Fibromyalgia and its clinical relevance in renal transplant recipients.

OBJECTIVE: Recent evidence suggests that fibromyalgia syndrome (FS) is associated with inflammation and endothelial dysfunction. Our aim was to determine the prevalence of FS in renal transplant recipients and to identify possible links between FS and clinical and laboratory parameters. METHODS: Ninety-nine kidney transplant recipients with normal graft functions (37.15 ± 10.83 years old, 67 male) were enrolled in the study. All subjects completed the Fibromyalgia Impact Questionnaire (FIQ). The biochemical and clinical parameters in the 1st post-transplantation year were retrospectively recorded. Cardiovascular parameters, including body composition analyses (Tanita), ambulatory blood pressure monitoring data, and pulse-wave velocity, were cross-sectionally analyzed. RESULTS: Mean FIQ score for the whole group was 21.4 ± 14.7. Eight patients had FIQ score >50, and these patients had significantly higher left ventricular mass index than patients with lower FIQ score (P = .048). Patients were divided according to their physical impairment score (PIS): PIS ≥5 (n = 50) and PIS <5 (n = 49). Patients with higher PIS had significantly higher serum creatinine (P = .047) and lower eGFR values (P = .008) than patients with lower PIS. Patients were also evaluated with the use of the stiffness score (SS): patients with (n = 41) and without (n = 58) stiffness. Patients with stiffness had significantly higher office systolic (P = .027) and diastolic (P = .044) blood pressure, body mass index (P = .033), and sagittal abdominal diameter (P = .05) than patients without stiffness. Decline in estimated glomerular filtration rate levels were significantly higher in patients with higher FIQ (7.6% vs 9.4%; P = .0001) than in other patients. CONCLUSIONS: FS in renal transplant recipients was strongly associated with hypertension, arterial stiffness, obesity, and renal allograft dysfunction.

Post-transplant Hyperuricemia as a Cardiovascular Risk Factor.

PURPOSE: Uric acid is known to impair endothelial cell function and to stimulate the development of renal interstitial fibrosis. The aim of this study was to evaluate the association between first-year hyperuricemia with graft dysfunction and the development of cardiovascular risk disorders in renal transplant recipients. METHODS: One hundred kidney transplant recipients (31 female, 45.9 ± 9.6 post-transplantation months) with normal graft functions were enrolled. The clinical biochemical parameters in the first post-transplantation year were retrospectively recorded and searched for the predictive value in yearly determined graft function and association with cross-sectionally analyzed cardiovascular parameters, including body composition analyses, ambulatory blood pressure monitoring data, and pulse wave velocity. Hyperuricemia was defined as an uric acid level of ≥ 6.5 mg/dL that persisted for at least 2 consecutive tests. RESULTS: One year after transplantation, 37% of subjects had hyperuricemia. According to cross-sectional data, sagittal abdominal diameter (P = .002) and hip circumferences (P = .013) were significantly higher in hyperuricemic patients than in normouricemic ones. Hyperuricemic patients had higher fat (P = .014) and muscle mass (P = .016) than normouremic patients. Hyperuricemic patients had significantly higher mean systolic BP (P = .044) than normouremic patients. Hyperuricemic patients had significantly higher pulse wave velocity levels (P = .0001) and left ventricular mass index (P = .044) than normouremic patients. The yearly decline in estimated glomerular filtration rate levels was significantly higher in hyperuricemic patients (P = .0001) than in normouricemic ones. CONCLUSION: Post-transplantation hyperuricemia is associated with hypertension, arterial stiffness, and dyslipidemia; it should be accepted not only as a marker for renal allograft dysfunction but also as a cardiovascular risk factor in renal transplant recipients.

Pulmonary hypertension is closely related to arterial stiffness in renal transplant patients.

INTRODUCTION AND AIMS: Pulmonary hypertension (PH) is an independent predictor of increased mortality in patients on dialysis and those undergoing renal transplantation. We investigated PH and its association with vascular calcification and endothelial dysfunction in renal transplant patients. METHODS: The records of 300 consecutive patients who underwent renal transplant in our center between 2005 to 2012 were evaluated. PH was defined as systolic pulmonary artery pressure (sPAP) ≥ 35 mm Hg. Demographic information, clinical characteristics, pulse wave velocity (PWv), and renal recessive indices (RRI) were collected and compared among patients with and without PH. RESULTS: Eight patients in PH group (age 36 [19] years) and 87 subjects in nPH group (age 35 [9] years) were evaluated. Demographic and clinical characteristics and laboratory data of the 2 groups were similar. Additionally, sPAP was positively correlated with PWv (r = 0.263, P = .01). In multivariate analyses, RRI (P = .004), serum CRP (P = .025), and PWv (P = .001) were associated with pulmonary artery pressure. CONCLUSION: PH is significantly associated with arterial stiffness in renal transplant recipients who have a high risk for cardiovascular disease. Considering the common prevalence of cardiovascular diseases, including PH, we suggested that all patients with renal transplantation should be evaluated for regular echocardiographic examination in clinical practice.

Endothelial nitric oxide synthase and angiotensin II type 1 receptor gene polymorphisms can influence chronic inflammatory state in renal transplant patients.

