The paradoxical effect of aldosterone on cardiovascular outcome in maintenance hemodialysis patients.

BACKGROUND: Patients with end-stage kidney disease face increased risk of cardiovascular events, and left ventricular diastolic dysfunction (LVDD) contributes to the high occurrence of cardiovascular mortality (CM). Although a high serum aldosterone (sALD) level is involved in the development of cardiovascular complications in the general population, this association is unclear in patients undergoing hemodialysis. We aimed to determine the impact of sALD on LVDD and CM among hemodialysis patients (HDPs). METHODS: We performed a prospective cohort study of maintenance HDPs without cardiovascular disease. The patients were divided into two groups according to the median level of sALD. All patients underwent baseline echocardiography to evaluate diastolic dysfunction (E/e' ratio > 15). The LVDD and CM rates were compared between the high and low aldosterone groups. RESULTS: We enrolled a total of 60 adult patients (mean age, 57.9 ± 12.1 years; males, 30.0%). The low aldosterone group had an increased left ventricular diastolic dimension compared with the high aldosterone group (52.2 ± 8.4 mm vs. 50.3 ± 5.2 mm, respectively; p = 0.03). Low log-aldosterone (odds ratio [OR], 0.40; 95% confidence interval [CI], 0.19-0.86) and large left atrial dimension (OR, 1.31; 95% CI, 1.11-1.54) were independent risk factors for LVDD at baseline. In addition, Cox regression analysis demonstrated that low sALD was an independent predictor of CM in HDPs (hazard ratio, 0.46; 95% CI, 0.25-0.85; p = 0.01) during follow-up. CONCLUSION: Low sALD was not only associated with LVDD but was also an independent predictor of CM among HDPs regardless of their interdialytic weight gain.

Effects of the route of erythropoietin administration on hemoglobin variability and cardiovascular events in hemodialysis patients.

INTRODUCTION: Despite of the routine use of erythropoietin in hemodialysis patients to correct anemia, its administration route's effects on hemoglobin variability and cardiovascular events remain elusive. Herein, we determined different erythropoietin administration routes' effects on hemoglobin variability in hemodialysis patients and the associated factors of hemoglobin variability and cardiovascular events. METHODS: This is a post hoc analysis of a prospective, controlled, randomized, unblinded study with 78 Korean hemodialysis patients receiving intravenous (n = 40) or subcutaneous (n = 38) erythropoietin therapy. We evaluated hemoglobin variability by calculating the frequency of hemoglobin measurements outside the target range during all visits. The high-frequency group was defined by those with hemoglobin variability over the median value (25%) while the low-frequency group was defined by those with hemoglobin variability of <25%. RESULTS: In this analysis, 37 patients (51.1%) were male, and the mean age was 50.6 ± 12.5 years. The frequency of the value being outside the target hemoglobin range was higher in the subcutaneous group compared to the intravenous group (p = 0.03). The low-frequency group required significantly lower erythropoietin doses compared to the high-frequency group. In the adjusted Cox analysis, the parameter high group was a significant independent risk factor for cardiovascular events (p = 0.03). CONCLUSION: The risk out of the target hemoglobin range increased with subcutaneous administration compared with intravenous erythropoietin administration in hemodialysis patients. An increased frequency of the value being outside the target hemoglobin range was also associated with an increased risk of cardiovascular events.

Stepwise achievement of high convection volume in post-dilution hemodiafiltration: A prospective observational study.

High-volume online hemodiafiltration (HDF) has been reported to reduce the patient's mortality. However, achieving a high convection volume is challenging. In this prospective study, we investigated the feasibility of achieving high-volume HDF with ≥21 L substitution volume via modification of blood flow rate (BFR), needle size, and dialysis membrane. In 30 patients undergoing hemodialysis, we followed a stepwise protocol and gradually increased the BFR (280→300→330 ml/min; steps 1, 2, and 3) and needle size (16→15 G; step 4). After changing dialyzer surface area (1.8 m2 →2.5 m2 ), the BFR and needle size were similarly increased stepwise (steps 5, 6, 7, and 8). The mean substitution volume was 18.7 ± 2.2 L at step 1 and it significantly increased to 25.1 ± 2.6 L by step 8. A substitution volume of 21 L was achieved by 13.3% of patients in step 1 and by 96.7% after step 8. The substitution volume was higher for the dialyzer with a large surface area and for the larger needle (15 G). Between steps 1 and 8, the Kt/V and ß2 microglobulin reduction ratios also improved significantly. High-volume HDF is feasible through a stepwise increase in the BFR, needle size, and surface area of the dialysis membrane.

