Normalized protein nitrogen appearance is correlated with hospitalization and mortality in hemodialysis patients with Kt/V greater than 1.20.

OBJECTIVES: Normalized protein nitrogen appearance (nPNA), also known as protein catabolic rate (nPCR), reflects the daily protein intake in maintenance hemodialysis (MHD) patients. Several studies indicate that nPNA and Kt/V correlate with clinical outcome and also with each other. Thus, the relationship between low nPNA and poor outcome could be due to uremia, low Kt/V or due to reported mathematical coupling between nPNA and Kt/V. We therefore investigated whether nPNA is associated with outcome in patients who have adequate or high Kt/V. DESIGN: Prospective cohort. SETTINGS: Outpatient dialysis unit affiliated with a tertiary-care community medical center. PATIENTS: From a pool of 135 MHD outpatients in one dialysis unit, 122 patients with a delivered, Kt/V(sp)>1.20, independent of their residual renal function, were evaluated. Patients (61 women, 61 men), aged from 23 to 89 years (53.4+/-14.0 years)(+/-SD), had been undergoing MHD for one month to 17 years. INTERVENTION: Review of laboratory values and clinical outcome. MAIN OUTCOME MEASURES: Twelve-month mortality and hospitalization. RESULTS: Delivered Kt/V(sp) ranged from 1.23 to 2.71 (1.77+/-0.34), nPNA from 0.5 to 2.15 (1.13+/-0.29 g/kg/day), and serum albumin, from 1.9 to 4.6 (3.76+/-0.37 g/dL). During the 12-month follow-up, 55 patients were hospitalized overnight at least once; 12 patients died; 5 patients underwent renal transplantation, and 6 patients left the study. The nPNA and Kt/V(sp) did not correlate significantly (r=.09) except when analysis was limited to Kt/V values < 1.5 (r=.54). Serum nPNA and albumin were the only variables with statistically significant correlations with both mortality and 3 measures of hospitalization (H): total days of H (H(D)), total number of H (H(F)), and time to first H (H(T)). The case-mix adjusted correlations for serum albumin and nPNA versus total days (r(HD)) and frequency of H (r(HF)) were significant, and Cox analysis based on H(T) and time to death resulted in significant odds ratios for each standard deviation decrement for both serum albumin and nPNA. Serum total iron binding capacity (TIBC) and creatinine concentrations also correlated with some but not all outcome measures: lower serum concentrations of these values were each significantly associated with poor clinical outcomes. CONCLUSIONS: Both nPNA and serum albumin predict prospective hospitalization and mortality in MHD patients with Kt/V > 1.20. Serum TIBC and creatinine concentrations appear to have association with some outcome measures as well. These data are consistent with the possibility that protein intake affects the clinical course even in the setting of an adequate to high hemodialysis dose. Studies based on randomized assignments to different protein intakes would be helpful to confirm these conclusions.     

Urinary biomarkers of tubular injury to predict renal progression and end stage renal disease in type 2 diabetes mellitus with advanced nephropathy: A prospective cohort study

BackgroundNovel potential tubular biomarkers in diabetic nephropathy could improve risk stratification and prediction. The study aimed to evaluate the association of tubular damage markers with rapid renal progression and incidence of end stage renal disease (ESRD) in type 2 diabetes (T2DM).MethodsA prospective cohort study, involving a total of 257 patients with T2DM, was included. The baseline values of urine albumin, cystatin-C, angiotensinogen, kidney injury molecule-1 (KIM-1) and neutrophil-gelatinase associated lipocalin (NGAL) were measured. The composite outcomes included a rapid glomerular filtration rate (GFR) decline or incident of ESRD at 3-year follow-up.Main findingsThe composite outcomes were noted in 26.1%. Using univariate followed by multivariate COX proportional hazard regression analysis, the patients with highest quartiles of urine cystatin-C (HR 2.96, 95% CI, 1.38–6.35), urine angiotensinogen (HR 2.93, 95% CI, 1.40– 6.13) urine KIM-1 (HR 2.77, 95% CI, 1.27-6.05) and urine NGAL (HR 2.53, 95% CI, 1.11-5.76) were significantly associated with rapid renal progression when compared with the patients with the lowest quartiles of all tubular biomarkers.ConclusionsPatients with T2DM with high levels of baseline urine tubular biomarkers (cystatin-C, angiotensinogen, KIM-1 and NGAL) had a greater incidence of ESRD and rapid GFR decline.     