UNLABELLED: Serum C-reactive protein (CRP) is a sensitive indicator of inflammation. Because increasing evidence shows the effect of endothelial nitric oxide synthase (eNOS) and the renin-angiotensin system on inflammation, we studied the association among chronic inflammation, chronic rejection, and gene polymorphisms of angiotensin II type 1 receptor (ATR1) and eNOS in renal transplant patients. METHODS: Data from 80 male and 35 female renal transplant patients (mean follow-up, 60.6 +/- 22.2 months) were analyzed. Patients were grouped according to posttransplant CRP levels: group 1 patients (n = 46) had normal CRP levels (CRP <10 mg/L); group 2 had intermittent (n = 26), and group 3 had persistently elevated (n = 43) CRP levels. eNOS and ATR1 gene polymorphisms of the groups and the impact of posttransplant CRP response on development of chronic rejection and graft failure were analyzed. The bb allele of the eNOS gene was found in 74% of the patients, whereas 62% had AA allele of ATR1. RESULTS: Patients in group 1 had a significantly lower incidence of chronic rejection and graft failure when compared with patients in groups 2 and 3 (P = .05 and P = .02 respectively). The bb allele of the eNOS gene predominated in group 1 (P = .02); presence of non-AA allele of ATR1 1166 gene was found less frequently in group 3 (P = .01). CONCLUSIONS: The presence of the bb allele of the eNOS and non-AA allele of ATR1 1166 gene is associated with an anti-inflammatory state and may predict renal outcome in transplant patients.

A new laparoscopic technique for the placement of a permanent peritoneal dialysis catheter: the preperitoneal tunneling method.

BACKGROUND: Mechanical outflow obstruction and leakage from the exit site of the catheter are two common complications of continuous ambulatory peritoneal dialysis. To lessen these complications and to achieve immediate use of the catheter, we developed a new laparoscopic technique for catheter placement. METHODS: A total of 12 consecutive patients with end-stage renal failure were included in this study between April 2003 and July 2003. The average age of the patients was 42.4 years (range, 37-72). Patients were excluded only if a serious risk for general anesthesia was found. Using two 5-mm ports and a 3.3-mm mini-laparoscope, a peritoneal dialysis catheter was passed through a preperitoneal tunnel before the tip of the catheter was introduced into the pelvis. Routine peritoneal dialysis was started immediately after the operation while the patients were still in the operating room. RESULTS: The mean operating time was 18.6 min (range, 12-37). There was no operative morbidity. The mean follow-up period was 4.3 months (range, 3-7). No leakage of the dialysate liquid or outflow obstruction was observed during this period. CONCLUSION: The advantages of this method include accurate placement, preperitoneal fixation, and immediate use of the catheter for routine peritoneal dialysis. We also believe that because of the preperitoneal fixation of the catheter, this technique will decrease outflow obstruction, which usually occurs due to omental wrapping or displacement of the catheter tip.

Clinical consequences of intermittent elevation of C-reactive protein levels in hemodialysis patients.

An elevated C-reactive protein (CRP) level has been associated with malnutrition, with erythropoietin resistance during hemodialysis (HD) therapy, and with a higher risk of chronic transplant rejection. Meanwhile, the clinical consequences of intermittent elevations of CRP levels observed among a large group of HD patients are unclear. We sought to compare the inflammatory and nutritional parameters as well as the erythropoietin requirements for HD patients with persistent or intermittent CRP elevations versus subjects with CRP levels in the normal range. The 6-month retrospective clinical and laboratory data of 100 HD patients (age 48.4 +/- 14.3 years, HD duration 69.3 +/- 49.0 months) were divided into three groups on the basis of at least six monthly values of CRP: for persistent (group 1) or intermittent high (at least one level of CRP >/=10 mg/L); (group 2) versus normal CRP levels (group 3). We compared the estimates of fibrinogen, ICAM-1, VCAM-1, albumin, prealbumin, normalized protein catabolic rate (nPCR), interdialytic weight gain (IDWG), and rhuuEpo/kg/Htc. Significant differences, were observed in fibrinogen, albumin, prealbumin, ICAM-1, nPCR, IDWG, and rHUuEpo/kg/wk values. Like group 1, group 2 patients seemed to show inflammation and malnutrition, namely decreased albumin levels, nPCR, and rHUEpo resistance, when compared with group 3. Finally, intermittent elevations of CRP must be considered to reflect a state of chronic inflammatory response associated with malnutrition and erythropoietin resistance similar to that observed among hemodialysis patients with persistently high CRP levels.

Association of helicobacter pylori infection with nutritional status in hemodialysis patients.

The presence of Helicobacter pylori (HP) infection may adversely influence outcome in renal transplant candidates because of its strong association with gastrointestinal disorders. We examined the association between HP infection and nutritional parameters in symptom-free hemodialysis patients and assessed prospectively the nutritional changes in patients who received therapy for the disease. The 163 study patients, including 114 men and 69 women of mean age 41.5 +/- 12.9 years on dialysis for 67.2 +/- 47.6 months, were selected from among the group who underwent routine endoscopic evaluation according to our renal transplant protocol. Patients with active peptic ulcer, acute gastritis, chronic inflammatory disease, malignancy, or diabetes mellitus were excluded. Endoscopy results revealed normal findings in 60 (group 1), gastritis in 86 (group 2), or gastritis with HP in 17 patients (group 3). Group 3 patients received a 2-week course of triple therapy (omeprazole, amoxicillin, clarithromycin). The patient groups were compared for nutritional metrics (albumin, phosphorus, interdialytic weight gain [IDWG], body mass index [BMI]), inflammatory indices (CRP, fibrinogen), and iPTH levels. Group 3 patients were observed to be malnourished when compared with groups 1 and 2, namely abnormal values of albumin (P <.0001), phosphorus (P <.009), IDWG (P <.03), and BMI (P <.02). Repeat endoscopy revealed a 94% rate of eradication of HP with increased levels of albumin and phosphorus in group 3. Although symptom-free hemodialysis patients with HP-associated gastritis displayed a state of malnutrition; its eradication improved the nutritional status. Therefore, the presence of HP infection should be sought and its eradication mandatory for this patient population.