Coronary events in obese hemodialysis patients before and after renal transplantation

We examined the impact of obesity (BMI ≥30 kg/m², n = 357) on prognosis in 1696 hemodialysis (HD) patients before and after renal transplantation (TX). End‐points were coronary events, composite cardiovascular (CV) events, and death. Obese HD patients were older (55.9 ± 9.2 vs. 54.2 ± 11), had more diabetes (54% vs. 40%), dyslipidemia (49% vs. 30%), altered myocardial scan (38% vs. 31%), myocardial infarction (MI) (16% vs. 10%), coronary intervention (11% vs. 7%), higher total cholesterol (186 ± 52 vs. 169 ± 47), and triglycerides (219 ± 167 vs. 144 ± 91). Obese undergoing TX had more dyslipidemia (46% vs. 31%), angina (23% vs. 14%), MI (18% vs. 5%), increased total cholesterol (185 ± 56 vs. 172 ± 48), and triglycerides (237 ± 190 vs. 149 ± 100). Obesity was independently associated with coronary events (log‐rank = 0.008, HR 2.55% CI 1.27–5.11) and death (log‐rank 0.046, HR 1.52, % CI 1.007–2.30) in TX but not in HD. Obese HD patients had more risk factors and ischemic heart disease, but these characteristics did not interfere with prognosis. In TX patients, obesity predicts coronary events and death.     

Blood pressure elevation during the night in chronic renal failure, hemodialysis and after renal transplantation

Diurnal blood pressure variation was studied by ambulatory 24-hour monitoring in patients with advanced chronic renal failure (n = 20), on chronic hemodialysis (n = 20), after renal transplantation (n = 21) and in matched control groups without renal disease. Nocturnal blood pressure reductions were significantly blunted in all patient groups as compared with the respective control groups. In almost none of the 61 controls did the mean values during nighttime (8 p.m.-8 a.m.) exceed the mean day time values (8 a.m.-8 p.m.). In 10 of the 61 renal patients blood pressure was higher during the night. In patients with chronic renal disease nocturnal blood pressure elevation may be diagnosed by ambulatory 24-hour monitoring. This may require adaptation of antihypertensive treatment.     

Heart rate variability during chronic hemodialysis and after renal transplantation: studies in patients without and with systemic amyloidosis.

The present study was undertaken to compare heart rate variability (HRV) values in patients on maintenance hemodialysis with no evidence of ischemic or hypertensive heart diseases to those of age- and gender-matched healthy individuals and those of patients after renal transplantation. To assess the effects of a common confounding factor, HRV values were also determined in patients with systemic amyloidosis, in chronic hemodialysis, and after successful renal transplantation. Spectral analyses of RR intervals from continuous electrocardiogram recordings were performed to quantify ultra low frequency, very low frequency, low frequency, and high frequency powers. HRV determinations were all significantly reduced in uremic patients undergoing hemodialysis compared with the healthy control subjects, especially in those with systemic amyloidosis. Renal transplantation normalized HRV in most patients; HRV, however, remained reduced in isolated amyloidosis patients with cardiac or adrenal involvement. HRV circadian day/night differences were preserved in hemodialysis patients and after renal transplantation in those without amyloidosis but not in those with amyloidosis. These data suggest that reduced HRV in chronic hemodialysis patients may precede other manifestations of cardiovascular disease. In uremic patients with amyloidosis, a more severe form of autonomic failure may occur. Successful transplantation corrects HRV abnormalities in most patients, suggesting that the autonomic dysfunction of uremia is caused by humoral factors reversed by the normalization of the renal function.     

