Uraemic pruritus and exposure to di(2-ethylhexyl)phthalate (DEHP) in haemodialysis patients

Uraemic pruritus is a frequent and disabling symptom in patientson dialysis. The pathogenesis of uraemic pruritus is neverthelessstill obscure. We investigated whether di (2-ethylhexyl ) phthalate(DEHP), the most commonly used plasticizer in polyvinyichloride(PVC) haemodialysis tubings, is a possible pathogenetic factorin uraemic pruritus. Serum concentrations of DEHP and its majorderivatives mono-(2-ethylhexyl ) phthalate (MEHP), 2-ethylhexanol(2-EH) and phthalic acid (PA) were determined in uraemic patientsbefore and after a haemodialysis session and compared with theoccurrence and intensity of pruritus in these patients. Twenty-onepatients on regular haemodialysis for at least 6 months wereexamined. The severity of uraemic pruritus was assessed usinga standard questionnaire (pruritus score). The quantitativeanalysis of DEHP and its derivatives was carried out by GC/selectedion monitoring mass spectrometry. Fourteen out of 21 patients(66%) complained about uraemic pruritus to a variable degree.The post-dialysis serum concentrations of DEHP, MEHP and 2-EHwere significantly higher than the corresponding pre-dialysisvalues, whereas the post-dialysis concentrations of PA (0.122±0.078µg/ml) were significantly lower than pre-dialysis levels(0.194±0.101 µg/ml, P=0.00068). Neither pre- norpost-dialysis serum concentrations of DEHP, MEHP, PA or 2-EHwere correlated with the severity of uraemic pruritus. Additionally,serum concentrations of DEHP and its metabolites did not differsignificantly in patients with and without pruritus. These findingssuggest that patients on haemodialysis are regularly exposedto considerable amounts of DEHP and metabolites. Phthalic acid,one of the presumed end products of DEHP metabolism, might beeliminated at least in part by haemodialysis. The expositionto DEHP and metabolites during haemodialysis, as assessed bymeasuring serum concentrations, bears no immediate realtionto the occurence or intensity of uraemic pruritus.     

The significance of serum homocysteine levels in diabetic patients on haemodialysis.

BACKGROUND: Atherosclerotic diseases are the major cause of mortality and morbidity in patients on haemodialysis (HD). Furthermore, the prognosis of diabetic patients on HD is especially poor due to atherosclerotic complications. Because homocysteine (Hcy), a sulfur-containing amino acid, is emerging as an important risk factor for atherosclerosis in patients with end-stage renal disease, we examined the significance of serum Hcy levels in diabetic patients on HD. METHODS: We measured total serum Hcy levels (tHcy) in 31 patients with diabetes mellitus on HD (DM group) and 37 non-diabetic patients on HD (N group), adjusting for age and HD duration. Linear regression analysis was used to assess the correlation of multiple variables to tHcy. RESULTS: The proportion of atherosclerotic disease in the DM group was significantly higher than in the N group. However, serum tHcy, serum creatinine and per cent creatinine generation rate in the DM group were significantly lower than in the N group. In the DM group, serum tHcy was positively correlated with creatinine, albumin and per cent creatinine generation rate, respectively. This was not the case in the N group. CONCLUSIONS: The demethylation pathway in methionine metabolism in the liver, which is linked directly to the creatinine generation system, may be disturbed in diabetic patients on HD. This may be the reason why serum tHcy and creatinine in diabetic patients on HD are lower than in non-diabetic patients on HD. Therefore, it is necessary to consider the possibility of an altered relation between serum tHcy and vessel disease when evaluating the atherogenic risk in diabetic patients on HD.     

The role of oral dryness in interdialytic weight gain by diabetic and non-diabetic haemodialysis patients.

