Relative lymphocyte count as a marker of progression of chronic kidney disease

Background

Although low relative lymphocyte count (RLC) is associated with poor outcomes in patients with chronic kidney disease (CKD), the relationship between low RLC and progression of CKD is poorly defined. The aim of this study was to determine the association between low RLC and the progression of CKD.

Methods

Between January 2003 and December 2009, 288 CKD patients were analyzed. RLC was calculated as the ratio between lymphocyte and total white blood cell counts.

Results

The median RLC was 29.1 % [interquartile range (IQR) 24.1–34.1]. When the patients were compared according to a level below or above the median value for RLC, the rate of CKD progression to end-stage renal disease (ESRD) was greater in patients with low RLC count than in patients with high RLC (48 vs. 25 %, p < 0.001) during the median follow-up of 5.5 years (IQR 3.5–7.6). The variables found to be predictive of progression to the ESRD included younger age, smoking, diabetes, higher systolic blood pressure, no use of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs), lower hemoglobin and serum albumin levels, higher low-density lipoprotein cholesterol concentration, presence of proteinuria, and low RLC in the univariate Cox proportional hazards regression analysis. However, after adjustment, younger age, male, higher systolic blood pressure, no use of ACEIs or ARBs, lower hemoglobin and serum albumin concentrations, higher proteinuria, and lower RLC were significantly associated with progression to ESRD in multivariate analysis.

Conclusions

Low RLC is independently associated with increased rate of progression in patients with CKD.     

The effect of withdrawal of ACE inhibitors or angiotensin receptor blockers prior to coronary angiography on the incidence of contrast-induced nephropathy

Background

The effect of continuing or discontinuing chronic angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) therapy prior to coronary angiography on the incidence of contrast-induced nephropathy (CIN) is not clear. We undertook a randomized trial to evaluate the effect of withdrawing ACEIs or ARBs 24 h prior to coronary angiography on the incidence of CIN associated with coronary angiography.

Methods

A total of 220 patients with chronic kidney disease (CKD) stages 3–4 (glomerular filtration rate 15–60 ml/min/1.73 m²) on ACEI or ARB therapy were randomized before angiography to either ACEI/ARB continuation group or discontinuation group. A third group of patients with CKD stages 3–4 but not on angiotensin blockade therapy were also followed. The primary outcome measure was the incidence of CIN defined by a rise in serum creatinine by 25% or 0.5 mg/dl (44 μmol/l) from baseline.

Results

There was no statistically significant difference in the incidence of CIN between the three groups (P = 0.66). The incidences were 6.2%, 3.7%, and 6.3% for the continuation, discontinuation, and angiotensin blockade naïve group, respectively. There was also no significant difference found between the groups in mean serum creatinine and glomerular filtration rate values at baseline and post contrast administration.

Conclusion

Withholding ACEIs and ARBs 24 h before coronary angiography does not appear to influence the incidence of CIN in stable patients with CKD stages 3–4.     

Is high-dose cholecalciferol justified in children with chronic kidney disease who failed low-dose maintenance therapy?

Background

We aimed to investigate the effect of single, high-dose intramuscular cholecalciferol on vitamin D3 and intact parathyroid hormone (iPTH) levels in children with chronic kidney disease (CKD).

Methods

Between January 2012 and June 2012, we conducted a prospective, uncontrolled study at the Pediatric Nephrology Unit of King Abdulaziz University Hospital, Jeddah, to investigate the effect of single, high-dose intramuscular vitamin D3 on 25(OH)D3 and iPTH levels in vitamin D insufficient/deficient children with CKD. Serum vitamin D3, iPTH, calcium, phosphate, alkaline phosphatase (ALP), and creatinine levels were measured before intramuscular vitamin D3 (300,000 IU) administration, and these were subsequently repeated at 1 and 3 months after treatment. Statistical analysis was performed with the Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL, USA).

Results

Nineteen children fulfilled the criteria. At 3 months after treatment, vitamin D3 levels were significantly higher than at baseline (p?<?0.001) but lower than the levels at 1 month. iPTH levels decreased significantly at 3 months (p?=?0.01); however, the drop in iPTH levels was not significant at 1 month (p?=?0.447). There were no changes in calcium, phosphate, ALP, or creatinine levels after treatment.

