The relationship between epicardial adipose tissue and malnutrition, inflammation, atherosclerosis/calcification syndrome in ESRD patients

Predictive role of cardiac valvular calcification in all-cause mortality of Chinese initial haemodialysis patients: a follow-up study of 4 years

BACKGROUND

Cardiac valvular calcification (CVC) is prevalent in haemodialysis (HD) patients. Its association with mortality in Chinese incident haemodialysis (IHD) patients remains unknown.

METHODS

A total of 224 IHD patients who had just begun HD therapy at Zhongshan Hospital, Fudan University, were enrolled and divided into two groups according to the detection of cardiac valvular calcification (CVC) by echocardiography. The patients were followed for a median of 4 years for all-cause mortality and cardiovascular mortality.

RESULTS

During follow-up, 56 (25.0%) patients died, including 29 (51.8%) of cardiovascular disease. The adjusted HR related to all-cause mortality was 2.14 (95% CI, 1.05-4.39) for patients with cardiac valvular calcification. However, CVC was not an independent risk factor for cardiovascular mortality in patients who had just begun HD therapy.

CONCLUSION

CVC at baseline is an independent risk factor for all-cause mortality in HD patients and makes an independent contribution to the prediction of all-cause mortality. These findings support the use of echocardiography at the beginning of HD.

Serum and Adipose Dipeptidyl Peptidase 4 in Cardiovascular Surgery Patients: Influence of Dipeptidyl Peptidase 4 Inhibitors

Dipeptidyl peptidase 4 (DPP-4) is a novel adipokine and may be involved in the association between adipose tissue and metabolic syndrome. We investigated DPP-4 and adiponectin levels in the serum, subcutaneous adipose tissue (SAT), and epicardial adipose tissue (EAT), and their relationship with preoperative factors, as well as comparing the DPP-4 levels in SAT and EAT with and without DPP-4 inhibitors. This study included 40 patients (25 men, age 67.5 ± 13.8 years). The serum adipokine, DPP-4, and adiponectin levels in SAT and EAT were measured using ELISA and Western blotting. The DPP-4 and adiponectin levels were significantly higher in the SAT than in the EAT. The serum DPP-4 and DPP-4 activity levels had no correlation with the DPP-4 levels in the SAT and EAT, but the DPP-4 levels in the SAT and EAT had a positive correlation. The DPP-4 levels in the SAT were positively correlated with atherosclerosis, diabetes mellitus, DPP-4-inhibitor use, and fasting blood glucose. The DPP-4 levels in the EAT showed a negative correlation with eGFR and a positive correlation with atrial fibrillation. The DPP-4 activity in the serum had a lower tendency in the group taking DPP-4 inhibitors than in the group not taking them. DPP-4 inhibitors may suppress angiogenesis and adipose-tissue hypertrophy.

The Relationship of Epicardial Adipose Tissue and Cardiovascular Disease in Chronic Kidney Disease and Hemodialysis Patients

Cardiovascular diseases remain the most common cause of morbidity and mortality in chronic kidney disease patients undergoing hemodialysis. Epicardial adipose tissue (EAT), visceral fat depot of the heart, was found to be associated with coronary artery disease in cardiac and non-cardiac patients. Additionally, EAT has been proposed as a novel cardiovascular risk in the general population and in end-stage renal disease patients. It has also been shown that EAT, more than other subcutaneous adipose tissue deposits, acts as a highly active organ producing several bioactive adipokines, and proinflammatory and proatherogenic cytokines. Therefore, increased visceral adiposity is associated with proinflammatory activity, impaired insulin sensitivity, increased risk of atherosclerosis, and high morbidity and mortality in hemodialysis patients. In the present review, we aimed to demonstrate the role of EAT in the pathophysiological mechanisms of increased cardiovascular morbidity and mortality in hemodialysis patients.

Association of Body Weight Variability with Adverse Cardiovascular Outcomes in Patients with Pre-Dialysis Chronic Kidney Disease

To investigate the association of body weight variability (BWV) with adverse cardiovascular (CV) outcomes in patient with pre-dialysis chronic kidney disease (CKD), a total of 1867 participants with pre-dialysis CKD from Korean Cohort Study for Outcomes in Patients With Chronic Kidney Disease (KNOW-CKD) were analyzed. BWV was defined as the average absolute difference between successive values. The primary outcome was a composite of non-fatal CV events and all-cause mortality. Secondary outcomes were fatal and non-fatal CV events and all-cause mortality. High BWV was associated with increased risk of the composite outcome (adjusted hazard ratio (HR) 1.745, 95% confidence interval (CI) 1.065 to 2.847) as well as fatal and non-fatal CV events (adjusted HR 1.845, 95% CI 1.136 to 2.996) and all-cause mortality (adjusted HR 1.861, 95% CI 1.101 to 3.145). High BWV was associated with increased risk of fatal and non-fatal CV events, even in subjects without significant body weight gain or loss during follow-up periods (adjusted HR 2.755, 95% CI 1.114 to 6.813). In conclusion, high BWV is associated with adverse CV outcomes in patients with pre-dialysis CKD.

Cardiorenal Fat: A Cardiovascular Risk Factor With Implications in Chronic Kidney Disease

There is a growing interest in the potential role of adipose tissues in cardiac and renal pathophysiology, and determining the mechanisms by which fat compartments around the heart and kidneys influence cardiovascular disease is of clinical importance in both general and high-risk populations. Epicardial fat and perirenal fat have been associated with adverse outcomes in chronic kidney disease (CKD) patients. Epicardial fat is a rich source of free fatty acids and is capable of secreting inflammatory and pro-atherogenic cytokines that promote atherosclerosis through a local paracrine effect. Recent evidence has demonstrated that perirenal fat has a closer correlation with kidney diseases than other visceral fat deposits in obesity or metabolic disturbances. Moreover, perirenal fat has been reported as an independent risk factor for CKD progression and even associated with cardiorenal dysfunction. Accordingly, these forms of organ-specific fat deposits may act as a connecter between vascular and cardiorenal disease. This review explores the possible links between epicardial and perirenal fat and its significant role as a modulator of cardiorenal dysfunction in CKD patients.

Risk factors for high fall risk in elderly patients with chronic kidney disease

PURPOSE

Patients with chronic kidney disease (CKD) usually represent an aging population, and both older age and CKD are associated with a higher risk of falling. Studies on risk factors among subjects with CKD are lacking.

METHODS

Records of outpatients from one geriatric clinic in Turkey were retrospectively reviewed. A result of ≥ 13.5 s on the timed up and go (TUG) test was accepted as a high risk of falls. Independent predictors of an increased risk of falls among subjects with CKD (estimated glomerular filtration rate of < 60 mL/min/1.73 m²) were identified using logistic regression models.

RESULTS

Patients with CKD (n = 205), represented the 20.2% of the entire cohort and was identified as an independent predictor of increased fall risk (OR 2.59). Within the CKD cohort, serum folic acid levels and frailty were independent predictors of an increased risk of falls. The CKD/fall risk group was older, had a lower median years of education, lower vitamin D levels, and lower serum folic acid levels than the CKD/non-fall risk group. In addition to higher serum creatinine and potassium levels, the only significant difference between patients with CKD/fall risk and a matched non-CKD/fall risk was a lower median folic acid level in the former group.

CONCLUSIONS

Frailty and low folic acid levels are independently associated with an increased risk of falls among elderly outpatients with CKD. Prevention of frailty may reduce the risk of falls in these subjects. Possible benefit of folic acid supplementation requires further studies.

