Predialysis Group Research Articles

The role of decoy receptor 3 in inflammation and atherosclerosis in patients with chronic kidney disease and renal transplant patients

IntroductionThe cardiovascular risk has been increased in chronic kidney disease associated with chronic inflammation and atherosclerosis. Decoy receptor 3, is a member of the TNF receptor superfamily and associated with inflammation and atherosclerosis. The aim of our study is to determine the relationship, between serum DcR3 levels and inflammatory markers in patients with renal transplantation, those receiving dialysis treatment and cases with chronic renal failure that did not receive replacement therapy, and to evaluate their correlation with USG findings. Material and methodsA total of 150 patients aged between 22–86 years, consisting of 4 groups, namely renal transplantation, dialysis, predialysis chronic kidney disease and control groups, were included in the study. Serum decoy receptor 3, VCAM-1, ICAM-1 and IL-8 measured with ELISA method. Carotid intima-media thickness and presence of carotis arter plaque performed by ultrasound probe, non-invasively. ResultsAll serum markers were higher in dialysis and pre-dialysis chronic kidney disease groups compared to renal transplant and control groups (p<0.05). Serum decoy receptor 3 level (median(min–max)) of renal transplant group (0.49ng/mL (0.19–1.65)) was higher than control group (0.35ng/mL (0.19–2.22)). There was no difference between patients receiving dialysis (0.89ng/mL (0.41–4.98)) and patients with pre-dialysis chronic kidney disease (0.71ng/mL (0.29–1.68)). There was no difference between patient groups in terms of the presence of plaque. ConclusionAlthough renal transplantation provides a significant improvement in the inflammatory process, not return completely. Inflammatory process associated with uremic milieu may predispose to atherosclerosis in patients with pre-dialysis chronic kidney disease and hemodialysis patients.

Histology and Immunohistochemistry of Radial Arteries Are Suggestive of an Interaction between Calcification and Early Atherosclerotic Lesions in Chronic Kidney Disease.

Background and Objectives: recent studies suggest an implication of immune mechanisms in atherosclerotic disease. In this paper, the interaction between inflammation, calcification, and atherosclerosis on the vessel walls of patients with chronic kidney disease (CKD) is described and evaluated. Materials and Methods: patients with stage V CKD, either on pre-dialysis (group A) or on hemodialysis (HD) for at least 2 years (group B), in whom a radiocephalic arteriovenous fistula (RCAVF) was created, were included in the study. The control group included healthy volunteers who received radial artery surgery after an accident. The expressions of inflammatory cells, myofibroblasts, and vascular calcification regulators on the vascular wall were estimated, and, moreover, morphometric analysis was performed. Results: the expressions of CD68(+) cells, matrix carboxyglutamic acid proteins (MGPs), the receptor activator of nuclear factor-kB (RANK) and RANK ligand (RANKL), and osteoprotegerin (OPG), were significantly increased in CKD patients compared to the controls p = 0.02; p = 0.006; p = 0.01; and p = 0.006, respectively. In morphometric analysis, the I/M and L/I ratios had significant differences between CKD patients and the controls 0.3534 ± 0.20 vs. 0.1520 ± 0.865, p = 0.003, and 2.1709 ± 1.568 vs. 4.9958 ± 3.2975, p = 0.03, respectively. The independent variables correlated with the degree of vascular calcification were the intensity of CD34(+), aSMA(+) cells, and OPG, R2 = 0.76, p < 0.0001, and, with intima-media thickness (IMT), the severity of RANKL expression R2 = 0.3, p < 0.0001. Conclusion: atherosclerosis and vascular calcification in CKD seem to be strongly regulated by an immunological and inflammatory activation on the vascular wall.

Assessment of Depression and Anxiety in Patients with Chronic Kidney Disease and after Kidney Transplantation-A Comparative Analysis.

Depression and anxiety are common among chronic kidney disease (CKD) patients but are rarely diagnosed and treated. Furthermore, the fraction of patients with depression is greater among hemodialyzed patients. The aim of the study was to assess the prevalence of depression symptoms, anxiety and assess the level of life satisfaction in three groups of patients based on the stage of CKD. The study group consisted of 283 patients—130 females and 153 males, mean aged was 54.7 (±15.3) with stage III–V chronic kidney disease and after kidney transplantation. The Beck Depression Inventory (BDI), the Satisfaction with Life Scale (SWLS), and the State-Trait Anxiety Inventory (STAI) were used. The highest percentage of patients with depressive symptoms was recorded in the group of dialysis patients with stage V CKD. The lowest percentage of patients with high satisfaction with life was noted in the pre-dialysis group. There was a significant relationship between BDI and STAI, SWLS in all groups while a significant relationship between BDI and handgrip strength was observed in dialysis and kidney transplantation patients. Anxiety as a trait was found to be the factor most significantly associated with depressive symptoms in each of the three patient groups. Screen testing and monitoring of the emotional state of patients with CKD are needed, regardless of the stage of the disease and treatment, including patients after kidney transplantation.

