Muscle mass assessment by computed tomography in chronic kidney disease patients: agreement with surrogate method

Background/objectives Patients with chronic kidney disease (CKD) are subjected to muscle wasting. Therefore, it is important to investigate surrogate methods that enable the assessment of muscle mass loss in the clinical setting. We aimed to analyze the agreement between computed tomography (CT) and surrogate methods for the assessment of muscle mass in non-dialysis CKD patients. Subjects/methods Cross-sectional study including 233 non-dialysis patients on CKD stages 3 to 5 (61±11 years; 64% men; glomerular filtration rate 22 (14­33) mL/min/1.73m2). The muscle mass was evaluated by CT and bioelectrical impedance, skinfold thicknesses, midarm muscle circumference (MAMC), the predictive equations of Janssen and Baumgartner and the physical examination of muscle atrophy from the subjective global assessment. Results In males, the MAMC showed the best agreement with CT as indicated by the kappa test (k=0.57, P<0.01), sensitivity (S=68%), specificity (S=89%) and accuracy (area under the curve­AUC=0.78), followed by the Baumgartner equation (kappa=0.46, P<0.01; sensitivity=60%; specificity=87% and AUC=0.73). In female, the Baumgartner equation showed the best agreement with CT (kappa=0.43, P<0.01; sensitivity=57%; specificity=86% and AUC=0.71). (AU)

Muscle mass assessment by computed tomography in chronic kidney disease patients: agreement with surrogate methods.

BACKGROUND/OBJECTIVES: Patients with chronic kidney disease (CKD) are subjected to muscle wasting. Therefore, it is important to investigate surrogate methods that enable the assessment of muscle mass loss in the clinical setting. We aimed to analyze the agreement between computed tomography (CT) and surrogate methods for the assessment of muscle mass in non-dialysis CKD patients. SUBJECTS/METHODS: Cross-sectional study including 233 non-dialysis patients on CKD stages 3 to 5 (61 ± 11 years; 64% men; glomerular filtration rate 22 (14-33) mL/min/1.73 m2). The muscle mass was evaluated by CT and bioelectrical impedance, skinfold thicknesses, midarm muscle circumference (MAMC), the predictive equations of Janssen and Baumgartner and the physical examination of muscle atrophy from the subjective global assessment. RESULTS: In males, the MAMC showed the best agreement with CT as indicated by the kappa test (k = 0.57, P < 0.01), sensitivity (S = 68%), specificity (S = 89%) and accuracy (area under the curve-AUC = 0.78), followed by the Baumgartner equation (kappa = 0.46, P < 0.01; sensitivity = 60%; specificity = 87% and AUC = 0.73). In female, the Baumgartner equation showed the best agreement with CT (kappa = 0.43, P < 0.01; sensitivity = 57%; specificity = 86% and AUC = 0.71). CONCLUSIONS: The MAMC and Baumgartner equation showed the best agreement with CT for the assessment of muscle mass in non-dialysis CKD patients.

Terapia dialítica no paciente cardiopata / Dialysis therapy in patients with heart disease

A otimização das medidas para controle volêmico tem papel preponderante naabordagem de pacientes com disfunção cardíaca e renal combinada, uma vez quealterações crônicas ou agudas em um desses órgãos, em geral, induzem ou perpetuam anormalidades (funcionais e/ou estruturais) no outro. Esta revisão de literatura propõe uma análise sobre as principais medidas terapêuticas no cardiopata com disfunção renal...

Optimizing the methods used in the control of volemia is very important in the treatment of patients with combined heart and renal dysfunction, as chronic or acute changes in either of these organs generally induces or perpetuates abnormalities (functional and/orstructural) in the other. This literature review analyzes the main therapeutic methods used in heart disease with renal dysfunction...

Visceral fat and coronary artery calcification in patients with chronic kidney disease.

