Blood stream Infections in chronic hemodialysis patients - characteristics and outcomes.

INTRODUCTION: Bloodstream Infections (BSI) are a major cause of death and hospitalization among hemodialysis (HD) patients. The rates of BSI among HD patients vary and are influenced by local patient and pathogen characteristics. Modifications in local infection prevention protocols in light of active surveillance of BSI has been shown to improve clinical outcomes. The aim of this study was to further explore factors associated with BSI in a contemporary cohort of HD patients at a public teaching hospital dialysis center in Israel. METHODS: This was a retrospective cohort study of HD patients with a BSI in the years 2014 to 2018. The primary outcome was the occurrence of BSI. Secondary outcomes were to describe the causative pathogens of BSI, and to assess for risk factors for BSI, and mortality. RESULTS: Included were 251 patients. The mean age was 68.5 ± 13.4 years, 66.9% were male. The mean time from initiation of dialysis was 34.76 ± 40.77 months, interquartile range (IQR) 1-47.5 months and the follow up period of the cohort was 25.17 ± 15.9 months. During the observation period, 44 patients (17.5%) developed 54 BSI events, while 10 of them (3.9% of the whole cohort) developed recurrent BSI events. Gram-negative microorganisms caused 46.3% of all BSI events. 31.4% of these BSI were caused by resistant bacteria. In a multivariate logistic regression analysis, patients receiving dialysis through a central line had a significantly increased risk for BSI adjusted Odds Ratio (aOR) 3.907, p = 0.005, whereas patients' weight was mildly protective (aOR 0.971, p = 0.024). CONCLUSIONS: We noted an increased prevalence of gram-negative pathogens in the etiology of BSI in HD patients. Based on our findings, additional empirical antibiotics addressing gram negative bacteria have been added to our empirical treatment protocol. Our findings highlight the need to follow local epidemiology for implementing appropriate preventative measures and for tailoring appropriate empiric antibiotic therapy.

Association of Nutrition Status at Dialysis Start With Long-Term Survival: A 10-Year Retrospective Study.

OBJECTIVE: The objectives of the study are to explore the association between nutritional status at the initiation of dialysis and the improvement or worsening of nutrition status during first 3 months of dialysis and first 5 years of survival on dialysis. METHODS: Two hundred ninety-seven patients who started dialysis between March 2009 and March 2019 were enrolled in the study. The nutritional status of the patients at dialysis commencement was evaluated by the method of The Integrative Clinical Nutrition Dialysis Score (ICNDS). Improvement or worsening of nutrition status was monitored by calculating the ICNDS slope for each patient enrolled in the study from 3 ICNDS values from the first 3 months on dialysis. The baseline ICNDS and the slope of 3 subsequent monthly ICNDS values were tested for correlation with the odds of all-cause mortality for each of the first 5 years on dialysis. RESULTS: There was a significant difference between the survival odds of patients who started dialysis with an ICNDS at 75 and those who started dialysis with an ICNDS <75 (hazard ratio [HR] 2.505, confidence interval [Cl] 1.235-5.079, P = .011 after 1 year on dialysis;, HR 1.543, Cl 1.083-2.198, P = .016 after 5 years). Deterioration of nutritional status (a negative ICNDS slope) during the first 3 months of dialysis was associated with increased mortality during 1-3 years after dialysis start, compared to a positive ICNDS slope indicating a stable or improved nutritional status (HR 1.732, Cl 1.151-2.607, P = .008 after 3 years on dialysis). CONCLUSIONS: Nutritional status at initiation of dialysis is associated with long-term (5 years) survival. Deterioration of nutritional status during the first 3 months on dialysis significantly increases the risk of death during the first 3 years on dialysis.

The effect of hemodialysis on individual retinal layer thickness.

