Is residual renal function and better phosphate control in peritoneal dialysis an answer for the lower prevalence of valve calcification compared to hemodialysis patients?

Introduction

Cardiac valve calcification (CVC) has long been regarded as a consequence of abnormal calcium–phosphate metabolism in uremic patient associated with increased cardiovascular mortality in this population. We evaluated the association between residual renal function (RRF), phosphate level and valve calcification in peritoneal dialysis (PD) and hemodialysis (HD) patients.

Methods

We studied 30 stable PD patients (60 % males; mean age 57 ± 12.36 years) and 34 HD patients (58.8 % males; mean age 50.8 ± 10.4 years) on renal replacement therapy (RRT) from 6 up to 36 months. The presence of CVC was assessed by standard bi-dimensional echocardiography. RRF was calculated by standard technique.

Results

Valve calcification was more frequently found in HD compared to PD patients (70.6 vs 29.4 %, p = 0.007). Significantly lower phosphate [1.38 ± 0.41 versus 1.99 ± 0.35 mmol/L (p < 0.0001)], a higher RRF [4.09 ± 2.09 ml/min vs 0.62 ± 0.89 ml/min (p < 0.0001)], and older age [57 ± 12.36 years vs 50.8 ± 10.4 years (p = 0.033)] were observed in PD as compared to HD patients. The logistic regression analysis for the presence of valve calcification when adjusted for age and diabetes, with type of therapy, serum phosphate, RRF, CRP, and serum albumin as variables in the model, revealed significant association between the presence of valve calcification and age and RRF. The correlation between phosphate levels and RRF was even stronger in PD patients than in HD patients (r = ?0.704; p = 0.0001) vs (r = ?0.502; p = 0.02).

Conclusions

Our study shows that the residual renal function in PD patients contributes significantly to the maintenance of phosphate balance and may explain the lower prevalence of valve calcification in PD patients compared with HD patients in the period up to first 3 years under renal replacement therapy.     

Early referral and planned initiation of dialysis: what impact on quality of life?

BACKGROUND: Early patient referral correlates with improved patient survival on dialysis. We examine whether early referral and a planned first dialysis affect quality of life (QoL). METHODS: All patients commencing dialysis in nine centres in seven European countries between 1 July 1998 and 31 October 1999 were recruited. Definitions: early referral=followed by a nephrologist >1 month before first dialysis (<1 month=late referral); planned=early referral and previous serum creatinine >300 micro mol/l and non-urgent first dialysis (early referral and no creatinine >300 micro mol/l or urgent first dialysis=unplanned). QoL was measured at 8 weeks using a visual analogue scale (VAS) and Short Form 36 (SF-36). RESULTS: VAS was significantly higher in early referral patients [mean (SD) 58.4 (20) vs 50.4 (19), P=0.005], particularly if the first dialysis was planned [60.7 (20) vs 54.2 (20), P=0.03]. Planned patients also had higher SF-36 mental summary scores [45.4 (12) vs 39.7 (11), P=0.003], role emotional scores [58.0 (43) vs 30.9 (38), P=0.003], and mental health scores [63.7 (24) vs 54.6 (22), P=0.01] than unplanned patients. Adjusting for centre and other confounding variables showed that having a planned first dialysis had an independent effect on QoL (VAS, and the SF-36's mental summary score, physical functioning, role physical, general health, role emotional and mental health). Early referral had no independent effect on QoL. Socio-economic status had an important positive effect on physical QoL. CONCLUSIONS: While the effect of early referral to a nephrologist on QoL appeared centre dependent, a smooth transition onto dialysis was associated with significantly better early QoL, independent of other variables.     

Kosovo 2002: the epidemiology of renal disease and the impact of 1999 Kosovo war on end-stage renal disease patients.

Sir, Kosovo is situated in the Balkans and shares its borders withAlbania, the Federal Republic of Yugoslavia (Serbia, Montenegro)and the Former Yugoslav Republic of Macedonia (FYROM). Profoundpolitical and social changes during the last decade in the formerYugoslavia have led to the independence of Kosovo in 1999 andhave established it under the protection of     

The potential effect of cardiac function on pulmonary hypertension,other risk factors,and its impact on survival in dialysis patients

Introduction

Pulmonary hypertension (PH) is a recently recognized as a complication of chronic kidney disease and end-stage renal disease. The pathogenesis of pulmonary hypertension in this group of patients is not fully understood, probably due to the interaction of multiple aspects of the altered cardiovascular physiology and also hormonal and metabolic disorders. The present study aimed to determine the prevalence of PH, correlation with cardiac function and other risk factors and its impact of survival in chronic hemodialysis and peritoneal dialysis patients.

Methods

We studied 125 stable hemodialysis and peritoneal patients (females 40%, mean age 52.42?±?11.88 years) on renal replacement therapy (RRT) for more than 3 months with a follow up 2 years. Demographic information, clinical characteristics, blood test, and thoroughly echocardiographic evaluation at the optimal dry weight were collected. After conventional echocardiographic examination, tissue Doppler echocardiographic (TDE) examination was performed to evaluate global and regional myocardial systolic as well as diastolic function, and pulmonary hypertension. PH was defined as systolic pulmonary artery pressure (sPAP)?≥?35 mmHg. To rule out secondary PH, patients with pulmonary disease, collagen vascular disease, and volume overload at the time of echocardiography were excluded. Variables were compared between two groups—subjects with PH and non-PH. Logistic regression analysis was used to evaluate the risk factor for PH and its impact on survival.

