Does dialysis therapy improve autonomic and peripheral nervous system abnormalities in chronic uraemia?

OBJECTIVES: Autonomic nervous system (ANS) dysfunction and peripheral neuropathy occur in patients with chronic renal insufficiency. Adequate renal replacement therapy should prevent development or correct these abnormalities. DESIGN AND SUBJECTS: We studied retrospectively ANS and peripheral neuropathy in 32 patients with chronic uraemia who received either haemodialysis (16) or peritoneal dialysis (16) therapy, and compared the observed dialysis efficiency with changes in neurological function. METHODS: Heart rate variability (HRV) time domain indices and peripheral sensory nerve conduction studies were followed for a mean of 2.9 years. The adequacy of haemodialysis (HD) efficiency was estimated by Kt/V, an index of fractional urea clearance. Adequacy of continuous ambulatory peritoneal dialysis (CAPD) was estimated on the basis of the patient's wellbeing and nutritional status as excellent, satisfactory or poor. Based on observed changes in HRV time domain measures, the observations were divided in three subgroups: improved, unchanged or deteriorated. RESULTS: The peripheral sensory nerve conduction studies were abnormal in 38% of the patients and did not change significantly during the study. Improvement in HRV time domain measures occurred in HD patients with mean Kt/V > 1.20 or in CAPD patients with satisfactory or excellent response to dialysis treatment. Values of Kt/V < 0.85 in HD patients were associated with progressive deterioration of autonomic neuropathy. Diabetic patients (n = 4) differed from others as their HRV was grossly abnormal and did not improve. CONCLUSIONS: The adequacy of haemodialysis is a predictor of improvement of cardiac autonomic nervous function in chronic uraemia. The same trend of improvement was seen also in CAPD patients.     

Physical Work Capacity in Diabetic Children and Adolescents with and without Cardiovascular Autonomic Dysfunction

The aim of the present study was to evaluate the influence of autonomic nervous system dysfunction on work capacity in children and adolescents with Type 1 (insulin-dependent) diabetes. Fifteen patients with autonomic dysfunction (abnormal autonomic tests, age: 14.9±2.3 years), 35 patients without autonomic dysfunction (normal autonomic tests, age: 15.2±2.5 years), and 25 non-diabetic subjects (age: 15.0±2.3 years) were investigated. Resting heart rate, deep breathing heart rate variation, standing/lying heart rate ratio, decrease in blood pressure during orthostasis, and increase in blood pressure during sustained handgrip were used to assess cardiovascular autonomic dysfunction. Physical work capacity at heart rate of 170 min⁻¹ was determined by bicycle ergometry. Glycated haemoglobin level was higher in patients with than without autonomic dysfunction (12.3±3.1 vs 9.4±2.9%, p = 0.04). Patients with autonomic dysfunction had significantlylower physical work capacity at heart rate of 170 min⁻¹ than those with normal autonomic function or non-diabetic subjects (0.81 ± 0.12 vs 1.49 ± 0.16 and 1.54 ± 0.20 W kg⁻¹ p = 0.01). Physical work capacity at heart rate of 170 min⁻¹ was related to glycated haemoglobin level (r = −0.55, p = 0.01), to resting heart rate (r = 0.57, p =0.01), and to deep breathing heart rate variation (r = 0.51, p = 0.02). In conclusion, impaired work capacity is associated with poor blood glucose control and cardiovascular autonomic dysfunction. Autonomic tests can help to identify those patients who may need special consideration during exercise.     

Role of macrophages in tuberculous peritonitis: longitudinal follow-up of 16 continuous ambulatory peritoneal dialysis patients

