The effect of "xanthan gum-based fluid thickener" on hydration, swallowing functions and nutritional status in total maxillectomy patients.

PURPOSE: Swallowing functions are affected after total maxillectomy operations and adjuvant chemoradiotherapy. The purpose of our study is to assess the role of xanthan gum based thickening agents on swallowing and hydration of maxillectomy patients on a randomized controlled fashion. METHODS: 12 of the 22 patients diagnosed with maxillary carcinoma and planned to undergo total maxillectomy was identified as study group and 10 of them were identified as control group. The study group used "xantham based liquid thickener" for liquid foods up to 3 months postoperatively and the control group did not use. Dysphagia-related quality of life, bioimpedance analysis, EAT-10 scores, swallowing functions were evaluated both preoperative and postoperative period. RESULTS: The mean age of the study group was 56 ± 9.87, and 41.6% were women. The mean age of control group was 60 ± 15.63, and 50% were women. Postoperative EAT-10 scores were statistically significant higher than preoperative scores in both groups (p < 0.05). In both of the study and control groups, a statistically significant reduction in dysphagia related quality of life was detected postoperatively (p < 0.05). Intracellular water, extracellular water and total body water detected statistically significant higher in study group at postoperative month three. CONCLUSION: Swallowing functions are affected due to total maxillectomy and radiotherapy. With this study, it has been shown that, total maxillectomy and radiotherapy reduce dysphagia-related quality of life. Swallowing dysfunction and dehydration has been shown to affect total maxillectomy patients. Using of 'xanthan gum-based fluid thickener' helps to maintain intracellular water, extracellular water, and total body water.

The impact of membrane permeability and dialysate purity on cardiovascular outcomes.

The effects of high-flux dialysis and ultrapure dialysate on survival of hemodialysis patients are incompletely understood. We conducted a randomized controlled trial to investigate the effects of both membrane permeability and dialysate purity on cardiovascular outcomes. We randomly assigned 704 patients on three times per week hemodialysis to either high- or low-flux dialyzers and either ultrapure or standard dialysate using a two-by-two factorial design. The primary outcome was a composite of fatal and nonfatal cardiovascular events during a minimum 3 years follow-up. We did not detect statistically significant differences in the primary outcome between high- and low-flux (HR=0.73, 95% CI=0.49 to 1.08, P=0.12) and between ultrapure and standard dialysate (HR=0.90, 95% CI=0.61 to 1.32, P=0.60). Posthoc analyses suggested that cardiovascular event-free survival was significantly better in the high-flux group compared with the low-flux group for the subgroup with arteriovenous fistulas, which constituted 82% of the study population (adjusted HR=0.61, 95% CI=0.38 to 0.97, P=0.03). Furthermore, high-flux dialysis associated with a lower risk for cardiovascular events among diabetic subjects (adjusted HR=0.49, 95% CI=0.25 to 0.94, P=0.03), and ultrapure dialysate associated with a lower risk for cardiovascular events among subjects with more than 3 years of dialysis (adjusted HR=0.55, 95% CI=0.31 to 0.97, P=0.04). In conclusion, this trial did not detect a difference in cardiovascular event-free survival between flux and dialysate groups. Posthoc analyses suggest that high-flux hemodialysis may benefit patients with an arteriovenous fistula and patients with diabetes and that ultrapure dialysate may benefit patients with longer dialysis vintage.

Effect of fluid management guided by bioimpedance spectroscopy on cardiovascular parameters in hemodialysis patients: a randomized controlled trial.

