A Modified Two-Bun Method for Routine Urea Modeling: Clinical Validation in 120 Patients on a Free Diet

Recently, a modified algorithm of the Two-BUN method (MA2p), avoiding dialyzer clearance measurement, was presented for routine assessment of Kt/V and NPCR. To validate MA2p in patients on a free diet (FDP), we studied 120 stable dialysis FDP by measuring Kt/V and NPCR with both MA2p and a modified version of the standard Three-BUN method (MA3p), for the 3 weekly sessions. The NPCR values (g/kg/day), calculated by MA3p for the 3 interdialyses were: 1.286∓0.274, 1.256∓0.276, and 1.116∓0.230, respectively. The correlation coefficient (r) for averaged Kt/V values obtained by the two methods was 0.999 and the percent error (Error%) for MA2p vs. MA3p results ranged from -1.5 to +0.78%. The respective results for NPCR were: r=0.967, Error% range from -11.7 to +13.9%. In conclusion, MA2p can be safely used in patients on a free diet. The lowest NPCR values were observed during the long interdialysis.

Charlson Comorbidity Index is a Predictor of Outcomes in Incident Hemodialysis Patients and Correlates with Phase Angle and Hospitalization

Background

The adjustment of comorbidity is important in international hemodialysis comparisons. The aim of this study is to verify if it is possible to use the Charlson Comorbidity Index (CCI), in an Italian population of incident hemodialysis patients from the Campania region as outcome predictors. A similar proposal has already been made for an American population of incident patients in peritoneal dialysis. Methods: The data for this study come from the Uremic Registry of Campania taken in the year 2001. This is an observational study in which demographic, comorbid, laboratory, treatment and insurance data were collected in 111 dialysis units (70%) in Campania. We evaluated 515 hemodialysis incident patients who were hemodialyzed in Campania between January 1 and December 31, 2001. The study was restricted to patients who had already undergone 90 days of hemodialysis. The duration of this study was 15 months. Charlson Comorbidity Index was performed. In 128 patients (24.8%) BIA measurements were performed after dialysis. Statistics: We used Student's t test for unpaired data and Cox proportional model to analyze predictors of mortality. The variables analyzed were age at start of hemodialysis, sex, CCI, hemoglobin, diabetes, hypertension, albumin, days of hospitalization. The statistically significant variables, analyzed initially by univariate analysis, were chosen for multivariate analysis. We considered p< 0.05 statistically significant.

Results

A total of 515 patients (M=316, F=199) (age: 63.62±15.35 years) presented with the following diseases: NO diagnosed in 93 patients (19%), GN in 64 (13%) IN in 42 (9%), Hereditary in 55 (11%), Vascular in 66 (14%), Diabetes in 135 (28%), others in 30 (6%). Hemoglobin levels were 10.71±1.51 g/dL and albumin was 3.79±0.54 g/dL. The days of hospitalization for the population studied were 3364/year. After the study, 75 patients died and the overall mortality rate was 11.65/100 patient/years. Univariate analysis shows that there are significant differences calculated for age (median value 73 and 65 years, respectively for non-survivers and survivers), BMI (median value and 22 and 24 kg/m2, respectively), Hb (median value 9.5 and 11g/dL, respectively), Albumin (median value 3.5 and 3.8 g/dL, respectively), days of hospitalization (median value 8 and zero days, respectively), CCI (median value 6 and 4 score, respectively, phase angle (median value 3.3 and 4 degree, respectively). The mortality rates (100 dialysis years) by the CCI score: the mortality rate was zero for patients with a CCI of 3; and it increased to approximately 60% of patient years with a CCI score of 6 or greater. The linear correlation between CCI and phase angle in living (y=18.90 × - 3.83; R2 = 0.56) and in the dead (y = 13.01 × - 1.87; R2 = 0.29).

Discussion

We found that CCI is a strong predictor of mortality in incident HD patients as has also been indicated in PD patients; CCI correlates with phase angle calculated from Bioelectrical Impedance Analysis and this last factor can be used in the following examinations; several days of hospitalization are a very important determinant in the survival in hemodialysis patients.

Central Venous Catheters in Hemodialysis: An Actual Conundrum without Solutions

Vascular access maintenance is a major problem for adequate care of End Stage Renal Disease. An ideal access delivers an adequate flow rate for the HD prescription, remains usable for an indefinitely long period of time, and has a low complication rate. The native arteriovenous fistula (AVF) remains the best access, but this option may be impraticable in many conditions. This paper describes why to use CVC, where CVC can be positioned and how CVC infections can be prevented. Also today, vascular access in hemodialysis remains the conundrum without solution, but it is often necessary and remains the only possible venous access in a particular category of patients.

