Role of Intravenous Ascorbic Acid in the Management of Anemia in Hemodialysis Patients.

INTRODUCTION: Patients with end-stage kidney disease (ESKD) suffer from functional iron deficiency where despite the presence of sufficient iron stores in the body, adequate iron is unavailable for heme synthesis. This study hypothesis was that in patients undergoing hemodialysis (HD), administration of intravenous (IV) ascorbic acid (AA) exerts a good effect on the management of anemia, either by increasing the mobilization of iron from tissue stores or acting as an antioxidant to overcome the inflammatory block and increase the erythropoietin sensitivity. METHODS: Fifty patients with ESRD who were on regular HD were included in the study. Patients' ferritin levels ranged from 500 to 1200 ng/mL with transferrin saturation of 30% or more. However, all patients were anemic and received erythropoietin therapy. Iron therapy was discontinued in the first group, whereas it was continued in the second group that received IV AA. RESULTS: A significant increase in the levels of Hb was observed in the second group after 6 months despite the decrease in ferritin levels in both the groups. Transferrin saturation decreased in both groups, the decrease being more in the first group. The levels of C-reactive protein (CRP) decreased in the second group, whereas these increased in the first group. CONCLUSIONS: Intravenous AA as an adjuvant therapy with iron exerts a favorable and significant effect on the Hb, serum ferritin, and CRP levels in patients with ESKD having anemia. The discontinuation of iron therapy only decreases the serum ferritin levels and does not improve the Hb or CRP levels.

Are there any further modalities for prediction of subclinical volume overload in advanced stages of chronic kidney disease?

BACKGROUND: Subclinical volume overload in chronic kidney disease (CKD) patient represents a debatable issue. Although many tools were used to detect volume overload in such patients, many non-specific results were due to presence of comorbidities. Bioimpedance spectroscopy is an objective fluid status assessment method, which is shown superior to classical methods in many studies. Combining some of these tools may improve their accuracy and specificity. Inferior vena cava collapsibility index (IVCCI) with brain natriuretic peptide (BNP) can be combined for more specific volume assessment. This study was performed to assess the usage of combined IVCCI and BNP levels in CKD patients to predict subclinical volume overload. METHODS: One hundred and ten patients with CKD (stages 4 and 5) not on dialysis and having normal left ventricular systolic function were included in this study. Exclusion criteria were: (1) patients with other causes of raised BNP than volume overload and (2) patients on diuretics. A complete medical history was obtained, and thorough examination and laboratory tests were performed for all included patients. IVCCI and BNP serum levels were evaluated. The patients who exhibited an overhydration (OH)/extracellular water (ECW) ratio of >15% were considered to have volume overload. RESULTS: Twenty-six patients (23.6%) had subclinical hypervolemia as diagnosed by OH/ECW ratio of >15%. IVCCI ≤ 38% had higher diagnostic performance than BNP ≥ 24 pg/mL. Combining both IVCCI ≤ 38% and BNP ≥ 24 pg/mL increased the specificity and positive predictive value for detection of subclinical hypervolemia. CONCLUSION: Combined elevated BNP level and decreased IVCCI are more precise tools for subclinical volume overload detection in CKD patients.

Histopathological Association between Vascular Hypertensive Changes and Different Types of Glomerulopathies.

INTRODUCTION: The term hypertensive nephrosclerosis has traditionally been used to describe a clinical syndrome characterized by long-term essential hypertension, hypertensive retinopathy, left ventricular hypertrophy, minimal proteinuria, and progressive renal insufficiency. In the absence of renal biopsy, the diagnosis of hypertensive nephrosclerosis is one of exclusion. METHODS: We retrospectively studied 735 patients who had renal biopsies at Ain Shams University Hospitals between January 2008 and Dec 2010. The prevalence of vascular hypertensive changes was studied in relation to clinical presentation and the glomerular pathology pattern. RESULTS: Male to female ratio was 1:1 and the mean age was 27±17 years. No vascular hypertensive changes were found in 44.5% of biopsies while mild, moderate and severe changes were found in 28%, 22% and 4.2% respectively. Malignant hypertensive changes were seen in 1.2% of biopsies. Lupus nephritis was the most common etiology representing 18.9% of all cases, followed by focal segmental glomerulosclerosis (FSGS) (13.5%), membranoproliferative glomerulonephritis (13.3%) and membranous glomerulonephritis (8.2%). Moderate to severe vascular hypertensive changes were more common in biopsies with FSGS compared to other glomerulopathies. Hypertensive nephrosclerosis as the sole cause of renal failure represented only 1.6% of cases. Significant associations were found between the degree of vascular hypertensive changes and the grade of hypertension. Patients with severe vascular hypertensive changes were significantly older and had significantly higher serum creatinine levels compared to other groups. CONCLUSION: History and grade of hypertension significantly influence the degree of vascular hypertensive changes in renal biopsy. Moderate to severe vascular hypertensive changes were more common in biopsies with FSGS compared to other pathologies. KEYWORDS: Hypertension; Nephroangiosclerosis; Renal Biopsies.