Study of Non-alcoholic fatty liver disease among chronic kidney disease patients by Controlled attenuation parameter

Abstract Background/Aim Preliminary data suggest an association between chronic kidney disease (CKD) and non-alcoholic fatty liver disease (NAFLD). The aim of this study was evaluate the frequency of NAFLD and its associated risk factors among nondiabetic CKD patients not on dialysis. METHODS A total of 40 subjects were enrolled in the study. Group A (30) Pre dialysis non-diabetic CKD patiens and Group B (10) normal subjects matched for age and sex as a control group. Liver stiffness measurement was used to detect liver fibrosis and CAP (controlled attenuation parameter) was used to detect and quantify liver steatosis (Fibroscan®). NAFLD was defined by CAP values ≥238 dB/m. RESULTS Results of the current study showed that CKD stage III was present in 17 patients (56.7%) and CKD stage IV in 9 patients (30%) and CKD stage V in in 4 patients (13.3%). The total frequency of presence of steatosis (CAP values ≥238 dB/m) whatever degree was significantly higher in CKD group than control; More than (53%) of CKD patients have NAFLD, and (30%) of control group have NAFLD. The severity of liver steatosis was negatively correlated with GFR, Hb and HDL, and positively correlated with Creatinine, BUN, CRP, Cholesterol, TG, LDL, SGPT, SGOT, FBG and HBA1C. There was significant relation between steatosis and CKD etiology. (82.3%) of Patients with hypertension have Steatosis, (33.3%) of Patients with reflux nephropathy have steatosis, (16.7%) of Patients had other causes have steatosis, while patients had renal stones have no steatosis. There was significant positive correlation between fibrosis degree and age of CKD patients and also significant positive correlation between steatosis and fibrosis among CKD patients. The study showed significant positive correlation between SGPT and fibrosis degree. The results suggest a high prevalence of NAFLD in non-diabetic CKD patients. The severity of liver steatosis is negatively correlated with kidney function; there was significant correlation between CKD stage and other risk factors of hepatic steatosis

MO777HISTOLOGICAL AND IMMUNOPHENOTYPICAL VESSEL CHANGES IN CHRONIC KIDNEY DISEASE

Abstract Background and Aims Recent studies suggest thw possibility of activating immune mechanism in the onset and progression of atherosclerotic disease. The aim of the present study was to evaluate the role of immune mechanisms in the vessel of patients with Chronic Kidney Disease (CKD) and the association with clinical and laboratory indicators of atherosclerosis. Method Patients with CKD stage V, in whom a radiocephalic arteriovenous fistula (RC-AVF) was created, were included in the study. Patients were divided in two groups, group A was consisted of patients who were on stage V, pre-dialysis, and being prepared to start on hemodialysis (HD), and those who had already been on HD for at least 3 years, and were having a new RC-AVF formation, due to previous failure, group B. Inclusion criteria were: age 25-80 years, gradual deterioration of renal function up to stage V or under dialysis for more than 3 years. All patients should have been under close follow up for at least 3 years prior to enrolment, with adequate control of diabetes, hypertension, dyslipidemia, secondary hyperparathyroidism and anemia. The control group included healthy volunteers of similar age, sex and ethnicity, who agreed to have a radial artery biopsy during an orthopedic procedure because of a fracture. All patients were informed and signed the consent form. Patients’ history, primary disease and comorbid conditions, medication and clinical examination were recorded based on hospital outpatients’ files. Prior to the scheduled day of RC-AVF creation, all patients underwent laboratory examination, included hematological and serum biochemical analyses. The histological characteristics, inflammatory activation and immunophenotypic alterations of the radial artery wall were estimated and their association with the severity of calcification and atherosclerosis were studied. Presence and severity of atherosclerotic lesions in CKD patients was assessed based on the measurement of common carotid intima – media thickness (IMT) of the common and internal carotid on both sides. Results Significant correlation was fount between inflammatory infiltration [expression of CD3(+), CD20(+), CD68(+) cells], cellular activation [CD34(+), a-SMA(+) cells] and calcification regulators (MPG, RANKL, OPG) with the degree of vascular calcification, as this was estimated and classified based on Verhoff’s Elastic and von Kossa staining Forty five patients with chronic kidney disease (CKD), stage V, either pre-dialysis (p=25) (group A) or on hemodialysis (HD) (p=20) (group B) were included in the study. There were no significant differences in age, sex, race, and also in the frequency of hypertension, diabetes mellitus or smoking habits between patients and controls. Presence and severity of atherosclerotic lesions in CKD patients was assessed based on the measurement of common carotid intima – media thickness (IMT) of the common and internal carotid on both sides. Conclusion Atherosclerotic disease in Chronic KidnEy Disease and its clinical effects appear to be directly related to inflammatory ifiltration of blood vessels by T, B lymphocytes, macrophages and myofibrolasts, as well as factors that affect calcification.

