Effects of vitamin C supplementation on oxidative stress and serum paraoxonase/arylesterase activities in patients on long-term hemodialysis

BackgroundOxidative stress increases oxidizability of apolipoprotein-B containing lipoproteins and decreases paraoxonase (PON) activity in hemodialysis (HD) patients and plays an important part in the development of atherosclerotic cardiovascular diseases. In HD patients, plasma ascorbic acid (AA) levels are decreased either due to the loss by hemodialysis membranes or due to malnutrition and contribute to the imbalance of antioxidant defense mechanisms. We hypothesized that long-term ascorbic acid (AA) supplementation recovers oxidizability of lipoproteins in HD patients by reinforcing PON activity.MethodsTwenty-nine adult patients were treated with 100 mg and 500 mg AA at the end of each HD session thrice a week for two consecutive 16 weeks-periods, respectively. Blood samples were obtained before the first HD session and prior to the first HD sessions following the 100 mg AA-supplemented and the 500 mg AA-supplemented periods.ResultsPON activities were significantly increased after 100 mg (p < 0.05) and 500 mg AA (p < 0.001) supplementation periods compared to the basal level. Apo-B lipoprotein oxidizability (Δ-MDA) was significantly decreased after 500 mg AA supplementation compared to both basal (p < 0.05) and 100 mg AA supplementation periods (p < 0.05). Plasma AA concentrations were negatively correlated with Δ-MDA levels (R = −0.327; p < 0.01).ConclusionOur results suggest that long-term parenteral 500 mg AA supplementation improves PON activity alleviating apo B-containing lipoproteins oxidizability in HD patients.     

Is there a relationship between hypomagnesemia and proton-pump inhibitors in patients on chronic hemodialysis?

AimWe investigated the association among long-term proton-pump inhibitors (PPIs) use with serum magnesium (Mg) levels in chronic hemodialysis (HD) patients, as well as possible association among PPI use and increased risk of cardiovascular (CVD) morbidity in HD patients.MethodsOf 418 HD patients that were screened for inclusion, 136 were excluded due to incomplete medical data, duration of renal replacement therapy (RRT) for less than 12 months, use of Mg-based-phosphate binders or other Mg-based medications or either to presence of chronic increased GI losses. Among 282 patients included in the study, 170 patients were on PPIs.ResultsSerum Mg levels were significantly lower among PPI users vs. non-users (0.94 ± 0.2 vs. 1.03 ± 0.2 mmol/L; p < 0.0001). The median duration of PPI use was 27 ± 9.6 months (range from 12 to 108) and it was not significantly associated with Mg levels (r = 0.116; p = 0.167). Additionally, residual renal function didn't show a significant correlation with Mg concentration (r = − 0.102; p = NS) in both groups of patients. The use of PPIs was an independent and strong predictor of low Mg concentrations even in multivariate analysis (OR 3.05; 95% CI 1.2498–7.4594, p = 0.01). On the other hand, the daily dose of PPIs was not associated with low Mg levels. PPI users had a higher rate of adverse CVD events during the 1 year of follow-up in comparison to non-PPI users but that difference wasn't statistically significant (17.6% vs. 10.7%; p = 0.110).ConclusionWe have found a significant association between PPI use and lower serum Mg levels in chronic HD patients.     

Etelcalcetide controls secondary hyperparathyroidism and raises sclerostin levels in hemodialysis patients previously uncontrolled with cinacalcet

