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.     

Relationship between peritoneal solute transport and dialysate inflammatory markers in peritoneal dialysis patients: A cross-sectional study

BackgroundThe associated factors of peritoneal small solute transport was not fully understood. This research aimed to investigate the connection between dialysate inflammatory markers (e.g. macrophage migration inhibitory factor, MIF) in peritoneal dialysis (PD) effluent and peritoneal solute transport rate (PSTR) properties.Subjects and designA total of 80 stable PD patients in the First ShaoYang Hospital were enrolled in present study. Overnight PD effluent and serum inflammatory markers including MIF, MCP-1, VEGF, IL-6, TNFα and TGFβ were detected. Pearson correlation analysis and Logistic regression was performed to determine the risk factors for the increased PSTR.ResultsA trend toward increased values of MIF, MCP-1 and IL-6 in PD effluent was observed in subjects with high PSTR when compared with those with low PSTR. The Pearson correlation test showed that D/P Cr exhibited positive correlations with dialysis effluent MIF (r = 0.32, p = 0.01), MCP-1 (r = 0.47, p = 0.01), IL-6 (r = 0.48, p = 0.01). Conversely, no significant correlation was found between D/P Cr and TGF-β (r = 0.04, p = 0.70), TNF-ɑ (r = 0.22, p = 0.05), VEGF (r = 0.02, p = 0.86) and serum inflammatory markers. In the unadjusted regression analysis, dialysis effluent MIF (OR 2.41), MCP-1 (OR 1.72), IL-6 (OR 1.55) were associated with high PSTR condition. Multivariate logistic regression analysis showed that the adjusted odds ratios (OR) of dialysis effluent MIF for high PSTR were 2.47 in all subjects (p = 0.03).ConclusionElevated MIF, MCP-1 and IL-6 levels in PD effluent were associated with increased PSTR. Elevated dialysis effluent MIF levels was an independent risk factor for high PSTR in subjects with PD treatment.     

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.     

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.     

Incidencia y resultados de la COVID-19 en una unidad de diálisis domiciliaria en Madrid (España) durante el pico de la pandemia

IntroductionThe 2019 coronavirus (COVID-19) is a viral infection caused by a new coronavirus that is affecting the entire world. There have been studies of patients on in-center hemodialysis, but home dialysis population data are scarce. Our objective is to study the incidence and course of COVID-19 in a home dialysis unit (HDU) at the height of the pandemic.MethodsAn observational, retrospective study enrolling all patients diagnosed with COVID-19 from the HDU of Hospital Universitario La Paz (La Paz University Hospital) (Madrid, Spain) between March 10 and May 15, 2020. We collected clinical data from the HDU (57 patients on peritoneal dialysis and 22 patients on home hemodialysis) and compared the clinical characteristics and course of patients with and without COVID-19 infection.ResultsTwelve patients were diagnosed with COVID-19 (9 peritoneal dialysis; 3 home hemodialysis). There were no statistically significant differences in terms of clinical characteristics between patients with COVID-19 and the rest of the unit. The mean age was 62 ± 18.5 years; most were men (75%). All patients but one required hospitalization. Ten patients (83%) were discharged following a mean of 16.4 ± 9.7 days of hospitalization. Two patients were diagnosed while hospitalized for other conditions, and these were the only patients who died. Those who died were older than those who survived.ConclusionThe incidence of COVID-19 in our HDU in Madrid at the height of the pandemic was high, especially in patients on peritoneal dialysis. No potential benefit for preventing the infection in patients on home dialysis was observed. Advanced age and nosocomial transmission were the main factors linked to a worse prognosis.     

