Effects of Coenzyme Q10 Supplementation on Exercise Performance and Markers of Oxidative Stress in Hemodialysis Patients: A Double-Blind Placebo-Controlled Crossover Trial.

Coenzyme Q10 (CoQ10) supplementation has been shown to decrease oxidative stress in a number of clinical settings. However, there are mixed results regarding the role of CoQ10 supplementation on exercise performance. Chronic kidney disease is recognized as an inflammatory state, and hemodialysis patients have low level of exercise performance. We aimed to evaluate the effect of CoQ10 supplementation on oxidative stress markers and exercise performance measures. This was a prospective, double-blind, placebo-controlled, crossover study in which all patients received placebo and oral CoQ10 200 mg/d. Participants underwent 6-minute walking test and cycle ergometer. Blood samples were drawn to determine malondialdehyde, oxidized low-density lipoprotein, superoxide dismutase, and glutathione peroxidase. Walking distance in 6-minute walking test and estimated maximal oxygen consumption (VO2max) were recorded. Twenty-eight patients were randomized, but 23 patients completed the study protocol. Serum CoQ10 level significantly increased with supplementation compared with basal values (P < 0.05). Neither walking distance nor estimated VO2max was different between the placebo and CoQ10 groups (P > 0.05). Serum malondialdehyde levels significantly increased in both groups compared with baseline values just after the exercise (P < 0.05). There was no difference in markers of oxidative stress and antioxidant system between placebo and CoQ10 supplementation with exercise (P > 0.05). The results of this study showed no significant effect of CoQ10 supplementation on exercise performance measures and oxidative system markers compared with placebo in maintenance hemodialysis patients.

Colchicine toxicity in end-stage renal disease patients: a case-control study.

Colchicine has been used in a number of disorders. Because colchicine is partially excreted from the kidney, there is a need for dose reduction in case of renal functional impairment. There are no data with regards to safe dosing schedule of colchicine in hemodialysis patients. We aimed to evaluate adverse effects of colchicine use in a hemodialysis cohort. We screened hemodialysis patients who were using colchicine for any reason. All patients were interviewed regarding possible toxicities of colchicine use and were examined with a special focus on neuromuscular system. Creatine kinase and myoglobin were used to detect any subclinical muscle injury or rhabdomyolysis, respectively. Twenty-two maintenance hemodialysis patients who were on colchicine for more than 6 months and 20 control hemodialysis patients not using colchicine were included in the study. Four of 22 patients were using 0.5 mg/day, 4 patients were using 1.5 mg/day, and 14 patients were using 1 mg/day colchicine. Mean duration for colchicine use was 8.9±8.2 years. There was no difference between the groups in terms of myoneuropathic signs and symptoms and blood counts except for white blood cell count, which was significantly higher in patients on colchicine. Serum creatine kinase (56.3±39.5 and 52.1±36.1 for colchicine and control groups, respectively, P=0.72) and myoglobin (191.4±108.8 and 214.6±83.5 for colchicine and control groups, respectively, P=0.44) levels were not different between the groups. We conclude that in a small number of haemodialysis patients who were apparently tolerating colchicine, detailed assessment revealed no evidence of sublinical toxicity when compared with controls.

Glomerulonephritis associated with tuberculosis: a case report and literature review.

Rapidly progressive glomerulonephritis caused mycobacterium tuberculosis is rare; however, three case have been reported to date. Crescentic glomerulonephritis is a life-threatening disease and together with the presence of tuberculous infection is associated with a poor outcome if treatment is inadequate and delayed. We describe the case of a 31-year-old female patient with nephrotic syndrome and progressive renal failure secondary to pulmonary tuberculosis. Renal biopsy showed crescent formation in 14 out of 27 glomeruli, and there was diffuse linear staining of immunoglobulin G deposits. Treatment included corticosteroids in combination with antituberculosis drugs for 2 months, and resulted in a significant improvement in renal function, the disappearance of proteinuria and pulmonary symptoms. We also present a review of the pertinent literature and discuss the pathophysiology of tuberculosis-related acute postinfectious glomerulonephritis.