Prevalence and Correlates of Anemia and Uncontrolled Anemia in Chronic Hemodialysis Patients – The Campania Dialysis Registry

Background

This study investigated prevalence and correlates of anemia and uncontrolled anemia in chronic hemodialysis patients.

Methods

A cross-sectional analysis was performed on registry data for 2,746 chronic (<6 months) hemodialysis patients aged 25–84. Data collection included years of dialysis, hours of dialysis/wk, disease causing hemodialysis, body mass index (BMI), erythropoietin (EPO) treatment, hemoglobin, markers of viral hepatitis, serum albumin, calcium, and phosphorus.

Results

Prevalence was 88.7% for anemia (hemoglobin <11 g/100 mL and EPO treatment at any Hb level), 39.4% for uncontrolled anemia (hemoglobin<11 g/100 mL). Gender, years of dialysis, hereditary cystic kidney disease (HCKD), and low BMI (<24 kg/m2) were independent correlates of anemia (P<0.001). Gender, HCKD, low BMI, serum albumin and calcium were independent correlates of uncontrolled anemia (P<0.05). An interaction was found between age (not correlated with anemia and uncontrolled anemia) and the association of gender with uncontrolled anemia (P<0.05). EPO doses were higher in patients with high prevalence of uncontrolled anemia than in patients with low prevalence (i.e., women vs men, other diseases vs HCKD, low vs not-low BMI, P<0.01). Gender, years of dialysis, HCKD, BMI, serum albumin, and calcium were independent correlates of the hemoglobin/EPO dose ratio in patients on EPO treatment (P<0.05).

Conclusion

Anemia and uncontrolled anemia are more frequent in hemodialysis patients with short-term dialysis, diseases other than HCKD, low BMI, and female gender. Gender effect was lower in elderly patients. Uncontrolled anemia was also associated with low serum albumin and calcium, suggesting that these parameters are indices of EPO resistance.

Nonvitamin K-dependent oral anticoagulants (NOACs) in chronic kidney disease patients with atrial fibrillation

Atrial fibrillation (AF) represents the most common arrhythmia in patients with chronic kidney disease (CKD). As in the general population, in CKD patients AF is associated with an increased risk of thromboembolism and stroke. However, CKD patients, especially those on renal replacement therapy (RRT), also exhibit an increased risk of bleeding, especially from the gastrointestinal tract. Oral anticoagulation is the most effective form of thromboprophylaxis in patients with AF presenting increased risk of stroke. Limited evidence on efficacy, the increased risk of bleeding as well as some concern regarding the use of warfarin in CKD, has often resulted in the underuse of anticoagulation CKD patients. A large body of evidence suggests that non-vitamin K-dependent oral anticoagulant agents (NOACs) significantly reduce the risk of stroke, intracranial hemorrhage, and mortality, with lower to similar major bleeding rates compared with vitamin K antagonist such as warfarin in normal renal function subjects. Hence, they are currently recommended for patients with atrial fibrillation at risk for stroke. However, NOACs metabolism is largely dependent on the kidneys for elimination and little is known in patients with creatinine clearance <25ml/min who were excluded from all pivotal phase 3 NOACs trials. This review focuses on the current pharmacokinetic, observational, and prospective data on NOACs in patients with moderate to advanced chronic kidney disease (creatinine clearance 15-49ml/min) and those on dialysis.

Pathophysiology of the cardio-renal syndromes types 1-5: An uptodate

According to the recent definition proposed by the Consensus conference on Acute Dialysis Quality Initiative Group, the term cardio-renal syndrome (CRS) has been used to define different clinical conditions in which heart and kidney dysfunction overlap. Type 1 CRS (acute cardio- renal syndrome) is characterized by acute worsening of cardiac function leading to AKI (5, 6) in the setting of active cardiac disease such as ADHF, while type - 2 CRS occurs in a setting of chronic heart disease. Type 3 CRS is closely link to acute kidney injury (AKI), while type 4 represent cardiovascular involvement in chronic kidney disese (CKD) patients. Type 5 CRS represent cardiac and renal involvement in several diseases such as sepsis, hepato - renal syndrome and immune - mediated diseases.

Subendocardial viability ratio predicts cardiovascular mortality in chronic kidney disease patients

BACKGROUND

The subendocardial viability ratio (SEVR), calculated by pulse wave analysis, is an index of myocardial oxygen supply and demand. Here we analyze the relation between SEVR and cardiovascular mortality in the chronic kidney disease (CKD) population of a post hoc analysis of a multicenter, prospective, randomized, nonblinded study.