Risk factors for herpes zoster reactivation in maintenance hemodialysis patients

ObjectiveHerpes zoster (HZ) reactivation is common in immunocompromised patients. Advanced renal failure is also reportedly associated with impairment of cellular immunity. There is not any study yet assessing risk factors of HZ reactivation in hemodialysis patients.MethodsAll patients undergoing maintenance hemodialysis for more than 3 months and who developed HZ between 2000/01/01 and 2009/12/31 in a tertiary referral medical center were identified, and matched 1:1 to hemodialysis patients without HZ by age and gender. Multivariate-adjusted conditional logistic regression model was constructed to determine possible risk factors.ResultsOut of a total of 126 maintenance hemodialysis patients (65.3% female), 63 belonged to the HZ reactivation group and 63 to the age/sex matched control patients. Conditional logistic regression model linked corticosteroid use with heightened risk (odds ratio [OR] 20.2, 95% confidence interval [CI] 3.5–125.6; p = 0.002), while iron therapy and 1α-hydroxylated vitamin D were associated with significantly lower likelihood of developing HZ (OR 0.12, 95%CI 0.0–0.6; p = 0.01, and OR 0.06, 95% CI 0.0–0.4; p = 0.005 respectively).ConclusionsUse of iron preparations and 1α-hydroxylated vitamin D is potentially associated with less risk of developing HZ reactivation in maintenance hemodialysis patients.     

Angiotensin Receptor Blockers Reduce Left Ventricular Hypertrophy in Dialysis Patients: A Meta-Analysis

IntroductionLeft ventricular hypertrophy (LVH) is a major cardiovascular complication and an important predictor of mortality in patients with end-stage renal disease. Angiotensin II blockades have been widely used in the treatment of hypertension; however, the influence of angiotensin receptor blockers (ARBs) on LVH in dialysis patients has not been thoroughly studied. In this meta-analysis, the authors analyzed the effect of ARBs on LVH and left ventricular function in patients on maintenance dialysis.MethodsThe authors did systematic search of PubMed, Embase and Cochrane Central Register of Controlled Trials, until November 2010. Data extracted from the literature were analyzed with the Review Manager.ResultsThe results of 6 randomized controlled trials (207 participants) reveal that ARB group had a greater regression of left ventricular mass index (LVMi) when compared with non-ARB group (P = 0.002) in dialysis patients while no significant difference for left ventricular ejection fraction (LVEF; P = 0.30). The ARB group had a nonsignificantly greater therapeutic value of LVMi or LVEF when compared with angiotensin-converting enzyme inhibitor (ACEI; P = 0.74 and 0.49, respectively). No significant alterations were observed in LVMi and LVEF between the combination of ARBs and ACEIs and ARBs group (P = 0.43 and 0.24, respectively).ConclusionsARBs are associated with a greater reduction in LVH in patients on dialysis. The ARB therapy tends to have a similar favorable effectiveness as ACEI; however, the combination of ARBs with ACEIs did not show additional benefit to LVH in patients on hemodialysis.     

Colorectal carcinoma and preceding fistula in Crohn's disease

BackgroundAn increased risk for intestinal carcinoma is known in Crohn's disease, but there are also several reports on patients with perianal fistula and later carcinoma at this location — so to call fistula associated carcinoma.MethodsWe retrospectively investigated 591 patients with CD who underwent abdominal surgery during the last 10 years (1997–2006) and found seven patients (5 male, 2 female, median age: 53 years (range 37–74)) with colorectal cancer (Dukes A–C), four of them (57%) with fistula associated CRC. These seven patients with CRC were matched 1:3 to randomly selected Crohn's patients based on age. The medical records of these 21 patients (11 with perianal fistula (52%)) were evaluated with respect to duration and pattern of intestinal involvement of CD, fistula history, intestinal surgery, perianal surgery, prior immunosuppressive and 5-ASA derivative intake.ResultsColorectal cancer was significantly (p = 0.048) associated with longstanding anorectal fistula (median = 11 years (range 0–28 years)) in the CRC group compared to the matched Crohn's patients (median = 1 year (range 0–6 years)). Earlier colonic surgery seemed to protect from later malignancy (p = 0.036). No significant symptoms preceded rectal carcinoma, except for new blood drainage from fistula in 2 patients. Two patients underwent ileocolonoscopy within 1 year before the diagnosis of malignancy and 2 patients underwent MRI of the pelvic region within 4 months.ConclusionColorectal carcinoma is frequently associated with the presence of longstanding anorectal fistula.     