Age-related decline in serum parathyroid hormone in maintenance hemodialysis patients is independent of inflammation and dietary nutrient intake.

BACKGROUND: There is a direct relationship between age and serum parathyroid hormone (iPTH) in the normal population, but several studies suggest this relationship is reversed in maintenance hemodialysis (MHD) patients. The pathophysiologic basis of this age-related decline in serum iPTH levels remains unclear, although others have proposed that it is related to low dietary phosphorus intakes. METHODS: We conducted a prospective, cross-sectional evaluation of the relationship between age and serum iPTH levels and factors affecting this relationship. All participating subjects were asked to complete a 3-day food diary. The charts were reviewed to obtain routinely measured laboratory values over the preceding 3 months, and serum was collected to measure markers of systemic inflammation. RESULTS: Ninety-two MHD patients (47 men; age, 51.3+/-14.9 [standard deviation] years; median dialysis vintage, 25.8 months) were studied. Age was inversely correlated with both serum phosphorus and iPTH; these relationships remained significant even when the data were adjusted for diabetic status, dialysis vintage, and dietary nutrient intake. However, there were no associations of age, serum phosphorus, or iPTH with dietary intakes of protein, calories, phosphorus, or calcium either on univariate or multivariate analyses. Markers of systemic inflammation (serum C-reactive protein, and alpha1 acid glycoprotein) did not correlate with age, serum phosphorus, and iPTH or dietary nutrient intake. On the other hand, serum albumin, which may reflect long-term effects of inflammation, did correlate inversely with age and positively with serum phosphorus. CONCLUSIONS: Our cross-sectional study confirms that there are age-related lower levels of both serum phosphorus and iPTH in MHD patients. The mechanisms regarding the inverse relationship between serum phosphorus and age are unclear, but may not be caused by low phosphorus intake or systemic inflammation. In elderly MHD patients, the reduced responsiveness of parathyroid glands may be related to age-dependent accumulation of uremic toxins.     

Efficacy of mulberry leaf tablets in patients with mild dyslipidemia

Mulberry leaf is well known for its several biological effects. The purpose of this study was to evaluate the hypolipidemic effect of mulberry leaf in non‐diabetic patients with mild dyslipidemia. A within‐subjects research design was conducted at the out‐patient clinic in Thailand. Twenty‐three patients who met the NCEP ATP III criteria guideline for dyslipidemia and failed a 4 week diet therapy were enrolled and assigned to receive three tablets of 280 mg mulberry leaf tablet three times a day before meals for a period of 12 weeks. Routine blood analyses including lipid parameters and liver function tests were performed every 4 weeks. At 4 and 8 weeks of mulberry leaf tablet therapy, triglyceride was significantly decreased by 10.2% (p < 0.05) and 12.5% (p < 0.05), respectively, from baseline. At the end of the study, total cholesterol, triglyceride and LDL were significantly decreased by 4.9% (p < 0.05), 14.1% (p < 0.05) and 5.6% (p < 0.05), respectively, from baseline, whereas HDL was significantly increased by 19.7% (p < 0.05). Even though some patients experienced side effects such as mild diarrhea (26%), dizziness (8.7%) or constipation and bloating (4.3%), mulberry leaf tablet therapy is still capable and safe in reducing cholesterol levels and enhancing HDL in patients with mild dyslipidemia. Copyright © 2010 John Wiley & Sons, Ltd.