Epicardial fat tissue, coronary arterial calcification and mortality in patients with advanced chronic kidney disease and hemodialysis

INTRODUCTION AND OBJECTIVES

Epicardial and mediastinal adipose tissue (EAT, MAT) are linked to metabolic syndrome and coronary artery disease. Patients with chronic kidney disease (CKD) have thicker EAT. We assessed if EAT and MAT could be associated with increased mortality and cardiovascular events in patients with advanced CKD and haemodialysis therapy.

METHODS

A post-hoc study was performed. We analyzed a prospective series of 104 cases. EAT thickness was quantified by a multislice synchronized computed tomography (MSCT).

RESULTS

The follow-up period was 112.68 (109.94-115.42) months. The optimal cut-off point of EAT for prediction of total mortality was 11.45 mm (92.86% and 43.75%). EAT thickness was associated with serum albumin levels, serum triglyceride levels, phosphorus and calcium phosphate product. The EAT was greater in haemodialysis patients compared to those with advanced CKD (P < .001). Patients with diabetes mellitus had greater EAT and MAT thickness (P = .018). At the end of follow up, the survival average time of patients with EAT thickness <11.45 mm was 97.48 months vs. 76.65 months for thickness > 11.45 mm (P = .007).

CONCLUSIONS

A higher EAT and MAT thickness was associated with increased mortality. Furthermore, EAT was associated with lower free survival time to fatal and non-fatal cardiovascular events. The measurement of EAT and MAT by MSCT could be a prognostic tool to predict cardiovascular events and mortality risk in advanced CKD patients.

Epicardial adipose tissue in patients with chronic kidney disease: a meta-analysis study and trial sequential analysis

BACKGROUND

Cardiovascular disease is the most common cause of death in patients with chronic kidney disease (CKD). Epicardial adipose tissue (EAT) is an independent predictor of cardiovascular disease in the general population, and usually increases in the patients with cardiovascular disease risk. The change of EAT in patients with CKD was still controversial. For further understanding, we conducted a meta-analysis of the relevant literature.

METHODS

Eligible studies were searched in PubMed, EMBASE, Web of Science, and Scopus on March 13, 2020. The summarized standard mean difference (SMD) with 95% confidence intervals (CIs) were used to assess the association between EAT (thickness and volume) and CKD. Trial sequential analysis was conducted to estimate whether the evidence of the results is sufficient.

RESULTS

In total, 17 studies with 1961 participants (1205 patients in the CKD group and 756 participants in the control group) were involved. The EAT thickness was significantly increased in the CKD group compared to the control group (SMD = 1.31, 95% CI 0.89-1.73, P < 0.001) in eleven studies. The EAT volume was significantly increased in the CKD group compared to the control group (SMD = 0.77, 95% CI 0.63-0.91, P < 0.001) in six studies. Trial sequential analysis indicated that the available samples were sufficient and confirmed that firm evidence was reached.

CONCLUSIONS

Patients with CKD have higher EAT thickness and volume compared to control subjects without CKD.

Relationship Between Epicardial Adipose Tissue and Body Composition as Determined by Multi-Frequency Bioelectrical Impedance Analysis in Patients with Stage 5 Chronic Kidney Disease

Background

The main cause of mortality among chronic kidney disease (CKD) patients is cardiovascular disease (CVD). Epicardial adipose tissue (EAT) is considered to be novel cardiovascular risk factor. We assessed EAT in non-dialyzed stage 5 CKD patients and explored the association of EAT with body composition as determined by multi-frequency BIA.

Material/Methods

The present included 70 stage 5 CKD patients who had not undergone dialysis and 40 healthy control subjects. EAT thickness was assessed by echocardiography. Hydration status and body composition were evaluated by multi-frequency bioelectrical impedance analysis.

Results

Stage 5 CKD patients had significantly higher EAT thickness than healthy subjects (6.56±1.18 vs. 4.05±1.45, p<0.001). Fat tissue mass, systolic blood pressure (SBP), age, fat tissue index, and body mass index were positively correlated with EAT thickness in the CKD patient group (p<0.05). Lean tissue mass, lean tissue index (LTI), and high-density lipoprotein (HDL) were negatively correlated with EAT thickness in the CKD patient group (p<0.05). Stepwise multiple regression analysis showed that age, SBP, and LTI were independently associated with EAT thickness in CKD patients.

Conclusions

We found significantly higher EAT thickness in stage 5 CKD patients who were not on dialysis compared to healthy controls. EAT was significantly associated with age, SBP, and LTI in CKD patients. Interventions to reduce the risk factors associated with EAT thickness might protect against CVD disease in CKD patients.

Epicardial Adipose Tissue, Adiponectin and Leptin: A Potential Source of Cardiovascular Risk in Chronic Kidney Disease

The importance of cardiometabolic factors in the inception and progression of atherosclerotic cardiovascular disease is increasingly being recognized. Beyond diabetes mellitus and metabolic syndrome, other factors may be responsible in patients with chronic kidney disease (CKD) for the high prevalence of cardiovascular disease, which is estimated to be 5- to 20-fold higher than in the general population. Although undefined uremic toxins are often blamed for part of the increased risk, visceral adipose tissue, and in particular epicardial adipose tissue (EAT), have been the focus of intense research in the past two decades. In fact, several lines of evidence suggest their involvement in atherosclerosis development and its complications. EAT may promote atherosclerosis through paracrine and endocrine pathways exerted via the secretion of adipocytokines such as adiponectin and leptin. In this article we review the current knowledge of the impact of EAT on cardiovascular outcomes in the general population and in patients with CKD. Special reference will be made to adiponectin and leptin as possible mediators of the increased cardiovascular risk linked with EAT.

Epicardial adipose tissue: A cardiovascular risk marker to evaluate in chronic kidney disease

Chronic kidney disease represents a true inflammatory state, and is related to multiple cardiovascular risk factors. Coronary artery disease is the major complication, and has usually been associated with non-classical or uraemic related factors that include the disturbance of calcium and phosphorus metabolism, among others. Recent clinical evidence shows that specific body fat deposition like epicardial adipose tissue is an additional factor to consider when evaluating cardiovascular risk in the general population and kidney patients. Direct interaction of this tissue and coronary vessels with consequent mediation of pro-atherogenic substances have a local process ending in endothelial damage. Although the population of renal patients has been poorly evaluated, future studies should determine precisely whether an increase in epicardial fat is truly associated with cardiovascular morbidity and mortality in this risk group.

Cardiac MRI measurements of pericardial adipose tissue volumes in patients on in-centre nocturnal hemodialysis

BACKGROUND

Conversion from conventional hemodialysis (CHD) to in-centre nocturnal hemodialysis (INHD) is associated with left ventricular (LV) mass regression, but the underlying mechanisms are not fully understood. Using cardiac MRI (CMR), we examined the effects of INHD on epicardial adipose tissue (EAT) and paracardial adipose tissue (PAT), and the relationships between EAT, PAT and LV remodeling, biomarkers of nutrition, myocardial injury, fibrosis and volume.

METHODS

We conducted a prospective multicenter cohort study of 37 patients transitioned from CHD to INHD and 30 patients on CHD (control). Biochemical markers and CMR were performed at baseline and 52 weeks. CMR images were analyzed by independent readers, blinded to order and treatment group.

RESULTS

Among 64 participants with complete CMR studies at baseline (mean age 54; 43% women), there were no significant differences in EAT index (60.6 ± 4.3 mL/m² vs 64.2 ± 5.1 mL/m², p = 0.99) or PAT index (60.0 ± 5.4 mL/m² vs 53.2 ± 5.9 mL/m², p = 0.42) between INHD and CHD groups. Over 52 weeks, EAT index and PAT index did not change significantly in INHD and CHD groups (p = 0.21 and 0.14, respectively), and the changes in EAT index and PAT index did not differ significantly between INHD and CHD groups (p = 0.30 and 0.16, respectively). Overall, changes in EAT index inversely correlated with changes in LV end-systolic volume index (LVESVI) but not LV end-diastolic volume index (LVEDVI), LV mass index (LVMI), and LV ejection fraction (LVEF). Changes in PAT index inversely correlated with changes in LVESVI, LVMI and positively correlated with changes in LVEF. There were no correlations between changes in EAT index or PAT index with changes in albumin, LDL, triglycerides, troponin-I, FGF-23, or NT-proBNP levels over 52 weeks (all p > 0.30).