PURPOSE: The aim of this study was to employ newly developed advanced image analysis software to evaluate changes in retinal layer thickness following hemodialysis. METHODS: A non-randomized prospective study of patients with end-stage renal disease assessed on the same day before and after hemodialysis. Intraocular pressure and central corneal thickness were analyzed, and spectral domain optical coherence tomography results were automatically segmented using the Orion software and then compared. All patients had normal retinal optical coherence tomography findings before hemodialysis. RESULTS: Of the 31 suitable end-stage renal disease patients treated with hemodialysis who provided consent to participate, seven were unable to complete all evaluations, leaving 24 patients for analysis in the final study group. Their mean age was 66.67±14.3 years (range: 35-88), and 62.5% were males. Mean central corneal thickness did not change following hemodialysis (563.4±30.2 µm to 553.1±47.2 µm, p=.247), while mean intraocular pressure decreased (14.48±2.5 mmHg to 13.16±2.28 mmHg, p=.028). Individual mean retinal layer thickness showed no significant change, including the retinal nerve fiber layer (40.9±6.8 µm to 40.1±5.2 µm, p=.412), the ganglion cell and the inner plexiform layer (68.66±8 µm to 69.03±7.6 µm, p=.639), and the photoreceptor layer (50.26±2.8 µm to 50.32±3.1 µm, p=.869). Total retinal thickness similarly remained constant, with a mean of 303.7±17.3 µm before and 304.33±18.4 µm after hemodialysis (p=.571). CONCLUSIONS: Thickness of retinal layers, as assessed by individual segmentation, and central corneal thickness were not affected by hemodialysis treatment, while intraocular pressure was significantly reduced among patients with end-stage renal disease without pre-existing ocular pathology who were undergoing hemodialysis. These results support the view that hemodialysis does not have a negative impact on the retinal morphology of end-stage renal disease patients, who comprise a population with high rates of diabetic and/or hypertensive retinopathy as well as vision-threatening complications.

Serum Chromium Levels Are Higher in Peritoneal Dialysis than in Hemodialysis Patients.

Background:An elevation in serum chromium levels in individuals treated with renal replacement therapy has been previously described, but chromium levels have not been systematically studied in patients treated with different dialysis modalities. The aim of this study was to compare serum chromium levels in patients treated with chronic peritoneal dialysis (PD) and hemodialysis (HD).Methods:We studied 169 chronic dialysis patients in a single medical center, of which 148 were treated with HD and 21 with PD. Serum chromium levels were measured by atomic absorption spectrometry.Residual renal function was accessed using a timed urine collection for the measurement of urine output and calculation of glomerular filtration rate (GFR).Results:The median (interquartile range) serum chromium level was significantly higher in patients treated with PD than in patients treated with HD: 5.00 (3.24 - 6.15) vs 1.83 (1.29 - 2.45) mcg/L, p < 0.001. In a univariate analysis, serum chromium level was associated with PD modality: Exp (B) 7.46 (95% confidence interval [CI] 2.1 - 26.4), p = 0.002. The association of PD modality with serum chromium level was even more significant using a multivariate logistic regression model: odds ratio (OR) 11.87 (95% CI 2.85 - 49.52), p = 0.001 after adjustment for age, gender, diabetes, smoking, dialysis vintage, use of diuretics, and residual renal function.Conclusions:In patients treated with chronic dialysis, serum chromium levels are higher in patients treated with PD than in those treated with HD.

Abdominal obesity in normal weight versus overweight and obese hemodialysis patients: Associations with nutrition, inflammation, muscle strength, and quality of life.

OBJECTIVE: The biological basis of abdominal obesity leading to more severe outcomes in patients with normal body mass index (BMI) on maintenance hemodialysis (MHD) is unclear. The aim of this study was to compare the properties of abdominal obesity in different BMI categories of patients on MHD. METHODS: We performed a cross-sectional study of 188 MHD patients (52.7% women; mean age, 69.4 ± 11.5 y) with abdominal obesity in different BMI groups using criteria from the World Health Organization. Appetite and dietary intake, body composition, handgrip strength, malnutrition inflammation score (MIS), inflammatory biomarkers, adipokines, and health-related quality-of-life (QoL) questionnaires were studied. RESULTS: According to multivariable analyses, abdominally obese patients with normal BMIs consumed less protein per day (P = 0.04); had lower measurements of surrogates of lean (P < 0.001) and fat mass (P < 0.001); and had higher total cholesterol, tumor necrosis factor-α (P < 0.05), and ratios of adiponectin to leptin (P = 0.003) than overweight and obese patients with abdominal obesity. Multivariable analyses showed no differences in handgrip strength among the study groups.The abdominally obese study participants with normal weight had significantly lower scores in role physical (P = 0.003) and pain (P = 0.04) scales after multivariable adjustments. CONCLUSIONS: Normal-weight MHD patients with abdominal obesity exhibited a more proatherogenic profile in terms of inflammatory markers and adipokine expression, lower body composition reserves, and lower physical ability than patients with abdominal obesity with overweight and obesity. This at least partially explains the abdominal obesity paradox in the MHD population in which worse clinical outcomes are seen in abdominally obese patients with normal BMIs, as opposed to overweight and obese patients who are also abdominally obese.

