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Cook O, Cervi A, Laureano M, Gangji AS, Verhovsek M. Combined preoperative plasma exchange and red blood cell exchange transfusion in a renal transplant patient with protein S deficiency and hemoglobin SC disease. Transfus Apher Sci 2021; 61:103345. [DOI: 10.1016/j.transci.2021.103345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 11/30/2021] [Accepted: 12/13/2021] [Indexed: 10/19/2022]
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Brimble KS, Ganame J, Margetts P, Jain A, Perl J, Walsh M, Bosch J, Yusuf S, Beshay S, Su W, Zimmerman D, Lee SF, Gangji AS. Impact of Bioelectrical Impedance-Guided Fluid Management and Vitamin D Supplementation on Left Ventricular Mass in Patients Receiving Peritoneal Dialysis: A Randomized Controlled Trial. Am J Kidney Dis 2021; 79:820-831. [PMID: 34656640 DOI: 10.1053/j.ajkd.2021.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 08/27/2021] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVES Hypervolemia and vitamin D (Vit D) deficiency occur frequently in patients receiving peritoneal dialysis and may contribute to left ventricular hypertrophy (LVH). The effect of bioimpedance analysis-guided volume management or Vit D supplementation on LV mass among those receiving peritoneal dialysis is uncertain. STUDY DESIGN Two-by-two factorial randomized controlled trial. SETTING & PARTICIPANTS Sixty-five patients receiving chronic peritoneal dialysis. INTERVENTION BIA-guided volume management versus usual care and oral cholecalciferol 50,000u weekly for 8 weeks followed by 10,000u weekly for 44 weeks or matching placebo. OUTCOMES Change in left ventricular mass at one-year measured by cardiac magnetic resonance imaging. RESULTS Total body water decreased by 0.9L (standard deviation: 2.4) in the BIA group compared to a 1.5L (± 3.4) increase in the usual care group (adjusted between group difference: -2.4L [95% confidence interval: -4.1, -0.68], p=0.01). Left ventricular mass increased by 1.3g (± 14.3) in the BIA group and decreased by 2.4g (±37.7) in the usual care group (between group difference; +2.2g [-13.9, 18.3], p=0.78). Serum 25-OH Vit D concentration increased by a mean of 17.2 nmol/L (standard deviation: 30.8 nmol/L) in the cholecalciferol group and declined by 8.2 nmol/L (±24.3 nmol/L) in the placebo group (between group difference: 28.3 nmol/L [95% confidence interval 17.2, 39.4]; p<0.001). Left ventricular mass decreased by 3.0g (± 28.1g) in the cholecalciferol group and increased by 2.0g (±31.2g) in the placebo group (between group difference; -4.5g [-20.4, 11.5], p=0.58). LIMITATIONS Relatively small sample size with larger than expected variation in change in left ventricular mass. CONCLUSIONS BIA-guided volume management had a modest impact on volume status with no effect on the change in LV mass. Vitamin D supplementation increased serum Vit D concentration but had no effect on left ventricular mass.
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Affiliation(s)
- K Scott Brimble
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Canada.
| | - Javier Ganame
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Canada
| | - Peter Margetts
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Canada
| | - Arsh Jain
- Department of Medicine, Western University, London, Canada
| | - Jeffrey Perl
- Division of Nephrology, St. Michael's Hospital and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Canada
| | - Michael Walsh
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Canada; Department of Health Research Methodology, Evidence and Impact, McMaster University, Hamilton, Canada; Population Health Research Institute, Hamilton Health Sciences / McMaster University, Canada
| | - Jackie Bosch
- Population Health Research Institute, Hamilton Health Sciences / McMaster University, Canada
| | - Salim Yusuf
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Canada; Population Health Research Institute, Hamilton Health Sciences / McMaster University, Canada
| | - Samy Beshay
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Canada
| | - Winnie Su
- University of Buffalo, Buffalo, New York, United States
| | - Deborah Zimmerman
- Department of Medicine, University of Ottawa, Ottawa, Ontario Canada
| | - Shun Fu Lee
- Population Health Research Institute, Hamilton Health Sciences / McMaster University, Canada
| | - Azim S Gangji
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Canada
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Hou C, Moffat KA, Gangji AS, Ning S. Circulating heparin-like anticoagulants: Case report and review of literature. Transfusion 2020; 61:968-973. [PMID: 33350473 DOI: 10.1111/trf.16236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/25/2020] [Accepted: 10/06/2020] [Indexed: 11/29/2022]
Abstract
We report a case of a 56-year-old woman with a history of idiopathic thrombocytopenic purpura (ITP) following splenectomy on mycophenolate mofetil (MMF), who developed moderate bleeding after stopping MMF. Her laboratory testing suggested the presence of an abnormal circulating heparin-like anticoagulant with demonstrable anti-Xa activity. She was initially treated with antifibrinolytic therapy and was subsequently started on MMF alongside intravenous immunoglobulin, which significantly improved her bleeding symptoms. The presence of abnormal circulating heparin-like anticoagulants is a rare cause of coagulopathy. Few cases exist in the literature, with nearly all occurring in the setting of hematologic or solid-organ malignancy. The mechanism by which these endogenous anticoagulants develop is unclear. Clinical manifestations range from mild bleeding and bruising to life-threatening hemorrhage refractory to conventional therapy. Diagnosis of a heparin-like anticoagulant is based on coagulation testing as well as exclusion of other exogenous anticoagulants, acquired inhibitors, and/or factor deficiencies.