Resultados de la ablación con catéter con mínimo o nulo empleo de fluoroscopia en pacientes pediátricos con taquiarritmias supraventriculares

Introduction and objectivesIonizing radiation exposure in catheter ablation procedures carries health risks, especially in pediatric patients. Our aim was to compare the safety and efficacy of catheter ablation guided by a nonfluoroscopic intracardiac navigation system (NFINS) with those of an exclusively fluoroscopy-guided approach in pediatric patients.MethodsWe analyzed catheter ablation results in pediatric patients with high-risk accessory pathways or supraventricular tachycardia referred to our center during a 6-year period. We compared fluoroscopy-guided procedures (group A) with NFINS guided procedures (group B).ResultsWe analyzed 120 catheter ablation procedures in 110 pediatric patients (11 ± 3.2 years, 70% male); there were 62 procedures in group A and 58 in group B. We found no significant differences between the 2 groups in procedure success (95% group A vs 93.5% group B; P = .53), complications (1.7% vs 1.6%; P = .23), or recurrences (7.3% vs 6.9%; P = .61). However, fluoroscopy time (median 1.1 minutes vs 12 minutes; P < .0005) and ablation time (median 96.5 seconds vs 133.5 seconds; P = .03) were lower in group B. The presence of structural heart disease was independently associated with recurrence (P = .03).ConclusionsThe use of NFINS to guide catheter ablation procedures in pediatric patients reduces radiation exposure time. Its widespread use in pediatric ablations could decrease the risk of ionizing radiation.     

Inflamación y adecuación de la hemodiálisis: ¿están los niveles de proteína C reactiva influidos por la dosis de diálisis recibida?

IntroductionChronic inflammation and the underlying cardiovascular comorbidity are still current problems in chronic hemodialysis patients. There are few studies comparing the “dialysis dose” (Kt/V) with the degree of inflammation in the patient. Our main objective was to determine whether there is a relationship between serum C-reactive protein (CRP) levels and the Kt/V using ionic dialysance.MethodsMulticenter cross-sectional study. A total of 536 prevalent chronic hemodialysis patients were included. CRP levels, neutrophil-lymphocyte ratio and platelet-lymphocyte ratio were collected. Kt was obtained by ionic dialysance and urea distribution volume was calculated from the Watson's formula. The sample was divided into 2 groups, taking the median CRP as the cut-off point. Dialysis adequacy obtained in each group was compared. Finally, a logistic regression model was carried out to determine the variables with the greatest influence.ResultsMedian CRP was 4.10 mg/L (q25-q75: 1.67-10) and mean Kt/V was 1.48 ± 0.308. Kt/V was lower in the patients included in the high inflammation group (P = .01). In the multivariate logistic regression, the “high” levels of CRP were directly correlated with the Log neutrophil-lymphocyte ratio (P < .001) and inversely proportional with serum albumin values (P = .014), Kt/V (P = .037) and serum iron (P < .001).ConclusionThe poorer adequacy in terms of dialysis doses (lower Kt/V values) may contribute to a higher degree of inflammation in chronic hemodialysis patients.     

Urgent start peritoneal dialysis: Is there room for more?

BackgroundDespite the increasing prevalence of end-stage renal disease, peritoneal dialysis (PD) is still offered to a minor subset of patients. One way to increment the utilization rates of this technique is the early start of PD after catheter placement, but there are several concerns related to this approach.MethodsRetrospective analysis in a single-center; 52 patients, 34.6% of the patients started in the first 14 days after catheter placement (Urgent start Group – Group 1) and percentage started PD in a conventional mode (Non-urgent start Group – Group 2). Baseline data, short-term (90-day) clinical outcomes, mechanical complications and infectious episodes were compared among Groups.ResultsAt baseline, Group 1 had an higher Charlson Comobidity Index (CCI). Exchange volumes were significantly lower in Group 1, as expected. Short-term outcomes were equal except for iPTH and albumin, both lower in urgent-start Group (p < 0.05). Episodes of leak, catheter dysfunction and rate of infections were similar among Groups (p > 0.05). In Urgent-start Group we didn’t observed a higher risk for the first peritonitis episode (HR 0.68; 95% CI 0.24–1.99; p > 0.05), higher dropout rate or risk to quit the technique (long rank test, p > 0.05; HR 0.57; 95% CI 0.29–1.13; p > 0.05).ConclusionAccording to our observations, urgent-start PD seems to be a valid and safe alternative to urgent hemodialysis with central venous catheter and should be offered to patients without major contraindications.     