CONCLUSIONS

INHD was not associated with any changes in EAT index and PAT index over 12 months. Changes in EAT index were not significantly associated with changes in markers of LV remodeling, nutrition, myocardial injury, fibrosis, volume status. In contrast, changes in PAT index, which paradoxically is expected to exert less paracrine effect on the myocardium, were correlated with changes in LVESVI, LVMI and LVEF. Larger and longer-term studies may clarify the role of PAT in cardiac remodeling with intensified hemodialysis. CLINICALTRIALS.

GOV IDENTIFIER

NCT00718848.

Effect of spironolactone on the progression of coronary calcification in peritoneal dialysis patients: a pilot study

INTRODUCTION

There is evidence that aldosterone plays a role in the pathogenesis of vascular calcification. The aim of this study was to evaluate the effect of spironolactone, a mineralocorticoid receptor antagonist, on the progression of coronary calcification (CC) in peritoneal dialysis patients and to identify the factors involved in this progression.

METHODS

Thirty-three patients with a coronary calcium score (CCS) ≥ 30, detected through multi-detector computed tomography (MDCT) and expressed in Agatston units, were randomly assigned to a group receiving 25mg spironolactone per day for 12 months (spironolactone group) and a control group not receiving this drug. The primary outcome was a percentage change in CCS from baseline to end of the study (relative progression), when a further MDCT was conducted. Patients who had progression of CC were compared with those who did not progress.

RESULTS

Sixteen patients, seven in the spironolactone group and nine in the control group, concluded the study. The relative progression of the CCS was similar in both groups, 17.2% and 27.5% in the spironolactone and control groups respectively. Fifty-seven percent of the treated patients and 67% of those in the control group presented progression in the CC scores (p = 0.697). Progressor patients differed from non-progressors because they presented higher levels of calcium and low-density lipoprotein cholesterol and lower levels of albumin.

CONCLUSION

In peritoneal dialysis patients, spironolactone did not attenuate the progression of CC. However, large-scale studies are needed to confirm this observation. Disorders of mineral metabolism and dyslipidemia are involved in the progression of CC.

Coronary calcification as a predictor of cardiovascular mortality in advanced chronic kidney disease: a prospective long-term follow-up study

BACKGROUND

Patients with advanced chronic kidney disease (CKD) exhibit higher prevalence of coronary artery calcification (CaC) than general population. CaC has been proposed as a risk factor for mortality in end-stage CKD, but most studies in the field are based on short-term follow-up.

METHODS

We conducted a cohort, 10-year prospective longitudinal study of consecutive cases referred to the renal unit. A non-enhanced multislice coronary computed tomography was performed at baseline. CaC was assessed by Agatston method. Patients were stratified according to their CaC score: severe calcification group (CaCs< 400 HU) and mild-moderate calcification group (CaCs≥400 HU). The overall and cardiovascular (CV) mortality, CV events, and factors potentially associated with CaC development were recorded.

RESULTS

137 patients with advanced CKD were enrolled and provided consent. Overall mortality rate was 58%; 40% due to CV events. The rate of overall mortality in the severe calcification group was 75%, and 30% in the low calcification group, whereas the rate of CV mortality was 35% vs. 6%, respectively (p < 0.001). The severe calcification group was older, had higher prevalence of type 2 diabetes mellitus, former cardiologic events, and lower albumin serum levels than the mild-moderate calcification group. In a multivariate Cox model, severe CaC was a significant predictor of CV mortality (HR 5.01; 95%CI 1.28 to 19.6, p = 0.02).

CONCLUSIONS

Among advanced CKD, there was a significantly increase of CV mortality in patients with severe CaCs during a 10-year follow-up period. CaCs could be a useful prognostic tool to predict CV mortality risk in CKD patients.

The Relationship Between Visceral Adiposity Index and Epicardial Adipose Tissue in Patients with Type 2 Diabetes Mellitus

Introduction and aim Cardiovascular diseases remain the most common cause of morbidity and mortality in patients with diabetes. Epicardial adipose tissue (EAT), visceral fat depot of the heart, was found to be associated with coronary artery disease in cardiac and non-cardiac patients. Increased visceral adiposity is associated with proinflammatory activity, impaired insulin sensitivity, increased risk of atherosclerosis and high mortality. In the present study we aimed to investigate the relationship between EAT and visceral adiposity index (VAI) in patients with diabetes.

Methods This was a cross-sectional study involving 128 patients with type 2 diabetes mellitus (73 females, 55 males; mean age, 54.09+±+9.17 years) and 32 control subjects (23 females, 9 males; mean age, 50.09+±+7.81 years). EAT was measured by using a trans-thoracic echocardiograph. Parameters such as waist circumference (WC), body mass index (BMI), triglyceride and high density lipoprotein (HDL) cholesterol were used to calculate VAI.

Result EAT and VAI measurements were significantly higher in patients with diabetes when compared to control subjects. In the bivariate correlation analysis, VAI was positively correlated with uric acid level (r=0.214, p=0.015), white blood cell count (r= 0.262, p=0.003), platelet count (r=0.223, p=0.011) and total cholesterol levels (r= 0.363, p<0.001). Also, VAI was found to be the independent predictor of EAT.

Conclusion Simple calculation of VAI was found to be associated with increased EAT in patients with type 2 diabetes.

Epicardial fat, cardiovascular risk factors and calcifications in patients with chronic kidney disease

Background

Epicardial adipose tissue (EAT) exerts cardiopathogenic effects, but the independent association between EAT and cardiovascular (CV) calcification in patients with chronic kidney disease (CKD) remains controversial. We therefore assessed the association between EAT, CV risk factors and CV calcifications.

Methods

257 patients with CKD Stage 3 and/or overt proteinuria underwent quantification of EAT, coronary artery calcification and aortic valve calcification by computed tomography. Framingham and American College of Cardiology and American Heart Association (ACC-AHA) 10-year CV event risk scores were calculated for each patient.

Results

Using multivariable regression analysis, higher EAT was significantly associated with the majority of investigated risk factors {higher age: odds ratio [OR] 1.05/year [95% confidence interval (CI) 1.02-1.08]; male sex: OR 4.03 [95% CI 2.22-7.31]; higher BMI: OR 1.28/kg/m² [95% CI 1.20-1.37]; former smoking: OR 1.84 [95% CI 1.07-3.17]; lower high-density lipoprotein cholesterol: OR 0.98/mg/dL [95% CI 0.96-1.00] and lower estimated glomerular filtration rate: OR 0.98/mL/min/1.73 m² [95% CI 0.97-0.99]; all P < 0.05} and was not associated with diabetes mellitus, hypertensive nephropathy, total cholesterol and albuminuria. EAT was positively associated with higher ACC-AHA and Framingham risk scores. EAT correlated with coronary artery calcification and aortic valve calcification [Spearman ρ = 0.388 (95% CI 0.287-0.532) and r _rb = 0.409 (95% CI 0.310-0.556), respectively], but these correlations were dependent on CV risk factors.

Conclusions

The increase of EAT can be explained by individual CV risk factors and kidney function and correlates with 10-year risk for CV event scores, suggesting that EAT is a modifiable risk factor in patients with CKD. Although EAT correlates with CV calcifications, these relations depend on CV risk factors.