Conclusions

Single-dose intramuscular vitamin D3 (300,000 IU) resulted in significant improvement of vitamin D3 and iPTH levels in children with CKD.     

Soluble TWEAK levels are independently associated with coronary artery disease severity in patients with stage 2–3 kidney disease

Purpose

Patients diagnosed with chronic kidney disease (CKD) have a greater rate of cardiovascular mortality compared with the general population. The soluble form of TNF-like weak inducer of apoptosis (TWEAK) plays a role in cellular proliferation, migration, and apoptosis. The current study aimed to analyze whether soluble TWEAK levels are associated with the severity of coronary arterial disease (CAD) in CKD patients.

Methods

Ninety-seven patients diagnosed with CKD stages 2–3 according to their estimated glomerular filtration rate and the presence of kidney injury were included in the study. Plasma sTWEAK concentrations were determined using commercially available ELISA kits. Coronary angiographies were performed through femoral artery access using the Judkins technique.

Results

Correlation analysis of sTWEAK and Gensini scores showed significant association (p < 0.01, r ² = 0.287). When patients were divided into two groups with a limit of 17 according to their Gensini score, sTWEAK levels indicated a statistically significant difference (p < 0.01).

Conclusions

Our results indicate a relationship between sTWEAK levels and CAD in CKD stages 2–3 patients.     

Hypervitaminosis A is prevalent in children with CKD and contributes to hypercalcemia

Background

Vitamin A accumulates in renal failure, but the prevalence of hypervitaminosis A in children with predialysis chronic kidney disease (CKD) is not known. Hypervitaminosis A has been associated with hypercalcemia. In this study we compared dietary vitamin A intake with serum retinoid levels and their associations with hypercalcemia.

Methods

We studied the relationship between vitamin A intake, serum retinoid levels, and serum calcium in 105 children with CKD stages 2–5 on dialysis and posttransplant. Serum retinoid measures included retinol (ROH), its active retinoic acid (RA) metabolites [all-trans RA (at-RA) and 13-cis RA] and carrier proteins [retinol-binding protein-4 (RBP4) and transthyretin (TTR)]. Dietary vitamin A intake was assessed using a food diary.

Results

Twenty-five children were in CKD 2–3, 35 in CKD 4–5, 23 on dialysis and 22 posttransplant; 53 % had vitamin A intake above the Reference Nutrient Intake (RNI) value. Children receiving supplemental feeds compared with diet alone had higher vitamin A intake (p?=?0.02) and higher serum ROH (p?<?0.001). Notably, increased ROH was seen as early as CKD stage 2. For every 10 ml/min/1.73 m² fall in estimated glomerular filtration rate (eGFR), there was a 13 % increase in ROH. RBP4 levels were increased in CKD 3–5 and dialysis patients. The lowest ratios of ROH:RBP4 were seen in dialysis compared with CKD 2–3 (p?=?0.03), suggesting a relative increase in circulating RBP4. Serum ROH, RBP4 and at-RA were associated with serum calcium. On multivariable analysis RBP4 levels and alfacalcidol dose were significant predictors of serum calcium (model R ² 32 %) in dialysis patients.

Conclusions

Hypervitaminosis A is seen in early CKD, with highest levels in children on supplemental feeds compared with diet alone. Serum retinoid levels significantly predict hypercalcemia.

     

Restless legs syndrome in children with chronic kidney disease

Background

Restless legs syndrome (RLS) is considerably more common among adults with chronic kidney disease (CKD) than in the general population and is associated with increased morbidity and mortality. There is limited information on RLS in children with CKD. Failure to account for conditions that might mimic RLS can lead to overdiagnosis of this syndrome.

Methods

In a prospective, cross-sectional study, RLS prevalence was compared between pediatric CKD patients and healthy children. RLS was assessed via a questionnaire that included exclusion of mimics. Sleep characteristics and health-related quality of life (HRQoL) were also assessed.