ObjectiveMycobacterium tuberculosis is an intracellular pathogen susceptible to macrophage action, which also has an important role in peritoneal defense. To explore the peritoneal host defense mechanism and inflammatory process, we longitudinally followed up 16 cases of continuous ambulatory peritoneal dialysis complicated by tuberculous peritonitis over the past 9 years in Prince of Wales Hospital.MethodsSerial peritoneal fluid cell population was monitored in 16 end-stage renal disease patients with tuberculous peritonitis.ResultsThe mean age of the participants was 53 ± 15 years with a mean peritoneal dialysis duration of 34 months. Peritoneal fluid lymphocytosis was not evident and their population contributed to 10% ± 7%, 10% ± 6%, and 9% ± 8% of all leukocytes on day 1, 10, and 20 after peritonitis, respectively. Of the 16 patients, six had either failed to resume peritoneal dialysis or died of tuberculous peritonitis, and they were defined as the failure group. Compared with the success group, referring to those who could pursue peritoneal dialysis, the peritoneal fluid macrophage cell count percentage was lower in the failure group. Twenty days after tuberculous peritonitis, the peritoneal fluid macrophage cell count proportion in success and failure groups was 45% ± 11% and 10% ± 10%, respectively (p=0.021). However, polymorphonuclear leukocytes were more abundant in failure groups as early as 3 days after peritonitis, 93% ± 3% versus 44% ± 12% in the success group (p=0.003).ConclusionData in this study support the hypothesis that macrophages represent an important defense mechanism of the peritoneal cavity against mycobacterial infection and possibly the major peritoneal inflammatory process.     

The impact of new comorbidities on nutritional status in continuous ambulatory peritoneal dialysis patients

OBJECTIVE: To study the prevalence and risk factors for malnutrition in a peritoneal dialysis (PD) center with an active PD program. METHODS: We assessed the nutritional status in 205 continuous ambulatory peritoneal dialysis (CAPD) patients, including stable and unstable patients, by subjective global assessment (SGA), dietary diaries and biochemistry index. Serum C-reactive protein (CRP) levels were examined as inflammatory marker. Fluid status including extracellular water (ECW), intracellular water, and total body water (TBW) was evaluated by multiple-frequency bioelectrical impedance analysis and brachial blood pressure was measured. New comorbidities included systemic infection, congestive heart failure and trauma that occurred within 1 month or less. Cardiovascular disease (CVD) was recorded too. Dialysis adequacy and residual renal function were calculated by a standard technique. RESULTS: Based on SGA, 15.6% of our CAPD patients were malnourished. The malnourished patients had advanced age, higher CRP and ECW/TBW levels than normally nourished patients (age: 68.78 +/- 11.92 vs. 59.26 +/- 13.46 years, p = 0.001; CRP: 11.98 +/- 20.22 vs. 5.56 +/- 8.30 mg/l, p = 0.004; ECW/TBW: 0.55 +/- 0.16 vs. 0.52 +/- 0.04, p = 0.049). Patients with malnutrition were more prone to have CVD (53.13 vs. 31.79%, p = 0.004) and new comorbidities (65.62 vs. 4.62%, p = 0.023). Multivariate analysis showed new comorbidities, mostly systemic infection, which were associated with nutritional status (p < 0.001). Both ECW/TBW and new comorbidities were associated with serum CRP, CVD and malnutrition (p < 0.001-0.05). In contrast, some traditional factors which were recognized as contributing to malnutrition such as residual renal function, dialysis adequacy, metabolic acidosis, total protein loss, diabetes and Charlson indexes were not different between normally nourished and malnourished patients in the present study. CONCLUSIONS: Our results suggest that only 15.6% of patients were malnourished in our PD program. Old age, inflammation, CVD, fluid overload and new comorbidities were all associated with malnutrition, with new comorbidities, mostly systemic infections, being the most significant risk factor. However, many traditional factors such as residual renal function, dialysis adequacy and diabetes were not.     

Impact of Renal Survival on the Course and Outcome of Systemic Lupus Erythematosus Patients Treated With Chronic Peritoneal Dialysis