"Watermelon stomach" in patients on chronic hemodialysis

"Watermelon stomach" is a common name for gastric antral vascular ectasia (GAVE syndrome). This endoscopic finding is characterized by the appearance of parallel longitudinal red columns along mucosal folds, along with capillars dilatation and hemorrhagy. Finding reliable method for its recognition is of paramount importance. Patient B.D., a 54-year-old woman, developed renal failure, which led to hemodialysis treatment, on the basis of pyelonephritis chronica. As a consequence of the gastrointestinal bleeding, the patient had black stools and developed severe anemia. The endoscopic finding showed the existence of visible columns of vessels transversing the antrum in longitudinal folds and converging in the pylorus, with clear red spots and surrounding hyperemy covered by drops of fresh blood. The diagnosis of "watermelon stomach" was confirmed after the pathohistological examination of the tissue taken at the biopsy, followed by total gastrectomy. Postoperative status was normal, without gastrointestinal hemorrhagia, and she went on with hemodialysis. Before the surgery she received 105 blood transfusions, and after surgical treatment she has received only 18 so far. At the moment she is in good health condition, and on hemodialysis. The reason we have reported this case of "watermelon stomach" syndrome in patient with chronic renal failure is to indicate that this rare anomaly of gastric blood vessels can lead to gastrointestinal blood loss in these patients. Since it is often the reason for many wrong diagnoses, it should be also taken into consideration in cases like these.     

Increased QT dispersion in hemodialysis patients improve after renal transplantation: a prospective-controlled study.

Increased QT dispersion (QTd), predicting patients with risk of malignant arrhythmia, have recently been reported in hemodialysis patients (HDp). In this prospective study, we aimed to investigate changes in QTd and signal averaged-ECG (SAECG) in HDp after transplantation. Twenty-seven HDp (M/F:18/9, mean age 30+/-8 years) and 24 controls (M/F:14/10, mean age 33+/-6 years) were included. All QT parameters (QTmax, Qtmin, and QTd) were increased in HDp. QTmax and QTd started to decrease at the first month after transplantation. Percentage change in QTd at the third month was significantly correlated with percentage change in LV mass index (r=0.45, P=0.04), serum calcium (r=-0.47, P=0.02) and intact parathyroid hormone (r=0.68, P=0.01). In multivariate regression analysis, only percent chance in LV mass index was retained as significant. As for analysis of SAECG, 4 of the 23 (17%) HDp has abnormal late potentials which disappeared after transplantation. HDp with LV hypertrophy had higher filtered-QRS duration compared to patients without hypertrophy (110+/-12 vs. 97+/-11 msec, P=0.01). It was concluded that increased QTd and presence of late potentials improved early after renal transplantation. These changes were mainly associated with the regression of the LV mass.     

Metabolic syndrome in children with chronic kidney disease and after renal transplantation

Visceral obesity and metabolic abnormalities typical for metabolic syndrome (MS) are the new epidemic in adolescence. MS is not only the risk factor for cardiovascular disease but also for chronic kidney disease (CKD). Thus, there are some reasons to recognize MS as a new challenge for pediatric nephrologists. First, hypertensive and diabetic nephropathy, the main causes of CKD in adults, both share the same pathophysiological abnormalities associated with visceral obesity and insulin resistance and have their origins in childhood. Secondly, as the obesity epidemic also affects children with CKD, MS emerges as the risk factor for progression of CKD. Thirdly, metabolic abnormalities typical for MS may pose additional risk for cardiovascular morbidity and mortality in children with CKD. Finally, although the renal transplantation reverses uremic abnormalities it is associated with an exposure to new metabolic risk factors typical for MS and MS has been found to be the risk factor for graft loss and cardiovascular morbidity after renal transplantation. MS is the result of imbalance between dietary energy intake and expenditure inducing disproportionate fat accumulation. Thus, the best prevention and treatment of MS is physical activity and maintenance of proper relationship between lean and fat mass.     

Changes in pulmonary function in patients with chronic renal failure after successful renal transplantation

