Autosomal Dominant Polycystic Kidney Disease in Young Adults

Background

The clinical manifestations of autosomal dominant polycystic kidney disease (ADPKD) usually appear in adulthood, however pediatric series report a high morbidity. The objective of the study was to analyze the clinical characteristics of young ADPKD adults.

Methods

Family history, hypertension, albuminuria, eGFR and imaging tests were examined in 346 young adults (18-30 years) out of 2580 patients in the Spanish ADPKD registry (REPQRAD). A literature review searched for reports on hypertension in series with more than 50 young (age <30 years) ADPKD patients.

Results

The mean age of this young adult cohort was 25.24 (SD 3.72) years. The mean age at diagnosis of hypertension was 21.15 (SD 4.62) years, while in the overall REPQRAD population was 37.6 years. The prevalence of hypertension was 28.03% and increased with age (18 to 24 years: 16.8%, 25 to 30 years: 36.8%). Although prevalence was lower in women than in men, the age at onset of hypertension (21 years) was similar in both sexes. Mean eGFR was 108 (SD 21) ml/min/1.73m2, 38.0% had liver cysts and 3.45% of those studied had intracranial aneurysms. In multivariate analyses, hematuria episodes and kidney length were independent predictors of hypertension (AUC 0.75). The prevalence of hypertension in 22 pediatric cohorts was 20-40%, but no literature reports on hypertension in young ADPKD adults were found.

Conclusions

Young adults present non-negligible ADPKD-related morbidity. This supports the need for a thorough assessment of young adults at risk of ADPKD that allows early diagnosis and treatment of hypertension.

[Serum potassium levels and long-term mortality in the elderly with hypertension]

There is increasing evidence that small variations within the normal range (3.5-5mEq/L) of potassium are associated with mortality.

OBJECTIVE

To determine whether there is an association between serum potassium level (sK) and mortality in a cohort of elderly hypertensive patients.

PATIENTS AND METHODS

A retrospective, observational study was conducted on patients who had sK levels available in a period of clinical stability during their recruitment between January and April 2006 and followed-up for 10 years. The study obtained a total of 62 stable patients, with a mean age of 82.19±6 years (range 69-97), with 74.2% women, 33.9% diabetics, 20.3% with a history of heart failure, Ischaemic heart disease was observed in 19.4% and 44.3% received Angiotensin Converting Enzyme (ACE) inhibitors. An analysis was performed on the mortality rate during the 10 year period. The statistics were performed using the SPSS15.0 package.

RESULTS

There were 49 deaths. The sK had a normal distribution. Baseline mean sK levels and median were 4.45±0.5mEq/L (range 3.1-5.5 mEq/L). Baseline sK levels were significantly higher in diabetic patients and patients on ACE inhibitors. The patients that died had higher sK levels (4.53±0.49mEq/L versus 4.14±0.40mEq/L, P=.011). Survival estimated using Kaplan Meier showed that patients with sK levels higher than the median and P75 had higher mortality.

CONCLUSIONS

In our study, sK levels greater than 4.45mEq/L were associated with mortality. When selecting antihypertensive treatment in hypertensive elderly patients,, the use of ACE inhibitors should be assessed individually, with close monitoring at sK levels and try to keep them in the lower limit of the normal range (<4.45 mEq/L).

The influence of initial peritoneal transport characteristics, inflammation, and high glucose exposure on prognosis for peritoneal membrane function

BACKGROUND

Fast transport status, acquired with time on peritoneal dialysis (PD), is a pathology induced by peritoneal exposure to bioincompatible solutions. Fast transport has important clinical consequences and should be prevented.

OBJECTIVE

We analyzed the repercussions of initial peritoneal transport characteristics on the prognosis for peritoneal membrane function, and also whether the influence of peritonitis and high exposure to glucose are different according to the initial peritoneal transport characteristics or the moment when such events occur.