METHODS

We studied 212 consecutive asymptomatic outpatients receiving care at 12 nephrology clinics in south Italy. Inclusion criteria were age >18 years, 6 months of follow-up before the enrollment and stage 3-4 CKD.

RESULTS

During follow-up, 34 subjects died, 29 of them for cardiovascular causes. SEVR correlated inversely with vascular calcifications (r = -0.37) and myocardial mass (r = -0.45); SEVR changed from 1.33 ± 0.24 to 1.36 ± 0.16 (p = NS; baseline and final values, respectively) in living patients, and from 1.16 ± 0.31 to 0.68 ± 0.26 in deceased patients (p < 0.001). Kaplan-Meier curves show that that a greater reduction of SEVR values during the study (third tertile) significantly predicts cardiovascular mortality (p < 0.0001).

CONCLUSIONS

This post hoc analysis shows that a reduction of SEVR values impacts cardiovascular mortality in CKD patients.

[Effects of dose of erythropoiesis stimulating agents on cardiovascular outcomes, quality of life and costs of haemodialysis. the clinical evaluation of the DOSe of erythropoietins (C.E. DOSE) Trial]

BACKGROUND

Anaemia is a risk factor for death, adverse cardiovascular outcomes and poor quality of life in patients with chronic kidney disease (CKD). Erythropoietin Stimulating Agents (ESA) are the most used treatment option. In observational studies, higher haemoglobin (Hb) levels (around 11-13 g/dL) are associated with improved survival and quality of life compared to Hb levels around 9-10 g/dL. Randomized studies found that targeting higher Hb levels with ESA causes an increased risk of death, mainly due to adverse cardiovascular outcomes. It is possible that this is mediated by ESA dose rather than haemoglobin concentration, although this hypothesis has never been formally tested.

METHODS

We present the protocol of the Clinical Evaluation of the Dose of Erythropoietins (C.E. DOSE) trial, which will assess the benefits and harms of a high versus a low ESA dose therapeutic strategy for the management of anaemia of end stage kidney disease (ESKD). This is a randomized, prospective open label blinded end-point (PROBE) design trial due to enroll 900 haemodialysis patients. Patients will be randomized 1:1 to 4000 UI/week i. v. versus 18000 UI/week i. v. of epoetin alfa, beta or any other epoetin in equivalent doses. The primary outcome of the trial is a composite of cardiovascular events. In addition, quality of life and costs of these two strategies will be assessed. The study has been approved and funded by the Italian Agency of Drugs (Agenzia Italiana del Farmaco (AIFA)) within the 2006 funding plan for independent research on drugs (registered at www.clinicaltrials.gov (NCT00827021)).

High-tone external muscle stimulation in end-stage renal disease: effects on symptomatic diabetic and uremic peripheral neuropathy

OBJECTIVE AND DESIGN

Pain and peripheral neuropathy are frequent complications of end-stage renal disease (ESRD). Because drug treatment is associated with numerous side effects and is largely ineffective in many maintenance hemodialysis (MHD) patients, nonpharmacologic strategies such as electrotherapy are a potential recourse. Among various forms of electrostimulation, high-tone external muscle stimulation (HTEMS) is a promising alternative treatment for symptomatic diabetic peripheral polyneuropathy (PPN), as demonstrated in a short-term study. Based on these novel findings, we performed a prospective, nonrandomized, pilot trial in MHD patients to determine (1) whether HTEMS is also effective in treating diabetic PPN in the uremic state, and (2) whether uremic PPN is similarly modulated.

PATIENTS AND INTERVENTIONS

In total, 40 MHD patients diagnosed with symptomatic PPN (25 with diabetic and 15 with uremic PPN) were enrolled. Both lower extremities were treated intradialytically with HTEMS for 1 hour, three times a week. Initially, a subgroup of 12 patients was followed for 4 weeks, and a further 28 patients for 12 weeks. The patients' degree of neuropathy was graded at baseline before HTEMS and after 1 and 3 months, respectively. Five neuropathic symptoms (tingling, burning, pain, numbness, and numbness in painful areas) as well as sleep disturbances were measured, using the 10-point Neuropathic Pain Scale of Galer and Jensen (Neurology 48:332-338, 1997). A positive response was defined as the improvement of one symptom or more, by at least 3 points. Other parameters included blood pressure, heart rate, dry body weight, and a routine laboratory investigation.

RESULTS

The HTEMS led to a significant improvement in all five neuropathic symptoms, and to a significant reduction in sleep disturbances for both diabetic and uremic PPN. The response was independent of the patient's age, with a responder rate of 73%. The improvement of neuropathy was time-dependent, with the best results achieved after 3 months of treatment. The HTEMS was well-tolerated by nearly all patients.