BACKGROUND: Abdominal fat is a metabolically active tissue which has been associated with cardiovascular events and death in chronic kidney disease (CKD) patients. We explore here the association between surrogates of abdominal fat and coronary artery calcium score (CACs). METHODS: Cross-sectional analysis of 232 non-dialysis-dependent CKD patients Stages 3-5 (median age 60 [25th-75th percentile 52-67] years; 60% men). Visceral adipose tissue (VAT) and CACs were assessed by computed tomography. Surrogates of abdominal fat included VAT and waist circumference (WC). RESULTS: VAT was positively associated with CACs in univariate analysis (ρ = 0.23). Across increasing VAT quartiles, patients were older, more often men and smokers. Although increasing VAT quartiles associated with higher glomerular filtration rate and leptin, better nutritional status (subjective global assessment) as well as larger muscle stores and strength, they were also more insulin resistant (HOMA-IR), dyslipidemic and inflamed (C-reactive protein and white blood cells). In addition, CACs were incrementally higher. Clinically evident coronary artery calcification (CACs ≥ 10 Agatston) was present in 63% of the patients. Both increased visceral fat (odd ratio 1.60 [95% CI 1.23-2.09] per standard deviation increase) and increased WC (1.05 [1.01-1.12] per cm increase), augmented the odds to present calcification. Such associations remained statistically significant after extensive multivariate adjustment for confounders. CONCLUSIONS: Abdominal fat is associated with coronary artery calcification in non-dialysis dependent CKD patients, supporting its potential role as a cardiovascular risk factor in uremia.

Comparação de critérios diagnósticos de insuficiência renal aguda em cirurgia cardíaca / Comparison of diagnostic criteria for acute kidney injury in cardiac surgery

FUNDAMENTO: Há grande controvérsia quanto ao diagnóstico de Insuficiência Renal Aguda (IRA), existindo mais de 30 diferentes definições. OBJETIVO: Avaliar a incidência e os fatores de risco para desenvolvimento de IRA no pós-operatório de cirurgia cardíaca de acordo com os critérios RIFLE, AKIN e KDIGO, e comparar o poder prognóstico desses critérios. MÉTODOS: Estudo de corte transversal que incluiu 321 pacientes (62 [53 - 71] anos, 140 homens) consecutivamente submetidos a cirurgia cardíaca entre junho de 2011 e janeiro de 2012. Os pacientes foram acompanhados por 30 dias, com vistas ao desenvolvimento de um desfecho composto (mortalidade, necessidade de diálise e internação prolongada). RESULTADOS: A incidência de IRA variou de 15% - 51%, conforme o critério diagnóstico adotado. Enquanto a idade se associou ao risco de IRA nos três critérios, houve variação nos demais determinantes. Durante o acompanhamento, 89 pacientes apresentaram o desfecho e todos os critérios se associaram ao risco aumentado na análise Cox univariada e após o ajuste para idade, sexo, diabetes e tipo de cirurgia. Contudo, após novo ajuste para tempo de circulação extracorpórea e presença de baixo débito cardíaco, apenas o diagnóstico de IRA pelo critério KDIGO manteve esta associação significativa (HR= 1,89 [95% IC: 1,18 - 3,06]). CONCLUSÕES: A incidência e os fatores de risco para IRA pós-cirurgia cardíaca têm grande variação de acordo com os critérios diagnósticos utilizados. Em nossa análise, o critério KDIGO se mostrou superior ao AKIN e ao RIFLE quanto ao seu poder prognóstico.

BACKGROUND: There is considerable controversy regarding the diagnosis of Acute Kidney Injury (AKI), and there are over 30 different definitions. OBJECTIVE: To evaluate the incidence and risk factors for the development of AKI following cardiac surgery according to the RIFLE, AKIN and KDIGO criteria, and compare the prognostic power of these criteria. METHODS: Cross-sectional study that included 321 consecutively patients (median age 62 [53-71] years; 140 men) undergoing cardiac surgery between June 2011 and January 2012. The patients were followed for up to 30 days, for a composite outcome (mortality, need for dialysis and extended hospitalization). RESULTS: The incidence of AKI ranged from 15% - 51%, accordingly to the diagnostic criterion adopted. While age was associated with risk of AKI in the three criteria, there were variations in the remaining risk factors. During follow-up, 89 patients developed the outcome and all criteria were associated with increased risk in the univariate Cox analysis and after adjustment for age, gender, diabetes, and type of surgery. However, after further adjustment for extracorporeal circulation and the presence of low cardiac output, only AKI diagnosed by the KDIGO criterion maintained this significant association (HR= 1.89 [95% CI: 1.18 - 3.06]). CONCLUSION: The incidence and risk factors for AKI after cardiac surgery vary significantly according to the diagnostic criteria used. In our analysis, AKI the KDIGO criterion was superior to AKIN and RIFLE with regard its prognostic power.