BACKGROUND: Factors influencing the percentage of daily interdialytic weight gain (IDWG%) and their interactions in haemodialysis (HD) patients have not been well-defined, especially in diabetic patients. We analysed contributing factors for the increase of IDWG%, particularly xerostomia (oral dryness), among diabetic and non-diabetic HD patients. METHODS: We collected 3 month prospective data in 184 stable HD patients (116 non-diabetic and 68 diabetic), including assessments of xerostomia by 100 mm visual analog scales (VASs), and the unstimulated whole salivary (UWS) flow rate was measured in 91 patients by a spitting method. RESULTS: Diabetic patients have higher IDWG% (P = 0.042) and VAS oral dryness score (P = 0.021), whereas, have lower UWS (P = 0.032). In non-diabetic patients, the VAS oral dryness score, age, Kt/V and blood urea nitrogen (BUN) level correlated independently with IDWG%. In diabetic patients, the haemoglobin A(1C) (HbA(IC)) correlated significantly with IDWG% after controlling for age, Kt/V and BUN level; however, when VAS oral dryness score was introduced into the regression model, the effect of HbA(IC) became marginally significant (P = 0.073) while the VAS oral dryness score became significantly correlated with IDWG%. The increases in IDWG% per unit change in VAS oral dryness score did not show significant difference between the non-diabetic and total diabetic patients; however, it was larger in patients with HbA(IC) >or=9%. CONCLUSIONS: Xerostomia plays a significant role in increasing IDWG% among diabetic and non-diabetic HD patients. In diabetic patients, the increased IDWG% associated with the increasing HbA(1C) level is largely dependent on the severity of xerostomia, and we speculate that insulin deficiency may operate synergistically with xerostomia in increasing IDWG% in patients with HbA(1C) >or=9%.     

Serum uric acid levels show a 'J-shaped' association with all-cause mortality in haemodialysis patients.

BACKGROUND: Although elevated serum levels of uric acid are common in patients with kidney disease or in those receiving maintenance dialysis therapy, the clinical impact of uric acid on mortality in haemodialysis (HD) patients remains unclear. This work was designed to explore the predictive value of serum uric acid levels on all-cause mortality of HD patients. METHODS: We retrospectively analysed mortality rates in 146 chronic HD patients that were treated with HD three times per week at our HD unit for a period of one full year. The analysed parameters included demographic characteristics, aetiology of end-stage renal disease, co-morbid conditions, duration (at least 1 year) and delivered dose of HD, normalized protein catabolic rate, serum albumin concentration, haematocrit, serum uric acid (UA) levels and other laboratory parameters. A multivariate Cox proportional hazards model, which included adjustment for the above factors, was applied to identify the predictive value of UA levels on patient mortality. RESULTS: A Cox proportional hazards model revealed that decreased serum albumin, underlying diabetic nephropathy (DMN) and UA groups (< or =20th, 20-80th and > or =80th percentiles; P = 0.016) were all significant, independent predictors of all-cause mortality in HD patients. The hazard ratios of death were: serum albumin (per 0.5 g/dl decrease), 3.10 [95% confidence interval (95% CI), 1.80-5.34, P < 0.001]; DMN (vs non-DMN), 3.47 (95% CI, 1.25-9.59, P = 0.017); and UA groups (vs 20th to 80th percentile): < or =20th percentile, 2.98 (95% CI, 0.82-10.90, P = 0.099); > or = 80th percentile, 5.67 (95% CI, 1.71-18.78, P = 0.004). CONCLUSIONS: These preliminary observations suggest that HD patients in the lowest and highest quintiles of UA levels would face higher risk of mortality. Further studies with larger sample sizes will be needed to confirm these findings.     

Favourable long-term outcome by repeated percutaneous coronary revascularization in diabetic haemodialysis patients.