CONCLUSIONS

This pilot study shows for the first time that HTEMS can ameliorate the discomfort and pain associated with both diabetic and uremic PPN in MHD patients, and could be a valuable supplement in the treatment of pain and neuropathic discomfort in patients who do not respond to, or are unable to participate in, exercise programs during hemodialysis treatment.

Prevalence and correlates of anemia and uncontrolled anemia in chronic hemodialysis patients--the Campania Dialysis Registry

BACKGROUND

This study investigated prevalence and correlates of anemia and uncontrolled anemia in chronic hemodialysis patients.

METHODS

A cross-sectional analysis was performed on registry data for 2,746 chronic (>6 months) hemodialysis patients aged 25-84. Data collection included years of dialysis, hours of dialysis/wk, disease causing hemodialysis, body mass index (BMI), erythropoietin (EPO) treatment, hemoglobin, markers of viral hepatitis, serum albumin, calcium, and phosphorus.

RESULTS

Prevalence was 88.7% for anemia (hemoglobin <11 g/100 mL and EPO treatment at any Hb level), 39.4% for uncontrolled anemia (hemoglobin<11 g/100 mL). Gender, years of dialysis, hereditary cystic kidney disease (HCKD), and low BMI (<24 kg/m2) were independent correlates of anemia (P<0.001). Gender, HCKD, low BMI, serum albumin and calcium were independent correlates of uncontrolled anemia (P<0.05). An interaction was found between age (not correlated with anemia and uncontrolled anemia) and the association of gender with uncontrolled anemia (P<0.05). EPO doses were higher in patients with high prevalence of uncontrolled anemia than in patients with low prevalence (i.e., women vs men, other diseases vs HCKD, low vs not-low BMI, P<0.01). Gender, years of dialysis, HCKD, BMI, serum albumin, and calcium were independent correlates of the hemoglobin/EPO dose ratio in patients on EPO treatment (P<0.05).

CONCLUSION

Anemia and uncontrolled anemia are more frequent in hemodialysis patients with shortterm dialysis, diseases other than HCKD, low BMI, and female gender. Gender effect was lower in elderly patients. Uncontrolled anemia was also associated with low serum albumin and calcium, suggesting that these parameters are indices of EPO resistance.

[Italian Registry of Dialysis and Transplantation: 1996-2001 experience]

The Italian Registry of Dialysis and Transplantation (RIDT) was born in 1996 under the aegis of the Italian Society of Nephrology, and it is organized as a federation of regional registries. This study aimed to completely revise the epidemiological data collected during the first 5 yrs (1996-2001) of RIDT activity to evaluate the trends of the main epidemiological features. During this period, regional registries were not always able to assure complete and exhaustive information according to RIDT requirements, owing to different levels of organization and functioning. To avoid any possible error in data analysis, information inadequately assessed was refused. The incidence of end-stage renal disease (ESRD) patients on renal replacement therapy (RRT) in Italy has increased from 114 pmp in 1996 to 139 pmp in 2001, that means an increase of 3.5%/yr, corresponding to 5718 patients during 1996 and 8000 patients during 2001. Primary renal diseases (according to the EDTA) in incident ESRD patients are vascular and diabetic nephropathy. Main dialysis modality in incident patients was hemodialysis (HD) (85%), while peritoneal dialysis (PD) was only 15%; pre-emptive transplantation was a very unusual modality. The prevalence of ESRD patients at 31 December was 693 pmp in 1996 and 827 pmp in 2001; among dialysis patients, the corresponding rates were 575 pmp and 657 pmp, respectively. Consequently, the number of dialyzed patients increased, respectively, from 28892 to 37919. The prevalent dialysis modality was bicarbonate dialysis in 74% of cases, followed by hemodiafiltration (HDF) in 15%, continuous ambulatory peritoneal dialysis (CAPD) in 7% and APD in 3%. The gross mortality rate in dialyzed patients was stable during this period, at approximately 14%, the main causes of death being cardiovascular diseases and cachexia.

The prediction of single-frequency BIA variables from individual characteristics

To define whether reference values for bioimpedance analysis (BIA) can be predicted in healthy individuals, individual characteristics and BIA variables (resistance index=height(2)/parallel resistance and reactance index= height(2)/parallel reactance) were evaluated in non-obese healthy individuals: 863 men and 769 women with an age range 20-70 years and body mass index (BMI) 19.0-29.9 kg/m(2). The following predictive equations were obtained using multiple regression analysis:Resistance index (cm(2)/ohm)Males 21.06 + 0.087xage + 1.091xweight -1.801xBMI,Females 20.35 + 0.037xage + 0.878xweight - 1.343xBMIReactance index (cm(2)/ohm)Males 0.57 + 0.117xweight - 0.096xBMIFemales 1.42 + 0.078xweight - 0.075xBMIIn conclusion, reference BIA values seem to be reasonably predicted based on individual characteristics.