Study of the incidence of dialysis in São Paulo, the largest Brazilian city.

OBJECTIVES: Chronic kidney disease is a major public health problem worldwide. In Brazil, approximately 100,000 patients (January 2012) receive renal replacement therapy. Nevertheless, data on dialysis incidence in the Brazilian population are scarce. This study aims to analyze the incidence of patients starting dialysis therapy in São Paulo City, the largest Brazilian metropolis. METHOD: This cohort study analyzed data from 9,994 patients starting hemodialysis or peritoneal dialysis funded by the Brazilian Public Health System during a 5-year period (2007-2011). Patient data for this study (recorded as electronic files) were obtained from the São Paulo City's Dialysis Regulatory Bureau, which regulates the allocation of patients requiring dialytic therapy. RESULTS: The dialysis incidence rates were 178, 174, 170, 185 and 188 per million population for the years 2007, 2008, 2009, 2010 and 2011, respectively. The incidence rates increased with age. Hypertension and diabetes were the main etiologies diagnosed. Hemodialysis was the chosen dialysis modality in the majority of patients (92.6%), whereas the percentage of patients referred for peritoneal dialysis decreased from 10.1% to 5.5%. CONCLUSION: The incidence of patients starting renal replacement therapy from 2007-2011 in São Paulo was stable but higher than the projected incidence for the entire country. The authors emphasize the need for further studies of the incidence of dialysis in the Brazilian population and for the creation of a Brazilian registry of dialysis patients, which would be a valuable tool for developing healthcare policies and renal replacement therapy strategies.

Comparison of diagnostic criteria for acute kidney injury in cardiac surgery.

BACKGROUND: There is considerable controversy regarding the diagnosis of Acute Kidney Injury (AKI), and there are over 30 different definitions. OBJECTIVE: To evaluate the incidence and risk factors for the development of AKI following cardiac surgery according to the RIFLE, AKIN and KDIGO criteria, and compare the prognostic power of these criteria. METHODS: Cross-sectional study that included 321 consecutively patients (median age 62 [53-71] years; 140 men) undergoing cardiac surgery between June 2011 and January 2012. The patients were followed for up to 30 days, for a composite outcome (mortality, need for dialysis and extended hospitalization). RESULTS: The incidence of AKI ranged from 15% - 51%, accordingly to the diagnostic criterion adopted. While age was associated with risk of AKI in the three criteria, there were variations in the remaining risk factors. During follow-up, 89 patients developed the outcome and all criteria were associated with increased risk in the univariate Cox analysis and after adjustment for age, gender, diabetes, and type of surgery. However, after further adjustment for extracorporeal circulation and the presence of low cardiac output, only AKI diagnosed by the KDIGO criterion maintained this significant association (HR= 1.89 [95% CI: 1.18 - 3.06]). CONCLUSION: The incidence and risk factors for AKI after cardiac surgery vary significantly according to the diagnostic criteria used. In our analysis, AKI the KDIGO criterion was superior to AKIN and RIFLE with regard its prognostic power.

Study of the incidence of dialysis in São Paulo, the largest Brazilian city

OBJECTIVES: Chronic kidney disease is a major public health problem worldwide. In Brazil, approximately 100,000 patients (January 2012) receive renal replacement therapy. Nevertheless, data on dialysis incidence in the Brazilian population are scarce. This study aims to analyze the incidence of patients starting dialysis therapy in São Paulo City, the largest Brazilian metropolis. METHOD: This cohort study analyzed data from 9,994 patients starting hemodialysis or peritoneal dialysis funded by the Brazilian Public Health System during a 5-year period (2007-2011). Patient data for this study (recorded as electronic files) were obtained from the São Paulo City's Dialysis Regulatory Bureau, which regulates the allocation of patients requiring dialytic therapy. RESULTS: The dialysis incidence rates were 178, 174, 170, 185 and 188 per million population for the years 2007, 2008, 2009, 2010 and 2011, respectively. The incidence rates increased with age. Hypertension and diabetes were the main etiologies diagnosed. Hemodialysis was the chosen dialysis modality in the majority of patients (92.6%), whereas the percentage of patients referred for peritoneal dialysis decreased from 10.1% to 5.5%. CONCLUSION: The incidence of patients starting renal replacement therapy from 2007-2011 in São Paulo was stable but higher than the projected incidence for the entire country. The authors emphasize the need for further studies of the incidence of dialysis in the Brazilian population and for the creation of a Brazilian registry of dialysis patients, which would be a valuable tool for developing healthcare policies and renal replacement therapy strategies. .