METHODS

The study included 275 peritoneal dialysis patients with at least 2 peritoneal function studies (at baseline and 1 year). Peritoneal kinetic studies were performed at baseline and annually. Those studies consist of a 4-hour dwell with glucose (1.5% during 1981 - 1990, and 2.27% during 1991 - 2002) to calculate the peritoneal mass transfer coefficients of urea and creatinine (milliliters per minute) using a previously described mathematical model.

RESULTS

Membrane prognosis and technique survival were independent of baseline transport characteristics. Fast transport and ultrafiltration (UF) failure are reversible conditions, provided that peritonitis and high glucose exposure are avoided during the early dialysis period. The first year on PD is a main determining factor for the membrane's future, and the mass transfer coefficient of creatinine at year 1 is the best functional predictor of future PD history. After 5 years on dialysis, permeability frequently increases, and UF decreases. Icodextrin is associated with peritoneal protection.

CONCLUSIONS

Peritoneal membrane prognosis is independent of baseline transport characteristics. Intrinsic fast transport and low UF are reversible conditions when peritonitis and high glucose exposure are avoided during the early dialysis period. Icodextrin helps in glucose avoidance and is associated with peritoneal protection.

Renal supportive care and palliative care: revision and proposal in kidney replacement therapy

Patients with chronic kidney disease may receive sustained renal supportive care and renal palliative care (RPC) starting with the diagnosis of the disease, throughout the various stages of renal replacement therapy (RRT), the cessation of the RRT, and in the decision of whether to provide conservative treatment or non-initiation of RRT. This article reviews the literature on the development of renal palliative care and proposed RPC models. We describe the progression of disease in organ failure, which is very different from other areas of palliative care (PC). We describe important components of resident nephrology training in PC. We discuss the management of pain and symptom control, as well as communication skills and other psychological and ethical aspects in the renal patient. We conclude that in chronic renal patients, a palliative care approach can provide a positive impact on the quality of life of patients and their families, as well as optimizing the complex treatment of the renal patient.

[The peritoneal kinetic study performed with hypertonic glucose permits better evaluation of UF capacity and determination of sieving of sodium]

INTRODUCTION

The use of solutions containing hypertonic glucose (3.86%/4.25%) has been postulated as the method of choice for study the peritoneal function, and permits a better evaluation of the ultrafiltration (UF) capacity.

OBJECTIVE

The aim of our study was to analyze the UF capacity and its relation with the peritoneal permeability and sieving of sodium, performing the peritoneal kinetic study with hypertonic glucose solutions.

PATIENTS AND METHODS

We performed 184 peritoneal kinetic studies with hypertonic glucose solutions in stable patients on peritoneal dialysis (PD), with a mean time on PD of 16 +/- 22 months. We measured the mass transfer coefficient of creatinine (CrMTC), dialysate to plasma ratio of creatinine (D/PCr), UF capacity and sieving of sodium at 60 minutes (difNa60).

RESULTS

The mean values were: CrMTC: 9.1 +/- 4.5 ml/min, D/PCr: 0.71 +/- 0.09, UF 759 +/- 233 ml/4 h and difNa60: 4.7 +/- 2.3. The best multivariate model that predicts the UF capacity included: difNa60, CrMTC, age and time on PD (r = 0.57; p > 0.0001). In patients with UF lower than 600 ml/4 h (Percentil 25) the correlation between UF and CrMTC was lost, but remains the correlation with difNa60 (r = 0.48). The patients with previous peritonitis (n = 38) showed no differences in UF, CrMTC or D/Pcr, but the had lower difNa60 (3.7 +/- 2.8 vs. 4.9 +/- 2.1; p = 0.002) than the remaining patients.

CONCLUSIONS

The peritoneal kinetic study performed with hypertonic glucose allows to standardize the UF capacity and by determination of sieving of sodium, the early detection of water transport alterations, before the UF capacity and small solutes permeability alteration develops.

Previous comorbidity and lack of patient free choice of technique predict early mortality in peritoneal dialysis

OBJECTIVE

To study the prognostic factors for mortality and hospital admission for patients on peritoneal dialysis (PD).