Phosphate binders, appetite and nutritional status in maintenance hemodialysis patients.

BACKGROUND AND OBJECTIVES: The potential side effects of common phosphate binders are gastrointestinal in practice. We hypothesized that regular use of phosphate binders may be associated with decreased appetite, dietary intake and consequently, poor nutritional status. METHODS AND STUDY DESIGN: This was cross-sectional study of 78 patients (mean age 67.5±13.0, 34.6% women) undergoing maintenance hemodialysis (MHD) treatment. Participants were divided into three equal groups - sevelamer (n=25), lanthanum (n=24) and the control group (n=29). Eating motivation was assessed using visual analogue scales (VAS) and by a self-reported appetite assessment which was graded on a 5-point Likert scale. Main outcome measure was differences in VAS scores for appetite, dietary intake and nutritional status (malnutrition-inflammation score [MIS]) in the study groups. RESULTS: Appetite, dietary intake, biochemical nutritional markers, anthropometric measures and MIS were similar in the three groups. A statistically significant difference was observed in sensation of fullness between the groups: multivariable adjusted ORs in the sevelamer carbonate group was 4.90 (95% CI: 1.12 to 21.43), p=0.04 and in the lanthanum carbonate group was 5.18 (95% CI: 1.15 to 23.30), p=0.03 versus the control group. However, no linear association was observed between MIS scores and VAS scores for appetite in any study group. CONCLUSIONS: Regular use of these phosphate binders was not associated with anorexia, decreased dietary intake and nutritional status in the study population. Therefore, there is no preference in the choice of phosphate binders in MHD patients with hyperphosphatemia, even those who are at nutritional risk.

Serum Obestatin: A Biomarker of Cardiovascular and All-Cause Mortality in Hemodialysis Patients.

BACKGROUND: Recent experimental studies have suggested that obestatin, a proposed anorexigenic gut hormone and a physiological opponent of acyl-ghrelin, has protective cardiovascular effects. We tested the hypothesis that obestatin is independent of inflammatory mediators and/or acyl-ghrelin in predicting outcomes of the maintenance hemodialysis (MHD) population. METHODS: It was a 6-year cohort study on 261 MHD patients. Obestatin, acyl-ghrelin, adipokines (leptin and adiponectin), markers of inflammation and nutrition, prospective all-cause and cardiovascular mortality were studied. RESULTS: During the follow-up, 160 patients died in total, with 74 deaths due to cardiovascular causes. For each ng/mL increase in baseline obestatin level in fully adjusted models (including malnutrition-inflammation score, Interleukin-6 [IL-6], adipokines and acyl-ghrelin), the hazard for death from all causes was 0.90 (95% CI 0.81-0.99) and for cardiovascular death 0.85 (95% CI 0.73-0.99). However, these associations were more robust in the subgroup of patients aged above 71 years: 0.85 (95% CI 0.73-0.98) for all-cause death and 0.66 (95% CI 0.52-0.85) for cardiovascular death. An interaction between high IL-6 (above median) and low obestatin (below median) levels for increased risk of all-cause mortality (synergy index [SI] 5.14, p = 0.001) and cardiovascular mortality (SI 4.81, p = 0.02) emerged in the development of multivariable adjusted models. Interactions were also observed between obestatin, Tumor necrosis factor-alpha, adipokines and acyl-ghrelin, which were associated with mortality risk. CONCLUSION: Serum obestatin behaves as a biomarker for cardiovascular and all-cause mortality in MHD patients. The prognostic ability of obestatin in this regard is independent of inflammation, nutritional status, acyl-ghrelin's and adipokines' activity and is modified by age being very prominent in patients older than 71 years.

Estimating of Residual Kidney Function by Multi-Frequency Bioelectrical Impedance Analysis in Hemodialysis Patients Without Urine Collection.

