Non-traditional risk factors for coronary calcification and its progression in patients with type 2 diabetes: The impact of postprandial glycemia and fetuin-A.

OBJECTIVE: This study was performed to assess the impact of risk factors on the presence and progression of coronary calcification in patients with type 2 diabetes. METHODS: We prospectively enrolled 45 patients without cardiovascular or kidney disease. Coronary calcification was measured with multidetector computed tomography at baseline and 18 months. We also measured blood pressure; body mass index; serum levels of calcium, phosphate, and 25-hydroxyvitamin D; mineral bone density; and levels of alkaline phosphatase, parathormone, fetuin-A, high-sensitivity C-reactive protein, fibrinogen, albumin, homocysteine, lipids, HbA1c, and average preprandial and postprandial blood glucose at 18 months. Information about severe hypoglycemia and smoking was recorded. Spearman's correlation coefficients were calculated. Multiple linear regression was used for the multivariate analysis. RESULTS: The median baseline calcium score was 63, and that at 18 months was 100. In the univariate analysis, albumin was significantly correlated with the baseline calcium score. Fetuin-A and postprandial glycemia were correlated with calcium score progression. In the multivariate model, postprandial glycemia and fetuin-A were independently associated with calcium score progression. CONCLUSIONS: Fetuin-A and postprandial glycemia influence coronary calcification progression in patients with type 2 diabetes. The absence of some correlations could be due to pharmacological treatments for cardiovascular risk reduction.

Determinants of maternal vitamin D concentrations in Slovenia : A prospective observational study.

OBJECTIVE: To analyze the vitamin D status of pregnant women in Slovenia and the factors influencing it. METHODS: The study was performed in Maribor University Medical Centre (location 46°N). Maternal serum 25-hydroxy-vitamin D (25(OH)D) in 4 groups of 100 pregnant women in 4 different seasons of the year was measured at the time of delivery. Data on life style, eating habits, sunbathing and intake of vitamin D supplements during pregnancy were obtained using a questionnaire. Information on maternal outcome was acquired from medical records. Duration of sunlight and average temperature in the month preceding delivery were calculated from meteorological data. RESULTS: The average maternal 25(OH)D concentration ranged from 28.5 ± 17.1 nmol/l in March to 54.8 ± 24.1 nmol/l in June (p < 0.001). Severe vitamin D deficiency, i.e. <25 nmol/l 25(OH)D was present in 23.6% of women overall. In multiple regression analysis supplements containing vitamin D (ß = 0.225, p < 0.001) and duration of intentional exposure to sunlight (ß = 0.192, p = 0.026) were associated with maternal 25(OH)D status. Significantly lower vitamin D levels were observed in women who had a cesarean section (t = 2.053, p = 0.041) and those with premature delivery (t = 2.296, p = 0.022). Vitamin D levels were not associated with the occurrence of gestational diabetes, gestational hypertension or infections during pregnancy. CONCLUSION: A high prevalence of vitamin D deficiency was detected at the end of pregnancy, especially in the months following autumn and winter and in women who did not take supplements containing vitamin D.

Problem-based learning in internal medicine: virtual patients or paper-based problems?

BACKGROUND: Teaching using paper problem-based learning (p-PBL) sessions has left some students fatigued with the learning process. Therefore, attempts have been made to replace p-PBL with digitally enhanced, decision-making PBL in the form of virtual patients (VP). Student enthusiasm for substituting p-PBL with VP has not been quantitatively evaluated on the intended educational effects. AIM: To determine the educational effects of substituting p-PBL sessions with VP on undergraduate medical students in their internal medicine course. METHODS: We conducted a randomised controlled study on 34 third-year undergraduate medical students in the academic year 2015-2016. Student performance after an intervention substituting p-PBL sessions with VP was analysed. The educational outcomes were measured with knowledge exams and the Diagnostic Thinking Inventory. RESULTS: There was no difference in exam performance between groups (P > 0.833) immediately after the intervention, or in long term. Nor was there a significant difference in improvement of diagnostic thinking between groups (P > 0.935 and P > 0.320). CONCLUSIONS: Our study showed no significant improvement in diagnostic thinking abilities or knowledge exam results with the use of VP. Educators can add VP to sessions to motivate students, but a significant improvement to educational outcome should not be expected.