METHOD

Biannual data on individual characteristics, clinical and analytical progress, treatment, and events were studied for a cohort of incident patients undergoing PD (2003-2006) in a reference area of 8.8 million people.

RESULTS

489 patients (age 53.58 years, 61.6% male) with 3-year follow-up were included. They presented at inclusion with Charlson Comorbidity Index (CCI) of 5.25; previous cardiovascular (CV) event, 23.7%; diabetes mellitus (DM), 19.1%; and hypertension (HT), 89.9%. Annual hospitalization rate per patient-year at risk was 0.6. The variables that predicted admission were CCI [odds ratio (OR) 1.14 per point], DM (OR 1.66), and previous CV event (OR 1.90). Anemia maintained significance when corrected for CCI: hemoglobin, 0.79 per 1 g/dL Hb; CCI, 1.15 per point. Annual mortality rate was 5.4%. Those that died were older (67.47 vs 52.78 years) and had a higher CCI (8.35 vs 5.0), a lower initial Hb (11.5 vs 12.2 g/dL), a higher hospital admission rate, a higher annual rate of peritonitis, more previous CV events (50.0% vs 22.1%), and higher prevalence of DM (38.5% vs 17.9%). Survival analysis identified the following prognostic factors: CCI [hazard ratio (HR) 1.51 per point], CV event (HR 2.85), DM (HR 2.52), age (HR 1.06 per year), and mandatory referral to PD (HR 6.54). The effect of CV events and DM persisted after correction for age, and that of choice of technique after correcting for CCI and/or age.

CONCLUSIONS

The CCI is useful for risk estimation in PD patients. Previous CV event, DM, and age are the most relevant risk factors. Control of anemia has prognostic value for hospital admissions. Mandatory referral to PD is associated with higher mortality. The prognosis in PD depends on predialysis patient management.

Previous Comorbidity and Lack of Patient Free Choice of Technique Predict Early Mortality in Peritoneal Dialysis

Objective

To study the prognostic factors for mortality and hospital admission for patients on peritoneal dialysis (PD).

Method

Biannual data on individual characteristics, clinical and analytical progress, treatment, and events were studied for a cohort of incident patients undergoing PD (2003-2006) in a reference area of 8.8 million people.

Results

489 patients (age 53.58 years, 61.6% male) with 3-year follow-up were included. They presented at inclusion with Charlson Comorbidity Index (CCI) of 5.25; previous cardiovascular (CV) event, 23.7%; diabetes mellitus (DM), 19.1%; and hypertension (HT), 89.9%. Annual hospitalization rate per patient-year at risk was 0.6. The variables that predicted admission were CCI [odds ratio (OR) 1.14 per point], DM (OR 1.66), and previous CV event (OR 1.90). Anemia maintained significance when corrected for CCI: hemoglobin, 0.79 per 1 g/dL Hb; CCI, 1.15 per point. Annual mortality rate was 5.4%. Those that died were older (67.47 vs 52.78 years) and had a higher CCI (8.35 vs 5.0), a lower initial Hb (11.5 vs 12.2 g/dL), a higher hospital admission rate, a higher annual rate of peritonitis, more previous CV events (50.0% vs 22.1%), and higher prevalence of DM (38.5% vs 17.9%). Survival analysis identified the following prognostic factors: CCI [hazard ratio (HR) 1.51 per point], CV event (HR 2.85), DM (HR 2.52), age (HR 1.06 per year), and mandatory referral to PD (HR 6.54). The effect of CV events and DM persisted after correction for age, and that of choice of technique after correcting for CCI and/or age.

Conclusions

The CCI is useful for risk estimation in PD patients. Previous CV event, DM, and age are the most relevant risk factors. Control of anemia has prognostic value for hospital admissions. Mandatory referral to PD is associated with higher mortality. The prognosis in PD depends on predialysis patient management.