BACKGROUND: Diabetic haemodialysis patients have a high prevalence of coronary events and very high mortality rates. Percutaneous coronary intervention has become a well-established and routine procedure for coronary revascularization. This study investigated the long-term outcome of multiple repeated interventions in diabetic haemodialysis patients with coronary artery disease. METHODS: A retrospective study compared 37 type II diabetic haemodialysis patients with coronary artery disease and 26 non-diabetic patients matched for age, angiographic morphology, and devices of percutaneous intervention. All patients had undergone successful percutaneous intervention prior to enrollment. Percutaneous interventions were repeated in the event of restenosis or the development of a de novo lesion. RESULTS: Diabetic and non-diabetic patients were similar in terms of the number of follow-up angiograms (2.3+/-1.6 vs 2.4+/-1.5/patient) and interventions (2.2+/-1.4 vs 2.2+/-1.5/patient), incidence of target lesion revascularization (85 vs 82%), and number of de novo lesions (15 vs 17%). The cumulative survival rates after the initial percutaneous intervention were similar in the groups (42% vs 31% at 80 months). Cardiac death occurred in 33% of diabetic patients and 42% of non-diabetic patients. Repeated intervention (regression coefficient=16.0, P<0.001) and a lower left ventricular ejection fraction (regression coefficient=-12.9, P=0.047) were determined for the important clinical factors associated with the survival duration after initial coronary intervention. CONCLUSIONS: Multiple repeated percutaneous interventions reduce the long-term mortality of diabetic and non-diabetic haemodialysis patients with coronary artery disease similarly. Multiple repeated percutaneous coronary interventions are a viable option for controlling myocardial ischaemia and improving the long-term outcome in high-risk diabetic haemodialysis patients.     

Pre-pubertal di(2-ethylhexyl) phthalate (DEHP) exposure of young boars did not affect sperm in vitro penetration capacity of homologous oocytes post-puberty

Di(2-ethylhexyl) phthalate (DEHP), a plastic softener used in polyvinylchloride (PVC) products (e.g., plastic bags and medical equipment), has been reported to have toxic effects on animal reproduction and is considered an environmental hazard based, mostly, on rodent studies. However, the doses used in these studies are often considerably higher than that presumed in human exposure. In the present study we used young boars as model animals to assess the effects of pre-pubertal DEHP exposure on the ability of spermatozoa to penetrate homologous oocytes in vitro. Eight pairs of cross-bred male boar siblings were used. One brother in each pair became, at random, the test animal exposed to DEHP per os, three times a week, from 3 to 7 weeks of age while the other acted as the control, i.e., placebo-exposed. Semen was collected and frozen between 8 and 9 months of age and stored until spermatozoa were evaluated for their ability to in vitro penetrate in vitro-matured homologous oocytes post-thaw. Both the penetration rate and the number of spermatozoa per oocyte were considered within expected ranges for frozen boar semen of good quality. Penetration rate did not significantly differ (p > 0.05) between the groups with DEHP-exposed: 50%; control: 59%, which could be owing to a large variation between boars, and between replicates. The number of spermatozoa in the ooplasm was low and similar (p > 0.05) between the groups with DEHP-exposed: 1.5 and the control: 1.7. Under the conditions of the present experiment, pre-pubertal exposure to DEHP does not seem to cause a deleterious effect on the in vitro fertilizing ability of frozen spermatozoa post-puberty.     

Interleukin-18 is a strong predictor of hospitalization in haemodialysis patients.

BACKGROUND: Morbidity and mortality rates are high among patients with end-stage renal disease (ESRD), and recent evidence suggests that this may be linked to inflammation. Current research has also demonstrated the crucial involvement of interleukin-18 (IL-18) in inflammation. In agreement, the activity of IL-18 has been markedly up-regulated in ESRD patients. However, it has not been established whether elevated plasma IL-18 predicts outcome in haemodialysis (HD) patients. METHODS: To determine whether plasma IL-18 predicts overall hospitalization, we studied 184 ESRD patients (62% males, 58.5+/-1.0 years of age) undergoing maintenance HD treatment. The patients were followed for 12 months and were stratified by the tertiles of plasma IL-18 levels. Classic factors, such as age, body mass index, duration of HD, nutritional and inflammatory parameters, co-morbidity, dialysis adequacy, and lipid status were entered into a Cox regression model to predict hospitalization. The Kaplan-Meier method was used to analyse the cumulative proportion of hospitalization-free events. RESULTS: Significantly different hospitalization days and frequencies (P<0.05) were observed when patients were divided according to tertiles of plasma IL-18 levels. Patients were stratified according to IL-18 tertiles and analysed separately according to the hospitalization-free period. In the Kaplan-Meier model, the upper tertile of IL-18 had the highest probability of a hospitalization event during the entire follow-up period (P log rank = 0.027). In the Cox proportional hazard model, the relative risk for first hospital admission for each increase in Ln IL-18 (pg/ml) concentration was associated with a 1.709 (95% CI, 1.114 to 2.620; P = 0.014) increase in the risk for future hospitalization events. CONCLUSIONS: The present study demonstrated a strong predictive value of elevated IL-18 levels for poor outcome in HD patients.     