A new serum cystatin C formula for estimating glomerular filtration rate in newborns.

BACKGROUND: The levels of serum cystatin C (CysC) and creatinine (Cr) were determined in small-for-gestational-age (SGA) babies and compared with those for normal term newborns appropriate for gestational age (AGA), at birth and 3 days later. We then compared a number of cysC-based, Cr-based and combined formulas for estimation of glomerular filtration rate (GFR) with the neonatal reference GFR. METHODS: Fifty full-term SGA and 50 AGA newborns were enrolled in the study. Kidney volume measurements were performed by ultrasound for each newborn. RESULTS: At birth, the mean level of CysC in SGA babies was 1.48 ± 0.30 mg/l in cord blood and 1.38 ± 0.18 mg/l in day 3 blood samples, and the mean Cr level, determined simultaneously, was 67.08 ± 17.62 and 55.62 ± 14.91 µmol/l, respectively. These levels did not differ significantly from those determined in AGA babies. A 10 % reduction in kidney volume was associated with an increase in CysC value of 9.3 % in cord blood. The Cr-based and Schwartz-combined equations underestimated GFR relative to CysC-based and Zappitelli-based equations at birth and 3 days later. CONCLUSIONS: A newly constructed Cys-C based formula which includes kidney volume and body surface area in the calculations for GFR is a reliable marker of GFR compared with neonatal reference clearance values.

Seasonal variations of vitamin D concentrations in pregnant women and neonates in Slovenia.

OBJECTIVE: While foreign research shows a high prevalence of vitamin D deficiency in pregnant women and consequently in neonates, we do not have any data on vitamin D concentration in these risk groups for Slovenia. We performed a prospective study to evaluate vitamin D concentration in pregnant women and neonates in Maribor region. STUDY DESIGN: We determined 25-hydroxy-vitamin D concentration from blood samples taken before delivery from 100 pregnant women who gave birth in Maribor University Clinical Centre in September and December 2013, respectively, and from the cord blood of their neonates. We collected data on nutrition and sun exposure during pregnancy. We calculated the vitamin D concentrations in pregnant women and neonates according to season of birth and use of nutrition supplements, determined the vitamin D levels in some pregnancy complications and checked the correlation of maternal and neonatal vitamin D concentrations. RESULTS: The average vitamin D concentration in the September group was 54.3±25.2nmol/L, and in the December group 33.3±18.6nmol/L (p<0.001). Optimal vitamin D concentration (>80nmol/L) was reached by 12.0% of pregnant women in September and by only 2.0% in December. Women who took nutrition supplements containing vitamin D during pregnancy had significantly higher vitamin D levels than those who did not (September 68.9±27.0nmol/L vs. 46.5±20.3nmol/L, p<0.001; December 38.7±17.9nmol/L vs. 30.2±18.4nmol/L, p=0.028). Neonates had higher average levels of vitamin D than their mothers but there was a good correlation between maternal and neonatal vitamin D values. CONCLUSION: Vitamin D deficiency is very common in pregnant women in Slovenia as well, especially in winter and in those women who do not take nutrition supplements containing vitamin D.

Serum cystatin-C as a marker of acute kidney injury in the newborn after perinatal hypoxia/asphyxia.