Comparison of Different Types of Oral Adsorbent Therapy in Patients with Chronic Kidney Disease: A Multicenter, Randomized, Phase IV Clinical Trial.

PURPOSE: Oral adsorbents delay disease progression and improve uremic symptoms in patients with chronic kidney disease (CKD). DW-7202 is a newly developed oral adsorbent with high adsorptive selectivity for uremic toxins. We evaluated patient preference for and adherence to DW-7202 versus AST-120 therapy and compared treatment efficacy and safety in patients with pre-dialysis CKD. MATERIALS AND METHODS: A seven-center, randomized, open-label, two-way crossover, active-controlled, phase IV clinical trial was conducted. Patients with stable CKD were randomly assigned to receive DW-7202 (capsule type) or AST-120 (granule type) for 12 weeks. The groups then switched to the other adsorbent and took it for the next 12 weeks. Patient preference was the primary outcome. Secondary outcomes included changes in estimated glomerular filtration rate (eGFR) and serum creatinine, cystatin C, and indoxyl sulfate (IS) levels. RESULTS: Significantly more patients preferred DW-7202 than AST-120 (p<0.001). Patient adherence improved after switching from AST-120 to DW-7202; there was no apparent change in adherence after switching from DW-7202 to AST-120. Changes in eGFR and serum creatinine, cystatin C, and IS levels were not significantly different according to adsorbent type. There was also no significant difference in the incidences of adverse events during treatment with DW-7202 and AST-120. CONCLUSION: DW-7202 can be considered as an alternative to AST-120 in patients who cannot tolerate or show poor adherence to granule type adsorbents. Further studies to evaluate factors affecting patient preferences and improved adherence are warranted (Clinical trial registration No. NCT02681952).

Effect of isolation practice on the transmission of middle east respiratory syndrome coronavirus among hemodialysis patients: A 2-year prospective cohort study.

Hemodialysis (HD) patients had a high rate of infection transmission and mortality during the middle east respiratory syndrome coronavirus (MERS-CoV) outbreak in Saudi Arabia. A standardized guideline on isolation technique for exposed HD patients is not available. Thus, this study aimed to evaluate the effect of different isolation strategies on the prevention of secondary viral transmission and clinical outcomes among exposed HD patients.During the 2015 MERS-CoV outbreak in Korea, 116 patients in 3 HD units were incidentally exposed to individuals with confirmed MERS-CoV infection and underwent different types of isolation, which were as follows: single-room isolation (n = 54, 47%), cohort isolation (n = 46, 40%), and self-imposed quarantine (n = 16, 13%). The primary outcome was rate of secondary viral transmission. The secondary outcome measures were changes in clinical and biochemical markers during the isolation period, difference in clinical and biochemical markers according to the types of isolation practice, and effect of isolation practice on patient survival.During a mean isolation period of 15 days, no further cases of secondary transmission were detected among HD patients. Plasma hemoglobin, serum calcium, and serum albumin levels and single-pool Kt/V decreased during the isolation period but normalized thereafter. Patients who were subjected to self-imposed quarantine had higher systolic and diastolic blood pressure, lower total cholesterol level, and lower Kt/V than those who underwent single-room or cohort isolation. During the 24-month follow-up period, 12 patients died. However, none of the deaths occurred during the isolation period, and no differences were observed in patient survival rate according to different isolation strategies.Although 116 participants in 3 HD units were incidentally exposed to MERS-CoV during the 2015 outbreak in Korea, strict patient surveillance and proper isolation practice prevented secondary transmission of the virus. Thus, a renal disaster protocol, which includes proper contact surveillance and isolation practice, must be established in the future to accommodate the needs of HD patients during disasters or outbreaks.

Diabetic retinopathy is a prognostic factor for progression of chronic kidney disease in the patients with type 2 diabetes mellitus.