Effect of dialysis and transplantation on myocardial repolarization parameters and P-wave dispersion in chronic kidney disease.

BackgroundChronic kidney disease (CKD) patients are at higher risk for cardiac arrhythmias. The risk of arrhythmia may change with different treatment modalities. We proposed to compare the effects of varied therapy methods on myocardial repolarization parameters (Tp‐e, QT, QTc intervals, Tp‐e/QT, Tp‐e/QTc ratios) and P‐wave dispersion (PWD) in patients with CKD.MethodsThree groups were formed from the patients aged between 18 and 65 years, as Group 1 consisting of CKD patients receiving hemodialysis (HD) three times a week, Group 2 consisting of predialysis CKD patients and Group 3 consisting of CKD patients who underwent successful transplantation. All patients’ basic demographic data, risk factors, and echocardiographic parameters were recorded, and electrocardiographic repolarization parameters and PWD were analyzed.ResultsThe PR, QT, and QTc intervals were significantly shorter in the transplantation group compared to the other groups (P = .020, P < .001, P = .035; respectively). Tp‐e interval, Tp‐e/QT, and Tp‐e/QTc ratios were significantly higher in the predialysis group compared to the other groups (P < .001, P < .001, P = .001; respectively), while there was no significant variation between the HD and transplantation groups (P > .05). PWD was significantly increased in the predialysis group compared to other two groups (P < .001), while no significant variation between the HD and transplantation groups was observed.ConclusionWe found that the Tp‐e interval, Tp‐e/QT, Tp‐e/QTc, and PWD were significantly higher in the predialysis CKD group, but the PR, QT, and QTc intervals were significantly shorter in the transplantation group compared to the other groups. The prognostic significance and prediction of these parameters in arrhythmic events in CKD patients requires further evaluation with long‐time follow‐up.

Patient-reported symptoms during dialysis: the effect of pre-dialysis extracellular water and change in extracellular water post-dialysis

BackgroundQuality of life for haemodialysis (HD) patients may be affected by symptoms during dialysis treatments, and patient groups have highlighted the need to improve post-dialysis fatigue and dialysis-related symptoms. As changes in extracellular water (ECW) may lead to cramps and other symptoms, we wished to determine whether there was an association between ECW and intra-dialytic symptoms.MethodsWe reviewed the hospital records of HD patients who completed a self-reported intra-dialytic symptom questionnaire, using a visual analogue scale, who had contemporaneous pre- and postdialysis bioimpedance ECW measurements adjusted to height (aECW).ResultsWe studied dialysis sessions of 506 patients, 314 (62.1%) male, 226 (44.7%) diabetic, mean age 64.6 ± 15.7 years, weight 69.9 ± 17.4 kg, and duration of dialysis treatment 26 (9.6–60.1) months. We divided patients into three groups according to pre-dialysis aECW, and total dialysis symptom scores were greater for those in the lower tertile (25 (10–41) vs middle 18 (8.5–34) vs upper 20 (7–31), p < 0.05). Only feeling cold, dizziness, and low blood pressure were statistically different between the three pre-dialysis aECW groups, and there was no difference in post-dialysis recovery times.We analysed the effect of the fall in aECW pre-to post-dialysis. Patients in the group with the greatest fall in aECW did not report more intra-dialytic symptoms or longer recovery times.ConclusionWe found that patients starting dialysis with lower relative ECW were more likely to report intra-dialytic symptoms than those with greater amounts of fluid to remove, and most commonly reported symptoms were associated with intra-vascular volume depletion.

Cross-sectional Study of Calcium Phosphate Product and Intact Parathyroid Hormone Levels in Predialysis and Postdialysis Patients with Stage 5 Chronic Kidney Disease.