BACKGROUND: Fluid overload is the main determinant of hypertension and left ventricular hypertrophy in hemodialysis patients. However, assessment of fluid overload can be difficult in clinical practice. We investigated whether objective measurement of fluid overload with bioimpedance spectroscopy is helpful in optimizing fluid status. STUDY DESIGN: Prospective, randomized, and controlled study. SETTING & PARTICIPANTS: 156 hemodialysis patients from 2 centers were randomly assigned to 2 groups. INTERVENTION: Dry weight was assessed by routine clinical practice and fluid overload was assessed by bioimpedance spectroscopy in both groups. In the intervention group (n = 78), fluid overload information was provided to treating physicians and used to adjust fluid removal during dialysis. In the control group (n = 78), fluid overload information was not provided to treating physicians and fluid removal during dialysis was adjusted according to usual clinical practice. OUTCOMES: The primary outcome was regression of left ventricular mass index during a 1-year follow-up. Improvement in blood pressure and left atrial volume were the main secondary outcomes. Changes in arterial stiffness parameters were additional outcomes. MEASUREMENTS: Fluid overload was assessed twice monthly in the intervention group and every 3 months in the control group before the mid- or end-week hemodialysis session. Echocardiography, 48-hour ambulatory blood pressure measurement, and pulse wave analysis were performed at baseline and 12 months. RESULTS: Baseline fluid overload parameters in the intervention and control groups were 1.45 ± 1.11 (SD) and 1.44 ± 1.12 L, respectively (P = 0.7). Time-averaged fluid overload values significantly decreased in the intervention group (mean difference, -0.5 ± 0.8 L), but not in the control group (mean difference, 0.1 ± 1.2 L), and the mean difference between groups was -0.5 L (95% CI, -0.8 to -0.2; P = 0.001). Left ventricular mass index regressed from 131 ± 36 to 116 ± 29 g/m(2) (P < 0.001) in the intervention group, but not in the control group (121 ± 35 to 120 ± 30 g/m(2); P = 0.9); mean difference between groups was -10.2 g/m(2) (95% CI, -19.2 to -1.17 g/m(2); P = 0.04). In addition, values for left atrial volume index, blood pressure, and arterial stiffness parameters decreased in the intervention group, but not in the control group. LIMITATIONS: Ambulatory blood pressure data were not available for all patients. CONCLUSIONS: Assessment of fluid overload with bioimpedance spectroscopy provides better management of fluid status, leading to regression of left ventricular mass index, decrease in blood pressure, and improvement in arterial stiffness.

Effects of three times weekly eight-hour nocturnal hemodialysis on volume and nutritional status.

BACKGROUND: This prospective cohort study compared the changes in body water composition and nutritional parameters measured with multifrequency bioimpedance analysis between 8-hour three times weekly nocturnal hemodialysis (NHD) and 4-hour conventional hemodialysis (CHD) patients. PATIENTS AND METHODS: 55 patients on CHD and 57 patients on NHD were included in the study. Multifrequency bioimpedance analysis was performed at baseline and at the 12th month. The primary outcomes of the study were changes in extracellular water (ECW), fat mass, dry lean mass and phase angle. Secondary outcomes of the study included changes in blood pressure and biochemical parameters related to nutrition and inflammation. RESULTS: ECW/height values decreased in the NHD group, while they increased in the CHD group. Fat mass, dry lean mass, and serum albumin increased and high sensitive CRP decreased in the NHD group but did not change in the CHD group. When changes in parameters from baseline to the 12th month between the groups were compared, NHD was associated with improvement in volume parameter including ECW/height (difference -0.44 l/m, p < 0.001). Change in blood pressure was not different between the groups, however requirement for antihypertensive medication decreased from 26.5 to 8.5% in the NHD group (p = 0.002). NHD was also associated with increases in fat mass (difference 1.8 kg, p < 0.001), dry lean mass (difference 0.6 kg, p = 0.006), serum albumin (difference 0.19 g/dl, p < 0.001) and cholesterol (difference 18.8 mg, p < 0.001). Phase angle values decreased in the CHD group but did not change in the NHD group (difference between the groups 0.37°, p = 0.04). CONCLUSION: This study revealed that longer HD facilitates volume control and improves nutritional status.

Mortality and cardiovascular events in online haemodiafiltration (OL-HDF) compared with high-flux dialysis: results from the Turkish OL-HDF Study.