Since both retinopathy and nephropathy are major diabetic microvascular complications, we investigated whether severity of diabetic retinopathy (DR) has adverse effects on renal function and albuminuria in the patients with type 2 diabetes mellitus (DM). We screened 2,197 adult patients with type 2 DM who had undergone fundus exam between August 2006 and February 2014. Among them, 1,592 subjects with available serial renal function and albuminuria measurement were included in the analysis. DR status was classified as no DR, non-proliferative DR (NPDR), and proliferative DR (PDR). The risk of CKD progression was assessed according to DR severity. A total of 384 (24.1%) had NPDR and 202 (12.7%) had PDR at either eye. The mean follow-up period was 5.6±2.1 years. DR was associated with lower body mass index, lower plasma hemoglobin, lower serum albumin level, longer duration of DM, poorer control of blood sugar, lower estimated glomerular filtration rate (eGFR), and greater amount of albuminuria. Interestingly, baseline DR severity was associated with faster renal function decline and greater albuminuria progression. In multivariate analysis, NPDR had 2.9 times and PDR had 16.6 times higher risk for CKD progression. Our findings showed that baseline DR severity is a prognostic factor for future CKD progression in type 2 DM patients. Therefore, clinicians must evaluate DR severity at the first visit and closely monitor renal function and albuminuria in the subjects with severe DR.

Malnutrition, inflammation, progression of vascular calcification and survival: Inter-relationships in hemodialysis patients.

BACKGROUND AND AIMS: Malnutrition and inflammation are closely linked to vascular calcification (VC), the severity of which correlate with adverse outcome. However, there were few studies on the interplay between malnutrition, inflammation and VC progression, rather than VC presence per se. We aimed to determine the relationship of malnutrition, inflammation, abdominal aortic calcification (AAC) progression with survival in hemodialysis (HD) patients. METHODS: Malnutrition and inflammation were defined as low serum albumin (< 40 g/L) and high hs-CRP (≥ 28.57 nmol/L), respectively. We defined AAC progression as an increase in AAC score using lateral lumbar radiography at both baseline and one year later. Patients were followed up to investigate the impact of AAC progression on all-cause and cardiovascular mortality. RESULTS: AAC progressed in 54.6% of 97 patients (mean age 58.2±11.7 years, 41.2% men) at 1-year follow-up. Hypoalbuminemia (Odds ratio 3.296; 95% confidence interval 1.178-9.222), hs-CRP (1.561; 1.038-2.348), low LDL-cholesterol (0.976; 0.955-0.996), and the presence of baseline AAC (10.136; 3.173-32.386) were significant risk factors for AAC progression. During the mean follow-up period of 5.9 years, 38(39.2%) patients died and 27(71.0%) of them died of cardiovascular disease. Multivariate Cox regression analysis adjusted for old age, diabetes, cardiovascular history, and hypoalbuminemia determined that AAC progression was an independent predictor of all-cause mortality (2.294; 1.054-4.994). CONCLUSIONS: Malnutrition and inflammation were significantly associated with AAC progression. AAC progression is more informative than AAC presence at a given time-point as a predictor of all-cause mortality in patients on maintenance HD.

Serum alkaline phosphatase and γ-glutamyl transferase in acute pyelonephritis.

BACKGROUND: Elevated serum alkaline phosphatase (AP) and γ-glutamyl transferase (γ-GT) are commonly observed in patients with acute pyelonephritis. The goal of this study was to examine the clinical significance of elevated serum AP and γ-GT levels and to explore the mechanisms underlying these changes. METHODS: We examined serum AP and γ-GT levels in 438 patients with acute pyelonephritis. Urine AP/creatinine (Cr), urine γ-GT/Cr, fractional excretion of AP, and fractional excretion of γ-GT (FEγ-GT) were evaluated in patients with elevated and normal serum levels. AP isoenzymes were also examined. RESULTS: We identified 77 patients (17.6%) with elevated serum AP and 134 patients (30.6%) with elevated serum γ-GT. Among them, both enzymes were elevated in 64 patients (14.6%). Older age, longer hospital stay, elevated baseline serum Cr, and complicated pyelonephritis were associated with increases in serum AP and γ-GT. Multivariate analysis showed that high serum AP levels were significantly correlated with renal impairment (odds ratio, 2.13; 95% confidence interval, 1.08-4.19; P = 0.029). FEγ-GT was significantly lower in patients with elevated serum enzyme levels. The liver fraction for AP isoenzyme profile did not increase in patients with elevated serum AP. CONCLUSION: Our results demonstrated that elevated serum AP and γ-GT levels are associated with complicated pyelonephritis and renal impairment. Lower FEγ-GT levels in patients with elevated serum enzymes may be the result of decreased urinary excretion of these enzymes.