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Affiliation(s)
- Chenchen Hou
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Karen A Moffat
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Hamilton Regional Laboratory Medicine Program, Hamilton, Ontario, Canada
| | - Azim S Gangji
- Division of Nephrology, McMaster University and St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Shuoyan Ning
- Division of Hematology, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
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Rochwerg B, Lalji F, Cheung JH, Ribic CM, Meade MO, Cook DJ, Wilkieson TT, Hosek P, Jones G, Margetts PJ, Gangji AS. Using bioimpedance analysis to assess intensive care unit patients with sepsis in the post-resuscitation period: a prospective multicentre observational study. Can J Anaesth 2020; 67:437-444. [PMID: 31863280 DOI: 10.1007/s12630-019-01557-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 09/19/2019] [Accepted: 10/22/2019] [Indexed: 12/31/2022] Open
Abstract
PURPOSE Clinicians lack well-validated, non-invasive, objective tools to guide volume management in the post-resuscitative period. Bioimpedance analysis (BIA) represents a novel method for guiding fluid management. We studied the relationship of BIA vector length (VL), an indicator of volume status, to the need for mechanical ventilation in patients with sepsis. METHODS This is a multicentre prospective observational study at four Canadian ICUs. We examined adult patients admitted to the ICU within 72 hr of a sepsis diagnosis. Patients underwent daily BIA measurements for 30 days, until discharge from the ICU, or until death. Our primary outcome was the ongoing need for invasive mechanical ventilation, and we examined the association with VL using a generalized estimating equation. Our secondary analyses were targeted to determine an association between VL and other measures of volume status and acute kidney injury (AKI). RESULTS We enrolled 159 patients from four centres over 27 months. The mean (standard deviation [SD]) age was 64 (15) yr with a mean (SD) APACHE (acute physiology, age, chronic health evaluation) II score of 25 (10); 57% (n = 91) were male. A 50-unit (ohm·m) increase in VL over any time period was associated with a 30% decrease in the probability of requiring invasive mechanical ventilation (P < 0.03). Volume expansion, indicated by a shorter VL, correlated with higher edema scores (r = - 0.31; P < 0.001) and higher net 24-hr fluid balance (r = - 0.27, P < 0.001). Patients with AKI had a shorter overall VL (r = - 0.23; P = 0.003). CONCLUSIONS An increase in VL over time is associated with a decrease in probability of requiring invasive mechanical ventilation. Vector length correlates with other commonly used volume assessment methods in post-resuscitation patients with sepsis.
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Affiliation(s)
- Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, ON, Canada.
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
- Hamilton Health Sciences, 711 Concession St, Hamilton, ON, L8V 1C3, Canada.
| | - Faraz Lalji
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jason H Cheung
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Hamilton Health Sciences, 711 Concession St, Hamilton, ON, L8V 1C3, Canada
- St Joseph's Healthcare, Hamilton, ON, Canada
| | - Christine M Ribic
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- St Joseph's Healthcare, Hamilton, ON, Canada
| | - Maureen O Meade
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Hamilton Health Sciences, 711 Concession St, Hamilton, ON, L8V 1C3, Canada
| | - Deborah J Cook
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- St Joseph's Healthcare, Hamilton, ON, Canada
| | | | - Paul Hosek
- Grand River Hospital, Kitchener, ON, Canada
| | - Graham Jones
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Hamilton Health Sciences, 711 Concession St, Hamilton, ON, L8V 1C3, Canada
| | - Peter J Margetts
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- St Joseph's Healthcare, Hamilton, ON, Canada
| | - Azim S Gangji
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- St Joseph's Healthcare, Hamilton, ON, Canada
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Gangji AS, Helal BA, Churchill DN, Brimble KS, Margetts PJ. Association between N-Terminal Propeptide B-Type Natriuretic Peptide and Markers of Hypervolemia. Perit Dial Int 2020. [DOI: 10.1177/089686080802800319] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Affiliation(s)
- Azim S. Gangji
- Division of Nephrology McMaster University Hamilton, Ontario, Canada
- McMaster University and St. Joseph's Healthcare Department of Clinical Epidemiology and Biostatistics McMaster University Hamilton, Ontario, Canada
| | - Bassam Al Helal
- Division of Nephrology McMaster University Hamilton, Ontario, Canada
| | - David N. Churchill
- Division of Nephrology McMaster University Hamilton, Ontario, Canada
- McMaster University and St. Joseph's Healthcare Department of Clinical Epidemiology and Biostatistics McMaster University Hamilton, Ontario, Canada
| | - K. Scott Brimble
- Division of Nephrology McMaster University Hamilton, Ontario, Canada
| | - Peter J. Margetts
- Division of Nephrology McMaster University Hamilton, Ontario, Canada
