according to patients’ vascular access of hemodialysis. There was no significant difference in the mean levels of hepcidin, ferritin, ESR and CRP of the patients according to the vascular access of hemodialysis, while hemoglobin level of patients with anemia of chronic in double lumen was significantly lower than those with arteriovenous fistula, P= 0.007.Conclusions: Anemia of chronic diseases was the most frequent in hemodialysis patients. There are higher levels of inflammatory parameters in hemodialysis patients than healthy controls.

Higher Serum Bisphenol A Levels in Diabetic Hemodialysis Patients

Background: Bisphenol A (BPA) has been implicated as an ‘endocrine disruptor'. We aimed at exploring the association between serum BPA levels and patient characteristics, particularly the presence of diabetes mellitus, and laboratory parameters in hemodialysis patients. Methods: This study included 47 chronic hemodialysis patients. Patient characteristics were recorded. Blood was drawn before and after hemodialysis session. Serum BPA levels were measured by the high-performance-liquid-chromatography and laboratory parameters were measured by using standard methods. Results: In hemodialysis patients, postdialysis serum BPA levels were significantly higher than predialysis after a single hemodialysis session (5.57 ± 1.2 vs. 4.06 ± 0.73, p < 0.0001). Predialysis serum BPA levels were significantly higher in patients with diabetes than non-diabetics (4.4 ± 0.6 vs. 3.9 ± 0.7, p = 0.025). No association was found between serum BPA levels and patient characteristics, and particularly laboratory parameters. Conclusion: Serum BPA levels were rising significantly after a single dialysis session. Diabetic hemodialysis patients had higher predialysis serum BPA levels.

MP604INSOMNIA, MUSCULAR CRAMPS AND PRURITUS ARE ABSENT IN HEMODIALYSIS PATIENTS WITH GOOD DIALYSIS EFFICIENCY, LOW INFLAMMATION AND ARTERIOVENOUS FISTULA

Introduction and Aims: Insomnia, muscular cramps, pruritus and recovery time after hemodialysis are still controversial quality of life (QoL) parameters in hemodialysis patients. Methods: This was a single center, prospective, transversal and observational study which included 171 end-stage renal disease patients (age: 59.5±15.2 years and dialysis vintage: 89.7±125.6 months). One hundred fifteen patients were on high-flux hemodialysis (HD) and 56 patients were treated with on-line hemodiafiltration (HDF). Patients were asked “How long does it take you to recover from a dialysis session?” and they evaluated the intensity (absent, mild, medium and severe) of insomnia, muscular cramps and pruritus in the past 4 weeks. We studied associations of postdialysis recovery time, insomnia, muscular cramps and pruritus with themselves and age, dialysis vintage, sex, body mass index, hemoglobin, albumin, C-reactive protein (CRP), Daugirdas single-pool Kt/V (Kt/V), ultrafiltration volume, blood processed volume and vascular access type. Results: Absence of insomnia was significantly associated with absence of muscular cramps (p=0.01) and with dialysis on arteriovenous fistula (AVF) (p=0.01). The absence of muscular cramps was associated with the absence of pruritus (p=0.007) and with AVF (p=0.007). Low albumin level was predictive for severe insomnia (p=0.008) and severe pruritus (p=0.04), while CRP was significantly higher in severe vs. absent insomnia (p=0,002). Severe pruritus was associated with significantly lower Kt/V compared to absent pruritus (p=0.01). Conclusions: HD patients with AVF had less insomnia, muscular cramps and pruritus. Inflammation (low albumin and high CRP levels) was associated with severe insomnia and pruritus. Increased dialysis efficiency improved pruritus. Recovery time after HD had no significantly relations with any studied parameter. There was no difference of studied QoL features between HD and HDF patients.

