Plasma adiponectin levels for prediction of cardiovascular risk among hemodialysis patients.

Adiponectin (ADPN) is an endogenous insulin sensitizing and anti-inflammatory hormone, released by the adipose tissue. We investigated the clinical and biochemical correlates of plasma ADPN levels and the predictive value of ADPN with respect to survival rates and cardiovascular (CV) events was tested prospectively in a cohort of hemodialysis (HD) patients. We measured baseline ADPN in 110 HD patients, in addition to, 34 healthy subjects to serve as reference group. ADPN levels, were related to different clinical and biochemical cardiovascular risk factors such as increased body mass index (BMI), serum triglycerides (TG), duration of HD, smoking, mean arterial blood pressure (MBP), heart rate (HR), high density (HDL) cholesterol, low density (LDL) cholesterol, serum glucose, hemoglobulin and C-reactive protein (CRP) levels in HD patients. Plasma ADPN levels were higher (P = 0.000) among HD patients (15.06 ± 3.54 µg/mL) than among reference subjects (6.52 ± 1.07 µg/mL), were independent of age, and higher among women (16.13 ± 3.09 µg/mL) than among men (13.94 ± 3.65 µg/mL). Plasma ADPN levels were inversely related to BMI, TG, CRP and glucose levels. Furthermore, plasma ADPN levels were directly related to HDL-cholesterol and Kt/V. Plasma ADPN levels were lower (P = 0.000) among patients who experienced new CV events (11.13 ± 2.15 µg/mL) than among event-free patients (16.82 ± 2.45 µg/mL), and seem to predict cardiovascular outcomes. The inverse relationships between ADPN and several cardiovascular risk factors indicate that ADPN may have a protective role in the prevention of CV events.

Ultrasound-guided internal jugular vein access: comparison between short axis and long axis techniques.

The use of real-time ultrasound (US) is advantageous in the insertion of central venous catheters (CVCs) in adults, especially in whom difficulties are anticipated for various reasons. The aim of the present study was to compare two different real-time 2-dimensional US-guided techniques [short axis view/out-of-plane approach (SAX OOP approach) versus long axis view/in-plane approach (LAX IP approach)] for internal jugular vein (IJV) cannulation. In this prospective study, 90 critical care and hemodialysis patients were assigned for insertion of CVCs using either the real-time US-guided (SAX OOP approach or LAX IP approach) or landmark technique (control group). Failed catheter placement, risk of complications from placement, failure on first attempt at placement, number of attempts until successful catheterization, time to successful catheterization, incidence of central line-associated blood stream infection (CLA-BSI) and demographics of each patient were recorded. There were no significant differences in patient's demographic characteristics, side of cannulation (right or left) or presence of risk factors for difficult venous cannulation between the three groups of patients. Cannulation of the IJV was achieved in all patients by using US (SAX OOP and LAX IP approaches) and in 27 of the patients (90%) by using the landmark technique (P = 0.045). Average access time (skin to vein) and number of attempts were comparable between the SAX OOP and the LAX IP approaches while significantly reduced in both US groups of patients compared with the landmark group (P <0.001). In the landmark group, puncture of the carotid artery occurred in 16.7% of the patients, hematoma in 23.3% of the patients, pneumothorax in 3.3% of the patients and CLA-BSI in 20% of the patients, which were all significantly increased compared with the US group (P <0.05). The findings of this study suggest that the SAX OOP and LAX IP approaches were comparable for cannulation of IJV in critical care and hemodialysis patients. Furthermore, both US-guided techniques were superior to the landmark technique for insertion of CVCs.

Cinacalcet hydrochloride therapy for secondary hyperparathyroidism in hemodialysis patients.

