Association between age and cardiovascular status by echosonography in asymptomatic predialysis patients with chronic kidney disease.

Age is an important risk factor for cardiovascular disease in the general population and in dialysis patients. The aim of this study is to investigate the influence of age on the cardiovascular status of asymptomatic predialysis patients with chronic kidney disease (CKD). Echocardiography and carotid ultrasound were performed in 61 patients with CKD stages 4-5, who were divided by age into two groups: group 1 (≥65 years, n = 31) and group 2 (<65 years, n = 30). Data were compared with those of control group (≥65 years, n = 20). Group 1 patients had significantly higher left ventricular mass index (LVMI), (P <0.001), worse LV diastolic function (lower E/A ratio: P<0.05, E' velocities: P< 0.001, E'/A' ratio: P <0.001, and a higher ratio E/E': P <0.05) and a higher prevalence of aortic (P <0.01) and mitral calcification (P <0.001) compared to group 2 patients. Elderly patients also had significantly increased intima-media thickness (IMT, P <0.001) and a greater prevalence of carotid plaques (P <0.05) and calcifications (P <0.001) than younger patients. Multiple regression analysis showed that IMT, LVMI, and E/A ratio were independent variables associated with aging (R2 = 0.605). We concluded that older CKD patients demonstrated more profound structural and functional abnormalities of the myocardium, as well as more prominent vascular changes compared to younger CKD patients. The changes in IMT, LVMI, and E/A ratio are independently associated with aging of CKD patients.

Epidemiology of end-stage renal disease and hemodialysis treatment in Serbia at the turn of the millennium.

The study presents the epidemiological features of patients treated with renal replacement therapy (RRT) in Serbia from 1997 to 2009 and compares the results of hemodialysis treatment in 1999 and 2009. Epidemiological data were obtained from the National Registry of RRT patients and data on hemodialysis treatment from special surveys conducted in 1999 and 2009. Within the period 1997-2009 the incidence of patients on RRT increased from 108 to 179 per million population (pmp), prevalence rose from 435 to 699 pmp, while mortality rate fell from 20.7% to 16.7%. The frequency of patients with glomerulonephritis decreased, while that of patients with diabetes and hypertensive nephropathy increased. In late 2009 there were 5208 patients receiving RRT in Serbia. Within the examined period new hemodialysis and reverse osmosis equipment were purchased, high-flux dialyzers with synthetic membranes were increasingly used and the number of patients receiving hemodiafiltration increased to 17.6%. Kt/V greater than 1.2 was recorded in 16% of the patients in 1999 but 52% in 2009. Options for correction of anemia and mineral disorders have also improved. The percentage of patients with HbsAg (13.8% vs. 4.8%) as well as anti-hepatitis C virus antibodies positive patients (23.2% vs. 12.7%) was significantly lower in 2009 than in 1999. Both the incidence and prevalence of RRT patients in Serbia are rising continuously, while the mortality rate is falling. More favorable conditions for dialysis treatment have brought about significant improvement in the results over the last 10 years.

[Inflammation and nutritional status in haemodialysis patients].

INTRODUCTION: Protein-calorie malnutrition is highly prevalent in patients with end-stage renal disease and hypoalbuminemia is considered the best clinical marker of malnutrition and mortality in this population. Recently, it has been recognized that inflammation may be also as important as protein intake in causing hypoalbuminemia. The aim of this study is to investigate the relationship between nutritional status, serum albumin concentration and C-reactive protein in patients on regular hemodialysis. MATERIAL AND METHODS: We performed subjective global assessment, anthropometric and laboratory measurements to evaluate nutritional and inflammatory status in 43 hemodialysis patients (27 M, 16 F, mean age 57.7+/-12.7 years). RESULTS: According to SGA, malnutrition was present in 46.5% patients on haemodialysis. By univariate logistic regression analysis, triceps skinfold, mid-arm muscle circumference, body fat %, lean body mass, body-mass index, total proteins, albumin, haemoglobin, creatinine, cholesterol, fibrinogen and CRP were shown to be associated with malnutrition (SGA 2-4). During multivariate analysis, BMI (p=0.011) and CRP (p=0.018) remained associated with malnutrition. In multiple regression models, the mean value of serum albumin concentration was explained (R=0.785, p=0.01) by CRP (r=-0.474; p<0.001), BMI (r=0.297: p=0.008) and total proteins (r=0.288; p=0.013). DISCUSSION AND CONCLUSION: The results suggested that malnutrition and chronic inflammation are important determinants of hypoalbuminemia. There is a complex cause and effect relationship between inflammation and nutritional status. Novel strategies aimed at attenuating the adverse nutritional effects of chronic inflammatory response may improve the clinical outcome in hemodialysis patients.