Epicardial Adipose Tissue and Renal Disease

Epicardial adipose tissue (EAT) is derived from splanchnic mesoderm, localized anatomically between the myocardium and pericardial visceral layer, and surrounds the coronary arteries. Being a metabolically active organ, EAT secretes numerous cytokines, which moderate cardiovascular morphology and function. Through its paracrine and vasocrine secretions, EAT may play a prominent role in modulating cardiac function. EAT protects the heart in normal physiological conditions by secreting a variety of adipokines with anti-atherosclerotic properties, and in contrast, secretes inflammatory molecules in pathologic conditions that may play a dynamic role in the pathogenesis of cardiovascular diseases by promoting atherosclerosis. Considerable research has been focused on comparing the anatomical and biochemical features of EAT in healthy people, and a variety of disease conditions such as cardiovascular diseases and renal diseases. The global cardiovascular morbidity and mortality in renal disease are high, and there is a paucity of concrete evidence and societal guidelines to detect early cardiovascular disease (CVD) in this group of patients. Here we performed a clinical review on the existing evidence and knowledge on EAT in patients with renal disease, to evaluate its application as a reliable, early, noninvasive biomarker and indicator for CVD, and to assess its significance in cardiovascular risk stratification.

Epicardial adipose tissue: new parameter for cardiovascular risk assessment in high risk populations. J Nephrol. 2018;31:847-853. [PMID: 29704210 DOI: 10.1007/s40620-018-0491-5]

Epicardial adipose tissue (EAT) is localized between the myocardial surface and visceral layer of the pericardium. It is a metabolically active organ that secretes several cytokines which modulate cardiovascular morphology and function. EAT may interact locally with coronary arteries through paracrine secretion mechanisms. Cytokines from peri-adventitial EAT may pass through the coronary wall by diffusion from the outside to the inside, interacting with cells. An additional potential mechanism by which EAT interacts locally with coronary arteries may be the vasocrine secretion.EAT may play a significant role as a modulator of cardiac functions. In physiologic conditions, EAT has biochemical cardio-protective properties, secreting anti-atherosclerosis substances; in metabolic disease states, EAT secretes bioactive molecules that may play an important role in the pathogenesis of coronary artery disease and cardiac arrhythmias by promoting atherosclerosis. EAT has been evaluated both in the general population and in metabolic disease states that are characterized by inflammation, such as cardiovascular diseases and chronic kidney disease.This review focuses on the current state of knowledge on EAT as a reliable new parameter for cardiovascular risk stratification in high risk populations.

Normal body mass index with central obesity has increased risk of coronary artery calcification in Korean patients with chronic kidney disease

In chronic kidney disease (CKD), overweight and mild obesity have shown the lowest cardiovascular (CV) risk. However, central obesity has been directly associated with CV risk in these patients. This bidirectional relationship of body mass index (BMI) and central obesity prompted us to evaluate CV risk based on a combination of BMI and waist-to-hip ratio (WHR) in nondialysis CKD patients. We included 1078 patients with CKD stage 2 through 5 (nondialysis) enrolled in a nationwide prospective cohort of Korea. Patients were divided into 3 groups by BMI (normal BMI, 18.5-22.9; overweight, 23.0-27.4; and obese, 27.5 and over kg/m²) and were dichotomized by a sex-specific median WHR (0.92 in males and 0.88 in females). Coronary artery calcification (CAC) was determined by multislice computed tomography. CAC (score above 10 Agatston units) was found in 477 patients. Multivariate logistic regression analysis indicated that BMI was not independently associated with CAC. However, WHR showed an independent linear and significant association with CAC (odds ratio, 1.036; 95% confidence interval, 1.007-1.065 per 0.01 increase). Furthermore, when patients were categorized into 6 groups according to a combination of BMI and WHR, normal BMI but higher WHR had the highest risk of CAC compared with the normal BMI with lower WHR group (2.104; 1.074-4.121). Thus, a normal BMI with central obesity was associated with the highest risk of CAC, suggesting that considering BMI and WHR, 2 surrogates of obesity, can help to discriminate CV risk in Korean nondialysis CKD patients.

The relationship between coronary artery calcium scores and left atrium size in hemodialysis patients

PURPOSE

Hemodialysis patients have extremely increased cardiovascular mortality. The coronary artery calcification score (CACS) in uremic patients receiving hemodialysis reflects the severity of atherosclerotic vascular disease and predicts the cardiovascular events. In cardiac conditions, left atrial (LA) size has a prognostic importance. In this study, relationship between coronary artery calcification and left atrial size was investigated.

METHODS

This was a cross-sectional study involving 32 hemodialysis patients (16 females, 16 males; mean age, 52.4 ± 14.1 years) receiving HD for ≥6 months. Coronary artery calcium scoring was performed by a 16-MDCT scanner, and CACS was calculated by Agatston score. A calcification was defined as a minimum of two adjacent pixels (>0.52 mm²) with a density over 130 Hounsfield units. Patients were divided into two subgroups (group 1: CACS ≤ 45.85, n = 16 and group 2: CACS > 45.85, n = 16) according to median CACS value.

RESULTS

Mean CACS value of 32 hemodialysis patients was 245.57 ± 373.91. LA size was significantly higher in patients with CACS > 45.85 (group 2) than in patients with CACS ≤ 45.85 (group 1). In the bivariate correlation analysis, total CACS was positively correlated with left atrium size (r = 0.47, p = 0.006). Total CACS was positively correlated with age (r = 0.43, p = 0.014). LA size was positively correlated with diastolic blood pressure (r = 0.42, p = 0.016) and negatively correlated with ejection fraction (r = -0.42, p = 0.016). The clinical parameters such as BMI, duration of dialysis, blood pressure, ejection fraction, serum levels of calcium, phosphorus, uric acid, albumin, CRP, triglyceride, cholesterol, hemoglobin and ferritin were not independently associated with total CACS.

CONCLUSIONS

We found a positive relationship between the CACS and LA size measured by echocardiography in hemodialysis patients. Therefore; echocardiography, which is cheaper and non-invasive than tomographic examinations, might be considered for the risk stratification of coronary artery disease in hemodialysis patients.

Increased serum renalase in peritoneal dialysis patients: Is it related to cardiovascular disease risk?

BACKGROUND

Renalase, with possible monoamine oxidase activity, is implicated in degradation of catecholamines; which suggests novel mechanisms of cardiovascular complications in patients with chronic kidney diseases. Epicardial adipose tissue (EAT) has been found to correlate with cardiovascular diseases (CVD) in dialysis patients. The present study aimed to evaluate the association of serum renalase levels with EAT thickness and other CVD risk factors in peritoneal dialysis (PD) patients.

METHODS

The study included 40 PD patients and 40 healthy controls. All subjects underwent blood pressure and anthropometric measurements. Serum renalase was assessed by using a commercially available assay. Transthoracic echocardiography was used to measure EAT thickness and left ventricular mass index (LVMI) in all subjects.

RESULTS

The median serum renalase level was significantly higher in the PD patients than in the control group [176.5 (100-278.3) vs 122 (53.3-170.0)ng/ml] (p=0.001). Renalase was positively correlated with C-reactive protein (r=0.705, p<0.001) and negatively correlated with RRF (r=-0.511, p=0.021). No correlation was observed between renalase and EAT thickness or LVMI. There was a strong correlation between EAT thickness and LVMI in both the PD patients and the controls (r=0.848, p<0.001 and r=0.640, p<0.001 respectively).

CONCLUSIONS

This study indicates that renalase is associated with CRP and residual renal function but not with EAT thickness as CVD risk factors in PD patients.