Effects of L-carnitine supplementation on nutritional, immunological, and cardiac parameters in hemodialysis patients: a pilot study

L-carnitine is an essential compound that facilitates the transport of long-chain fatty acid across the inner mitochondrial membrane for β-oxidation. However, the effect of L-carnitine supplementation remains to be fully explored in patients with chronic kidney disease. We aimed in this study to determine the multidirectional effects of L-carnitine supplementation on clinical parameters in more detail. We orally administered L-carnitine to maintain serum-free carnitine levels within the normal range (30 to 70 μmol/L) for 6 months in 21 hemodialysis (HD) patients (age, 74 ± 11 years; time on HD, 60 ± 84 months). L-carnitine supplementation significantly increased serum transferrin from 155 ± 41 to 175 ± 48 mg/dL (p < 0.01) and retinol-binding protein from 8.9 ± 2.5 to 10.0 ± 3.4 mg/dL (p < 0.05). The triceps skinfold thickness was also significantly increased (p < 0.05), while the skeletal muscle mass in limbs and handgrip strength was not. L-carnitine enhanced natural killer (NK) cell activity at the E (effector cell)/T (target cell) ratio of 20:1 from 17.3 ± 14.1 to 20.8 ± 17.7 % (p < 0.01). In addition, L-carnitine improved left ventricular functional shortening (p < 0.01) with a significant decrease of brain natriuretic peptide (BNP) from 621.4 ± 666.8 to 412.0 ± 426.0 pg/mL (p < 0.05). These findings suggest that oral L-carnitine treatment improves immunological and cardiac markers in HD patients. In contrast, L-carnitine did not change the skeletal mass-related parameters during the 6-month follow-up.

Changes in biochemical, hemodynamic, and dialysis adherence parameters in hemodialysis patients during Ramadan

This paper aimed to study the effect of Ramadan fasting on biochemical and clinical parameters and compliance for dialysis. A prospective multicenter observational cross-sectional study comparing fasting with a non-fasting stable adult hemodialysis patients for demographic and biochemical parameters, compliance with dialysis, inter-dialytic weight gain, pre- and post-blood pressure, and frequency of intradialytic hypotensive episodes was carried out. Six hundred thirty-five patients, of whom 64.1% fasted, were studied. The fasters were younger (53.3 ± 16.2 vs. 58.4 ± 16.1 years; P = 0.001) but had similar duration on dialysis (P = 0.35). More fasters worked (22.0% vs. 14.6%; P = 0.001) and missed dialysis sessions during Ramadan. No differences were noted between groups in sex, diabetic status, or dialysis shift or day. There were no differences in the pre- and post-dialysis blood pressure; serum potassium, albumin or weight gain; diabetic status; sex; and dialysis shift time or days. However, serum phosphorous was significantly higher in the fasting group (2.78 ± 1.8 vs. 2.45 ± 1.6 mmol/L; P = 0.045). There were no intragroup differences in any of the parameters studied when comparing the findings during Ramadan with those in the month before Ramadan. Fasters were significantly younger and more likely to be working, to miss dialysis sessions, and to have higher serum phosphorous levels. No other differences were observed.

Predictive value of echocardiography and its relation to Kt/V and anthropometric parameters in hemodialysis patients

Background: In order to evaluate the predictive value of echocardiograph parameters for mortality of hemodialysis patients and their relation to Kt/V and anthropometry, a prospective, single center study was analyzed post-hoc. Methods: This analysis encompassed 106 patients on maintenance hemodialysis monitored for 108 months from 1996 to 2004. spKt/V was calculated using the Daugirdas formula. Anthropometric measurements included mid-arm muscle measurements (MAMC) and percentage of body fat (%fat). Echocardiography included the estimations of left ventricular wall thickness, dimensions and volumes (EDV, ESV), systolic LV function (ejection fraction - EFLV, fractional shortening - VCF, stroke volume - SV) and diastolic LV function (E/A, VTI-A wave of transmitral flow velocity), left atrial diameter, as well as assessment of clinical and biochemical parameters. The Cox proportional hazard model was used to estimate predictive values of echocardiograph parameters. Results: Kt/V correlated significantly with left ventricular systolic and diastolic volumes and function, septal and posterior wall thickness and left atrium dimension. MAMC and %fat also correlated with many echocardiograph parameters. Multivariate Cox regression selected age [HR 1.07; CI (1.03–1.12); p < 0.01], albumin [HR 0.88; CI (0.79–0.97); p < 0.05] and left atrium dimension – binary [values > 4 cm were marked as “1” and others “0” – HR 3.76; CI (1.56–9.03); p < 0.01] as independent predictors of death. Conclusion: Left atrium dimension was the most important predictor of mortality among the echocardiograph parameters. Many of these parameters were related to Kt/V and anthropometric measurements and could be the combined consequence of hypervolemia and hypertension.