We evaluated cystatin-C (cysC) in the umbilical blood as a predictor of acute kidney injury (AKI) after perinatal hypoxia/asphyxia compared with creatinine (Cr). One hundred full-term newborns were enrolled in the study (50 in a group affected by perinatal hypoxia/asphyxia [AS] and 50 controls). CysC and Cr were measured in blood samples from the umbilical cord at birth (cysC-umb and Cr-umb) and from a peripheral vein 3 days later (cysC-3 and Cr-3). At birth, the mean level of cysC in healthy term babies was found to be 1.39 ± 0.19 mg/L and 1.34 ± 0.21 mg/L after 3 days of life, not significantly decreased (P = 0.137). The mean of cysC in the AS group was 2.12 ± 0.53 mg/L in cord blood and 1.56 ± 0.32 g/L in day 3 blood samples, also decreased (P < 0.001) and different from the control (P < 0.001). Cr levels, determined simultaneously at birth were different (P = 0.001) between the control (62.74 ± 12.84 µmol/L) and AS (72.60 ± 15.55 µmol/L) group, significantly decreased after 3 days in both groups (P < 0.001). The receiver-operating characteristic curve analysis, comparing AS and the control group, showed area under the curve for cysC-umb, cysC-3, Cr-umb and Cr-3 (0.918; 0.698; 0.692; 0.660). The highest diagnostic accuracy was achieved with a chosen cut-off for cysC-umb of 1.67 mg/L (sensitivity of 84.0%, specificity of 90.0%) or 1.69 mg/L (sensitivity of 82.0%, specificity of 94.0%). Our results indicate serum CysC is a more sensitive marker of glomerular filtration rate than Cr in the newborns.

Ankle-brachial index and cardiovascular mortality in nondiabetic hemodialysis patients.

Atherosclerosis is a leading cause of morbidity and mortality in hemodialysis (HD) patients. Low (<0.90) and high (>1.40) ankle-brachial index (ABI) is known as a non-invasive diagnostic marker for generalized atherosclerosis associated with higher cardiovascular (CV) mortality in the general population. Less is known about associations between ABI and CV mortality in HD patients. The aim of our study was to determine the impact of the ABI on CV mortality in nondiabetic HD patients. Fifty-two nondiabetic HD patients (mean age 59 years, range 22 - 76 years) were enrolled in our study. Twenty-three (44%) were women and 29 (56%) men. The ABI was determined using an automated, non-invasive, waveform analysis device. All patients were divided according to the ABI into three groups: low ABI (<0.9), normal ABI (0.9-1.4) and high ABI (>1.4). The presence of arterial hypertension and smoking was established. Serum cholesterol (HDL and LDL) and triglycerides were measured by routine laboratory methods. Survival rates were analyzed using Kaplan-Meier survival curves. The Cox regression model was used to assess the influence of the ABI on CV outcomes. The model was adjusted for age, arterial hypertension, smoking, cholesterol and triglycerides. Mean ABI value was 1.2 ± 0.3 (range 0.2-2.2). Patients were observed from the date of the ABI measurement until their death or maximally up to 1620 days. Kaplan-Meier survival analysis showed that the risk for CV death was higher for HD patients with low and high ABI compared to normal ABI (log rank test: P < 0.006; P < 0.0001). In the adjusted Cox multivariable regression model low and high ABI (P < 0.011; P < 0.003) remained predictors of mortality in our patients. The results indicate a U-shaped association between the ABI and CV mortality in nondiabetic HD patients and showed that low and high ABI were directly associated with higher mortality of our patients.

Prognostic value of 48-hour ambulatory blood pressure measurement and cardiovascular mortality in hemodialysis patients.

BACKGROUND: Hypertension is common and contributes to high cardiovascular morbidity and mortality in hemodialysis (HD) patients. It is unknown which blood pressure (BP) better defines the influence on cardiovascular mortality. The purpose of our study was to analyze the relationship between various BP measurements, traditional risk factors, markers of asymptomatic atherosclerosis [left ventricular mass (LVM), carotid intima media thickness (IMT)], and cardiovascular mortality in HD patients. METHODS: Seventy-three patients (44 males and 29 females; mean age: 54.2 years) were included. BP was measured before and after HD and 48-hour ambulatory blood pressure monitoring (ABPM) was performed. Using sonography, the LVM index and carotid IMT were measured. RESULTS: During a follow-up period up to 3,664 days, 28 patients died - 16 of them from cardiovascular causes. In a Cox regression model, which included age, gender, smoking, diabetes, sensitive C-reactive protein, albumin, hemoglobin, troponin T, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglycerides, calcium, phosphorus, carotid IMT, and LVM index, only 48-hour systolic ABPM (p = 0.037) and 48-hour diastolic ABPM (p = 0.006) turned out to be independent predictors of cardiovascular death. CONCLUSION: Only 48-hour ABPM and not single BP measurements before or after HD were associated with cardiovascular mortality in HD patients.