IntroductionThere is scarce clinical experience with etelcalcetide in patients with secondary hyperparathyroidism uncontrolled with cinacalcet. The effect of etelcalcetide on serum sclerostin levels remains to be clarified.Materials and methodsProspective cohort study in prevalent hemodialysis patients with uncontrolled sHPT under cinacalcet for at least 3 months, mean parathyroid hormone (PTH) > 800 pg/mL and calcium (Ca) > 8.3 mg/dL. Etelcalcetide 5 mg IV/HD was initiated after cinacalcet washout. Levels of PTH, Ca, and phosphorus (Pi) followed monthly for 6 months. Plasma sclerostin levels measured before etelcalcetide treatment and after 6 months.ResultsThirty-four patients were enrolled, 19 (55.9%) male gender. Mean age 60.7 (± 12.3) years; median time on HD 82.5 (7–296) months and median cinacalcet dose was 180 mg/week (Interquartile Range: 180–270).Serum Ca, Pi and PTH levels showed a significant reduction after etelcalcetide treatment from 8.8 mg/dL, 5.4 mg/dL and 1005 pg/mL to 8.1 mg/dL (p = 0.08), 4.9 mg/dL (p = 0.01) and 702 pg/mL (p < 0.001), respectively. Median etelcalcetide dose remained at 5 mg/HD. Plasma sclerostin concentration increased from 35.66 pmol/L (IQR11.94–54.58) to 71.05 pmol/L (IQR54.43–84.91) (p < 0.0001).ConclusionEtelcalcetide improved sHPT control in this group of patients, previously under cinacalcet treatment, and significantly increased plasma sclerostin concentration. The impact of etelcalcetide treatment on sclerostin levels is a novel finding.     

Malnutrition in elderly patients with renal failure: Importance of pre-dialysis period

Background and aimsIn elderly, renal failure is one of the major comorbidities. Malnutrition is another clinical problem in these patients’ follow-up. In this study, we compared nutritional states of elderly patients with different renal functions.MethodsEighty-three predialysis and 121 hemodialysis (HD) patients of 65 years and older and as control group, 46 elderly patients with no renal failure were compared. Blood urea nitrogen, creatinine, thyroid stimulating hormone, vitamin B12 and folic acid levels were measured in every patient. Nutritional status of all patients was evaluated with Mini Nutritional Assessment Short Form (MNA-SF). One-way ANOVA, post-hoc Tukey and Pearson correlation analysis were used for statistics.ResultsThe mean MNA-SF of pre-dialysis patients was 8.67 ± 3.00. In HD patients, it was 11.44 ± 2.43 and in control, it was 11.48 ± 2.27. In HD patients, a weak correlation was detected between higher BUN, creatinine and higher MNA-SF (r = 0.181, P = 0.047), (r  =  0.181, P = 0.046). In HD patients, vitamin B12 levels were higher than pre-dialysis and control group (P < 0.001).ConclusionIn elderly patients with renal failure, malnutrition starts in pre-dialysis period and MNA-SF can be a reliable technic for these patients’ nutritional evaluation.     

Bacteremia during COVID-19 pandemic in a tertiary hospital in Spain

IntroductionThe reasons for the decrease in blood cultures were investigated and the rate and aetiology of bacteremia and contaminated blood cultures collected from COVID and non-COVID patients were assessed.MethodsWe performed a retrospective analysis in a tertiary hospital in Spain during the COVID period from 4th March 2020 to 21st June 2020.ResultsThe number of blood cultures processed was 5313, representing 22.7% and 18.8% of decrease compared to the same months of 2019 and 2018, respectively (p = 0.173). The rate of bacteremia was 1.2% higher among COVID-patients than among non-COVID patients (p < 0.001). COVID patients had a higher proportion of nosocomial bacteremia (95.5%) than non-COVID patients (30.5%) (p < 0.001). In COVID-positive patients, the contamination rate was 12.3% vs 5.7% in non-COVID patients (p < 0.001).ConclusionThere was a decrease in the number of blood cultures collected during the COVID period compared to previous years. Bacteremia in COVID patients was mainly nosocomial and catheter-related.     