Cross-over, open-label trial of the effects of gabapentin versus pregabalin on painful peripheral neuropathy and health-related quality of life in haemodialysis patients.

BACKGROUND: Painful peripheral neuropathy (PPN) is common in haemodialysis patients and associated with impaired health-related quality of life (HR-QoL). Gabapentin and pregabalin have not been fully investigated in haemodialysis patients. Therefore, we compared the effects of gabapentin and pregabalin on intensity of pain and associated HR-QoL in haemodialysis patients with PPN. METHODS: Gabapentin and pregabalin were administered after each haemodialysis session at doses of 300 and 75 mg, respectively. Patients were randomized into two groups; after 6 weeks patients underwent a 2-week washout and crossover and received another 6 weeks of treatment. All patients underwent electromyography at the outset. The short-form McGill pain questionnaire (SF-MPQ) for assessment of pain, and short-form medical outcomes study for assessment of HR-QoL at baseline and at the end of the study were applied. RESULTS: Forty patients completed the 14-week study period. Gabapentin and pregabalin significantly improved SF-MPQ total scores compared with pretreatment values (mean ± SD) [from 18.9 ± 4.3 to 9.3 ± 4.3 for gabapentin, p < 0.001, and from 18.5 ± 3.9 to 9.8 ± 3.6 for pregabalin, p < 0.001]. There was no significant difference between the study drugs in terms of efficacy against neuropathic pain (p > 0.05). Both gabapentin and pregabalin significantly improved HR-QoL at the end of the study compared with pretreatment scores (p < 0.001). CONCLUSION: Our results showed strong efficacy of gabapentin and pregabalin on pain intensity in the given doses. HR-QoL was also significantly improved by both drugs.

Coenzyme Q10 supplementation and diastolic heart functions in hemodialysis patients: a randomized double-blind placebo-controlled trial.

Coenzyme Q10 (CoQ10) supplementation has been shown to improve diastolic heart function in various patient cohorts. Systolic and diastolic dysfunctions are common in patients with end-stage renal disease. Favorable effects of CoQ10 on cardiac functions are yet to be seen in hemodialysis patients. We aimed to evaluate effect of CoQ10 supplementation on diastolic function in a cohort of maintenance hemodialysis patients. This was a prospective, double-blind, placebo-controlled, crossover study in which all patients received placebo and oral CoQ10 200 mg/d during the 8 weeks in each phase, with a 4-week washout period. Participants underwent conventional and tissue Doppler echocardiography before and after each study phase. Parameters characterizing left ventricle diastolic function and other standard echocardiographic measurements were recorded. Twenty-eight patients were randomized, but 22 patients completed study protocol. Intraventricular septum (IVS) thickness and left ventricle mass were significantly decreased in CoQ10 group (P = 0.03 and P = 0.01, respectively). Myocardial peak systolic and early diastolic velocities derived from IVS were significantly increased (P = 0.048 and P = 0.04, respectively). Isovolumetric relaxation time and E/Em ratio calculated for IVS also significantly reduced in CoQ10 group (p = 0.02 and p = 0.04, respectively). There was no significant difference in any of the studied echocardiographic parameters in placebo group. The results of this study showed that CoQ10 supplementation did not significantly improved diastolic heart functions compared with placebo in maintenance hemodialysis patients.

Gabapentin versus pregabalin in improving sleep quality and depression in hemodialysis patients with peripheral neuropathy: a randomized prospective crossover trial.