BACKGROUND/AIMS: Residual kidney function (RKF) is a pivotal predictor of better clinical outcomes in maintenance hemodialysis (MHD) patients. So far there has been no attempt to use bioimpedance analysis (BIA) measurements to calculate residual glomerular filtration rate (GFR) in dialysis population. We hypothesized that performing of multi-frequency BIA at the beginning and end of hemodialysis session can enable us to predict the measured residual GFR in MHD patients. Thus our aim was to develop and validate a new RKF prediction equation using multi-frequency BIA in MHD patients. METHODS: It was diagnostic test evaluation study in a prospective cohort. Participants (n=88; mean age, 66.3±13.2 years, 59.1% males) were recruited from a single hemodialysis center. A new equation (eGFRBIA) to predict RKF, utilizing BIA measurements performed pre- and post-dialysis, was generated and cross-validated by the leave-one-out procedure. GFR estimated as the mean of urea and creatinine clearance (mGFR) using urine collections during entire interdialytic period. RESULTS: A prediction equation for mGFR that includes both pre- and post-dialysis BIA measurements provided a better estimate than either pre- or post-dialysis measurements alone. Mean bias between predicted and measured GFR was -0.12 ml/min. Passing and Bablok regression showed no bias and no significant deviation in linearity. Concordance correlation coefficient indicated good agreement between the eGFRBIA and mGFR (0.75, P<0.001). Using cut-off predicted mGFR levels >2 ml/min/1.73 m2 yielded an area under curve of 0.96, sensitivity 85%, and specificity 89% in predicting mGFR. The κ scores for intraobserver reproducibility were consistent with substantial agreement between first and second estimation of RKF according to eGFRBIA (weighted κ was 0.60 [0.37-0.83]). CONCLUSION: We present a valid and clinically obtainable method to predict RKF in MHD patients. This method, which uses BIA, may prove as accurate, convenient and easily reproducible while it is operator independent.

A single center, open-label, randomized, parallel group study assessing the relationship between asymptomatic bacteriuria and inflammation in maintenance hemodialysis patients.

INTRODUCTION: The significance of asymptomatic bacteriuria in maintenance hemodialysis (MHD) patients remains controversial. We hypothesized that the presence of asymptomatic bacteriuria as a sole clinical manifestation of urinary tract infection (UTI) in asymptomatic MHD patient may contribute to the chronic inflammatory response. Our aim was to explore the relationship between asymptomatic bacteriuria and elevated levels of inflammatory markers in MHD patients. METHODS: A randomized open-label single center study of 114 MHD patients was conducted. Forty-six patients presented negative urine culture and 41 subjects were excluded due to different reasons. The remaining 27 patients (mean age of 71.5 ± 12.2 years, 63% men), fulfilling the criteria for having asymptomatic bacteriuria, were randomly assigned to either the treatment group (13 patients) or the observational group (14 subjects). The treatment group received 7 days of antibiotic treatment given according to bacteriogram sensitivity. After 3 months of follow-up all measurements of the study were repeated. The primary end point was change in inflammatory biomarkers from baseline by the end of the study. FINDINGS: There were no statistically significant differences in white blood cell changes (P = 0.27), ferritin (P = 0.09), C-reactive protein (P = 0.90), and interleukin-6 (P = 0.14) levels between the groups from baseline to the end of study or at the end of the study. Analyzing cross-sectional data, asymptomatic bacteriuria was found to not be a predictor of higher levels of inflammatory parameters at baseline. DISCUSSION: Asymptomatic bacteriuria is not a modifiable risk factor for chronic inflammation in the MHD population.

A rise in mean platelet volume during hospitalization for community-acquired pneumonia predicts poor prognosis: a retrospective observational cohort study.

BACKGROUND: Clinical characteristics and the prognostic significance of changes in mean platelet volume (MPV) during hospitalization for community-acquired pneumonia (CAP) have not been investigated. METHODS: Among 976 adults hospitalized for CAP, clinical characteristics, in-hospital outcomes (transfer to the intensive care unit, treatment with mechanical ventilation, prolonged hospital stay and death), and all-cause mortality following discharge, were compared according to ΔMPV (MPV on discharge minus MPV on admission): groups A (no rising MPV, ΔMPV < 0.6 fL) and B (rising MPV, ΔMPV ≥ 0.6 fL). RESULTS: Groups A and B comprised 83.8% and 16.2% of patients, respectively. Patients with a rise in MPV were more likely to be older, and to present with renal dysfunction, cerebrovascular disorder and severe pneumonia than were patients with no rise in MPV. On discharge, lower values of platelets and higher levels of neutrophils were observed in group B. Rising MPV strongly predicted a need for mechanical ventilation and in-hospital death (the respective relative risks: 2.62 and 6.79; 95% confidence intervals: 1.54-4.45 and 3.48-13.20). The respective 90-day, 3-year and total (median follow-up of 54 months) mortality rates were significantly higher in group B (29.1%, 43.0% and 50.0%) than group A (7.3%, 24.2% and 32.6%), p < 0.001 for all comparisons. A rise in MPV was a powerful predictor of all-cause mortality (relative risk 1.26 and 95% confidence interval 1.11-1.43). CONCLUSIONS: Rising MPV during hospitalization for CAP is associated with a more severe clinical profile than no rise in MPV. A rise in MPV strongly predicts in-hospital and long-term mortality.