Effect of depression on health care utilization in patients with end-stage renal disease treated with hemodialysis

Background and objectivesDepression is regarded as the most common psychiatric abnormality in patients on hemodialysis (HD) for end-stage renal disease (ESRD). Although several studies have demonstrated a relationship between depression and utilization of health care in ESRD and other chronic illnesses in developing countries, such evidence from hemodialysis patients is lacking in Iran. This study aims to investigate the effect of depression on health care utilization among Iranian hemodialysis patients.DesignA longitudinal study.SettingBaqiyatallah Hospital (Tehran, Iran) between 2005 and 2006.PatientsOf the 70 enrolled hemodialysis patients, 68 finished the study including 19 depressed and 49 non-depressed ones according to the Hospital Anxiety and Depression Scale (HADS).MeasurementsThe subjects' health care utilization in a six-month period was prospectively assessed by recording the hospital admission and home nurse visits, outpatient physician visits, and patients' emergency department visits for any medical reason. The results were subsequently compared between the study groups.ResultsA higher hospital admission rate (94.7% vs. 55.1%, p = .002; Pearson's chi-square test) as well as a higher likelihood of emergency department visits (73.7% vs. 40.8%, p = 0.002; Pearson's chi-square test) was seen in depressed patients. The frequencies of the other types of health care utilization were not statistically different between the two groups (p > 0.05, Pearson's chi-square test).ConclusionDepression in hemodialysis patients is associated with higher rate of hospital admission, and prospective studies should be conducted to assess whether treatment of depression will decrease health care utilization in these patients.     

Effect of cilostazol on arteriovenous fistula in hemodialysis patients

BackgroundThe maturation and patency of permanent vascular access are critical in patients requiring hemodialysis. Although numerus trials have been attempted to achieve permanently patent vascular access, little have been noticeable. Cilostazol, a phosphodiesterase-3 inhibitor, has been shown to be effective in peripheral arterial disease including vascular injury-induced intimal hyperplasia. We therefore aimed to determine the effect of cilostazol on the patency and maturation of permanent vascular access.MethodsThis single-center, retrospective study included 194 patients who underwent arteriovenous fistula surgery to compare vascular complications between the cilostazol (n = 107) and control (n = 87) groups.ResultsThe rate of vascular complications was lower in the cilostazol group than in the control group (36.4% vs. 51.7%; p = 0.033), including maturation failure (2.8% vs. 11.5%; p = 0.016). The rate of reoperation due to vascular injury after hemodialysis initiation following fistula maturation was also significantly lower in the cilostazol group than in the control group (7.5% vs. 28.7%; p < 0.001). However, there were no significant differences in the requirement for percutaneous transluminal angioplasty (PTA), rate of PTA, and the interval from arteriovenous fistula surgery to PTA between the cilostazol and control groups.ConclusionCilostazol might be beneficial for the maturation of permanent vascular access in patients requiring hemodialysis.     

Epidemiology of healthcare-associated infections among patients from a hemodialysis unit in southeastern Brazil

Patients submitted to hemodialysis are at a high risk for healthcare-associated infections (HAI). Presently there are scarce data to allow benchmarking of HAI rates in developing countries. Also, most studies focus only on bloodstream infections (BSI) or local access infections (LAI). Our study aimed to provide a wide overview of HAI epidemiology in a hemodialysis unit in southeastern Brazil. We present data from prospective surveillance carried out from March 2010 through May 2012. Rates were compared (mid-p exact test) and temporally analyzed in Shewhart control charts for Poisson distributions. The overall incidence of BSI was 1.12 per 1000 access-days. The rate was higher for patients performing dialysis through central venous catheters (CVC), either temporary (RR = 13.35, 95% CI = 6.68–26.95) or permanent (RR = 2.10, 95% CI = 1.09–4.13), as compared to those with arteriovenous fistula. Control charts identified a BSI outbreak caused by Pseudomonas aeruginosa in April 2010. LAI incidence was 3.80 per 1000 access-days. Incidence rates for other HAI (per 1000 patients-day) were as follows: upper respiratory infections, 1.72; pneumonia, 1.35; urinary tract infections, 1.25; skin/soft tissues infections, 0.93. The data point out to the usefulness of applying methods commonly used in hospital-based surveillance for hemodialysis units.     