Correlation between anthropometry, biochemical markers and subjective global assessment-dialysis malnutrition score as predictors of nutritional status of the maintenance hemodialysis patients

Background: Protein energy malnutrition is the major cause of poor prognostic outcome in patients on maintenance hemodialysis (MHD). The assessment of nutritional status in patients on maintenance hemodialysis should be done both subjectively and objectively by integrating clinical, biochemical and anthropometric measurements. A study was conducted to assess the possible correlations between the subjective global assessment-dialysis malnutrition score (SGA-DMS), anthropometric measurements, and biochemical parameters in hemodialysis patients. Methods: The study included 90 patients (55 males and 35 females; age range of 25 to 73 years; mean age 52.62 ± 11.7 years) undergoing twice/thrice weekly maintenance hemodialysis for six months and above in the dialysis unit of a tertiary care teaching hospital. The MHD patients were assessed by SGA -DMS, anthropometry and biochemical indicators (serum albumin, iron, ferritin and transferrin) of nutritional status. Results: According to the SGA-DMS 54.4 % were moderate to severely malnourished, 31% were mild to moderately nourished and 14.4% were well nourished. There was a highly significant negative correlation between SGA –DMS and serum albumin, iron, transferrin; positive correlation between SGA-DMS and ferritin (P<0.0001). Body mass index, upper arm circumferences, and skin fold thickness had a highly significant negative correlation with SGA-DMS (P<0.001), where as the lean body mass, total body water and the fat free mass had a significant negative correlation (P<0.05). Conclusion: SGA-DMS correlated with anthropometric and biochemical parameters that are indicative of nutritional status. SGA –DMS used in conjunction with other objective nutritional assessment methods may be of greater impact in determining nutritional status of hemodialysis patients.

The Relationship between Serum Oxalic Acid, Central Hemodynamic Parameters and Colonization by Oxalobacter formigenes in Hemodialysis Patients

Background/Objective: Elevated pulse wave velocity (PWV) and central aortic blood pressures are independent predictors of increased cardiovascular morbidity and mortality in hemodialysis (HD) patients. Oxalic acid is a uremic retention molecule that is extensively studied in the pathogenesis of calcium oxalate stones. Oxalobacter formigenes, a member of the colon microbiota, has important roles in oxalate homeostasis. Data regarding the colonization by and the exact role of O. formigenes in the pathogenesis of oxalic acid metabolism in HD patients are scant. Hence, we aimed to determine the relationship between fecal O. formigenes colonization, serum oxalic acid and hemodynamic parameters in HD patients with regard to the colo-reno-cardiac axis. Methods: Fifty HD patients were enrolled in this study. PWV and central aortic systolic (cASBP) and diastolic blood pressures (cADBP) were measured with a Mobil-O-Graph (I.E.M. GmbH, Stolberg, Germany). Serum oxalic acid levels were assessed by ELISA, and fecal O. formigenes DNA levels were isolated and measured by real-time PCR. Results: Isolation of fecal O. formigenes was found in only 2 HD patients. One of them had 113,609 copies/ml, the other one had 1,056 copies/ml. Serum oxalic acid levels were found to be positively correlated with PWV (r = 0.29, p = 0.03), cASBP (r = 0.33, p = 0.001) and cADBP (r = 0.42, p = 0.002) and negatively correlated with LDL (r = -0.30, p = 0.03). In multivariate linear regression analysis, PWV was independently predicted by oxalic acid, glucose and triglyceride. Conclusions: This is the first study that demonstrates the absence of O. formigenes as well as a relation between serum oxalic acid and cASBP, cADBP and PWV in HD patients. Replacement of O. formigenes with pre- and probiotics might decrease serum oxalic acid levels and improve cardiovascular outcomes in HD patients.