Microsurgical approach for hemodialysis access: A pilot study of Brescia-Cimino fistulas constructed under microscopic guidance.

The distal forearm is the preferred site for hemodialysis access. However, forearm vessels have small diameter, which may lead to complications of arteriovenous fistulas constructed at this site. Indeed, the mean patency rate of such fistulas has been reported at 65.2% (range, 56-79%) at 1 year postoperatively. In this study, we aimed to evaluate the patency rate of Brescia-Cimino arteriovenous fistulas constructed under microscopic guidance. We retrospectively evaluated the records of patients with chronic renal failure who received a Brescia-Cimino arteriovenous fistula between 2014 and 2015 for hemodialysis access. Preoperative venography and Doppler mapping were used to evaluate vein diameter at the wrist. Veins with a diameter of >2 mm were chosen. End-to-side microanastomosis was performed using Nylon #9-0 suture under microscopic guidance. Postoperatively, monthly follow-up (first with venography; with Doppler ultrasound thereafter) was conducted to detect vessel obstruction and evaluate blood flow. Six of the seven patients included in this study received hemodialysis without signs of obstruction or complications. On Kaplan-Meier survival analysis, the mean patency rate at 2 years postoperatively was 85.7%. One patient (female, 60 years) had vessel obstruction and underwent percutaneous transluminal angioplasty 3 times after receiving the arteriovenous fistula. The median follow-up duration was 41 months (range, 25-47 months). Our experience indicates that, for relatively healthy vessels with a diameter of >2 mm, Brescia-Cimino arteriovenous fistulas at the wrist can be safely constructed using microsurgical suturing under microscopic guidance, without complications such as ischemic hand syndrome or infection.

Impact of sarcopenia on long-term mortality and cardiovascular events in patients undergoing hemodialysis.

BACKGROUND/AIMS: A high body mass index (BMI) is known to correlate with better survival in patients on hemodialysis (HD). However, the impacts of body composition and sarcopenia on survival have not been well studied in this population. METHODS: One hundred and forty-two prevalent HD patients were recruited and followed prospectively for up to 4.5 years. Low muscle mass (measured using a portable, whole-body, bioimpedance spectroscopic device) was defined as a lean tissue index (LTI) two standard deviations (SD) or more below the normal gender-specific mean for young people. Low muscle strength was a handgrip strength (HGS) of less than 30 kg in males and less than 20 kg in females. Sarcopenia was considered present when both LTI and HGS were reduced. RESULTS: The mean age was 59.8 ± 13.1 years; 57.0% were male and 47.2% had diabetes. Forty-seven patients (33.1%) had sarcopenia. During follow-up, 28 patients (19.7%) died, and low LTI (adjusted hazard ratio [HR], 2.77; 95% confidence interval [CI], 1.10 to 6.97) and low HGS (HR 5.65; 95% CI, 1.99 to 16.04) were independently associated with mortality. Sarcopenia was a significant predictor for death (HR, 6.99; 95% CI, 1.84 to 26.58; p = 0.004) and cardiovascular events (HR, 4.33; 95% CI, 1.51 to 12.43; p = 0.006). CONCLUSION: Sarcopenia was strongly associated with long-term mortality and cardiovascular events in HD patients. Assessment of muscle strength and muscle mass may provide additional prognostic information to survival in patients with end-stage renal disease.

Seropositive rate of the anti-hepatitis A immunoglobulin G antibody in maintenance hemodialysis subjects from two hospitals in Korea.

