Could cooling dialysate improve inflammatory and nutritional status of hemodialysis patients?

BACKGROUND: It has been shown that dialysate cooling (lowering the dialysate temperature to 0.5 °C below central body temperature) reduces the incidence of intradialytic hypotension. Other influences on hemodialysis patients, however, have not been adequately investigated. The purpose of this study was to determine the impact of individualized dialysate cooling on nutritional and inflammatory parameters in chronic hemodialysis (HD) patients. METHODS: Seventy HD patients were separated into two groups: group A: (control group) standard dialysate temperature was 37 °C, and group B: (intervention group) dialysate temperature was 0.5 °C below core body temperature. In addition to routine laboratory tests, blood pressure, anthropometric measurements, inflammatory markers, and the malnutrition inflammation score (MIS) were calculated. RESULTS: After six months of dialysate cooling, intradialytic hypotension episodes were much less prevalent in the intervention group (p = 0.001). Serum ferritin, transferrin saturation (TSAT), high sensitive C-reactive protein (HS-CRP), and Interleukin-6 (IL-6) reduced following dialysate cooling, whereas serum albumin rose. In the control group, IL-6 dropped but serum ferritin, TSAT, albumin, and HS-CRP rose. In both groups, hemoglobin levels dropped, and erythrocyte sedimentation rate (ESR) rose, both groups' midarm muscle circumference and MIS worsened. CONCLUSION: Cold dialysate decreased intradialytic hypotension with no significant improvement of the nutritional and inflammatory surrogates. However, more studies including larger number of patients with longer duration of follow up are required to adequately assess its effect on inflammation and nutrition in chronic hemodialysis patients.

Amenorrhea, premenstrual tension syndrome, and dysmenorrhea among women of reproductive age on hemodialysis: A national study in Egypt.

BACKGROUND AND AIM: The current literature concerning the reproductive health of end stage renal disease (ESRD) females is scarce, outdated, and largely unknown in women living in developing countries. This study aims to estimate the prevalence of menstrual abnormalities and their associated factors among ESRD women in reproductive age undergoing chronic hemodialysis (HD) in Egypt. METHODS: Thirty-five dialysis centers were selected by simple random sampling to represent the different regions of Egypt. Non-pregnant women in the reproductive age (15-50 years) receiving dialysis at the participating centers completed a questionnaire about their menstrual health during a routine hemodialysis session. Their responses were verified by reviewing the medical records and assessing their clinical data. RESULTS: Out of the 472 women, 32.6% had amenorrhea. Menstrual irregularities were reported in 37% of the menstruating women. Premenstrual tension syndrome (PMS) was reported in 70% while dysmenorrhea in 58%. Amenorrhea was more prevalent in non-working women who started hemodialysis after the age of 30. PMS was more encountered in women with hypertension or in those with obstructive uropathy or autoimmune disease as a cause of ESRD. Dysmenorrhea was more prevalent among patients with autoimmune disease or chronic hepatitis C virus and those who started dialysis after the age of 30. CONCLUSION: Secondary amenorrhea, dysmenorrhea, and PMS are common among premenopausal women with ESRD on dialysis. Several factors including socio-economic factors, cause of ESRD, and hypertension contribute to these disorders. Future studies are needed to understand the underlying pathophysiologic mechanisms and management of these abnormalities.

Angiogenic markers predict kidney injury and obstetric complications in women with preeclampsia and pregnancy-related acute kidney injury.

Pregnancy-related acute kidney injury (PRAKI) particularly on top of preeclampsia (PE) represents a major cause of maternal and fetal morbidity and mortality. Reliable diagnostic tools are needed to further evaluate the diagnosis and prognosis of PRAKI. Our objective was to study the diagnostic and prognostic value of angiogenic markers (e.g., stromal cell-derived factor 1 (SDF-1), vascular endothelial growth factor (VEGF), alarmins as uric acid) in women with PE and PRAKI. This prospective study included three groups; PRAKI, PE patients, and healthy controls that were compared regarding serum levels of the studied markers correlated to renal, maternal, and fetal outcomes. SDF-1, VEGF, and uric acid levels were significantly different between the three included groups and predicted PRAKI diagnosis. Patients with hemolysis, elevated liver enzymes, and low platelet (HELLP) syndrome exhibited the highest titers of SDF-1 and VEGF. A positive correlation was found between SDF-1 and renal recovery. Conclusively, serum assays of SDF-1, VEGF, and uric acid may add a diagnostic value in PRAKI and PE.