Effect of hemodialysis access blood flow on cardiac events after coronary artery bypass grafting using an internal thoracic artery.

BACKGROUND: The possibility of coronary steal through an arteriovenous fistula (AVF) in hemodialysis (HD) patients with coronary artery bypass grafts (CABGs) using an ipsilateral internal thoracic artery (ITA) has been suggested. In order to define the significance of such a possibility, we analyzed cardiac events and mortality risk in patients in relation to AVF flow. METHODS: A retrospective cohort study was performed on prevalent HD patients from a single center. The outcomes included a first cardiac event, cardiac death and death from any cause. RESULTS: The group consisted of 23 chronic HD patients having ITA CABG and upper extremity AV access, 12 patients had an ipsilateral and 11 patients had a contralateral location of ITA CABG and an upper extremity AV access. The mean follow-up period was for 37.0 months.Multivariable Cox proportional-hazards regression analysis of risk of death from any cause in relation to AV access flow showed no increased risk, neither in the group with ipsilateral location of ITA grafts and dialysis accesses (adjusted HR, 3.047 [95% CI, 0.996 to 1.000], p = 0.081), nor in the group with contralateral location of both shunts (adjusted HR, 0.173 [95% CI, 0.997 to 1.002], p = 0.678). There was no significant correlation between AV access blood flow and the risk of first cardiac event as well as cardiac death in either study group. CONCLUSIONS: In this study on HD patients having ipsilateral ITA CABG and AVF, fistula flow rate was not found to be associated with mortality or cardiac risk.

End-stage renal disease and adherence to angiotensin-converting enzyme inhibitors and angiotensin receptor blockers among patients with diabetes.

Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) have become standards of care for diabetic nephropathy. The authors assessed the association between treatment adherence to ACEIs and ARBs and the development of end-stage renal disease (ESRD). The cohort comprised the 9895 members of the Central District of Clalit Health Services aged 40 to 70 years, diagnosed with diabetes before 2002, who filled at least four ACEI or ARB monthly prescriptions during 2002-2011. Forty-six percent of patients made 10 or more purchases a year. Hazard ratios for ESRD development and death decreased as adherence increased, with no evidence of a cutoff threshold or plateau. For both outcomes, hazard ratios were significantly lower among patients who purchased at least 10 monthly prescriptions (83% adherence), after adjusting for age, sex, and a number of clinically relevant factors. While ACEIs/ARBs have become standards of care in diabetes, treatment adherence is essential to achieve full benefit.

Interaction between acyl-ghrelin and BMI predicts clinical outcomes in hemodialysis patients.

BACKGROUND: Ghrelin, a gastric orexigenic peptide, and body mass index (BMI) are known as inversely associated to each other and are both linked to cardiovascular (CV) risk and mortality in maintenance hemodialysis (MHD) patients. However, it is unclear whether the interaction between ghrelin and BMI is associated with a risk of all-cause and CV death in this population. METHODS: A prospective observational study was performed on 261 MHD outpatients (39% women, mean age 68.6 ± 13.6 years) recruited from October 2010 through April 2012, and were followed until November 2014 (median follow-up-28 months, interquartile range-19-34 months). We measured acyl-ghrelin (AG) levels, appetite, nutritional and inflammatory markers, prospective all-cause and cardiovascular (CV) mortality. RESULTS: During follow-up, 109 patients died, 51 due to CV causes. A significant interaction effect of high BMI and high AG (defined as levels higher than median) on all-cause mortality was found. Crude Cox HR for the product termed BMI x AG was 0.52, with a 95% confidence interval (CI): 0.29 to 0.95 (P = 0.03). Evaluating the interaction on an additive scale revealed that the combined predictive value of BMI and AG is larger than the sum of their individual predictive values (synergy index was 1.1). Across the four BMI-AG categories, the group with high BMI and high AG exhibited better all-cause and cardiovascular mortality irrespective of appetite and nutritional status (multivariable adjusted hazard ratios were 0.31, 95% CI 0.16 to 0.62, P = 0.001, and 0.35, 95% CI 0.13 to 0.91, P = 0.03, respectively). Data analyses made by dividing patients according to fat mass-AG, but not to lean body mass-AG categories, provided similar results. CONCLUSIONS: Higher AG levels enhance the favourable association between high BMI and survival in MHD patients irrespective of appetite, nutritional status and inflammation.