Association between cardiovascular autonomic neuropathy and left ventricular hypertrophy in diabetic haemodialysis patients.

BACKGROUND: Patients with diabetic nephropathy are likely to have neurological complications including cardiovascular autonomic dysfunction, which is related to increased risk of mortality. We investigated whether cardiovascular autonomic neuropathy is associated with left ventricular hypertrophy (LVH) in diabetic haemodialysis patients. METHODS: Holter electrocardiography was carried out for 24 h with time and frequency domain analyses of heart rate variability in 154 diabetic (age 62+/-11 years) and 63 non-diabetic haemodialysis patients (62+/-10 years). The left ventricular mass index (LVMI) was determined by echocardiography. We used the percentage of differences exceeding 50 ms between adjacent normal RR intervals (pNN50) in time domain analysis and the power in the high-frequency range (HF: 0.15-0.40 Hz) in frequency domain analysis as indicators of parasympathetic activity. RESULTS: The mean LVMI was greater in diabetic than in non-diabetic patients (168+/-63 vs 144+/-54 g/m(2), P<0.01). LVMI inversely correlated with pNN50 (r = -0.270, P = 0.0007, n = 154) and HF (r = -0.277, P = 0.0005, n = 154) in diabetic patients, but not in non-diabetic patients. By multiple logistic analysis, LVH was strongly associated with pNN50 (odds ratio 0.088; 0, <2%; 1, >/=2%) and HF (odds ratio 0.058; 0, <500 ms(2); 1, >/=500 ms(2)) in diabetic patients. CONCLUSIONS: Impaired parasympathetic activity, which indicates cardiovascular autonomic neuropathy, was associated with the presence of LVH in diabetic haemodialysis patients. The co-existence of cardiovascular autonomic neuropathy and LVH may be one of the key factors for the high incidence of cardiovascular events in diabetic haemodialysis patients.     

Correlation between parathyroid hormone, bone alkaline phosphatase and N-telopeptide of type 1 collagen in diabetic and non-diabetic haemodialysis patients

BACKGROUND: Haemodialysis (HD) patients with diabetes mellitus often have renal osteodystrophy (ROD) characterized by reduced bone turnover, but little is known about the correlation between bone formation and bone resorption in this population. METHODS: The authors measured serum parathyroid hormone (PTH), bone alkaline phosphatase (BAP), N-telopeptides of type 1 collagen (NTx) and fasting glucose in 48 patients with diabetic nephropathy (DN) and 80 patients with glomerulonephritis (non-DN) who had received or=5 years HD (r = 0.568) this correlation was similar to that in the non-DN group (r = 0.653), whereas there was no significant correlation in those receiving <5 years HD. Patients receiving >or=5 years HD had a comparable glucose level (111.1 +/- 19.2 mg/dL) to the non-DN group, whereas those receiving <5 years had a higher level (196.1 +/- 53.1 mg/dL). CONCLUSION: Differences in the interaction between bone cells between DN and non-DN patients are one potential cause of lower bone turnover in the former group. Research of this correlation is needed to increase understanding of the complexities of bone metabolism in DN patients.     