Decreased IGF-1 levels potentiate association of inflammation with all-cause and cardiovascular mortality in prevalent hemodialysis patients

ObjectiveInsulin-like growth factor-1 (IGF-1) and inflammation have both been linked to high cardiovascular risk and mortality in the general population, as well as in hemodialysis (HD) patients. We hypothesized that the association of low IGF-1 with chronic inflammation may increase the mortality risk in HD patients.DesignWe investigated the interactions between inflammatory biomarkers (IL-6 and TNF-α) and IGF-1 as predictors of death over a 4 years of follow-up (median — 47 months, interquartile range — 17.5–75 months) in 96 prevalent HD patients (35% women, mean age of 64.9 ± 11.6 years).ResultsA significant interaction effect of low IGF-1 (defined as a level less than median) and high IL-6 (defined as a level higher than median) on all-cause and cardiovascular mortality was found: crude Cox hazard ratios (HR) for the product termed IGF-1 × IL-6 were 4.27, with a 95% confidence interval (CI): 2.10 to 8.68 (P < 0.001) and 7.49, with a 95% CI: 2.40–24.1 (P = 0.001), respectively. Across the four IGF-1–IL-6 categories, the group with low IGF-1 and high IL-6 exhibited the worse outcome in both all-cause and cardiovascular mortality (multivariable adjusted hazard ratios were 4.92, 95% CI 1.86 to 13.03, and 14.34, 95% CI 1.49 to 137.8, respectively). The main clinical characteristics of patients in the low-IGF-1-high IL-6 group didn't differ from other IGF-1–IL-6 categorized groups besides gender that consequently was inserted in all multivariable models together with the other potential confounders.ConclusionsAn increase in mortality risk was observed in HD patients with low IGF-1 and high IL-6 levels, especially cardiovascular causes.     

Vascular access type and mortality in elderly incident hemodialysis patients

IntroductionThe ideal vascular access type for elderly hemodialysis (HD) patients remains debatable. The aim of this study was to analyze the association between patterns of vascular access use within the first year of HD and mortality in elderly patients.MethodsSingle-center retrospective study of 99 incident HD patients aged ≥ 80 years from January 2010 to May 2021. Patients were categorized according to their patterns of vascular access use within the first year of HD: central venous catheter (CVC) only, CVC to arteriovenous fistula (AVF), AVF to CVC, and AVF only. Baseline clinical data were compared among groups. Survival outcomes were analyzed using Kaplan–Meier survival curves and Cox's proportional hazards model.ResultsWhen compared with CVC to AVF, mortality risk was significantly higher among CVC only patients and similar to AVF only group [HR 0.93 (95% CI 0.32–2.51)]. Ischemic heart disease [HR 1.74 (95% CI 1.02–2.96)], lower levels of albumin [HR 2.16 (95% CI 1.28–3.64)] and hemoglobin [HR 4.10(95% CI 1.69–9.92)], and higher levels of c-reactive protein [HR 1.87(95% CI 1.11–3.14)] were also associated with increased mortality risk in our cohort, p < 0.05.ConclusionOur findings suggested that placement of an AVF during the early stages of dialysis was associated with lower mortality compared to persistent CVC use among elderly patients. AVF placement appears to have a positive impact on survival outcomes, even in those who started dialysis with a CVC.     

Sonographic features suggestive of amyloidosis in hemodialysis patients: Relations to serum beta2-microglobulin

Aim of the workTo determine sonographic features suggestive of amyloidosis in hemodialysis patients complaining of shoulder pain, and to study their relations to serum beta2-microglobulin (β2M).Patients and methodsClinical examination, skeletal survey, musculoskeletal ultrasonography of the shoulder joints, and serum β2M were done for 32 patients with end stage renal disease, who were regular on hemodialysis.ResultsSerum β2M levels were markedly raised in all patients, and increased with increasing duration of dialysis (r = 0.91, p < 0.001). Twenty-five patients had a non homogeneous thickening of the supraspinatus tendon >7 mm, and thickening of the biceps tendon >4 mm, 30 had synovial deposits, 27 had subdeltoid bursa effusion, 25 had thickened subacromial bursa, 7 had supraspinatus tendon tear, and 17 had bony erosions. Serum β2M levels significantly correlated with thickened supraspinatus tendon (>7 mm) and supraspinatus tendon tear (r = 0.41, p = 0.03 and r = 0.42, p = 0.01 respectively). Long time on hemodialysis was the significant independent determinant for supraspinatus tendon tear and humeral head erosions (p = 0.001 for each).ConclusionElevated serum β2M levels and sonographic features suggestive of dialysis-related amyloidosis (DRA) were found in all hemodialyzed patients complaining of shoulder pain either with or without clinical and/or radiological features suggestive of DRA. So, for diagnosis of DRA, sonographic features should correspond to the presence of clinically or radiologically evident β2M amyloid, and we should exclude other causes of non-amyloid changes.     

