Bioelectrical Impedance Phase Angle Value and Prolongations of PR and Corrected QT Intervals in Patients Undergoing Dialysis.

INTRODUCTION: Phase angle value, derived from bioelectrical impedance analysis, represents the body cell mass and nutritional status of patients undergoing hemodialysis. Although the phase angle value has clinical significance in these patients, its relationship with electrocardiogram (ECG), another clinically relevant bioelectrical examination, has not yet been well clarified. METHODS: Two hundred and twenty-four patients undergoing dialysis (80 females and 144 males; mean ± SD, 72.2 ± 12.0 years old; 117 diabetic and 107 nondiabetic patients) were studied retrospectively. Multifrequency bioelectrical impedance analysis was performed immediately after the end of dialysis therapy. The phase shift was geometrically converted into a phase angle value. The ECG was recorded simultaneously, and the upper limits of the PR interval, QRS width, and corrected QT interval (QTc) were set at 0.20, 0.12, and 0.44 s, respectively. The geriatric nutritional risk index (GNRI), a representative nutritional index, was also determined. In addition, we examined the incidence of cardiac events, including heart failure, myocardial infarction, cardiac revascularization procedure, cardiac arrhythmia, and cardiac death, or all-cause death. RESULTS: Of 224 patients undergoing dialysis, the prolongation of the PR interval, QRS width, and QTc was found in 30.7, 17.4, and 62.1%, respectively. The prevalence of QTc prolongation was higher in females and diabetic patients than in males and nondiabetic patients. An inverse relationship between phase angle value and QTc was observed only in males and nondiabetic patients. The relationships of GNRI both with phase angle value and QTc were stronger in males and nondiabetic patients. In addition, PR interval was inversely correlated with a phase angle value only in nondiabetic patients. No significant correlation was found between phase angle value and QRS width. Five-year survival probability for the composite endpoints was significantly worse in patients with lower phase angle values. QTc prolongation was associated with survival in males and nondiabetic patients. Prolonged PR was associated with survival in nondiabetic patients. DISCUSSION: Relationships between phase angle value and ECG findings were demonstrated in patients undergoing dialysis, especially in males and nondiabetic patients. Although the phase angle value has been considered as an index for evaluating nutritional status, another clinical application of phase angle value in predicting cardiac complications seems to be useful.

QT Prolongation in Dialysis Patients: An Epidemiological Study with a Focus on Malnutrition.

BACKGROUND/AIMS: QT prolongation is a known risk factor for ventricular fibrillation and ventricular tachycardia. Therefore, more refined management is necessary to reduce sudden cardiac death secondary to such arrhythmias. METHODS: Electrocardiographic findings were reviewed in 224 patients, and the associations of QT prolongation with various clinical parameters were examined, including the nutritional state. Correlations were also examined between QT prolongation and body composition measurements determined by multifrequency bioelectrical impedance analysis. RESULTS: Prolongation of the corrected QT (QTc) interval over 0.44 s was seen in 140 patients (62.5%). QT prolongation was independent of age and dialysis therapy duration and was more frequent in diabetics (70.1%) than in nondiabetics (54.2%, p = 0.014) and more frequent in women (78.8%) than in men (53.5%, p < 0.001). Serum levels of albumin (p < 0.001) and Cr (p < 0.001) and the Geriatric Nutritional Risk Index (GNRI, p < 0.001) were negatively correlated with QTc interval; no significant correlation was noted with total protein, urea nitrogen, or uric acid. Negative correlations with QTc interval were found for BMI(p < 0.01), percent total body water (%TBW; p < 0.05), and percent intracellular water (%ICW; p < 0.01) but not with the percent extracellular water/TBW ratio or edema ratio. The longer the QTc interval, the lower the fat-free mass (FFM; p < 0.01) and muscle mass (MM; p < 0.01), but there was no significant correlation with percent fat. CONCLUSION: These results suggest that QT prolongation is a common complication and is more frequent in women and diabetic patients. The decreases in serum albumin and Cr levels, GNRI, BMI, %TBW, %ICW, FFM, and MM together coincided with malnutrition and thus suggest a close relationship of QT prolongation with malnutrition. Management of QT prolongation may be achieved better in the future by understanding these biochemical and biophysical changes, particularly those regarding malnutrition.