BACKGROUND/AIMS: Hepatitis A virus (HAV) is a self-limiting infectious disease, but 1% of subjects develop fulminant hepatitis. The prevalence of the anti-HAV immunoglobulin G (IgG) antibody in hemodialysis subjects in Korea remains unknown. The purpose of this study was to describe and compare the seropositive rate of anti-HAV antibody among hemodialysis subjects in two hospitals according to age group. METHODS: A total of 170 hemodialysis subjects were evaluated for the seropositive rate of the anti-HAV IgG antibody and its titer. RESULTS: Of the 170 maintenance hemodialysis subjects in two hospitals (Kangnam 92 vs. Chuncheon 78), 79 (46.5%) were male. The mean age was 53.2 years old, and 94.1% of the subjects were over 40 years old. The median vintage of hemodialysis was 29.0 months. Anti-HAV antibody was found in 163 subjects (95.9%), with no significant difference between the two areas (Kangnam 97.8% [n = 90] vs. Chuncheon 93.6% [n = 73]). Subjects younger than 40 years old showed a seropositive rate of 50%, while the seropositive rate increased with age for subjects aged 40 or older (p for trend < 0.001). Seropositive subjects from Kangnam showed a higher anti-HAV antibody titer than those from Chuncheon (median: Kangnam 14.2 vs. Chuncheon 11.7). Only age influenced seropositivity. The only factor that influenced the antibody level was the location of hospital (p < 0.001). CONCLUSION: The seropositive rate of the anti-HAV antibody in hemodialysis subjects was 95%, which is similar to findings in the general population. Active immunization against hepatitis A is strongly recommended for hemodialysis subjects under 40 years of age after anti-HAV testing.

Effects of aspirin resistance and mean platelet volume on vascular access failure in hemodialysis patients.

BACKGROUND/AIMS: Maintaining the patency of vascular access (VA) in hemodialysis (HD) patients is important and can be life-saving. We investigated the effects of aspirin resistance and mean platelet volume (MPV) on VA failure in HD patients. METHODS: We enrolled 163 patients on maintenance HD. VA failure was defined as thrombosis or a decrease of > 50% of the normal vessel diameter, as revealed by angiography. RESULTS: Aspirin resistance was observed in 17 of 109 patients in whom this parameter was measured, and was not significantly associated with VA failure (p = 0.051). The mean MPV was 9.15 ± 0.05 fL. The 163 patients were grouped by the median MPV value (9.08 fL) at baseline; patients with higher MPVs (n = 82) had lower platelet counts (p = 0.002) and albumin levels (p = 0.009). During 34 months of follow-up, 65 VA failures (39.9%) occurred. The Kaplan-Meier curve revealed significant differences between the two groups in terms of cumulative VA failure (54.1% vs. 35.3%, p = 0.018). On multivariate analysis, the MPV (hazard ratio [HR], 1.794; 95% confidence interval [CI], 1.066 to 3.020; p = 0.028), platelet count (HR, 1.003; 95% CI, 1.001 to 1.006; p = 0.01), and smoking status (HR, 1.894; 95% CI, 1.019 to 3.519; p = 0.043) independently predicted VA failure. CONCLUSION: A high MPV was associated with an increased risk of VA failure, whereas aspirin resistance showed only a weak association. The MPV may predict VA survival in HD patients.

Prediction of vascular access stenosis: Blood temperature monitoring with the Twister versus static intra-access pressure ratio.

BACKGROUND: The Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines recommend intra-access flow (Qa) measurement as the preferred vascular access surveillance method over static intra-access pressure ratio (SIAPR). Recently, it has become possible to perform Qa measurement during hemodialysis using thermodilution method called blood temperature monitoring (BTM) with the Twister device. The aim of this study was to investigate the correlation between Qa by BTM and SIAPR and to compare the performance of two tests in prediction of vascular access stenosis. METHODS: The study was performed from January 2016 to November 2017 and included 97 patients with arteriovenous fistulas (AVF). Qa by BTM and SIAPR were simultaneously measured every 1~3 months with a total of 449 measurements during study period. RESULTS: In our study population, mean age was 59.9±10.0 years and 61.9% were diabetes. The mean Qa obtained by BTM was 1186±588 mL/min. There was no correlation between Qa by BTM and venous SIAPR (r = 0.061, P = 0.196). Angiography identified 36 stenotic AVFs (37.1%) among the study subjects. They included 13 cases with only inflow stenosis, 6 with only outflow stenosis, and 17 with stenosis on both sides. Receiver-operating characteristic (ROC) curve analysis showed that Qa by BTM had higher discriminative ability to diagnose vascular access stenosis compared to SIAPR (P <0.001). The Qa less than 583 mL/min showed the highest diagnostic accuracy in vascular stenosis prediction. CONCLUSION: Intradialytic measurement of Qa by BTM showed better diagnostic power over venous SIAPR in prediction of vascular access stenosis.