Neutrophil-to-lymphocyte ratio as a possible indicator of epicardial adipose tissue in patients undergoing hemodialysis

INTRODUCTION

Chronic inflammation is a major risk factor in the pathogenesis of cardiovascular disease in end-stage renal disease (ESRD) patients. Epicardial adipose tissue (EAT) is the true visceral fat depot of the heart. The relationship between coronary artery disease and EAT was shown in healthy subjects and ESRD patients. In the present study we aimed to investigate the relationship between EAT and inflammation parameters including neutrophil-to-lymphocyte ratio (NLR) in hemodialysis (HD) patients.

MATERIAL AND METHODS

Forty-three HD patients (25 females, 18 males; mean age: 64.1 ±11.9 years) receiving HD and 30 healthy subjects (15 females, 15 males; mean age: 59.1 ±10.8 years) were enrolled in the study. Epicardial adipose tissue measurements were performed by echocardiography.

RESULTS

Neutrophil-to-lymphocyte ratio levels were significantly higher in HD patients than in the healthy control group. Hemodialysis patients were separated into two groups according to their median value of NLR (group 1, NLR < 3.07 (n = 21) and group 2, NLR ≥ 3.07 (n = 22)). Group 2 patients had significantly higher EAT, C-reactive protein and ferritin levels, while albumin levels were significantly lower in this group. In the bivariate correlation analysis, EAT was positively correlated with NLR (r = 0.600, p < 0.001) and ferritin (r = 0.485, p = 0.001) levels.

CONCLUSIONS

Neutrophil-to-lymphocyte ratio was found to be an independent predictor of EAT in HD patients (odds ratio = 3.178; p = 0.008). We concluded that this relationship might be attributed to increased inflammation in uremic patients.

Aortic Arch Calcification as a Predictor of Repeated Arteriovenous Fistula Failure within 1-Year in Hemodialysis Patients

Objectives

The aim of the study was to identify the factors associated with repeated arteriovenous fistula (AVF) failure within 1-year, especially the impact of aortic arch calcification (AAC) on patency of AVF.

Materials and Methods

We retrospectively assessed chest radiography in hemodialysis patients who had undergone initial AVF. The extent of AAC was categorized into four grades (0–3). The association between AAC grade, other clinical variables, and repeated failure of AVF was then analyzed by binary logistic regression analysis.

Results

This study included 284 patients (158 males, mean age 61.7 ± 13.1 years). Patients with higher AAC grade were older, had more frequently diabetes mellitus and cardiovascular disease, had lower diastolic blood pressure, and had higher corrected calcium and lower intact parathyroid hormone levels. In multivariate analysis, the presence of higher AAC grade (odds ratio (95% confidence interval): 2.98 (1.43–6.23); p = 0.004), lower mean corrected calcium (p = 0.017), and mean serum albumin level (p = 0.008) were associated with repeated failure of AVF.

Conclusions

The presence of higher AAC grade, lower mean corrected calcium and mean serum albumin level were independently associated with repeated AVF failure within 1 year in hemodialysis patients.

Epicardial adipose tissue in patients with end-stage renal disease on haemodialysis. Curr Opin Nephrol Hypertens. 2015;24:517-524. [PMID: 26335554 DOI: 10.1097/mnh.0000000000000161]

PURPOSE OF REVIEW

Epicardial adipose tissue (EAT) is the visceral fat of the heart, sharing many of the pathophysiological properties of other visceral fat depots. EAT is a metabolically active paracrine and vasocrine organ that causes local cardiac inflammation and is strongly implicated in the pathogenesis of coronary atherosclerosis. This article highlights the findings of recent observational studies in patients on haemodialysis that link the quantity of EAT to increased rates of cardiovascular and coronary artery disease and review the proposed methods of pathogenesis and the possible role of EAT quantification to improve cardiovascular risk assessment.

RECENT FINDINGS

Increasing volumes of EAT in patients on haemodialysis correlate with increased inflammatory mediators, higher rates of cardiovascular disease and coronary artery calcification, independent of general adiposity. EAT is an independent predictor of mortality and a potentially modifiable target for therapeutic interventions.

SUMMARY

EAT is likely to play a central role in the pathogenesis of cardiovascular disease in patients on haemodialysis, adds incrementally to conventional cardiovascular risk stratification models and is a potential target for therapeutic intervention.

Atrial electromechanical delay and left atrial mechanical functions in hemodialysis and peritoneal dialysis patients

INTRODUCTION

Left atrium (LA) mechanical functions and atrial electromechanical delay (AEMD) times were considered independent predictors of cardiovascular morbidity in general population. Data are scant about these parameters in end-stage renal disease (ESRD) patients receiving hemodialysis (HD) and peritoneal dialysis (PD). We aimed to evaluate AEMD times and LA mechanical functions and associated risk factors in HD and PD patients.

METHODS

Forty-four healthy individuals, 62 HD and 50 PD patients were enrolled in the study. Echocardiography was performed before midweek dialysis session for HD patients and on admission for PD patients. Data were expressed as mean ± SD. Spearman's test was used to assess linear associations. Predictors of left intra-atrial EMD time and LA active emptying volume (LAaeV) were assessed by regression analysis.

RESULTS

Left intra-atrial-AEMD times were significantly longer in HD patients compared to PD patients. LAaeV was positively correlated with inter-atrial time, left intra-atrial time, systolic and diastolic BP, calcium and neutrophil-to-lymphocyte ratio (NLR) (r 0.22, p 0.016; r 0.28, p 0.002; r 0.34, p < 0.001; r 0.35, p < 0.001; r 0.37, p < 0.001; r 0.46, p < 0.001, respectively) and negatively correlated with serum uric acid (r -0.31, p 0.013) in ESRD patients. We found positive correlations between left intra-atrial time and LAaeV, LAVmax, LAVp and NLR (r 0.28, p 0.002; r 0.27, p 0.003; r 0.27, p 0.003; r 0.22, p 0.03, respectively) and negative correlations with albumin, uric acid and potassium (r -0.24, p 0.008; r -0.19, p 0.04; r -0.26, p 0.037, respectively). Advanced age, decreased serum albumin and increased NLR were found to be independent predictors of LAaeV; however, only NLR was found to be an independent predictor of AEMD time in this population.

CONCLUSIONS

Increased inflammation might be a risk factor of AEMD and LA mechanical dysfunction in ESRD patients.

Epicardial adipose tissue in long-term hemodialysis patients: its association with vascular calcification and long-term development

BACKGROUND

Epicardial adipose tissue (EAT) is associated with coronary artery disease (CAD) in the general population. EAT is suggested to promote CAD by paracrine mechanisms and local inflammation. We evaluated whether in chronic hemodialysis (HD) patients EAT associates with CAD, how the amount of EAT develops over time, and if EAT independently predicts the mortality risk.

METHODS

Post-hoc analysis of a prospective study in 59 chronic HD patients who underwent non-enhanced multi-slice computed tomography (MSCT) at baseline. Thirty-seven patients underwent another MSCT after 24 ± 5 months. We measured EAT volume (cm³) and Agatston calcification scores of coronary arteries (CAC) and aortic valves (AVC). All-cause mortality was assessed after a follow-up of 88 months (IQR 52-105).

RESULTS

Baseline EAT was 128.2 ± 60.8 cm³ and significantly higher than in a control group of non-renal patients (94 ± 46 cm³; p < 0.05). Median Agatston score for CAC was 329 (IQR 23-1181) and for AVC was 0 (IQR 0-25.3) in HD patients. We observed significant positive correlations between baseline EAT and age (r = 0.386; p = 0.003), BMI (r = 0.314; p = 0.016), CAC (r = 0.278; p = 0.03), and AVC (r = 0.282; p = 0.03). In multivariate analysis, age, BMI and AVC remained as significant predictors of EAT (p < 0.01). Calcification scores significantly increased over 2 years; in contrast EAT change was not significant (+11 %, IQR -10 to 24 %; p = 0.066). The limited patient number in the present study precludes analysis of the EAT impact upon survival.