Safety Management of Dialysis Fluid in Japan: Important Duties and Responsibilities of Clinical Engineers.

Dialysis therapy is the predominant choice for renal failure in Japan, and almost 30% of the patients with renal failure have been treated for 10 years or more. Dialysis became the standard procedure to treat renal failure nationwide in the 1980s. However, at that time, managing the increased number of patients on maintenance hemodialysis as well as operating and maintaining the newly developed advanced medical technologies at extensive numbers of clinical sites proved problematic. To help address this, the clinical engineer system was established in 1987 and certain aspects of the clinical engineers' role remain unique to Japan today. For the last 30 years, clinical engineers have worked as frontline medical personnel not only operating dialysis-related devices but also placing their hands directly on patients when providing care, routinely performing puncture, and administering drugs through the blood circuit under physicians' instructions. As part of their work, they crucially maintain the use of central dialysis fluid delivery systems (CDDSs) - also unique to Japan - which prepare and deliver a large quantity of dialysis fluid through a central circuit to individual dialysis consoles. CDDSs are widely used because they effectively alleviated the early confusion at clinical sites caused by the rapidly increasing hemodialysis population and the serious shortage in medical personnel. Moreover, clinical engineers alone have the technical ability to provide safe dialysis fluids adjusted to strict standards at clinical sites. In this review article, we focus on the crucial roles that clinical engineers have in maintaining the safety of dialysis-related medical devices and the preparation and delivery of dialysis fluid at many dialysis facilities across the country.

Cumulative C-Reactive Protein Levels and Progression of Malnutrition in Dialysis Patients: A Longitudinal Study.

BACKGROUND/AIMS: Malnutrition is a serious complication in dialysis patients that develops slowly but steadily. Cross-sectional studies may not adequately characterize this complication because not only the intensity but longitudinally cumulative effect should also be taken into consideration. Relationship between time-dependent changes in a nutritional marker, Geriatric Nutritional Risk Index (GNRI), and cumulative C-reactive protein (CRP) values was examined whether both intensity and duration of inflammation correlated with time-dependent progression and severity of malnutrition over 3 years, retrospectively. METHODS: One hundred and sixty-four dialysis patients were examined over 3 years retrospectively. Based on analysis of clinical and laboratory findings over a period of 3 years, patients were divided into 2 groups: those with a >3.0 decrease in GNRI after 3 years (n = 84) and those in whom GNRI was unchanged (n = 80). RESULTS: When comparing the 2 groups at 3 years, the GNRI-decreased group had 12% lower serum albumin (p < 0.001) and lower levels of creatinine (9%, p < 0.001), BUN (6%, p < 0.05), total cholesterol (6%, p < 0.05), and low-density lipoprotein cholesterol (10%, p < 0.01), which suggest onset of malnutrition. CRP levels, routinely measured twice a month in all patients, were summed to calculate the cumulative CRP. Cumulative CRP after 3 years was 57.6 ± 7.8 (mg/dL/3 years) in the GNRI-decreased group, which was significantly higher than that in the GNRI-unchanged group (38.6 ± 3.9; p < 0.05). Over 3 years, the GNRI-decreased group showed a time-dependent increase in cumulative CRP alongside a time-dependent decrease in the GNRI, producing an obvious mirror image; however, such inverse correlation was absent in the GNRI-unchanged group. CONCLUSION: A long-term perspective is needed in the management of malnutrition in dialysis patients because this complication develops progressively and is often irreversible when diagnosed. Cumulative CRP values may be useful in evaluating the degree of the progression of malnutrition in following up individual patients longitudinally.

Supportive Effects of Online Hemodiafiltration Therapy on the Nutritional State and Lipid Profile in Very Elderly Dialysis Patients.

