Epicardial Adipose Tissue and Coronary Artery Calcification in Diabetic and Nondiabetic End-Stage Renal Disease Patients

Background/aims: Atherosclerosis, coronary artery calcification, diabetes mellitus, inflammation, endothelial dysfunction, and left ventricular hypertrophy are the most commonly encountered risk factors in the pathogenesis of cardiovascular disease in end-stage renal disease (ESRD) patients. Epicardial adipose tissue (EAT) is the true visceral fat depot of the heart. The relationship between coronary artery disease (CAD) and EAT was shown in healthy subjects and patients with high risk of CAD. To date, there is not enough data about EAT in diabetic and nondiabetic ESRD patients. Therefore, we aimed to investigate the EAT and coronary artery calcification score (CACS) in diabetic and nondiabetic ESRD patients and healthy subjects. Methods: Sixty ESRD patients (17 diabetic, 43 nondiabetic ESRD patients) and 20 healthy subjects were enrolled in the study. EAT and CACS were performed by a 64-slice multidetector computed tomography scanner. Results: There were no differences in age, gender, body mass index, predialysis systolic and diastolic blood pressure levels, biochemical parameters including serum low-density lipoprotein and high-density lipoprotein cholesterol, triglycerides, and C-reactive protein between healthy subjects, diabetic, and nondiabetic ESRD patients. Total CACSs and EAT measurements were significantly higher in diabetic ESRD patients when compared with nondiabetic ESRD patients and healthy subjects. There was statistically significant relationship between EAT and CACS in ESRD patients (p < 0.0001, r = 0.48). Conclusion: In conclusion, we found a significant increase in terms of EAT and CACS in diabetic ESRD patients when compared with nondiabetic ESRD patients and healthy subjects.     

Kidney Transplantation Substantially Improves Endothelial Progenitor Cell Dysfunction in Patients with End-Stage Renal Disease

Endothelial progenitor cells (EPC) are involved in endothelial repair and maintenance. Dysfunction of EPC may contribute to accelerated arteriosclerosis in chronic kidney disease. Kidney transplantation (KTx) improves both survival and endothelial function of dialysis patients. In a prospective study, we tested to which extent KTx changes EPC biology. We studied number and function (migratory activity, adhesion to extracellular matrix proteins and to mature endothelial cells [EC]) of EPC in 20 patients during dialysis and 3, 6, 9 and 12 months after KTx. Twenty-two healthy volunteers served as matched controls. Circulating precursor populations were measured by flow cytometric analysis. Cytokines relevant for EPC mobilization were monitored. Compared to the dialysis state, KTx increased the migration of EPC to approximately 2-fold. Adhesion to fibronectin and to collagen type IV was significantly increased after KTx. An improved adhesion rate of EPC to mature EC was observed. The number of EPC decreased. The amount of precursor populations showed no difference compared to the pretransplant state. Our study shows an improved function of EPC after KTx. This finding indicates an improved potential for endothelial repair which in turn may contribute to enhanced endothelial function and reduced cardiovascular morbidity after KTx.     

Acute Coronary Syndromes after Renal Transplantation in Patients with End-Stage Renal Disease Resulting from Diabetes

Coronary heart disease is the leading cause of death in both diabetes mellitus and end-stage renal disease. Although renal transplantation is known to reduce mortality in end-stage renal disease, its effect on the incidence of acute coronary syndromes is unknown. Using data from the United States Renal Data System, we studied 11,369 patients with end-stage renal disease due to diabetes enrolled on the renal and renal-pancreas transplant waiting list from 1 July 1994 to 30 June 1997. Cox nonproportional hazards regression models were used to calculate the adjusted, time-dependent relative risk for the most recent hospitalization for acute coronary syndromes (including acute myocardial infarction, unstable angina, or other acute coronary syndromes, ICD9 Code 410.x or 411.x) for a given patient in the study period. Demographics and comorbidities were controlled by using data from the medical evidence form (HCFA 2728). After renal transplantation, patients had an incidence of acute coronary syndromes of 0.79% per patient year, compared to 1.67% per patient year prior to transplantation. In comparison to maintenance dialysis, renal transplantation was independently associated with a lower risk for acute coronary syndromes (hazard ratio 0.38, 95% confidence interval, 0.30-0.49). Patients with end-stage renal disease due to diabetes on the renal transplant waiting list were much less likely to be hospitalized for acute coronary syndromes after renal transplantation. The reasons for this decreased risk should be the subject of further study.     