Chronic kidney disease (CKD) gradually deteriorates the mineral homeostasis, with a disruption of normal serum phosphorus, calcium, and intact parathyroid hormone (iPTH). Hemodialysis is one of the replacement therapies used to treat CKD patients to achieve normal kidney function. The present study aimed to evaluate the impact of dialysis on serum levels of calcium, phosphorus, and iPTH in CKD patients. A cross-sectional observational study was conducted between May 2015 and April 2017 in patients with CKD stage 5. The demographic characteristics including age, sex, body weight, and estimated glomeruli filtration rate were recorded. Serum levels of calcium, phosphorus, and iPTH were measured. A total of 100 patients divided into predialysis (n = 50) and postdialysis group (n = 50) with the mean age 50.34 and 51.88 years were included in this study, respectively. Mean levels of serum calcium and iPTH in the postdialysis patients were significantly lower than predialysis patients (P = 0.0183 and P <0.001). The proportion of patients (74%) with serum phosphorus level >4.5 mg/dL was significantly higher in postdialysis group (0.003). The risk of having high level of iPTH was 3.20 times more among the patients with level of phosphorus between 2.5 and 4.5 mg/dL [odds ratio (OR), 3.20; 95% confidence interval (CI), 1.16-8.80; P = 0.02] and 2.82 times more among patients with level of calcium <8.5 mg/dL (OR, 2.82; 95% CI, 1.13-7.01; P = 0.02). Overall observations suggest a significant reduction in levels of serum calcium and iPTH after dialysis in patients with CKD stage 5.

Left Ventricular Geometry and N-terminal Pro-Brain Natriuretic Peptide in Egyptian Children with Chronic Kidney Disease.

Introduction: Cardiovascular disease is the main cause of death in Chronic Kidney disease (CKD) patients especially for those on dialysis. Left ventricular echocardiography changes are common. N-terminal pro-Brain Natriuretic peptide (NAP) is a sensitive predictor for ventricular stress. Aim of the Study: Our aim is to assess left ventricular Echocardiography abnormalities in CKD patients and their relation to serum NT pro BNP levels. Methods: TheStudy included; 51 patients with different stages of CKD (21 patients were (CKD1-4) on predialysis conservative treatment, 30 patients with (CKD 5) on hemodialysis), and 20 healthy control group. Patients were subjected to echocardiography and serum measurement of BNP by enzyme linked immunosorbent assay. Results: Abnormal left ventricular geometry patterns were seen in 17/21 (81%) CKD pre dialysis patients (concentric hypertrophy in 8 patients, eccentric hypertrophy in 8 patients and concentric remodeling in one patient). Those on dialysis 28/30 (93%) showed abnormal left ventricular geometry patterns (23 had concentric hypertrophy, 4 had eccentric hypertrophy and one patient had concentric remodeling). Mean NT pro BNP level was significantly higher in ESRD on dialysis (182.49 ± 136.57) vs pre dialysis group (29.72 ± 34.77) and control group (1.13 ± 2.97) (p < 0.001). Total patient sample (51cases) showed significant positive correlations between NT pro BNP level with hypertension, left ventricular mass (LVM), LVM2.7, LVM2, relative wall thickness (RWT) and serum creatinine (p = 0.0007, 0.01, 0.0007, 0.0005, 0.0002 respectively),significant negative correlation with ejection fraction (P = 0.04). Conclusion: Measuring plasma concentration of BNP, may be useful for the identification of CKD patients with abnormal left ventricular Geometry. Recommendations: Routine echocardiography is recommended in early stages of CKD.

Abnormal rich club organization in end-stage renal disease patients before dialysis initiation and undergoing maintenance hemodialysis

BackgroundEnd-stage renal disease (ESRD) patients are at a substantially higher risk for developing cognitive impairment compared with the healthy population. Dialysis is an essential way to maintain the life of ESRD patients. Based on previous research, there isn’t an uncontested result whether cognition was improved or worsened during dialysis.MethodsTo explore the impact of dialysis treatment on cognitive performance, we recruited healthy controls (HCs), predialysis ESRD patients (predialysis group), and maintenance hemodialysis ESRD patients (HD group). All ESRD patients performed six blood biochemistry tests (hemoglobin, urea, cystatin C, Na+, K+, and parathyroid hormone). Neuropsychological tests were used to measure cognitive function. By using diffusion tensor imaging and graph-theory approaches, the topological organization of the whole-brain structural network was investigated. Generalized linear models (GLMs) were performed to investigate blood biochemistry predictors of the neuropsychological tests and the results of graph analyses in the HD group and predialysis group.ResultsNeuropsychological analysis showed the HD group exhibited better cognitive function than the predialysis group, but both were worse than HCs. Whole-brain graph analyses revealed that increased global efficiency and normalized shortest path length remained in the predialysis group and HD group than the HCs. Besides, a lower normalized clustering coefficient was found in the predialysis group relative to the HCs and HD group. For the GLM analysis, only the Cystatin C level was significantly associated with the average fiber length of rich club connections in the predialysis group.ConclusionsOur study revealed that dialysis had a limited effect on cognitive improvement.