Ambulatory blood pressure monitoring in patients with hyperthyroidism before and after control of thyroid function

BACKGROUND AND OBJECTIVE

Thyroid hormones have pronounced effects on the cardiovascular system. Thyrotoxicosis affects blood pressure (BP), modifying both diastolic (DBP) and systolic (SBP) pressures. There are no studies examining BP with ambulatory blood pressure monitoring (ABPM) in hyperthyroidism before and after control of thyroid function. Our aims were (1) to analyse ABPM in a group of normotensive hyperthyroid patients before and after normalizing circulating thyroid hormones and (2) to compare these results with those obtained in a group of euthyroid subjects.

PATIENTS AND MEASUREMENTS

We studied 20 normotensive hyperthyroid subjects [18 women; age (mean +/- SEM) 49.0 +/- 3.0 years] and 15 healthy subjects. Patients were evaluated by ABPM over 24 h, at diagnosis and after therapy (n = 18).

RESULTS

The average 24-h, daytime and night-time SBP was significantly greater in hyperthyroid patients than in controls with no significant differences in DBP. Circadian BP rhythm, estimated by the difference between mean values of SBP, DBP and mean BP during daytime and night-time, was unchanged. The average 24-h and daytime SBP significantly decreased after normalizing thyroid function in the 18 hyperthyroid evaluated patients. Daytime SBP and DBP were higher than night-time values both before and after control of thyroid function. However, no differences in circadian BP rhythm were observed.

CONCLUSIONS

Normotensive hyperthyroid patients exhibit higher ambulatory SBP throughout 24 h than normotensive euthyroid subjects. Control of hyperthyroidism decreases ambulatory SBP values. Mean nocturnal fall in BP is comparable in normotensive hyperthyroid patients and control subjects.

Ultrafiltration and small solute transport at initiation of PD: questioning the paradigm of peritoneal function

BACKGROUND

Human peritoneal function on commencing peritoneal dialysis (PD) is not yet adequately understood. The objective of this study was to determine peritoneal functional patterns on commencing PD.

METHODS

367 end-stage renal disease (ESRD) patients on PD for the first time were studied between their initial second to sixth weeks on PD. Urea and creatinine mass transfer area coefficients (MTAC) and standardized ultrafiltration (UF) capacity were determined.

RESULTS

Mean parametric values were MTAC urea 22.9 +/- 7.04 mL/min, MTAC creatinine 10.31 +/- 4.68 mL/min, and UF 896 +/- 344 mL. Gender, patient size, and diabetes or kidney disease did not affect these parameters. The relationship between values of MTAC creatinine and UF reached statistical significance, although with a low value for Pearson's coefficient (r = -0.30, p = 0.001). Age showed a significant inverse linear correlation with UF capacity (r = -0.15, p = 0.003) and MTAC urea (r = -0.11, p < 0.05). Logistic regression analysis demonstrated that UF below 400 mL was independently related to a high MTAC creatinine and older age. Diabetes was least frequent in patients with the lowest UF. However, in the analysis of MTAC creatinine quintiles, UF values did not follow the expected inverse pattern. The lack of differences in UF between the second and third to fourth MTAC creatinine quintiles is remarkable; MTAC creatinine ranged from 6.71 to 13.54.

CONCLUSIONS

The functional characteristics of human peritoneum varied markedly and there was a less intense than expected relationship between solute and water transports. This mild inverse relationship is intriguing and suggestive of the necessity of redefining some basic concepts. Age was associated with a lower peritoneal UF capacity, in part independently of small solute transport.

[Physical symptoms and emotional disorders in patient on a periodic hemodialysis program]

OBJECTIVES

To establish the frequency and severity of somatic symptoms and emotional distress (anxiety and/or depression) among our chronic hemodialysis (CHD) patients and to study the relationship between them as well as their influence on the perceived health status.

PATIENTS AND METHODS

All patients who had been on CHD for a minimum of three months were eligible for the study. Eight of them were excluded: six because they were unable to answer the questionnaires and two because they refused to participate. The 58 remaining patients were the subject of our study (median age 68.5 years; median duration of HD 29.5 months). Diverse sociodemographic and clinical data were recorded. The patients answered the following questionnaires: 1) The "physical symptoms" dimension of the Kidney Disease Questionnaire; 2) A measure of anxiety (STAI); 3) A measure of depression (Beck Depression Inventory and Cognitive Depression Index); and 4) The Nottingham Health Profile (NHP).

