Pralatrexate in Combination with Bortezomib for Relapsed or Refractory Peripheral T Cell Lymphoma in 5 Elderly Patients

Peripheral T cell lymphoma (PTCL) is a heterogeneous group of aggressive lymphomas with poor prognosis. Elderly (age ≥ 65years) patients generally have impaired bone marrow function, altered drug metabolism, comorbidities, and poor functional status. Thus, treatment of elderly patients with relapsed or refractory PTCL remains a challenge for clinicians. A recent study disclosed that pralatrexate has a synergistic effect in combination with bortezomib. Weekly pralatrexate and bortezomib were administered intravenously for 3 weeks in a 4-week cycle. Of 5 patients, one achieved complete response after 4 cycles which has lasted 12 months until now. Another patient attained partial response after 2 cycles. Only 1 patient experienced grade 3 thrombocytopenia and neutropenia. Two patients suffered from grade 3 mucositis. Combination therapy with pralatrexate and bortezomib may be used as a salvage therapy for relapsed or refractory PTCL in the elderly with a favorable safety profile.

Salvage chemotherapy with R-BAD (rituximab, bendamustine, cytarabine, and dexamethasone) for the treatment of relapsed primary CNS lymphoma

No abstract available.

Oliguria as an early indicator of mortality risk in patients with multiple myeloma and renal impairment

BACKGROUND: A change in urine output has been recently recognized as a valuable biomarker of acute kidney injury that is associated with mortality in critically ill patients. We investigated the prognostic impact of oliguria for survival outcomes in multiple myeloma (MM) patients presenting with renal impairment (RI). METHODS: Retrospective data on 98 patients with MM and RI, who received initial treatment with novel therapies, were analyzed. Oliguria was defined as a urine output of <0.5 mL/kg/h. RESULTS: The baseline median eGFR was 39.7 mL/min (range, 5.1-59.8). Achievement of renal complete response (CR) was observed in 39.8% of patients. Nine patients (9.2%) presented with oliguria at initial diagnosis, and 4 initially required dialysis. Over a median follow-up period of 17.1 months (range, 1.7-100.0), the median overall survival (OS) was 38.7 months (95% CI 25.0-52.5). Multivariate analyses indicated that oliguria at diagnosis [hazard ratio (HR) 3.628, 95% CI 1.366-9.849, P=0.011], and thrombocytopenia <100x10(9)/L at diagnosis (HR 2.534, 95% CI 1.068-6.015, P=0.035), were significantly associated with overall survival. CONCLUSION: Oliguria was significantly associated with higher mortality in MM patients with RI. Therefore, close monitoring of urine output could be important for these patients.

A Case of Hemolytic Uremic Syndrome Caused by Escherichia coli O104:H4

A 29-year-old woman presented with bloody diarrhea, abdominal pain, hemolytic anemia, thrombocytopenia, and acute renal failure. She was diagnosed with Escherichia coli O104:H4-associated hemolytic-uremic syndrome (HUS) and treated with plasmapheresis and hemodialysis for 3 weeks. She recovered without sequelae. To the best of our knowledge, this is the first report of Escherichia coli O104:H4-associated HUS in Korea. We recommend that Escherichia coli O104:H4, as well as the more common O157:H7, be considered in the diagnosis of bloody diarrhea-associated HUS.

Diagnostic Noninvasive Tests for Coronary Artery Disease in Chronic Renal Failure Patients / 대한신장학회잡지

BACKGROUND: As ischemic heart disease is the major cause of death in chronic renal failure patients, screening tests are clinically important. Although coronary angiography is considered the gold standard for the diagnosis of coronary artery disease, other noninvasive tests are usually used to avoid this potentially dangerous and costly procedure. METHODS: We retrospectively determined the sensitivity, specificity, and positive and negative predictive values for electrocardiography, echocardiography, cardiac enzyme determination, and Technetium 99m tetrofosmin (TF) single photon emission computed tomography (SPECT) in 61 chronic renal failure patients who underwent coronary angiography. RESULTS: Nineteen patients (31.1%) were undergoing chronic hemodialysis, seven patients (11.4%) were undergoing peritoneal dialysis, and thirty five patients (57.3%) were undergoing conservative treatment. 99mTc SPECT had a sensitivity of 96% and specificity of 19%. Although echocardiography and tronponin-T had a relatively lower sensitivity of 69 % and 56% than 99mTc SPECT, they had a higher specificity of 63% and 63%, respectively. 99mTc SPECT had the highest sensitivity of 88% and echocardiography had the highest specificity of 78% in renal replacement group. 99mTc SPECT had the highest sensitivity of 100% and Troponin T had the highest specificity of 71% in conservative treatment group. CONCLUSION: Noninvasive test for coronary artery disease in patients with chronic renal failure, especially 99mTc SPECT is of limited value because of their low specificity, so echocardiography and troponin T may helpful for diagnosing coronary artery disease.