[Hyperkalemia in hypertensive patients undergoing regular hemodialysis during enalapril and fosinopril therapy].

INTRODUCTION: Hypertension is evident in 80%-85% of patients with chronic renal failure and antihypertensive therapy is needed in 25%-30% of patients. Apart from antihypertensive effect, ACEi's decrease the left ventricular hypertrophy and mortality in dialysis patients. Even so, their use is limited due to hyperkalemia. OBJECTIVE: The objective of the study was to compare the effect of fosinopril and enalapril on serum potassium level in hypertensive hemodialysis patients. METHOD: Prospective pilot study included 16 patients undergoing chronic hemodialysis, with mean age of 58.9 +/- 9.6 years and mean duration of hypertension 11.3 +/- 7.1 years. The effect of antihypertensive drugs of equivalent dose was followed during three periods (three months each): period 1 (therapy with enalapril), period 2 (therapy with fosinopril) and period 3 (therapy with enalapril). Dialysis conditions were constant and patients were without signs of catabolic state. Laboratory results were followed on monthly basis and mean values were compared by ANOVA-one way test. Difference between variables between periods was tested using Bonferoni method. RESULTS: There was significant difference between mean serum potassium levels throughout three therapeutic periods (5.88 +/- 0.38 vs. 4.9910.44 vs. 5.46 +/- 0.46mmol/l; p<0.001). Difference was evident even in the first month of fosinopril therapy. The effect can not be explained by dialysis adequacy since Kt/ V was similar throughout three treatment periods (1.18 +/- 0.24 vs. 1.25 +/- 0.21 vs. 1.25 +/- 0.14; p=ns). Systolic blood pressure was regulated even better with fosinopril than with enalapril (187.5 +/- 21.4 mmHg vs. 160.0 +/- 20.0 mmHg; p=0.01) and this effect was prolonged during period 3 (160.0 +/- 26.1mmHg). Hemoglobin values mainly depended on specific anemia therapy and not on particular ACEi drug. CONCLUSION: Fosinopril carries less risk of hyperkalemia in hypertensive hemodialysis patients than enalapril. Although definite conclusion may be drawn after well-designed studies, the results presented in this pilot study suggest that fosinopril may be recommended for hypertensive hemodialysis patients who are at risk to develop inter-dialytic hyperkalemia.

C-reactive protein as an independent risk factor for carotid atherosclerosis in hemodialysis patients.

C-reactive protein is a known risk factor for cardiovascular diseases, but the association of CRP with the early phase of atherosclerosis has been insufficiently investigated. The aim of the present study was to investigate the relationship between CRP and indicators of subclinical atherosclerosis in hemodialysis patients. Intima-media thickness, lumen-diameter and cross-sectional intima-media area (CSIM area) of the common carotid artery were established using B-mode ultrasound imaging in 43 HD patients and 21 age- and gender-matched healthy controls. CSIM area and LD were significantly higher in HD patients compared with control subjects. Inflammation (CRP> 10 mg/l) was present in 58.1% of HD patients and was associated with higher values of all ultrasonographic markers of atherosclerosis, as well as higher prevalence of atherosclerotic vascular diseases. Higher CSIM area was associated with elevated CRP level (r=0.619, p=0.000), advanced age (R=0.704, p=0.005) and smoking habits (R=0.742, p=0.039). Results of our investigation support the concept on key role of inflammation in the development of atherosclerosis in HD patients.