Kidney-Alone Transplantation in Diabetic Patients with End-Stage Renal Disease

From January 1989 to December 1995, 5 diabetic patients with end-stage renal disease (1 woman, 4 men) underwent kidney-alone transplantation. The mean age of the recipients at the time of transplantation was 37.4 years (range, 32 to 43). Graft function and glucose tolerance was evaluated for 5 to 72 months after surgery. Postoperative complications were seen in 2 patients; nonspecific subcutaneous infections and an asymptomatic partial allograft infarction. All renal allografts were functioning 1 year after transplantation, with a mean serum creatinine level of 1.10mg/dL (range, 0.8 to 1.8mg/dL), and a mean urinary protein level of 1 7.8mg/dL (range, 5 to 27mg/dL). The postoperative daily dose of insulin was higher than the preoperative dose, while the level of glycated hemoglobin (HbA_1c) increased after surgery and peaked 6 months after transplantation; 1 year after transplantation it had reverted to the preoperative level. As long as the diabetic complications of the renal allograft recipients are not severe, the short-term survival and the renal function of diabetic patients with end-stage renal disease improves after kidney-alone transplantation, which is still the standard method of treatment in Japan.     

Coronary angiography prior to renal transplantation

Summary: A retrospective analysis of coronary angiography in 89 patients (57 male, 32 female) on regular dialysis treatment, prior to their acceptance onto the cadaveric renal transplant waiting list, was performed. Patients studied included those older than 40 years and those symptomatic of coronary artery disease (CAD) or diabetics. Thirty patients (34%) had significant CAD: 18 one-vessel, 8 two-vessel, 3 three-vessel and 1 four-vessel disease. Significant predictors of CAD were a history of cardiac ischaemic symptoms, a diagnosis of diabetes mellitus, and a family history of CAD. There was no difference in survival between those with and those without CAD. Total mortality, and that due to myocardial infarction, was similar in patients with one- and two-vessel disease and those without CAD, but increased in those with three- or four-vessel disease ( P <0.001). Thirteen patients (11 with CAD) were excluded from the transplant waiting list, and their survival was significantly worse ( P <0.001). Restriction of coronary angiography to patients who were either symptomatic or diabetic would have resulted in 63% fewer angiograms without altering acceptance onto the transplantation waiting list for any patient.     

Spontaneous Perirenal Hemorrhage in End-Stage Renal Disease Treated with Selective Embolization

Spontaneous nontraumatic rupture of the kidney (Wunderlich syndrome) is an extremely uncommon condition on hemodialysis. We report a case of 44-year-old hemodialysis patient presented with hemorrhagic shock and a right quadrant abdominal pain to the emergency department. There was no history of trauma. A kidney rupture was revealed by abdominal computed tomography, and active bleeding was successfully managed with arterial embolization. This case illustrates the safe and successful application of interventional radiology in the management of nontraumatic renal hemorrhage in the specific group of hemodialyzed patients even in the emergency setting.     

Kidney Transplantation Halts Cardiovascular Disease Progression in Patients with End-Stage Renal Disease

Morbidity and mortality from cardiovascular disease have a devastating impact on patients with chronic kidney disease (CKD) and end-stage renal disease. Renal function decline in itself is thought to be a strong risk factor for cardiovascular disease (CVD). In this study, we investigated the hypothesis that the elevated CV mortality in kidney transplant patients is due to the preexisting CVD burden and that restoring renal function by a kidney transplant might over time lower the risk for CVD. We analyzed 60,141 first-kidney-transplant patients registered in the USRDS from 1995 to 2000 for the primary endpoint of cardiac death by transplant vintage and compared these rates to all 66813 adult kidney wait listed patients by wait listing vintage, covering the same time period. The CVD rates peaked during the first 3 months following transplantation and decreased subsequently by transplant vintage when censoring for transplant loss. This trend could be shown in living and deceased donor transplants and even in patients with end-stage renal disease secondary to diabetes. In contrast, the CVD rates on the transplant waiting list increased sharply and progressively by wait listing vintage. Despite the many mechanisms that may be in play, the enduring theme underlying rapid progression of atherosclerosis and cardiovascular disease in renal failure is the loss of renal function. The data presented in this paper thus suggest that the development or progression of these lesions could be ameliorated by restoring renal function with a transplant.     