Changes in serum and dialysate levels of Cancer Antigen 125 (CA125) in continuous ambulatory peritoneal dialysis patients / 대한내과학회지

BACKGROUND: Peritoneal mesothelial cells are the most important intraperitoneal cells quantitatively and have the capability to secret different types of substances. It may therefore be essential to have information on the mesothelial cell mass during peritoneal dialysis. Cancer Antigen 125 (CA125) is a 22KDa glycoprotein which is a clinically useful tumor marker of non-mucinous epithelial ovarian carcinoma. Recently, other cells including pleural and peritoneal mesothelial cell have been proved to express CA125. This study was undertaken to determine whether CA125 can be used as a marker of mesothelial cell mass in clinically stable 39 CAPD patients. METHODS: We checked serum and peritoneal dialysate CA125 level, D/P creatinine and D/Do glucose after 4 hours dwell in 39 stable continuous ambulatory CAPD patients. RESULTS: No statistically significant correlation was seen among the patient's age, sex, serum and dialysate levels of CA125. The dialysate CA125 levels correlated with the duration of CAPD, negatively (r=-0.345, p=0.039) and a significant positive correlation was seen between the duration of CAPD and D/Do glucose at 4 hours (r=0.523, p=0.001). But there were not a correlation between the dialysate CA125 levels and D/P creatinine after 4 hours dwell nor between the dialysate CA125 levels and D/Do glucose after 4 hours dwell. CONCLUSION: Although the duration of CAPD affects CA125 levels in dialysate, no specific alteration in peritoneal membrance transport properties can be detected or predicted by changes in dialysate concentration of CA125. However longitudinal follow-up of changes in concentration of dialysate CA125 may be useful in evaluating mesothelial cell mass in stable CAPD patients.Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea.

Splenic Abscess Associated with Endocarditis in a Patient on Hemodialysis: A Case Report

Splenic abscess is an unusual condition usually seen in immunocompromised patients or associated with intravenous drug abuses. Several conditions including trauma, immunodeficiency, corticosteroid and/or immunosuppressive therapy and diabetes mellitus have been listed under the predisposing factors for a splenic abscess. Splenic abscess in a patient on hemodialysis is a rare but life-threatening condition if not corrected. We describe a case of splenic abscess with bacterial endocarditis on maintenance hemodialysis. He had staphylococcal septicemia secondary to bacterial endocarditis at the mitral valve from the dialysis accesssite infection. Although hematologic seeding from endocarditis has been the predisposing factor for splenic abscess, we postulate that access-site infections may predispose hemodialysis patients to splenic abscess. Splenic abscess may be considered as one of the causes when patients on hemodialysis develop unexplained fever.

SIADH Associated with Guillain-Barre Syndrome / 대한신장학회잡지

The most common cause of hyponatremia in hospitalized patients is syndrome of inappropriate antidiuretic hormone secretion (SIADH) characterized by water retention leading to decreased serum sodium concentration and osmolality. Since the report of Schwartz and his co-workers1), this syndrome has been described in various clinical settings. There are some reports on SIADH associated with Guillain-Barre syndrome in the literature2-6). However, to our knowledge, there was only one reported case of SIADH associated with Guillain-Barre syndrome in Korea

Usefulness of Assessing Hemodialysis Adequacy Using the Stop Dialysate Flow (SDF) Method / 대한신장학회잡지

