Prevalence, clinical characteristics, and predictors of peripheral arterial disease in hemodialysis patients: a cross-sectional study.

BACKGROUND: Peripheral arterial disease (PAD) is common in patients with end-stage renal disease on hemodialysis, but is frequently underdiagnosed. The risk factors for PAD are well known within the general population, but they differ somewhat in hemodialysis patients. This study aimed to determine the prevalence of PAD and its risk factors in patients on hemodialysis. METHODS: This cross-sectional study included 156 hemodialysis patients. Comorbidities and laboratory parameters were analyzed. Following clinical examinations, the ankle-brachial index was measured in all patients. PAD was diagnosed based on the clinical findings, ankle-brachial index < 0.9, and PAD symptoms. RESULTS: PAD was present in 55 of 156 (35.3%; 95% CI, 27.7-42.8%) patients. The patients with PAD were significantly older (67 ± 10 years vs. 62 ± 11 years, p = 0.014), more likely to have diabetes mellitus (p = 0.022), and anemia (p = 0.042), and had significantly lower serum albumin (p = 0.005), total cholesterol (p = 0.024), and iron (p = 0.004) levels, higher glucose (p = 0.002) and C-reactive protein (p < 0.001) levels, and lower dialysis adequacies (p = 0.040) than the patients without PAD. Multivariate analysis showed higher C-reactive protein level (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.00-1.06; p = 0.030), vascular access by Hickman catheter (OR, 4.66; 95% CI, 1.03-21.0; p = 0.045), and symptoms of PAD (OR, 5.20; 95% CI, 2.60-10.4; p < 0.001) as independent factors associated with PAD in hemodialysis patients. CONCLUSION: The prevalence of PAD was high among patients with end-stage renal disease on hemodialysis. Symptoms of PAD, higher C-reactive protein levels, and Hickman vascular access were independent predictors of PAD in patients on hemodialysis.

Normal or low initial PTH levels are not a predictor of morbidity/mortality in patients undergoing chronic peritoneal dialysis.

OBJECTIVE: During the past few decades, the pattern of bone disease in uremic patients has changed significantly. There has been an increase in the number of patients with normal or low initial parathyroid hormone (PTH) levels, particularly in patients on chronic peritoneal dialysis (CPD). Previous authors have described a higher prevalence of bone pain, microfractures, and fractures, and higher mortality among these patients. The aim of this study was to determine the incidence, morbidity, and mortality of patients who had a low or normal intact PTH (iPTH) level when they started CPD. DESIGN: We reviewed the records of 251 patients in our program that started CPD during the past 5 years (January 1996-December 2000). Clinical data, laboratory variables, medication, and dialysis parameters/dose were available at every clinic visit (approximately every 4 weeks). Intact PTH was used to express parathyroid function; values 3 times higher than the upper limit of normal (ULN) were assumed to be optimal. Variables predictive of the development of parathyroid dysfunction were calculated by univariate and multivariate logistic regression analysis. RESULTS: Of the patients who started CPD, 15.5% had iPTH values below the ULN (7.6 pmol/L), and an additional 29.5% had an iPTH of less than 3 times the ULN (i.e., between 7.6 and 22.8 pmol/L). We call these two groups of patients the normal/low initial iPTH group. During the follow-up period (3-63 months), we found a trend toward increasing iPTH levels. By the end of the study period, 61.2% of those with normal/low initial iPTH remained in the normal/low iPTH range, and 38.8% had converted to a group with an iPTH range higher than 22.8 pmol/L. The patients who converted their iPTH grouping were younger, fewer of them were diabetics (p = not significant), and they were more frequently on low calcium dialysate (p < 0.05). Hyperphosphatemia was an independent risk factor for subsequent iPTH changes during the course of continuous ambulatory PD treatment. All patients in the normal/low iPTH groups had a low prevalence of bone fractures (3.5%). Also, patients who remained in the normal/low iPTH group at the end of the follow-up period did not have more fractures than those who converted to the hyperparathyroid group (3.8% vs 3.1%). We found no differences in bone fractures between patients with iPTH levels below 22.8 and those with levels above 22.8 pmol/L (3.5% vs 5.4%), nor were there differences in patient and technique survival between these two groups. CONCLUSION: Normal/low initial iPTH is a frequent finding among patients starting CPD. Serum phosphorus was an independent risk factor for subsequent iPTH changes during the course of CPD treatment. Use of low calcium dialysate was significantly higher in patients who converted their iPTH into the high iPTH range. Very few patients with low/normal iPTH had bone-related symptoms (pain and fractures), and their morbidity and mortality did not differ from those patients with a high initial iPTH level.

Renal stone disease, elevated iPTH level and normocalcemia.

BACKGROUND: There is a well established relationship between primary hyperparathyroidism and recurrent calcium-containing calculi. Traditionally, the diagnosis is confirmed by the presence of elevated intact parathyroid hormone (iPTH) and serum ionised calcium levels. The prevalence and role of elevated iPTH in the presence of normocalcemia in patients with renal stone disease is poorly understood. The aim of the present study was to describe the findings in patients who had renal stone disease, an elevated iPTH level and normocalcemia. METHODS: During the last decade, 414 patients, who had normal renal function, were investigated and treated for renal calculi in the Renal Stone Clinic of the Toronto Western Hospital. Of these 414 patients, 40 (9.6%) had an elevated intact iPTH level and normal serum calcium (total and ionised) on repeated measurements. In all these patients we performed detailed clinical and laboratory investigations to determine risk factors for stone formation. Correlation analysis was done using Pearson test and the weights of factors influencing iPTH level were compared using multiple regression analysis. RESULTS: The average duration of a history of stone disease was 12.0 +/- 10.5 years. Most of these patients had passed their stones spontaneously, 15 underwent lithotripsy, in six the stones were removed by basket catheters and one patient each had partial nephrectomy, nepholithotomy or uretero-lithotomy. Twelve had a positive family history, two had history of intestinal malabsorption and one patients had a history of immobilisation. All of these patients had elevated serum parathyroid hormone in the range of 3% to 134% (median 20.5%) above upper limit of normal (F = M); all had normal serum total and ionised calcium and normal urine excretion of calcium (except in one). Additional risk factor for stone formation included: low level of 25-hydroxyvitamin D in four patients, low output and high urine osmolality in four patients, high urine sodium in nine and high oxalate excretion in eight patients. Citrate excretion was low in seven, magnesium excretion in six patients and tubular reabsorption of phosphate in 22 patients. Urine hydroxyprolin was increased in two and decreased in four patients. Combined abnormalities were found in 14 while 17 patients did not have any abnormality apart from elevated iPTH level. Multiple regression analysis did not suggest that any of the selected predictors had a significant influence on PTH release. CONCLUSIONS: 9.6% of patients with recurrent kidney stones had normocalcemia and elevated iPTH level in the presence of normal renal function. The study did not show any distinct pattern of abnormalities that would suggest a mechanism of stone disease in these patients. Further investigations are necessary to determine the significance of elevated iPTH in normocalcemic patients with renal stone disease and establish whether we should consider neck exploration for parathyroidectomy in these patients.