Results

Restless legs syndrome was more prevalent in CKD patients (n?=?124) than in 85 normal children (15.3 vs. 5.9 %; p = 0.04). There was no significant association between RLS and CKD stage, CKD etiology, CKD duration, and dialysis or transplant status. Children with RLS were more likely to rate their sleep quality as fairly bad or very bad (41.2 vs. 8.8 %; p?=?0.003) and report using sleep medications (42.1 vs. 14.7 %; p?=?0.01). RLS was associated with lower HRQoL by parent report (p?=?0.03). Only five of the 19 patients (26.3 %) with CKD and RLS had discussed RLS symptoms with a healthcare provider, and only one of these patients had been diagnosed with RLS prior to this study.

Conclusions

The prevalence of RLS is increased in children with CKD and appears to be underdiagnosed. Systematic screening for RLS and sleep problems would therefore appear to be warranted in children with CKD.     

Ceramides and cardiac function in children with chronic kidney disease

Background

Chronic kidney disease (CKD) is associated with increased incidence of cardiac dysfunction. Recent animal studies have demonstrated that elevated levels of ceramides cause dilated lipotoxic cardiomyopathy. We hypothesized ceramides are increased in children with CKD and associated with abnormal cardiac structure and function.

Methods

Ceramide levels were determined in 93 children aged 1–16 years enrolled in the Chronic Kidney Disease in Children (CKiD) study and compared to levels from 24 healthy controls. Complete demographic, clinical, and laboratory information, and ceramide measurements were analyzed cross-sectionally. Echocardiography was performed to determine cardiac structure and function.

Results

Very long-chain C24:0 ceramides were the most abundant species in both control (56 %) and CKD subjects (55 %), followed by C24:1 (controls 19 %, CKD 23 %) and C22:0 (controls 19 %, CKD 13 %). Total serum ceramide levels were significantly higher in CKD children versus controls (p?<?0.001). Ceramide metabolites lactosylceramide, C24:0L, and C16:0L were significantly higher in CKD subjects than controls (p?<?0.001). The proportion of C24:0L was dramatically higher in CKD (59 %) versus control (17 %) subjects (p?<?0.001). In adjusted multivariate analyses, higher log₁₀C24:0L and log₁₀C16:0L were significant predictors of lower shortening fraction and mid-wall shortening.

Conclusions

Ceramide levels are increased in children with CKD. Our study identified lactosylceramides as an independent predictor of lower systolic function in these children.     

Comparison Between Different Intramuscular Vitamin B<Subscript>12</Subscript> Supplementation Regimes: a Retrospective Matched Cohort Study

Background

The incidence of vitamin B₁₂ deficiency after bariatric surgery can range from 26 to 70 %. There is no consensus on optimal vitamin B₁₂ supplementation in postbariatric patients. The objective of this study was to compare three different regimes.

Methods

In this retrospective matched cohort study, we included 63 patients with methylmalonic acid (MMA) levels ≥300 nmol/L. Group A (n?=?21) received 6 intramuscular (im) vitamin B₁₂ injections including a loading dose, group B (n?=?21) received 3 im vitamin B₁₂ injections without loading dose and group C (n?=?21) received no im vitamin B₁₂ injections.

Results

The total post-bariatric patient population consisted of 14 males (22.2 %) and 49 women (77.8 %) with a mean current body mass index of 30.6?±?8.0 kg/m². There was no significant difference in vitamin B₁₂ and MMA levels between 3 groups at baseline. There was a significant difference in follow-up vitamin B₁₂ levels of group A compared to group B (p?=?0.02) and group A compared to group C (p?=?0.03). In the follow-up results, there is also a significant decrease in MMA levels of group A compared to group B (p?=?0.02), group A compared to group C (p?<?0.001), and group B compared to group C (p?<?0.01).

Conclusions

In this study, a shorter injection regime is probably not sufficient to treat a vitamin B₁₂ deficiency. An injection regime with 6 injections recovered all vitamin B₁₂ deficiencies biochemically. MMA levels cannot recover spontaneously over time without additional im injection regime.

     

Use of pedometers to increase physical activity among children and adolescents with chronic kidney disease

Background

Children and adolescents with chronic kidney disease (CKD) are inactive relative to their peers.