BACKGROUND: K/DOQI guidelines recommend the slow flow method as a standardized method of postdialysis blood sampling for measuring hemodialysis adequacy. However, it is not easy to adopt this method when working in busy renal units where it is often difficult to obtain repeated samples exactly at the specified time. The stop dialysis flow (SDF) method recommended by the Scottish Renal Association since 1998 has the advantage of involving 2 steps only: (1) switch off dialysate flow at the end of hemodialysis without altering the blood pump speed and (2) take a blood sample after 5 minutes from the arterial or venous port. However, there are some limitations to SDF mthod in that it does not allow for tissue rebound after the first 5 minutes postdialysis and cannot be used directly to calculate equilibrated Kt/V (Kt/Veq) using either a 30-minute postdialysis sample. We derived a formula that uses a 5-minute postdialysis BUN sample using the SDF method to estimate the BUN concentration at 30 minutes and investigated if it is useful to assess hemodialysis adequacy using this method. METHODS: A total of 51 patients who had been undergoing hemodialysis in Chonnam National University Hospital and had agreed in joining this study were involved. Patients were randomly selected to 2 groups. Blood samples were obtained immediately before dialysis and at 0, 5, and 30 minutes postdialysis. We calculated the linear relationship between the 5-minute and 30-minute postdialysis samples in group A patients (n=25) and validated this equation using the data from the other group B patients (n= 26). We predicted what the 30-minute BUN concentration would be using the measured value of BUN at 5 minutes and compared directly the value of our estimated 30-minute BUN with the measured 30- minute BUN. RESULTS: There was a tight linear correlation (R2=0.993, p<0.05), between measured 5-minute postdialysis BUN concentrations and measured 30-minute postdialysis BUN concentrations in group A patients. This relationship is described by the linear regression equation: 30-minute BUN concentration=1.05x(5-minute BUN concentraion)+1.04. We used this equation to estimate the 30-minute BUN concentration in group B patients based on the 5-minute postdialysis BUN sample from these patients. And there was a close correlation between estimated and measured 30-minute postdialysis BUN concentration (R2= 0.989, p<0.05). The sensitivity, specificity, positive, and negative predictive values of this equation were high when used to estimate 30-minute urea reduction ratio (URR) greater than 65% (88.9%, 100%, 100 %, and 94.4%, respectively) and 30-minute Kt/Vsp greater than 1.2 (100%, 100%, 100%, 100%, respectively). CONCLUSION: We could estimate 30-minute postdialysis BUN concentration, 30-minute Kt/V, and 30-minute URR exactly using SDF method and linear regression equation derived in this study. The advantage of involving 2 steps only makes SDF method a useful tool in assessing hemodialysis adequacy.

Relationship between the Serum Parathyroid Hormone and Magnesium Levels in Continuous Ambulatory Peritoneal Dialysis (CAPD) Patients using Low-magnesium Peritoneal Dialysate

BACKGROUND: Patients on continuous ambulatory peritoneal dialysis (CAPD) have increased risk of low-turnover bone disease and relative hypoparathyroidism. Recently, it has been believed that magnesium plays an important role in regulating secretion of parathyroid hormone (PTH). The aim of this study was to evaluate the relationship between serum PTH and serum magnesium as a factor increasing the frequency of relative hypoparathyroidism. METHODS: We analyzed the data of 56 patients who had been on CAPD for more than 6 months without any significant problems. No patient had been previously treated with vitamin D or aluminum hydroxide. The patients had used peritoneal dialysate with the magnesium concentration of 0.5 mEq/L. Biochemical parameters, such as BUN, creatinine, alkaline phosphatase bony isoenzyme, total protein, albumin, total calcium, ionized calcium and intact parathyroid hormone level were measured. RESULTS: The mean serum magnesium level was 1.99 +/- 0.36 mEq/L. Among total 56 patients, 15 patients (26.8%) showed hypermagnesemia (serum magnesium > 2.2 mEq/L) and 5 patients (8.9%) showed hypomagnesemia (serum magnesium < 1.6 mEq/L). Among all 56 patients, serum iPTH (intact PTH) level was not correlated with serum magnesium level. However, it was inversely correlated with serum total calcium and ionized calcium levels, respectively (r=-0.365, p=0.006; r=-0.515 p < 0.001). Among 49 patients whose serum iPTH level was less than 300 pg/mL, serum iPTH level was inversely correlated with serum magnesium level (r=-0.295, p=0.039) and inversely correlated with serum total calcium and ionized calcium levels, respectively (r=-0.546, p < 0.001; r=-0.572 p < 0.001). Among 49 patients whose serum iPTH level was less than 300 pg/mL, lower iPTH group (serum iPTH < 120 pg/mL) showed higher serum magnesium level (p=0.037), higher serum total calcium level (p < 0.001) and lower bone isoenzyme of alkaline phosphatase level (p < 0.001) than those of higher iPTH group (120 pg/mL