This longitudinal study investigated whether renal survival can affect the course and outcome of systemic lupus erythematosus (SLE) patients treated with chronic peritoneal dialysis (PD). Thirty-five SLE patients, out of 1115 end-stage renal disease (ESRD) patients treated with chronic PD, were seen between 1990 and 2007 at the Chang Gung Memorial Hospital. Patients were followed up for a mean of 38.8 ± 22.9 months. There were no significant differences between patients with short renal survival (<3 years) and long renal survival (>3 years) for the various demographic variables such as age, sex, PD duration, immunosuppressive drug administration, or exchange system (P > 0.05). Interestingly, before PD, patients with short renal survival had lower serum complement levels than patients with long renal survival (C3, 40.2 ± 14.4 vs 76.3 ± 18.5 mg/dL, P < 0.001; and C4, 14.8 ± 4.7 vs 22.4 ± 8.1 mg/dL, P < 0.05). However, the differences in complement levels between the groups disappeared after PD (C3, 76.5 ± 27.3 vs 84.2 ± 27.8 mg/dL; and C4, 26.7 ± 11.3 vs 22.6 ± 10.8 mg/dL, both P > 0.05). Patients with short renal survival were more likely to have a high peritoneal solute transporter rate (PSTR) than their long renal survival counterparts (χ²-test, P = 0.02, and AUROC = 0.744 and P = 0.040); however, there were no significant differences for other variables such as cardiothoracic ratio (CTR), Kt/V, residual renal function, exit site infection, and peritonitis (P > 0.05). Finally, Kaplan–Meier analysis revealed that the two groups did not differ in patient and technical survival (P > 0.05). Therefore it was concluded that renal survival might be associated with PSTR, but not with patient and technical survival in SLE patients treated with PD.     

The adequacy of peritoneal dialysis in a single Chinese center

ObjectiveTo assess the adequacy of peritoneal dialysis in Chinese by analyzing the relationship between weekly urea kinetics (Kt/V) and clinical outcomes.MethodsA total of 146 patients on continuous ambulatory peritoneal dialysis for more than 6 months in the Shanghai Renji Hospital between July 1997 and March 1999 were enrolled into this study. They were assigned to three groups according to weekly Kt/V: Group A, Kt/V less than 1.7; Group B, Kt/V between 1.7 and 2; and Group C, Kt/V greater than 2. Patient and technique survivals were analyzed by using the log rank method.ResultsThe overall 2-year actuarial patient and technique survivals were 90% and 76%, respectively. The 2-year actuarial patient survival was 78% for Group A, 97% for Group B, and 96% for Group C (p<0.05). The 2-year technique survival was 56% for Group A, 88% for Group B, and 88% for Group C. Both actuarial patient and technique survivals in Group A were significantly lower (p<0.05) compared with the other two groups.ConclusionThe study showed that clinical outcomes in Groups B and C patients were similar. However, patients with weekly Kt/V values less than 1.7 had poorer clinical outcomes compared with patients from groups B and C. We conclude that Chinese patients who were receiving peritoneal ambulatory dialysis may benefit from weekly Kt/V greater than 1.7.     

Role of soluble intercellular adhesion molecule-1 in the process of peritonitis in peritoneal dialysis

ObjectiveTo investigate the role and clinical significance of changes of levels of soluble intercellular adhesion molecule-1 in the process of peritonitis in peritoneal dialysis patients.MethodsA total of 50 patients on continuous ambulatory peritoneal dialysis in the Shanghai Changhai Hospital between May 1999 and July 2000 were enrolled into this study. They were assigned to two groups according to diagnostic standard of peritonitis-Group A, with episodes of peritonitis; Group B, in the absence of peritonitis. The serum and peritoneal effluent levels of soluble intercellular adhesion molecule-1 during and after peritonitis were assessed by using sandwiched enzyme-linked immunosorbent assay.ResultsThe serum levels of soluble intercellular adhesion molecule-1 in Group A were significantly lower compared with Group B (214.5 ± 90.7 vs 511.2 ± 124.7 ng/mL; p<0.01). The peritoneal effluent levels of soluble intercellular adhesion molecule-1 in Group A were significantly higher than those in Group B (5.8 ± 1.6 vs 2.1 ± 0.9 ng/mL; p<0.01). For Group A, after treatment of peritonitis, the serum levels of soluble intercellular adhesion molecule-1 profoundly increased to 506.1 ± 107.8 ng/mL and the peritoneal effluent levels of soluble intercellular adhesion molecule-1 markedly decreased to 3.9 ± 1.1 ng/mL, compared with those during peritonitis, respectively (p<0.01).ConclusionThe study showed that increased peritoneal effluent levels of soluble intercellular adhesion molecule-1 during peritonitis possibly activate or damage peritoneal mesothelial cells. Monitoring changes of levels of soluble intercellular adhesion molecule-1 in peritoneal dialysis fluid may be useful for analyzing the process of peritonitis.     