Blood pressure measurements and left ventricular mass index in hemodialysis patients.

Left ventricular hypertrophy (LVH) is the most frequent cardiac abnormality in hemodialysis (HD) patients. It is related to cardiovascular diseases and is an important risk factor for mortality in HD patients. Arterial hypertension is an established risk factor for LVH in HD patients. Inferior vena cava (IVC) diameter is a good indicator of circulating fluid volume; hypervolemia is an important pathogenetic factor of hypertension in HD patients. The purpose of our study was to evaluate possible association between LVH, IVC diameter, and different blood pressure (BP) measurements in HD patients. In the present study, 85 HD patients were included. BP was measured with a standard mercury sphygmomanometer before and after the HD session; the average 1-monthly values of the routine BP measurements were also analyzed. 24- and 48-h ambulatory blood pressure measurements (ABPMs) were performed after the end of HD sessions using a noninvasive ABPM. Average values of systolic and diastolic BP were analyzed separately for the first (HD) and second (interdialytic) day ABPM and for both days together. Using echocardiography, left ventricular mass was measured and left ventricular mass index (LVMI) was calculated. Using ultrasonography, IVC diameter was measured on the interdialytic day. Using multiple regression analysis, we found statistically significant correlations between LVMI and mean monthly postdialysis systolic BP (P < 0.05) and mean 48-h diastolic BP (P < 0.05). Only longer BP measurements (average 1-month post-HD and 48-h ABPM) were associated with LVMI in HD patients.

Fetuin-A as a risk factor for mortality in hemodialysis patients.

OBJECTIVES: Fetuin A, a circulating inhibitor of calcification, is regulated as a negative acute-phase protein. However, its relationship with outcomes of patients undergoing hemodialysis has not been well evaluated. The aim of our study was to determine the association between fetuin-A and some factors of metabolism and their impact on all-cause mortality in hemodialysis patients. PATIENTS AND METHODS: The study comprised 106 hemodialysis patients, 45 of whom were women. Levels of serum fetuin-A were measured by ELISA and serum intact parathyroid hormone (iPTH) by immunoassay in each patient. Serum Ca, serum P, Ca x P product, alkaline phosphatase, cholesterol, triglycerides, bicarbonate, albumin, homocysteine and C-reactive protein (CRP) were measured using routine laboratory methods. Survival rates were analyzed using Kaplan-Meier survival curves. A Cox regression model was used to access the possible influence of variables on all-cause mortality. RESULTS: The mean value of fetuin-A was 15.3 +/- 3.8 g/l, range 5.5-23.7 g/l. Significant correlations were found between serum fetuin-A and serum iPTH (r = -0.239; P = 0.014), alkaline phosphatase (r = -0.240; P = 0.013), triglycerides (r = +0.236; P = 0.015) and serum albumin level (r = +0.286; P = 0.003). Patients were followed-up prospectively from the first day of the laboratory measurement for a maximum of 752 days or until death. A total of 24 patients died. Surviving patients had higher levels of fetuin-A (P = 0.005), serum cholesterol (P = 0.0001), triglycerides (P = 0.004), albumin (P = 0.0001) and homocysteine (P = 0.028). Kaplan-Meier survival analysis showed higher mortality in the first tertile of fetuin-A than in the third tertile (P = 0.0297). In our patients, serum Ca (P = 0.025), serum P (P = 0.040) and the Ca x P product (P = 0.039) were found to be predictors of mortality in the Cox multivariable regression model. CONCLUSIONS: In patients undergoing hemodialysis, lower fetuin-A levels are associated with higher mortality. Metabolism of Ca and P were directly associated with higher mortality.