Is health-related quality of life associated with adequacy of hemodialysis in chronic kidney disease patients?

INTRODUCTION: Monitoring Health Related Quality of Life (HRQoL) in different stages of chronic kidney disease is advised by all nephrology societies. We aimed to study the relation between quality of life and dialysis adequacy. METHODS: One hundred patients (51% males), on regular hemodialysis 3/week for > 6 months in two hospitals were included. Single pool Kt/V was used to assess dialysis adequacy. Patients were grouped into 3 divisions according to Kt/v: Group A > 1.5 (n = 24), group B 1.2-1.5 (n = 54) and group C < 1.2 (n = 22). KDQOL-SF™ questionnaire was used to study quality of life in our groups. Group C was reassessed after 3 months of improving Kt/v. RESULTS: Mean values were: Kt/V (1.48 ± 0.41), Cognitive Function (84.27 ± 9.96), Work status (30.00 ± 33.33), Energy (45.70 ± 13.89), Physical Function and Role limitations due to physical function (45.30 ± 12.39 and 31.25 ± 19.26, respectively). Group A had significantly higher scores of KDQOL-SF except Role limitations due to Physical Function. All subscales improved in group C after Kt/v improvement except 3 subscales, namely, work status, patient satisfaction and role limitation due to physical and emotional functions. CONCLUSION: Inadequate HD badly affects quality of life and improving adequacy refines many components of quality of life.

Acute kidney injury during pregnancy and puerperium: an Egyptian hospital-based study.

INTRODUCTION: While acute kidney injury (AKI) in pregnancy is currently a rare entity in developed countries, it is still a common occurrence in developing countries, representing a major cause of maternal and fetal morbidity and mortality. Scarce data are published regarding pregnancy-related acute kidney injury (PRAKI) in Middle Eastern and African countries. The aim of this work is to report on the frequency, the underlying causes, and the outcomes of patients with PRAKI in an Egyptian tertiary care hospital. METHODS: This is a prospective observational study that included 40 patients representing all women who presented to the Mansoura Nephrology and Dialysis Unit with PRAKI over two years. All patients were followed up for three months after hospital discharge to assess renal outcome, and till the end of pregnancy to assess the maternal and fetal outcomes. RESULTS: PRAKI was reported  in about 1% of women who presented to the obstetrics service, and accounted for 14% of all AKI patients who presented to the renal service in our hospital. Preeclampsia (PE) and obstetric hemorrhage were the commonest causes of PRAKI. Maternal mortality occurred in 22.5% of PRAKI patients. The majority of survivors (62.5%) fully recovered, while the remaining (37.5%) individuals became dialysis dependent. Unfavorable fetal events occurred in 24 pregnancies (60%). CONCLUSION: In our hospital in Mansoura, Egypt, PRAKI represents a relevant burden with potential ominous outcomes obstetric hemorrhage and preeclampsia were the major causes. Further research is needed to understand the causes and improve the outcomes of pregnancy-related AKI.

Fish oil plus wheat germ oil have no prominent effect on homocysteine levels and nutritional indices in hemodialysis patients.

Background: Elevated homocysteine levels and malnutrition are frequently detected in hemodialysis patients and are believed to exacerbate cardiovascular comorbidities. Omega-3 fatty acids have been postulated to lower homocysteine levels by up-regulating metabolic enzymes and improving substrate availability for homocysteine degradation. Additionally, it has been suggested that prevention of folate depletion by vitamin E consumption decreases homocysteine levels. However, data on the effect of omega-3 fatty acids and/or vitamin E on homocysteine levels and nutritional status have been inconclusive. Therefore, this study was planned to examine the effect of combined supplementation of fish oil, as a source of omega-3 fatty acids, with wheat germ oil, as a source of vitamin E, on homocysteine and nutritional indices in hemodialysis patients. Methods: This study was a randomized, double-blind, placebo-controlled trial. Forty-six hemodialysis patients were randomly assigned to two equally-sized groups; a supplemented group who received 3000 mg/day of fish oil [1053 mg omega-3 fatty acids] plus 300 mg/day of wheat germ oil [0.765 mg vitamin E], and a matched placebo group who received placebo capsules for 4 months. Serum homocysteine and different nutritional indices were measured before and after the intervention. Results: Twenty patients in each group completed the study. At the end of the study, there were no significant changes in homocysteine levels and in the nutritional indices neither in the supplemented nor in the placebo-control groups (p > 0.05). Conclusions: Fish oil and wheat germ oil combination did not produce significant effects on serum homocysteine levels and nutritional indices of hemodialysis patients.