BACKGROUND: Online haemodiafiltration (OL-HDF) is considered to confer clinical benefits over haemodialysis (HD) in terms of solute removal in patients undergoing maintenance HD. The aim of this study was to compare postdilution OL-HDF and high-flux HD in terms of morbidity and mortality. METHODS: In this prospective, randomized, controlled trial, we enrolled 782 patients undergoing thrice-weekly HD and randomly assigned them in a 1:1 ratio to either postdilution OL-HDF or high-flux HD. The mean age of patients was 56.5 ± 13.9 years, time on HD 57.9 ± 44.6 months with a diabetes incidence of 34.7%. The follow-up period was 2 years, with the mean follow-up of 22.7 ± 10.9 months. The primary outcome was a composite of death from any cause and nonfatal cardiovascular events. The major secondary outcomes were cardiovascular and overall mortality, intradialytic complications, hospitalization rate, changes in several laboratory parameters and medications used. RESULTS: The filtration volume in OL-HDF was 17.2 ± 1.3 L. Primary outcome was not different between the groups (event-free survival of 77.6% in OL-HDF versus 74.8% in the high-flux group, P = 0.28), as well as cardiovascular and overall survival, hospitalization rate and number of hypotensive episodes. In a post hoc analysis, the subgroup of OL-HDF patients treated with a median substitution volume >17.4 L per session (high-efficiency OL-HDF, n = 195) had better cardiovascular (P = 0.002) and overall survival (P = 0.03) compared with the high-flux HD group. In adjusted Cox-regression analysis, treatment with high-efficiency OL-HDF was associated with a 46% risk reduction for overall mortality {RR = 0.54 [95% confidence interval (95% CI) 0.31-0.93], P = 0.02} and a 71% risk reduction for cardiovascular mortality [RR = 0.29 (95% CI 0.12-0.65), P = 0.003] compared with high-flux HD. CONCLUSIONS: The composite of all-cause mortality and nonfatal cardiovascular event rate was not different in the OL-HDF and in the high-flux HD groups. In a post hoc analysis, OL-HDF treatment with substitution volumes over 17.4 L was associated with better cardiovascular and overall survival.

Increased arterial stiffness in patients with nephrotic syndrome.

INTRODUCTION: Nephrotic syndrome (NS) and arterial stiffness (AS) have each been linked with increased risk for cardiovascular diseases. However, there is no data in the literature up-to-date on AS in adult patients with NS. Thus, in this study, we aimed to evaluate the potential associations between AS, volume and nutritional status in patients with NS in comparison to a healthy control group. METHODS: 34 adult patients with newly diagnosed but untreated NS and 34 healthy controls were studied. AS was assessed by carotid-femoral PWV (cf-PWV) and body composition, nutritional status by multifrequency bioelectric impedance analysis (BIA). RESULTS: Mean age was 44.6 ± 18.7 years (18 - 72). Mean cf-PWV was 8.3 ± 2.5 m/s in patients with NS and 6.7 ± 1.1 m/s in controls (p = 0.002) . In univariate analysis, cf-PWV and positively correlated with age, systolic blood pressure, mean arterial pressure (MAP), pulse pressure, body mass index, body fat ratio, waisthip ratio, creatinine, uric acid and negatively with creatinine clearance. In linear regression analysis, only age and MAP predicted arterial stiffness. Total body fluid, extracellular water (ECW), ECW/Height, ECW/body surface area and third space volumes were higher in patients with NS. CONCLUSION: Patients with NS have increased AS and are more hypervolemic compared to the healthy subjects.

Relations between malnutrition-inflammation-atherosclerosis and volume status. The usefulness of bioimpedance analysis in peritoneal dialysis patients.