Effects of switching from sevelamer hydrochloride to bixalomer on laboratory parameters in hemodialysis patients.

In Japan, the clinical use of bixalomer, a new polymer preparation like sevelamer hydrochloride, became possible from 2012. In our study, in order to investigate the clinical characteristics of this new phosphorus (P) binder, bixalomer in a clinical practice, for 18 cases of hemodialysis patients at our hospital being treated with sevelamer hydrochloride, we switched the P binder to bixalomer, and compared the laboratory parameters before and after switching. Subjects used for analysis were nine cases in which it was possible to use bixalomer continuously for 10 months. The laboratory parameters measured were the concentrations of serum P, corrected calcium (Ca), whole parathyroid hormone (PTH), albumin and alkaline phosphatase (ALP) as indicators of mineral and bone disorder, and serum high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C) and triglyceride (TG) as indicators of lipid metabolism. Regarding the results after switching to bixalomer and starting treatment using the same dosage as the dosage previously used for sevelamer hydrochloride, there were many cases that showed increasing P concentrations that required increasing the dosage of bixalomer, the dosage after switching was increased significantly (P=0.002). In the comparison of laboratory parameters before and after switching, the concentrations of serum P and albumin decreased significantly (P=0.035 and 0.033). From these results, it was considered that the decreases in serum P concentrations were due not only to the effects of bixalomer, but that suppression of food intake by patients was another reason. There were no significant changes in corrected Ca, whole PTH or ALP. In addition, after changing the P binder, serum HDL-C concentration decreased significantly (P=0.015) and LDL-C increased significantly (P<0.001), and serum TG concentration showed no significant changes. This indicated that the beneficial effects of bixalomer on lipid metabolism may be less than those of sevelamer hydrochloride.

A comparison of markers of myocardial injury and their relation to nutritional parameters in hemodialysis patients

Background: Serum cardiac troponin T (cTnT) is a valuable marker of ischemic heart disease (IHD) and left ventricular hypertrophy, as well as a mortality predictor in hemodialysis populations. We compared the value of cTnT, creatinine kinase (CK)-MB mass and myoglobin as mortality predictors in our hemodialysis patients and evaluated their relation to nutritional status. Methods: A total of 118 hemodialysis patients were prospectively studied from January 2004 to April 2013. Clinical and laboratory evaluations during the 12-month baseline period included the history of IHD, signs of left ventricular hypertrophy (LVH), Kt/V and serum cardiac markers together with the percentage of body fat (%fat), mid-arm circumference (MAC), mid-arm muscle circumference (MAMC), triceps skinfold (TSF) and BMI. Results: Underweight patients had significantly higher cTnT values (Mann–Whitney, p < 0.05). Correlation analysis (Spearman) showed an inverse association between cTnT and TSF (ρ = −0.22, p < 0.05), as well as between CK-MB mass and TSF (ρ = −0.26, p < 0.01). In men cTnT also correlated inversely with %fat (ρ = −0.27, p < 0.05) and BMI (ρ = −0.33, p < 0.05). In addition, myoglobin was correlated significantly with MAC, MAMC and albumin. Among cardiac markers cTnT was the only independent variable predicting mortality (Multivariate Cox regression, HR = 1.04 CI (1.01–1.07); p < 0.01; measurement units 0.01 μg/L). Conclusion: Troponin T and CK-MB mass were significantly elevated in the underweight patient group. Troponin T was the only independent cardiac marker predictor of all cause mortality in our hemodialysis patients.

Increased frequency of gallbladder stone and related parameters in hemodialysis patients.