Diffusion Tensor Imaging in early prediction of renal fibrosis in patients with renal disease: Functional and histopathological correlations.

AIM: Renal fibrosis (RF) is a well-known marker of chronic kidney disease (CKD) progression. However, renal biopsy is an available tool for evaluation of RF, non-invasive tools are needed not only to detect but also to monitor the progression of fibrosis. The aim of this study is to evaluate the role of diffusion tensor imaging (DTI) in the assessment of renal dysfunction and RF in patients with renal disease. METHODS: Fifty-six patients with renal disorders and 22 healthy controls were recruited. All participants underwent DTI. Renal biopsy was performed for all patients. Mean renal medullary and cortical fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values were compared between patients and healthy controls and correlated to serum creatinine (SCr), estimated glomerular filtration rate (eGFR), 24-h urinary protein (24h-UPRO) and renal histopathological scores. RESULTS: Cortical FA values were significantly higher (P = .001), while cortical ADC values were significantly lower in the patients' group (P = .002). Cortical FA values positively correlated to SCr (P = .006) and negatively correlated to eGFR (P = .03), while cortical ADC negatively correlated to percentage of sclerotic glomeruli, atrophic tubules and interstitial fibrosis (P = .001 for all variables). Medullary ADC negatively correlated to tubular atrophy (P = .02). The diagnostic performance of DTI for detecting RF was supported by ROC curve. Multiple linear regression analysis revealed that the mean cortex ADC was significantly decreased by 0.199 mg/dL for patients with >50% glomerulosclerosis in renal biopsy. CONCLUSION: DTI appears to represent a valuable tool for the non-invasive assessment of renal dysfunction and renal fibrosis.

Impact of malnutrition on health-related quality of life in patients on maintenance hemodialysis.

Malnutrition is considered as one of the most important risk factors that adversely affect the quality of life (QOL) in maintenance hemodialysis (MHD) patients. Many clinically useful nutrition assessment techniques are now available, but the usefulness of such techniques in predicting QOL in MHD patients had not been sufficiently tested. The aim of this study was to explore the relation between different nutritional assessment methods, and QOL and identify nutritional parameter that can best predict physical and mental domains of QOL in MHD patients. This cross-sectional study involved 84 MHD patients. Nutritional status was assessed by using International Society of Renal Nutrition and Metabolism criteria for diagnosis of protein-energy wasting (PEW), malnutrition inflammation score (MIS), subjective global assessment (SGA), anthropometric measurements, bioelectrical impedance analysis, and biochemical tests. Quality of life was evaluated by using the Kidney Disease Quality of Life (36 KDQOL-36). Only mental health composite component of QOL (MHC) showed statistically significant differences between PEW and non-PEW groups. MHC was correlated with serum albumin, MIS, and SGA. Physical health composite component (PHC) was correlated with age, hemodialysis duration, socioeconomic status, comorbidity, educational level, serum creatinine and ferritin, MIS, and SGA. On multiple linear regression analysis, MIS was found to be the most significant predictor of PHC while none of the nutritional parameters can predict MHC. Malnutrition is not uncommon problem in MHD patients that is associated with poor QOL. There are multiple factors associated with PHC and only malnutrition afflicts MHC in those patients.

Relation of protein energy wasting to carotid intima media thickness in hemodialysis patients.

