Reliability of the Epworth Sleepiness Scale and the Berlin Questionnaire for screening obstructive sleep apnea syndrome in the context of the examination of candidates for drivers.

BACKGROUND: The aim of the study has been to assess the usefulness of the Epworth Sleepiness Scale (ESS) and the Berlin Questionnaire (BQ) for obstructive sleep apnea syndrome (OSAS) screening. The capacity of both tests to discriminate between healthy individuals or with mild OSAS (apnea-hypopnea index (AHI) < 15/h) vs. patients with moderate or severe OSAS (AHI ≥ 15/h) was evaluated. MATERIAL AND METHODS: The study encompassed 223 patients with a suspicion of the OSAS. The ESS and BQ were completed by patients unassisted. Screening polysomnography was performed using the Porti SleepDoc. The OSAS was diagnosed when AHI ≥ 15/h or AHI ≥ 5/h with simultaneous occurrence of clinical symptoms. RESULTS: The ESS score was found to be significantly higher in the study group compared to the control group (8.9±5.9 vs. 11.6±5.2 pt, p < 0.0001). Otherwise, there were no significant inter-group differences in the percentage of high-risk individuals according to the BQ (83.7% vs. 92.3%, p > 0.05). Sensitivity of the ESS and BQ was 53.2% and 93.1%, respectively while specificity was 58.8% and 16.2%, respectively. Poor correlation between the ESS score and AHI and apnea index were noticed (r = 0.22, p = 0.001 and r = 0.24, p < 0.001, respectively). CONCLUSIONS: Considering its low sensitivity, the ESS should not be used as a screening test for the OSAS diagnosis amongst candidates for drivers. The BQ is characterised by high sensitivity for the OSAS diagnosis with AHI ≥ 15/h, however, due to low specificity, the questionnaire may increase the number of healthy individuals referred for needless diagnostic procedures. Med Pr 2016;67(6):721-728.

Syndecan-4 Is an Independent Predictor of All-Cause as Well as Cardiovascular Mortality in Hemodialysis Patients.

BACKGROUND: Left ventricular hypertrophy is associated withincreased mortality in hemodialysis (HD) patients.Syndecan-4 plays a role in many processes that are involved in the heart fibrosis and hypertrophy.We designed this study to prospectively determine whether syndecan-4 was predictive of mortality in a group of HD patients. METHODS: In total, 191 HD patients were included. Clinical, biochemical and echocardiographic parameters were recorded. HD patients were followed-up for 23.18 ± 4.02 months. RESULTS: Syndecan-4 levels correlated strongly with geometrical echocardiographic parameters and ejection fraction. Relations with pressure-related parameters were weak and only marginally significant. Using the receiver operating characteristics the optimal cut-off points in predicting all-cause as well as cardiovascular (CV) mortality were evaluated and patients were divided into low and high syndecan-4 groups. A Kaplan-Meier analysis showed that the cumulative incidences of all-cause as well as CV mortality were higher in high serum syndecan-4 group compared with those with low serum syndecan-4 (p<0.001 in both cases).A multivariate Cox proportional hazards regression analysis revealed syndecan-4 concentration to be an independent and significant predictor of all-cause (hazard ratio, 2.99; confidence interval, 2.34 to 3.113; p<0.001)as well as CV mortality (hazard ratio, 2.81;confidence interval, 2.28to3.02; p<0.001). CONCLUSIONS: Serum syndecan-4 concentration reflects predominantly geometrical echocardiographic parameters. In HD patients serum syndecan-4 concentration is independently associated with all-cause as well as CV mortality.

Takotsubo syndrome in a patient after renal transplantation.