Fat-to-Lean Mass Ratio Can Predict Cardiac Events and All-Cause Mortality in Patients Undergoing Hemodialysis.

BACKGROUND: Although higher body mass index (BMI) is associated with better survival in patients undergoing dialysis, BMI is not an adequate obesity indicator. We hypothesized that the fat-to-lean (F/L) mass ratio could be a suitable marker of nutritional status and evaluated its prognostic impact on long-term outcomes in patients undergoing hemodialysis (HD). METHODS: In total, 131 patients undergoing HD were recruited and monitored prospectively for up to 5 years. Body composition was analyzed, and other nutritional and inflammatory parameters were measured. RESULTS: The mean age of the cohort was 60.7 ± 13.6 years, and 65 patients were diabetic. Age, sex, diabetes, comorbidity, and inflammation were associated significantly with the F/L mass ratio. During the follow-up period, 21 patients experienced cardiac events and 22 patients died. Patients with higher F/L mass ratios had significantly higher risks of all-cause death (hazard ratio [HR] 3.61, 95% CI 1.07-12.13; p = 0.038) and cardiac events (HR 3.54, 95% CI 1.05-11.94; p = 0.041) than those with lower F/L mass ratios. CONCLUSIONS: The F/L mass ratio was a useful surrogate marker of nutritional and inflammatory status, and an independent predictor of cardiac events and all-cause mortality, in patients undergoing HD.

The relationship between intradialytic hypotension and vascular calcification in hemodialysis patients.

BACKGROUND: Vascular calcification is associated with structural and functional abnormality of the heart and blood vessels. We investigated the relationship between intradialytic hypotension (IDH) and vascular calcification in hemodialysis (HD) patients, and their impacts on cardiovascular events (CVEs). METHOD: We enrolled 191 maintenance HD patients who underwent plain abdomen radiography for abdominal aortic calcification score (AACS). A nadir systolic blood pressure (BP) < 90 mm Hg or the requirement of bolus fluid administration was required to quantify the hypotension diagnosis. IDH was defined as > 2 hypotension episodes during 10 HD treatments. RESULTS: Among the 191 patients, IDH occurred in 32. AACS was higher in the IDH group compared with the no-IDH group (8.4 ± 6.0 vs. 4.9 ± 5.2, respectively; P = 0.001). High AACS was an independent risk factor after adjustment for age, diabetes mellitus, ultrafiltration, diastolic BP, and calcium level (odds ratio (OR) = 1.09, 95% CI = 1.01-1.18; P = 0.03). Patients with both IDH and AACS ≧ 4 had the highest cumulative CVE rate (27.9%, P = 0.008) compared with 11.2%, 12.5%, and 6% for those with AACS ≧ 4 only, with IDH only, and neither, respectively. In multivariate analysis, the presence of both IDH and AACS ≧ 4 was a significant predictor of CVE (hazard ratio (HR) = 2.84, 95% CI = 1.04-7.74, P = 0.04). CONCLUSION: IDH is associated with abdominal aortic calcification and is an independent risk factor for IDH. Both IDH and high AACS were significant predictors of CVE.

Vascular calcification and cardiac function according to residual renal function in patients on hemodialysis with urination.

