Obesity paradox and chronic kidney disease.

INTRODUCTION AND OBJECTIVES: In general population, obesity is associated with increased risk of adverse outcomes. However, the studies carried out in the past years have offered a new insight into obesity when associated with chronic disease states such as chronic heart disease, heart failure, chronic kidney disease, end-stage renal disease, etc. Studies of patients with these chronic diseases suggest that the outcomes of overweight and obese patients may be paradoxically better than in lean patients. The aim of our study was to identify how BMI can influence the renal and cardiac functions. METHODS: We carried out a retrospective study on 93 patients (51 males and 42 females; mean age 60.83 +/- 12.32 years) with chronic kidney disease in different stages of chronic renal failure according to K/DOQI. RESULTS: We found significantly higher GFR and lower creatinine levels in obese patients when compared to normal subjects (p = 0.0009, and p = 0.05, respectively). When comparing the group of obese patients (BMI >30) with normal subjects, we found significantly higher values of EF (p = 0.05) and S vel (global radial myocardial velocity of the left ventricle in systole; p = 0.04) in obese patients. There were no significant differences between these three groups of patients in other parameters such as B-type of natriuretic peptide, C-reactive protein, and fibrinogen (p = 0.2, p = 0.4, and 0.9, respectively). CONCLUSION: In our group of 93 patients with chronic kidney disease in different stages of chronic renal failure, we have proved no adverse effect of obesity on cardiac or renal function (Tab. 4, Fig. 3, Ref. 27).

[BNP and echocardiographic parameters in patients with chronic kidney disease and dialyzed patients]. / BNP a echokardiografické parametre u pacientov s chronickými chorobami obliciek a dialyzovaných chorých.

We assessed the relation between BNP levels and some echocardiographic parameters of systolic and diastolic function of the left ventricle in 49 patients (mean age 69.39 +/- 8.47 years) with chronic kidney disease in different stages of chronic renal failure according to K/DOQI and in 45 subjects (mean age 52.6 +/- 14.85 years) on dialysis. Median for BNP in the group of patients with chronic renal failure was 132 pg/ml, and in dialysis subjects 320 pg/ml. None of our patients had clinical signs of heart failure during the last six months. Using a method of correlation matrix we found the left ventricular mass and its indexed value as a common indicator of increased BNP level in both groups of patients (dialysis patients, p = 0.0003, and p = 0.0005, respectively; patients with chronic renal failure, p = 0.03, and p = 0.04, respectively). Further analysis proved that in the group of dialysis patients the main determinants of increased BNP level were volumes of the left heart side: left ventricular end diastolic volume (p = 0.004), endsystolic volume (p = 0.01), and left atrial volumes (maximal, minimal, and total atrial stroke volume; p = 0.004, p = 0.009 and p = 0.04, respectively). In the group of patients with chronic renal failure the major contributors to increased BNP level were echocardiographic parameters of diastolic filling assessed from transmitral and pulmonary venous flow: E wave (p = 0.001), A wave (p = 0.01), E/A (p < 0.001), IVRT (p = 0.004), E/EDT (p < 0.0001), S wave (p = 0.01), D wave (p = 0.0003), S/D (p = 0.001), Ar duration (p = 0.02), and E/Vp (p = 0.003). No significant relation to left ventricular ejection fraction was found in both groups of patients. Our results suggest that the main determinant of increased BNP level in patients with different stages of chronic renal failure is diastolic dysfunction, whereas in dialysis patients high left heart volumes due to volume overload. The common denominator of high BNP level in both groups of patients is especially the left ventricular mass.

Successful therapy with intravenous immunoglobulin in the management of polymyositis.

Polymyositis is an inflammation of muscle tissue of unknown etiology. It is characterized by symmetric, mainly proximal muscle weakness, muscle fiber damage proved on biopsy, increased enzymes and myoglobin, and has corresponding electromyography findings. Other systems such as joints, lungs, heart, and gastrointestinal system are involved. Lung involvement is rather common. The most frequent symptom represents shortness of breath caused by muscle weakness. We report a case of a 66 year old woman with primary idiopathic polymyositis. The clinical state of the patient was complicated by progressive muscle weakness, dysphagia, and respiratory failure. Due to the ineffectiveness of the treatment with corticsteroids and cyclophosphamide, treatment with high doses of immunoglobulins was started. A total of 100 g of i.v. immunoglobulin therapy was administered beginning on the 13th day after hospital admission. The state of the patient progressively improved and after 7 weeks of treatment in a significantly improved state the patient was transferred to a Rehabilitation Unit. We therefore conclude that IVIg therapy may be an effective therapeutic approach for the treatment of acute complications of polymyositis, especially in cases in whom other therapeutic strategies are ineffective or harmful (Ref. 10). Full Text (Free, PDF) www.bmj.sk.

Cardiac biomarkers and chronic renal diseases.

Accelerated atherosclerosis can lead to an increased prevalence of coronary artery disease, heart failure, brain stroke and peripheral arterial disease. Thus, subjects with chronic renal failure are exposed to increased morbidity and mortality from cardiovascular events. A strong and pervasive link exists between kidney failure and cardiac disease. A variety of individual biomarkers have been evaluated and several have been found to successfully predict the outcome in patients with kidney disease. These include markers of myocardial necrosis, such as cardiac troponin T and I, markers of heart failure, such as B-type of natriuretic peptide and its associated inactive N-terminal fragment, markers of systemic inflammation--C-reactive protein, and an endogenous inhibitor of nitric oxide synthase-asymmetric dimethyl arginin. Increased concentrations of C-reactive protein, B-type of natriuretic peptide, asymmetric dimethyl arginine, and troponin predict a high risk of cardiovascular mortality as well as a mortality due to other causes in patients with chronic renal failure or end stage renal disease (Tab. 1, Ref. 33). Full Text (Free, PDF) www.bmj.sk.

An intravenous immunoglobulin therapy of serious autoimmune rheumatic diseases.

Intravenous immunoglobulins (IVIg) have been widely used in clinical practice for more than 35 years. Their efficacy has been established in many clinical trials for the treatment of autoimmune rheumatic diseases including systemic lupus erythematosus, ANCA positive vasculitis and dermatomyositis, but these indications are classified as the "off label" treatment. For the diseases mentioned above there are no generally accepted therapeutic guidelines. The case reports (one patient with lupus erythematosus chorea, two patients with dermatomyositis and one with the Wegener's granulomatosis) present a treatment of systemic connective tissue diseases with IVIg following the failure of standard therapeutic regimens. A successful therapy has been realized using different doses of IVIg, which raises a question on an appropriate dose. Based on our experience, we conclude that intravenous immunoglobulins are effective in the treatment of many "off label" indications in rheumatology, particularly in cases when standard immunosuppressive therapy could be harmful. Despite the evidence of efficacy, the dosage and timing of IVIg therapy, and questions of costs/benefits ratio still remain insufficiently documented and multicentric controlled clinical trials with consecutive development of guidelines are necessary (Ref. 27).