PURPOSE: In dialysis patients, painful peripheral neuropathy (PPN) is associated with sleep disturbance and mood disorders. Our goal was to compare the effects of gabapentin and pregabalin on improving sleep quality and depression among hemodialysis patients with PPN. METHODS: Fifty hemodialysis patients with PPN were randomized into 2 groups, to receive gabapentin and pregabalin, respectively. After 6 weeks of treatment, patients underwent a 2-week washout period, followed by crossover and another 6 weeks of treatment. All patients underwent electromyography (EMG) at the outset and completed the modified Short Form of McGill Pain Questionnaire (SF-MPQ), the Beck Depression Inventory (BDI) and the Pittsburgh Sleep Quality (PSQI) assessment at baseline and at the end of the study. Forty out of 50 patients completed the 14-week study period. RESULTS: Thirty-one out of 40 patients (77.5 %) had EMG-proven PPN. Both gabapentin and pregabalin significantly improved SF-MPQ, BDI and PSQI scores at the end of the study compared with pretreatment scores (p < 0.001). There was no significant difference between the two drugs in any studied parameter. CONCLUSIONS: Our results showed for the first time a good and similar efficacy of both drugs on pain intensity, quality of sleep and depression in hemodialysis patients with PPN.

Electrocardiographic P-wave characteristics in patients with end-stage renal disease: P-index and interatrial block.

PURPOSE: P-wave parameters including P-wave dispersion (P d) have been examined in general population to predict development of atrial fibrillation (AF). But data on end-stage renal disease (ESRD) population are limited. P index (Pi) and interatrial block (IAB) as novel parameters may more accurately predict AF and have not been previously investigated in ESRD patients. We aimed to evaluate these novel ECG parameters in ESRD patients. METHODS: Eighty-six HD, 47 CAPD, and 43 age- and gender-matched control subjects were enrolled in the study. P-wave duration was measured in all 12-leads of the surface ECG. The standard deviation of the P-wave duration across the 12 ECG leads was accepted as a Pi. P-wave duration above and equal to 110 ms was defined as IAB. All P-wave parameters were evaluated digitally by two observers. RESULTS: Pi was found to be significantly different among the groups in ANOVA. In post hoc analysis, P i was increased in HD group compared with the control group (p = 0.01). Also, P i tended to increase in CAPD group compared with controls (p = 0.06). The effect of ESRD on P i was independent of age, gender, and systolic blood pressure in univariate covariant analysis. The prevalence of IAB was 61, 55, and 32 % in patients with HD, CAPD, and controls, respectively (p = 0.001). P d was significantly higher in HD group compared with healthy controls. However, Pd values of CAPD patients did not show significant difference compared with controls. CONCLUSION: The present study demonstrated that IAB frequency and Pi were increased in patients with ESRD.

Pregabalin versus gabapentin in the treatment of neuropathic pruritus in maintenance haemodialysis patients: a prospective, crossover study.

AIM: Pruritus is common in dialysis patients. Peripheral neuropathy is also prevalent in this patient population. However, the role of neuropathy in the genesis of uraemic itch has not been adequately studied to date. Therefore, we aimed to investigate the effects of gabapentin and pregabalin on uraemic pruritus along with neuropathic pain in patients receiving haemodialysis. METHODS: This is a 14 week long randomized, prospective, cross-over trial. Haemodialysis patients with established neuropathy and/or neuropathic pain were included. Fifty patients were randomly assigned to gabapentin 300 mg after each haemodialysis session and pregabalin 75 mg daily. After 6 weeks of treatment, cross-over was performed and patients received the other drug for another 6 weeks. Short Form of McGill Pain Questionnaire and Visual Analogue Scale were used to evaluate pain and pruritus, respectively. At each week's visit, patients were interrogated in terms of adverse effects of study drugs. Baseline laboratory data and demographic characteristics were recorded from patient charts. RESULTS: Forty (12 males, 28 females) out of 50 patients completed the study. Mean age was 58.2 ± 13.7. Overall, 29 out of 40 patients (72.5%) had pruritus symptoms at baseline evaluation. Fifteen patients (37.5%) were diabetic. Thirty-one out of 40 patients (77.5%) had electromyography (EMG)-proven peripheral neuropathy. Twenty three patients (57.5%) had both EMG-proven neuropathy and pruritus. Gabapentin and pregabalin improved both neuropathic pain and pruritus significantly. There was no difference between the study drugs in terms of efficacy against pain and pruritus. CONCLUSION: Treatment of neuropathic pain with either pregabalin or gabapentin effectively ameliorates uraemic itch.