BACKGROUND: Chronic fluid overload (FO) is frequently present in peritoneal dialysis (PD) patients and is associated with hypertension and left ventricular hypertrophy and dysfunction, which are important predictors of death in dialysis patients. In the present study, we investigated the relationship between nutrition, inflammation, atherosclerosis and body fluid volumes measured by multi-frequency bioimpedance analysis (m-BIA) in PD patients. In addition, we analysed the relationship of extracellular volume values by m-BIA to echocardiographic parameters in order to define its usefulness as a measure of FO. METHODS: Ninety-five prevalent PD patients (mean age 50 ± 13 years, 10 of them diabetic) were enrolled. Extracellular water (ECW), total body water (TBW), dry lean mass (DLM) and phase angle (PA) were measured by m-BIA. Volume status was determined by measuring left atrium diameter (LAD) and left ventricular end-diastolic diameter (LVEDD). Measurement of carotid artery intima-media thickness (CA-IMT) was used to assess the presence of subclinical atherosclerosis. Serum albumin was used as a nutritional marker, and serum C-reactive protein (CRP) was used as an inflammatory marker. RESULTS: Mean ECW/height was 10.0 ± 1.0 L/m for whole group and 9.3 ± 0.6 L/m in patients with normal clinical hydration parameters. In correlation analysis, markers of nutrition, inflammation and atherosclerosis correlated well with m-BIA parameters. When we used echographically measured LAD (> 40 mm) or LVEDD (> 55 mm) as a confirmatory parameter, a cut-off value of 10.48 L/m ECW/height (78% specificity, with a sensitivity of 77% for LAD and 72% specificity, with a sensitivity of 70% for LVEDD) was found in ROC analysis for the diagnosis of FO. Patients with FO were older and had higher systolic blood pressure, cardiothoracic index, serum CRP level and mean CA-IMT than patients without FO. Patients with inflammation had higher CA-IMT values. In multivariate analysis, only two factors-low urine output and ECW/height-were independently associated with the presence of inflammation. CONCLUSIONS: FO defined by m-BIA is significantly correlated with markers of malnutrition, inflammation and atherosclerosis in PD patients. The indices obtained from m-BIA, especially ECW/height, correlated well with volume overload as assessed by echocardiography and might be a measure worth testing in a properly designed clinical study.

The impact of strict volume control strategy on patient survival and technique failure in peritoneal dialysis patients.

Strict volume control strategy provides better cardiac functions and control of hypertension in dialysis patients. We investigated the effect of this strategy on mortality and technique failure in peritoneal dialysis patients over a 10-year period. 243 patients were enrolled. Strict volume control by dietary salt restriction and ultrafiltration was applied. Mean systolic and diastolic blood pressures decreased from 138.4 ± 29.9 and 86.3 ± 16.8 to 114.9 ± 32.3 and 74.7 ± 18.3 mm Hg, respectively. Overall and cardiovascular mortality rates were 48.4 and 29.6 per 1,000 patient-years, respectively. In multivariate analysis, age, diabetes and baseline serum albumin level were independent predictors of overall mortality, and age, diabetes and baseline serum calcium of cardiovascular mortality. Residual diuresis and peritoneal equilibration test values were not related to mortality. Strict volume control leads to lower mortality than comparable series in the literature. Technique survival is better during the first 3 years, but not after 5 years.

Factors related to pulse wave velocity and augmentation index in chronic hemodialysis patients.

BACKGROUND: Augmentation index (AIx) and pulse wave velocity (PWV) are early markers of atherosclerotic vascular changes and also have been shown to be predictive of cardiovascular disease and total mortality. The aim of our study was to evaluate the relationship between PWV and AIx-HR75, which is the corrected form of AIx according to a heart rate of 75 beats/min, echocardiographic parameters and biochemical parameters in chronic hemodialysis (HD) patients. SUBJECTS AND METHODS: AIx-HR75 and PWV were measured in 556 HD patients by applanation tonometry using the SphygmoCor device. RESULTS: The mean PWV and AIx-HR75 values of the study group were 10.2 ± 2.4 and 28.4 ± 10.2 m/s. A positive correlation was found between PWV and AIx-HR75 (r = 0.214, p = 0.000). AIx-HR75 correlated with age (r = 0.093, p = 0.028), body surface area (BSA) (r = -0.194, p = 0.000), mean arterial pressure (MAP) (r = 0.335, p = 0.000), pulse pressure (PP) (r = 0.212, p = 0.000), cardiothoracic index (r = 0.155, p = 0.016), and presence of left ventricular hypertrophy (r = 0.152, p = 0.001). PWV correlated with MAP (r = 0.208, p = 0.000), PP (r = 0.098, r = 0.021), left ventricular mass (r = 0.105, p = 0.023), and predialysis sodium level (r = -0.105, p = 0.023). In the multivariate analyses, PWV was associated with MAP (t = 3.78, p = 0.000), presence of diabetes (t = 3.20, p = 0.001), and predialysis sodium level (t = -2.06, p = 0.040), and AIx-HR75 was associated with age (t = 2.48, p = 0.014), female sex (t = 3.98, p = 0.000), BSA (t = -2.15, p = 0.033), and MAP (t = 7.02, p = 0.000). CONCLUSION: There is a strong association between MAP and arterial stiffness parameters in HD patients. We feel that efficient control of blood pressure could lead to reduced arterial stiffness in HD patients.