Impact of lockdown COVID-19 on metabolic control in type 2 diabetes mellitus and healthy people

AimsThe impact of prolonged COVID-19 lockdown on metabolic control in type 2 diabetes patients and healthy individuals has not exactly been known. We aimed to evaluate the change in body weight and metabolic control in type 2 diabetic and non-diabetic healthy subjects during the prolonged lockdown period.MethodsDiabetic (n = 85), and age-and sex-matched non-diabetic subjects (n = 55) were included in this prospective study. Body mass index and metabolic parameters were compared between before and 6th months of lockdown. Changes in values were evaluated using the difference before and after lockdown.ResultsAge (54.81 ± 10.53 vs. 52.61 ± 4.88 years), gender (female, 68.2% vs. 56.4%) and, BMI (33.44 ± 6.48 vs. 31.63 ± 3.57 kg/m²) were similar between groups (p > 0.05). Before and after lockdown, BMI increased both in non-diabetic (0.54 ± 0.95 kg) and diabetic groups (1.91 ± 5.48 kg) (p > 0.05). Increase in HbA1c was more in diabetic than in non-diabetic groups (0.71 ± 1.35 vs. 0.02 ± 0.19%, p = 0.002). Glucose, LDL-C, and TG increased in diabetic (39.69 ± 74.69, 7.60 ± 34.33, and 58.21 ± 133.54 mg/dl, p < 0.05) whereas non significantly decreased in non-diabetic group (?0.51 ± 4.40, ?3.52 ± 14.53, and ?6.47 ± 41.77 mg/dl, respectively. After adjusting BMI, increase in blood glucose (p = 0.021), HbA1c (p = 0.018), and TG (p = 0.041) levels were more in diabetic than non-diabetic group. Duration of diabetes was an independent predictor of the change in HbA1c (OR: 1.2, 95% CI = 1.1–1.8, p = 0.032).ConclusionsBody weight gain was observed in type 2 diabetic patients and healthy subjects. This is the first study to show that prolonged lockdown COVID-19 pandemic worsened glucose regulation and increased TG level in diabetes mellitus independent of weight gain.     

Patient and technique survival in continuous ambulatory peritoneal dialysis (CAPD) with a basic three 2-liter daily exchanges: a 12- year single center experience in the pre-urea kinetics era

Continuous ambulatory peritoneal dialysis (CAPD) is the prevailing mode of renal replacement therapy in Hong Kong and the routine practice is three 2 L daily exchanges with four exchanges reserved for patients with ultrafiltration problems or clinically inadequate dialysis. In our hospital, Tung Wah Hospital, adequacy of dialysis assessment by urea kinetics was conducted after 1993 and adjustment of dialysis regime according to Kt/V was made only after 1995. This study represented the survival data of CAPD patients in our center before the urea kinetics era. From 1983 to 1994, we have accepted 569 patients into our CAPD program with a mean age ±SD of 47.8 ±15.4 and incidence of diabetes of 17.9%. The overall patient survival rates were 92%, 56% and 26% at 1, 5 and 10 years respectively. The corresponding technique survival rates were 97%, 86% and 60%. A cross-sectional analysis of the CAPD population from 1993 to 1994 showed that only 5% of patients were on four 2 L exchanges and the mean Kt/V was 1.76 ±0.35 and creatinine clearance 58.1 ±23.2 L/week/1.73 m². The patient and technique survival rates were comparable to western centers with a higher mean Kt/V and creatinine clearance. Our data showed that favorable clinical outcome can be achieved with three 2 L daily exchange regime in Chinese patients. This indicates different Kt/V standards may exist for different racial populations.     