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Padwal M, Cheng G, Liu L, Boivin F, Gangji AS, Brimble KS, Bridgewater D, Margetts PJ. WNT signaling is required for peritoneal membrane angiogenesis. Am J Physiol Renal Physiol 2018; 314:F1036-F1045. [DOI: 10.1152/ajprenal.00497.2017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
The wingless-type mouse mammary tumor virus integration site family (WNT) signaling pathway is involved in wound healing and fibrosis. We evaluated the WNT signaling pathway in peritoneal membrane injury. We assessed WNT1 protein expression in the peritoneal effluents of 54 stable peritoneal dialysis (PD) patients and WNT-related gene expression in ex vivo mesothelial cell cultures from 21 PD patients. In a transforming growth factor-β (TGF-β)-mediated animal model of peritoneal fibrosis, we evaluated regulation of the WNT pathway and the effect of WNT inhibition on peritoneal fibrosis and angiogenesis. WNT1 and WNT2 gene expression were positively correlated with peritoneal membrane solute transport in PD patients. In the mouse peritoneum, TGF-β-induced peritoneal fibrosis was associated with increased expression of WNT2 and WNT4. Peritoneal β-catenin protein was significantly upregulated after infection with adenovirus expressing TGF-β (AdTGF-β) along with elements of the WNT signaling pathway. Treatment with a β-catenin inhibitor (ICG-001) in mice with AdTGF-β-induced peritoneal fibrosis resulted in attenuation of peritoneal angiogenesis and reduced vascular endothelial growth factor. Similar results were also observed with the WNT antagonist Dickkopf-related protein (DKK)-1. In addition to this, DKK-1 blocked epithelial-mesenchymal transition and increased levels of the cell adhesion protein E-cadherin. We provide evidence that WNT signaling is active in the setting of experimental peritoneal fibrosis and WNT1 correlates with patient peritoneal membrane solute transport in PD patients. Intervention in this pathway is a possible therapy for peritoneal membrane injury.
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Affiliation(s)
- Manreet Padwal
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Genyang Cheng
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Limin Liu
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Felix Boivin
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Azim S. Gangji
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | | | - Peter J. Margetts
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Ribic CM, Holland D, Howell J, Jevnikar A, Kim SJ, Knoll G, Lee B, Zaltzman J, Gangji AS. Study of Cardiovascular Outcomes in Renal Transplantation: A Prospective, Multicenter Study to Determine the Incidence of Cardiovascular Events in Renal Transplant Recipients in Ontario, Canada. Can J Kidney Health Dis 2017; 4:2054358117713729. [PMID: 28660072 PMCID: PMC5476328 DOI: 10.1177/2054358117713729] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 03/27/2017] [Indexed: 12/14/2022] Open
Abstract
Background: Renal transplant recipients (RTRs) are at significantly higher risk for morbidity and mortality compared with the general population, largely attributed to cardiovascular disease (CVD). Previous estimates of CVD events have come from health care databases and retrospective studies. Objective: The objective of this study was to prospectively determine the prevalence of risk factors and incidence of CVD events in a Canadian cohort of RTRs. Design: Study of Cardiovascular Outcomes in Renal Transplantation (SCORe) was a prospective, longitudinal, multicenter observational study. Setting: Adult RTRs were recruited from 6 participating transplant sites in Ontario, Canada. Patients: Eligible patients were those receiving a living or deceased donor renal transplant. Patients who received simultaneous transplant of any other organ were excluded. Measurements: Primary outcomes included myocardial infarction (MI) defined by American College of Cardiology (ACC-MI) criteria, and major adverse cardiac events (MACE), defined as cardiovascular (CV) death, ACC-MI, coronary revascularization, and nonhemorrhagic stroke. CV events were adjudicated by a single, independent cardiologist. Methods: CV and transplant-specific risk factors that predict MACE and ACC-MI were identified by stepwise regression analysis using the Cox proportional hazards model. Results: A total of 1303 patients enrolled across 6 transplant centers were followed for 4.5 ± 1.6 years (mean ± SD). Incidence of MACE was 7.0%, with significant independent predictors/risk factors including age, diabetes, coronary revascularization, nonhemorrhagic stroke, and renal replacement therapy (RRT). ACC-MI incidence was 4.0%, with significant independent predictors/risk factors including age, coronary revascularization, and duration of RRT in excess of the median value (2.91 years). Limitations: Patients were recruited from a single province, so may not reflect the experience of RTRs in other areas of Canada. Conclusions: Using a prospective design and rigorous methodology, this study found that the incidence of CV events after renal transplantation was elevated relative to the general Canadian population and was comparable with that reported in patient registries, thus helping validate the utility of retrospective analysis in this field. SCORe highlights the importance of monitoring RTRs for traditional cardiac and transplant-specific CV risk factors to help prevent CV morbidity and mortality. Further research is needed to investigate a broader range of potential risk factors and their combined effects on incident CV events.