Diabetes acts on mortality in hemodialysis patients predicted by asymmetric dimethylarginine and inflammation

BackgroundThe mortality rate of diabetic patients on dialysis is higher than that of non-diabetic patients. Asymmetric dimethylarginine and inflammation are strong predictors of death in hemodialysis. This study aimed to evaluate asymmetric dimethylarginine and C-reactive protein interaction in predicting mortality in hemodialysis according to the presence or absence of diabetes.MethodsAsymmetric dimethylarginine and C-reactive protein were measured in 202 patients in maintenance hemodialysis assembled from 2011 to 2012 and followed for four years. Effect modification of C-reactive protein on the relationship between asymmetric dimethylarginine and all-cause mortality was investigated dividing the population into four categories according to the median of asymmetric dimethylarginine and C-reactive protein.ResultsAsymmetric dimethylarginine and C-reactive protein levels were similar between diabetics and non-diabetics. Asymmetric dimethylarginine – median IQR μM – (1.95 1.75–2.54 versus 1.03 0.81–1.55 P = 0.000) differed in non-diabetics with or without evolution to death (HR 2379 CI 1.36–3.68 P = 0.000) and was similar in diabetics without or with evolution to death. Among non-diabetics, the category with higher asymmetric dimethylarginine and C-reactive protein levels exhibited the highest mortality (69.0% P = 0.000). No differences in mortality were seen in diabetics. A joint effect was found between asymmetric dimethylarginine and C-reactive protein, explaining all-cause mortality (HR 15.21 CI 3.50–66.12 P = 0.000).ConclusionsAsymmetric dimethylarginine is an independent predictor of all-cause mortality in non-diabetic patients in hemodialysis. Other risk factors may overlap asymmetric dimethylarginine in people with diabetes. Inflammation dramatically increases the risk of death associated with high plasma asymmetric dimethylarginine in hemodialysis.     

Risk factors for pan-resistant Pseudomonas aeruginosa bacteremia and the adequacy of antibiotic therapy

IntroductionThe aim of this study was to determine risk factors for acquiring carbapenem-resistant Pseudomonas aeruginosa bacteremia (CR-PA) and factors associated with in-hospital mortality.MethodsSeventy-seven cases of bacteremia caused by P. aeruginosa were evaluated in a hospital with high incidence of CR-PA. Clinical and laboratorial factors, and previous use of antibiotics were also evaluated. In one analysis, CR-PA and carbapenem-susceptible P. aeruginosa (CS-PA) bacteremia were compared. A second analysis compared patients who died with survivors.ResultsAmong 77 P. aeruginosa bacteremia, 29 were caused by CR-PA. Admission to the intensive care unit, higher number of total leukocytes, and previous use of carbapenem were statistically associated with CR-PA. In the multivariate analysis, only previous use of carbapenem (including ertapenem) turned out to be a risk factor for CR-PA (p = 0.014). The 30-day mortality of patients with P. aeruginosa bloodstream infection was 44.8% for CS-PA and 54.2% for patients with CR-PA (p = 0.288). Chronic renal failure, admission to the intensive care unit, mechanical ventilation, and central venous catheter were risk factors for mortality. Incorrect treatment increased mortality of patients with bacteremia caused by CS-PA, but not for CR-SA. The odd ratio of mortality associated with incorrect therapy in patients with CS-PA was 3.30 (1.01–10.82; p = 0.043). The mortality of patients with bacteremia caused by CR-PA was unexpectedly similar regardless of antimicrobial treatment adequacy.ConclusionAppropriate treatment for CS-PA bacteremia initiated within the first 24 hours was associated with lower mortality, but this cannot be extrapolated for CR-PA.     

