C-reactive protein and procalcitonin as markers of mortality in hemodialysis patients: a 2-year prospective study.

OBJECTIVE: We have previously shown in a transversal study that PCT combined to CRP is associated to an altered nutritional status in hemodialysis patients. In a 2-year prospective study, we have assessed the relationship between markers of inflammation or nutrition and mortality. DESIGN: Two-year prospective study, in 61 patients dialyzed in our unit (29 M/32 F, age 63 +/- 15 years, on dialysis for 76 +/- 94 months, 12 hrs/wk, on high-flux (HF) membrane for 25 patients and low-flux (LF) for 36 patients, without reuse). Kt/V was 1.53 +/- 0.30. SETTING: Hospital-based dialysis unit. MAIN OUTCOME MEASURE: CRP, PCT, ferritin, albumin, and prealbumin, were measured in 04/99 (T0) and every 6 months thereafter. Interleukin-6 (IL6) and fibrinogen were measured at the start of study. The outcome and the causes of death of patients were noted in 58 patients, 3 patients were lost of follow-up. RESULTS: The mortality (24 deaths) was 42% at 2 years in this hospital based unit. The main causes of mortality were cardiovascular diseases (71%) and infection (17%). Patients were classified according to their CRP (CRP+ if CRP > or = 5 mg/L; n = 40), and PCT values (PCT + if PCT > or = 0.5 ng/mL; n = 25). IL6 level was > or = 10 pg/mL for 95% of the patients. Mortality was higher in the CRP+ group (Kaplan-Meier test P < .01) but not in the PCT or IL6 positive patients. All patients of the CRP+ group at T0 remained CRP+. Only 56% of patients of PCT+ remained positive at 6 months. When patients were grouped according to CRP quartile the difference on survival remained significant (P = .03), patients who were classified in the third and fourth quartile (upper than 9.9 mg/L), exhibited a higher rate of mortality than the lower quartile. The concomitant presence of a high level of PCT and CRP was associated with a worsened nutritional status at T0 but PCT level had no influence on 2-year mortality. CONCLUSION: In this 2-year prospective study in a hospital-based cohort of high-risk hemodialysis patients, elevated CRP, but not raised PCT, was associated with increased mortality. Inflammation remained present throughout a 2-year follow-up in patients with an initial CRP higher than 5 mg/L. An upper value of CRP above 9.9 mg/L is independly predictive of mortality, mainly from cardiovascular causes. The association of high PCT and CRP was no more predictive of mortality than high CRP.

Amelogenesis imperfecta and nephrocalcinosis: a new case of this rare syndrome.

This article describes a new case of a rare syndrome including enamel agenesis of the primary and permanent dentition, delayed or absent eruption of the permanent dentition, coronal intra-alveolar resorption and gingival enlargement. Renal symptoms include medullary nephrocalcinosis without any apparent cause, and evolution to a renal failure. The early diagnosis provided by the oral symptoms leads to a better renal prognosis. As a consequence, pediatric dentists should be aware of this pathology.

Performance of twin central venous catheters: influence of the inversion of inlet and outlet on recirculation.

BACKGROUND: The use of a central venous catheter as a permanent vascular access is constantly growing. The recirculation rate in this type of vascular access varies depending on the site of insertion, the length of the catheter, the blood flow and the time elapsed since catheter insertion. When the in/out flow of the lumens of the catheter is reduced, it is sometimes necessary to inverse the arterial and venous lines of the catheter at the beginning or in the course of the dialysis session. The impact of such a practice on the recirculation rate has only been assessed by the low flow urea dilution method. METHODS: The blood recirculation rate was measured using the ultrasound dilution velocity method (Transonic system, Ithaca, N.Y.) in 14 patients (aged 64 +/- 15 years), with a right internal jugular (n = 9) or right subclavian (n = 5) central catheter (Twincath, Medcomp), used over a mean period of 16.3 (range 1-42) months. No clinical dysfunction of the catheter was apparently noted. The distance between the vein and the artery end of the catheter was 3.9 +/- 2.8 cm, measured on chest radiography. The recirculation rate was measured over a single dialysis session at increasing blood flows in the normal and inversed position of the catheter. RESULTS: The difference between the prescribed and effective blood flow was significant with an effective blood flow of 180 +/- 16 ml/min for 200 ml/min, 264 +/- 27 ml/min for 300 ml/min and 329 +/- 16 ml/min for 400 ml/min prescribed blood flow. There was no relationship between the recirculation rate and blood flow whatever the position of the lines on the catheter. There was also no relationship between the recirculation rate and the distance between the catheter ends. However, reversing the catheter ends significantly increased the recirculation rates from 2.9 +/- 5 to 12 +/- 9% whatever the blood flow. CONCLUSION: The use of central catheters in an inversed position can result in a higher recirculation rate. Reversing the lines of the central catheters may lead to less effective hemodialysis and it seems particularly important for the nursing staff to be aware of this phenomenon. Thus, measurement of the effective blood flow and recirculation by ultrasound velocity should be included in quality monitoring and maintenance.