An outbreak of hemodialysis catheter-related bacteremia with sepsis caused by Streptococcus agalactiae in a hemodialysis unit

BackgroundRates of invasive group B Streptococcus (GBS; Streptococcus agalactiae) disease in adults are on the rise. Invasive GBS disease can be community- or healthcare-associated. We report an outbreak of GBS catheter-related bacteremia in a hemodialysis (HD) unit.Materials and methodsTwo patients undergoing HD at the same outpatient HD unit were admitted on the same day (within a few hours of each other) with catheter-related GBS bacteremia. A retrospective study was undertaken at the HD unit to address risk factors for febrile illness on the last HD session day. A detailed questionnaire was completed by all HD patients treated on the same day as the two GBS patients and by all members of the nursing and medical staff. Medical and nursing records of the HD unit were reviewed, as well as infection control and catheter care practices. Patients and staff members submitted swabs for culture.ResultsNo rectal or vaginal culture of any HD patient or staff member was positive for GBS. The development of recent febrile disease was significantly associated with the presence of a hemodialysis catheter (p = 0.028) and care for more than 30 min by a specific nurse during the last two HD sessions (p = 0.007).ConclusionsWe speculate that the GBS strain was transmitted from one patient to the other through the hands of medical personnel. No such outbreak has ever been reported in HD patients. The importance of strict infection control practices in HD units and the avoidance of catheters for long-term HD should be emphasized.     

Seguridad y efectividad del oxihidróxido sucroférrico en pacientes españoles en diálisis: subanálisis del estudio VERIFIE

Background and aimsIn this study, we show the results of the subset of Spanish patients of the VERIFIE study, the first post-marketing study assessing the long-term safety and effectiveness of sucroferric oxyhydroxide (SFOH) in patients with hyperphosphatemia undergoing dialysis during clinical practice.Patients and methodsPatients undergoing hemodialysis and peritoneal dialysis with indication of SFOH treatment were included. Follow-up duration was 12–36 months after SFOH initiation. Primary safety variables were the incidence of adverse drug reactions, medical events of special interest, and variations in iron-related parameters. SFOH effectiveness was evaluated by the change in serum phosphorus levels.ResultsA total of 286 patients were recruited and data from 282 were analyzed. Among those 282 patients, 161 (57.1%) withdrew the study prematurely and 52.5% received concomitant treatment with other phosphate binders. Adverse drug reactions were observed in 35.1% of patients, the most common of which were gastrointestinal disorders (77.1%) and mild/moderate in severity (83.7%). Medical events of special interest were reported in 14.2% of patients, and 93.7% were mild/moderate. An increase in ferritin (386.66 ng/mL vs 447.55 ng/mL; P = .0013) and transferrin saturation (28.07% vs 30.34%; P = .043) was observed from baseline to the last visit. Serum phosphorus levels progressively decreased from 5.69 mg/dL at baseline to 4.84 mg/dL at the last visit (P < .0001), increasing by 32.2% the proportion of patients who achieved serum phosphorus levels ≤ 5.5 mg/dL, with a mean daily SFOH dose of 1.98 pills/day.ConclusionsSFOH showed a favorable effectiveness profile, a similar safety profile to that observed in the international study with most adverse events of mild/moderate severity, and a low-daily pill burden in Spanish patients in dialysis.     