Associations of Peritoneal Glucose Load With Male Sexual Dysfunction and Depression in Peritoneal Dialysis Patients

This cross‐sectional study examined possible associations of peritoneal glucose load with male sexual dysfunction and depression in peritoneal dialysis patients. Compared to patients with peritoneal glucose load ≤3 g/kg per day, those with load >3 g/kg per day had higher Beck Depression Inventory scores, (18.9 ± 5.4 vs. 11.4 ± 5.8, P = 0.002) and lower International Index of Erectile Function scores, serum total testosterone and DHEA [(15.4 ± 6.4 vs. 45.1 ± 20.7, P < 0.001), (8.5 ± 3.0 vs. 13.9 ± 3.2, P < 0.001), (113.9 ± 58.8 vs. 280.2 ± 128.3, P < 0.001); respectively)]. Of participants with peritoneal glucose load >3 g/kg per day, 84.6% had mild to moderate erectile dysfunction and 92.3% had abnormal Beck Depression Inventory scores. Peritoneal glucose load inversely correlated with International Index of Erectile Function scores (P < 0.001), total serum testosterone (P = 0.002) and serum DHEA (P = 0.001); and directly with Beck Depression Inventory scores (P < 0.001) and serum estradiol (P < 0.001). This study demonstrated higher prevalence of sexual dysfunction, depression and sex hormone disturbances in male peritoneal dialysis patients receiving higher peritoneal glucose load.     

Asociación entre hiperkaliemia y evolución clínica en la enfermedad renal crónica avanzada

IntroductionPatients with advanced chronic kidney disease (CKD) are at greatest risk of hyperkalemia (HK). The relationship between HK and negative outcomes (mortality or progression of renal insufficiency) in non-dialysis dependent CKD patients is controversial.AimsTo determine the incidence, prevalence, and factors related with HK in a cohort of CKD patients, and its relationship with mortality, hospitalization rate, CKD progression, and dialysis initiation.Material and methodsA retrospective, observational study in an incident cohort of adult patients with stage 4 or 5 CKD not on dialysis. Inclusion criteria were: having at least three consecutive estimated glomerular filtration rate (eGFR) measurements in a follow-up period >3 months. Decline in renal function was estimated as the slope of the individual linear regression line of eGFR over follow-up time. HK was defined as serum K levels ≥5.5 meq/l. Associations of HK with outcomes were adjusted for major confounding variables in the multivariate analysis.ResultsThe study group consisted of 1079 patients (574 males, mean age: 65±14 years) with mean baseline eGFR 14.8±4.5 ml/min/1,73 m². Mean follow-up time was 15 months with a median of 7 serum sample determinations per patient. HK was observed at baseline in 26% of patients; in at least one serum sample during the individual follow-up period in 68%; or chronically (>50% of samples) in 33% of patients. By multivariate logistic regression, the best determinants of chronic HK were: male sex (OR = 1.529; 95% CI [1.154-2.025], p = .003), serum bicarbonate (OR = 0.863 [0.829-0.900], p <.0001), diuretic treatment (OR = 0.743 [0.556-0.992], p = .044), and angiotensin converting enzyme inhibitor and/or angiotensin receptor blockers (OR = 4.412 [2.915-6.678], p <.0001). Patients whose serum K levels were in the upper quartile showed a significantly faster CKD progression (?4.05±5.22 vs. ?2.69±5.61 ml/min/1.73 m²/year, p <.0001), and more frequent dialysis initiation (63% vs. 57%, p = .115), though lower mortality (9% vs. 17%, p = .003) and hospitalization rates (2.68±5.94 vs. 3.16±6.77 days per year, p = .301) than the other study patients. However, in the multivariate analysis, average serum K levels were not independently associated with the clinical outcomes investigated.ConclusionHK is a common biochemical finding in non-dialysis dependent CKD patients, mainly associated with prescribed medication. However, HK was not independently associated with major negative clinical outcomes.     