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Affiliation(s)
- Christine M Ribic
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - David Holland
- Department of Medicine, School of Medicine, Queen's University, Kingston, Ontario, Canada
| | - John Howell
- Astellas Pharma Canada, Inc, Markham, Ontario, Canada
| | - Anthony Jevnikar
- Division of Nephrology, Department of Medicine, Western University, London, Ontario, Canada
| | - S Joseph Kim
- Division of Nephrology, Department of Medicine, University of Toronto, Ontario, Canada
| | - Greg Knoll
- Division of Nephrology, Department of Medicine, University of Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Health Research Institute, Ontario, Canada
| | - Brenda Lee
- Astellas Pharma Canada, Inc, Markham, Ontario, Canada
| | - Jeffrey Zaltzman
- Division of Nephrology, Department of Medicine, University of Toronto, Ontario, Canada
| | - Azim S Gangji
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Wilkieson TJ, Rahman MO, Gangji AS, Voss M, Ingram AJ, Ranganath N, Goldsmith CH, Kotsamanes CZ, Crowther MA, Rabbat CG, Clase CM. Coronary artery calcification, cardiovascular events, and death: a prospective cohort study of incident patients on hemodialysis. Can J Kidney Health Dis 2015; 2:29. [PMID: 26269747 PMCID: PMC4534029 DOI: 10.1186/s40697-015-0065-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 07/21/2015] [Indexed: 11/18/2022] Open
Abstract
Background Coronary calcification in patients with end-stage renal disease (ESRD) is associated with an increased risk of cardiovascular outcomes and death from all causes. Previous evidence has been limited by short follow-up periods and inclusion of a heterogeneous cluster of events in the primary analyses. Objective To describe coronary calcification in patients incident to ESRD, and to identify whether calcification predicts vascular events or death. Design Prospective substudy of an inception cohort. Setting Tertiary care haemodialysis centre in Ontario (St Joseph’s Healthcare Hamilton). Participants Patients starting haemodialysis who were new to ESRD. Measurements At baseline, clinical characterization and spiral computed tomography (CT) to score coronary calcification by the Agatston-Janowitz 130 scoring method. A primary outcome composite of adjudicated stroke, myocardial infarction, or death. Methods We followed patients prospectively to identify the relationship between cardiac calcification and subsequent stroke, myocardial infarction, or death, using Cox regression. Results We recruited 248 patients in 3 centres to our main study, which required only biochemical markers. Of these 164 were at St Joseph’s healthcare, and eligible to participate in the substudy; of these, 51 completed CT scanning (31 %). Median follow up was 26 months (Q1, Q3: 14, 34). The primary outcome occurred in 16 patients; 11 in the group above the median and 5 in the group below (p = 0.086). There were 26 primary outcomes in 16 patients; 20 (77 %) events in the group above the coronary calcification median and 6 (23 %) in the group below (p = 0.006). There were 10 deaths; 8 in the group above the median compared with 2 in the group below (p = 0.04). The hazard ratios for coronary calcification above, compared with below the median, for the primary outcome composite were 2.5 (95 % CI 0.87, 7.3; p = 0.09) and 1.7 (95 % CI 0.55, 5.4; p = 0.4), unadjusted and adjusted for age, respectively. For death, the hazard ratios were 4.6 (95 % CI 0.98, 21.96; p = 0.054) and 2.4 (95 % CI 0.45, 12.97; p = 0.3) respectively. Limitations We were limited by a small sample size and a small number of events. Conclusions Respondent burden is high for additional testing around the initiation of dialysis. High coronary calcification in patients new to ESRD has a tendency to predict cardiovascular outcomes and death, though effects are attenuated when adjusted for age.
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Affiliation(s)
- Trevor J Wilkieson
- Department of Medicine, McMaster University, 50 Charlton Avenue East, Hamilton, L8N4A6 ON Canada
| | - M Omair Rahman
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
| | - Azim S Gangji
- Department of Medicine, McMaster University, 50 Charlton Avenue East, Hamilton, L8N4A6 ON Canada ; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
| | - Maurice Voss
- Department of Radiology, McMaster University, Hamilton, Canada
| | - Alistair J Ingram
- Department of Medicine, McMaster University, 50 Charlton Avenue East, Hamilton, L8N4A6 ON Canada
| | - Nischal Ranganath
- Department of Medicine, McMaster University, 50 Charlton Avenue East, Hamilton, L8N4A6 ON Canada
| | - Charlie H Goldsmith
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada ; Faculty of Health Sciences, Simon Fraser University and Arthritis Research Centre of Canada, Richmond, Canada
| | - Cathy Z Kotsamanes
- Department of Medicine, McMaster University, 50 Charlton Avenue East, Hamilton, L8N4A6 ON Canada
| | - Mark A Crowther
- Department of Medicine, McMaster University, 50 Charlton Avenue East, Hamilton, L8N4A6 ON Canada
| | - Christian G Rabbat
- Department of Medicine, McMaster University, 50 Charlton Avenue East, Hamilton, L8N4A6 ON Canada
| | - Catherine M Clase
- Department of Medicine, McMaster University, 50 Charlton Avenue East, Hamilton, L8N4A6 ON Canada ; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
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Siddique I, Curran SP, Ghayur A, Liu L, Shi W, Hoff CM, Gangji AS, Brimble KS, Margetts PJ. Gremlin promotes peritoneal membrane injury in an experimental mouse model and is associated with increased solute transport in peritoneal dialysis patients. Am J Pathol 2014; 184:2976-84. [PMID: 25194662 DOI: 10.1016/j.ajpath.2014.07.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Revised: 07/10/2014] [Accepted: 07/14/2014] [Indexed: 11/29/2022]