Production of biofilm by Staphylococcus aureus: Association with infective endocarditis?

ObjectivesStaphylococcus aureus is a well-known biofilm-producing pathogen that is capable of causing chronic infections owing to its ability to resist antibiotic treatment and obstruct the immune response. However, the possible association between high biofilm production and infective endocarditis (IE) has not been assessed. Our objective was to compare production of biofilm by S. aureus strains isolated from patients with bacteremia and IE, catheter-related bloodstream infection (C-RBSI), or non-device associated bacteremia.MethodsWe isolated 260 S. aureus strains from the blood of patients with bacteremia who were diagnosed during hospital admission between 2012 and 2015. Patients were divided into 3 groups according to whether they had IE, C-RBSI, or non-device associated bacteremia. Biofilm production was measured in terms of biomass and metabolic activity using the crystal violet and XTT assays, respectively. High biomass and metabolic activity rates (based on tertile ranks classification) were compared between the 3 groups.ResultsThe high biomass and metabolic activity rates of each group were 41.9% and 37.2% for IE, 32.5% and 35.0%, for C-RBSI, and 29.0% and 33.3% for non-device associated bacteremia (p = 0.325 and p = 0.885, respectively).ConclusionsHigh biomass and metabolic activity levels for S. aureus isolates from IE were similar to those of S. aureus isolates from C-RBSI or non-device associated bacteremia.     

The Relationship between Red Cell Distribution Width with Erythropoietin Resistance in Iron Replete Hemodialysis Patients

BackgroundRecently, erythropoietin resistance (ER) has been shown to be related with cardiovascular and overall mortality in hemodialysis (HD) patients. Red blood cell distribution width (RDW) has also shown to be associated with cardiovascular and all cause mortality in general population. Thus in the current study we tested the hypothesis that RDW and erythropoietin resistance as determined by erythropoiesis stimulating agents (ESA) hyporesponsiveness index (EHRI) may be related with each other in iron replete HD patients.MethodsStudy participants underwent medical history taking, physical examination, calculation of dialysis adequacy and biochemical analysis. EHRI was calculated as the weekly dose of EPO divided by per kilogram of body weight divided by the hemoglobin level.ResultsTwo separate analyses were performed. In the first analysis performed in 94 HD patients; the stepwise linear regression analysis revealed that being female (P = 0.031), HD duration (P = 0.021), presence of diabetes mellitus (P = 0.008), RDW (P = 0.023), and predialysis sodium (P = 0.05) were independently related with logarithmically converted EHRI. We made second analysis after 4 months. The second analysis revealed that when compared to first EHRI, the EHRI was increased in 40, unchanged in one and decreased in 40 patients The second stepwise regression analysis also showed that the independent relationship with RDW and EHRI was persisted (β = 0.050, CI: 0.022–0.078, P = 0.001).ConclusionRed blood cell distribution width was independently related with EHRI in iron replete HD patients.     

A new technique for the detection of dry weight in hemodialysis patients: Estimated pulmonary capillary wedge pressure. A tissue Doppler imaging study

Background and objectiveFluid overload is an important factor of morbidity and mortality in hemodialysis patients. Today correct determination of dry weight (DW) remains an important issue of hemodialysis practice. Within this context, it is subjected to new method searching. The objective of this study was to calculate estimated pulmonary capillary wedge pressure (ePCWP) with Tissue Doppler Imaging (TDI) in hemodialysis patients and to evaluate its correlation with the other volume markers and to evaluate whether it can be a new method for detection of DW.Materials and methodsEchocardiographic, hemodynamic, and biochemical volume markers of 41 hemodialysis patients were evaluated in the pre- and post-dialysis periods. Patients were divided into two groups based on ePCWP values (Group 1 ePCWP < 20 mmHg, Group 2 ePCWP > 20 mmHg).ResultsIn the pre-dialysis period; parameters related to volume load including ePCWP, systolic blood pressure, mean arterial pressure, pulse pressure, left atrial diameter, left atrial volume, E/é, ratio and E/V_p ratio were statistically significantly higher in Group2 compared to Group1. On the other hand, strong correlations were found between pre-dialysis ePCWP and systolic blood pressure, mean arterial pressure, pulse pressure, NT-ProBNP, left atrial diameter, E/é ratio and E/V_p ratio.ConclusionsStrong correlations found between ePCWP which was calculated with TDI and the other volume markers both in pre-dialysis and post-dialysis periods. These findings can provide a significant contribution to routine evaluating of DW in hemodialysis patients. From this aspect, the prediction of ePCWP with TDI can be a new practical and reproducible method for the determination of DW.     