P0866EVALUATION OF ERYPTOSIS IN PATIENTS WITH CHRONIC KIDNEY DISEASE

Abstract Background and Aims One of the many factors in the pathogenesis of renal anaemia, is eryptosis. The aim of this study is to evaluate eryptosis in patients with chronic renal disease stage 3-5 and 5 dialysis (5D). Method Patients with CKD who were monitored in our nephrology department were included in the study. The age range of the patient groups was 18-80 years and haemoglobin levels were &amp;lt;13 g / dl in men and &amp;lt;12 g / dl in women. As parameters of eryptosis, flow cytometric annexin V binding and intracellular calcium, and superoxide dismutase (SOD) activity with ELISA method were measured in 59 predialysis patient (eGFR&amp;lt;60 mL / min 1.73 m2), 26 haemodialysis patient, 21 peritoneal dialysis patient and 29 healthy volunteers with similar age (control). Haematological and biochemical tests including complete blood count(CBC), erythrocyte sedimentation rate (ESR), Parathormone (PTH), 25-OH vit D3, Blood urea nitrogen (BUN), Creatinine (Cr), C-reactive protein (CRP), Na, K, phosphor (P), ionized and total Calcium, Ferritin, B12 and Folate, were performed. IBM SPSS Statistics Version 20.0 was used for statistical analysis of the data Results The amount of intracellular calcium were 3.05 ± 1.66 in predialysis group, 2.24 ± 0.99 in haemodialysis group, 2.38 ± 0.87 in peritoneal dialysis group and 1.71 ± 0.46 in control group. For intracellular calcium there was statistically significant difference only between predialysis group and control group (p &amp;lt;0. 000). Annexin V binding were calculated as 1.05 ± 0.99 in predialysis group, 1.15 ± 0.56 in haemodialysis group, 1.06 ± 0.87 in peritoneal dialysis group and 0.88 ± 0.86 in control group. Comparing to control group annexin V binding in predialysis, haemodialysis and peritoneal dialysis groups, were statistically significantly increased (for all p &amp;lt;0.000). SOD activity was 0.07 ± 0.07 in predialysis group, 0.13 ± 0.08 in haemodialysis group, 0.14 ± 0.07 in peritoneal dialysis group and 0.03 ± 0.01 in control group. The difference between the control group and dialysis group was statistically significant (p &amp;lt;0. 00). Comparing to nonusers; patients using calcium channel blockers (CCB) had low annexin V binding level (p = 0.013). Patients using erythropoietin (EPO) had elevated annexin V binding level (p &amp;lt;0.000) and lower intracellular calcium (p = 0.014) according to non- users. Conclusion We determined increased eryptosis in patients with CKD stage 3-5 and 5D in our study. Inflammation and elevated parathormone were also associated with increased eryptosis. Therefore, eryptosis may be an important factor in the pathogenesis of renal anaemia. Inflammation associated CKD may increase eryptosis. In addition, this effect can be taken into consideration in the planning of treatment because of the lower incidence of eryptosis in patients using calcium channel blocker and EPO.

Reduction of functional cardiovascular reserve in the stages of chronic kidney disease.

Patients with chronic kidney disease (CKD) present reduced oxygen consumption at peak exercise (VO2 peak). No studies have evaluated objective measures of the cardiovascular reserve, besides VO2 peak and VO2 at the anaerobic threshold (VO2 AT), and compared these measures among ckd patients at different stages of the disease. Fifty-eight patients [pre-dialysis group (PD)=26, hemodialysis group (HD)=20, and post-kidney transplant group (KT)=12] were included. The following measures of cardiovascular reserve were obtained: 1) peak heart rate (HR); 2) peak systolic blood pressure (SBP); 3) VO2 peak and % predicted; 4) VO2 AT and % of predicted VO2; 5) peak circulatory power; 6) ventilatory efficiency for the production of carbon dioxide (VE/VCO2 slope); 7) oxygen uptake efficiency slope (OUES); and 8) recovery of gas exchange. The VO2 peak and VO2 AT in the PD, HD, and KT groups were reduced to 86% and 69%, 70% and 57%, and 79% and 64% of the predicted value, respectively. Patients in the HD group had lower VO2 peak (17.5±5.9 vs. 23.2±8.2 [p-value=0.036]) and VO2 AT (14.0±5.2 vs. 18.3±4.7 [p-value=0.039]) compared to patients in the KT group. OUES was significantly lower in the HD group compared to the KT group (p-value=0.034). Age in the PD, HD, and KT groups and sedentary lifestyle in the KT group were predictors of VO2 peak. CKD patients presented a reduction in cardiovascular reserve regardless of the stage of the disease. However, hemodialysis patients presented a greater reduction of cardiovascular reserve when compared to post-kidney transplant patients.