BACKGROUND: Takotsubo syndrome (TTS) is a transient cardiomyopathy of unknown origin, clinically manifesting as acute coronary syndrome (ACS). This syndrome mainly occurs in postmenopausal women and has a temporary relationship with emotional or physical stress. CASE REPORT: TTS occurred in 46-year-old female patient on the first day after renal transplantation. The predominant symptoms were connected with ACS, performed with low grade troponin elevation and characteristic shape of left ventricle depicted in echocardiography. Taking into consideration the risk of the development of contrast-induced nephropathy, coronary angiography (CA) was delayed; myocardial perfusion scintigraphy and iodine-123 metaiodobenzylguanidine (¹²³I-mIBG) myocardial uptake were performed to confirm the clinical suspicion. Myocardial perfusion scintigraphy (MPS) performed in rest condition showed normal perfusion but myocardial uptake of ¹²³I-mIBG was impaired. Within 6 months after surgery, full recovery of all biochemical and functional parameters of the left ventricle were observed. At that time CA was done, depicting normal coronary arteries. CONCLUSIONS: TTS could be diagnosed by the use of non-nephrotoxic tests - ¹²³I-mIBG myocardial scintigraphy, MPS and echocardiography.

[Severe, life-threatening renal anemia treatment in patients who do not accept heterologous blood transfusion for religious reasons--case report]. / Leczenie niedokrwistosci nerkopochodnej zagrazajacej zyciu u pacjentów odmawiajacych transfuzji krwi z przyczyn religijnych--opis przypadków.

The management of severe anemia in patients who do not accept heterologous blood transfusion for religious reasons presents many different challenges both at the level of treatment strategy and ethics. Recently, new interventional treatment strategies have become available, including human and bovine hemoglobin substitutes and high-dose recombinant human erythropoietin. We present the successful management of two Jehovah's Witnesses patients with severe, life-threatening anemia caused by chronic renal failure and exacerbated by sepsis.

Effect of haemodialysis on signal-averaged electrocardiogram P-wave parameters.

BACKGROUND: The P-wave signal-averaged electrocardiogram (SAECG) is a non-invasive technique considered to indicate an increased risk for paroxysmal atrial fibrillation. The study was designed to evaluate the effect of the haemodialysis (HD) process on SAECG parameters in the group of selected HD patients. METHODS: Forty-seven HD patients (without relevant cardiac diseases) were included. SAECGs were performed pre- and post-dialysis together with evaluating extracellular body water (ECW) by using bioimpedance and biochemical measurements. For each SAECG, filtered P-wave duration (FPD) and root mean square voltage of the final 20 ms of filtered P-wave (RMS20) were established. RESULTS: The duration of either pre- or post-dialysis FDP was higher in HD patients than in the control group (P<0.001 and P = 0.005, respectively). The voltage of either pre- or post-dialysis RMS20 was reduced in HD patients compared with controls (P<0.001 in both cases). HD induced a decrease in the duration of the FDP and a significant increase in the voltage of RMS20 (P<0.001 in both cases). Stepwise multiple regression identified independent predictors of pre- and post-dialysis FDP as: (1) age; (2) pre- and post-dialysis ECW/kg body weight, respectively and; (3) pre- and post-dialysis haemoglobin levels, respectively. In the case of RMS20, we did not find any independent predictors either pre- or post-dialysis. CONCLUSIONS: Our study revealed that P-wave SAECG parameters are abnormal in a significant portion of HD patients and improved with HD process. We have also demonstrated that patients' age, volume status as well as the presence of anaemia are important factors influencing P-wave SAECG parameters in HD patients.

[Factors producing increase of QRS complex amplitude during hemodialysis]. / Czynniki wplywajace na wzrost amplitudy zespolów QRS podczas hemodializy.