The evaluation of immune responses to hepatitis B vaccination in diabetic and non-diabetic haemodialysis patients and the use of tetanus toxoid

Aim: The aim of this study was to investigate whether haemodialysis (HD) patients suffering from diabetes mellitus could be considered at risk for the development of the protective antibodies to hepatitis B (HB) vaccination and, to evaluate the effectiveness of tetanus toxoid (TT) administrated 2 days before HB vaccination. Methods: Forty-nine HD patients were divided into two groups: group A (19 diabetic patients) and group B (30 non-diabetic patients). A dose of 40 μg recombinant HB vaccine was injected intramuscularly to the patients at 0, 1, 2 and 6 months. Results: After the completion of the course, the patients in group A were found to have a lower protective antibody rates than the patients in group B (57.8% vs 70%) (P > 0.05). After the administration of additional booster doses during 12 months, the protective antibody to hepatitis B surface antigen (HBsAb) levels were detected in 78.9% and 96.6% of the patients in group A and group B, respectively (P > 0.05). The patients not having protective HBsAb levels were administered TT and HB vaccines, and after course, all of them have produced protective HBsAb levels. Conclusion: The present study showed that diabetic patients on HD may carry a greater risk of not seroconverting than non-diabetic ones for antibody response to HB vaccination. The use of TT 2 days before HB vaccination may be a useful and effective method of enhancing the immune response to HB vaccination, especially in the patients with diabetes mellitus on HD.     

A registry of haemodialysis patients and the progress of haemodialysis services in Lithuania.

Background. Until 1990, haemodialysis (HD) in Lithuania wasunderdeveloped, but after independence, development of HD started.Until 1996, no precise data about HD patients in Lithuania wereavailable. In order to create a registry of HD, we started tocollect data about dialysis services and HD patients in 1996.Every collection of data was followed by distribution and discussionof the results within the nephrological community. This studydescribes the changes of Lithuanian HD between 1996–2002. Methods. Between 1996 till 2002 all HD centres in Lithuaniawere annually visited and data were collected about all HD patients(response rate of 100%). The evaluation of the results duringour observational study was made according to the European BestPractice Guidelines. During annual conferences for nephrologists,the guidelines and data of our HD registry were presented. Results. There was an increase in the number of HD stations(from 25 p.m.p. to 75 p.m.p., P<0.001), in HD patients (from60 p.m.p. to 237 p.m.p., P<0.001) and in the incidence ofnew HD patients (from 54.3 p.m.p. to 103 p.m.p., P<0.01).The mean age of HD patients increased from 47.2±16.1years in 1996 to 56.0±14.9 in 2002 (P<0.001). Themain underlying cause of ESRD was chronic glomerulonephritis,but its rate decreased from 54.5% in 1996 to 27.5% in 2002 (P<0.001).The percentage of diabetics increased from 7.1% to 16.4%, P<0.05,and in hypertensive nephropathy from 3.1% to 10.9%, P<0.05.We observed improvement of the quality of HD in Lithuania duringthese 5 years. The percentage of patients on bicarbonate HDincreased from 7.1% in 1996 to 100% in 2002 (P<0.001). Thepercentage of patients receiving more than 12 h HD/week increasedfrom 30.8% in 1996 to 53.5% in 2002 (P<0.001). The mean Kt/Vin 1999 was 0.81±0.53, but it increased in 2002 to 1.22±0.27,P<0.001. In 2002, 84.6% of all HD patients were examinedfor HB_sAg, 82.3% for anti–HCV, 31.2% for anti-HB_s and57.1% for anti-HB_c. The percentage of patients receiving phosphatebinders increased from 65.2% in 1996 to 84.4% in 1997 and 90.5%in 2002. Serum parathyroid hormone (PTH) levels were measuredin 27.3% of HD patients in 1999 but in 85.2% of patients in2002. The mean haemoglobin (Hb) concentration increased from92±15.4 g/l to 105±14.7 g/l; the percentage ofpatients with Hb>100 g/l increased from 27.5% to 64% in 2001.The percentage of HD patients receiving epoetin was 94.6% in2001 as compared with 78% in 1997. There was a marked increasein the use of intravenous iron (from 7.5% patients in 1997 to70.8% in 2000). The mean weekly dose of Epo was lower in HDpatients receiving intravenous iron than in patients receivingoral iron. Conclusions. Over the period of 1996–2002 the HD servicessignificantly expanded in Lithuania. The introduction of EuropeanBest Practice Guidelines and the establishment of a HD registrywith feedback of the results stimulated the significant progressin the quality of HD and in the management of the patients.     