RESULTS

The most frequent and severe symptoms were tiredness, itching, thirst, bone and joint pain and sleep disturbance. The severity of the symptoms was positively associated with female sex, and the presence of clinically relevant degrees of anxiety and/or depression. A quarter of the patients were anxious and almost half of them suffered from depression. Emotional disturbances were associated with the severity of somatic symptoms and comorbidity. Only anxiety and depression were significantly associated with the global NHP score; they explained 47% of its variance. A score of 50 or more in the "Emotional Reactions" dimensions with the NHP detected 69% of the patients with anxiety and 81% of those with depression.

CONCLUSIONS

Somatic symptoms are common among patients on CHD and they appear to be associated with emotional distress (anxiety and depression) that influences significantly the perceived health status. Measuring the perceived health status by means of generic and specific questionnaires, may help to establish the diagnosis of these problems.

A Comparative Study of C-Reactive Protein Plasma Levels in Patients on Hemodialysis and Peritoneal Dialysis

In dialysis patients, C-reactive protein (CRP), a well-recognized marker of inflammation, predicts mortality. Higher levels have been described in hemodialysis (HD) patients as compared with peritoneal dialysis (PD) patients. Our aim was to determine, based on CRP plasma levels, the degree of inflammation in HD patients using low-permeability polysulfone membranes and relatively pure dialysate, and that in PD patients. A secondary objective was to study factors associated with hypoalbuminemia and inflammation in both populations. We studied 69 stable patients on dialysis (32 on HD and 37 on PD). The mean age was 69.9 ± 8.2 years, and the mean time on dialysis was 27 months. The two populations were comparable for overall and cardiovascular comorbidities. Nephelometry was used to measure CRP plasma levels (normal levels < 0.6 mg/dL). The Kt/V_urea , corrected for residual renal clearance, and the equivalent of protein nitrogen appearance (PNA) were also calculated. Of the patients studied, 53% showed CRP plasma levels higher than 0.6 mg/dL; in 36%, the levels were higher than 1 mg/dL. No significant differences in these percentages were noted between the two dialysis groups. Patients with CRP levels higher than 1 mg/dL showed lower serum albumin, iron, hemoglobin, and transferrin levels, and higher ferritin values and leukocyte counts. Under logistic regression analysis, CRP levels higher and lower than 1 mg/dL were significantly associated with serum albumin [p = 0.01; odds ratio (OR): 0.15], iron (p = 0.006; OR: 0.96), transferrin (p = 0.004; OR: 0.97), and hemoglobin (p = 0.02; OR: 0.67). Serum albumin levels were significantly lower in PD patients. Under regression analysis, serum albumin levels correlated with cholesterol (r: 0.25; p = 0.04), serum iron (r: 0.5; p = 0.0001), transferrin (r: 0.3; p = 0.015), ultrafiltration capacity (r: 0.42; p = 0.008), and CRP values above 0.6 mg/dL (r: -0.65; p = 0.001). In conclusion, the frequent elevation of CRP plasma levels observed in both HD and PD patients suggests the presence of a silent inflammatory state. Hemodialysis performed with biocompatible, low-permeability membranes is not associated with higher CRP plasma levels than those seen in PD. In both groups, hypoalbuminemia is related to CRP level. Levels of serum albumin, slightly lower in PD patients, are also related to peritoneal ultrafiltration capacity.

[Nutritional status, comorbidity, and inflammation in hemodialysis]

Low y serum albumin and high C-reactive protein (CRP) have been shown to be significant predictors of mortality in hemodialysis (HD) patients. Although hypoalbuminemia has been attributed to malnutrition, it has recently been recognized evidence of inflammation that predicts serum albumin concentration in dialysis patients.

AIM

To establish, in our HD patients, the factors associated with malnutrition, hypoalbuminemia and elevated levels of C-reactive protein to determine its influence in the incidence and cause of death during a one year follow-up period.