Abstract
The peritoneal membrane becomes damaged in patients on peritoneal dialysis (PD). Gremlin 1 (GREM1) inhibits bone morphogenic proteins (BMPs) and plays a role in kidney development and fibrosis. We evaluated the role of gremlin in peritoneal fibrosis and angiogenesis. In a cohort of 32 stable PD patients, GREM1 concentration in the peritoneal effluent correlated with measures of peritoneal membrane damage. AdGrem1, an adenovirus to overexpress gremlin in the mouse peritoneum, induced submesothelial thickening, fibrosis, and angiogenesis in C57BL/6 mice, which was associated with decreased expression of BMP4 and BMP7. There was evidence of mesothelial cell transition to a mesenchymal phenotype with increased α smooth muscle actin expression and suppression of E-cadherin. Some of the GREM1 effects may be reversed with recombinant BMP7 or a pan-specific transforming growth factor β (TGF-β) antibody. Neovascularization was not inhibited with a TGF-β antibody, suggesting a TGF-β-independent angiogenic mechanism. Swiss/Jackson Laboratory (SJL) mice, which are resistant to TGF-β-induced peritoneal fibrosis, responded in a similar fashion to AdGrem1 as did C57BL/6 mice with fibrosis, angiogenesis, and mesothelial-to-mesenchymal transition. GREM1 was associated with up-regulated TGF-β expression in both SJL and C57BL/6 mice, but SJL mice demonstrated a defective TGF-β-induced GREM1 expression. In summary, GREM1 induces fibrosis and angiogenesis in mouse peritoneum and is associated with increased solute transport in these PD patients.
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Affiliation(s)
- Imad Siddique
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Simon P Curran
- Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
| | - Ayesha Ghayur
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Limin Liu
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Wei Shi
- Children's Hospital Los Angeles, University of Southern California, Los Angeles, California
| | | | - Azim S Gangji
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - K Scott Brimble
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Peter J Margetts
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
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Brimble KS, Mehrotra R, Tonelli M, Hawley CM, Castledine C, McDonald SP, Levidiotis V, Gangji AS, Treleaven DJ, Margetts PJ, Walsh M. Estimated GFR reporting influences recommendations for dialysis initiation. J Am Soc Nephrol 2013; 24:1737-42. [PMID: 23990673 DOI: 10.1681/asn.2013010035] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Automated reporting of estimated GFR (eGFR) with serum creatinine measurement is now common. We surveyed nephrologists in four countries to determine whether eGFR reporting influences nephrologists' recommendations for dialysis initiation. Respondents were randomly allocated to receive a survey of four clinical vignettes that included either serum creatinine concentration only or serum creatinine and the corresponding eGFR. For each scenario, the respondent was asked to rank his or her likelihood of recommending dialysis initiation on a modified 8-point Likert scale, ranging from 1 ("definitely not") to 8 ("definitely would"). Analysis of the 822 eligible responses received showed that the predicted likelihood of recommending dialysis increased by 0.55 points when eGFR was reported (95% confidence interval, 0.33 to 0.76), and this effect was larger for eGFRs >5 ml/min per 1.73 m(2) (P<0.001). Subgroup analyses suggested that physicians who had been in practice ≥13 years were more affected by eGFR reporting (P=0.03). These results indicate that eGFR reporting modestly increases the likelihood that dialysis is recommended, and physicians should be aware of this effect when assessing patients with severe CKD.
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Affiliation(s)
- K Scott Brimble
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Miller S, Pallan S, Gangji AS, Lukic D, Clase CM. Mercury-associated nephrotic syndrome: a case report and systematic review of the literature. Am J Kidney Dis 2013; 62:135-8. [PMID: 23602193 DOI: 10.1053/j.ajkd.2013.02.372] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Accepted: 02/25/2013] [Indexed: 11/11/2022]
Abstract
Kidney injury from mercury is known to cause dose-related tubular dysfunction and idiosyncratic nephrotic syndrome according to various case reports. Motivated by a patient with subacute-onset nephrotic syndrome, histologic features of secondary focal segmental glomerulosclerosis, and concurrent mercury toxicity, we conducted a systematic review to explore renal histologic changes in patients with toxic mercury exposures and nephrotic syndrome. Data were extracted from a patient's clinical record. MEDLINE/Ovid was searched from 1950 to November 2010 using a prespecified search strategy. Two nephrology textbooks and the UpToDate online database also were searched. Inclusion criteria were studies of humans with nephrotic syndrome, nephrotic-range proteinuria, or kidney biopsy results reported. There were no exclusion criteria. We identified 27 other reports of 42 patients with nephrotic syndrome or nephrotic-range proteinuria. Of the 26 individuals, including our patient, who underwent kidney biopsy, histology showed glomerular disease in 21. Of these 20 biopsies, 4 showed minimal change disease and 15 showed membranous glomerulonephritis. Mercury exposure can lead to various glomerular lesions; we emphasize the importance of a careful occupational and dietary history in elucidating a cause for the undetermined nephrotic syndrome.