Poor quality of life is associated with increased mortality in maintenance hemodialysis patients: a prospective cohort study.

Despite all developments in hemodialysis (HD), the mortality rate is still apparently higher than that in the general population, and worse health-related quality of life (HRQOL) is associated with increased mortality. We prospectively investigated the mortality status of HD patients during a five-year period and the association between mortality, HRQOL, laboratory parameters and clinical and sociodemographic characteristics at baseline. At the end of the five years, 293 patients out of 420 patients were still on HD treatment and 127 patients died. Those who died had a higher mean age, lower mean values of serum creatinine and albumin, higher prevalence of diabetes mellitus, received more HD twice weekly for less than 4 h in almost all HD sessions and had lower HRQOL than the survivors. We conclude that age, comorbidity, HD sessions lasting less than 4 h, malnutrition [hypoalbuminemia, low body mass index (BMI)] and lower physical component scores of SF-36 survey (PCS) were associated with higher risk of death in the HD population.

Efficacy and tolerability of intravenous paricalcitol in calcitriol-resistant hemodialysis patients with secondary hyperparathyroidism: 12-month prospective study.

RATIONALE/OBJECTIVES: Data are limited regarding the use of paricalcitol in calcitriol-resistant patients with secondary hyperparathyroidism (SHPT). We aimed to evaluate the effects of paricalcitol in calcitriol-resistant hemodialysis patients with SHPT. METHODS: This is a 12-month, open-label, prospective study. Forty patients with calcitriol-resistant and/or calcitriol-intolerant SHPT were included. After a washout period, all patients converted to paricalcitol with a 1:3 conversion ratio. Serum calcium and phosphorus were monitored monthly, while serum intact parathyroid hormone (iPTH) once in every 3 months. Paricalcitol dose was reduced or discontinued in case of hypercalcemia and/or hyperphosphatemia. Pre- and posttreatment electrolyte and iPTH values were compared with Student's t-test and Wilcoxon signed-rank test, respectively. MAIN FINDINGS: Forty patients completed the study. Mean initiation dose of paricalcitol was 23 ± 7 µg/week. Mean serum calcium was 8.9 ± 0.8 mg/dL at baseline and 9.4 ± 0.7 mg/dL at study end (p = 0.07). Mean monthly serum phosphorus levels stayed stable. Paricalcitol was effective in reducing iPTH levels when compared with pretreatment values (747.9 ± 497.2 pg/mL, 307.3 ± 417.1 pg/mL, respectively; p < 0.001). Thirty-two patients had to discontinue intravenous (IV) paricalcitol at some time during their treatment. Main reasons for discontinuation were as follows: hyperphosphatemia (58%), hypercalcemia (25%), and iPTH < 150 pg/mL (17%). PRINCIPLE CONCLUSIONS: Paricalcitol was found to be effective in reducing iPTH levels in calcitriol-resistant patients with SHPT despite relatively frequent drug discontinuation rates.

Evaluation of performance of quantiferon assay and tuberculin skin test in end stage renal disease patients receiving hemodialysis.

