Comparison of creatinine clearance estimates in subgroups based on Body Mass Index and albumin.

BACKGROUND: The establishment of accurate equations for glomerular filtration rate (GFR) estimations is still far from the realization. Factors such as age, diabetes, stage of CKD, pregnancy, muscle mass and ethic nation are associated with less reliance upon commonly utilized estimation equations. We aimed to compare the routine use of 24-hour creatinine clearance (CrCl) and GFR estimates calculated by Crockoft-Gault (CG) and modification of diet in renal disease (MDRD) formulas in patients with different levels of renal dysfunction in subgroups, based on Body Mass Index (BMI) and serum albumin (Alb) levels. METHODS: Two hundred and seventy-nine non diabetic patients (172 men and 107 women), aged 54±23 years, with BMI 27.3±4.4 were enrolled in the study. All patients presented creatinine 1.8±1.2 (mg/dL) and Alb 3.5±1.3g/dL. The comparison of CrCl versus CG had bias 3.1 while the comparison of CrCl versus MDRD had a bias of 6.6. RESULTS: Univariate analysis showed that age, sex and BMI were not significant biases related to the CG, MDRD and CrCl. Indeed, the bias related to the CG was significantly lower than that related to MDRD in patients with either low or high serum albumin. Interestingly, the bias associated with CG was 1.3 in non-diabetic patients with Alb ≤3.5 mg /dL suggesting that CG equation could be used interchangeable to CrCl in these patients. CONCLUSION: CG gave a better prediction of measured CrCl than MDRD in Mediterranean, non-diabetic, non-hospitalized patients although misclassification of patients with regard to renal impairment stage was not present.

Factors influencing first vascular access placement in patients starting hemodialysis.

BACKGROUND: The aim of the study was to assess whether age, gender and the primary renal disease are associated with differences in the type of first vascular access placement. METHODS: We reviewed the records of 145 patients on hemodialysis (HD) 44 females and 101 males with a mean age of 64±14.5 years, on HD for 46.9±41.2 months (range 1-252). RESULTS: The primary renal diseases were diabetes (23.4%), hypertension (17.2%), glomerulonephritis (25.7%), cardiac failure (6.9%) and others (26.8%). Double lumen catheter and arteriovenous fistula was the first vascular access in 109 (75%) and 35 patients (24%) patients, respectively. Graft was the first vascular access in 1 patient (0.5%). Arteriovenous fistula was the first choice for 29.7% of the male patients and 9% of the female. Double lumen catheter was the first choice for 70.3% of the male (subclavian 50.5%, femoral 4.95%, and jugular 14.85%) and 86.4% of the female (subclavian 75%, femoral 2.3%, and jugular 9.1%) (P=0.04). Double lumen catheter was the first choice for 79.7% of the patients older than 65 years and 70.4% for the patients younger than 65 years (P=0.19). Double lumen catheter was the first choice for all the patients with cardiac failure as the primary cause of renal disease. CONCLUSION: Double lumen catheter was the first vascular access for the majority of our patients, probably due to late Nephrologist's referral. Cardiac failure being the primary cause of renal disease and female gender influence also this choice, but not the age of the patients.

Serum hepcidin levels are associated with serum triglycerides and interleukin-6 concentrations in patients with end-stage renal disease.

Hepcidin has emerged as a peptide with a key role in the regulation of iron homeostasis in patients with chronic kidney disease (CKD), having a strong dependence on inflammation. Recent studies reveal that hepcidin may be also associated with the progression of atherosclerosis. This study was performed to analyze the relation of hepcidin to markers of atherosclerosis and inflammation in patients on dialysis. A total of 90 individuals were enrolled. Sixty patients with end-stage renal disease, who were on hemodialysis (HD) (N = 30) and peritoneal dialysis (N = 30) were compared with 30 normal controls (NC). Age, body mass index, time on dialysis, serum lipids, C-reactive protein (CRP) and interleukin-6 (IL-6) were measured and analyzed in correlation with hepcidin concentration. It was found that patients on HD and peritoneal dialysis have significantly higher (P < 0.0001) levels of hepcidin, CRP and IL-6 than NC. Hepcidin in dialysis patients is significantly related to age (r = 0.373, P = 0.012), serum triglycerides (r = 0.401, P = 0.005), HDL-C (r = -0.268, P = 0.048), CRP (r = 0.436, P = 0.0007) and IL-6 (r = 0.569, P < 0.0001). In multiple regression analysis, hepcidin correlated independently with triglycerides (ß = 0.402, P = 0.041) and IL-6 (ß = 0.559, P = 0.006). Moreover, patients with high triglycerides in combination with high IL-6 levels have significantly increased concentrations of hepcidin than those with low triglycerides and low IL-6 levels (P < 0.0001). Elevated levels of hepcidin in patients with CKD on dialysis may be related to the occurrence of high triglycerides and high IL-6 serum concentrations. This probably suggests that hepcidin may play a role to the progression of atherosclerosis and inflammation, but this hypothesis should be further evaluated.

Renal graft outcome in autosomal dominant medullary cystic kidney disease type 1.