The high incidence of left atrial appendage thrombosis in patients on maintenance haemodialysis

Background. The incidence of intracardiac thrombosis in haemodialysispatients has not been studied. Here we determined the incidencein end-stage renal disease patients on maintenance haemodialysis. Methods. Transoesophageal echocardiography was performed in215 patients (125 males, 90 females; mean age 60 ± 9years). Any potential candidate with current or past chronicor intermittent atrial fibrillation or with cardiovascular diseaseswas excluded from the study. Results. Thrombi were found in the left atrial appendages in71 out of 215 subjects (33%). Based on multiple logistic regressionanalyses, the probability of finding a thrombus was found tobe increased in patients on chronic antiplatelet therapy (oddsratio 4.268) and in those with diabetes mellitus and a low haematocrit(0.3; odds ratio 7.173). Other clinical parameters, includinggender, age, duration of haemodialysis, blood pressure, leftventricular dimension, smoking habit or type of anticoagulationduring dialysis, were not associated with the incidence of leftatrial appendage thrombosis. Conclusions. Maintenance haemodialysis patients have a highincidence of left atrial appendage thrombosis. Either chronicuse of antiplatelet drugs or the background conditions requiringantiplatelet therapy, and the concomitant presence of diabetesmellitus and a low haematocrit may be involved in left atrialappendage thrombosis.     

Blood 8-hydroxy-2'-deoxyguanosine is associated with erythropoietin resistance in haemodialysis patients.

BACKGROUND: 8-Hydroxy-2'-deoxyguanosine (8-OHdG), a product of oxidized DNA, is increased in haemodialysis (HD) patients, but the clinical relevance of enhanced 8-OHdG production in these patients remains unknown. METHODS: We cross-sectionally measured serum 8-OHdG in 73 patients on maintenance HD (age 68+/-2 years, time on HD 85+/-11 months, male/female=42/31), and examined the relationship between blood 8-OHdG and the severity of renal anaemia and the weekly dosage of recombinant human erythropoietin (rHuEPO). RESULTS: There was a significant increase in serum 8-OHdG in HD patients compared with normal subjects. Serum 8-OHdG was positively correlated with the patients' age (r=0.231, P<0.05) but not with the duration of HD. Serum 8-OHdG was significantly higher in diabetic subjects than in non-diabetic subjects (P<0.05). Serum 8-OHdG had a significant inverse correlation with haemoglobin (Hb) (r=-0.526, P<0.01) but a positive correlation with the rHuEPO dose (r=0.443, P<0.01) and the ratio of the weekly rHuEPO dose divided by Hb (r=0.487, P<0.01). Serum 8-OHdG was not correlated with inflammatory and nutritional parameters. CONCLUSIONS: These findings suggest that the elevation of circulating 8-OHdG may be associated, at least in part, with rHuEPO resistance in HD patients.     

Low-molecular-weight heparin (LMWH): influence on blood lipids in patients on chronic haemodialysis

A low-molecular-weight heparin (LMWH) has been compared to conventionalheparin in haemodialysis in a 12-month study. In a group of22 patients who had been on chronic haemodialysis for longerthan 12 months, the conventional, unfractionated heparin wasreplaced by a low-molecular-weight analogue (LMWH) (Fragmin,Kabi-Pharmacia Erlangen) for 6 months. Baseline values of lipoproteinprofile prior to the intervention were compared with resultsobtained after 2, 4 and 6 months of LMWH. Control values wereobtained 3 and 6 months after switching back to conventionalheparin. During the LMWH treatment total cholesterol decreasedsignificantly. This coincided with a significant decrease inLDL cholesterol and a minor decrease in total HDL cholesterol.There was no noticeable change in the HDL cholesterol subfractions.The decrease of LDL and HDL was accompanied by a distinct andcontinuous decrease of apolipoprotein B throughout the LMWHperiod while the apolipoprotein Al declined during the first2 months and then stabilized at this lower value. Triglyceridesincreased significantly during the first 2 months and then reboundedto the initial values by the end of the LMWH treatment period.After switching back again to conventional heparin the lipoproteinparameters returned to the starting values. We conclude thatthe long-term use of low-molecular-weight heparin instead ofconventional heparin for anticoagulation during dialysis maycontribute to a reduction of the cardiovascular risk factorsof haemodialysis patients.     