INTRODUCTION: Online hemodiafiltration (HDF) therapy has been recognized as one of the potential dialysis modalities. However, the long-term effects of online HDF therapy on very elderly dialysis patients older than 75 years have yet to be fully elucidated. METHODS: Seventy-four very elderly patients older than 75 years undergoing maintenance dialysis therapy were studied retrospectively. Twenty-four (mean ± SE, 81.5 ± 1.0 years) were treated by predilution online HDF, and fifty (81.2 ± 0.6 years) were treated by conventional hemodialysis (HD) for 3 years. Laboratory data related to the nutritional state and lipid profile were collected. Body composition was measured by a bioelectrical impedance method. RESULTS: Dry weight and body mass index decreased in HD patients (2.9%, p = 0.003 and 3.1%, p = 0.001, respectively), while no significant changes were found in online HDF patients. Serum albumin levels reduced in both HD and online HDF groups (3.5%, p = 0.003 and 2.9%, p = 0.026, respectively). The geriatric nutritional risk index decreased in HD patients (3.0%, p < 0.001), while no significant change was shown in online HDF patients. Body composition analysis demonstrated a significant decrease in intracellular water and increases in extracellular water and edema ratio in both groups. Fat mass and %fat showed significant decreases in HD patients (8.1%, p = 0.003 and 7.3%, p = 0.003, respectively), but no significant changes in online HDF patients. Among laboratory data, serum high-density lipoprotein cholesterol levels did not change in HD patients. However, the levels elevated significantly (10.6%, p = 0.03) in online HDF patients. DISCUSSION/CONCLUSION: These results indicated that the time-dependent deterioration of the nutritional state in very elderly dialysis patients was inevitable; however, such deterioration was not prominent in online HDF patients. Moreover, the lipid profile showed unique changes in online HDF patients. In order to treat very elderly dialysis patients, online HDF should preferentially be taken into consideration because the maintenance of general condition seems to be a practical goal against the natural time-dependent deterioration.

One-year intradialytic leg exercises with resistance bands and fat mass increase in elderly hemodialysis patients: a retrospective study.

BACKGROUND: Intradialytic exercises are recommended to be available as a treatment for enhancing physical functioning. However, there have been few reports which evaluated the results of long-term mild intradialytic exercises in elderly patients. The purpose of this study is to investigate the changes in body weight, body composition, and laboratory data in elderly hemodialysis patients after 1-year intradialytic leg exercises with resistance bands. METHODS: A retrospective study. Twenty-one outpatients, aged 65 or older (mean ± SD, 75.2 ± 5.1 years), received intradialytic leg exercises with resistance bands for a year were analyzed. The values of dry weight, body composition, and laboratory data were collected from the year-ago period, at baseline and 1 year after baseline. Fat and muscle mass were evaluated by using a multi-frequency bioimpedance device. RESULTS: Physical performance changed and body weight increased after 1-year resistance band exercises. However, the participants gained fat mass, not muscle mass. Although the changes in biochemical data related to protein intake were equivocal, triglyceride levels increased significantly after 1-year exercises. An elevation in serum creatinine levels was observed, even if solute clearance increased significantly. CONCLUSIONS: One-year intradialytic leg exercises with resistance bands may have a potential clinical benefit for body mass index even in elderly hemodialysis patients. However, optimal dietary modification is needed to achieve a balanced increase of muscle and fat mass. An increase of serum creatinine levels does not always mean muscle mass hypertrophy. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s41100-021-00341-z.

Evaluation of microincision vitrectomy surgery using wide-viewing system for complications with ocular sarcoidosis.

We evaluate the outcomes of microincision vitrectomy surgery (MIVS) using wide-viewing system for complications with ocular sarcoidosis resistance to medical treatment.Consecutive clinical records of 24 eyes (19 patients) with complications of ocular sarcoidosis underwent MIVS between April 2010 and December 2013 were retrospectively reviewed. MIVS and phacoemulsification were performed in 18 eyes and MIVS only in 6 eyes. Best-corrected visual acuity (BCVA), inflammation scores in the anterior segment and in the posterior segment, and central retinal thickness (CRT) of eyes with cystoid macular edema (CME) before surgery and after 1 week, 1, 3, 6, and 12 months were evaluated.LogMAR (log of the minimum angle of resolution) converted from BCVA was improved in 83.3% after 12 months and 66.7% showed improvement of more than 2 lines. The mean LogMAR was significantly improved from 1.14 ± 1.18 to 0.36 ± 0.79 in all eyes and 0.83 ± 0.86 to 0.23 ± 0.41 in eyes with MIVS and phacoemulsification, although no improvement was observed in eyes with MIVS only. Significant decrease of the mean anterior inflammation score was observed after 1 month in eyes with MIVS only and after 12 months in eyes with MIVS and phacoemulsification, and the mean posterior inflammation scores decreased after 1 week in all eyes. In eyes with preoperative CME, mean CRT was significantly decreased from 1 week after surgery. There was no case in which ocular inflammation was exacerbated by surgical stress. Improvement of visual acuity and resolution of ocular inflammation could be achieved by MIVS using wide-viewing system for complications of ocular sarcoidosis.