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Affiliation(s)
- Saul Miller
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Su WS, Gangji AS, Margetts PM, Bosch J, Yusuf S, Clase CM, Ganame J, Noseworthy M, Lonn E, Jain AK, McCormick B, Brimble KS. The fluid study protocol: a randomized controlled study on the effects of bioimpedance analysis and vitamin D on left ventricular mass in peritoneal dialysis patients. Perit Dial Int 2011; 31:529-36. [PMID: 21632446 DOI: 10.3747/pdi.2010.00232] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES We will evaluate the effects of bioimpedance analysis-guided fluid management to reduce volume expansion, of vitamin D(3) supplementation, and of the combination of those techniques on decrease of left ventricular mass in peritoneal dialysis (PD) patients. DESIGN This multicenter randomized controlled trial, with a 2 × 2 factorial design, will be conducted at PD clinics affiliated with 3 Canadian teaching hospitals. Consenting PD patients 18 years of age or older will be included. Patients will be excluded if they have contraindications to bioimpedance or magnetic resonance imaging, life or technique expectancy of less than 1 year, peritonitis within the preceding 3 months, or serum calcium above 2.55 mmol/L. INTERVENTION The study will randomize 70 patients to bio-impedance-guided volume management or to usual care and to vitamin D(3) 50,000 U weekly for 8 doses, and then 10,000 U weekly or to matching placebo. MAIN OUTCOME MEASURES The primary outcome will be change in left ventricular mass at 1 year as determined by cardiac magnetic resonance imaging. The secondary outcome will be a composite endpoint of death, nonfatal cardiovascular event, and transfer to hemodialysis for dialysis inadequacy or ultrafiltration failure. Other outcome measures will include blood pressure, quality of life, 6-minute walk test, inflammatory and fibrotic markers and their association with peritoneal membrane transport properties, and residual renal function. Patients will be followed for clinical outcomes for up to 3 years. CONCLUSIONS This study will assess whether bioimpedance-directed volume management and vitamin D(3) supplementation can improve left ventricular mass in PD patients.
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Affiliation(s)
- Winnie S Su
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Su WS, Clase CM, Brimble KS, Margetts PJ, Wilkieson TJ, Gangji AS. Waist-to-Hip Ratio, Cardiovascular Outcomes, and Death in Peritoneal Dialysis Patients. Int J Nephrol 2010; 2010:831243. [PMID: 21188241 PMCID: PMC3003982 DOI: 10.4061/2010/831243] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2010] [Revised: 04/16/2010] [Accepted: 05/25/2010] [Indexed: 11/20/2022] Open
Abstract
Objectives. The primary objective of this study was to determine the relationship between waist-to-hip ratio (WHR), cardiovascular (CV) events, and mortality in peritoneal dialysis (PD) patients. A secondary objective was to investigate the association between abdominal obesity and systemic inflammatory markers. Methods. This is a prospective study of 22 prevalent PD patients. WHR was measured at baseline. C-reactive protein (CRP), tumour necrosis factor-α (TNF-α), and interleukin-6 (IL-6) were measured. Main outcomes were first CV event and death from all causes. Survival analysis was used to examine the relationship between anthropomorphic measures and clinical outcomes. Results. Mean follow-up period was 3.1 years. In Kaplan-Meier analysis, survival was lower in those with higher WHR (P = .002). In Cox regression, WHR independently predicted mortality and first CV event after adjustment for known ischemic heart disease (hazard ratio [HR] 1.17, confidence interval [CI] 1.05-1.30 for death; HR 1.13, CI 1.01-1.26 for CV event). WHR correlated with serum TNF-α (r = 0.45; P = .05). Conclusion. The results of this study suggest WHR may be a risk factor for increased CV events and mortality in PD patients. Abdominal obesity is also associated with inflammatory markers. Larger studies are warranted to confirm these findings.