METHODS

A cross sectional study was performed in 64 patients (35 males, 13% diabetics; mean age 64 +/- 12), who had beep on HD for 64 +/- 58 months. We assessed nutritional status by anthropometric and biochemical parameters and estimated protein and calorie intake by diet recall. The dialysis dose was measure by KT/V normalized for actual and ideal body weight (BW). Comorbidity (total and cardiovascular) were measured using a modified M. Charlson index. CRP was used as a marker of inflammation. During a one year follow-up period we determined the incidence and cause of death.

RESULTS

According to Bilbrey index only seven patients (11%) were well nourished. The variables associated with malnutrition were civil status (not married) and dialysis dose estimated by KT/V normalized to ideal BW. Serum albumin (mean 4.1 +/- 0.3 g/dl) was associated with creatinine, comorbidity age and infection. 37.5% of the patients had CRP > 1 mg/dl and they had more cardiovascular comorbidity and lower serum albumin, and they used higher doses of erythropoietin (table III). Patients using modified cellulosic membranes had higher levels of CRP. Multivariate analysis showed that high global comorbidity, low serum cholesterol, and high level of CRP and hematocrit predicted death. The principal cause of mortality was infection.

CONCLUSIONS

Malnutrition is a common problem in HD patients. Low dialysis dose is associated with malnutrition in some patients. We propose to normalize urea clearances to ideal body weight. Inflammatory activity is frequent in HD, probably as a result of intermittent activation of the acute phase response during the dialysis procedure. Low serum albumin in HD patients is principally associated with infection/inflammation but not with malnutrition. CRP is a sensitive marker of inflammation and an power predictor of mortality in HD patients.

Short-term recombinant human growth hormone therapy does not modify growth hormone, thyrotropin and prolactin responses to thyrotropin-releasing hormone in adult dialysis patients

BACKGROUND

We recently have reported the first randomized, controlled study on the effects of short-term recombinant human growth hormone (rhGH|| therapy on the nutritional status of a group of malnourished adult dialysis patients. In order to evaluate whether rhGH administration exerts any influence on GH, thyrotropin (TSH|| and prolactin (PRL|| responses to TSH-releasing hormone (TRH||, we assessed these responses before and after rhGH therapy.

METHODS

GH, PRL and TSH responses to TRH before and 1 month after rhGH therapy in a group of adult dialysis patients were evaluated. Seventeen dialysis patients (11 on continuous ambulatory peritoneal dialysis/six on haemodialysis|| were studied (rhGH group, n=8; control group, n=9||. In the rhGH group, 0.2 IU/kg/day rhGH was administered subcutaneously. Each patient was tested with TRH (400 microg bolus i.v.|| on two separate occasions, just before and immediately after the treatment period.

RESULTS

rhGH treatment did not modify baseline serum GH concentrations (6.6+/-2.7 vs 4.1+/-1.1 microg/l||, paradoxical GH responses to TRH (six out of eight patients||, GH peak (11.9+/-4.6 vs 11.2+/-5.3 microg/l, NS|| or area under the secretory curve of GH (GH AUC; 19.1+/-4.5 vs 12.1+/-3.1 microg/h/l||. Both basal PRL (35.5+/-7.1 vs 36.7+/-8.6 microg/l|| and TSH (2.3+/-1.1 vs 2.8+/-1.7 mU/l|| concentrations, as well as their responses to TRH stimulation (PRL peak, 59.9+/-16.6 vs 59. 5+/-11.8 microg/l; TSH peak, 6.2+/-2.6 vs 7.1+/-3.9 mU/l||, were also unaffected by rhGH therapy.

CONCLUSION

These results suggest that short-term rhGH therapy does not significantly influence the magnitude of the somatotropic, lactotropic or thyrotropic response to TRH in adult dialysis patients. However, this finding has to be interpreted with caution due to the two different patient groups included in this study.