Carotid intima media thickness (CIMT) can reflect the degree of atherosclerosis and cardiovascular risk in hemodialysis patients. Factors such as advanced age, male gender, family history, and smoking can increase the risk of CIMT. In hemodialysis (HD) patients, lower serum albumin level was found to be correlated with higher CIMT. This study aimed to evaluate the relation between CIMT and protein energy wasting (PEW) diagnosed according to the diagnostic criteria of International Society of Renal Nutrition and Metabolism (ISRNM) expert panel in HD patients. This study involved 45 HD patients who were divided into two groups according to the diagnostic criteria for PEW proposed by the ISRNM expert panel including group with PEW (11 patients) and group without PEW (34 patients). Caloric intake was evaluated by food frequency questionnaire for 3 days. Subjective global assessment (SGA) and malnutrition inflammation score (MIS) were fulfilled. Anthropometric measurements, as well as body composition, was evaluated by electrical bioimpedance analysis. Doppler ultrasonography was used to assess CIMT that was significantly higher in patients with PEW (p = 0.030). CIMT had significant positive correlation to age, SGA, and MIS (p = 0.008, 0.002, and 0.003, respectively). Significant negative correlation was observed between CIMT and serum albumin. Multiple linear regression analysis revealed that serum albumin was the only predictor of mean CIMT. In conclusion, CIMT seems to be related to malnutrition in HD patients. Low serum albumin was the only predictor of CIMT.

Relation Between Health-Care Medical Provider Opinion and Hemodialysis Patient Attitude Toward Fasting in Ramadan.

INTRODUCTION: Muslim hemodialysis (HD) patients are motivated to practice fasting in Ramadan. Health-care providers may be unable to make a recommendation based on lack of evidence. The aim of the present study was to investigate patients' and medical professionals' opinion toward fasting in 4 HD centers in Egypt as well as the impact of physicians' attitude on their patient behavior. MATERIALS AND METHODS: This observational multicentric study was conducted on 161 patients undergoing HD and 23 physicians in 4 HD centers in Egypt just after Ramadan 1438 Hijri. Patients' demographic characteristics as well as any associated comorbidities were recorded. Patients and physician were interviewed and were asked about their opinion toward fasting in HD patients and any experienced complications during fasting. RESULTS: Eighty-one (50.3%) patients of the studied HD patients practiced fasting in Ramadan. No statistical difference was observed between fasting and nonfasting groups regarding age, gender, and duration of HD. Eighty percent of patients reported no complications. Fifteen (65.2%) physicians support the opinion that HD patients are capable to fast with precautions. There was a significant variation in fasting frequency among HD patients in the studied centers with a significantly low fasting frequency observed in the third center (10.5%). Most physicians from this HD center adopted that HD patients should not fast. CONCLUSION: HD patients were keen to practice fasting in Ramadan and were to a considerable extent capable of completing this Islamic worship. Patient decision seems to be affected by their physician's opinion. Absence of clear recommendations to guide fasting in Ramadan in HD patients as in diabetic patients makes permission or prohibition of such practice unjustified.

Erroneous introduction of femoral venous catheter into a broad ligament varicose vein causing hemoperitoneum in a woman with postpartum thrombotic microangiopathy.

Femoral venous catheterization is a common procedure in critical care patients. Pregnant women and those in the postpartum period are at risk of various complications such as shock, acute kidney injury, and thrombotic microangiopathic syndromes requiring hemodialysis and plasma exchange, which may necessitate central venous catheterization. Femoral vein catheters may also sometimes be needed. These women may have underlying pelvic congestion and varicosities. Here we present a 24-year-old female patient, who has been treated for postpartum thrombotic microangiopathy with initial clinical improvements, became hemodynamically unstable with diffuse abdominal tenderness and a significant drop in the hemoglobin/hematocrit. Her abdominal ultrasound showed fluid in the peritoneal cavity with hemorrhagic diagnostic tap. The patient underwent exploratory laparotomy which unexpectedly revealed an erroneously introduced femoral vein catheter into a broad ligament varicose vein causing hemoperitoneum and evident ovarian injury. Puncturing of broad ligament varicosities causing hemoperitoneum in peripartum women has not been previously reported as a complication of femoral vein catheterization. This indicates that femoral catheterization in pregnant and peripartum women should be cautiously done and that development of acute abdominal issues, following insertion of femoral vein catheter should raise clinical suspicion and warrant evaluation of catheter misplacement.