CONCLUSION

EAT correlated significantly with cardiovascular calcification in long-term HD patients. Mean EAT did not significantly change over 2 years.

Serum paraoxonase activity is associated with epicardial fat tissue in renal transplant recipients

AIMS

Cardiovascular disease is a major cause of mortality in renal transplant recipients. Paraoxonase-1 (PON-1) has been shown to protect against atherosclerosis by modifying lipoproteins. Epicardial fat tissue (EFT) has been proposed as a new cardiovascular risk factor. The aim of this study was to investigate the relationship between PON-1 activity and EFT in renal transplant recipients.

METHODS

Eighty renal transplant recipients were enrolled in this cross-sectional study. PON-1 activity was assessed from the rate of enzymatic hydrolysis of paraoxon to p-nitrophenol. EFT was measured by echocardiography.

RESULTS

The mean age of the patients was 40.4 ± 12.3 years and mean post transplant follow-up duration was 57.2 ± 46 months. Mean PON-1 activity was 68.5 ± 30 U/L. PON-1 activity was positively correlated with age and body mass index and negatively correlated with parathyroid hormone, dialysis duration and EFT. The mean EFT thickness was 0.64 ± 0.17 cm. Multiple linear regression analysis was used to define independent determinants of EFT in renal transplant recipients. According to linear regression analysis, PON-1 levels and age were found to be independent predictors of EFT.

CONCLUSION

Reduced PON-1 activity was negatively associated with EFT and PON-1 activity independently predicts EFT in renal transplant recipients.

Epicardial fat accumulation, cardiometabolic profile and cardiovascular events in patients with stages 3-5 chronic kidney disease

BACKGROUND

It has been hypothesized that epicardial adipose tissue (EAT) exerts pathogenic effects on cardiac structures. We analysed the associations between EAT and both cardiovascular (CV) disease risk factors and CV events in patients with chronic kidney disease (CKD).

PATIENTS AND METHODS

We included 277 nondialysed patients [median age 61, interquartile range (IQR) 53-68 years; 63% men] with stages 3-5 CKD in this cross-sectional evaluation. EAT and abdominal visceral adipose tissue (VAT) were assessed by computed tomography. Patients were followed for median 32 (IQR 20-39) months, and the composite of fatal and nonfatal CV events was recorded.

RESULTS

With increasing EAT quartiles, patients were older, had higher glomerular filtration rate, body mass index, waist, VAT and coronary calcification, higher levels of haemoglobin, triglycerides, albumin, C-reactive protein and leptin and higher prevalence of left ventricular hypertrophy and myocardial ischaemia; total and high-density lipoprotein cholesterol, 25-hydroxy-vitamin D and 1, 25-dihydroxy-vitamin D progressively decreased. Associations between EAT and cardiac alterations were not independent of VAT. During follow-up, 58 CV events occurred. A 1-SD higher EAT volume was associated with an increased risk of CV events in crude [hazard ratio (HR) 1.41, 95% confidence interval (CI) (1.12-1.78) and adjusted (HR 1.55, 95% CI 1.21-1.99) Cox models. However, adding EAT to a standard CV disease risk prediction model did not result in a clinically relevant improvement in prediction.

CONCLUSION

Epicardial adipose tissue accumulation in patients with CKD increases the risk of CV events independent of general adiposity. This is consistent with the notion of a local pathogenic effect of EAT on the heart or heart vessels, or both. However, EAT adds negligible explanatory power to standard CV disease risk factors.

Effects of nutritional supplementation on fatigue, and autonomic and immune dysfunction in patients with end-stage renal disease: a randomized, double-blind, placebo-controlled, multicenter trial

BACKGROUND

Fatigue is a predictor of cardiovascular events in patients with end-stage renal disease (ESRD) undergoing hemodialysis treatment. We hypothesized that multinutritional support would improve quality of life, fatigue symptoms, and potential quantitative measures including endocrine, immune and autonomic functions in patients with ESRD undergoing hemodialysis.

METHODS

Two hundred and two hemodialysis patients were randomly assigned to receive active treatment (containing vitamin B1, vitamin B2, niacin, vitamin B6, vitamin B12, folic acid, vitamin C, carnitine, coenzyme Q10, naïve galacto-oligosaccharide, and zinc) or placebo after each dialysis session for 12 weeks. The patients and attending physicians were blinded to the treatment, and 172 patients (86 in each group) completed the study. Fatigue was evaluated via fatigue questionnaire at 0, 4, and 12 weeks. To assess human herpes virus (HHV) 6 and 7 reactivation, numbers of viral DNA copies were determined in saliva by polymerase chain reaction at weeks 0 and 12. Autonomic function was determined via measurement of beat-to-beat variation by using acceleration plethysmography.

RESULTS

Clinical characteristics, changes in fatigue, quality of life score, endocrine functions, and laboratory data did not differ significantly between the two groups. Several parameters of heart rate variability significantly increased after nutritional treatment compared to placebo. Nutritional drink for 12 weeks significantly suppressed HHV7 DNA copy numbers. Similarly, HHV6 DNA copy numbers tended to be decreased by treatment but without reaching statistical significance.

CONCLUSIONS

Nutritional supplementation may modulate immune and autonomic dysfunction in ESRD patients undergoing hemodialysis.

Association of epicardial adipose tissue, neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio with diabetic nephropathy

BACKGROUND

The relationship between diabetic nephropathy, visceral adipose tissue (VAT), and inflammation has been shown. The neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) are simple, inexpensive, and useful markers to determine inflammation. However, to date, in the literature, there have been no studies demonstrating the relationship between epicardial adipose tissue (EAT), inflammation, and albuminuria.

AIMS

We aimed to investigate the association between diabetic nephropathy, NLR, and PLR as inflammatory markers and EAT thickness.

METHODS

This was a cross-sectional study involving 200 diabetic patients. The patients were separated into three groups according to their albuminuria levels. The NLR and PLR were calculated from a complete blood count. EAT was measured by transthoracic echocardiography. The estimated glomerular filtration rate (eGFR) was calculated by the modification of diet in renal disease (MDRD) equation.

RESULTS

Disease duration, EAT, creatinine, NLR, PLR, absolute neutrophil, lymphocyte, and platelet count tended to increase with increasing albuminuria while the eGFR decreased. When patients were separated into two groups according to NLR and PLR medians, albuminuria levels increased with an increase of the NLR (p = 0.003) and PLR (p = 0.009). A correlation analysis showed that albuminuria was significantly correlated with EAT, disease duration, creatinine, eGFR, PLR, and NLR levels. Additionally, in a binary logistic regression analysis, EAT, NLR, and PLR were found to be independently associated with albuminuria.

CONCLUSIONS

Determining various inflammatory cytokines and measuring abdominal VAT in diabetic patients is complex and expensive. Simply measuring EAT and calculating NLR and PLR can predict inflammation and albuminuria in patients with diabetes.

A low serum free triiodothyronine level is associated with epicardial adipose tissue in peritoneal dialysis patients

AIM

Cardiovascular disease is a major cause of mortality in dialysis patients. Epicardial adipose tissue (EAT) has been proposed as a cardiovascular risk marker in this population. Subclinical hypothyroidism and low free triiodothyronine (fT3) levels are associated with EAT in patients without chronic renal failure. The aim of this study was to investigate the relationship between EAT and low free T3 levels in peritoneal dialysis (PD) patients.