BACKGROUND: Vascular calcification is common and may affect cardiac function in patients with end-stage renal disease (ESRD). However, little is known about the effect of residual renal function on vascular calcification and cardiac function in patients on hemodialysis. METHODS: This study was conducted between January 2014 and January 2017. One hundred six patients with residual renal function on maintenance hemodialysis for 3 months were recruited. We used residual renal urea clearance (KRU) to measure residual renal function. First, abdominal aortic calcification score (AACS) and brachial-ankle pulse wave velocity (baPWV) were measured in patients on hemodialysis. Second, we performed echocardiography and investigated new cardiovascular events after study enrollment. RESULTS: The median KRU was 0.9 (0.3-2.5) mL/min/1.73m2. AACS (4.0 [1.0-10.0] vs. 3.0 [0.0-8.0], p = 0.05) and baPWV (1836.1 ± 250.4 vs. 1676.8 ± 311.0 cm/s, p = 0.01) were significantly higher in patients with a KRU < 0.9 mL/min/1.73m2 than a KRU ≥ 0.9 mL/min/1.73m2. Log-KRU significantly negatively correlated with log-AACS (ß = -0.29, p = 0.002) and baPWV (ß = -0.19, P = 0.05) after factor adjustment. The proportion of left ventricular diastolic dysfunction was significantly higher in patients with a KRU < 0.9 mL/min/1.73m2 than with a KRU ≥ 0.9 mL/min/1.73m2 (67.9% vs. 49.1%, p = 0.05). Patients with a KRU < 0.9 mL/min/1.73m2 showed a higher tendency of cumulative cardiovascular events compared to those with a KRU ≥ 0.9 ml/min/1.73m2 (P = 0.08). CONCLUSIONS: Residual renal function was significantly associated with vascular calcification and left ventricular diastolic dysfunction in patients on hemodialysis.

Effects of low calcium dialysate on the progression of coronary artery calcification in hemodialysis patients: An open-label 12-month randomized clinical trial.

BACKGROUND: The association between the dialysate calcium level and coronary artery calcification (CAC) has not yet been evaluated in hemodialysis patients. The objective of this study was to determine whether lowering the dialysate calcium levels would decrease the progression of coronary artery calcification (CAC) compared to using standard calcium dialysate. METHODS: We conducted an open-label randomized trial with parallel groups. The patients were randomly assigned to either 12-month treatment with low calcium dialysate (LCD; 1.25mmol/L, n=36) or standard calcium dialysate (SCD; 1.5mmol/L, n=40). The primary outcome was the change in the CAC scores assessed by 64-slice multidetector computed tomography after 12months. RESULTS: During the treatment period, CAC scores increased in both groups, especially significant in LCD group (402.5±776.8, 580.5±1011.9, P=0.004). When we defined progressors as patients at second and third tertiles of CAC changes, progressor group had a higher proportion of LCD-treated patients than SCD-treated patients (P=0.0229). In multivariate analysis, LCD treatment is a significant risk factor for increase in CAC scores (odds ratio=5.720, 95% CI: 1.219-26.843, P=0.027). CONCLUSIONS: Use of LCD may accelerate the progression of CAC in patients with chronic hemodialysis over a 12-month period. TRIAL REGISTRATION: Clinical Research Information Service [Internet]; Osong (Chungcheongbuk-do): Korea Centers for Disease Control and Prevention, Ministry of Health and Welfare (Republic of Korea), 2010: KCT0000942. Available from: https://cris.nih.go.kr/cris/search/search_result_st01_kren.jsp?seq=3572&sLeft=2&type=my.

Acid-base disorders after orthotopic bladder replacement: comparison of an ileal neobladder and an ileal conduit.

OBJECTIVES: For many years, creation of an orthotopic neobladder after cystectomy has been popular. In the present study, we measured the extent of metabolic acidosis in patients with ileal neobladders compared with ileal conduits and defined risk factors for development of metabolic acidosis. METHODS: We retrospectively studied 95 patients, who underwent radical cystectomy and urinary diversion to treat invasive bladder cancer from January 2001 to December 2014 at Hallym University Kangnam Sacred Heart Hospital, through investigation of acid-base balance, serum electrolyte levels and renal function one month and one year after operation. RESULTS: One month after the operation, metabolic acidosis was found from 18 patients (31.0%) in an ileal neobladder group and from 4 (14.8%) in an ileal conduits group. One year after the operation, the numbers became 11 (22.9%) and 2 (10.0%), respectively. However, there was not a statistical difference. The blood biochemical profiles of the two groups did not differ significantly after urinary diversion. Logistic analysis revealed that lower estimated glomerular filtration rate (eGFR) was associated with metabolic acidosis at one month (odds ratio, OR = 0.94 [0.91-0.97]; p < 0.001) and one year (OR = 0.94 [0.92-0.97]; P = 0.001) after urinary diversion. In multivariate analysis, lower eGFR is a significant risk factor for metabolic acidosis at one month. CONCLUSIONS: Patients with ileal neobladders and conduits are at the similar risk of metabolic acidosis. A close association between renal function and development of metabolic acidosis was observed, especially stronger in an early period after operation.