Drug-eluting stents in patients on chronic hemodialysis: Paclitaxel-eluting stents vs. limus-eluting stents

BackgroundPatients requiring chronic hemodialysis (HD) are at high risk for restenosis after percutaneous coronary intervention (PCI) with bare metal stents. Outcome data on drug-eluting stent (DES) implantation in HD patients are limited and suggest superiority of paclitaxel-eluting stents (PES) over limus-eluting stents (LES).MethodsIn total, 218 consecutive patients were prospectively enrolled. A comparison of post-PCI outcomes up to 2 years was carried out between patients receiving PES (n = 62) and LES (n = 156; SES n = 112, EES n = 44). The primary end point was 2-year major adverse cardiac events [MACE; death, Q-wave myocardial infarction and target lesion revascularization (TLR)].ResultsBaseline characteristics were comparable. The overall prevalence of diabetes mellitus was 71%. On clinical follow-up to 2 years, MACE rates were similar [PES 32/51 (62.7%) vs. LES 77/132 (58.3%), p = 0.59]; however, clinically-driven revascularization occurred more than twice as frequently in LES patients: TLR [PES 4/36 (11.1%) vs. LES 24/93 (25.8%), p = 0.07] and target vessel revascularization [5/37 (13.5%) vs. 33/96 (34.4%), p = 0.02]. Given that overall mortality was nominally higher for PES patients [31/50 (62.0%) vs. 61/127 (48.0%), p = 0.09], a competing outcome analysis was implemented for TLR against mortality, which demonstrated that the trend for increased TLR with LES was no longer apparent (p = 0.282). On multivariable adjustment, only diabetes mellitus was independently associated with TLR (use of PES was not).ConclusionsPatients on chronic HD experience high rates of clinically driven TLR despite DES implantation. Use of PES does not demonstrate a significant advantage over LES in this population.     

Colorectal neoplasm in cases of Clostridium septicum and Streptococcus gallolyticus subsp. gallolyticus bacteraemia

BackgroundBacteremia with Clostridium septicum (CS) and Streptococcus gallolyticus subsp. gallolyticus (SGG) have both been associated with colorectal neoplasms (CRN) and colonoscopic examination is advised, however the differences and similarities in colorectal findings are not well known.MethodsThis is a multicenter, comparative study of patients with CS bacteremia [44 of 664 cases (6.6%) of Clostridium spp.] and SGG bacteremia [257 of 596 cases (44.2%) of S. bovis group], carried out in three hospitals from Spain. Clinical findings related to bacteremia and associated CRN were collected.ResultsThe main sources of infection were abdominal (77.7%) for CS bacteremia and endovascular (75%) for SGG bacteremia. CS bacteremia was more often associated with malignancies, (72.6% vs. 19.4%) and neutropenia (29.5% vs. 3.1%), and was more acute, with shock at presentation (63.6% vs. 3.9%) and higher 30-day mortality (47.7% vs. 9.7%) compared to SGG (P < 0.05 for all).Both, patients with CS and SGG bacteremia often had concomitant CRN (43.1% vs. 49.8%) and most of them presented as occult CRN (73.7% vs. 91.4%; P = 0.02). CS cases more often had invasive carcinomas (94.7% vs. 19.5%), location of CRN in the right colon (73.7% vs. 23.4%), larger tumor size (median 7 vs. 1.5 cm), and a higher overall CRN related mortality rate (68.4% vs. 7.8%) compared to SGG cases (P < 0.05 for all).ConclusionsBoth, CS and SGG bacteremia are associated with occult CRN. CS cases more often had advanced carcinomas than SGG cases, suggesting a distinct temporal association with CRN.     