Clinical Burden of Screening Asymptomatic Patients for Coronary Artery Disease Prior to Liver Transplantation

The aim of this study is to assess the clinical burden of silent coronary artery disease (CAD) in cirrhotic candidates for liver transplantation (LT), and to evaluate the usefulness of a CAD screening approach. Between July 1999 and January 2006, we evaluated 627 LT candidates. All of them underwent a detailed clinical history. Sixteen had a previous diagnosis of CAD or symptoms suggestive (2.5%). The remaining 611 underwent further tests according to a predefined protocol, including EKG, echocardiogram and, on the basis of CAD risk factors, heart stress tests. Selective coronary angiography (SCA) was performed in the 30 patients with positive heart stress test: in only 2 did SCA show any CAD, and in both it was subcritical disease requiring neither intervention nor contraindicating LT. The 611 screened patients continued their follow-up until study closure or death. No coronary events occurred in the study population in a mean follow-up of 32.50 months (+/− 23.67 DS). No perioperative mortality related to CAD occurred in the 233 transplanted patients. In conclusion, no prognostic advantage was achieved by following a strict CAD screening protocol, leading us to believe that the cost-effectiveness of a similar screening can be unacceptably high in our setting.     

The Relationship between Oxidative Stress,Inflammation, and Atherosclerosis in Renal Transplant and End-Stage Renal Disease Patients

Objectives: Cardiovascular risk is increased in the early stages of chronic kidney disease (CKD) and is also found to be ongoing in renal transplant (Rtx) patients. As a sign of atherosclerosis, increased carotid intima–media thickness (CIMT) has been widely accepted as a strong predictor of cardiovascular disease (CVD) and mortality in the end-stage renal disease (ESRD) patients. Ischemia-modified albumin (IMA), pentraxin-3 (PTX-3), and neutrophil-to-lymphocyte ratio (NLR) were introduced as oxidative stress and inflammatory biomarkers in ESRD. The role of Rtx in terms of atherogenesis, oxidative stress, and inflammation is still unclear. We aimed to investigate the relationship between IMA, PTX-3, NLR, and CIMT in Rtx patients without overt CVD and to compare these results with those obtained from healthy subjects and ESRD patients receiving hemodialysis (HD) and peritoneal dialysis (PD). Design and methods: Cross-sectional analysis in which CIMT measurements, NLR, and serum PTX-3 and IMA levels were assessed in 18 Rtx patients (10 females; mean age: 40.0 ± 13.3 years), 16 PD patients (7 females; 40.2 ± 12.9 years), 14 HD patients (8 females; 46.6 ± 10.7 years), and 19 healthy subjects (9 females; 36.9 ± 8.9 years). Results: IMA, PTX-3, and high-sensitive C-reactive protein (hs-CRP) levels, NLR, and CIMT of Rtx patients were found to be significantly higher compared with healthy subjects (?p = 0.04, p < 0.0001, p < 0.005, p = 0.005, and p = 0.005, respectively). IMA level was positively correlated with hs-CRP and PTX-3 levels, NLR, and CIMT when all participants were included (r = 0.338, p = 0.005; r = 0.485, p < 0.0001; r = 0.304, p = 0.013; and r = 0.499, p < 0.0001, respectively). Conclusion: There has been ongoing inflammation, oxidative stress, and atherosclerosis in Rtx patients.     