Plasma Endothelin Levels and Blood Pressure in Hemodialysis and in Capd Patients. Effect of Subcutaneous Erythropoietin Replacement Therapy

We investigated plasma endothelin (ET) concentration and blood pressure in 44 patients with end stage renal failure chronically treated with either hemodialysis (n = 24) or continuous ambulatory peritoneal dialysis (CAPD) (n = 20). Half of the subjects were on chronic erythropoietin (r-HuEPO) replacement therapy (30-60 U/kg) subcutaneously, 3 times weekly. The mean plasma ET level of the whole group was about five fold higher than the normal range. Plasma ET concentration and mean blood pressure were higher in hemodialysis than in CAPD patients (33.3 ± 2.1 vs 24.8 ± 1.2 pg/ml, p < 0.01, and 101 ± 2.4 vs 91 ± 3 mmHg, p < 0.025). There was a significant correlation between plasma ET levels and systolic blood pressures in both groups (r = 0.45, p < 0.05). Patients (hemodialysis and CAPD) receiving subcutaneous r-HuEPO had higher mean blood pressure (99 f 3 vs 85 Ifi 4 mmHg, p < 0.01), while their plasma ET levels were similar to untreated patients independent of the dialysis mode. However, a statistically significant correlation between plasma ET and systolic blood pressure was present only in the r-HuEPO treated group (r = 0.46, p < 0.05 vs r = 0.29, N.S., for the untreated group). These results show that plasma ET levels are markedly increased on both dialysis mode, but the values are lower in CAPD patients. Plasma ET concentrations significantly correlated with systolic blood pressures in the whole group of patients, and also in those receiving r-HuEPO replacement therapy.     

Thermoregulatory sudomotor dysfunction and diabetic neuropathy develop in parallel in at-risk feet

Aims To establish the longitudinal relationship of foot complications to neuropathy based on a 4-year follow-up of diabetic patients stratified by sudomotor dysfunctions. Methods One hundred and nineteen Type 2 diabetic patients and 36 non-diabetic subjects were initially registered in the prospective cohort study. Plantar skin temperature and sympathetic skin response (SSR) were used to monitor sympathetic mediated thermoregulation and sudomotor function. Peripheral somatic and central autonomic functions were studied using clinical, nerve conduction and cardiovascular reflex tests. At enrolment, the diabetic patients were classified into one of three groups by the progressive stages of sudomotor dysfunction: SSR+ (SSR present; 49 patients), SSR− (SSR absent; 41 patients) and at-risk group (SSR absent but with cracked skin involving partial thickness of the dermis; 29 patients). Results The at-risk group had 13.4 times (95% confidence interval 1.4–125.7) higher plantar ulceration rates than the other two patient groups during the 4 years. Skin temperature elevation occurred in parallel with development of foot sweating problems. There were no significant differences between the three patient groups in the ratios of abnormal heart rate variation, orthostatic test and clinical neuropathy score at follow-up. After 4 years of follow-up, nerve conduction abnormalities were more frequent in the at-risk and SSR− groups than in the SSR+ group. Conclusions Early deterioration of small sympathetic fibres could not be quantified accurately by the clinical, somatic and autonomic tests. Assessing skin integrity and sudomotor function in at-risk individuals identifies early peripheral sympathetic neuropathy, even if the patients have no overt clinical symptoms.     

The effects of fasting on heart rate variability in hypertensive patients

ABSTRACT

Heart rate variability (HRV) is an independent indicator of increased mortality in patients with myocardial infarction and congestive heart failure. The effects of fasting on the HRV are not known in hypertensive patients. Therefore, studying the effects of Ramadan fasting on hypertensive patients’ HRV seems reasonable to address.

We conducted a prospective study including 20 hypertensive patients with sinus rhythm. HRV was determined twice by ambulatory 24-hour Holter recordings at fasting during and after Ramadan.

Subjects mean age was 55 ± 11.8 years. Sex-ratio was 1.5. When two groups compared, statistically significant differences were found in terms of SDNN (113 ± 71 vs 140 ± 38, p = 0.001), SDANN (109.7 ± 45 vs 134.8 ± 48.3, p = 0.008), T power (2368.7 ± 121.3 vs 3660.5 ± 170.9, p = 0.03) and LF (552.2 ± 31.3 vs 903.7 ± 48.9, p < 0.0001) values.

HRV parameters were found to be decreased in Ramadan. Thus, Ramadan fasting enhances the activity of the sympathetic system in hypertensive patients.     