PURPOSE: End stage renal disease (ESRD) cases are associated with increased risk of tuberculosis. There is no gold standard method for detecting latent tuberculosis infection (LTBI) in ESRD. The aim of the present study was to analyze the performance of the tuberculin skin test (TST) and QuantiFERON-TB Gold in tube (QFT-G) in cases receiving hemodialysis (HD). METHODS: The TST and QFT-G were prospectively performed in 96 ESRD cases undergoing HD. The agreement of the QFT-G and TST was assessed in two TST cut off values (10 mm and 5 mm) in Bacille Calmette Guèrin (BCG) vaccinated and non-vaccinated cases. RESULTS: Of 96 cases 67 were BCG vaccinated and 29 were BCG non-vaccinated. QFT-G was positive in 39.6% cases and indeterminate in 3.1%. TST was positive in 43.8% of cases in cut off value of 10 mm and positive in 58.3% of cases in cut off value of 5 mm. Agreement between TST and QFT-G results was fair in both BCG vaccinated and non-vaccinated cases in either cut off values, except in cut off value of 10 mm in BCG vaccinated cases in which the agreement was moderate. CONCLUSION: The agreement between QFT-G and TST test is fair and there is no significant difference in both cut off values of TST in screening of LTBI in ESRD cases receiving HD.

Coenzyme Q10 and its relation with oxidant and antioxidant system markers in patients with end-stage renal disease.

RATIONALE AND OBJECTIVES: Oxidative stress is increased in chronic kidney disease (CKD) patients and end-stage renal disease (ESRD) patients undergoing dialysis treatment. Coenzyme Q(10) (CoQ(10)) is a ubiquitous and strong antioxidant. Role of CoQ(10) is not fully evaluated in renal patients. We aimed to investigate the relationship of CoQ(10) with oxidant and antioxidant system markers in patients with renal disease. MATERIAL AND METHODS: Forty patients with CKD (stages 3-5) who were managed conservatively without dialysis treatment, 40 hemodialysis, and 60 chronic ambulatory peritoneal dialysis (CAPD) patients were included in the study. Biochemical and whole blood analyses were done using hospital auto-analyzers from stored samples. Serum CoQ(10), malondialdehyde (MDA), superoxide dismutase (SOD), and antioxidant activity (AOA) levels were determined. MAIN FINDINGS: There was no difference among the groups in terms of serum CoQ(10) levels. However, other components of antioxidant system, namely, SOD and AOA were significantly higher in CAPD patients when compared to CKD patients. MDA levels were not significantly different among the groups. PRINCIPAL CONCLUSION(S): The results of this study showed no difference among CKD, CAPD, and hemodialysis patients in terms of serum CoQ(10) levels.

Safety profiles of total dose infusion of low-molecular-weight iron dextran and high-dose iron sucrose in renal patients.

Iron sucrose and low-molecular-weight iron dextran (LMW-ID), two commonly used iron solutions, have been compared in terms of allergic adverse event profiles to date. However, the safety of total dose infusion of LMW-ID has been investigated by only one study in chronic kidney disease (CKD) (not dialysis) patients. Thus, we aimed to compare adverse event profiles of total and high-dose LMW-ID and iron sucrose infusions in a heterogenous renal patient group comprising CKD, hemodialysis, and peritoneal dialysis. In this retrospective chart review study, we included 110 predialysis CKD, 101 peritoneal dialysis, and 118 hemodialysis patients. We included a total of 329 patients who were administered parenteral iron sucrose or LMW-ID between September 2006 and April 2010. Adverse events were determined both by medical and nursing follow-up notes. Laboratory data and clinical characteristics were collected from patient charts. Adverse event rates were compared between iron sucrose and LMW-ID infusions. In a total of 329 patients, 530 infusions (3470 ampules) were administered. We detected adverse reaction in only 1 patient. This adverse reaction, which manifested as generalized pruritus, occurred in a patient who received 500 mg of iron sucrose infusion. There were neither anaphylactic reactions nor deaths associated with infusion of either preparation. We did not observe any other adverse event related to administration of 500 and 1000 mg of iron sucrose at single infusion. The results of this study showed comparable safety of total dose LMW-ID and high-dose iron sucrose in a heterogenous group of renal patients.

Comparison of adverse-event profiles of intravenous low-molecular-weight iron dextran and iron sucrose in peritoneal dialysis patients.