Iron supplementation therapy in end-stage renal disease patients on maintenance hemodialysis.

Iron supplementation therapy seems almost indispensable in adequate management of the patients with end - stage renal disease on maintenance hemodialysis, since at least one and a half grams iron is considered to be required per year to keep sufficient erythropoiesis. Iron supplementation in conjunction with erythropoietic-stimulating agents is widely carried out as a standard therapy. However, definite diagnosis of iron deficiency in hemodialysis patients is often difficult since serum ferritin levels increase frequently by various reasons including inflammation and malignancy. Although several guidelines to treat anemia of the hemodialysis patients have been proposed, they seem still insufficient and careful clinical observation is required in individual patient to avoid possible complications of iron overload. We, here, reassess the adequate iron supplementation therapy in those patients, and the necessity of new guideline employing recent advances including magnetic resonance imaging - based method (FerriScan) and hemoglobin content per each reticulocyte is also discussed.

Blood color is influenced by inflammation and independently predicts survival in hemodialysis patients: quantitative evaluation of blood color.

Blood color of dialysis patients can be seen routinely. Darkened blood color is often observed in critically ill patients generally because of decreased oxygen saturation, but little is known about the other factors responsible for the color intensity. In addition, quantitative blood color examination has not been performed yet. Therefore, no one has evaluated the predictive power of blood color. The aim of this study was to evaluate if blood color darkness reflects some medical problems and is associated with survival disadvantage. Study design is a prospective cohort study. One hundred sixty-seven patients were enrolled in this study. Quantification of blood color was done using a reflected light colorimeter. Demographic and clinical data were collected to find out the factors that can be related to blood color. Follow-ups were performed for 2 years to analyze the risk factors for their survival. Regression analysis showed that C-reactive protein and white blood cell count were negatively correlated with blood color. In addition, blood color was positively correlated with mean corpuscular hemoglobin concentration and serum sodium concentration as well as blood oxygen saturation. During a follow-up, 34 (20.4%) patients died. Cox regression analysis revealed that darkened blood color was an independent significant risk factor of mortality in hemodialysis patients as well as low albumin and low Kt/V. These results suggest that inflammation independently affects blood color and quantification of blood color is useful to estimate prognosis in patients undergoing hemodialysis. It is possible that early detection of blood color worsening can improve patients' survival.

The quantitative evaluation of online haemodiafiltration effect on skin hyperpigmentation.

BACKGROUND: Skin pigmentation is a common problem for dialysis patients, but little is known about the factor responsible for the colour intensity. Middle-molecular-weight (MMW) substances have been suggested to be responsible for the skin colour. Several papers have reported that ß(2)-microglobulin (ß(2)-MG) correlates with the skin colour, and haemodiafiltration (HDF) is effective to reduce the skin hyperpigmentation. However, a quantitative skin colour follow-up on patients treated with online haemodiafiltration (online HDF) has not been performed. METHODS: Sixty-one patients were enrolled in this study. Quantification of skin colour was done using a reflected light colorimeter. Among them, 51 patients were under haemodialysis (HD), and the other 10 patients were under online HDF. Follow-ups to estimate the skin colour change were performed for 6 months. Among 10 patients under online HDF, four patients were also investigated by crossover way between HD and online HDF. RESULTS: Compared with controls, patients treated with HD had darker skin. The colour value was well correlated with age, haematocrit, sex, diabetes and ß(2)-MG but not with Kt/V. The skin colour got worse under HD treatment as well as the values of ß(2)-MG, but online HDF improved the hyperpigmentation and the ß(2)-MG values. CONCLUSIONS: Our data show the effectiveness of online HDF on skin colour and suggest that HD patients' skin colour can be improved by modality change.