Prognostic significance of platelet count changes during hospitalization for community-acquired pneumonia.

The prognostic significance of platelet count (PC) changes during hospitalization for community-acquired pneumonia (CAP) has not been investigated. For 976 adults, clinical data during hospitalization for CAP and all-cause mortality following discharge were compared according to ΔPC (PC on discharge minus PC on admission): groups A (declining PC, ΔPC < -50 × 109/l), B (stable PC, ΔPC ± 50 × 109/l), and C (rising PC, ΔPC >50 × 109/l), and according to the presence of thrombocytopenia, normal PC, and thrombocytosis on admission/discharge. Groups A, B, and C comprised 7.9%, 46.5%, and 45.6% of patients, respectively. On hospital admission/discharge, thrombocytopenia, normal PC, and thrombocytosis were observed in 12.8%/6.4%, 84.1%/84.4%, and 3.1%/9.2% of patients, respectively. The respective 90-day, 3-year, and total (median follow-up of 54 months) mortality rates were significantly higher: in group A (40.3%, 63.6%, and 72.7%), compared to groups B (12.3%, 31.5%, and 39.0%) and C (4.9%, 17.3%, and 25.4%), p < 0.001; and in patients with thrombocytopenia at discharge (27.4%, 48.4%, and 51.6%), compared to those with normal PC (10.2%, 26.9%, and 35.4%) and thrombocytosis (8.9%, 17.8%, and 24.4%) at discharge (p < 0.001). Mortality rates were comparable among groups with thrombocytopenia, normal PC, and thrombocytosis at admission (p = 0.6). In the entire sample, each 100 × 109/l increment of ΔPC strongly predicted lower mortality (p < 0.001, relative risk 0.73, 95% confidence interval 0.64-0.83). In conclusion, PC changes are common among CAP inpatients. Rising PC throughout hospitalization is a powerful predictor of better survival, while declining PC predicts poor outcome. Evaluation of PC changes during hospitalization for CAP may provide useful prognostic information.

Changes in Red Cell Distribution Width During Hospitalization for Community-Acquired Pneumonia: Clinical Characteristics and Prognostic Significance.

PURPOSE: We investigated outcomes of patients hospitalized with community-acquired pneumonia (CAP) according to the changes in red cell distribution width (RDW). METHODS: For 980 adults, clinical characteristics, outcomes during hospitalization for CAP (transfer to the intensive care unit, treatment with mechanical ventilation, prolonged hospital stay, and death), and all-cause mortality following discharge were compared: according to RDW changes versus stable RDW during hospitalization, and according to normal (≤14.7 %) versus high (>14.7 %) RDW values on admission/discharge. RESULTS: RDW changes (n = 386) during hospitalization were associated with more severe clinical and laboratory characteristics than stable RDW (n = 594). Changes in RDW strongly predicted poor in-hospital outcomes (p < 0.001). The respective 30, 90-day, and total (median follow-up 54 months) mortality rates were significantly higher (9.8, 16.0 and 43.5 %) among patients with RDW changes, compared to 4.0, 7.6 and 30.5 % among those with stable RDW (p < 0.001 for all comparisons). RDW changes, as well as high RDW (each 1 % increment) on admission and discharge, were powerful predictors of mortality (the respective relative risks 1.41, 1.13, and 1.15, and 95 % confidence intervals 1.13-1.74, 1.08-1.19, and 1.10-1.21). CONCLUSIONS: RDW changes during hospitalization for CAP are common and associated with a severe clinical profile. Time-dependent RDW changes strongly predict poor in-hospital outcomes and increased short- and long-term mortality. Repeated RDW determinations during hospitalization for CAP may provide useful prognostic information.

Amlodipine treatment of hypertension associates with a decreased dementia risk.