El fracaso de la ablación por catéter de la fibrilación auricular se asocia con mayor remodelado y menos eficacia de una posterior ablación toracoscópica

Introduction and objectivesRecent observations suggest that patients with a previous failed catheter ablation have an increased risk of atrial fibrillation (AF) recurrence after subsequent thoracoscopic AF ablation. We assessed the risk of AF recurrence in patients with a previous failed catheter ablation undergoing thoracoscopic ablation.MethodsWe included patients from 3 medical centers. To correct for potential heterogeneity, we performed propensity matching to compare AF freedom (freedom from any atrial tachyarrhythmia > 30 s during 1-year follow-up). Left atrial appendage tissue was analyzed for collagen distribution.ResultsA total of 705 patients were included, and 183 had a previous failed catheter ablation. These patients had fewer risk factors for AF recurrence than ablation naïve controls: smaller indexed left atrial volume (40.9 ± 12.5 vs 43.0 ± 12.5 mL/m², P = .048), less congestive heart failure (1.5% vs 8.9%, P = .001), and less persistent AF (52.2% vs 60.3%, P = .067). However, AF history duration was longer in patients with a previous failed catheter ablation (6.5 [4-10.5] vs 4 [2-8] years; P < .001). In propensity matched analysis, patients with a failed catheter ablation were at a 68% higher AF recurrence risk (OR, 1.68; 95%CI, 1.20-2.15; P = .034). AF freedom was 61.1% in patients with a previous failed catheter ablation vs 72.5% in ablation naïve matched controls. On histology of the left atrial appendage (n = 198), patients with a failed catheter ablation had a higher density of collagen fibers.ConclusionsPatients with a prior failed catheter ablation had fewer risk factors for AF recurrence but more frequently had AF recurrence after thoracoscopic AF ablation than ablation naïve patients. This may in part be explained by more progressed, subclinical, atrial fibrosis formation.     

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.     

The general characteristics of acute urticaria attacks and the factors predictive of progression to chronic urticaria

BackgroundThe natural history of progression from acute urticaria (AU) to chronic urticaria (CU) remains poorly understood. This study aimed to investigate the potential triggers of AU attacks and factors associated with their duration, as well as the factors which may be predictive of progression to CU.MethodsThe study included 281 AU patients (AU group). Data were obtained from 207 AU patients retrospectively and from 74 AU patients prospectively. The CU group consisted of 953 patients, whose data were previously published.ResultsAccording to the medical history, the most common potential triggers of AU attacks were drugs (38.1%); infections (35.2%); stress (24.7%); and foods (17.8%). Attack duration was shorter in cases in which food (p = 0.04) or infection (p = 0.04) was the suspected trigger. Patients with a history of rhinitis (p = 0.04) and food allergy (p = 0.04), and positive skin prick test results for pollens (p = 0.02) and dog (p = 0.02) also had attacks of shorter duration. Patients with asthma had attacks of longer duration (p = 0.01). Based on history and/or provocation test results, the prevalence of non-steroidal anti-inflammatory drug hypersensitivity (NSAIDH) was significantly higher in the CU group than the AU group (24.9% vs. 4.3%, respectively, (p < 0.01)), as was antibiotic hypersensitivity (10.6% vs. 4.6%, respectively, (p < 0.01)) and food allergy (18.3% vs. 3.9%, respectively, (p < 0.01)). NSAIDH (OR: 7.97; 95%CI: 4.33–14.66; p < 0.01) and food allergy (OR: 5.17; 95%CI: 2.71–9.85; p < 0.01) were observed to be independent factors associated with CU.ConclusionsAs NSAIDH and food allergy were associated with CU, their presence should be carefully evaluated in patients with AU in order to predict progression to CU.     

Facteurs de risque de progression des calcifications des artères coronaires après 5 ans d’évolution en dialyse

BackgroundAlthough progression of coronary artery calcification (CAC) has been established as an important marker for cardiovascular morbidity, very few studies have studied it in end-stage renal disease patients. Thus we examined and evaluate risk factors of calcification changes in dialysis patients.MethodAmong 28 hemodialysis (HD) patients, CAC was measured in Agatston units at baseline and after five years using the 64 multi-slice ultra-fast CT. The HD patients were classified as progressors or no progressors according to the change in the CAC score across these 2 measurements.ResultsOver an average 63 months follow-up, participants without CAC at baseline had no incident CAC. The progression of CAC was slow and was found only in 6 patients (21.4%). It was significantly associated with several cardiovascular risk factors, namely, older age (P = 0.03), diabetes (P = 0.05), male sex (P = 0.02), hypercholesterolemia (P = 0.05), anemia (P = 0.017), inflammation (P = 0.05), and hyperphosphataemia (P = 0.012). However, calcemia, parathormone levels, dialysis duration, tobacco, high blood pressure and dialysis dose did not seem to influence the progression of CAC in our series. A strong association was found between basal calcification scores and Delta increment at 5 years.ConclusionsOur study suggests that CAC progression in dialysis is a complex phenomenon, associated with several risk factors with special regard to elevated basal scores. This progression can be avoided or slowed with appropriate management, which must begin in the early stages of chronic kidney disease.     