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Affiliation(s)
- Winnie S Su
- Division of Nephrology, McMaster University, St. Joseph's Healthcare, Hamilton, ON, Canada L8N 4A6
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Lau JH, Gangji AS, Rabbat CG, Brimble KS. Impact of haemoglobin and erythropoietin dose changes on mortality: a secondary analysis of results from a randomized anaemia management trial. Nephrol Dial Transplant 2010; 25:4002-9. [PMID: 20530806 DOI: 10.1093/ndt/gfq330] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Anaemia is a common complication of chronic kidney disease. A number of studies have identified an adverse association between haemoglobin (Hgb) variability and mortality. To date, no study has evaluated the impact of Hgb variability on mortality in the setting of a uniform Hgb target and erythropoiesis-stimulating agents (ESA) dosing strategy. METHODS One hundred and fifty-four haemodialysis (HD) patients from a previous randomized anaemia management study were followed up for up to 6 years. The impact of Hgb variability and ESA dosing parameters on subsequent mortality risk were evaluated. RESULTS More rapid rises in Hgb (Hgb deflect(pos)) and ESA dose increases were independently associated with mortality in multivariate analysis, whereas more rapid Hgb declines (Hgb deflect(neg)) and ESA dose decreases were not. Each gram per litre per week increase in Hgb deflect(pos) was associated with an adjusted hazard ratio (HR) of 1.23 (1.03-1.48), while for every 1000-unit increase in ESA dose, the adjusted HR was 1.12 (1.01-1.24). Factors associated with positive Hgb deflections included frequency and magnitude of ESA dose changes, baseline Hgb, patient weight and presence of an HD catheter. CONCLUSIONS Rapid Hgb rises and greater average Eprex dose increases were independently associated with a higher mortality risk in HD patients after adjustment for baseline Hgb and Eprex dose. A randomized controlled trial evaluating different ESA dosing strategies in response to individual patient ESA responsiveness is needed.
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Affiliation(s)
- Joanne H Lau
- Division of Nephrology, Department of Medicine, McMaster University, Hamilton, Canada
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Gangji AS, Brimble KS, Margetts PJ. Association between markers of inflammation, fibrosis and hypervolemia in peritoneal dialysis patients. Blood Purif 2009; 28:354-8. [PMID: 19729905 DOI: 10.1159/000232937] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2008] [Accepted: 06/02/2009] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIM Volume expansion in peritoneal dialysis (PD) patients is associated with left ventricular hypertrophy. The link between inflammation and hypervolemia has not been extensively studied. The aim of this study was to determine if an association exists between hypervolemia and markers of inflammation in PD patients. METHODS In this cross-sectional study of 22 prevalent PD patients, volume was determined by bioelectrical impedance analysis. Serum and peritoneal effluent interleukin-6 (IL-6) and peritoneal transforming growth factor (TGF)-beta(1) were measured. A fast peritoneal equilibration test determined peritoneal transport status. RESULTS Bioimpedance-derived measures of hypervolemia correlated with peritoneal effluent IL-6 and TGF-beta(1). Peritoneal IL-6 was also associated with high peritoneal transport status. CONCLUSIONS Markers of inflammation and fibrosis (peritoneal IL-6 and TGF-beta(1)) are associated with markers of hypervolemia.
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Affiliation(s)
- Azim S Gangji
- Division of Nephrology, McMaster University and St. Joseph's Healthcare, Hamilton, Ont., Canada
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Gangji AS, Helal BA, Churchill DN, Brimble KS, Margetts PJ. Association between N-terminal propeptide B-type natriuretic peptide and markers of hypervolemia. Perit Dial Int 2008; 28:308-311. [PMID: 18474925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023] Open
Affiliation(s)
- Azim S Gangji
- Division of Nephrology, McMaster University, McMaster University, Hamilton, Ontario, Canada
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Gangji AS, Cukierman T, Gerstein HC, Goldsmith CH, Clase CM. A systematic review and meta-analysis of hypoglycemia and cardiovascular events: a comparison of glyburide with other secretagogues and with insulin. Diabetes Care 2007; 30:389-94. [PMID: 17259518 DOI: 10.2337/dc06-1789] [Citation(s) in RCA: 228] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Glyburide is the most widely used sulfonylurea but has unique pharmacodynamic properties that may increase harm. We hypothesized that glyburide causes more hypoglycemia and cardiovascular events than other secretagogues or insulin. RESEARCH DESIGN AND METHODS Data sources were Medline, Embase, Cochrane, and three other web-based clinical trial registers (1966-2005). Parallel, randomized, controlled trials in people with type 2 diabetes comparing glyburide monotherapy with monotherapy using secretagogues or insulin were selected. Outcomes were hypoglycemia, glycemic control, cardiovascular events, body weight, and death. Titles and abstracts of 1,806 publications were reviewed in duplicate and 21 relevant articles identified. Data on patient characteristics, interventions, outcomes, and validity were extracted in duplicate using predefined criteria. RESULTS Glyburide was associated with a 52% greater risk of experiencing at least one episode of hypoglycemia compared with other secretagogues (relative risk 1.52 [95% CI 1.21-1.92]) and with 83% greater risk compared with other sulfonylureas (1.83 [1.35-2.49]). Glyburide was not associated with an increased risk of cardiovascular events (0.84 [0.56-1.26]), death (0.87 [0.70-1.07]), or end-of-trial weight (weighted mean difference 1.69 kg [95% CI -0.41 to 3.80]) compared with other secretagogues. Limitations included suboptimal reporting of original trials. Loss to follow-up exceeded 20% in some studies, and major hypoglycemia was infrequently reported. CONCLUSIONS Glyburide caused more hypoglycemia than other secretagogues and other sulfonylureas. Glyburide was not associated with an increased risk of cardiovascular events, death, or weight gain.