[Can anemia be corrected in hemodialysis patients with thalassaemia minor? ]

BACKGROUND

Anemia is an important negative prognostic factor for dialysis patients, whose correction reduces hospitalisation and mortality. Besides, the presence of the thalassaemia minor (Thal-m) in haemodialysed patients causes erythropoietin resistance and more serious anemia. The goal of this study is the correction of anemia (Hb >11 g/dL) in haemodialysed Thal-m patients.

MATERIALS AND METHODS

Multicentric, prospective and controlled 12-month study for the correction of anemia (up to values ranging from 11 to 12 g/dL) followed by a 12-month observation period. Ten Thal-m patients with inadequate anemia correction were studied after therapy with rHuEPO. Their age at the beginning of the study was 62.8+/-4 years while their dialytic age was 89+/-20 months.

RESULTS

During the study we observed no changes in dry weight (p=NS), no increase in interdialytic weight (p=NS), cardiac frequency (p=NS), serum albumin (p=NS), serum aluminium (p=NS), PTH (p=NS), URR (p=NS), flow FAV (p=NS), TSAT (p=NS) and ferritin (p=NS) (maintained at their optimal values by means of intravenous therapy with trivalent iron. The hypotensive therapy (1.6 drug/patient/year) required no modifications during the 24-month study. The rHuEPO dose varied from 200.3+/-94.3 to 286.6+/-116.2, 317.0+/-119.5, 446.9+/-142.3, and 407.0+/-130.5 U/kg/wk (p < 0.0001 vs. initial value) (from the start to the 3rd, 6th, 9th and 12th month, respectively). The dose was subsequently reduced to 385.2+/-119.7 U/kg/wk at 15 months (p < 0.0001 vs. initial value) and remained unchanged until the end of the study. Simultaneously, the Hb values at corresponding times were 9.2+/-0.9, 9.4+/-1.1, 10.2+/-1.4, 10.9+/-1.5, 11.2+/-1.4 and 11.0+/-1.4 (p=0.002 vs. initial value). The correction of anemia produced progressive reduction in cardiac mass from 141+/-12 to 120+/-10 and 110+/-8 g/mq at the beginning, 12th month and 24th month (p < 0.0001), respectively. During the study the hospitalisation time was 4.3+/-1.2 day/patient/year during the 3-month run-in period, 3.4+/-1.4 day/patient/year during the first year, and 3.1+/-1.1 day/patient/year during the second year (p=0.098).

CONCLUSIONS

In conclusion we can say that the question of Thal-m in dialysis patients cannot be ignored or underestimated. The rHuEPO dosage in these patients must be reassessed (a dose of 450 U/kg/wk corresponding to approximately 60,000 units/week is acceptable and does not produce an increase in side effects if the correction is done gradually); moreover, other factors responsible for EPO-resistance must be eliminated (hyperthyroidism, aluminium intoxication, iron overloaded or deficiency).

[Prevalence of pre-obesity and obesity in uremic hemodialysis patients from Puglia and Lucania]

BACKGROUND

Obesity is a well-known cause of increased morbidity and mortality in the general population, while its influence on the hemodialysis population is yet to be defined. Obesity probably has a protective effect on survival in hemodialysis. In this study, we evaluated the prevalence of obesity in the hemodialysis population of Puglia and Lucania, two regions of Southern Italy, by using simple and easily accessible parameters collected by the participating centres.

METHODS

One thousand five hundred and forty-six patients on stable hemodialysis for at least 6 months from 23 Centres were studied. One hundred and sixty patients had a body mass index (BMI) more than 25 kg/m2; "preobesity" was defined as a BMI ranging between 25 and 30 kg/mq, while "obesity" as a BMI > 30. All data regarding the underlying renal disease, the use of low-protein diet before beginning hemodialysis, weight and height at the beginning of treatment and the different kinds of treatment were collected. A careful analysis of the last dialysis treatment by means of biochemical data was carried out.

RESULTS

The prevalence of preobesity and obesity was 3.1 and 7.3%, respectively. Eighty-three percent of patients in the preobesity group and seventy-two percent in the obesity group were female (p<0.001). The prevalence of diabetes was 19 and 24% in the preobesity and obesity groups, respectively, while it was 8% in patient with normal BMI (p<0.0001). Age and duration of low-protein diet were similar to those observed in the general population, while dialytic age was greater in preobesity group (p<0.01). Conclusions. Our study has shown that the prevalence of obese people undergoing hemodialysis is increasing. It is therefore necessary to introduce new measures to obtain a good nutritional status in end stage renal disease patients; in particular fat free mass is to be increased, since an improvement in the patient's nutritional status acts as a protecting factor against morbidity and mortality.