Impact on hypertension reclassification by Ambulatory Blood Pressure Monitoring (ABPM) according to the V Brazilian Guidelines on ABPM.

BACKGROUND: New recommendations on reference values for normal test results in ambulatory blood pressure monitoring (ABPM) were proposed by the V Brazilian Guidelines on Ambulatory Blood Pressure Monitoring, based mainly on the IDACO study. OBJECTIVES: This epidemiological study is aimed at evaluating the impact of adopting these new standards in an arterial hypertension referral center. METHODS: The results of 1,567 ABPM tests carried out between 2005 and 2010 were analyzed; 481 patients were excluded from the sample for not meeting minimum quality criteria of the test. Reference values from the IV Brazilian Guidelines on ABPM (2005) were used for the classification of these tests regarding the abnormality and compared with the changes proposed by the V Brazilian Guidelines on ABPM (2011). Statistical analysis was performed by Pearson's chi-square method and p values < 0.05 were considered statistically significant. RESULTS: For the 1,086 tests evaluated, there was a significant difference in the proportion of patients with altered ABPM results, especially for the variable systolic pressure in the sleeping period: 49% when adopting the cutoff values of 2005 and 71% when adopting the values of 2011, with statistical significance, p < 0.0001. CONCLUSIONS: The recommendations of the new guidelines had a great impact on the hypertension classification by ABPM test results in the study population. The question of thresholds of these tests for therapeutic targets of patients known to be hypertensive is still open and requires further studies, preferably national ones, for better definition of the subject.

Impacto na reclassificação da hipertensão pela Monitorização Ambulatorial da Pressão Arterial (MAPA) segundo a V Diretriz Brasileira de MAPA / Impact on hypertension reclassification by Ambulatory Blood Pressure Monitoring (ABPM) according to the V Brazilian Guidelines on ABPM

FUNDAMENTOS: Novas recomendações sobre valores de referência para normalidade em exames de monitorização ambulatorial da pressão arterial (MAPA) foram propostas pela V Diretriz Brasileira de Monitorização Ambulatorial da Hipertensão Arterial, com base principalmente no estudo IDACO. OBJETIVOS: O presente estudo epidemiológico tem o objetivo de avaliar o impacto da adoção desses novos critérios em um ambulatório de referência em hipertensão arterial. MÉTODOS: Foram analisados resultados de 1.567 exames de MAPA realizados entre 2005 e 2010, excluídos 481 pacientes da amostra por não preencherem critérios mínimos de qualidade do exame. Para a classificação desses exames quanto à anormalidade, foram utilizados os valores de referência da IV Diretriz Brasileira de MAPA (2005) e comparados com as mudanças propostas na V Diretriz Brasileira de MAPA (2011). Foi realizada análise estatística pelo método do Q² de Pearson, considerando-se p significativo < 0,05. RESULTADOS: Para os 1.086 exames avaliados, houve importante diferença na proporção de pacientes com MAPA alterado, em especial para a variável pressão arterial sistólica do sono: 49% adotando os valores de corte de 2005 e 71% adotando os de 2011, com significância estatística, p < 0,0001. CONCLUSÕES: A recomendação da nova diretriz causou grande impacto na classificação da hipertensão pelos exames de MAPA dentro da população estudada. A questão sobre os limiares desses exames para metas terapêuticas de pacientes sabidamente hipertensos ainda está em aberto e carece de mais estudos, preferencialmente nacionais, para melhor definição do assunto.