Risk factors and consequences of post-transplant diabetes mellitus.

BACKGROUND: The aim of this study is to investigate the clinical course as well as risk factors and prognosis of post-transplant diabetes mellitus (PTDM). METHODS: Five hundred fifty-five kidney transplant recipients were retrospectively evaluated. PTDM was defined as fasting blood glucose ≥140 mg/dL on at least two consecutive measurements or requirement of oral antidiabetic drug or insulin. Patients with PTDM were divided into subgroups according to time of onset (early; <90 d vs. late, ≥90 d) and duration of diabetes (transient, <90 d vs. sustained ≥90 d). RESULTS: The frequency of PTDM was 18.3%. In multivariate analysis age (p < 0.001), hepatitis C virus (HCV) infection (p < 0.05) and tacrolimus use (p < 0.001) were independent risk factors. Among 220 HCV+ patients, liver biopsy was performed in 158, the histological grade (3.3 ± 2.8 vs. 4.4 ± 3.1) and stage (0.9 ± 1.1 vs. 1.4 ± 1.2) were significantly more severe in patients with PTDM than in non-diabetics. Incidence of PTDM in patients with severe fibrosis was 46.7%; 19.2% in nil or mild fibrosis (p < 0.05). Patient and graft survival were significantly worse, and cardiovascular events and life-threatening infection episodes were more frequent in PTDM. Half of the patients had early PTDM, while 30.3% of patients with PTDM showed transient nature. Five- and 10-yr death censored graft survival rates were worse in transient subgroup compared with sustained patients with diabetes (log rank 0.025) whereas there was no difference in outcome between early and late subgroups. CONCLUSIONS: Age, tacrolimus, and HCV are independent risk factors for PTDM. PTDM has a negative impact on both patient and graft survival, irrespective of the time of onset and duration of diabetes.

In Vitro Closure Times (PFA-100) Are Different Between Peritoneal Dialysis and Hemodialysis.

INTRODUCTION: Platelet dysfunction is not uncommon in patients with end-stage renal disease (ESRD). Type of renal replacement therapy may have an effect on platelet functions, which has not been well investigated. We evaluated in vitro closure time (CT) differences between peritoneal dialysis (PD) and hemodialysis (HD) patients using platelet function analyzer (PFA-100)and observed a significant difference between these renal replacement therapies. METHODS: Patients with ESRD undergoing PD (n = 24) or HD (n = 23) for more than 6 months were included. Blood samples for collagen/epinephrine (Col/EPI) and collagen/adenosine diphosphate (Col/ADP) measurements were obtained before HD at a mid-week session for HD patients and at an outpatient control time for PD patients. RESULTS: Three of 24 (12.5%) PD patients and 16 of 23 (69.5%) HD patients had prolonged PFA-100 Col/EPI, p< 0.001. Likewise, 4.2% of PD patients and 87.0% of HD patients had prolonged PFA-100 Col/ADP, p< 0.001. Moreover, the median times of PFA-Col/EPI and PFA-100 Col/ADP were significantly lower in PD patients compared with those of HD patients (p< 0.001). Multivariate analysis showed that the type of renal replacement was a risk factor for both elevated PFA-100 Col/ADP and PFA-100 Col/EPI after adjusted for platelets, hematocrit, and urea (p< 0.001). CONCLUSIONS: The type of renal replacement therapy may have an effect on in vitro CTs; therefore, studies including more patients with long-term follow-up are needed to investigate if the difference has any impact on clinical outcomes.