BACKGROUND: Both erythropoiesis-stimulating agents and iron treatments are underutilized in peritoneal dialysis (PD) patients. Studies to evaluate safety profiles of various intravenous iron preparations are limited in PD patients compared to hemodialysis. No study in the literature compared safety of low-molecular-weight iron dextran (LMW-ID) with that of iron sucrose in PD patients. We aimed to compare adverse-effect profiles of LMW-ID and iron sucrose with varying dosing schedules in PD patients with a hope to foster use of parenteral iron solutions in PD patients. METHODS: We retrospectively reviewed patient charts and included patients who were administered iron sucrose or LMW-ID parenterally. Sociodemographic characteristics, clinical features, and pertinent laboratory data were collected. Adverse events which were deemed to be related to infusion of parenteral iron were recorded. We double-checked both physician records and nursing documents for observed adverse events. RESULTS: A total of 167 chronic PD patients were included in the study, and 92 patients were administered LMW-ID, whereas 75 patients were administered iron sucrose. Only one adverse event occurred in a patient who was administered 500 mg iron sucrose in a single infusion. CONCLUSIONS: This study showed the comparable safety of LMW-ID in varying doses over that of iron sucrose in PD patients.

Comparison of effects of automated peritoneal dialysis and continuous ambulatory peritoneal dialysis on health-related quality of life, sleep quality, and depression.

Few studies investigating the effects of automated peritoneal dialysis (APD) and continuous ambulatory peritoneal dialysis (CAPD) on health-related quality of life (HRQoL), depression, and sleep quality exist in the literature. We aimed to determine differences between APD and CAPD modalities with respect to these parameters. Twenty APD and 48 CAPD patients were included in this cross-sectional study. Biochemical values were measured at outpatient evaluation. A modified postsleep inventory was used to evaluate sleep quality. Health-related quality of life and depression were evaluated by the Short Form of Medical Outcomes Study and Beck Depression Inventory, respectively. Automated peritoneal dialysis and CAPD patients were compared in terms of sleep quality, HRQoL, and depression. Our results showed that there were no significant differences between APD and CAPD in any of the studied parameters. Moderate or severe sleep problems were found in 60% and 69% of the APD and CAPD patients, respectively. Mean HRQoL scores for any of the 8 Short Form of Medical Outcomes Study-36 domains were similar in the 2 groups. The mean physical component score was 51.1 ± 21.2 and 48.9 ± 18.2 in APD and CAPD patients, respectively (P=0.672). The mean mental component score was 47.5 ± 20.1 in APD patients, whereas it was 42.4 ± 19.5 in CAPD patients (P=0.291). Depression was detected in 70% of APD and 62.5% of the CAPD patients. The mean Beck Depression Inventory scores were also similar in the 2 groups. This study showed that HRQoL, sleep quality, and depression were similar in APD and CAPD patients.

A rare masquerader of lung cancer: nonsecretory multiple myeloma with plasmacytoma of bone presenting as acute kidney injury.

Multiple myeloma (MM) is a neoplasm of B cell lineage characterized by excessive proliferation of abnormal plasma cells which produce immunglobulins. If a monoclonal spike is not found in serum or urine but the patient has clinical findings and bone marrow plasma cell infiltration suggestive of MM, then the patient may have a rare subtype known as nonsecretory multiple myeloma (NSMM). Here, we describe a rare case of NSMM with plasmacytoma of bone who presented with severe hypercalcemia, acute kidney injury and a large thoracal mass on chest X-ray masquerading as lung cancer.

Lithium intoxication causing ST segment elevation and wandering atrial rhythms in an elderly patient.

Lithium overdoses causing cardiotoxicity are uncommon and electrocardiographic changes suggesting myocardial ischemia are rare. However, some authors have specifically reported the occurrence of ischemic electrocardiography changes due to a lithium overdose. This paper describes a case where electrocardiography changes mimic inferior myocardial infarction during the course of chronic lithium treatment in an elderly patient. The patient's electrocardiography changes were partially resolved after hemodialysis.