The prevalence of gallbladder stone (GBS) is shown to be increased in some studies in patients with chronic kidney disease (CKD). Nevertheless, some other studies did not confirm these findings. The controversial results about the prevalence of GBS in hemodialysis (HD) patients demand new studies to search GBS prevalence and associating risk factors in HD patients. In the present study, we aimed to investigate GBS prevalence and risk factors in our HD patients. A total of 104 HD and 149 control patients were involved. Complete physical examinations, including measurements of dry body weight and height, were done. Abdominal ultrasonography was conducted by the same experienced radiologist. Blood samples were drawn via venipuncture from the study participants after they had fasted overnight just before a midweek hemodialysis session for laboratory examinations. The prevalence of GBS in HD patients was 34.6 % (36/104), and that was significantly higher than that of control group 12.9% (17/149; p=0.0001). In all study participants (HD patients and control group), patients with GBS were older than patients with no GBS (63.2±14.2 vs 53.7±16.7; p=0.0001). However, in HD patients, mean age was similar in patients with GBS and no GBS (64.3±13.8 vs 60.1±16.6; p>0.05). Patients with GBS had a higher prevalence of units of blood transfusions than patients with no GBS in hemodialysis patients (2.0±2.9 vs 0.9±1.3; p=0.047) CONCLUSION: The present study showed an increased prevalence of GBS in HD patients compared to healthy controls. The number of blood transfusions and autonomic neuropathy may be responsible for the increased prevalence of GBS in HD patients.

Losartan and QT Dispersion in Hypertensive Patients on Maintenance Hemodialysis

Abstract QT and corrected QT (QTc) intervals and their increased dispersions (QTd, QTcd) have been linked to the occurrence of arrhythmias in hemodialysis (HD) patients. This study was performed to determine the effects of the angiotensin II receptor blocker losartan on these parameters in HD patients. Our cohort comprised 24 dialysis patients and 14 healthy controls. 15 dialysis patients were treated for 16 weeks with losartan (HD losartan group) but not 9 patients (HD control group). Blood pressures (BP) and electrocardiogram-derived data (Sokolow-Lyon and Cornell voltages, QT, QTd, QTc and QTcd) were measured in all patients. At the beginning of the study, there were no differences in patient characteristics among the 3 groups. Baseline maximum QTc, QTd, QTcd and Socolow-Lyon and Cornell voltages and BPs of the healthy group were lower than those of HD groups. While these parameters were similar in the dialysis groups, only BPs in losartan group were higher. After 16 weeks, BPs, Socolow-Lyon and Cornell voltages values in losartan group significantly decreased but not in the HD control group. Whereas maximum QT and QTc, QTd, QTcd, heart rate and QRS interval did not change in the HD groups. Electrocardiographic LVH of 2 patients improved in the losartan group. Losartan reduced BP and electrocardiographic LVH was improved in HD patients without affecting QTd and QTcd during the 16-week study period. Key words: Hemodialysis, losartan, QT dispersion

Assessment of hematological and biochemical parameters in hemodialysis patients and the impact of hemodialysis duration on hepcidin, ferritin and CRP

Assessment of hematological and biochemical parameters in hemodialysis patients and the impact of hemodialysis duration on hepcidin, ferritin and CRP

Interdialytic weight gain, systolic blood pressure, serum albumin, and C-reactive protein levels change in chronic dialysis patients prior to death

Reports from a United States cohort of chronic hemodialysis patients suggested that weight loss, a decline in pre-dialysis systolic blood pressure, and decreased serum albumin may precede death. However, no comparative studies have been reported in such patients from other countries. Here we analyzed dynamic changes in these parameters in hemodialysis patients and included 3593 individuals from 5 Asian countries; 35,146 from 18 European countries; 8649 from Argentina; and 4742 from the United States. In surviving prevalent patients, these variables appeared to have notably different dynamics than in patients who died. While in all populations the interdialytic weight gain, systolic blood pressure, and serum albumin levels were stable in surviving patients, these indicators declined starting more than a year ahead in those who died with the dynamics similar irrespective of gender and geographic region. In European patients, C-reactive protein levels were available on a routine basis and indicated that levels of this acute-phase protein were low and stable in surviving patients but rose sharply before death. Thus, relevant fundamental biological processes start many months before death in the majority of chronic hemodialysis patients. Longitudinal monitoring of these dynamics may help to identify patients at risk and aid the development of an alert system to initiate timely interventions to improve outcomes.