Study of serum sclerostin levels and its role in vascular calcification in patients with chronic kidney disease

ObjectiveThe aim of this work was to study serum sclerostin levels in patients with chronic kidney disease (CKD) not on dialysis and those on regular hemodialysis and its role in vascular calcification.BackgroundCKD, whether starting hemodialysis (HD) or not, is associated with an increase in the risk for vascular calcification, which can only be partially explained by known classical risk factors. Sclerostin is an osteocyte-derived inhibitor of the Wnt pathway and has been shown to play a key role in vascular calcification in patients with CKD.Patients and methodsThis cross-sectional study was carried out on 80 patients with CKD attending Menoufia University Hospital. Patients were classified into 40 patients with CKD who were not on HD (group I) and 40 patients with CKD on regular HD more than 6 months (group II), who were compared with 15 controls (group III). Abdominal aortic calcification (AAC) was assessed using lateral lumbar radiography. Echocardiography was used to assess aortic valve calcification (AVC) calcification. Patient’s basic clinical and biochemical data were recorded. Serum sclerostin level was measured using commercially available enzyme-linked immunosorbent assay kits.ResultsSclerostin levels among the patients with CKD on HD (116.8±0.103.69 Pmol/l) was significantly higher than that of CKD predialysis group (28.63±0.36.26 Pmol/l), which in turn was statistically higher than control group (6.6±0.2.9 Pmol) (P=0.000). AAC was observed in 16 (40%) patients in CKD predialysis group, whereas in CKD on HD group, 26 (65%) patients had AAC. AVC was observed in 14 (35%) patients in CKD predialysis group, whereas in CKD on HD group, 21 (52.5%) patients had AVC. Using binary regression analysis, sclerostin was identified as an independent predictor for the presence of AAC (OR: 1.017; P=0.000) and AVC (OR: 1.013; P=0.001) in patients with CKD.ConclusionPatients with CKD (predialysis and on HD) exhibit an increase in sclerostin levels. Sclerostin expansion correlated positively with vascular and valvular calcification. Sclerostin is an independent risk factor for heart valve calcification and AAC in patients with CKD.

Nondipping heart rate and associated factors in patients with chronic kidney disease.

Nondipping heart rate (NHR) is a condition reported to be associated with cardiovascular events and cardiovascular mortality recently. We aimed to search whether there is difference among hypertensive patients with and without chronic kidney disease (CKD) in terms of NHR pattern and the factors associated with NHR in patients with CKD. The study included 133 hypertensive patients with normal kidney functions, 97 hypertensive patients with predialysis CKD, and 31 hypertensive hemodialysis patients. Heart rate, blood pressure and pulse wave velocity (PWV) were measured by 24-h ambulatory blood pressure monitorization. NHR was defined as a decrease of less than 10% at night mean heart rate when compared with daytime values. NHR pattern was established as 26.3% in non-CKD hypertensive group, 43.3% in predialysis group and 77.4% in dialysis group. Among patients with CKD, when NHR group was compared with dipper heart rate group, it was seen that they were at older age, there were higher prevalence of diabetes mellitus and more female sex, and while the value of urea, creatinine, phosphorus, intact parathyroid hormone, and PWV were significantly higher, the value of hemoglobin, albumin and calcium were significantly lower. By multivariate analysis, hemoglobin [odds ratio (OR) 0.661; 95% CI 0.541-0.806; p < 0.001] and PWV (OR 1.433; 95% CI 1.107-1.853; p = 0.006) were established as independent determinants of NHR pattern. NHR pattern is significantly more frequently seen in hypertensive CKD patients than in hypertensive patients with non-CKD. Anemia and increased arterial stiffness are seen independently associated with NHR in CKD patients.

The cartonectin levels at different stages of chronic kidney disease and related factors

Introduction: Cartonectin was defined as a new adipokine released from rat and human adipocyte tissues, which is also known as CORS 26 or CTRP3 protein. Although there are several studies investigating the effects of cartonectin with obesity, anti-inflammatory mechanisms, and cardioprotective effects, there is no study about the effects of cartonectin in patients with chronic kidney disease yet. We aimed to investigate cartonectin levels in predialysis and dialysis patient groups, in other words, at different stages of chronic kidney disease, by comparing with the control group. In addition, we aimed to discuss the probable causes of the differences between the patient groups that would be determined, together with the factors that might be effective.Methods: A total of 150 patients, including 47 hemodialysis patients, 73 predialysis CKD patients, and 30 healthy individuals were enrolled in the study. Serum cartonectin levels were determined by using enzyme-linked immunosorbent assay (ELISA) method.Findings: Serum cartonectin levels were found to be significantly higher in the hemodialysis patient group compared to predialysis group and healthy individuals (p < 0.01). Furthermore, serum cartonectin levels were found to be negatively correlated with GFR, BMI, glucose, LDL, and platelet levels, whereas a positive correlation was observed with creatinine levels.Discussion: In our study, we found that the cartonectin levels increased as GFR decreased and were significantly higher in hemodialysis patients. Cartonectin is structurally closely related to adiponectin. It is remarkable that the level of cartonectin is also high in hemodialysis patients, like adiponectin.