弥漫性冠状动脉病变的外科治疗

目的总结非体外循环心脏跳动下冠状动脉内膜剥脱后行非体外循环冠状动脉旁路移植术（off—pump CABG）治疗弥漫性冠状动脉病变的早期临床结果和经验，以提高手术疗效。方法2003年5月～2006年11月，对83例弥漫性冠状动脉病变患者在非体外循环下做冠状动脉内膜剥脱后行off—pump CABG，其中男61例，女22例；年龄55-80岁（65±7岁）；加拿大心脏病协会（CCS）心绞痛分级：Ⅱ级7例，Ⅲ级20例，Ⅳ级56例。有心肌梗死史36例（43．4％）。冠状动脉造影显示：双支血管病变5例，3支病变78例，其中合并左主干病变16例。左心室射血分数25％～65％（51％±16％）。83例共行110支冠状动脉内膜剥脱，其中左前降支系统67支，回旋支、钝缘支9支，右冠状动脉系统34支。20例内膜剥脱后先用大隐静脉片行左前降支成形，再在补片上用乳内动脉行旁路血管移植；应用左乳内动脉83支，桡动脉2支，余均为大隐静脉，每例移植血管3．9±1．2支。结果无手术死亡。术中移植血管血流满意101支（92％），血流量为22±16ml／min。术后发生心肌梗死4例，梗死面积小，无血流动力学改变，未给予特殊治疗。83例患者皆痊愈出院。随访75例（90．4％），8例失访，随访时间8～50个月，无心绞痛发作。8例患者在手术后3～29个月复查冠状动脉造影显示：冠状动脉内膜剥脱后行off—pump CABG的移植血管均通畅。结论非体外循环下冠状动脉内膜剥脱后行off—pump CABG，安全可行，再血管化程度高，是治疗弥漫性冠状动脉病变的有效方法。     

End-Stage Renal Disease and Its Treatment in Latin America in the Twenty-First Century

The Latin American Society of Nephrology and Arterial Hypertension's Dialysis and Transplant Registry was chartered in 1991. It collects information on ESRD and its treatment in 20 countries of the region. The prevalence of patients on renal replacement therapy (RRT) increased from 129 pmp in 1992 to 447 pmp in 2004; in 2004, 56% of the patients were on hemodialysis, 23% on peritoneal dialysis, and 21% had a functioning kidney graft. The highest rates of prevalence were reported in Puerto Rico (1027 pmp), Chile (686 pmp), and Uruguay (683 pmp). Hemodialysis was widely used, except in El Salvador, Mexico, Guatemala, Nicaragua, and the Dominican Republic, where peritoneal dialysis predominated. Incidence rate increased from 27.8 pmp to 147 pmp in the same period of observation; the lowest rate was reported in Guatemala (11.4 pmp) and the highest in Puerto Rico (337.4 pmp). Diabetes mellitus was the leading cause of renal failure in incident patients; the highest rates were reported in Puerto Rico (62.2%) and Mexico (60%). Forty-four percent of the incident population were older than 65 years. Access to renal replacement therapy was universal in Argentina, Brazil, Chile, Cuba, Puerto Rico, Uruguay, and Venezuela, while was restricted in other countries. Main causes of death in dialysis were cardiovascular (44%) and infectious disease (26%). The rate of renal transplantation increased from 3.7 pmp in 1987 to 14.5 in 2004; fifty-three percent of the organs came from cadavers. Overall, donation rate was 5.9 pmp. In conclusion, the prevalence and incidence rates have increased over the years, and diabetes mellitus has emerged as the leading cause of kidney disease in the region. Although the rate of kidney transplantation has increased, the number remains insufficient to match the growing demand. The implementation of renal health programs in the region is urgently needed.     

Impact of HLA on the Underlying Primary Diseases in Turkish Patients with End-Stage Renal Disease

The number of patients with end stage renal disease (ESRD) is increasing faster than the number of renal transplantations performed per year worldwide. Of the primary diseases leading to ESRD, diabetic nephropathy is the leading cause. The purpose of the present study is to investigate the association of HLA with the primary diseases leading to ESRD in Turkish patients. A total of 3230 individuals comprising 587 ESRD patients and 2643 healthy controls were enrolled into the study. Class I HLA-A, -B typing was performed by CDC method, while class II HLA-DRB1 typing was performed by low resolution PCR-SSP. We found a significant negative association between almost all A locus antigens and primary disease groups classified as chronic glomerulonephritis and hypertensive nephrosclerosis (p?<?0.05). HLA-B58 and HLA-DRB1*03 significantly correlated with amyloidosis and diabetic nephropathy, respectively. Determination of HLAs as risk factors for primary diseases leading to ESRD might be beneficial in preventing progression to ESRD and recurrence of the primary disease post-transplantation.     