[Acute and chronic effects of standard hemodialysis and soft hemodiafiltration on interdialytic serum phosphate levels]

INTRODUCTION

The dialytic management of hyper-phosphoremia, which is inadequate because of insufficient intra-dialytic removal of phosphate (P), is further limited by PDR-P, i.e. the significant increase in serum P levels during the early postdialytic period. Patients and methods. To investigate the effects of enhanced P removal by haemodiafiltration on the inter-dialytic phosphoremia, we studied 12 uremic patients that were switched, with cross-over randomised modality, to a single session of standard hemodialysis (HD) and hemodiafiltration (HDF) (Acute Study). Blood samples were obtained before the treatment, at the end (T0), after 30, 60, 90 and 120 minutes, and at 24, 48 and 68 hours. During both dialytic treatments the whole effluent dialysate was collected to evaluate the intradialytic removal of P. Thereafter, patients were randomised to receive either HD or HDF for three months, in the presence of constantly similar Kt/V, food intake and dose of phosphate binder (Chronic Study).

RESULTS

Acute Study. Compared to HD, P removal in HDF was about 44% greater in the presence of identical predialytic P levels (6.0+/-0.2 and 5.9+/-0.4 mg/dl) and Kt/V (1.35+/-0.06 and 1.34+/-0.05); however, the inter-dialytic decline of serum P levels did not differ (-50+/-3% versus -42+/-3%, p=0.098). In HDF, PDR-P was faster (30 min versus 90 min) and better (at T120: +69+/-6% versus +31+/-4%, p<0.001). The higher P levels were maintained throughout the inter-dialytic period whereas Ca x P changed in parallel. Chronic Study. During the three months, pre-dialytic serum P diminished in HDF (from 5.8+/-0.2 to 4.4+/-0.3 mg/dl, p<0.05), while it remained unchanged in HD. A similar pattern of changes was detected in Ca x P.

CONCLUSIONS

Enhancement of P removal, acutely amplifies the extent of PDR-P, but allows better control of Ca-P homeostasis in the medium term. This effect is likely to be dependent on the enhanced mobilisation of phosphate from a deep compartment.

[Prevalence of malnutrition in uremic patients undergoing hemodialysis therapy in Puglia and Lucania]

BACKGROUND

Calorie-protein malnutrition is associated with increased morbidity and mortality in hemodialysis patients. The aim of this study was to evaluate the prevalence of malnutrition in uremic patients treated with hemodialysis in two areas of Southern Italy.

METHODS

A questionnaire was sent out to all Dialysis Centers in the two regions to select and enrol eligible patients by considering these parameters: Body Mass Index (BMI), serum albumin, serum creatinine, urea, calcium, phosphate, triglycerides, cholesterol, body weight. Enrolment criteria were patients on dialysis for at least six months and BMI less than 21 kg/m2. The dialytic dose was evaluated by reporting the hours of dialysis and filter surfaces. The number of weekly sessions (n. 3) remained unchanged over time.

RESULTS

Twenty-three Dialysis Centers in the two Regions replied to our questionnaire and 149 patients were enrolled in the study out of the 1546 patients examined. The overall prevalence of calorie-protein malnutrition was observed in 9.6% of the patients. The prevalence of malnutrition was found to be higher in males and in patients on dialysis for longer time. We observed no correlation with the hypoproteic diet administered in the pre-dialysis phase. Malnourished patients showing progressive weight loss were older and had undergone dialysis for a longer time.

CONCLUSIONS

This retrospective study indicates low prevalence of malnutrition in the two regions examined. The lack of correlation between the hypoproteic diet and dialytic dose suggests the need for further studies to evaluate if increased dialytic dose or early start of dialysis could improve the nutritional status and quality of life in elderly patients.

Bioelectrical impedance analysis in heart transplantation: early and late changes

The objectives of this study were to perform bioelectrical impedance analysis before and after heart transplantation with comparison to healthy subjects. Eight patients (7 men, 1 woman) before (day 0) and after transplantation (day 3, 7, 12, 15, and 180) and 24 healthy controls, matched for sex, age, and body mass were studied. Data collection included bioelectrical impedance analysis (resistance, reactance, and estimates of body water), clinical, and laboratory measurements. Compared with controls, patients had at baseline significantly higher reactance, not significantly different resistance, body weight, total body water, and intra- to extracellular water ratio. After surgery, for reactance, there was an acute decrease followed by a slow, progressive increase up to normal level by day 15. Resistance and body weight did not significantly change; the intra- to extracellular water ratio significantly decreased with stable total body water. Changes in reactance are the main effects induced on bioelectrical impedance by heart transplantation. Acutely, there is a large decrease which likely reflects changes both in water distribution and in cell membrane function. The late changes more likely reflect the shift of body water from the extra- to the intracellular space with stable total body water.