Role of Lung Ultrasound in Adjusting Ultrafiltration Volume in Hemodialysis Patients

Chronic fluid over-hydration is common in dialysis patients. It is associated with mortality and cardiovascular events. Optimal methods for adjusting fluid volume status and ideal dry weight remain uncertain. The purpose of this study was to evaluate the usefulness of ultrasound in quantifying body water. In 35 hemodialysis patients, we performed ultrasound of the chest, pre-tibial skin tissue thickness (TT), heart and inferior vena cava (IVC) before and after dialysis. We compared B-line scores of lungs, IVC diameters and cardiac functions in pre-dialysis and post-dialysis groups. We then estimated the correlations between ultrasound parameters and ultrafiltration volumes. Ultrafiltration parameters were adjusted prospectively for subsequent dialysis. As a result, both extravascular and intravascular water decreased during ultrafiltration. The median numbers of B-line scores (10 [0–42] vs. 4 [0–30]; p < 0.001); mitral valve blood flow velocities E (0.83 ± 0.23 m/s vs. 0.70 ± 0.20 m/s; p < 0.001), A (0.93 ± 0.28 vs. 0.89 ± 0.23 m/s; p < 0.001) and E/e' (12.47 ± 4.92 vs. 10.37 ± 4.0; p < 0.001); IVC diameters at end-expiration (17.51 ± 3.33 mm vs. 14.26 ± 3.45 mm; p < 0.001); and right pre-tibial TT (2.86 ± 1.36 mm vs. 2.43 ± 1.24 mm; p < 0.001) decreased during dialysis. Ultrafiltration volume was most associated with B-line score (adjusting for age and sex) (β = –3.340; p = 0.003). In addition, the B-line score after dialysis was significantly associated with left ventricular ejection fraction (r = –0.393; p = 0.019) and TT (r = –0.447; p = 0.007). Ultrafiltration volume was prospectively increased then if the B-line score was >6 in the previous dialysis. All patients tolerated the protocol well without any symptoms. Ultrafiltration volume was most associated with lung water, reflected by variation in B-line score. It was not associated with cardiac function, IVC diameter, IVC collapse rate or TT. Lung ultrasound is a useful imaging tool for dialysis patients.

Mitral valve velocity time integral and passive leg raise as a measure of volume responsiveness

BackgroundFluid responsiveness is an important topic for clinicians. Aggressive hydration has been shown to lead to worse outcomes. The aim of this study was to investigate the sensitivity and specificity of mitral valve (MV) velocity time integral (VTI) as a non-invasive marker of volume responsiveness.MethodsThis was a prospective observational study conducted in a tertiary emergency department. End-stage renal disease patients presenting to the emergency department requiring emergent hemodialysis were enrolled. A focused echocardiogram was done on enrolled patients. Two sets of measurements were obtained before and after hemodialysis. During each scanning session, the left ventricular outflow tract and the mitral valve VTI were obtained before and after a passive leg raise maneuver.Results54 patients were enrolled, of which, 30 (55%) were male. The mean age was 47.4 years. The mean volume of fluid removed was 3.89 ± 0.91 L. All patients had a diagnosis of hypertension, 22 (41%) patients were diabetic, 14 (26%) patients had coronary artery disease, and 19 (35%) patients had congestive heart failure. The mean change in LVOT VTI was 1.83% (95% CI 0.12–3.55) in the pre-dialysis group and 15.05% (95% CI 12.76–17.34) in the post-hemodialysis cohort. The mean change in MV VTI was 3.74% (95% CI 2.84–4.65) in the pre-dialysis cohort and 12.95% (95% CI 11.50–14.39) in the post-dialysis cohort. For patients who had < 4 L removed, the mean delta LVOT VTI post-hemodialysis was 12.64% (95% CI 9.79–15.49) and the mean delta MV VTI was 10.48% (95% CI 8.28–12.69). For patients who had > 4 L removed, the mean delta LVOT VTI was 16.84% (95% CI 13.47–20.22) and the mean MV VTI was 14.77% (95% CI 13.03–16.51). Mitral valve VTI with PLR was found to have a sensitivity of 89.18% and a specificity of 94.11% in detecting volume responsiveness.ConclusionMitral valve velocity time integral in conjunction with passive leg raise seem to correlate with volume responsiveness in hemodialysis patients.

Prognostic value of pre-dialysis blood pressure and risk threshold on clinical outcomes in hemodialysis patients: The Q-Cohort Study.