Recombinant human growth hormone therapy in malnourished dialysis patients: a randomized controlled study

Recombinant human growth hormone (rhGH; Saizen, Serono, Spain) has been recently used as an anabolic agent in several catabolic states, including malnourished chronic dialysis patients. However, up-to-date, comparative studies with control groups of dialysis patients have not been reported. The aim of the present study was to assess the effects of rhGH on nutritional status in a group of malnourished adult chronic dialysis patients undergoing both continuous ambulatory peritoneal dialysis (CAPD) and hemodialysis (HD). The patients were randomly assigned to the control group (nine patients; 6 women, 3 men; mean age, 58.3 +/- 5.6 years; seven undergoing CAPD, two undergoing HD) or the rhGH group (eight patients; three women, five men; mean age, 63.9 +/- 3.1 years; four undergoing CAPD, four undergoing HD). Both groups were similar at baseline. All patients were given dietary prescriptions (35 kcal/kg/d and 1 g protein/kg ideal body weight/d) during 4 weeks. In the rhGH group, rhGH was administered at 0.2 IU/kg/d subcutaneously (SC) during this period. Anthropometric and analytic parameters were assessed before (0 weeks) therapy and at 2 and 4 weeks after starting therapy. The rhGH group showed an increase of 1.238 kg in body weight from 64.3 +/- 4.3 (mean +/- standard error of the mean [SEM]) to 65.6 +/- 4.9 kg (P < 0.05). Serum insulin-like growth factor type 1 (IGF-1) concentrations increased from 216.6 +/- 42.5 to 581.2 +/- 171.5 ng/mL (4 weeks; P < 0.01) and transferrin levels increased from 271.2 +/- 16.3 to 314.5 +/- 21.2 mg/dL (4 weeks; P < 0.05). A significant reduction in blood urea nitrogen (BUN) level was observed (62.1 +/- 1.8 v 46.8 +/- 3.8 mg/dL; 4 weeks; P < 0.05). Mean daily protein intake, determined by individual dietary survey, at 0 and 4 weeks, remained constant in both groups. In conclusion, weight gain and IGF-1 and transferrin level increases and BUN level decreases, despite the constant oral intake, suggest that short-term rhGH administration is associated with an anabolic reaction in malnourished dialysis patients.

Erythropoietin treatment decreases cardiovascular morbidity and mortality in CAPD patients

OBJECTIVE

To analyze the effects of recombinant human erythropoietin (rHuEPO) therapy on cardiovascular (CV) morbidity and mortality among continuous ambulatory peritoneal dialysis (CAPD) patients.

DESIGN

Retrospective comparative study.

SETTING

CAPD unit in a university hospital.

PATIENTS

Forty-two patients on rHuEPO treatment for at least one year were compared with an rHuEPO nonuser group of 113 patients. Subcutaneous rHuEPO doses were adjusted to a hemoglobin objective level of 10.5-13.5 g/dL. Fifty-seven patients were considered as high cardiovascular risk (HCVR), 17 in the rHuEPO group and 40 in the rHuEPO nonuser group. Ninety-eight patients were classified as low cardiovascular risk (LCVR), 25 of whom were in the rHuEPO group.

RESULTS

The incidence of cardiovascular morbidity was more frequent in the rHuEPO nonuser than in the rHuEPO user group (40% vs 22%) and in HCVR than in LCVR patients (59.6% vs 20.4%). By multiple logistic regression analysis, the best model to explain the development of cardiovascular morbidity comprises rHuEPO treatment, CV risk, and age. In the rHuEPO user group, HCVR and LCVR patients did not show significant differences in survival, while in the rHuEPO nonuser group, HCVR patients had a lower survival rate than LCVR patients (p = 0.0003). Cox proportional hazards model revealed that LCVR patients had an excellent prognosis compared with HCVR patients in the rHuEPO nonuser group, but this difference disappeared in the rHuEPO user group.

CONCLUSION

These data show a beneficial effect of rHuEPO treatment on cardiovascular morbidity and mortality in CAPD patients, evidenced by the elimination of the correlation between prior cardiovascular risk and subsequent mortality.