OBJECTIVE: Pulmonary function abnormalities have been described in patients with chronic renal failure. There are very few longitudinal studies showing the effect of renal transplantation on pulmonary function. We aimed to study the effects of renal failure on pulmonary functions and to observe the changes following successful renal transplantation. MATERIAL AND METHODS: Patients with end-stage renal failure (n=25) of various etiologies who presented to the renal transplant unit of a teaching hospital were included in this prospective, longitudinal study. Patients with a prior history of pulmonary disease and chronic smokers were excluded. Pulmonary function tests were performed and blood gases evaluated before and 6 months after successful renal transplantation. RESULTS: Most patients showed pulmonary function abnormalities which improved significantly after transplantation. The mean vital capacity increased from 2.89 (95% CI 2.63-3.15) l pre-transplantation to 3.32 (95% CI 3.09-3.54) l post-transplantation (p<0.001), indicating that subjects had a restrictive pulmonary function defect which improved after transplantation. The large airways were normal, as evidenced by normal forced expiratory volume in the first second:forced vital capacity ratios. There was significant small airways dysfunction, as shown by low maximal mid-expiratory flow rates, which tended to improve after renal transplantation (p=0.013). There was also a highly significant (p<0.001) improvement in maximal voluntary ventilation (MVV) after transplantation. The MVV test is a composite test which measures all aspects of pulmonary function, including respiratory muscle strength. However, not all patients achieved normal pulmonary function due to uremia-induced irreversible pre-transplantation changes. CONCLUSION: Pulmonary function abnormalities are common in patients with chronic renal failure but can be significantly ameliorated following successful renal transplantation.     

Cholesterol metabolism in patients with chronic renal failure on hemodialysis

Premature atherosclerosis is a major concern in patients on chronic dialysis and the identification of risk factors is important for preventive and interventional strategies. Other than the recognized atherogenic lipoprotein levels, little is known about overall cholesterol metabolism in patients on chronic hemodialysis (HD) and the best therapeutic intervention is still being debated. Therefore, we investigated intestinal cholesterol absorption, cholesterol and bile acid synthesis, and non-cholesterol plasma sterols in eight patients on dialysis and compared the results to those of 16 healthy male controls matched for body mass index and dietary cholesterol intake. Total, low-density lipoprotein (LDL) cholesterol, and triglycerides did not differ between the groups, but dialysis patients had a significantly lower high-density lipoprotein (HDL) cholesterol level (39 +/- 11 mg/dL vs. 48 +/- 10 mg/dL, p < 0.045). However, fractional cholesterol absorption, was significantly lower in dialysis patients (42.8 +/- 10.9% vs. 53.4 +/- 11%, p < 0.035), whereas plasma plant sterol concentrations and their ratios to cholesterol did not differ. Bile acid and total cholesterol synthesis were lower in dialysis patients (40% and -25%, respectively), although the differences were not significant. In contrast, lathosterol and its ratio to cholesterol in plasma was significantly lower in dialysis patients (0.176 +/- 0.084 mg/dL vs. 0.251 +/- 0.102 mg/dL, p < 0.024 and 0.733 +/- 0.353 microg/mg vs. 1.172 +/- 0.407 microg/mg, p < 0.017, respectively), indicating reduced hepatic de novo cholesterol synthesis. It is concluded that reduced HDL cholesterol and reduced bile acid synthesis contributes to atherosclerosis pathogenesis in dialysis patients, whereas intestinal cholesterol absorption and hepatic cholesterol synthesis did not seem dominant in this process at this stage of disease. Consequently, treatment with bile acid binding resins could be preferable to treatment with cholesterol absorption and synthesis inhibitors.     

Impact of recurrent nephrotic syndrome after renal transplantation in young patients

Recurrent disease is a frequent complication of patients transplanted for steroid-resistant nephrotic syndrome associated with focal segmental glomerulosclerosis. Its long-term prognosis has rarely been studied. We examined 39 patients aged 4–25 (mean 13.5) years at the time of first transplantation (TX). Twelve of these (30%) developed nephrotic syndrome after the first TX and 2 of 8 after the second TX. The mean observation period from first TX to last observation with a functioning graft or graft loss was 5.4 (0.1–19.3) years. We confirmed that recurrent disease is associated with older age at onset of the primary disease, shorter time from onset to end-stage renal disease, and diffuse mesangial proliferation in the initial kidney biopsy. Remissions occurred in all 3 children undergoing early repeated plasma exchange and in 1 adolescent following introduction of cyclosporin A 7 years after TX. At last observation 42% of relapsing and 48% of non-relapsing patients with a similar follow-up period had a functioning first graft. Median first graft survival was almost identical in the relapsing and the non-relapsing patients (4.3 vs. 4.2 years). Histological lesions of focal glomerulosclerosis were detected in the posttranplant biopsies of only 3 patients. In conclusion, young patients with nephrotic syndrome associated with focal segmental sclerosis have a similar graft survival with and without recurrence of the nephrotic syndrome. Received October 29, 1997; received in revised form February 17, 1998; accepted February 18, 1998     