BACKGROUND: New recommendations on reference values for normal test results in ambulatory blood pressure monitoring (ABPM) were proposed by the V Brazilian Guidelines on Ambulatory Blood Pressure Monitoring, based mainly on the IDACO study. Objectives: This epidemiological study is aimed at evaluating the impact of adopting these new standards in an arterial hypertension referral center. METHODS: The results of 1,567 ABPM tests carried out between 2005 and 2010 were analyzed; 481 patients were excluded from the sample for not meeting minimum quality criteria of the test. Reference values from the IV Brazilian Guidelines on ABPM (2005) were used for the classification of these tests regarding the abnormality and compared with the changes proposed by the V Brazilian Guidelines on ABPM (2011). Statistical analysis was performed by Pearson's chi-square method and p values < 0.05 were considered statistically significant. RESULTS: For the 1,086 tests evaluated, there was a significant difference in the proportion of patients with altered ABPM results, especially for the variable systolic pressure in the sleeping period: 49% when adopting the cutoff values of 2005 and 71% when adopting the values of 2011, with statistical significance, p < 0.0001. CONCLUSIONS: The recommendations of the new guidelines had a great impact on the hypertension classification by ABPM test results in the study population. The question of thresholds of these tests for therapeutic targets of patients known to be hypertensive is still open and requires further studies, preferably national ones, for better definition of the subject.

Visceral fat and coronary artery calcification in patientswith chronic kidney disease

Background. Abdominal fat is a metabolically active tissuewhich has been associated with cardiovascular events anddeath in chronic kidney disease (CKD) patients. We explorehere the association between surrogates of abdominal fat andcoronary artery calcium score (CACs).Methods. Cross-sectional analysis of 232 non-dialysisdependentCKD patients Stages 3–5 (median age 60 [25th–75thpercentile 52–67] years; 60% men). Visceral adipose tissue(VAT) and CACs were assessed by computed tomography. Surrogatesof abdominal fat included VAT and waist circumference(WC).Results. VAT was positively associated with CACs in univariateanalysis (ρ = 0.23). Across increasing VAT quartiles,patients were older, more often men and smokers. Althoughincreasing VAT quartiles associated with higher glomerular filtrationrate and leptin, better nutritional status (subjectiveglobal assessment) as well as larger muscle stores and strength,they were also more insulin resistant (HOMA-IR), dyslipidemicand inflamed (C-reactive protein and white blood cells).In addition, CACs were incrementally higher. Clinicallyevident coronary artery calcification (CACs ≥ 10 Agatston) was present in 63% of the patients. Both increased visceral fat(odd ratio 1.60 [95% CI 1.23–2.09] per standard deviation increase)and increased WC (1.05 [1.01–1.12] per cm increase),augmented the odds to present calcification. Such associationsremained statistically significant after extensive multivariateadjustment for confounders.Conclusions. Abdominal fat is associated with coronary arterycalcification in non-dialysis dependent CKD patients, supportingits potential role as a cardiovascular risk factor in uremia.

Índice Internacional de Função Erétil Simplificado e doença coronariana em pacientes hipertensos / Simplified International Index of Erectile Function (IIEF-5) and coronary artery disease in hypertensive patients

FUNDAMENTO: A Disfunção Erétil (DE) se associa ao risco aumentado de Doença Arterial Coronariana (DAC). OBJETIVO: Avaliar a associação entre DE, determinada pelo Índice Internacional de Função Erétil Simplificado (IIFE-5), e DAC. MÉTODOS: Estudo de corte transversal que avaliou 263 hipertensos (55 [50 - 61] anos). A DE foi avaliada pelo IIEF-5 e a DAC, por meio da história de revascularização miocárdica prévia e/ou por cineangiocoronariografia. RESULTADOS: O IIFE-5 se correlacionou com o clearance de creatinina [ClCr] (Rho = 0,23; p < 0,001) e com a idade (Rho = -0,22; p < 0,001). Quarenta e dois pacientes apresentavam DAC; e o IIFE-5 foi capaz de discriminá-los (área sob a curva ROC = 0,63; p = 0,006). Os pacientes foram divididos em dois grupos: IIFE-5 < 20 (n = 140) e IIFE- 5 > 20 (n = 123); aqueles com menor IIFE-5 tinham idade mais elevada (57 [52 - 61] vs. 54 [45 - 60] anos; p = 0,002), maior prevalência de DAC (22% vs. 9%; p = 0,004), tabagismo (64% vs. 47%; p = 0,009) e do uso de inibidores dos canais de cálcio (65 % vs. 43%; p = 0,001), além de menor ClCr (67,3 [30,8 - 88,6] vs. 82,6 [65,9 - 98,2] ml/min; p < 0,001). O IIFE-5 < 20 se associou ao maior risco de DAC em regressão logística; tanto univariada (RR = 2,89 [IC 95% 1,39 - 6,05]), quanto após ajustes para idade, diabetes, ClCr, tabagismo, pressão arterial média e uso de anti- hipertensivos (RR = 2,59 [IC 95%: 1,01 - 6,61]). CONCLUSÃO: O IIFE-5 se associa ao diagnóstico de DAC e sua utilização pode agregar informação ao estadiamento do risco cardiovascular em pacientes hipertensos.