Association between Plasma Dehydroepiandrosterone Sulfate and Carotid Intima-Media Thickness among Male and Female Patients with End-Stage Renal Disease on Hemodialysis.

BACKGROUND AND AIM: Serum dehydroepiandrosterone sulfate (DHEA-S) is known to be lower in chronic kidney disease (CKD) patients and in those with cardiac disease, and correlates with a poor cardiovascular outcome. This study aimed to assess the correlation between DHEA-S and carotid intima-media thickness (CIMT) as a predictor of cardiovascular disease in hemodialysis (HD) patients. METHODS: A total of 88 HD patients were included in this cross-sectional study. They included 53 male (group I) and 35 female patients (group II). In addition to conventional history taking, clinical examination, and routine laboratory investigations, serum DHEA-S and CIMT were measured for all patients. CIMT was measured using B-mode ultrasonography, and the mean of maximum CIMT was recorded. The 2 patient groups were further classified according to the level of DHEA-S. The correlation between serum DHEA-S and CIMT was studied. RESULTS: In male patients, CIMT and age were significantly higher in the group with low DHEA-S level (p = 0.003 and 0.001, respectively), while there was no significant difference in both parameters in females. A higher percentage of HCV-positive patients is present in the male group with low DHEA-S level (p = 0.009). Serum DHEA-S is significantly negatively correlated with CIMT in males (p = 0.003) but not in females, and has a significant negative correlation to age in both genders (p = 0.001 and 0.04, respectively). CONCLUSION: Endocrinal disturbance representing as lower serum DHEA-S is associated with increased CIMT, which is considered a predictor of cardiovascular disease in male HD patients, although it is largely explained by advancing age.

Status of fasting in Ramadan of chronic hemodialysis patients all over Egypt: A multicenter observational study.

There is a paucity of data concerning safety of fasting in Ramadan in chronic kidney disease patients on hemodialysis (HD). The aim of the present study was to assess the frequency of fasting in Ramadan in HD patients in Egypt and the possible effect of fasting on clinical and biochemical variables. This observational multicentric study was carried out during 2016 when fasting duration was around 16 h.

Community Acquired Acute Kidney Injury in Mansoura Nephrology Dialysis Unit: One Year Prospective Observational Study.

AIM: Acute kidney injury (AKI) is a major health problem with poor patient prognosis. We evaluated the clinical characteristics, risk factors, associated comorbidities, and outcomes of AKI patients. METHODOLOGY: A single-center prospective observational study. The patients were admitted in Mansoura Nephrology and Dialysis Unit over a period of 1 year from January to December, 2016. Patients were diagnosed as AKI or AKI in addition to chronic kidney disease according to the creatinine criteria of KDIGO 2013. All patients were subjected to complete history taking, physical examination, and full laboratory and pelvi-abdominal ultrasound investigations. The study outcomes were all-cause hospital mortality, and recovery of renal function. Predictors of mortality were assessed using multivariate logistic regression analysis. The study was reviewed and approved by local Ethical Committee of IBR. RESULTS: We evaluated 199 (96 males plus 103 females) aged between 18 and 88 years old. Dehydration was the commonest precipitating factor for AKI in our patients (68.8%) and Oliguria was the commonest symptom present in 47.7% of patients. Intravenous fluids were received by 79.9% of patients, 22.6% of patients received diuretics, and 33.7% received renal replacement therapy in the form of intermittent hemodialysis. Death occurred in 25 patients (13.16%) and 69 (36.32%) showed no renal recovery. Shock and sepsis were the most significant predictors of mortality. Conclusion: Community acquired AKI is a major health problem with high morbidity and mortality.

Obesity may be erythropoietin dose-saving in hemodialysis patients.