Mortality Risk Factors in Chronic Renal Failure Patients after Coronary Artery Bypass Grafting

Perioperative risk during coronary artery bypass grafting (CABG) is high in patients with chronic renal disease. We aimed to determine postoperative two-year mortality and identify the preoperative risk factors of mortality during CABG surgery in hemodialysis (HD)-dependent and HD-non-dependent CRF patients. We included 102 CRF patients who underwent CABG in Baskent University Hospital between 2000 and 2005. There were 47 patients with CRF undergoing HD (Group I) and 55 CRF patients without dialysis requirement (Group II). We retrospectively retrieved demographic variables; clinical, operative, and echocardiographic data; and biochemical parameters at the time of the operation and six months postoperation. Postoperative HD requirement in Group II patients and infectious complications were recorded. In the second postoperative year, mortality rate was 27.7% in group I and 16.4% in group II (p > .05). When preoperative risk factors evaluated by univariate Cox analysis, only age (RR = 1.06, p = .04) was a significant determinant of survival in Group I patients. Among the operative and postoperative risk factors of mortality such as duration of operation, numbers of coronary vessel bypass, HD requirement, and infection were investigated in Group I and II patients. Rate of infectious complication (including mediastinitis) was found to be a major determinant of mortality by multivariate Cox analyses in both group I (RR = 4.42, p ≤ .05) and group II (RR = 9.39, p ≤ .05). HD dependency did not increase mortality if the patients are younger and were electively prepared for CABG surgery. High infection rates have increased the postoperative mortality and hospitalization in CRF patients. Early diagnosis of infections in CRF patients is important for early recovery, shorter hospitalization, and lower mortality after CABG operation     

Fibrinolytic and Protease Inhibitory Systems in Spinal Cord Injured Patients with End-Stage Renal Disease

ABSTRACT

Earlier studies have revealed a variety of coagulation abnormalities in patients with long-standing spinal cord injury (SCI) and end-stage renal disease (ESRD). The present study was undertaken to examine the fibrinolytic and protease inhibitory systems in this population. Twelve spinal cord injured men with ESRD were studied. All patients had chronic active urinary tract infections, pressure ulcers and were practically bed-bound. The results were compared with those obtained in a group of 32 normal volunteers. Plasma plasminogen and unstimulated tissue-type plasminogen activator(t-PA) concentrations in the SCI-ESRD group were comparable with those found in the control group. No significant difference was found in plasma plasminogen activator inhibitor (PAI) activity in the two groups. In contrast, plasma α2-antiplasmin antigen concentration and antiplasmin activity were significantly reduced in the study population. In addition, plasma α1-antitrypsin activity and antigen concentration were significantly increased while the α2-macroglobulin activity-to-antigen concentration ratio was significantly reduced in the SCI-ESRD group.

Although the mechanism of the observed reduction in α2-antiplasmin and total antiplasmin activity is uncertain, its presence could enhance fibrinolysis in this otherwise thrombosis-prone population. Likewise, elevated α1-antitrypsin could attenuate tissue damage by leukocyte-derived proteases in the face of persistent suppurative infections. The reduced α2-macroglobulin activity-to-antigen concentration ratio was thought to reflect the presence of α2-macroglobulin complexes with various proteases generated by the activation of leukocytes, coagulation, fibrinolytic and other proteolytic systems.     

End-Stage Renal Failure and National Resources: The Brazilian Experience

Brazil is the fifth largest and the fifth most populous nation in the world. Its economy rivals Mexico as the strongest in Latin America and ranks among the 15 largest economies in the world. Despite these achievements, a substantial fraction of the Brazilian population still lives in poverty, and many still have limited access to medical assistance. There are currently about 380 patients on hemodialysis per million populations (pmp), approximately one third of the U.S. prevalence, suggesting that a large fraction of end-stage renal disease (ESRD) patients are not diagnosed and treated properly. In Brazil, access to renal replacement therapy (RRT), including renal transplantation, is universal, and the corresponding costs, including those of medications (immunosuppressors and treatment of ESRD complications), are covered by the Brazilian government. However, given the continuous growth of the ESRD population and of the costs incurred by RRT, the efficacy and reach of this system may be severely limited in years to come. In the current struggle against the ESRD epidemics, the Brazilian medical community and health authorities face a triple challenge: to limit the incidence of renal disease, slow or detain the progression of established chronic nephropathies, and ensure that access to quality RRT remains granted to all those who, despite all efforts, reach ESRD.     