Hypertension has been shown to be a risk factor for development of dementia. However, medical treatment of hypertension failed to reduce consistently the risk of dementia. Experimental study pointed to the possibility of difference between different calcium channel blockers (CCB) in their neuro-protective effect. The aim of our study was to evaluate the risk of dementia during treatment of hypertension with different CCBs. This is a retrospective cohort study based on electronic database of a large public health care organization. Study period was 11 years and it included patients aged 40-75 years old, having diagnosis of hypertension without diagnosis of dementia at the starting point, treated with either single specific CCB (study group) or with other than CCBs antihypertensive medications (control group) for at least 30 months during the study period. A total of 15,664 patients that satisfied these criteria were identified: 3,884 were treated with amlodipine, 2,062 were treated with nifedipine, 609 were treated with lercanidipine, and 9,109 never received CCBs. Dementia developed in 765 (4.9%) patients. Adjusted hazard ratio (HR) for dementia in patients treated with amlodipine, nifedipine, and lercanidipine was 0.60 (p < 0.001), 0.89 (NS), and 0.90 (NS). Decreased adjusted HR of dementia with amlodipine was demonstrated in the patients aged 60 or more (HR 0.61 [0.49-0.77], p < 0.001), but not in the patients aged less than 60 years old. This study shows that amlodipine therapy may be associated with a decreased dementia risk in hypertensive individuals older than 60 years, compared to those treated without CCBs.

Geriatric nutritional risk index, muscle function, quality of life and clinical outcome in hemodialysis patients.

BACKGROUND & AIMS: The geriatric nutritional risk index (GNRI) has been reported as a useful predictor of prognosis in maintenance hemodialysis (MHD) patients, demonstrating GNRI less than 90 as a marker of a poorer nutritional status and significantly increased mortality. We tested whether GNRI as a whole associated stronger with clinical and laboratory surrogates of nutrition and inflammation, muscle function, health-related quality of life (QoL), and predicts all-cause and cardiovascular (CV) morbidity and mortality in this population better than its individual components (albumin and body weight to ideal body weight ratio). METHODS: A prospective observational study with a median follow-up of 30 months (interquartile range - 19-41 months) was performed on 352 MHD outpatients (38.0% women) with a mean age of 67.4 ± 13.2 years. All-cause and cardiovascular hospitalization and mortality, GNRI, handgrip strength (HGS), body composition parameters (anthropometry and bioimpedance) and short form 36 (SF-36) quality-of-life scores were measured. Multivariate linear regression analyses were performed to obtain adjusted correlations. Receiver operating characteristic (ROC) curves were generated and multivariate Cox proportional hazards models were applied to identify the predictive value of GNRI and its components separately. RESULTS: GNRI positively correlated with total score (r = 0.15, P < 0.05), the physical health dimension (r = 0.14, P < 0.05), the general health (r = 0.18, P < 0.01) and some other scales of the SF-36. A significant correlation of GNRI with HGS in male patients didn't stand up to multivariable adjustments. For each one unit increase in baseline GNRI levels, the first hospitalization hazard ratio (HR) after adjustments for confounders was 0.98 (95% confidence interval (CI), 0.97 to 0.99) and the first CV event HR was 0.98 (95% CI, 0.97 to 0.99); all-cause death HR was 0.97 (95% CI, 0.96 to 0.99) and CV death HR was 0.97 (95% CI, 0.95-0.99). Albumin was related to QoL and clinical outcomes with higher strength and magnitude than GNRI. CONCLUSIONS: Despite the significant relationship with clinical outcomes and QOL, GNRI is not better and is even slightly worse than albumin's performance. This raises doubts as to the clinical utility of GNRI as a prognostic tool in the MHD population.

Longitudinal Study of Serum Uric Acid, Nutritional Status, and Mortality in Maintenance Hemodialysis Patients.