AUTONOMIC AND ENDOTHELIAL DYSFUNCTION IN EXPERIMENTAL DIABETES

The effect of streptozotocin induced diabetes on autonomic regulation of heart rate and endothelial function was examined in Sprague-Dawley rats. Weanling rats (3–4 weeks of age) of either sex were randomly assigned to a non-diabetic (male 5, female 6) or diabetic (male 4, female 5). Diabetes was induced with a single intraperitoneal (IP) injection of streptozotocin (STZ, 100 mg/kg). Non-diabetic rats received an IP injection of saline. Eight weeks after injection, rats were chronically instrumented with a left jugular venous catheter and a left carotid arterial catheter. After recovery (5 days) cardiac sympathetic tonus, parasympathetic tonus and intrinsic heart rate were determined. On an alternative day, the pressor response to nitric oxide synthase inhibition (NOS-X) was determined in areflexic rats. Cardiac sympathetic tonus (72 ± 13 vs. 41 ± 7), parasympathetic tonus (?51 ± 10 vs. ?22 ± 7), and intrinsic heart rate (368 ± 6 vs. 292 ± 9), were reduced in diabetic rats. Furthermore, diabetic rats had a smaller pressor response (Δ33 ± 7 vs. Δ66 ± 5) to NOS-X. These results document impaired autonomic control of heart rate and endothelial dysfunction in 8-week streptozotocin induced diabetic rats.     

Increased masked hypertension prevalence in patients with obesity

ABSTRACT

Objectives: Masked hypertension is associated with an increased risk for cardiovascular conditions. The aim of the study was to evaluate the relationship obesity parameters, including body weight, waist circumference, and body mass index.

Methods: The study group consisted of 251 consecutive outpatient subjects without overt hypertension. Subjects were classified according to BMI. After a complete medical history and laboratory examination, patients’ height, weight, waist circumference heart rate, and office blood pressure were recorded. All subjects underwent ambulatory blood pressure monitoring. Masked hypertension is defined as normal office blood pressure measurement and high ambulatory blood pressure level.

Results: Baseline characteristics in patients and controls were similar. Prevalence of Masked hypertension was significantly higher in patients with obesity than controls (30.9% vs 5.7%, p < 0.001). Body mass index (33.2 ± 4.3 vs 25.1 ± 2.7 p < 0.001), waist circumference (98.5 ± 11.7 vs 86.8 ± 8.8, p < 0.001), and weight (86.5 ± 11.8 vs. 69 ± 9.1, p < 0.001) in patients with obesity were significantly higher than in patients with normal weight. Office Systolic BP (121.8 ± 4.4 vs 120.5 ± 4.78, p = 0.035), ambulatory daytime systolic BP (128.8 ± 8.9 vs 124.5 ± 7.4, p < 0.001), ambulatory daytime diastolic BP (73.9 ± 9.5 vs 71.5 ± 7.0, p = 0.019), ambulatory night-time systolic BP in patients with obesity was significantly higher than in patients with normal weight.

Conclusion: This study demonstrated that masked hypertension prevalence is higher in patients with obesity than control patients. It can be suggested that predefining obesity might be helpful in early detection of masked hypertension.     

Cardiac autonomic neuropathy in patients with type 2 diabetes mellitus having peripheral neuropathy: A cross-sectional study

AimsThe aim was to see the frequency of CAN in type 2 diabetes mellitus patients with peripheral neuropathy, and its association with peripheral nerve conduction abnormalities.MethodsA cross-sectional study at BIRDEM was conducted in 62 patients with type 2 diabetes mellitus having electrophysiologically diagnosed peripheral neuropathy. CAN was detected by four clinical tests - heart rate response to deep breathing and valsalva maneuver, blood pressure response to standing and sustained handgrip.ResultThe study showed that all patients had CAN – 14.52% had early, 26.67% had definitive and 59.68% had severe CAN. Patients with severe CAN had significantly reduced nerve conduction velocity and amplitude of peripheral nerves (sural 4.36 ± 12.77 vs 9.65 ± 17.77 m/s, p = 0.009; 2.23 ± 1.89 vs 3.01 ± 2.76 mV, p = 0.001; peroneal 7 ± 4.23 vs 8.53 ± 5.99 mV, p = 0.047; tibial 0.008 ± 0.03 vs 0.026 ± 0.05 mV, p = 0.009) and higher serum triglyceride levels (221.17 ± 120.61 vs 197.76 ± 68.43 mg/dl, p = 0.033).ConclusionDiabetic patients with peripheral neuropathy have CAN, the severity of which increases with worsening neuropathy.     