Effect of renal transplantation on left ventricular function in hemodialysis patients

The effect of renal transplantation on left ventricular function was evaluated in 14 patients with end-stage renal disease requiring maintenance hemodialysis. They had no apparent clinical evidence of heart disease. Ischemic heart disease was excluded by history, electrocardiography and radionuclide ventriculography. Echocardiography and radionuclide ventriculography were recorded in the interdialytic periods. Sixty-four per cent of the patients had abnormal left ventricular function despite adequate hemodialysis. Left ventricular function was reassessed within the first two months after successful renal transplantation. All parameters improved shortly after the transplantation. Cardiac index increased by an average of 0.76 +/- 0.11/min/m2 (P less than 0.001), stroke volume by 23.9 +/- 0.5 ml (P less than 0.001), ejection fraction by 9.7 +/- 1.9% (P less than 0.001), mean normalized posterior wall velocity by 0.17 +/- 0.06 second-1 (P less than 0.01), mean velocity of circumferential fiber shortening by 0.28 +/- 0.02 circle/second (P less than 0.001), and mitral valve diastolic closure rate by 17.2 +/- 2.3 mm/second (P less than 0.01). Our findings support the existence of a specific uremic cardiomyopathy which is a functional defect probably related to poorly dialyzed uremic toxins.     

Outcome of thirty patients with Alport's syndrome after renal transplantation

Graft antiglomerular basement membrane nephritis in patients with Alport's syndrome (AS) is a unique complication related to the glomerular basement membrane (GBM) abnormality characteristic of the disease. Its prevalence and clinical significance however remain unknown. We used strict criteria of AS to select 30 patients (26 men, 4 women), aged 17 to 44 years (m: 27) in whom 35 grafts (30 first, 5 second) had been performed at our center between 1968 and 1988. Patient and graft survival were, respectively, 96 and 75% at 5 years, 77 and 42% at 10 years. Graft survival and function, as well as the incidence of rejection episodes in the AS group were not different from those of a control group without AS, matched for age, sex, graft origin, and immunosuppressive regimen. Fifteen grafts were examined by immunofluorescence at least 3 months after TP: linear IgG deposits along GBM were present in 5 cases in the absence of signs of crescentic glomerulonephritis. Circulating anti-GBM antibodies detected in one of these cases 8 months post-TP had disappeared 24 months later. The presence of linear IgG did not seem to influence graft survival and function. We conclude: (1) the overall outcome of TP in AS patients does not differ from a control group without AS; (2) appearance of linear glomerular IgG is frequent but is not necessarily associated with a poor graft outcome; (3) the course of de novo graft anti-GBM disease may be benign; and (4) the aggressivity of the disease could be determined by the degree of immunosuppression and/or by the specificity of the anti-GBM antibodies.     

Prune belly syndrome: treatment of terminal renal failure by hemodialysis and renal transplantation.

The second case of successful renal transplantation in a patient with "prune belly" syndrome is reported. In spite of early aggressive surgical approach in the management of this disease terminal renal failure frequently ensues. Hemodialysis and renal transplantation have offered new possibilities of prolonging life in these patients. The success of renal transplantation depends on the anatomic and functional state of the lower urinary tract. Pretransplant urologic examination is extremely important for the evaluation of urinary tract abnormalities.     

Retroperitoneal compartment syndrome after renal transplantation

We report the case of a 21-year-old man with end-stage renal disease secondary to systemic lupus erythematosus who underwent living related renal transplantation and developed an extraperitoneal compartment syndrome postoperatively.     

Effect of renal transplantation on cognitive function in hemodialysis patients: a longitudinal study

International Urology and Nephrology - The literature notes high prevalence of cognitive function (CF) impairment among hemodialysis patients. Renal transplantation by reversing metabolic factors...