Vitamin D as a novel nontraditional risk factor for mortality in hemodialysis patients.

We examined the prevalence of vitamin D deficiency in hemodialysis patients and tested the hypothesis that decreased levels of 25-hydroxyvitamin D (25D) are associated with an increased risk for early all-cause mortality. One hundred and two patients, 57 (56%) men and 45 (44%) women, mean age 60.5 +/- 13.1 years, were included in our study. Serum calcium and phosphorus levels were measured by routine laboratory methods. Parathyroid hormone (PTH) was measured by immunoassay and 25D by enzyme immunoassay. Patients were divided into two groups depending on the serum concentration of 25D: below or above 50 nmol/L. Survival rates were analyzed using the Kaplan-Meier survival curves. The Cox regression model was used to define potential variables effecting all-cause mortality. The mean level of 25D in all patients was 58 +/- 35.6 nmol/L, 52% of patients had 25D levels >50 nmol/L and 48% had levels of 10.5-50 nmol/L. Compared with men, women were more likely to be 25D deficient (67% vs. 37%; P = 0.005). Patients were observed from the date of laboratory measurement until their death or to a maximum of 730 days. Kaplan-Meier survival analysis showed that mortality in patients was significantly higher in the group with 25D levels < or =50 nmol/L (P < 0.033). With Cox multivariable regression modeling, the PTH level (P < 0.029) turned out to be the only predictor of mortality in our patients. Using the definitions recommended in the National Kidney Foundation Kidney Disease Outcomes Quality Initiative guidelines, we found that our hemodialysis patients on average have vitamin D insufficiency. Our results indicate that patients with 25D levels < or =50 nmol/L are associated with higher all-cause early mortality.

Blood pressure measurements and carotid intima media thickness in hemodialysis patients.

In hemodialysis (HD) patients, routine dialysis center blood pressure (BP) measurements may be a poor indicator of BP control. Ambulatory blood pressure monitoring (ABPM) improves the predictability of BP as a risk factor for target organ damage. Carotid intima-media thickness (IMT) is an important indicator of asymptomatic atherosclerosis and a predictor of cardiovascular events. The purpose of our study was to evaluate the possible association between different BP measurements and carotid IMT in HD patients. Eighty-five HD patients were included in our study. BP was measured with a standard mercury sphygmomanometer before and after each HD session. The average one-monthly values of routine BP measurements were also analyzed. 24- and 48-h ABPM was performed after the end of each HD session using non-invasive ABPM. The average values of systolic and diastolic BP were analyzed separately for the first (HD) and second (interdialytic) days ABPM, and for both days together. Using B-mode ultrasonography, carotid IMT was measured and plaque occurrence investigated. We found a statistically significant correlation between carotid IMT and the average one-monthly pre-HD diastolic BP (P < 0.05), diastolic BP on the HD-day ABPM, the interdialytic-day ABPM, and during 48-h ABPM (P < 0.05). By multiple regression analysis, we found a statistically significant correlation only between carotid IMT and diastolic BP on the HD-day ABPM, the interdialytic-day ABPM, and during 48-h ABPM (P < 0.05). Only longer BP measurements (24- and 48-h ABPM) were associated with carotid IMT in HD patients.

Non-insertion-related complications of central venous catheterization--temporary vascular access for hemodialysis.

The authors analyzed 309 central venous catheters (CVC) inserted in 147 hemodialysis patients before the maturation of the first or new arteriovenous fistula. One clinical manifestations of sepsis after CVC insertion was found. In all, 33.7% of the catheters were removed because of early minor complications: CVC occlusion, inadequate blood flow in CVC, shattered suture and malposition of CVC, fever, signs of infection at the site of CVC insertion, and bleeding at the site of CVC insertion. The most frequently isolated pathogenic bacteria at the tips of the catheters were coagulase-negative staphylococci highly sensitive to vancomycin and gentamicin.

Cystatin C versus creatinine as a marker of glomerular filtration rate in the newborn.