BACKGROUND: Medullary cystic kidney disease (MCKD) is an inherited interstitial nephritis, leading to end-stage renal disease (ESRD) between the fourth and seventh decade of life. MCKD shares clinical and morphological features with nephronophthisis, although advances in molecular genetics have distinguished these 2 entities. Data regarding graft survival after kidney transplantation in MCKD patients are extremely limited. The aim of this study was to compare renal graft survival in transplanted MCKD1 and non-MCKD1 patients, to discover whether renal transplantation can be considered as an acceptable treatment for MCKD. METHODS: Thirty-three transplanted patients with MCKD1 and 33 controls (transplanted due to other causes) were included in the study. Graft losses were considered censored for death. Graft survival was evaluated with the Kaplan-Meier method, and comparisons between groups were made by log-rank test. Cox regression analysis was used to estimate the effect of several variables on graft survival, and the chi-square test was used to compare groups of categorical data. RESULTS: The 1-year cumulative graft survival rate for the MCKD1 group was 97%, while at 5 and 10 years it was 94% and 86%, respectively. For the control group, the respective values at years 1, 5 and 10 were 97%, 97% and 90%. Comparisons of graft survival rates between the 2 groups revealed no significant differences. CONCLUSIONS: Renal graft survival of transplanted MCKD1 patients was not shown to be inferior in comparison with that for patients undergoing transplants due to other causes. Therefore, it may represent a treatment of choice in MCKD1 patients with ESRD.

Multiple histopathological skin alterations in a hemodialysis patient with severe pruritus.

Pruritus is an alarming symptom in patients with end-stage renal disease (ESRD) accompanied by sleep disturbances and physical and mental disorders. Although its prevalence is very high among hemodialysis patients (90%), its etiology and its successful treatment have been unconfirmed (Melo N, Elias R, Castro M, Romao G, Abensur H. Pruritus in hemodialysis patients: The problem still remains. Hemodial Int. 2009;13:38-42.). Common pruritus etiologies, such as high parathyroid hormone levels, dialysis inadequacy, and iron deficiency are matters of conflict. The case of a hemodialysis patient with consistent itching and a variety of cutaneous eruptions, which after performing skin biopsy were explored and cured, is described. This article addresses the possibility of other causes of pruritus in ESRD and encourages watchful waiting with simple medical interventions, which would relieve patients' symptoms.

Successful non-surgical treatment of perirenal haematoma after percutaneous renal artery angioplasty in a solitary kidney.

Renal artery angioplasty with stent placement represents an effective choice for correcting renal artery stenosis. However, if iatrogenic renal artery injury occurs, as in the case of solitary kidney, the risk of requiring chronic dialysis increases. This article reports the case of a patient with a solitary kidney, who underwent renal stenting and developed a retroperitoneal haematoma. The patient was managed conservatively and the perirenal haematoma resolved. Within the period of follow-up, the patient had maintained stable renal function with adequate blood pressure control.

Reversal of experimental posthepatectomy liver failure in pigs: a new application of hepatocyte bioreactors.

Postoperative liver failure remains a major cause of morbidity and mortality after extensive hepatectomies. This study aims to evaluate the effectiveness of a hepatocyte bioreactor in the treatment of experimental post-hepatectomy liver failure. Our experimental model included a combination of a side-to-side portacaval shunt, occlusion of the hepatoduodenal ligament for 150 min, 70% hepatectomy, and reperfusion. Following the development of liver failure, 12 pigs were randomized into a control group (n = 6) and a treatment group (n = 6). Both groups underwent extracorporeal perfusion through a plasma separation device, a membrane oxygenator, and two parallel bioreactors. In the latter group, the bioreactors were loaded with 10 billion fresh hepatocytes, isolated from a donor pig. Following hepatocyte treatment, all animals were maintained for 24 h under mechanical ventilation, with intravenous fluid and glucose supplementation. Hemodynamic parameters, intracranial pressure, and biochemical parameters were measured. Liver biopsies were obtained during the 24-h autopsy. The extracorporeal circuit was well-tolerated hemodynamically. Treated animals had lower intracranial pressure compared with controls (at 24 h, 15 ± 3.1 vs. 22 ± 3.5 mm Hg, P = 0.006). Plasma ammonia in treated animals was lower compared with controls at 12 h (100 ± 29 vs. 244 ± 131 µmol, P = 0.026). Liver histological study showed decreased necrosis and increased regeneration activity in treated animals compared with controls. Treatment through an extracorporeal hepatocyte bioreactor attenuates brain edema and improves histological and functional parameters of the liver remnant of pigs with posthepatectomy liver failure.

Early myocardial injury is an integral component of experimental acute liver failure - a study in two porcine models.