METHODS

A total of 125 prevalent PD patients were enrolled in this cross-sectional study. The epicardial fat thickness (EFT) was measured by echocardiography, and the endothelial function was assessed by flow mediated dilatation (FMD). Thyroid function tests were performed by an enzyme immunoassay.

RESULTS

The mean age of the patients was 51 ± 13, and the time on PD was 36 months. The mean EFT was 6.7 ± 2.9 mm. The EFT correlated positively with the patient age, systolic blood pressure (BP), mean BP, high sensitivity C-reactive protein (hs-CRP) level and body mass index (BMI), and negatively with the fT3 level and FMD. The median fT3 value was 2.53, and patients were divided according to their serum fT3 values (within the normal range and below the reference level). Compared with patients in the low fT3 group, the subjects in the normal fT3 group had higher serum albumin levels and FMD, but a lower BMI, plasma fasting glucose level, EFT, TSH level, hs-CRP level, low density lipoprotein (LDL) cholesterol level and mean BP in office measurements, and both the diastolic BP and mean BP by ambulatory blood pressure measurement. A multivariate linear regression analysis showed that the EFT was predicted by the hs-CRP and fT3 levels.

CONCLUSION

Low free T3 levels are associated with the epicardial fat thickness in PD patients. Further studies are needed to evaluate the pathogenesis and to support these findings.

Epicardial fat tissue thickness is correlated with diminished levels of co-enzyme Q10, a major antioxidant molecule among hemodialysis patients

OBJECTIVES

Accelerated atherosclerosis is the major cause of mortality in patients on chronic maintenance hemodialysis (HD). Epicardial fat tissue (EFT) is a new risk factor in cardiovascular disease (CVD). The aim of this study was to evaluate the relation between plasma coenzyme Q10 levels (Co-Q10) which is a potent physiologic antioxidant and EFT thickness in HD patients.

DESIGN AND METHODS

Seventy one chronic HD patients and 65 age and sex matched healthy individuals were included in the study. Plasma Co-Q10 levels were performed by high-performance liquid chromatography (HPLC) measurements. EFT was measured by transthoracic echocardiograpy (TTE) performed with a VIVID 7 instrument.

RESULTS

Plasma Co-Q10 levels (1.36±0.43 vs 2.53±0.55, p<0.001) were significantly lower in HD patients compared to controls. EFT was significantly increased in HD patients compared to healthy controls (6.53±1.01 vs. 5.79±1.06 mm respectively, p<0.001). Correlation analysis showed that plasma Co-Q10 levels were inversely correlated with EFT (r=-0.263, p<0.05). Multiple linear regression analysis was used to define independent determinants of EFT in HD patients. According to linear regression analysis, age, BMI, total cholesterol and Co-Q10 levels were found to be independent predictors of EFT (adjusted r(2)=0.38, p<0.001).

CONCLUSION

This study demonstrated that EFT thickness was significantly higher among HD patients compared to healthy controls. In addition; this study was the first to demonstrate an inverse correlation between EFT thickness and Co-Q10 levels in this patient population.

An update on coronary artery disease and chronic kidney disease

Despite the improvements in diagnostic tools and medical applications, cardiovascular diseases (CVD), especially coronary artery disease (CAD), remain the most common cause of morbidity and mortality in patients with chronic kidney disease (CKD). The main factors for the heightened risk in this population, beside advanced age and a high proportion of diabetes and hypertension, are malnutrition, chronic inflammation, accelerated atherosclerosis, endothelial dysfunction, coronary artery calcification, left ventricular structural and functional abnormalities, and bone mineral disorders. Chronic kidney disease is now recognized as an independent risk factor for CAD. In community-based studies, decreased glomerular filtration rate (GFR) and proteinuria were both found to be independently associated with CAD. This paper will discuss classical and recent epidemiologic, pathophysiologic, and clinical aspects of CAD in CKD patients.

Predictors of epicardial adipose tissue in patients with type 2 diabetes mellitus

BACKGROUND

Epicardial adipose tissue (EAT), visceral fat depot of the heart, was found to be associated with coronary artery disease in cardiac and non-cardiac patients. Platelet-to-lymphocyte ratio (PLR) and neutrophil-to-lymphocyte ratio (NLR) were introduced as potential markers to determine inflammation in various disorders. Recently, atherogenic index of plasma (AIP) was found to be closely associated with atherosclerosis in general population. Waist circumference is commonly used to assess the risk factors in various metabolic disorders. There has been a well known relation between inflammation and peripheral adipose tissue in diabetes mellitus. However, the data regarding EAT and inflammation is scant in this population. Hence, we aimed to determine the relationship between PLR, NLR, AIP, waist circumference and EAT in diabetic patients.

METHODS

This was a cross-sectional study involving 156 patients with type 2 diabetes mellitus (87 females, 69 males; mean age, 53.62 ± 9.33 years) and 50 control subjects (35 females, 15 males; mean age, 51.06 ± 8.74 years). EAT was measured by using a trans-thoracic echocardiogram. Atherogenic index of plasma was calculated as the logarithmically transformed ratio of the serum triglyceride to high density lipoprotein (HDL)cholesterol. NLR and PLR were calculated as the ratio of the neutrophils and platelets to lymphocytes, respectively.

RESULTS

Waist circumference, PLR, NLR, AIP and EAT measurements were significantly higher in diabetic patients when compared to control subjects. When diabetic patients were separated into two groups according to their median value of EAT (Group 1, EAT < 4.53 (n = 78) and group 2, EAT ≥4.53 (n = 78)), group 2 patients had significantly higher Body mass index (BMI), waist circumference, AIP, NLR and PLR levels. In the bivariate correlation analysis, EAT was positively correlated with PLR, NLR, AIP, BMI and waist circumference (r = 0.197, p = 0.014; r = 0.229, p = 0.004; r = 0.161, p = 0.044; r = 0.248, p = 0.002; r = 0.306, p < 0.001, respectively). Waist circumference was found to be independent variables of EAT.

CONCLUSIONS

Simple calculation of PLR and measurement of waist circumference were found to be associated with increased EAT in diabetic patients.

Hybrid myocardial imaging for risk stratification prior to kidney transplantation: added value of coronary calcium and epicardial adipose tissue

BACKGROUND

Patient selection and optimal approach to risk stratification prior to kidney transplantation remain uncertain. We sought new predictors of an abnormal myocardial perfusion (MYP) stress test result.

METHODS

Retrospective study of 411 consecutive chronic kidney disease stages 4-5D patients awaiting kidney transplantation referred for risk stratification. PET-CT or SPECT-CT was used to assess MYP and quantify coronary artery calcium (CAC) and epicardial adipose tissue (EAT). Abnormal MYP was defined as a perfusion defect involving ≥5% of the left ventricular myocardium.

RESULTS

Fixed or reversible MYP defects were present in 41 patients (10%). Male sex, smoking, and history of cardiovascular disease were more prevalent; age was higher and CAC and EAT were greater in patients with MYP defects than in those with normal MYP. On multivariate logistic regression, EAT and CAC were independent predictors of abnormal MYP while diabetes mellitus showed a borderline association (P = .08). EAT added incremental diagnostic value to a model including age, CAC and diabetes mellitus [AUC 0.73 (95% CI 0.64-0.81) to 0.76 (95% CI 0.68-0.84; P = .02)]. Furthermore, the model containing EAT showed improved diagnostic discrimination.

CONCLUSIONS

Abnormal MYP on screening stress testing appears to be rare in patients awaiting kidney transplantation suggesting an excess of testing. EAT and CAC may help predict what patients are at higher risk of developing abnormalities of MYP under stress.