Serum homocysteine concentration in kidney transplant recipients / 대한내과학회지

BACKGROUND: Cardiovascular disease (CVD) after kidney transplantation is a major cause of both graft loss and patient death in kidney transplant recipeints. There are several well known risk factors of CVD, such as hyperlipidemia, hypertension, diabetes melitus, old age and smoking. Non-classic risk factors are acute rejection episode, LVH, C-reactive protein and hyperhomocysteinemia. Homocysteine is an amino acid filtered through the glomerulus and hyperhomocysteinemia is considered as a risk factor of CVD in end-stage renal disease (ESRD) and kidney transplant patients. So homocysteine lowering trials, such as folic acid and vitamine supplement therapy, are being made. We evaluated the prevelance and determinants of hyperhomocysteinemia in kidney transplant recipients. METHODS: We measured serum total homocysteine concentration (tHcy) and its determinants in 21 normal persons, 37 chronic renal failure (CRF) patients with conservative treatment (predialysis) and 48 kidney transplant patients. RESULTS: The prevalence of hyperhomocysteinemia was 4.8%, 83.8% and 45.8% among normal persons, predialysis and kidney tranplant patients, respectively. Among the kidney transplant recipients the prevelence of hyperhomocysteinemia was 18.8% in normal renal function (serum creatitine concentration male: below 1.2 mg/dL, female: below 1.1 mg/dL) group and 59.4% in abnormal renal function group. The tHcy values in kidney transplant patients are significantly lower than those in predialysis patients (16.38+/-6.48 nmol/L vs. 24.68+/-9.01 nmol/L, p < 0.01), but higher than those in normal persons (16.38+/-6.48 nmol/L vs. 8.80+/-2.07 nmol/L, p < 0.01). Among the kidney transplant recipients the tHcy values in normal creatinine group are significantly lower than those in abnormal creatinine group (12.02+/-3.68 nmol/L vs. 18.57+/-6.51 nmol/L, p < 0.01). Using muliple regression analysis, this study showed increased serum creatinine concentration is a major determinant of tHcy concentrations in kidney transplant recipients and hyperhomocysteinemia is not correlated with whole blood trough level of cyclosporin (mean 126.26+/-62.19 ng/mL, range: 26~322 ng/mL) or vitamines supplement therapy. CONCLUSION: In this study the serum homocysteine values in kidney transplant recipients were higher than in normal control group but significantly lower than in CRF patients with conservative treatment. The major determinant for serum homocysteine concentration is a serum creatinine concentration.

The Efficacy and Safety of Intravenous Iron Sucrose in Hemodialysis Patients / 대한신장학회잡지

BACKGROUND: The objective of the present study was to assess the efficacy and safety of iron sucrose by determining the subsequent change in hemoglobin (Hgb), hematocrit (Hct), transferrin saturation (TAST), serum ferritin values and blood pressures in hemodialysis patients receiving Epoetin. METHODS: A total of 19 adult patients who had been receiving hemodialysis three times a week at Chonnam Natinal University Hospital were assigned. Their Hgb level was less than 10 g/dL and their serum ferritin level was less than 100 ng/mL, and/or TSAT was less than 20%. Iron sucrose was administered as 1,000 mg in 10 divided doses diluted in 100 mL normal saline over the last 60 minutes during hemodialysis with a one-time prior test dose of 20 mg on 10 consecutive dialysis sessions. Iron sucrose dosage was adjusted to 25-100 mg/week depending on serum ferritin level, and TSAT in the following 3 months. Epoetin administration was stopped due to insurance regulation when Hgb level was more than 10 g/dL and Hct level was more than 30 %. To evaluate efficacy of iron sucrose, assessment of serum iron parameters and anemia indices was determined just before the first dose (baseline), at 1 month after the first dose (loading) and then, monthly for 3 months (maintenance). To evaluate safety of iron sucrose, we recorded blood pressure 1 hour before and at the time of completion of iron sucrose injection, and also recorded blood pressure during observation sessions before dialysis and at intervals of 2 hours and 4 hours after starting dialysis. We determined routine serum chemistry and hematologic results at 1 month after the first dose and compared results with those obtained at baseline. RESULTS: 1,000 mg iron surcose injection in 10 divided dose (loading) produced a significant rise in Hgb, Hct, serum iron, serum ferritin, TSAT, MCV and MCH at 1 month after first dose (respectively p<0.001, p<0.001, p<0.01, p<0.001, p<0.01, p<0.01, p< 0.01). During the following maintenance period of 3 months, Hgb, Hct, serrum ferritin, and TSAT level remained more elevated than at baseline respectively. In 19 enrolled patients, we experienced no serious adverse drug reactions and no significant changes in intradialytic blood pressure associated with iron sucrose administration. Serum albumin concentrations was higher at 1 month than at base line and however, changes in other serum chemistry and hematologic results were not statistically significant. CONCLUSION: Intravenous iron sucrose administration is an efficient and safe method to supply iron in end-stage renal disease patients receiving Epoetin with iron deficiency, who are undergoing hemodialysis.