Methods

Forty-four children and adolescents aged 7–20 years with CKD, end-stage renal disease (ESRD) on dialysis or a kidney transplant participated in a 12-week pedometer-based intervention to increase physical activity. Patients recorded daily step counts and reported them weekly. Pediatric Quality of Life Inventory (PedsQL) and 6-min walk (6 MW) were administered at baseline and after 12 weeks.

Results

Age was 15.1?±?3.4 years; 27 % had CKD, 16 % were receiving dialysis, and 57 % had received a kidney transplant. Mean daily step count did not change significantly (+48, 95 % CI ?48 to +145 steps/day per week). Transplant recipients and patients with CKD increased their activity by 100 steps/day (95 % CI ?14 to 208) and 73 steps/day (95 % CI ?115 to 262) each week, respectively, and patients on dialysis decreased by 133 steps/day (95 % CI ?325 to 58; p value for interaction 0.03) in multivariable analysis. Change in physical activity was associated with change in 6 MW distance (r?=?0.74, p?<?0.001) and change in physical functioning (r?=?0.53, p?=?0.001).

Conclusions

Youths with CKD did not significantly increase their activity over 12 weeks of a pedometer-based intervention. However, changes in physical activity were associated with changes in physical functioning and performance.     

Value and level of circulating endothelial progenitor cells, angiogenesis factors and mononuclear cell apoptosis in patients with chronic kidney disease

Background

Chronic renal failure on dialysis can reduce the number of circulating endothelial progenitor cells (EPCs), but this biomarker has not been fully investigated in patients with chronic kidney disease (CKD). A link between CKD and increased mononuclear cell apoptosis (MCA) in circulation has been reported but the effect of vascular endothelial growth factor (VEGF) and stromal cell-derived factor (SDF)-1α, two angiogenesis factors, on circulating EPC levels in CKD has not been clarified. This study examined the relationships between the numbers of circulating EPCs and the severity of CKD, degree of MCA and serum levels of VEGF and SDF-1α in CKD patients.

Methods

The numbers of circulating EPCs (CD31/CD34+, CD62E/CD34+, KDR/CD34+, CXCR4/CD34+) were measured in 166 patients with varying degrees of CKD under regular treatment at an outpatient department and in 30 volunteer control subjects.

Results

CKD patients had significantly lower numbers of EPCs (p < 0.007), higher MCA in circulation and higher serum levels of VEGF and SDF-1 compared with the control subjects (all p < 0.001). Compared with patients with early CKD (stages I–III), patients with late CKD [stage IV–V or end-stage renal disease (ESRD)] had significantly lower numbers of EPCs (CXCR4/CD34+), higher MCA, and elevated serum levels of VEGF and SDF-1α (all p < 0.01). Serum VEGF level but not MCA or SDF-1α was strongly correlated with increased numbers of circulating EPCs. Multivariate analysis showed that ESRD along with lower serum albumin was independently predictive of lower numbers of circulating EPCs (p < 0.04).

Conclusion

Circulating EPCs were markedly reduced in CKD patients. ESRD was strongly and independently predictive of decreased numbers of circulating EPCs.     

In-hospital mortality in patients with renal dysfunction admitted for myocardial infarction: the Emilia-Romagna region of Italy database of hospital admissions

Background

In-hospital mortality of patients with myocardial infarction (MI) in different European populations and renal dysfunction is variable. We aimed to evaluate in-hospital mortality for MI in chronic kidney disease (CKD), in end-stage renal disease (ESRD), and in subjects admitted for MI without renal dysfunction living in the Emilia-Romagna region of Italy.

Methods

We considered all cases of MI (first event) recorded in the database of hospital admissions of the region Emilia-Romagna of Italy, from January 1999 to December 2009. The criterion for inclusion was the presence, as a first discharge diagnosis, of acute MI (International Classification of Diseases, 9th Revision, Clinical Modification). The Charlson comorbidity index (CCI), with the exclusion of CKD, was calculated. The outcome variable was in-hospital mortality for MI, and its association with comorbidities, CKD and ESRD, was analyzed.