AIM: Serum cystatin C (cysC) has been proposed as a promising endogenous marker of glomerular filtration rate (GFR) in adults and children. The aim of this study was to determine the reference values of cysC at birth and three days later in comparison with creatinine (Cr) and Schwartz's estimated clearance. PATIENTS AND METHODS: 75 newborns (42 boys, 33 girls) were enrolled in the study. The gestational age ranged from 34 to 41 weeks, and the birth weight from 2070 to 4410 g. Blood samples were taken from the umbilical cord at birth and from a peripheral vein three days after birth. CysC and Cr were measured in all serum samples and values analyzed in different subgroups of neonates according to sex, gestational age, birth weight, umbilical blood pH, the influence of bilirubin, hemoglobin and hydration state. The Mann-Whitney U-test and Wilcoxon's analysis were used. RESULTS: At birth, serum cysC values ranged from 1.38 to 3.23 mg/l, not significantly decreasing after 3 days of life. Cr levels, determined simultaneously at birth, ranged from 34 to 99 mumol/l and were also not significantly different from day 3 levels. Both CysC and Cr levels were independent of sex, gestational age, birth weight, bilirubin levels and hydration state. CysC correlated positively only with the hemoglobin level (r = 0.28, P = 0.01) and negatively with cord blood pH (r = -0.40, P = 0.001), similarly to Cr. Significant correlation was found between cysC and Cr in umbilical cord blood (r = 0.30, P = 0.006) and day 3 blood samples (r = 0.37, P = 0.001). No correlation was found between 1/cysC and Schwartz GFR in cord blood (r = 0.18, P = 0.18), but correlation became significant in day 3 blood samples (r = 0.27, P = 0.02). CONCLUSION: This study suggests that cysC is not more sensitive than Cr as a marker of GFR in the newborn.

Cardiovascular calcification in patients with end-stage renal disease.

Vascular calcifications are very frequent extraosseous calcifications in patients with chronic renal disease. They occur in the intima and in the media. They are associated with decreased arterial elasticity and increased mortality. The risk factors are: advanced age, duration of dialysis treatment, diabetes, increased phosphate concentration, the dose of Ca-containing phosphate binders and inflammation. It is now well established that vascular smooth muscle cells actively take up phosphate to form bioapatite. This process is associated with a phenotypic transformation of vascular smooth muscle cells during which they express osteoblast markers. Lipids and inflammatory cytokines also increase bioapatite formation. Calcification inhibitors are matrix Gla protein and fetuin-A. Decreased serum fetuin-A concentration is associated with a higher mortality rate in dialysis patients. An important preventive measure for vascular calcification is the substitution of Ca-containing by non-Ca-containing phosphate binders.

[Comparison of the intact PTH test with the total PTH test in hemodialyzed patients]. / Usporedba intaktnog PTH testa s ukupnim PTH testom u hemodijaliziranih bolesnika.

We measured PTH by intact PTH assays (iPTH) and whole PTH kit. iPTH includes 1-84 PTH (CAP) and the PTH antagonist fragment (CIP). The CAP/CIP ratio more precisely indicates the net relative actions of the agonist PTH (CAP) and the antagonist PTH fragment (CIP). The CAP/CIP ratio > 1 identifies patients with normal or high bone turnover disease, and the CAP/CIP ratio < 1 indicates patients with adynamic low bone turnover disease. Serum samples were obtained from 98 hemodialysis patients. We measured iPTH with intact PTH assay (PTH, intact Elecsys Systeme, Roche), and whole PTH with Duo PTH Assay (Scantibodies Laboratories, Santee, CA, USA), which determine human whole PTH or Cyclase Activating PTH (CAP) as well as total immunoreactive PTH (the sum of 1-84PTH and N truncated PTH fragments). Cyclase inactive PTH (CIP) is an inactive fragment 7-84 PTH and is calculated as total PTH--CAP. For the evaluation of bone turnover, the activity of serum alkaline phosphatase (AP) was determined by the method standardized according to IFCC. The adenosine monophosphate (AMP) buffer, reagents by LEK (Boehringer), and the Technicon RA-XT device were used. Mean intact PTH = 578 +/- 767 pg/ml; CAP = 332 +/- 366 pg/ml; total PTH = 518 +/- 560 pg/ml; mean AP = 1.9 + 2.9 mukat/l; CAP/CIP ratio < 1 was found in 9 patients. Mean CAP in these patients was 71 +/- 42 pg/ml; total PTH = 172.6 +/- 104.8 and intact PTH = 150 +/- 65 pg/ml; AP = 0.8 +/- 0.2 mukat/l. It is known that patients with adynamic bone disease have intact PTH below 200 pg/ml, and our next step will be to evaluate with bone biopsy whether patients with CAP/CIP ratio actually have adynamic bone disease.