The influence of dialysate calcium on progression of arterial stiffness in peritoneal dialysis patients.

BACKGROUND: One of the origins of cardiovascular disease in dialysis patients is arterial stiffness. The aim of our study was to assess the relationship between the calcium content of peritoneal dialysis (PD) solution and arterial stiffness. PATIENTS AND METHODS: We enrolled into the study 49 PD patients who had been treated with the same PD solution for the preceding 6 months. The calcium content of the PD solution was 1.25 mmol/L in 34 patients (low-Ca group) and 1.75 mmol/L in 15 patients (high-Ca group). Study patients were followed for 6 months on the same PD prescription. Arterial stiffness was assessed by measurement of augmentation index (AI) and brachial pulse wave velocity (PWV) at baseline and at month 6 (SphygmoCor: Atcor Medical, West Ryde, NSW, Australia). Demographic data were recorded from patient charts. RESULTS: Mean age of the whole group was 51 +/- 11 years, prevalence of diabetes was 14%, duration of PD was 43 +/- 30 months, percentage of women was 45%, and percentage of patients using a cycler was 33%. We observed no differences between groups with regard to those variables or creatinine clearance, residual renal function, Ca, phosphorus, parathormone, C-reactive protein, lipid parameters, and use of phosphate binder with or without Ca content. Mean arterial pressure was higher in the high-Ca group, but the difference was not statistically significant (100 +/- 22 mmHg vs 88 +/- 18 mmHg, p = 0.06). At baseline, AI was significantly higher in the high-Ca group than in the low-Ca group (27% +/- 10% vs 21% +/- 9%, p < 0.05). Measurements of PWV were not different between the groups (8.4 +/- 1.1 m/s vs 8.5 +/- 1.7 m/s). Measurement of arterial stiffness parameters at month 6 revealed that PWV had increased in the high-Ca group (to 9.6 +/- 2.3 m/s from 8.4 +/- 1.1 m/s, p < 0.05), but had not changed in the low-Ca group (to 8.2 +/- 1.9 m/s from 8.5 +/- 1.7 m/s). The AI did not change in either group. CONCLUSIONS: These data suggest that Ca exposure through PD solution plays a role in the progression of arterial stiffness, which may be related to increased vascular calcification.

The effect of hypercalcemia on allograft calcification after kidney transplantation.

PURPOSE: Persistent hypercalcemia after kidney transplantation (KTx) may cause nephrocalcinosis and graft dysfunction. The aim of this study was to evaluate patients with hypercalcemia and assess its effect on tubulointerstitial calcification. METHODS: A total of 247 recipients were enrolled. Transient and persistent hypercalcemia was defined as hypercalcemia (corrected serum calcium >10.2 mg/dL) persisting for 6 and 12 months after KTx, respectively. The severity of calcification in the 0-h, 6- and 12-month protocol biopsies of patients with transient (n = 8) and persistent hypercalcemia (n = 20) was compared with a matched control group (n = 28). RESULTS: Twenty-eight patients were hypercalcemic at 6 months posttransplantation. Serum calcium levels were normalized in eight of them at the end of the first year. Dialysis duration was a positive predictor of persistent hypercalcemia. Tubulointerstitial calcification was detected in 70.6 and 90 % of patients with persistent hypercalcemia at 6 and 12 months posttransplantation, respectively. In 20 % of patients with transient hypercalcemia, severity of calcification regressed at 12 months posttransplantation along with normalization of serum calcium levels. Graft functions and histopathological findings (ci, ct, ci + ct, cv, ah, percentage of sclerotic glomeruli) were not different at 6 and 12 months posttransplantation. CONCLUSIONS: Hypercalcemia and persistent hyperparathyroidism are not rare after KTx. Tubulointerstitial calcification is more common and progressive among patients with persistent hypercalcemia. Normalization of calcium levels may contribute to regression of calcification in some patients.