Results

During the considered period, 88,014 cases of first MI were recorded. The percentage of patients admitted with MI and died during hospitalization were higher in patients with ESRD (38.3 %) and CKD (16.5 %) than in those without renal dysfunction (14 %) (p < 0.01). In CKD and ESRD patients, data of in-hospital mortality for MI exhibited a twofold increase in the analyzed period. In-hospital mortality for MI was independently associated with age (OR 1.077, 95 % CI 1.075–1.080, p < 0.001), CCI excluding CKD (OR 1.101, 95 % CI 1.069–1.134, p < 0.001), cerebrovascular disease (OR 1.450, 95 % CI 1.349–1.557, p < 0.001), malignancy (OR 1.234, 95 % CI 1.153–1.320, p < 0.001), and ESRD (OR 4.137, 95 % CI 3.511–4.875, p < 0.001).

Conclusions

As for the Emilia-Romagna region of Italy, in-hospital mortality for MI is increasing over the last years, and mortality seems to be related with patients’ comorbidities and presence of advanced stages of CKD.     

The effect of a multidisciplinary care clinic on the outcomes in pediatric chronic kidney disease

Background

Current best evidence-based practice for children with chronic kidney disease (CKD) attempts to achieve good clinical outcomes through careful management of comorbidities and is likely best achieved with a multidisciplinary care (MDC) CKD clinic.

Methods

In this retrospective study of children with CKD in British Columbia, Canada, we analyzed clinical outcomes in a cohort of 73 CKD patients from 2003 under a standard care model and a second cohort of 125 CKD patients from 2009 under a MDC clinic model.

Results

Patient demographics were similar, but there was a decrease in the percentage of patients with CKD stage 3–5 in 2009 (59 vs. 75 %; p = 0.002), although the absolute number increased. After adjustment for severity of CKD, hemoglobin was significantly higher (13.0 g/dl vs. 12.2 g/dl, p < 0.03), calcium was significantly higher (9.6 mg/dl vs. 9.1 mg/dl, p < 0.001), and albumin was significantly higher (4.4 g/dl vs. 3.8 g/dl, p < 0.001) in the 2009 MDC cohort. The rate of disease progression, assessed by annualized estimated glomerular filtration rate (eGFR) slope, improved from –4.0 ml/min/1.73 m² in the 2003 cohort to 0.5 ml/min/1.73 m² in the 2009 cohort (p < 0.01). Blood pressure control was better in 2009 although not statistically significant.

Conclusions

Multidisciplinary care improved the outcomes of children with CKD especially in anemia management, bone mineral metabolism, nutrition, and renal disease progression.     

Relationship between total testosterone, cognitive function, depressive behavior, and sleep quality in chronic kidney disease patients not on dialysis

Background

Studies show that testosterone levels are associated with cognitive function, depression, and sleep quality in the general population. However, these relationships in chronic kidney disease (CKD) patients not on dialysis have not yet been evaluated before.

Methods

All patients underwent history taking, physical examination, blood pressure measurement, routine urine and biochemical analysis, 24-h urine collection to measure urinary protein excretion and creatinine clearance, and evaluation of cognitive function, depressive behavior, and sleep quality.

Results

In total, 109 CKD patients were enrolled. Total testosterone levels in stage 3, 4, and 5 CKD patients were 8.32 ± 4.35, 6.71 ± 3.12, and 4.22 ± 1.28 ng/ml, respectively (p < 0.0001). Post hoc analysis revealed that total testosterone levels were different between stages 3 and 5 (p < 0.0001) and stages 4 and 5 CKD patients (p < 0.0001) but not between stages 3 and 4 CKD patients (p 0.094). Standardized Mini Mental State Examination (SMMSE) score, Pittsburgh Sleep Quality Index (PSQI) score, and Beck Depression Inventory (BDI) score were 26.2 ± 1.9, 7.1 ± 3.4, and 8.6 ± 6.4, respectively. In linear regression analysis, total testosterone levels were independently associated with SMMSE score [b 0.170, confidence interval (CI) 0.047–0.293, p 0.008] and BDI score (b ?0.750, CI ?1.283 to ?0.216, p 0.006) but not with sleep quality.

Conclusion

Total serum testosterone levels were independently associated with cognitive function and depressive behavior but not with sleep disorders in stage 3–5 CKD patients not on dialysis.     

Fast GFR decline and progression to CKD among primary care patients with preserved GFR

Background

Fast glomerular filtration rate (GFR) decline is associated with adverse outcomes, but the associated risk factors among patients without chronic kidney disease (CKD) are not well defined.