Homocysteine and vascular access thrombosis in hemodialysis patients.

BACKGROUND: Vascular access remains the Achilles' heel of successful hemodialysis, and thrombosis is the leading cause of vascular access failure. Hyperhomocystinemia is common in hemodialysis patients and is associated with venous and arterial thrombosis in patients without end-stage renal disease. SUBJECTS AND METHODS: In the study, 65 hemodialysis patients with native arteriovenous fistula were included. Two groups of patients were defined: group A including 45 patients with their vascular access either never or only once thrombosed, and group B including 20 patients with two or more thromboses of their vascular access. We determined serum concentrations of total homocysteine (immunoassay, Abbott) in our patients. RESULTS: In 63 (96.9%) patients, hyperhomocystinemia was presented. There was no statistically significant difference between group A and B regarding age, gender and duration of hemodialysis treatment. Total homocysteine concentrations were higher in group A (42.1 +/- 18.6 micromol/l) than in group B (36.1 +/- 18.1 micromol/l) patients but the difference was small and not statistically significant. CONCLUSION: We found no significant differences in total homocysteine concentrations between group A (thrombosis non-prone) and group B (thrombosis prone) patients. Our results suggest that thrombosis of native arteriovenous fistulas may not be caused by hyperhomocystinemia in these patients.

[Sterile peritonitis after administration of icodextrin]. / Sterilni peritonitis nakon primjene ikodekstrina.

INTRODUCTION: Icodextrin is an 7.5% isoosmotic solution of the glucose polymer maltodextrin, recently frequently used in continuous ambulatory peritoneal dialysis (CAPD). It improves ultrafiltration and decreases glucose absorption. Among side effects of icodextrin, skin reactions and sterile peritonitis have been described. The authors present two cases of sterile peritonitis after icodextrin. CLINICAL PRESENTATION: In these two patients, the adverse events included peritoneal reaction to icodextrin solution. The reaction did not occur immediately after the initial administration of icodextrin, but after 70 (case 1) and 412 days (case 2) of regular use. This reaction to icodextrin solution resembled chemical peritonitis, however, the clinical picture was not absolutely typical of bacterial peritonitis either. Both patients had cloudy dialysate, elevated WBC in dialysate, no microorganisms were isolated, and no signs of allergic reaction could be detected. The clinical course was characterized by rapid remission upon isodextrin withdrawal. One patient received empiric antibiotic therapy, the other did not. Upon switching from icodextrin to glucose-based dialysate, the two patients were not challenged to icodextrin, and were doing well, without any symptoms of peritonitis. DISCUSSION AND CONCLUSION: The icodextrin solution contains an isoosmolar glucose polymer which allows longterm stable ultrafiltration. Among side effects, cutaneous reactions have been described (exfoliative, in the form of vesicles, psoriatic plaque or generalized exanthema in the form of pustules), which may occur in as many as 15% of patients. These symptoms and signs disappear upon discontinuation of icodextrin. Icodextrin side effects also include mild abdominal pain, allergic and hypersensitivity reactions, and recently sterile peritonitis. The patients described developed a clinical picture suggestive of chemical peritonitis. From the effluent no microorganisms were isolated, and the clinical picture was not absolutely typical of bacterial peritonitis either. Discontinuation of icodextrin was followed by immediate clearing of the effluents and normalization of WBC count.