Extracellular Fluid/Intracellular Fluid Volume Ratio as a Novel Risk Indicator for All-Cause Mortality and Cardiovascular Disease in Hemodialysis Patients.

BACKGROUND: In hemodialysis patients, fluid overload and malnutrition are accompanied by extracellular fluid (ECF) expansion and intracellular fluid (ICF) depletion, respectively. We investigated the relationship between ECF/ICF ratio (as an integrated marker reflecting both fluid overload and malnutrition) and survival and cardiovascular disease (CVD) in the context of malnutrition-inflammation-arteriosclerosis (MIA) complex. METHODS: Seventy-seven patients from a single hemodialysis unit were prospectively enrolled. The ECF/ICF volume was measured by segmental multi-frequency bioimpedance analysis. MIA and volume status were measured by serum albumin, C-reactive protein (CRP), pulse wave velocity (PWV) and plasma B-type natriuretic peptide (BNP), respectively. RESULTS: The mean ECF/ICF ratio was 0.56±0.06 and the cut-off value for maximum discrimination of survival was 0.57. Compared with the low ECF/ICF group, the high ECF/ICF group (ratio≥0.57, 42%) had higher all-cause mortality, CVD, CRP, PWV, and BNP, but lower serum albumin. During the 5-year follow-up, 24 all-cause mortality and 38 CVD occurred (18 and 24, respectively, in the high ECF/ICF group versus 6 and 14 respectively in the low ECF/ICF group, P<0.001). In the adjusted Cox analysis, the ECF/ICF ratio nullifies the effects of the MIA and volume status on survival and CVD and was an independent predictor of all-cause mortality and CVD: hazard ratio (95% confidence interval); 1.12 (1.01-1.25) and 1.09 (1.01-1.18) for a 0.01 increase in the ECF/ICF ratio. The degree of malnutrition (albumin), inflammation (CRP), arteriosclerosis (PWV), and fluid overload (BNP) were correlated well with the ECF/ICF ratio. CONCLUSIONS: Hemodialysis patients with high ECF/ICF ratio are not only fluid overloaded, but malnourished and have stiff artery with more inflammation. The ECF/ICF ratio is highly related to the MIA complex, and is a major risk indicator for all-cause mortality and CVD.

Increased urinary Angiotensinogen/Creatinine (AGT/Cr) ratio may be associated with reduced renal function in autosomal dominant polycystic kidney disease patients.

BACKGROUND: Autosomal dominant polycystic kidney disease (ADPKD) is one of the most common hereditary kidney diseases that frequently result in renal failure. In this cross-sectional observational cohort study, we evaluated urinary angiotensinogen (AGT) as a potential biomarker to assess renal function in ADPKD. METHODS: Urinary AGT was measured in 233 ADPKD patients and its association with estimated glomerular filtration rate (eGFR) and height-adjusted total kidney volume (htTKV) were evaluated. The localization of AGT and other renin-angiotensin system (RAS)-related molecules were identified using immunohistochemistry in human ADPKD tissues. RESULTS: Baseline urinary AGT/Cr was negatively correlated with CKD-EPI eGFR (r(2) = 0.162, P < 0.001) and positively correlated with htTKV (r(2) = 0.107, P < 0.001). Both urinary AGT/Cr and plasma renin activity levels were significantly elevated in hypertensive ADPKD patients. Among hypertensive subjects, urinary AGT/Cr was significantly increased in the advanced CKD stages (III-V) compared to early CKD stages (I-II) (28.6 ± 60.3 vs. 93.2 ± 139.3 µg/g, P < 0.001). Immunohistochemical study showed strong expression of AGT along the cyst-lining epithelial cells as well as the nearby compressed tubular epithelial cells. CONCLUSIONS: Our results suggested that urinary AGT/Cr may be a valuable biomarker for renal damage in ADPKD since intrarenal ischemic insults induced by cyst growth and subsequent intrarenal RAS activation may play a potential role in the development of hypertension and renal dysfunction in ADPKD.