This study compared the efficacy of a cinacalcet-based regimen with unrestricted conventional therapy (vitamin D and phosphate binders) for achieving Kidney Disease Outcome Quality Initiative (K/DOQI) targets for dialysis patients. In this multicenter, prospective study, hemodialysis patients with poorly controlled secondary hyperparathyroidism (SHPT) were randomized to receive a cinacalcet-based regimen (n=55) or a conventional therapy (n=27). Doses of cinacalcet, vitamin D sterols, and phosphate binders were adjusted during a 12-week dose-titration phase to achieve intact parathyroid hormone (iPTH) levels ≤ 31.8 pmol/L. The primary end point was the percentage of patients with values in this range during a 24-week efficacy-assessment phase. The clinical response to 36-week cinacalcet treatment was evaluated. A dual energy X-ray absorptiometry was performed before and after 36 weeks of cinacalcet therapy. Fifty-eight percent of the cinacalcet group reached the primary end point, as compared with 19% of the conventional therapy group (P=0.001). A higher percentage of patients receiving the cinacalcet-based regimen versus conventional therapy achieved the targets for calcium, phosphorus and Ca×P. Achievement of targets was greatest in patients with less severe disease (intact PTH range, 31.8 to 53 pmol/L). Cinacalcet therapy increased proximal femur bone mineral density (BMD), but did not affect the lumbar spine. Itching intensity decreased significantly. Cinacalcet based treatment facilitates achievement of the K/DOQI targets for iPTH and bone mineral metabolism compared with conventional therapy in hemodialysis patients. Suppression of iPTH with cinacalcet reverses bone loss in the proximal femur. Cinacalcet alleviated itching.

Is mycophenolate mofetil superior to pulse intravenous cyclophosphamide for induction therapy of proliferative lupus nephritis in Egyptian patients?

BACKGROUND: Recent studies have suggested that mycophenolate mofetil (MMF) may offer advantages over intravenous cyclophosphamide (IVC) for the treatment of lupus nephritis. The aim of this study was to evaluate the efficacy of MMF compared with IVC in the induction therapy of proliferative lupus nephritis. METHODS: We randomly assigned 47 patients with newly diagnosed active proliferative lupus nephritis class III or IV to open-label oral MMF 2 g/day for 6 months or intravenous cyclophosphamide 0.5-1 g/m(2) monthly for 6 months in addition to corticosteroids. RESULTS: In the intention-to-treat analysis, 14 of the 24 patients (58.33%) receiving MMF and 12 of the 23 patients receiving cyclophosphamide (52.17%) had remission (P = 0.48); complete remission occurred in 6 of the 24 patients (25%) and 5 of the 23 patients (21.74%), respectively (P = 0.53). Improvements in packed cell volume, the erythrocyte sedimentation rate, anti-double-stranded DNA antibodies titer (anti-dsDNA), serum complement, proteinuria, urinary activity, renal function, serum soluble interleukin-2 receptor alpha concentration and the systemic lupus activity measure score were similar in both groups. Two patients assigned to MMF and another patient assigned to IVC developed end-stage renal failure with commencement of dialysis. Adverse events were similar. Major infections occurred in two patients in each group. There was no difference in gastrointestinal side effects, but more diarrhea occurred in those receiving MMF. CONCLUSION: In this 24-week trial, MMF or IVC combined with corticosteroids demonstrated equal efficacy in inducing remission of proliferative lupus nephritis.

Serum soluble interleukin-2 receptor alpha in systemic lupus erythematosus.

INTRODUCTION: This study aimed at determination of circulating soluble interleukin-2 receptor (IL-2 R) alpha in the sera of patients with systemic lupus erythematosus (SLE) and correlating the level of expression of these receptors with the SLE disease activity. MATERIALS AND METHODS: The study included 55 patients with SLE and 20 healthy volunteers as controls. The following investigations were done: serum complement component 3, complement 4, erythrocyte sedimentation rate, complete blood count, serum creatinine, creatinine clearance, 24-hour urinary protein, urinalysis, and serum soluble IL-2R alpha level. Kidney biopsy was performed and examined with light microscopy for patients with lupus nephritis by a single pathologist blinded to the clinical activity of the disease. The results were analysed in relation to the clinical activity index of systemic lupus activity measure (SLAM). RESULTS: The study showed that levels of soluble IL-2R alpha were significantly higher in the total group of patients with SLE compared to the controls (P < .001). Furthermore, serum IL-2R alpha levels were significantly higher in patients with lupus nephritis than those without nephritis. There were strong positive correlations between IL-2R alpha levels and the SLAM score, histological activity index, erythrocyte sedimentation rate, and 24-hour urinary protein excretion. Also, significant inverse correlations with complement 3 and packed cell volume was observed (r = 0.738; r = 0.669; r = 0.328; r = 0.705; r = -0.444; r = -0.420, respectively). CONCLUSIONS: Serum soluble IL-2R alpha is a reliable marker of disease activity in patients with SLE and could be used as an indicator of early renal involvement with the possibility of using it for follow-up.