Successful use of central venous catheter as permanent hemodialysis access: 84-month follow-Up in lucania

Cuffed tunneled venous access catheters are commonly used for temporary and permanent access in hemodialysis (HD) patients. These catheters serve an essential role in providing permanent access in subjects in whom all other access options have been exhausted. The predominant complications are catheter thrombosis, catheter fibrin sheating and infection. The aim of this study was to evaluate long-term survival and complications of permanent venous catheters (PVC) placed for the purpose of HD during the period from January 1992 to December 1998, at the Dialysis Units of Lucania (a southern Italian region). A total of 98 PVC were placed in 88 patients during this period. The catheters used were of three types: (a) 72 VasCath Soft Cell catheters (Bard Instrument Company, Toronto, Ont., Canada); (b) 22 PermCath catheters (Quinton Instrument Company, Seattle, Wash., USA), and (c) 4 Tesio catheters (Bellco SpA, Mirandola, Italy). Survival curves of catheters were calculated using the Kaplan-Meier product-limit estimator. The patient survival was 60% at the 78th month. Actually, 52 patients (27 males, 25 females) are still alive: 15 (26.9%) of these patients have diabetes mellitus and 1 has been transplanted. The actuarial survival rate of PVC was 89% in the whole population studied and 82% in subjects alive after 84 months. Twenty-five patients (28.4%) had PVC as the first reliable vascular access. Long-term complications occurred 27 times (1 episode every 44.81 month/patient) as: breakage (3.1%); thrombosis (10.2%); displacement (2.0%); subcutaneous tunnel bleeding (3.1%); inadequate blood flow (7.1%), and infection (10.2%). In conclusion, our data confirm that PVC might represent an effective long-term blood access route for HD. Again, PVC are getting the access of choice for selected patients (i.e., older subjects with cardiovascular diseases and cancer patients) and are enjoying a dramatic increase in use for subjects who are terrified of repetitive venopuncture.

Normal values of the bioelectrical impedance vector in childhood and puberty

The purpose of this study was to determine the reference, bivariate, and tolerance intervals of the whole-body impedance vector in Italian children. This was a cross-sectional, multicenter study, and participants were chosen from the general school population. The impedance vector (standard, tetrapolar analysis at 50-kHz frequency) was measured in 3110 subjects, ages 2 to 15 y, and 2044 healthy children (1014 male and 1030 female) with weight and height within the 95th percentile were selected for the analysis (resistance-reactance graph method). The age-specific 95% confidence intervals of mean vectors and the 95%, 75%, and 50% tolerance intervals for individual vector measurements were plotted using resistance and reactance components standardized by the subject's height. Mean vectors from both sexes with separate 95% confidence ellipses were considered as representative of eight different age groups, from 2 to 13 y. There was a statistically significant sex effect on vector distribution from boys and girls in the age group of 14 to 15 y. The impedance vector distribution of children was also compared with healthy adult subjects (354 male and 372 female, age 15 to 85 y). There was a progressive, statistically significant vector shortening from age 2 to 15 y toward the adults' vector position. In conclusion, we established the trajectory followed by the mean impedance vector in children over ages 2 to 15 y and also obtained the reference, bivariate, and 95%, 75%, and 50% tolerance intervals of the impedance vector by age for healthy children, with which the vectors from children with altered body composition can be tested.

Bioelectrical Impedance Analysis before and after Novacor Implantation

In this study Bioelectrical Impedance Analysis was performed in 5 patients with end stage heart failure in whom a left ventricular assist device (Novacor) was successfully implanted. Whole body measurements of bioelectrical indices resistance and reactance were taken before surgery and 3, 7, 12, and 15 days after it. After surgery there was a significant decrease in reactance, indicating a shift of body fluids from intra- to extra-cellular space.

Bioelectrical impedance analysis before and after Novacor implantation

In this study Bioelectrical Impedance Analysis was performed in 5 patients with end stage heart failure in whom a left ventricular assist device (Novacor) was successfully implanted. Whole body measurements of bioelectrical indices resistance and reactance were taken before surgery and 3, 7, 12, and 15 days after it. After surgery there was a significant decrease in reactance, indicating a shift of body fluids from intra- to extra-cellular space.