INTRODUCTION: There is accumulating clinical evidence that acute liver failure may be regularly associated with myocardial injury. To test this hypothesis in a standardized experimental setting, we used two porcine models of ALF. MATERIAL AND METHODS: In 14 domestic pigs ALF was induced by either a) surgical devascularization of the liver (DV group, n = 7), or b) partial (70-75%) hepatectomy and ischaemia/reperfusion of the liver remnant for 150 min (I/R group, n = 7). Four additional animals constituted the sham operation group. All animals were monitored for a 12-h period, at the end of which their hearts were harvested. Plasma troponin I (cTnI) and malondialdehyde (MDA) were measured before the operation (baseline) and at 6 h and 12 h postoperatively. The harvested hearts were histologically analysed, appointing a score from 0 (no injury) to 3 (maximum injury) to selected injury indicators. RESULTS: In the sham group, all cTnI measurements and total myocardial injury score were zero in all animals. In both ALF groups, plasma cTnI levels increased by the 6(th) and remained elevated up to the 12(th) postoperative hour (p < 0.01 vs. sham animals). Total myocardial injury score and total histological score revealed some extent of myocardial injury. The rise of MDA levels suggests an underlying oxidative mechanism. CONCLUSIONS: Our study provides direct evidence of early myocardial injury in the setting of acute liver failure in pigs. The mechanism of injury remains to be elucidated.

Two cases of silent superior vena cava syndrome associated with vascular access and end-stage renal disease.

Due to the unavoidable use of indwelling devices and the magnitude of the operative problems encountered, superior vena cava syndrome (SVCS) has become a serious threat for patients with a history of multiple catheter placements. True diagnosis sometimes is not available due to paucity of symptoms or due to the inadequate considerations of the disease. Particularly in patients with chronic kidney disease, the evidence of central venous occlusion dictates the avoidance of placing peripheral dialysis access in this extremity. In this article, we report two patients (case 1- a patient with end stage renal disease and case 2 - a patient with chronic kidney disease) with silent SVCS related to stenosis resulting from indwelling pacemaker leads. Furthermore, the first patient had an extrinsic factor of compression, a brachial artery pseudoaneurysm - which although it was not causative - it may certainly have contributed to the development of SVCS. The brachial artery pseudoaneurysm restricted even more the flow to cephalic vein and consequently to superior vena cava. Though pacemaker leads have been well identified previously in the literature as a cause of the SVCS, the brachial artery pseudoaneurysm causing extrinsic compression constitutes a novel factor. Through the publication of this paper the awareness of SVCS in these patients shall be definitely enhanced. Moreover, physicians, nurses and patients shall be educated regarding the requirement for peripheral vein presentation in chronic kidney disease.

Cardiovascular risk factors in non-diabetic hemodialysis patients: a comparative study.

Patients on hemodialysis (HD) are prone to atherosclerotic cardiovascular complications. In an attempt to determine the significance of several atherosclerotic and thrombogenic parameters as risk factors for atherothrombotic cardiovascular disease (CVD) in these patients, we compared two groups of non-diabetic HD patients matched for age and sex, selected according to the absence (group 1, n = 30) or presence (group 2, n = 30) of symptomatic atherothrombotic vascular disease affecting the coronary, cerebral, or peripheral arteries. Duration of HD, primary renal disease (PRD), presence of hypertension, EPO treatment, and smoking habits were recorded. Serum total cholesterol (TC), triglycerides (TG), HDL-C, LDL-C, TC/HDL-C ratio, lipoprotein(a) (Lp(a)), fibrinogen (FG), plasminogen (PLG), fibronectin (FN), and hematocrit (HCT) were measured pre-HD in a midweek session. The same blood parameters were also assessed in twenty matched clinically healthy subjects (controls). None of the blood parameters differed between groups 1 and 2, except for serum Lp(a) and FN, which were higher in group 2 (p = 0.005 and p = 0.041, respectively). Both groups were not different regarding PRD, duration of HD, and EPO treatment, but the presence of hypertension and smoking habits were more common in group 2 (p = 0.008 and p = 0.045, respectively). Moreover, multiple stepwise logistic regression analysis with Lp(a), FN, hypertension, and smoking showed that the presence of hypertension (p = 0.016) and the Lp(a) (p = 0.027) and FN (p = 0.024) levels, but not smoking, were independent predictors for the presence of atherothrombotic CVD. Our results suggest that hypertension, abnormal lipid particles, and thrombogenic proteins may contribute to the high prevalence of CVD in HD patients.

Telematics Service for Home and Satellite Hemodialysis.

Home hemodialysis (HD) for the treatment of end-stage renal disease was first implemented about 30 years ago. In this paper the application of telematics monitoring services for supporting patients who need home HD or satellite HD is described. Two modified HD machines were located in two renal units, and a central control station (CCS, UNIX workstation with multimedia PC terminal) was located in another room of the hospital. Bidirectional communication between the modified HD machines and the CCS was managed using ISDN (Integrated Services Digital Network) links. Nine patients had 150 HD sessions performed using these HD machines over a period of 5 months. This system, called the HOMER-D system, provided on-line, remote supervision of the HD machine-related functions and the clinical condition of the patients through measurement of blood pressure, pulse rate, PO2 (pulse oxymetry), and ECG from the CCS. Any disturbances in the functioning of the HD machines were both visible and audible in the CCS, and the observer could give teleconsultation to the renal unit staff. No major dialysis-associated complications were observed; all data and alarms were transmitted correctly; and patients received adequate HD treatment.