Methods

From a primary care registry of 37,796, we identified 2219 (6%) adults with at least three estimated (e)GFR values and a baseline eGFR between 60 and 119 ml/min/1.73 m² during an observation period of 8 years. We defined fast GFR decline as > 5 ml/min/1.73 m² per year. The outcome measure was incident CKD (eGFR < 60 ml/min/1.73 m²). Clinical and demographic characteristics were compared using Chi-square and independent-samples t tests.

Results

Older age, African-American race, unmarried status, hypertension and type 2 diabetes were more common in both fast decliners and those who developed incident CKD (p < 0.0001 to < 0.05). Lower neighborhood socioeconomic status, current smoking and baseline eGFR 90–119 ml/min/1.73 m² were associated with fast decline (p < 0.01), while baseline eGFR 60–74 ml/min/1.73 m² with incident CKD (p < 0.05). In multivariate regression models, among fast decliners with mildly reduced baseline eGFR (60–89 ml/min/1.73 m²), older age was significantly associated with incident CKD [odds ratio (OR) 1.04; 95% CI 1.01–1.08], and among those with normal baseline eGFR (≥ 90–119 ml/min/1.73 m²), type 2 diabetes was significantly associated with incident CKD (OR 3.83; 95% CI 1.35–10.89).

Conclusions

Among primary care patients without CKD, GFR is checked infrequently. We have identified patients at high risk of progressive CKD, in whom we suggest a closer monitoring of renal function.

     

Intraoperative Parathyroid Hormone Assay Remains Predictive of Cure in Renal Impairment in Patients with Single Parathyroid Adenomas

Background

Parathyroid hormone (PTH) has a short half-life and is cleared by the liver and kidneys. This study examined whether declining estimated glomerular filtration rate (eGFR) affects application of the Miami criterion for intraoperative PTH (ioPTH) decline during parathyroidectomy for primary hyperparathyroidism (pHPT).

Methods

A retrospective review of consecutive patients undergoes parathyroidectomy for pHPT. Patients with multi-gland disease, without ioPTH, failure-to-cure and those <18 years were excluded. Baseline demographics, pre-operative PTH, ioPTH and 6-month follow-up data were available. Patients were categorised into normal or chronic kidney disease (CKD stage 2–5) based on pre-operative eGFR. Nonparametric data were compared using Mann–Whitney U test/Kruskal–Wallis test. The primary outcome measure was to assess whether CKD-affected ioPTH decline in parathyroidectomy for pHPT.

Results

A total of 476 patients were included [75.4% women; median age 63.8 years (18–92)]. CKD was present in 362 (76%) (CKD2:289; CKD3:66; CKD4/5:7). Increasing CKD stage was associated with advancing age [normal 53 years (41–61); CKD2 65 (57–73); CKD3 73.5 (66–78); CKD4/5 74(63–81); p < 0.001] and higher pre-operative PTH [16.6 pmol/L (11.1–22.9); 13.1 (10.4–17.7); 22.6 (13.8–33.7); 33.8(12.4–41.7); p < 0.001]. Baseline and post-excision ioPTH were significantly higher in those with CKD4/5 (p < 0.05). The Miami criterion was met in all patients, but median fall in ioPTH at 10-min varied between groups [normal:0.78 (0.71–0.82); CKD2:0.76 (0.69–0.83); CKD3:0.75 (0.69–0.82); CKD4/5:0.69 (0.61–0.70); p = 0.048)]. It was significantly lower in those with CKD4/5 compared with the remainder of patients [0.69 (0.61–0.70) vs. 0.76 (0.70–0.82); p = 0.008].

Conclusions

Although the reduction in ioPTH after successful parathyroidectomy is lower in severe CKD, the Miami criterion remains predictive of cure. Differences in absolute levels of PTH and tumour weight suggest that renal HPT may be a confounding factor.

     

Nutritional vitamin D use in chronic kidney disease: a survey of pediatric nephrologists

Background

Vitamin D deficiency may contribute to risk of cardiovascular disease, diabetes, and infections, in addition to known effects on mineral metabolism. Controversy remains regarding the use of nutritional vitamin D supplementation in chronic kidney disease (CKD), and the supplementation practices of pediatric nephrologists are unknown.