Relationship between the serum parathyroid hormone and magnesium levels in continuous ambulatory peritoneal dialysis (CAPD) patients using low-magnesium peritoneal dialysate / 대한내과학회지

BACKGROUND: One of the most common complications in patients with end stage renal disease is renal osteodystrophy and parathyroid hormone (PTH) plays a key role in the pathogenesis of renal osteodystrophy. It is known that patients undergoing CAPD (continuous ambulatory peritoneal dialysis) have increased risk of low turnover bone disease and relative hypoparathyroidism is related to its pathogenesis. Factors related to relative hypoparathyroidism are increased in extracellular calcium level, accumulation of aluminum, vitamin D treatment, good control of serum phosphate, diabetes mellitus, and old age. Recently it has been believed that magnesium plays an important role in regulating secretion of PTH. The aim of this study was to evaluate the relationship between serum PTH and serum magnesium as a factor increasing the frequency of relative hypoparathyroidism. METHODS: Author studied 56 patients who had undergone CAPD for more than 6 months without any significant problems and had been followed by Chonnam National University Hospital. No patient had been previously treated with vitamin D or aluminum hydroxide. The patients had used peritoneal dialysate with the magnesium concentration of 0.5 mEq/L. Biochemical parameters were checked. RESULTS: 1. The mean serum magnesium level was 1.99+/-0.36 mEq/L. Among total 56 patients, 15 patients (26.8%) showed hypermagnesemia (serum magnesium > 2.2 mEq/L), and 5 patients (8.9%) showed hypomagnesemia (serum magnesium < 1.6 mEq/L)2. On all 56 patients, serum iPTH level was not correlated with serum magnesium level. But, it was inversely correlated with serum total calcium and ionized calcium levels, respectively (r=-0.365, p=0.006; r=-0.515 p<0.001).3. Among the 49 patients whose serum iPTH level was less than 300 pg/mL, serum iPTH level was inversely correlated with serum magnesium level (r=-0.295, p=0.039), and inversely correlated with serum total calcium and ionized calcium levels, respectively (r=-0.546, p<0.001; r=-0.572 p<0.001).4. Among the 49 patients whose serum iPTH level was less than 300 pg/mL, lower iPTH group (serum iPTH<120 pg/mL) showed higher serum magnesium level (p=0.037), higher serum total calcium level (p<0.001), and lower bone isoenzyme of alkaline phosphatase level (p<0.001) than those of higher iPTH group (120 pg/mL serum< or =iPTH<300 pg/mL). CONCLUSION: Among the CAPD patients whose serum iPTH level was less than 300 pg/mL, there was a significantly inverse correlation between serum iPTH level and serum magnesium level. This study indicates that not only serum calcium level, but also serum magnesium level are important in the regulation of serum iPTH levels of CAPD patients who have been dialyzed by low-magnesium peritoneal dialysate.

Dialysis Adequacy and Nutritional Status in Patients with Continuous Ambulatory Peritoneal Dialysis(CAPD) / 대한신장학회잡지