End-Stage Renal Disease Following Carboplatin Chemotherapy for a Nasopharyngeal Carcinoma

Renal failure secondary to carboplatin therapy is due to acute tubular necrosis and is usually reversible. However, acute renal failure with rapid progression to end-stage renal disease is an exceedingly rare complication of carboplatin therapy. The authors report a case of definitive renal failure secondary to carboplatin chemotherapy for a nasopharyngeal carcinoma. The mechanisms that give rise to the chronic nephropathy are discussed.     

Complications and Readmission Incidence Following Total Hip Arthroplasty in Patients Who Have End-Stage Renal Failure

BackgroundThe number of patients who have end-stage renal disease undergoing primary total hip arthroplasty (THA) has increased over the past decade. The purpose of this study is to evaluate mortality, complications, and 90-day readmission incidences in patients who have end-stage renal disease undergoing THA.MethodsPatients who had a primary THA between January 1, 2007, and December 31, 2016, were identified from the 5% Medicare database. A total of 55,297 THA patients were stratified into 3 groups: renal dialysis (without transplant), renal transplant, and those without such renal problems. Risk of readmissions, dislocations, periprosthetic joint infections (PJIs), venous thromboembolic diseases, and mortalities up to 5 years following primary THA was compared. Multivariate Cox regression analyses were used to evaluate the effect of patient and hospital characteristics on the adjusted complication risks.ResultsMortalities at 5 years was 62.6% in the renal dialysis group, 37.3% in the renal transplant group, compared to 15.0% in the nonrenal group. Dislocations (7.6%) and PJIs (7%) were significantly higher in the dialysis group (P < .001). No significant differences in venous thromboembolic diseases (all timepoints) and revisions (all timepoints except at 90 days) between the renal groups were observed. The 90-day readmission risks were significantly greater in both the dialysis (55%) and transplant (43%) groups compared to the nonrenal cohort (30%) (P < .001).ConclusionRenal dialysis patients undergoing THA are at increased risk of PJIs (7%), dislocations (7.6%), revisions, and mortalities at 90 days compared to transplant and nonrenal patients. Both dialysis and transplant patients are high-risk groups with significantly increased 90-day readmission incidences of 55% and 43%, respectively, which makes their inclusion into a bundled payment model challenging.     

“一站式”复合技术治疗冠状动脉多支病变患者早中期随访结果

目的观察"一站式"复合技术治疗冠状动脉多支病变患者的早中期随访结果。方法 2007年6月至2009年12月共104例冠状动脉多支病变患者在阜外心血管病医院接受"一站式"复合技术再血管化治疗,其中男93例,女11例;年龄35～81(61.8±10.2)岁。所有患者均为包括左前降支(left anterior descending,LAD)病变在内的多支病变。"一站式"复合技术要点为:胸骨下段小切口左侧第2肋间横断胸骨,心脏不停跳完成左乳内动脉(left internal mammary artery,LIMA)至LAD吻合,关胸后立即造影确定LAD血运重建满意后即经胃管给予波立维300 mg,静脉肝素化[全血激活凝血时间(ACT)250 s],行经皮冠状动脉介入(percutaneous coronary intervention,PCI)治疗其他非前降支狭窄病变。结果本组患者均顺利施行"一站式"复合技术再血管化治疗,全部行LIMA至LAD血管移植,植入药物支架191枚,裸金属支架3枚;全组无手术及院内死亡。所有患者均获得随访,平均随访1.5年,其中1例出现支架狭窄,再次接受介入治疗;全组无心肌梗死发生,无脑血管事件及死亡患者。结论 "一站式"复合技术再血管化是治疗多支冠状动脉粥样硬化心脏病的一种安全有效的选择。