Methods

An electronic survey containing eight vignettes was sent to physician members of the International Pediatric Nephrology Association in 2011 to identify physician and patient characteristics that influence nephrologists to supplement CKD patients with nutritional vitamin D. Vignettes contained patient characteristics including light vs dark skin, CKD stage, cause of renal disease, parathyroid hormone (PTH), and 25(OH) vitamin D levels. Multivariate logistic generalized estimating equation regression was used to identify predictors of supplementation.

Results

Of 1,084 eligible physicians, 504 (46%) completed the survey. Supplementation was recommended in 73% of cases overall (ranging from 91% of those with vitamin D levels <10 ng/mL to 35% with levels >30). Greater CKD severity was associated with greater recommendation of supplementation, especially for patients with higher vitamin D levels (test for interaction p?<?0.0001). PTH level above target for CKD stage was associated with greater recommendation to supplement in pre-dialysis CKD, but did not have an impact on recommendations in dialysis patients (test for interaction p?<?0.0001). Skin color, cause of CKD, and albumin levels were not associated with supplementation recommendation.

Conclusions

Recommending nutritional vitamin D is common worldwide, driven by CKD stage and vitamin D and PTH levels. Future studies are needed to establish the risks and benefits of supplementation.     

Plasma <Emphasis Type="Italic">p</Emphasis>-cresol lowering effect of sevelamer in non-dialysis CKD patients: evidence from a randomized controlled trial

Background

The accumulation of p-cresol, a metabolic product of aromatic amino acids generated by intestinal microbiome, increases the cardiovascular risk in chronic kidney disease (CKD) patients. Therefore, therapeutic strategies to reduce plasma p-cresol levels are highly demanded. It has been reported that the phosphate binder sevelamer (SEV) sequesters p-cresol in vitro, while in vivo studies on dialysis patients showed controversial results. Aim of our study was to evaluate the effect of SEV on p-cresol levels in non-dialysis CKD patients.

Methods

This was a single-blind, randomized placebo-controlled trial (Registration number NCT02199444) carried on 69 CKD patients (stage 3–5, not on dialysis), randomly assigned (1:1) to receive either SEV or placebo for 3 months. Total p-cresol serum levels were evaluated at baseline (T0), and 1 (T1) and 3 months (T3) after treatment start. The primary end-point was to evaluate the effect of SEV on p-cresol levels.

Results

Compared to baseline (T0, 7.4 ± 2.7 mg/mL), p-cresol mean concentration was significantly reduced in SEV patients after one (? 2.06 mg/mL, 95% CI ? 2.62 to ? 1.50 mg/mL; p < 0.001) and 3 months of treatment (? 3.97 mg/mL, 95% CI ? 4.53 to ? 3.41 mg/mL; p < 0.001); no change of plasma p-cresol concentration was recorded in placebo-treated patients. Moreover, P and LDL values were reduced after 3 months of treatment by SEV but not placebo.

Conclusions

In conclusion, our study represents the first evidence that SEV is effective in reducing p-cresol levels in CKD patients in conservative treatment, and confirms its beneficial effects on inflammation and lipid pattern.

     

Sexual dysfunction is more than twice as frequent in Danish female predialysis patients compared to age- and gender-matched healthy controls

Purpose

This study aimed to compare sexual dysfunction in Danish female predialysis patients with chronic kidney disease (CKD) stage 4–5 with age-matched healthy women in Denmark.

Methods

Twenty-seven adult female predialysis patients (CKD stage 4–5 ~ creatinine clearance ≤ 30 ml/min) without diagnosed depression and 54 randomly assigned healthy female controls completed the questionnaires Female Sexual Function Index, Female Sexual Distress Scale, and the Major Depression Inventory.

Results

Predialysis patients reported lower Female Sexual Function Index scores compared to the controls (14.2 ± 2.1 vs. 20.1 ± 1.7, respectively, p = 0.048), more frequent sexual distress (44 vs. 22 %, respectively, p = 0.044), and more frequent sexual dysfunction (41 vs. 17 %, respectively, p = 0.041). There was no difference between the patients’ and the controls’ depression scores (12.2 ± 2.2 vs. 8.6 ± 1.1, respectively, p = 0.180).