BACKGROUND: Erectile Dysfunction (ED) is associated with increased risk of coronary artery disease (CAD). OBJECTIVE: To evaluate the association between ED, determined by the Simplified International Index of Erectile Function (IIEF-5) and CAD. METHODS: This was a cross-sectional cohort study that evaluated 263 hypertensive patients (55 [50-61] years). ED was assessed through the IIEF-5 and CAD by the history of previous myocardial revascularization and/or coronary angiography. RESULTS: The IIEF-5 correlated with creatinine clearance [CrCl] (Rho = 0.23, p <0.001) and age (Rho = -0.22, p <0.001). Forty-two patients had CAD, and IIEF-5 was able to discriminate them (area under the ROC curve = 0.63, p = 0.006). Patients were divided into two groups: IIEF-5 < 20 (n = 140) and IIEF-5 > 20 (n = 123); those with lower IIEF-5 scores were older (57 [52-61] vs. 54 [45-60] years, p = 0.002), had higher prevalence of CAD (22% vs. 9%, p = 0.004), smoking (64% vs. 47%, p = 0.009) and use of calcium channel inhibitors (65% vs. 43.%, p = 0.001), as well as lower CrCl (67.3 [30.8 to 88.6] vs. 82.6 [65.9 - 98.2] ml/min, p <0.001). The IIEF-5 < 21 was associated with increased risk of CAD in the logistic regression, both univariate (RR = 2.89 [95%CI: 1.39 - 6.05]), and after adjusting for age, diabetes, CrCl, smoking, mean arterial pressure and use of antihypertensive drugs (RR = 2.59 [95% CI: 1.01 - 6.61]). CONCLUSION: The IIEF-5 is associated with the diagnosis of CAD and its use can add information to cardiovascular risk staging in hypertensive patients.

Simplified International Index of Erectile Function (IIEF-5) and coronary artery disease in hypertensive patients.

BACKGROUND: Erectile Dysfunction (ED) is associated with increased risk of coronary artery disease (CAD). OBJECTIVE: To evaluate the association between ED, determined by the Simplified International Index of Erectile Function (IIEF-5) and CAD. METHODS: This was a cross-sectional cohort study that evaluated 263 hypertensive patients (55 [50-61] years). ED was assessed through the IIEF-5 and CAD by the history of previous myocardial revascularization and/or coronary angiography. RESULTS: The IIEF-5 correlated with creatinine clearance [CrCl] (Rho = 0.23, p <0.001) and age (Rho = -0.22, p <0.001). Forty-two patients had CAD, and IIEF-5 was able to discriminate them (area under the ROC curve = 0.63, p = 0.006). Patients were divided into two groups: IIEF-5 < 20 (n = 140) and IIEF-5 > 20 (n = 123); those with lower IIEF-5 scores were older (57 [52-61] vs. 54 [45-60] years, p = 0.002), had higher prevalence of CAD (22% vs. 9%, p = 0.004), smoking (64% vs. 47%, p = 0.009) and use of calcium channel inhibitors (65% vs. 43.%, p = 0.001), as well as lower CrCl (67.3 [30.8 to 88.6] vs. 82.6 [65.9 - 98.2] ml/min, p <0.001). The IIEF-5 < 21 was associated with increased risk of CAD in the logistic regression, both univariate (RR = 2.89 [95%CI: 1.39 - 6.05]), and after adjusting for age, diabetes, CrCl, smoking, mean arterial pressure and use of antihypertensive drugs (RR = 2.59 [95% CI: 1.01 - 6.61]). CONCLUSION: The IIEF-5 is associated with the diagnosis of CAD and its use can add information to cardiovascular risk staging in hypertensive patients.

Influence of erythropoiesis-stimulating agents on glycated hemoglobin in nondiabetic kidney diseases at the start of dialysis.