Autonomic dysfunction in psoriatic arthritis

Autonomic nervous system (ANS) involvement has been studied in systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis, Sjogren’s syndrome, and ankylosing spondylitis but still has not been studied in psoriatic arthritis (PsA). The aim of this study was to investigate the prevalence and the nature of autonomic neuropathy in patients with PsA. Sixteen patients of PsA and 15 age and sex matched control subjects were studied prospectively using a battery of noninvasive tests. Cardiovascular autonomic neuropathy (CAN) was diagnosed by applying four cardiovascular reflex tests, and peripheral sympathetic autonomic function was assessed by Sudoscan. Patients with PsA had significantly higher heart rate response to standing (p?=?0.01), blood pressure response to standing (p?=?0.02), and Sudoscan (p?=?0.01) when compared with healthy controls. Fifty percent (n?=?8) of the patients with PsA had at least two or more abnormal CAN parasympathetic dysfunction; of these, 18.75 % (n?=?3) of the patients had abnormal parasympathetic and sympathetic dysfunction, 68.7 % (n?=?11) and 25 % (n?=?4) of the patients had at least one abnormal parasympathetic and sympathetic parameters, respectively, and 37.5 % (n?=?6) of the patients had moderate sudomotor dysfunction. About 18.7 % (n?=?3) of our parasympathetic dysfunction patients had autonomic symptoms. None of healthy volunteers had abnormal ANS dysfunction. Heart rate response significantly correlated with erythrocyte sedimentation rate (p?<?0.05) and C-reactive protein (p?<?0.05) levels. In conclusion, cardiovascular autonomic and peripheral sympathetic neuropathy occurs in PsA. Parasympathetic function is more commonly found to be abnormal than sympathetic function. There is no correlation of peripheral sympathetic dysfunction with cardiovascular autonomic neuropathy.     

Age itself is not a prognostic indicator of poor outcome in elderly Chinese patients treated with continuous ambulatory peritoneal dialysis (CAPD)

Data from most dialysis registries suggest that advanced age is associated with poor outcome in dialysis patients. However, it may simply be the result of higher prevalence of coexisting medical conditions in this group of patients. We performed a retrospective study to examine this hypothesis. We identified 44 continuous ambulatory peritoneal dialysis (CAPD) patients of age over 65 (the geriatric group) and 127 patients of age between 50 to 64 (the control group). Their nutritional status, duration of hospitalization, peritonitis rate, 2-year patient and technique survival were compared. Patients of geriatric group had higher prevalence of diabetes, cardiovascular disease, and requirement of helper for dialysis procedure than the control group. Geriatric group had lower normalized protein catabolic rate (nPCR) (0.81 ±0.16 vs 0.91 ±0.18 g/kg/day, p < 0.005) and percentage of lean body mass (%LBM) (54.7 ±10.1 vs 61.3 ±10.2, p < 0.005). They had marginally lower 2-year patient survival (72.6% vs 82.8%, p = 0.08) and technique survival (68.8% vs 79.4%, p = 0.15). Hospitalization and peritonitis rate did not differ between groups. Furthermore, requirement of helper for dialysis procedure was the major confounding factor. Patients who need helper had significantly lower 2-year actual survival (58.0% vs 86.0%, p < 0.02) and technique survival (54.1% vs 82.6%, p < 0.01). They stayed in hospital longer (median 13.1 versus 4.4 days/year, p < 0.01). Multivariate analysis showed that requirement of helper and diabetic status, but not age, were independent factors affecting patient and technique survival; requirement of helper, diabetic status, and duration on dialysis were independent factors predicting hospitalization. We conclude that age is not an important factor determining morbidity and mortality of CAPD patient. Requirement of helper for dialysis procedure, which probably represents a poor overall functional status, is a more important factor predicting outcome. Elderly patients should not be excluded from dialysis program by advanced age alone.