Epicardial adipose tissue predicts mortality in incident hemodialysis patients: a substudy of the Renagel in New Dialysis trial

BACKGROUND

Epicardial adipose tissue (EAT) has been described in the general population as an independent risk marker for incident coronary artery disease. In hemodialysis patients, it correlates with other markers of cardiovascular disease, but it is unknown if it is associated with adverse events.

METHODS

post hoc analysis of the Renagel in New Dialysis (RIND) patients study, a randomized trial of sevelamer versus calcium-based phosphate binders in 109 incident hemodialysis patients, followed for all-cause mortality for a median of 49.3 months. Patients underwent baseline cardiac computed tomography imaging within 120 days of dialysis initiation.

RESULTS

Baseline EAT measurements were available in 95 patients; EAT was positively correlated with age, body mass index, triglycerides, C-reactive protein, coronary artery calcium and aortic calcium, and negatively correlated with systolic and diastolic blood pressure, serum high density lipoprotein (HPL) cholesterol and serum phosphate (all P < 0.05). During follow-up, a total of 27 (28.4%) patients expired [mortality per 1000 patients/year: 95% confidence interval (95% CI) = 77 (64-94)]. Five-year survival rate was 44. 6% (95% CI: 21.1-65.7) and 71.2% (95% CI: 45.95-86.25) in patients with EAT above or below the median, respectively. Each 10 cc increase in EAT volume was associated with a significant 6% increase in the risk of death during follow-up [hazard ratio (HR): 1.060; 95% CI: 1.013-1.109; P-value = 0.012].

CONCLUSIONS

In this subanalysis of a randomized trial, EAT was an independent predictor of mortality in incident hemodialysis patients after ~4 years of follow-up. These hypothesis-generating findings will need confirmatory evidence.

Associations of epicardial fat with coronary calcification, insulin resistance, inflammation, and fibroblast growth factor-23 in stage 3-5 chronic kidney disease

BACKGROUND

Epicardial fat, quantified in a single multi-slice computed tomography (MSCT) slice, is a reliable estimate of total epicardial fat volume (EFV). We sought to determine risk factors for EFV detected in a single-slice MSCT measurement (ssEFV) in pre-dialysis chronic kidney disease (CKD) patients. Our primary objective was to determine the association between ssEFV and coronary artery calcification (CAC).

METHODS

94 pre-dialysis stage 3-5 CKD patients underwent MSCT to measure ssEFV and CAC. ssEFV was quantified at the level of the left main coronary artery. Measures of inflammation, traditional and kidney-related cardiovascular disease risk factors were collected.

RESULTS

Mean age: 63.7 ± 14 years, 56% male, 39% had diabetes, and mean eGFR: 25.1 ± 11.9 mL/min/1.73 m2. Mean ssEFV was 5.03 ± 2.4 cm3. By univariate analysis, body mass index (BMI) (r = 0.53; P = <0.0001), abdominal obesity (r = 0.51; P < 0.0001), high density lipoprotein (HDL) cholesterol (r = - 0.39; P = <0.0001), insulin resistance (log homeostasis model assessment of insulin resistance (log HOMA-IR)) (r = 0.38, P = 0.001), log interleukin-6 (IL-6) (r = 0.34; P = 0.001), and log urinary albumin to creatinine ratio (UACR) (r = 0.30, P = 0.004) demonstrated the strongest associations with ssEFV. Log coronary artery calcification (log CAC score) (r = 0.28, P = 0.006), and log fibroblast growth factor-23 (log FGF-23) (r = 0.23, P = 0.03) were also correlated with ssEFV. By linear regression, log CAC score (beta =0.40; 95% confidence interval (CI), 0.01-0.80; P = 0.045), increasing levels of IL-6 (beta = 0.99; 95% CI, 0.38 - 1.61; P = 0.002), abdominal obesity (beta = 1.86; 95% CI, 0.94 - 2.8; P < 0.0001), lower HDL cholesterol (beta = -2.30; 95% CI, - 3.68 to -0.83; P = 0.002) and albuminuria (log UACR, beta = 0.81; 95% CI, 0.2 to 1.4; P = 0.01) were risk factors for increased ssEFV.

CONCLUSIONS

In stage 3-5 CKD, coronary calcification and IL-6 and were predictors of ssEFV. Further studies are needed to clarify the mechanism by which epicardial fat may contribute to the pathogenesis of coronary disease, particularly in the CKD population.

Progression of aortic arch calcification over 1 year is an independent predictor of mortality in incident peritoneal dialysis patients

Backgrounds and Aims

The presence and progression of vascular calcification have been demonstrated as important risk factors for mortality in dialysis patients. However, since the majority of subjects included in most previous studies were hemodialysis patients, limited information was available in peritoneal dialysis (PD) patients. Therefore, the aim of this study was to investigate the prevalence of aortic arch calcification (AoAC) and prognostic value of AoAC progression in PD patients.

Methods

We prospectively determined AoAC by chest X-ray at PD start and after 12 months, and evaluated the impact of AoAC progression on mortality in 415 incident PD patients.

Results

Of 415 patients, 169 patients (40.7%) had AoAC at baseline with a mean of 18.1±11.2%. The presence of baseline AoAC was an independent predictor of all-cause [Hazard ratio (HR): 2.181, 95% confidence interval (CI): 1.336–3.561, P = 0.002] and cardiovascular mortality (HR: 3.582, 95% CI: 1.577–8.132, P = 0.002). Among 363 patients with follow-up chest X-rays at 12 months after PD start, the proportion of patients with AoAC progression was significantly higher in patients with baseline AoAC (64.2 vs. 5.3%, P<0.001). Moreover, all-cause and cardiovascular death rates were significantly higher in the progression groups than in the non-progression group (P<0.001). Multivariate Cox analysis revealed that AoAC progression was an independent predictor for all-cause (HR: 2.625, 95% CI: 1.150–5.991, P = 0.022) and cardiovascular mortality (HR: 4.008, 95% CI: 1.079–14.890, P = 0.038) in patients with AoAC at baseline.

Conclusions

The presence and progression of AoAC assessed by chest X-ray were independently associated with unfavorable outcomes in incident PD patients. Regular follow-up by chest X-ray could be a simple and useful method to stratify mortality risk in these patients.

Epicardial adipose tissue volume and cardiovascular disease in hemodialysis patients

OBJECTIVE

Epicardial adipose tissue (EAT) is proposed as a cardiovascular risk marker in non-uremic subjects. However, little is known about its role in patients with higher cardiovascular risk profile such as chronic kidney disease. The aim of this study was to investigate the relationship between EAT and several cardiovascular surrogate markers (coronary artery calcification (CAC), arterial stiffness and atherosclerosis) in patients on maintenance hemodialysis.

METHODS

A total of 191 prevalent hemodialysis patients were enrolled in this cross-sectional study. EAT and CAC scores (CACs) were determined by multi-slice computerized tomography, arterial stiffness by carotid-femoral pulse wave velocity (PWV), and carotid artery intima-media thickness (CA-IMT) by B-mode doppler ultrasonography.

RESULTS

Mean age was 59 ± 13 years and time on hemodialysis 75 ± 44 months. Twenty percent of the patients had diabetes. Mean EAT volume was 62.6 ± 26.8 cm(3)/m(2). Mean CA-IMT and PWV values increased across the EAT tertiles. EAT was correlated with age, female gender, body mass index, albumin and lipid parameters. Additionally, CA-IMT and PWV values were positively correlated with EAT. EAT volume was significantly higher in patients with CACs >10 compared to the patients with CACs ≤10. Despite the univariate associations between EAT and cardiovascular surrogate markers, only age, body mass index and total cholesterol levels were associated with EAT in adjusted models.

CONCLUSIONS

In prevalent hemodialysis patients, EAT is correlated with atherosclerosis, arterial stiffness and the presence of CAC. However, this correlation is not independent of other risk factors.