Carotid atherosclerosis is a predictor of coronary calcification in chronic haemodialysis patients.

BACKGROUND: Coronary artery calcification scores (CACS) calculated by electron beam computed tomography (EBCT) have been correlated with atherosclerotic burden in the non-uraemic population. However, the validity of this test in chronic haemodialysis patients (HD) is currently uncertain. In the present cross-sectional study, associations between carotid atherosclerosis and coronary calcification in HD patients are investigated. METHODS: We studied 79 chronic HD patients (39 male, 40 female; mean age, 45+/-12 years). The mean time on HD was 68+/-54 months (range, 6-187 months). In these patients, we measured serum calcium, phosphorus, total cholesterol, cholesterol subgroups and iPTH levels. EBCT, echocardiography, and high-resolution B-mode carotid Doppler ultrasonography were also performed. RESULTS: Plaque-positive HD patients had significantly higher CACS than plaque-negative patients (851+/-199 vs 428+/-185, mean+/-SE, P = 0.006). Coronary calcification scores were correlated with serum phosphorus (r = 0.37; P = 0.001). Only 8 of the 24 HD patients without coronary calcification had carotid plaques (33%), whereas 34 of the 53 patients with coronary calcification had carotid plaques (64%) (P = 0.015). Carotid plaque scores were correlated with CACS (r = 0.40; P = 0.001). A stepwise linear regression (model r = 0.72; P<0.001) revealed that CACS (log-transformed data of CACS) was associated with age (P<0.001), time on dialysis (P = 0.004), serum phosphorus level (P = 0.016) and carotid plaque scores (P = 0.037). CONCLUSIONS: Atherosclerosis is independently associated with coronary artery calcification and with hyperphosphataemia in chronic HD patients. CACS appeared to be predictive of both coronary atherosclerosis and carotid atherosclerosis.     

Longitudinal validation of a modified Edmonton symptom assessment system (ESAS) in haemodialysis patients.

BACKGROUND: Health-related quality of life (HRQL) is an important outcome in the treatment of end-stage renal disease (ESRD) and appears to be highly associated with patient self-report of symptom burden. This study examines the longitudinal validity of the modified Edmonton symptom assessment system (ESAS) to determine the impact of change in symptom burden on the change in HRQL of haemodialysis (HD) patients. METHODS: 261 haemodialysis patients completed the Kidney Disease Quality of Life-Short Form (KDQOL-SF) and the ESAS at baseline and at 6 months. RESULTS: The change in overall symptom distress score was strongly correlated with the change in KDQOL-SF subscales symptom/problem list (R=-0.73, P<0.01), effects of kidney disease (R=-0.53, P<0.01), and burden of kidney disease (R=-0.46, P<0.01) as well as overall physical health composite (R=-0.58, P<0.01) and overall mental health composite (R=-0.68, P<0.01). The change in symptom burden, as described by the ESAS, accounted for 46% of the change in the mental HRQL and 34% of the change in the physical HRQL. There was no correlation between baseline demographics, comorbidity or changes in biochemical markers with changes in either the ESAS or HRQL scores. CONCLUSION: The modified ESAS is a simple, valid tool for the longitudinal assessment of physical and psychological symptom burden in ESRD and is responsive to change in HD patients. The use of this symptom assessment scale and improved management of patient symptoms would be expected to positively impact HD patients' HRQL.     

Atherogenic lipid profile and lipoprotein(a) in relation to serum albumin in haemodialysis patients