An increase of total amplitudes of QRS complexes induced by the hemodialysis (HD) procedure is a common phenomenon in hemodialysed patients. The aim of the study was to define factors responsible for the growth of QRS complex amplitude as a result of HD. The study was carried out on a group of 48 patients. Before and after HD procedure basic biochemical blood tests were performed and the following parameters calculated for each patient: (a) the total amplitude of QRS complex, (b) the total volume of body water (TBW), the extracellular volume (ECW), and the intracellular volume (ICW), as well as the TBW, ECW and ICW indices standardized against the patient body weight. The levels of albumin, total protein, intact PTH (iPTH), interleukin-6 (IL-6), and tumor necrosis factor alpha (TNF-alpha) were determined before HD. The rates of Kt/V and normalized protein catabolic rate (nPCR) were calculated. The total amplitude of QRS complexes before HD was 13.09 +/- 3.3 mV and it increased significantly after HD to the value of 17.68 +/- 4.03 mV (p<0.001). An increase of QRS amplitude was observed in 35 patients (72.92%). The results of the study revealed, that the most important factor responsible for the growth of the total amplitude of QRS complexes after HD procedure is the value and changes in the ECW volume. The validation of the correlations disclosed in our study between the increase of the total amplitude of QRS complexes and IL-6 )positive correlation), and the nPCR value (negative correlation) require further studies on large groups of HD patients as well as a retrospective analysis of patients' survival rates.

Effect of haemodialysis on regional and transmural inhomogeneities of the ventricular repolarisation phase.

Recent studies have indicated increased ventricular repolarisation dispersion in haemodialysis (HD) patients. The purpose of this study was to estimate the effect of the HD process on parameters of regional and transmyocardial repolarisation inhomogeneities. Thirty-two selected HD patients (without relevant diseases and medication known to affect the QT interval) were included. Dispersion of the QT corrected interval (QT-c-D) and the corrected interval between the peak and the end of the T wave (Tpe-c-D) were evaluated before and after HD, and in controls. Blood chemistry and extracellular body water (ECW) were evaluated before and after HD. Predialysis QT-c-D and Tpe-c-D were higher in patients (53.40 +/- 17.39 and 47.50 +/- 13.68 ms, respectively) than in controls (34.91 +/- 17.70 ms, p < 0.001 and 31.9 +/- 16.76 ms, p < 0.001, respectively). HD induced an increase in the QT-c-D (67.59 +/- 19.40 ms; p < 0.001) and Tpe-c-D (62.89 +/- 14.33 ms; p < 0.001). Stepwise multiple regression identified the independent risk factors of QT-c-D (the differences between pre- and postdialysis phosphorus, potassium and calcium levels and ECW values) and Tpe-c-D (the differences between pre- and postdialysis phosphorus levels, calcium levels and ECW values) increases, induced by the HD process. The HD process increases regional and transmyocardial repolarisation phase inhomogeneities in HD patients. Changes of phosphorus, calcium and potassium levels plus ECW values seem to be important predisposing factors as far as the increase in ventricular inhomogeneities in HD patients is concerned.

[Factors influencing signal-averaged ECG parameters in hemodialysis patients]. / Czynniki wplywajace na parametry usrednionego EKG wysokiego wzmocnienia u pacjentów leczonych hemodializami.

The aim of the present study was to estimate the influence of hemodialysis process (HD) on the signal-averaged ECG (SAECG) parameters and to evaluate possible factors promoting SAECG parameters disturbances in the group of hemodialysis patients (HD-pts). 55 selected HD-pts entered the study. SAECG parameters (QRS duration, root-mean-square of the terminal 40 ms of the QRS--RMS40, low-amplitude signal duration--LAS40), were measured pre and postdialysis. Total (TBW), extracellular (ECW) and intracellular body water (ICW) calculated per kg of HD-pts body weight were estimated pre and postdialysis by using whole body bioimpedance. Two dimentional echocardiography was performed before HD. Serum levels of interleukin-6 (IL-6), tumor necrosis factor-alpha, CRP and intact parathormon were measured before HD. LP were found only before HD in 12.73% of patients. HD induced the decrease of LAS40 duration and the increase of RMS40 value in the of group of LP positive HD-pts (p<0.001 in both cases). The values of TBW and ECW calculated per kg of body weight as well as IL-6 and CRP levels were significantly higher in the LP positive in comparison with the LP negative patients (p=0.006 and 0.004 respectively). Induced by HD changes of RMS40 correlated with pre vs postdialysis values of TBW (r=0.499, p=0.001) and ECW (r=0.556, p<0.001) calculated per kg of body weight. Our study revealed that, that abnormal SAECG parameters and LP are frequently detected in HD-pts. The presence of LP in HD-pts in great part depends on the functional abnormalities (especially on the HD-pts hydration status) corrected by the HD process. The clinical significance of the proinflammatory factors (IL-6 and CRP) needs further investigation.