Influence of mild pulmonary congestion on diaphragmatic mobility and activities of daily living in chronic kidney disease: An experimental and clinical study

BackgroundPulmonary congestion is a strong predictor of mortality and cardiovascular events in chronic kidney disease (CKD); however, the effects of the mild form on functionality have not yet been investigated. The objective of this study was to assess the influence of mild pulmonary congestion on diaphragmatic mobility (DM) and activities of daily living (ADL) in hemodialysis (HD) subjects, as well as compare ADL behavior on dialysis and non-dialysis days. In parallel, experimentally induce CKD in mice and analyze the resulting pulmonary and functional repercussions.MethodsThirty subjects in HD underwent thoracic and abdominal ultrasonography, anthropometric assessment, lung and kidney function, respiratory muscle strength assessment and symptoms analysis. To measure ADL a triaxial accelerometer was used over seven consecutive days. Twenty male mice were randomized in Control and CKD group. Thoracic ultrasonography, TNF-α analysis in kidney and lung tissue, exploratory behavior and functionality assessments were performed.ResultsMild pulmonary congestion caused a 26.1% decline in DM (R² = .261; P = .004) and 20% reduction in walking time (R² = .200; P = .01), indicating decreases of 2.23 mm and 1.54 min, respectively, for every unit increase in lung comet-tails. Regarding ADL, subjects exhibited statistically significant differences for standing (P = .002), walking (P = .034) and active time (P = .002), and number of steps taken (P = .01) on days with and without HD. In the experimental model, CKD resulted in increased levels of TNF-α on kidneys (P = .037) and lungs (P = .02), attenuation of exploratory behavior (P = .01) and significant decrease in traveled distance (P = .034). Thoracic ultrasonography of CKD mice showed presence of B-lines.ConclusionThe mild pulmonary congestion reduced DM and walking time in subjects undergoing HD. Individuals were less active on dialysis days. Furthermore, the experimental model implies that the presence of pulmonary congestion and inflammation may play a decisive role in the low physical and exploratory performance of CKD mice.     

Morbimortality study of infection in patients undergoing different types of dialysis in a renal replacement therapy center

IntroductionRenal replacement therapy is the treatment of end-stage chronic kidney disease and can be performed through dialysis catheters, arteriovenous fistulas/grafts, and peritoneal dialysis. Patients are usually immunocompromised and exposed to invasive procedures, leading to high rates of infection and increased mortality.ObjectivesTo compare the prevalence of infection and related deaths, as well as the sensitivity profile of the putative bacteria in patients treated with peritoneal dialysis, arteriovenous fistula hemodialysis and catheter hemodialysis.MethodsThis is case–control study. Six hundred forty-four patients undergoing renal replacement therapy were selected. Patients were divided into three groups according to the modality of dialysis treatment: peritoneal dialysis (126 patients), arteriovenous fistula hemodialysis (326 patients), and catheter hemodialysis (192 patients).ResultsOne hundred sixteen patients (18.01%) developed infection. There was a higher incidence of infection in the peritoneal dialysis group (44 patients; 34.92%; OR: 3.32; CI 95% = 2.13–5.17; p = 0.0001). In the catheter hemodialysis group, 48 patients (25%) had infection (OR: 1.88; CI 95%: 1.24–2.85; p = 0.0035). In the arteriovenous fistula hemodialysis group, 24 patients (7.36%) developed infection (OR: 0.19; CI 95%: 0.12–0.31; p = 0.0001). Five patients (4.31%) died due to infection (four in the peritoneal dialysis group and one in the catheter hemodialysis group). There were no deaths due to infection in the arteriovenous fistula hemodialysis group.ConclusionsPeritoneal dialysis is the treatment with greater risk of infection and mortality, followed by catheter hemodialysis. The lowest risk of infection and mortality was observed in arteriovenous fistula hemodialysis group.