PURPOSE: Malnutrition is common in CAPD patients and depends on many factors such as dialysis-related and nondialysis-related factors. The present study aimed to assess nutritional status, dialysis adequacy and their relationships with overall mortality and morbidity. METHODS: We studied 102 patients who had been receiving CAPD for at least 6 months. Dialysis adequacy was assessed by parameters derived from urea kinetic modeling(UKM) and nutritional status was assessed by serum biochemical measurement, normalized protein catabolic rate(nPCR), normalized protein equvalent of total nitrogen appearance(nPNA) and urea kinetic studies. Spearman's simple correlation and multiple linear stepwise regression analysis were used to assess correlation between dialysis adequacy and nutritional status in CAPD patients. We compared the differences between patients who suf fered morbid events, defined as either an infectious complication or hospitalization, and patients who remained well. RESULTS: The results showed that the total dialysis dose(total weekly Kt/Vurea) has statistically significant correlation with nPCR(r=0.234, p=0.028), nPNA (r=0.246, p=0.021), total weekly creatinine clearance (WCC)(r=0.479, p=0.0001), serum albumin levels(r= 0.233, p=0.029), serum cholesterol(r=0.266, p=0.013), serum BUN(r=-0.290, p=0.006) and serum creatinine levels(r=-0.408, p=0.0001). nPNA was positively correlated with serum cholesterol(r=0.217, p=0.045), serum transferrin(r=0.218, p=0.042) and serum ferritin levels(r=0.220, p=0.043). Patients who suffered morbid events had an old age(p=0.001), long duration of CAPD(p=0.0001), higher CRP(p=0.021), lower serum albumin level(p=0.020), lower hematocrit(p=0.049) and lower WCC(p=0.017). Conclusions : These results indicate that adequate dialysis is very important for the maintenance of adequant nutrition because nutritional status positively correlated with dialysis dose, which is best assessed by UKM. In addition, assessment of nutritional status and dialysis adequacy are important in predicting clinical outcomes in CAPD patients.

Hyperhomocysteinemia in Patients with Chronic Renal Failure / 대한신장학회잡지

OBJEVTIVE: It has been reported that hyperhomocysteinemia is an independent risk factor for atherosclerotic complications, although the mechanisms remain unclear. The major determinents of total fasting plasma homocysteine(tHcy) concentrations have been recently reported but there are still conflicting data on the influence of those in peritoneal and hemodialysis patients. Therefore, we evaluated the prevalence and association of vascular complications and the determinents of hyperhomocysteinemia in chronic renal failure patients receiving conservative treatment(predialysis), peritoneal dialysis(PD) and hemodia- lysis (HD) patients. METHODS: We measured the factors, including fasting plasma vitamine levels(folate, vitamin B6 and vitamin B12), serum creatinine concentration, dialysis adequacy-related varibles as well as associated risk factors for vascular diseases that might affect tHcy concentrations in 37 predilysis, 30 PD, 34 HD patients and 21 normal persons. Continuous variables were compared using independent sample t-test. Spearman's correlation was used to determine the strength of association between tHcy and other predictive variables. Percentages were compared using Pearson's chi-square test or Fisher's exact test, depending on the frequencies. Independent determinents of tHcy concentration and atherosclerotic vascular complications were identified using multiple regression analysis. RESULTS: The prevalence of hyperhomocysteinemia was 83.8, 72, 88% among predialysis, PD and HD patients,respectively(Odds ratio was 103.33, 81.43, 150.0 vs. controls, respectively). tHcy values in predialysis, PD and HD patients are significantly higher than those in controls(24.68+/-9.01, 21.04+/-8.82, 23.62+/-9.46 vs. 8.80+/-2.07 mumoL/L, repectively, p<0.01). Predialysis, PD and HD patients with atherosclerotic vascular complications had higher tHcy concentrations than did predialysis, PD and HD patients without vascular complications(21.93+/-8.71 vs. 32.09+/-4.71 mumoL/L, p<0.01, 17.57+/-5.85 vs. 28.74+/-9.70 mumoL/L, p<0.01, 19.00+/-4.29 vs. 33.28+/-10.13, p<0.01 respectively). We also observed increasing odds ratios of vascular events with increasing tHcy concentrations. For predialysis, PD and HD patients, fasting plasma folate level had negative correlation with tHcy concentrations by spearman's simple correlaltion. And using muliple regression analysis, we recognized hyperhomocysteinemia is an independent risk factor for atherosclerosis and fasting plasma folate is a major determinent of tHcy concentrations in predialysis, PD and HD patients. CONCLUSIONS: Hyperhomocysteinemia in predialysis, PD and HD patients was more prevalent than that in normal controls. Risk of atherosclerotic vascular complications increased with increasing tHcy concentrations. Hyperhomocysteinemia is an independent risk factor for atherosclerosis and fasting plasma folate is a major determinent of tHcy concentrations in predialysis, PD and HD patients.