Hemodialysis-associated Hemosiderosis in the Era of Erythropoiesis-stimulating Agents: A MRI Study

BackgroundMost dialysis patients receiving erythropoesis-stimulating agents (ESA) also receive parenteral iron supplementation. There are few data on the risk of hemosiderosis in this setting.MethodsWe prospectively measured liver iron concentration by means of T1 and T2* contrast magnetic resonance imaging (MRI) without gadolinium, in a cohort of 119 fit hemodialysis patients receiving both parenteral iron and ESA, in keeping with current guidelines.ResultsMild to severe hepatic iron overload was observed in 100 patients (84%; confidence interval, [CI] 76%-90%), of whom 36% (CI, 27%-46%) had severe hepatic iron overload (liver iron concentration >201 μmol/g of dry weight). In the cross-sectional study, infused iron, hepcidin, and C-reactive protein values correlated with hepatic iron stores in both univariate analysis (P < .05, Spearman test) and binary logistic regression (P <.05). In 11 patients who were monitored closely during parenteral iron therapy, the iron dose infused per month correlated strongly with both the overall increase and the monthly increase in liver iron concentration (respectively, rho = 0.66, P = .0306 and rho = 0.85, P = 0.0015, Spearman test). In the 33 patients with iron overload, iron stores fell significantly after iron withdrawal or after a major reduction in the iron dose (first MRI: 220 μmol/g (range: 60-340); last MRI: 50 μmol/g (range: 5-210); P <.0001, Wilcoxon's paired test).ConclusionsMost hemodialysis patients receiving ESA and intravenous iron supplementation have hepatic iron overload on MRI. These findings call for a revision of guidelines on iron therapy in this setting, especially regarding the amount of iron infused and noninvasive methods for monitoring iron stores.     

Resultados clínicos tempranos tras el implante percutáneo de válvula aórtica por acceso transaxilar comparado con el acceso transfemoral. Datos del registro español de TAVI

Introduction and objectivesTransaxillary access (TXA) has become the most widely used alternative to transfemoral access (TFA) in patients undergoing transcatheter aortic valve implantation (TAVI). The aim of this study was to compare total in-hospital and 30-day mortality in patients included in the Spanish TAVI registry who were treated by TXA or TFA access.MethodsWe analyzed data from patients treated with TXA or TFA and who were included in the TAVI Spanish registry. In-hospital and 30-day events were defined according to the recommendations of the Valve Academic Research Consortium. The impact of the access route was evaluated by propensity score matching according to clinical and echocardiogram characteristics.ResultsA total of 6603 patients were included; 191 (2.9%) were treated via TXA and 6412 via TFA access. After adjustment (n = 113 TXA group and n = 3035 TFA group) device success was similar between the 2 groups (94%, TXA vs 95%, TFA; P = .95). However, compared with the TFA group, the TXA group showed a higher rate of acute myocardial infarction (OR, 5.3; 95%CI, 2.0-13.8); P = .001), renal complications (OR, 2.3; 95%CI, 1.3-4.1; P = .003), and pacemaker implantation (OR, 1.6; 95%CI, 1.01-2.6; P = .03). The TXA group also had higher in-hospital and 30-day mortality rates (OR, 2.2; 95%CI, 1.04-4.6; P = .039 and OR, 2.3; 95%CI, 1.2-4.5; P = .01, respectively).ConclusionsCompared with ATF, TXA is associated with higher total mortality, both in-hospital and at 30 days. Given these results, we believe that TXA should be considered only in those patients who are not suitable candidates for TFA.