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Affiliation(s)
- Azim S Gangji
- Division of Nephrology, McMaster University and St. Joseph's Healthcare, 708-25 Charlton Avenue East, Hamilton, Ontario L8P 3P7, Canada
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Gangji AS, Sohal AS, Treleaven D, Crowther MA. Bleeding in patients with renal insufficiency: A practical guide to clinical management. Thromb Res 2006; 118:423-8. [PMID: 15975636 DOI: 10.1016/j.thromres.2005.03.029] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2005] [Revised: 03/04/2005] [Accepted: 03/08/2005] [Indexed: 12/01/2022]
Affiliation(s)
- Azim S Gangji
- Department of Medicine, McMaster University, 25 Charlton Avenue East, Hamilton, Ontario, Canada L8N lY2
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Sohal AS, Gangji AS, Crowther MA, Treleaven D. Uremic bleeding: pathophysiology and clinical risk factors. Thromb Res 2005; 118:417-22. [PMID: 15993929 DOI: 10.1016/j.thromres.2005.03.032] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2005] [Revised: 03/04/2005] [Accepted: 03/08/2005] [Indexed: 12/31/2022]
Abstract
Renal insufficiency appears clinically to be associated with a bleeding tendency. This has been documented in clinical settings including as a complication of medical interventions such as surgery and also in spontaneous bleeding events at gastrointestinal and intracranial sites. The pathophysiology that underlies this tendency appears to involve platelet dysfunction and an imbalance of mediators of normal endothelial function. It is also may be complicated by the co-morbidities in this population, such as vascular disease, hypertension and anemia, and the medical interventions required to treat such co-morbidities. This article reviews the evidence, the pathophysiology and the risk factors for increased bleeding in patients with chronic renal insufficiency.
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Affiliation(s)
- Avtar S Sohal
- Department of Medicine, McMaster University, 25 Charlton Avenue East, Hamilton, Ontario, Canada L8N lY2
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Gangji AS, Rabbat CG, Margetts PJ. Benefit of continuous renal replacement therapy in subgroups of acutely ill patients: a retrospective analysis. Clin Nephrol 2005; 63:267-75. [PMID: 15847253 DOI: 10.5414/cnp63267] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
AIMS Acute renal failure in the intensive care setting is common and impacts on patient's outcome. Continuous hemodialysis or hemofiltration offers theoretical benefit for patients with acute renal failure, but the clinical benefit has not been demonstrated in randomized trials. ICU patients with acute renal failure are a heterogeneous population and we hypothesize that patients with increased illness severity would benefit from continuous renal replacement therapy. METHODS From a comprehensive ICU database, we identified patients with acute renal failure exposed to continuous or intermittent renal replacement therapy. We a priori identified a subgroup of patients with multiple organ dysfunction syndrome, then used survival analysis to assess the effect of dialysis modality in the overall acute renal failure population and in the subgroup with increased illness severity. RESULTS We identified 66 patients treated with intermittent and 36 patients treated with continuous renal replacement therapy. Patients with severe illness were preferentially selected for treatment with continuous dialysis (p = 0.01). Overall, there was no significant difference in survival between patients treated with intermittent or continuous dialysis. The relative risk of in-hospital mortality was significantly decreased in patients with multiple organ dysfunction syndrome (relative risk = 0.42+/-0.22, p = 0.027) treated with continuous therapy as compared with intermittent therapy. Among the survivors, continuous dialysis did not appear to hasten the return of renal function. CONCLUSIONS This retrospective study suggests that continuous dialysis may be beneficial in a subgroup of ICU patients with multiple organ dysfunction syndrome or severe sepsis. Further randomized trials of dialysis modality should, if possible, concentrate on this population.
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Affiliation(s)
- A S Gangji
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Gangji AS, Windrim R, Gandhi S, Silverman JA, Chan CTM. Successful pregnancy with nocturnal hemodialysis. Am J Kidney Dis 2004; 44:912-6. [PMID: 15492959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
A 31-year-old woman with end-stage renal disease was referred to the Toronto General Hospital (Ontario, Canada) for conversion from conventional hemodialysis (CHD; 4 h/session, 3 sessions/wk) to nocturnal hemodialysis (NHD; 7 h/session, 5 to 6 treatments/wk) because of refractory hypertension. As expected, blood pressure control was superior with NHD therapy, and her requirement of vasoactive medications also decreased. To our surprise, 8 months after conversion to NHD therapy, she regained normal menstrual cycles. Two years after NHD therapy initiation, the patient became pregnant, at which time her dialysis prescription was changed to 7.5 h/session, 7 nights/wk. During her pregnancy, blood pressure was well controlled, and biochemical, hematologic, and metabolic parameters were targeted to physiological levels. The patient had an uncomplicated vaginal delivery of a healthy 3,025-g infant at 38 weeks' gestation. This case shows that on NHD therapy, our patient was able to resume ovulation and have an uncomplicated pregnancy. We speculate that augmentation of uremic clearance by means of NHD was pivotal in maintaining a normal nonproblematic pregnancy. Future studies are required to further understand the impact of intensive hemodialysis therapy on reproductive endocrine functions and determine the best management of such patients during pregnancy.
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Affiliation(s)
- Azim S Gangji
- Department of Medicine, Division of Nephrology, Toronto General Hospital and University Health Network, Toronto, Canada
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