BACKGROUND: Although glycated hemoglobin (HbA1(C)) is a practical tool to assess long-term glucose control in the general population, it may underestimate glycemic control in chronic kidney disease (CKD) patients - especially those undergoing treatment with erythropoiesis-stimulating agents (ESA). We evaluated the association of HbA1(C) with other parameters of glucose homeostasis and tested its association with ESA use and mortality in nondiabetic incident dialysis patients. METHODS: We studied 270 nondiabetic CKD stage 5 patients referred to initiate dialysis therapy [median age: 54 years (43-63), 154 males]. Patients were followed for up to 5 years for survival analysis. RESULTS: HbA1(C) was positively correlated with age (Rho = 0.13; p = 0.031), C-reactive protein (Rho = 0.14; p = 0.024), total cholesterol (Rho = 0.19; p = 0.001), triglycerides (Rho = 0.21; p < 0.001) and glucose (Rho = 0.21; p = 0.001), but it was negatively correlated with HDL-cholesterol (Rho = -0.22; p < 0.001) and ESA dose (Rho = -0.27; p < 0.001). Across increasing HbA1(C) tertiles, increased glucose levels and reduced use of ESA and dose of ESA were observed (p < 0.001), but there were no differences in insulin and HOMA index. In a stepwise multivariate linear regression analysis, ESA dose was negatively associated with logHbA1(C). HbA1(C) did not predict mortality. CONCLUSION: In nondiabetic CKD stage 5 patients, HbA1(C) levels were associated with ESA dose. HbA1(C) was not independently associated with surrogate markers of insulin resistance or mortality.

Influence of erythropoiesis-stimulating agentson glycated hemoglobin in nondiabetic kidney diseases at the start of dialysis

Background: Although glycated hemoglobin (HbA 1C ) is apractical tool to assess long-term glucose control in the generalpopulation, it may underestimate glycemic control inchronic kidney disease (CKD) patients – especially those undergoingtreatment with erythropoiesis-stimulating agents(ESA). We evaluated the association of HbA 1C with other parametersof glucose homeostasis and tested its associationwith ESA use and mortality in nondiabetic incident dialysispatients. Methods: We studied 270 nondiabetic CKD stage 5patients referred to initiate dialysis therapy [median age: 54years (43–63), 154 males]. Patients were followed for up to 5years for survival analysis. Results: HbA 1C was positively correlatedwith age (Rho = 0.13; p = 0.031), C-reactive protein(Rho = 0.14; p = 0.024), total cholesterol (Rho = 0.19; p = 0.001),triglycerides (Rho = 0.21; p ! 0.001) and glucose (Rho = 0.21;p = 0.001), but it was negatively correlated with HDL-cholesterol(Rho = –0.22; p ! 0.001) and ESA dose (Rho = –0.27; p !0.001). Across increasing HbA 1C tertiles, increased glucoselevels and reduced use of ESA and dose of ESA were observed(p ! 0.001), but there were no differences in insulinand HOMA index. In a stepwise multivariate linear regressionanalysis, ESA dose was negatively associated with logHbA 1C .HbA 1C did not predict mortality. Conclusion: In nondiabeticCKD stage 5 patients, HbA 1C levels were associated with ESAdose. HbA 1C was not independently associated with surrogatemarkers of insulin resistance or mortality.

The emerging pleiotrophic role of adipokines in the uremic phenotype.

PURPOSE OF REVIEW: The obesity epidemic is undoubtedly increasing the total end-stage renal disease population, which has a larger proportion of obese individuals on reaching the dialysis stage. This review discusses recent advances in the pathophysiology of adipose tissue and adipokines that may contribute to increased risk of progression towards end-stage renal disease and cardiovascular damage. RECENT FINDINGS: Although leptin effects on blood pressure may negatively affect kidney function, leptin may also induce vascular damage through central and direct effects on both vessels and heart. The contradictory results of adiponectin in uremia are possibly confounded by the disease circumstances. Visfatin may have previously unrecognized roles in angiogenesis and nutrient homeostasis. As visfatin is a ubiquitously expressed enzyme, it may be inaccurate to refer to it as an adipokine. SUMMARY: We still face many unknowns when understanding the putative pleiotrophic effects that adipokines exert in the uremic milieu. Mechanistic and interventional studies are needed to move forward in this area. Conflicting results in patients with ESRD, in whom both beneficial and detrimental effects in uremia outcome are found, are perhaps the consequence of different timing or context-sensitive effects. Specifically, the presence of protein energy wasting and the changing pattern of disease risk may hinder or even reverse the natural action of these molecules.