The influence of pre-dialysis blood pressure (BP) on the prognosis of hemodialysis (HD) patients is still inconclusive.A total of 3436 HD patients were prospectively followed up for 4 years. The patients were divided into quintiles of pre-dialysis systolic BP (SBP) and diastolic BP (DBP) levels [mm Hg]: Quintile 1 (Q1), SBP <134, DBP <66; Q2, SBP 134 to 147, DBP 66 to 72; Q3, SBP 148 to 158, DBP 73 to 79; Q4, SBP 159 to 171, DBP 80 to 85; Q5, SBP ≥172, DBP ≥86. The association between the pre-dialysis BP and outcomes were examined using a Cox proportional hazards model.During a 4-year follow-up period, 564 (16.4%) patients died of any cause and 590 (17.2%) developed cardiovascular (CV) events. The lowest level of pre-dialysis SBP group (Q1) showed a significantly increased risk of all-cause mortality (hazard ratio [HR] 1.83, 95% confidence interval [CI] 1.40–2.39) and the highest group (Q5) significantly increased risk of CV events (HR 1.31, 95% CI 1.02–1.68) compared with the reference group (Q3), respectively. The highest level of pre-dialysis DBP group was significantly associated with increased risk for both all-cause mortality and CV events. Restricted cubic spline analysis for BP and outcomes suggested the optimal pre-dialysis BP value associated with the lowest risk of outcomes was SBP 152 mm Hg for all-cause mortality, SBP 143 mm Hg for CV events, and DBP 68 mm Hg for all-cause mortality.Our results suggested that pre-dialysis BP was independently associated with all-cause mortality and CV events among Japanese HD patients.

Bedside Echocardiography and Passive Leg Raise as a Measure of Volume Responsiveness in the Emergency Department.

The aim of this study was to investigate the value of bedside echocardiography with a passive leg raise as a noninvasive marker of volume responsiveness. This work was a prospective observational study of patients with end-stage renal disease presenting to the emergency department. The left ventricular outflow tract (LVOT) velocity time integral (VTI) was obtained. Measurements before and after dialysis as well as before and after the passive leg raise were recorded. Fifty-four patients were enrolled, in whom the mean volume of fluid removed ± SD was 3.89 ± 0.91 L. In the predialysis cohort, the mean LVOT VTI was 28.05 cm (95% confidence interval [CI], 26.55-29.55 cm). After the passive leg raise, the mean VTI was 28.52 cm (95% CI, 26.98-30.07 cm). In the postdialysis cohort, the mean VTI was 30.31 cm (95% CI, 28.92-31.69 cm), and it increased to 34.91 cm (95% CI, 33.11-36.72 cm) after the passive leg raise. The Δ VTI values were 1.83% (95% CI, 0.12%-3.55%) in the predialysis group and 15.05% (95% CI, 12.76%-17.34%) in the postdialysis cohort. When stratified by fluid removal, the mean Δ VTI values after hemodialysis were 12.64% (95% CI, 9.79%-15.49%) and 16.84% (95% CI, 13.47%-20.22%) for patients who had less than 4 L and 4 L or greater removed, respectively. In patients without congestive heart failure, the Δ VTI was 15.28% (95% CI, 12.25%-18.32%), whereas for those with congestive heart failure, the mean change was 14.63% (95% CI, 10.91%-18.35%). The LVOT VTI in conjunction with a passive leg raise seems to correlate with the volume status and volume responsiveness.

Sofosbuvir with NS5A inhibitors in hepatitis C virus infection with severe renal insufficiency

Treatment of Hepatitis C virus (HCV) in patients with severe renal insufficiency is cumbersome as sofosbuvir is mainly excreted by the kidneys. There is paucity of data on the use of sofosbuvir and NS5A inhibitors in these patients. We hereby report our experience of treating chronic hepatitis C in patients with severe renal insufficiency with full dose sofosbuvir and NS5A inhibitors. Forty-seven patients with severe renal insufficiency (on dialysis n=39, predialysis n=8) with HCV infection were treated between December 2015-August 2017 with full dose sofosbuvir with ledipasvir or daclatasvir for 12/24weeks depending on the genotype and the presence or absence of cirrhosis. The distribution of HCV genotype was genotype 1 in 32 (68.1%), genotype 3 in 13 (27.7%) and 4 in 2 (4.3%) patients. Among 12 (25.5%) patients with cirrhosis, 7 (14.9%) were decompensated with ascites. All patients had end of treatment response, and sustained viral response at 12weeks was achieved in 45 (95.7%) patients. There was significant improvement in liver stiffness at 3months after treatment (8.8 (3.8-42) to 7.1 (3.3-24.1)kPa; (P=0.047)). There was no change in haemoglobin and eGFR with treatment in predialysis group (haemoglobin- 10.2±1.5g/dL vs 9.6±1.3g/dL, P=0.44; eGFR- 19.8±9.4mL/min vs 17.9±8.5mL/min, P=0.67). Therapy was very well accepted. Full dose sofosbuvir with NS5A inhibitors is a well tolerated and effective therapy for HCV infection in severe renal insufficiency.