Comparison of prescribed and delivered doses of dialysis using anthropometrically and bioelectrically measured patient volumes.

BACKGROUND: One of the uncertainties in the prescription of dialysis dose, measured as Kt/V for urea (Kt/Vu), is the volume of urea distribution (V). The aim of our study was to compare two different approaches to estimating V and Kt/V, respectively, and to compare the predicted (prescribed) dose with the actually delivered dose, measured by urea kinetics. MATERIAL/METHODS: V was estimated using anthropometric measures with the Watson formula (VWatson), and also by multi-frequency bioimpedance analysis (VBIS). Both volumes were determined for the state at the end of dialysis and ultrafiltration, and then used to predict (prescribe) Kt/VWatson and Kt/VBIS, respectively. The delivered Kt/Vu was determined from pre- and postdialysis urea concentrations. RESULTS: 209 patients were studied in 254 measurements. VWatson and VBIS correlated significantly (VBIS=0.64*VWatson+15.03, r2=0.67) but VWatson (36.0 +/- 6.4 L) was higher than VBIS (32.5 +/- 8.1 L). The bias between techniques was 3.5 +/- 4.6 L. As a consequence of volume underestimation, Kt/VBIS was overestimated (1.44 +/- 0.38) when compared to the actually delivered Kt/Vu (1.28 +/- 0.32). However, Kt/VWatson (1.27 +/- 0.25) based on VWatson was almost identical to the actually delivered treatment dose. CONCLUSIONS: The close correspondence between the delivered and predicted (prescribed) dose of dialysis using anthropometric volumes leads to the conclusion that in this study kinetic distribution volume was best described by VWatson. The overestimation of prescribed dialysis dose based on bioimpedance analysis suggests caution in the use of bioimpedance volumes, because of the risk of prescribing inadequate dialysis.

Influence of the hepatocellular damage on the clinical usefulness of biochemical markers of bone metabolism and parathormon in haemodialysed patients.

BACKGROUND: The present study was undertaken to determine if hepatitis C virus (HCV) and cytomegalovirus (CMV) infections, as well as biochemical indices of liver damage, can significantly influence the relationships occurring between markers of bone formation, resorption and PTH in hemodialysis patients. MATERIAL/METHODS: 76 HD patients were tested for anti-HCV and anti-CMV antibodies. Serum intact PTH osteocalcin, total and bone isoenzyme of alkaline phosphatase, and plasma tartrate-resistant acid phosphatase were determined as bone metabolism indices. Serum alanine aminotransferase (ALT) and gamma-glutamyl transferase (gamma-GT) were measured as markers of hepatocyte function. The patients were divided into subgroups according to serological and enzymatic status. RESULTS: 37 patients were anti-HCV positive, 61 were anti-CMV positive, and 35 were both anti-HCV and anti-CMV positive. 13 patients were free of viruses. Elevated ALT and gamma-GT activity was found in 26 and 15 patients respectively. Indices of bone formation, resorption and PTH values showed no significance differences in the respective subgroups. Markers of bone formation significantly correlated with one another, as well as markers of bone resorption and intact PTH in all patients. In the subgroup of patients with increased gamma-GT activity, significant differences were found in the slopes of the regression lines occurring in most of the estimated correlations in comparison with all other subgroups. CONCLUSIONS: In renal osteodystrophy, hepatocellular damage indicated by an increase of gamma-GT influences the relationship between the biochemical markers of bone metabolism and parathormon levels, but the presence of anti-HCV and anti-CMV antibodies does not.