BACKGROUND: In dialysis patients, the obesity-survival paradox still requires an explanation. Anemia and high doses of erythropoiesis-stimulating agents (ESAs) are associated with worse outcomes in the hemodialysis (HD) population. In the present study, we explored the relation between obesity and anemia control in a sample of maintenance HD patients in Egypt. METHODS: This multicenter observational study included 733 patients on maintenance HD from 9 hemodialysis centers in Egypt. Clinical and laboratory data as well as average doses of ESAs and parenteral iron were recorded. The erythropoietin resistance index (ERI) was calculated. RESULTS: Obesity, defined as a body mass index (BMI) ≥ 30 kg/m2, was present in 22.6% of the studied population. The target hemoglobin level (10.0-11.5 g/dL) was achieved in 27.3% of non-obese and 25.3% of obese patients, with no significant difference. The median serum ferritin and the values of transferrin saturation index did not differ significantly between these two groups. The weekly ESA dose was significantly lower in obese than in non-obese patients (P = 0.0001). A trend toward higher ESA doses and ERI values was observed in patients with lower BMIs (P < 0.0001). Multiple linear regression revealed that the BMI and urea reduction ratio were the strongest predictors of the ERI. CONCLUSION: Our study adds more evidence to obesity-associated advantages in HD patients. BMI may determine ESA response, with better responses observed in patients with higher BMIs.

The impact of fish oil and wheat germ oil combination on mineral-bone and inflammatory markers in maintenance hemodialysis patients: a randomized, double-blind, placebo-controlled clinical trial.

PURPOSE: This study aimed to examine the impact of combined supplementation of fish oil (FO) with antioxidants like wheat germ oil (WGO) on mineral-bone and inflammatory markers in maintenance HD patients. METHODS: This randomized, double-blind, placebo-controlled trial involved 46 HD patients who were randomly assigned into two groups to receive daily 3000 mg of FO [1053 mg omega-3 fatty acids (ω-3 FAs)] plus 300 mg of WGO [0.765 mg vitamin E] or placebo for 4 months. Blood concentrations of hemoglobin (Hgb), white blood cells, mineral-bone parameters including serum calcium (Ca), phosphorus, calcium-phosphorus product, parathyroid hormone, alkaline phosphatase, and osteoprotegerin and serum concentrations of inflammatory markers including high-sensitivity C-reactive protein, ferritin, and uric acid were measured before and after the intervention. RESULTS: Eighty-seven percentage of patients in each group completed the study. The mean serum Ca levels increased significantly in the supplemented group at the end of study (p = 0.0016), and this increment was also significant as compared to placebo group (p = 0.0418). No significant alterations were observed in the other measured parameters within each group during the study (as p values were >0.05). CONCLUSION: FO plus WGO supplementation showed beneficial effect on serum Ca levels of HD patients without any statistically significant effect on other mineral-bone and inflammatory markers. Further investigations are required to confirm it.

Effect of concomitant administration of cyclosporine and ketoconazole in children with focal segmental glomerulosclerosis.

BACKGROUND: Focal segmental glomerulonephritis (FSGS) is now the most common primary glomerulonephritis that leads to end-stage renal disease in both adults and children. Cyclosporine (CsA) is a well-known and effective immunosuppressive agent that has become a cornerstone of immunotherapy in solid organ transplantation and it has been used in the treatment of FSGS for over 15 years. The deliberate use of ketoconazole (keto) to reduce the need for CsA is not new, but it is particularly relevant because of the high cost of CsA. Many studies have documented this benefit in renal and cardiac transplants, but this co-administration has not been reported in children with nephrotic syndrome (NS). METHODS: This study included 116 children (below 18 years of age) with primary FSGS who were steroid resistant or dependent and received CsA therapy. Among them, 88 received daily keto therapy (keto group) in a dose of 50 mg with concomitant decrease of CsA dose by one third, while 28 patients received CsA alone (non-keto group). Mean (+/-SD) age was 6.17 +/- 4.68 years and male to female ratio was 1.9:1. The great majority of the study population received the drugs for 1-2 years. The characteristics of both groups were comparable. RESULTS: Co-administration of keto significantly reduced mean doses of CsA by 46% at 1 year with overall net cost savings of 36%. It also significantly improved the response to CsA therapy and decreased the frequency of renal impairment. No significant side effects for keto were observed. CONCLUSION: Co-administration of keto and CsA in idiopathic FSGS children is safe. This combination not only reduces the costs but also may improve the response to CsA and stabilize the renal function.