Results

According to the echocardiographic findings, PH was found in 28% (35 patients) of all patients. Mean PH was 33.46?±?5.38 mmHg. The higher level of higher parathormone (PTH), C-reactive protein (CRP) and E/E’ average, lower left ventricular ejection fraction (EF), peak systolic velocity at the lateral mitral annulus (MASa) and the peak systolic velocity at the lateral tricuspid annulus (TASa) were found predictor of PH. The cardiovascular mortality rate was 15.5%. Patients evaluated with PH have a significantly lower cardiovascular survival rate [Long Rank (Mantel–Cox) p?=?0.0001]. In ROC analysis for CV mortality, the area under the curve (AUC) for PH and CRP was found 0.8; for LVM-I, E/E’ and PP, AUC?=?0.76; 0.75; 0.72 respectively while the inverse relationship was found with MASa and TASa with AUC?=?0.66 and 0.95 respectively.

Conclusion

Our study shows that PH is frequent in dialysis patients. It is influenced by inflammation, CKD-MBD biomarkers associated with diastolic and also systolic left and right ventricle dysfunction. Pulmonary hypertension, inflammation, vascular stiffness, and left ventricular hypertrophy are interrelated and all contribute to cardiovascular morbidity and mortality among dialysis patients. Easy to implement, cardiac imaging at the bedside and in outpatient clinics offers a positive perspective in early diagnosis of cardiac abnormalities and immediate approach to this condition, so is highly recommended in the dialysis population.

     

Impact of liver cysts in progression of polycystic kidney disease

Introduction

Liver involvement is the most frequent extrarenal manifestation in autosomal dominant polycystic kidney disease (ADPKD). We studied the impact of liver cysts on renal function in our patients with ADPKD.

Methods

a retrospective observational from January 2002 to January 2009 e divided 138 patients with ADPKD into two groups: one group of 68 patients without liver cysts and another group of 70 patients with liver cysts. Renal function was considered to be impaired when the creatinine clearance was less than 60 ml/min. Differences were considered significant at the P<0.05 level.

Results

The liver cysts were more frequent in female patients. No renal failure survival difference was found between patients in both groups (P=0.05). Female patients with liver cysts and three or more pregnancies had a worse survival rate than female patients with liver cysts with fewer than three or no pregnancies (P<0.01).

Conclusion

Our study showed that there was no renal failure survival difference between patients with liver cysts compared with those without liver cysts. Female patients with liver cysts and three or more pregnancies had a greater risk of developing end stage renal disease when compared with patients with liver cysts and fewer than three or no pregnancies.     

A major milestone in the history of Albanian kidney transplant

Abstract:  Albania is a young Democracy emerging from under 40 yr of dictatorship. During this era Albanians were subjected to isolation, purges, shortages, repression of civil, political and religious rights. This resulted in the least developed healthcare system in Europe. After the mid 90s, there have been relentless attempts to modernize Albania. Recently an international medical team collaborated with an Albanian team of physicians to perform the first successful renal transplant. With continued cooperation and perseverance developing a transplant program in Albania is within reach.     

Influence of Residual Renal Function in Carotid Modeling as a Marker of Early Atherosclerosis in Dialysis Patients

Atherosclerosis is frequently present in patients with chronic kidney disease (CKD) treated with dialysis. We evaluated the association between residual renal function (RRF), phosphate level, inflammation and other risk factors in carotid modeling as a marker of early atherosclerosis in peritoneal dialysis (PD) compared with hemodialysis (HD) patients. We studied 39 stable PD and 53 HD patients on renal replacement therapy (RRT) for 3 to 36 months duration. B‐mode ultrasonography was used to determine carotid artery intima media thickness (CIMT). We classified patients with atherosclerosis if they have CIMT >10 mm and or presence of plaque. Out of our total dialysis population studied of 92 patients, 16.3% were diabetics and 57.6% were on hemodialysis. Expectedly, PD patients had a higher RRF (P < 0.001), 24 h urine volume (P < 0.001); C‐reactive protein (P = 0.047), and a lower serum phosphate (P = 0.01), PTH (P < 0.05), alkaline phosphatase (P < 0.05), and albumin levels (P < 0.001) compared to hemodialysis patients. Atherosclerosis was found in 66.3% of patients and in 100% of a diabetic population. There was no significant difference in the presence of atherosclerosis between PD and HD patients [56.4 vs 73.6% HD, respectively]. Multiple regression analysis showed age, diabetes, HD modality, RRF, phosphate, PTH and pulse pressure as independent parameters associated with atherosclerosis. Apart from the traditional risk factors like age and diabetes, our study showed a link of atherosclerosis with metabolic abnormalities secondary to renal failure. We demonstrated a novel, independent association between RRF and atherosclerosis, underlining the importance of preservation of the RRF in dialysis patients.     

Prevalence of nephrolithiasis in polycystic kidney disease

We aim to define the prevalence of nephrolithiasis, the impact of anatomic and metabolic factors to stone formation and prognosis of patients with autosomal dominant polycystic kidney disease in Albania. We included 200 patients with autosomal dominant polycystic kidney from 2002 to 2009. The patients underwent X-ray, renal ultrasonography. We performed the metabolic evaluation of blood and urine. Survival times were calculated as the time to dialysis, transplantation, or death. Kaplan-Meier product-limit survival curves were constructed. Log rank test was used to compare the survival curves. Nephrolithiasis was present in 116 of our patients with autosomal dominant polycystic kidney disease (58%), with a mean age 46.4±5.7 years. Sixty five patients with kidney stones (56%) were women. The stones were composed primarily of urate (47%) and calcium oxalate (39%), and other compounds 14%. In 40% of patients the presence of stones was associated with a history of urinary tract infections and flank pain. In our study the prevalence of nephrolithiasis is 58%, higher than it reported in literature. Except anatomic and metabolic factors, there are other contributor factors to stone formation in our patients such socioeconomic status of patients, geographic zones and dietary habits.