BACKGROUND AND OBJECTIVES: We hypothesized that longitudinal changes in uric acid (UA) may have independent associations with changes in nutritional parameters over time and consequently, long-term survival of patients on maintenance hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We conducted a retrospective, longitudinal cohort study of a clinical database containing the medical records of patients on maintenance hemodialysis receiving dialysis between June of 1999 and December of 2012 in a single center; 200 patients (130 men and 70 women) with a median age of 69.0 (interquartile range, 59.3-77.0) years old were included in the study. Dietary intake, biochemical markers of nutrition, anthropometric measurements, and UA levels were recorded at 0, 6, 12, 18, 24, 30, and 36 months followed by 15 additional months of clinical observations. The patients were followed until January 31, 2015 (median follow-up was 38.0 [interquartile range, 30.0-46.8] months). RESULTS: In a linear mixed effects model adjusted for baseline demographics and clinical parameters, each 1.0-mg/dl longitudinal increase in UA was associated with a 13.4% slower rate of decline in geriatric nutritional risk index (GNRI) levels over 3 years of observation (95% confidence interval [95% CI], 0.11 to 0.39; P<0.001 for UA × time interaction). UA remained associated with the rate of change in GNRI, even after controlling for C-reactive protein. During the follow-up, 87 (43.5%) all-cause and 38 (19.0%) cardiovascular deaths were reported. For each 1.0-mg/dl increase in serum UA over time, the multivariate adjusted all-cause mortality hazard ratio using Cox models with the effect of time-varying risk was 0.83 (95% CI, 0.74 to 0.95; P<0.01), which continued to be significant, even after including the baseline GNRI levels in this model: 0.89 (95% CI, 0.79 to 0.98; P=0.02). CONCLUSIONS: Longitudinal changes in serum UA seem to track with changes in nutritional status over time, and these changes are associated with survival of patients on maintenance hemodialysis. An increase in serum UA levels over time is accompanied by improvement of nutritional status and lower mortality rate.

Heart failure and orthostatic hypotension.

Orthostatic hypotension (OH) is traditionally defined as a fall of ≥20 mmHg in systolic and/or ≥10 mmHg in diastolic blood pressure within 3 min of active standing. OH is a common comorbidity among patients with heart failure (HF). A comprehensive review regarding the relationship between OH and HF has not been published in the English literature. Here we provide current information about concomitant HF and OH, including: pathophysiology, methods of evaluation, prevalence, risk factors, prognosis and management of OH in HF patients, as well as the incidence of HF among patients with OH. The prevalence of OH in HF ranges from 8 % among community-living individuals to 83 % in elderly hospitalized patients. Dizziness and palpitations are the most frequent OH symptoms. Main predisposing factors for OH are HF severity, non-ischemic HF etiology, prolonged bed rest, hypertension and polypharmacy. OH in HF is generally managed according to recommendations for treatment of OH in the non-HF population. However, since acceptable pharmacotherapy with fludrocortisone and midodrine is problematic in HF due to adverse effects, the management of OH is based mainly on non-pharmacologic interventions. Several prospective epidemiological studies reported that OH is independently associated with an increased risk of developing HF. Since OH is a common and frequently symptomatic condition in HF patients, its clinical implications should be emphasized. Longitudinal studies should be conducted to investigate the prognostic significance and optimal management of OH in the HF population.

Serum uric acid as a clinically useful nutritional marker and predictor of outcome in maintenance hemodialysis patients.

OBJECTIVE: The importance of serum uric acid (SUA) for the maintenance of a hemodialysis (MHD) population has not been well established. The aim of this study was to determine if SUA levels are associated with nutritional risk and consequently with adverse clinical outcomes in MHD patients. METHODS: This was a 2-y prospective observational study, performed on 261 MHD outpatients (38.7% women) with a mean age of 68.6 ± 13.6 y. We measured prospective all-cause and cardiovascular (CV) hospitalization and mortality, nutritional scores (malnutrition-inflammation score [MIS) and geriatric nutritional risk index (GNRI), handgrip strength (HGS), and short-form 36 (SF36) quality-of-life (QoL) scores. RESULTS: SUA positively correlated with laboratory nutritional markers (albumin, creatinine), body composition parameters, HGS (r = 0.26; P < 0.001) and GNRI (r = 0.34; P < 0.001). SUA negatively correlated with MIS (r = -0.33; P < 0.001) and interleukin-6 (r = -0.13; P = 0.04). Patients in the highest SUA tertile had higher total SF-36 scores (P = 0.04), higher physical functioning (P = 0.003), and role-physical (P = 0.006) SF-36 scales. For each 1 mg/dL increase in baseline SUA levels, the first hospitalization hazard ratio (HR) was 0.79 (95% confidence interval [CI], 0.68-0.91) and first CV event HR was 0.60 (95% CI, 0.44-0.82); all-cause death HR was 0.55 (95% CI, 0.43-0.72) and CV death HR was 0.55 (95% CI, 0.35-0.80). Associations between SUA and mortality risk continued to be significant after adjustments for various confounders including MIS and interleukin-6. Cubic spline survival models confirmed the linear trends. CONCLUSIONS: In MHD patients, SUA is a good nutritional marker and associates with body composition, muscle function, inflammation, and health-related QoL, upcoming hospitalizations, as well as independently predicting all-cause and CV death risk.