Vertebral bone density by quantitative computed tomography mirrors bone structure histomorphometric parameters in hemodialysis patients

Diagnosing low bone mass is of clinical importance for hemodialysis (HD) patients due to its association with fractures and cardiovascular disease. We investigated whether bone density obtained by quantitative computed tomography (QCT) is associated with the histologically determined bone volume and microarchitecture parameters in HD patients. Twenty-six HD patients were studied. Bone biopsy samples were obtained from the iliac crest and trabecular bone volume, thickness, number and separation were evaluated by histomorphometry. Vertebral trabecular bone density (VTBD) was evaluated by QCT. VTBD correlated positively with trabecular bone volume (r = 0.69, p < 0.001), trabecular thickness (r = 0.45, p = 0.022) and trabecular number (r = 0.62, p < 0.001), and negatively with trabecular separation (r = -0.50, p < 0.01). In the multiple linear regression analysis adjusting for age, gender and diabetes, VTBD remained associated with bone volume by histomorphometry (β = 0.06; 95 % CI 0.02-0.11; p = 0.006; R² = 0.49). VTBD measured by QCT mirrored bone volume and microarchitecture parameters obtained by histomorphometry in HD patients.

Effect of Fluid Management Guided by Bioimpedance Spectroscopy on Cardiovascular Parameters in Hemodialysis Patients: A Randomized Controlled Trial

Fluid overload is the main determinant of hypertension and left ventricular hypertrophy in hemodialysis patients. However, assessment of fluid overload can be difficult in clinical practice. We investigated whether objective measurement of fluid overload with bioimpedance spectroscopy is helpful in optimizing fluid status. Prospective, randomized, and controlled study. 156 hemodialysis patients from 2 centers were randomly assigned to 2 groups. Dry weight was assessed by routine clinical practice and fluid overload was assessed by bioimpedance spectroscopy in both groups. In the intervention group (n = 78), fluid overload information was provided to treating physicians and used to adjust fluid removal during dialysis. In the control group (n = 78), fluid overload information was not provided to treating physicians and fluid removal during dialysis was adjusted according to usual clinical practice. The primary outcome was regression of left ventricular mass index during a 1-year follow-up. Improvement in blood pressure and left atrial volume were the main secondary outcomes. Changes in arterial stiffness parameters were additional outcomes. Fluid overload was assessed twice monthly in the intervention group and every 3 months in the control group before the mid- or end-week hemodialysis session. Echocardiography, 48-hour ambulatory blood pressure measurement, and pulse wave analysis were performed at baseline and 12 months. Baseline fluid overload parameters in the intervention and control groups were 1.45 ± 1.11 (SD) and 1.44 ± 1.12 L, respectively (P = 0.7). Time-averaged fluid overload values significantly decreased in the intervention group (mean difference, -0.5 ± 0.8 L), but not in the control group (mean difference, 0.1 ± 1.2 L), and the mean difference between groups was -0.5 L (95% CI, -0.8 to -0.2; P = 0.001). Left ventricular mass index regressed from 131 ± 36 to 116 ± 29 g/m(2) (P < 0.001) in the intervention group, but not in the control group (121 ± 35 to 120 ± 30 g/m(2); P = 0.9); mean difference between groups was -10.2 g/m(2) (95% CI, -19.2 to -1.17 g/m(2); P = 0.04). In addition, values for left atrial volume index, blood pressure, and arterial stiffness parameters decreased in the intervention group, but not in the control group. Ambulatory blood pressure data were not available for all patients. Assessment of fluid overload with bioimpedance spectroscopy provides better management of fluid status, leading to regression of left ventricular mass index, decrease in blood pressure, and improvement in arterial stiffness.

The Relations Between Levels of Cadmium and Thyroid Parameters in Hemodialysis Patients

The Relations Between Levels of Cadmium and Thyroid Parameters in Hemodialysis Patients