Conclusion

Sexual dysfunction was found to be more than two times as frequent in Danish female predialysis patients with CKD stage 4–5 compared to age- and gender-matched healthy controls, and this result emphasizes the need for attention towards sexual function in the treatment for CKD.     

Remifentanil temporarily improves renal function in adult patients with chronic kidney disease undergoing orthopedic surgery

Purpose

The objective of this study was to confirm the renal protective effect of remifentanil-based anesthesia in perioperative adult patients with chronic kidney disease (CKD).

Methods

A total of 90 non-dialysis perioperative adult patients with CKD, with preoperative estimated glomerular filtration rate from creatinine (eGFRcreat) values of lower than 50 ml/min/1.73 m², who had undergone orthopedic surgery under general anesthesia were retrospectively selected. The subjects were divided into two groups according to whether or not remifentanil was used for anesthesia management: group R, in which remifentanil was used for anesthesia management (n = 45), and group NR, in which remifentanil was not used for anesthesia (n = 45). eGFRcreat was measured pre-surgery (pre), 7 days after surgery (day-7), and 14 days after surgery (day-14).

Results

In group R, both day-7 eGFRcreat (52.2 ± 17.0 ml/min/1.73 m²) and day-14 eGFRcreat (49.7 ± 15.5 ml/min/1.73 m²) were significantly higher than the pre eGFRcreat (40.7 ± 7.5 ml/min/1.73 m²) (day-7: p < 0.01; day-14: p < 0.01). In group NR, on the other hand, pre eGFRcreat (37.8 ± 7.6 ml/min/1.73 m²), day-7 eGFRcreat (41.2 ± 10.9 ml/min/1.73 m²), and day-14 eGFRcreat (40.2 ± 10.5 ml/min/1.73 m²) values were similar. Furthermore, both day-7 eGFRcreat and day-14 eGFRcreat were significantly higher in group R than in group NR (day-7: p < 0.01; day-14: p < 0.01).

Conclusions

Our findings suggest that anesthesia management using remifentanil may have a renal protective effect in perioperative adult CKD patients undergoing orthopedic surgery.     

Vitamin D3 Deficiency is Associated with Late-Onset Hypocalcemia After Minimally Invasive Parathyroidectomy in a Vitamin D Borderline Area

Background

Concurrent vitamin D₃ deficiency is common in primary hyperparathyroidism (pHPT). We aimed to examine the clinicopathologic features and short-term outcomes of vitamin D₃-deficient patients after minimally invasive parathyroidectomy (MIP).

Methods

Over 2-year period, 80 consecutive MIP patients had preoperative-fasting 25-hydroxyvitamin D₃ (25OHD₃) checked. Forty-five patients had a 25OHD₃ level <20 ng/ml and were defined as deficient. Intraoperative parathyroid hormone (IOPTH) assay was used for all MIP. Postoperative adjusted calcium (Ca) was checked at 6, 16 (with intact PTH), and 24 h. Oral calcium and vitamin D supplements were given if hypocalcemic symptoms developed or Ca < 2.00 mmol/l. Late-onset hypocalcemia (LOH) was defined as symptoms developed after 24 h.

Results

Both deficient and nondeficient groups had similar demographic data and bone density scores. The deficient group had significantly higher PTH (190 vs. 121 pg/ml, p = 0.015). Although IOPTH in the deficient group were higher at induction and 0 min after excision, the percentage drop from induction to 10 min after excision was similar. Ca was similar at 6 and 16 h in the two groups but was significantly lower in the deficient group at 24 h (2.10 vs. 2.45 mmol/l, p = 0.033). At 1 week, the proportion of LOH was significantly higher in the deficient group (12/42 vs. 3/34, p = 0.043) and in those with preoperative PTH > 100 pg/ml (15/57 vs. 0/19, p = 0.013).

Conclusions

Vitamin D₃ deficiency was associated with a higher preoperative PTH level and a greater risk of LOH after MIP. However, the likely cause of LOH remains unclear as both low preoperative vitamin D₃ and high PTH levels could be responsible.