Malnutrition in haemodialysis patients is associated with anincreased cardiovascular mortality. Lipoprotein(a) (Lp(a)) isan independent risk factor for atherosclerotic cardiovasculardisease. To evaluate the relationship between atherogenic lipidprofile and serum albumin in haemodialysis patients we measuredfasting serum Lp(a), total cholesterol (TC), high-density lipoprotein-cholesterol(HDL-C), triglyceride (TG), apoprotein A-I (ApoA-I), apoproteinB (ApoB) and albumin in 101 haemodialysis patients and in 46healthy subjects as a control. The haemodialysis patients weredivided into two groups on the basis of the level of serum albumin:group I, serum albumin <4.0 g/dl; group II, serum albumin>4.0 g/dl. Haemodialysis patients as a whole (n=101, 17.1 mg/dl (10.3–30.9))had higher serum Lp(a) than normal subjects (n = 46, 10.5 mg/dl(3.3–24)) (P<0.05). Lp(a) in group I (n = 38, 27.1mg/dl (14.6-35.0)) was significantly higher than in group II(n = 63, 14.5mg/dl(7.7–21.7), P<0.005) and normal subjects(P<0.0005). However, serum Lp(a) level of group II was notdifferent from those of normal subjects. There was a significantinverse correlation between serum Lp(a) and albumin concentration(r_s = -0.26, P<0.01). TC, TG, HDL-C, ApoA-I, ApoB, TC/HDL-C,and ApoA-I/ApoB ratios were not different between group I andgroup II. No correlation was found between albumin and TC, TG,HDL-C, TC/HDL-C, and ApoA-I/ApoB ratios. These results suggest that Lp(a) could be responsible for anincreased cardiovascular mortality in haemodialysis patientswith malnutrition.     

Lipoprotein (a) in patients on maintenance haemodialysis and continuous ambulatory peritoneal dialysis

Lipoprotein (a) concentrations and apoprotein (a) isoforms weremeasured in 99 haemodialysis and 79 peritoneal dialysis patientsand compared with a normal population. Peritoneal dialysis patientsdemonstrated a threefold and haemodialysis a twofold increasein median Lp(a) values compared to controls (P0.001). The peritonealdialysis group had significantly more patients with Lp(a) valuesgreater than 30 mg/dl compared to controls, (53% versus 22%P0.001). In addition both patient groups demonstrated significanthypertriglyceridaemia (P0.001), reduction in HDL (P0.001) andelevation of the cholesterol/HDL ratio (P0.001) compared withcontrols. Peritoneal dialysis patients also demonstrated significanthypercholesterolaemia (P0.003). Lipoprotein (a) concentrations are considerably elevated inpatients on maintenance dialysis and this occurs in additionto the typical lipoprotein disturbances. This elevation mayincrease vascular risk, particularly in the peritoneal dialysisgroup who also have hypercholesterolaemia and reduced HDL.     

History of acute coronary events during the predialysis phase of chronic kidney disease is a strong risk factor for major adverse cardiac events in patients initiating haemodialysis.

An initial acute coronary event is an important predictor of future cardiovascular events and all-cause mortality in patients with chronic kidney disease. The aim of this study was to identify an association between acute coronary events during the predialysis phase of chronic kidney disease and major adverse cardiac events in patients initiating maintenance haemodialysis. One hundred sixty-nine patients initiating maintenance haemodialysis were enrolled in this study. In the subsequent follow-up period (median: 60 months), subjects experiencing an initial major adverse cardiac event were compared with those who did not have such an event on the basis of several clinical parameter measurements at the end of the predialysis phase. A history of an acute coronary event was present in 21 patients (12%), and these patients had a higher cumulative major adverse cardiac event rate during follow-up than subjects without a history of acute coronary event (75 vs 19%, P < 0.001). Multivariate Cox regression analysis showed that the following four parameters independently predicted major adverse cardiac events: a history of acute coronary events (hazard ratio, 4.19; 95% confidence interval, 1.61 to 8.13; P < 0.001), presence of diabetes (hazard ratio, 7.70; 95% confidence interval, 3.29 to 23.83; P < 0.001), each 1 g/dl increment in haemoglobin (hazard ratio, 1.57; 95% confidence interval, 1.23 to 2.34; P = 0.002) and each 1 kg/m(2) decrement in body mass index (hazard ratio, 0.80; 95% confidence interval, 0.72 to 0.98; P = 0.005). In conclusion, these results suggest that a history of acute coronary events, presence of diabetes, increased haemoglobin concentration or decreased body mass index at the end of the predialysis phase were significantly associated with the occurrence of a major adverse cardiac event in patients initiating maintenance haemodialysis.