Body impedance studies in end-stage heart failure

This study adds another category of patients to those amenable to body impedance analysis (BIA). BIA measurements were obtained for the first time in 23 male patients with end-stage heart failure who were waiting for heart transplantation, and the data were compared with those obtained in 69 healthy controls matched for age, sex, height and weight. The data indicate that in end-stage heart failure there is an increased reactance (p<0.01) and an altered intracellular water/extracellular water ratio (p<0.03) due to the increased intracellular water (p<0.01) and decreased extracellular water (p<0.01).

A modified Two-BUN method for routine urea modeling: clinical validation in 120 patients on a free diet

Recently, a modified algorithm of the Two-BUN method (MA2p), avoiding dialyzer clearance measurement, was presented for routine assessment of Kt/V and NPCR. To validate MA2p in patients on a free diet (FDP), we studied 120 stable dialysis FDP by measuring Kt/V and NPCR with both MA2p and a modified version of the standard Three-BUN method (MA3p), for the 3 weekly sessions. The NPCR values (g/kg/day), calculated by MA3p for the 3 interdialyses were: 1.286 +/- 0.274, 1.256 +/- 0.276, and 1.116 +/- 0.230, respectively. The correlation coefficient (r) for averaged Kt/V values obtained by the two methods was 0.999 and the percent error (Error%) for MA2p vs. MA3p results ranged from -1.5 to +0.78%. The respective results for NPCR were: r = 0.967, Error% range from -11.7 to +13.9%. In conclusion, MA2p can be safely used in patients on a free diet. The lowest NPCR values were observed during the long interdialysis.

Factors affecting nPCR in hemodialysed patients

The determination of dialysis adequacy is difficult and definitions are in a state of flux (Lindsay). In fact, after fifteen years from the introduction of urea kinetics into clinical practice, nephrologists still do not agree on recognizing the real utility of it. Gotch and Sargent in their mechanistic analysis of the NCDS indicated that the dose of small molecules removal could be defined by Kt/V urea. The results of the NCDS were depicted in a three-variable plot in which six domains could be seen. Several reports have documented malnutrition as being frequently present in patients on maintenance hemodialysis. It is generally accepted that a suboptimal nutritional status is associated with an increased morbidity and may adversely affect rehabilitation and the quality of life. In 1989 Lindsay et al showed that low levels of Kt/V corresponded with low levels of nPCR and found a direct correlation between the two parameters. On this basis, they suggested the hypothesis of nPCR dependence on Kt/V. The Authors showed a good correlation (r = 0.73) between nPCR and Kt/V in 55 patients. This work aims to evaluate the correlation between Kt/V and nPCR, real age and dialytic age in a dialytic population in Southern Italy, during a long period of observation (six years, follow up 2,692 months). One hundred and thirty-four patients were studied in six years of observation. Follow up: 2,692 months. Twenty-six patients died during the observation period. The simple regression analysis of nPCR vs. Kt/V, real age and dialytic age was performed in 63 anuric patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Population based data on urinary excretion of calcium, magnesium, oxalate, phosphate and uric acid in children from Cimitile (southern Italy)

Population based data on 24-h urinary excretion of calcium, oxalate, magnesium, phosphate, uric acid and creatinine were collected from 220 children (aged 3-16 years) living in Cimitile, Campania, southern Italy. Mean excretion rates for 7 days were correlated with age, body weight, body mass index and height. The prevalence of hypercalciuria (greater than 4 mg/kg body weight) and of hyperoxaluria (greater than 60 mg/day) were 9.1% and 1.8%, respectively. The same 20 children were also identified as hypercalciuric when a calcium/creatinine ratio of greater than 0.15 was considered. No significant differences between boys and girls were found in the urinary excretion of the five constituents implicated in urolithiasis. The study data provide additional childhood reference values for urinary excretion of compounds related to stone formation.

Cis-platin-Mecy as salvage chemotherapy in recurrent advanced ovarian carcinoma

Cis-platin (DDP) has proved to be highly active in the treatment of ovarian adenocarcinoma. The Authors have treated 12 patients with istologically proven advanced ovarian carcinoma with a type of alternating regimen consisting of four weekly DDP courses (1 mg/kg b.w./week) followed by monthly courses high-dose methotrexate (750 mg/mq i.v.) plus cyclophosphamide (250 mg/mq for 5 days) (Mecy). The alternating regimen DDP + Mecy proved to have significant activity as a salvace chemiotherapy regimen for patients with advanced ovarian carcinoma.

Amino acid losses during CAPD

Amino acid losses in peritoneal dialyzate during CAPD were less than 2 g a day (15, 128 micrometers). CAPD does not correct the tyrosine/phenylalanine ratio in plasma and does not prevent accumulation of 3-methylhistidine.