How quickly can acute symptomatic hyponatremia be corrected?

The systemic absorption of the flush liquid, including sorbitol, glycine or mannitol, can lead to complications, such as hyponatremia, volume overload and pulmonary or cerebral edema. Acute hyponatremia is defined as a reduction in the plasma sodium level in less than 48 h. Acute symptomatic hyponatremia should be corrected aggressively because it may cause irreversible neurological damage and death. Rapid correction of hyponatremia causes severe neurologic deficits, such as central pontine myelinolysis; thus, the optimal therapeutic approach has been debated. This article examined acute symptomatic hyponatremia in a patient undergoing transcervical myomectomy for a submucosal myoma. A thirty-seven-year-old patient was evaluated in obstetrics and gynecology clinic because of altered mental status and agitation. There was no history of chronic illness or drug use. It was discovered that during the operation, 12 L of the flush fluid, which contained 5 % mannitol, had been infused, but only 7 L of the flush fluid had been collected. On physical examination, the patient's general condition was moderate, her cooperation was limited, she was agitated, and her blood pressure was 120/70 mmHg. The sodium level was 99 mEq/L. Furosemid and 3 % NaCl solution were given. Her serum sodium returned to normal by increasing 39 mEq/L within 14 h. Her recovery was uneventful, and she was discharged 24 h after her serum sodium returned to normal. In conclusion, if there is a difference between the infused and collected volumes of the mannitol irrigant, severe hyponatremia may develop due to the flush fluid used during transcervical hysteroscopy and myomectomy. In these patients, acute symptomatic hyponatremia may be corrected as rapidly as the sodium level dropped.

Pre-transplant HbA1c level as an early marker for new-onset diabetes after renal transplantation.

BACKGROUND: New-onset diabetes after transplantation (NODAT) is a common complication in renal transplant (RT) patients. The clinical significance of pre-transplant HbA1c level remains unclear in RT patients. Thus, we investigated the predictive role of pre-transplant HbA1c levels for the NODAT diagnosed in 1 year after renal transplantation. METHODS: Two hundred and four RT patients older than 18 years were analyzed. NODAT diagnosis during the 1-year follow-up after RT was based on the 2003 modified criteria of the ADA. HbA1c level was measured at pre-transplantation period and every 3 months after RT. RESULTS: Mean age was 39.3 ± 10.7 (20-73) years and 36 % were female. Mean pre-transplant HbA1c level was 4.9 ± 0.5 % (4.0-6.4 %). Pre-transplant HbA1c level was positively correlated with age, pre-transplant body mass index (BMI) and cholesterol level. Fifty-four patients (25.9 %) developed NODAT and 33.8 % had impaired fasting blood glucose levels. Patients with NODAT were significantly older and had higher pre-transplant BMI and HbA1c than those without. Use of Tacrolimus was also higher in patients with NODAT. In stepwise logistic regression analysis, pre-transplant HbA1c level was an independent predictor for the development on NODAT (OR = 4.63, 95 % CI: 2.09-10.2, p < 0.001) together with age, Tacrolimus-based regimen and pre-transplant fasting blood glucose level. CONCLUSIONS: Assessment of pre-transplant HbA1c levels may be a valuable tool for early diagnosis of NODAT in RT recipients.

Soluble TWEAK level: is it a marker for cardiovascular disease in long-term hemodialysis patients?

BACKGROUND: Reduced soluble tumor necrosis factor-like weak inducer of apoptosis (sTWEAK) levels follow declining renal function, are strongly associated with endothelial dysfunction and predict cardiovascular events in nondialyzed chronic kidney disease patients. In contrast, elevated levels of sTWEAK predict poor survival in hemodialysis (HD) patients. Recent evidence suggests a role for sTWEAK in the pathophysiology of vascular calcification. The aim of the study was to investigate plausible links between sTWEAK, atherosclerosis, arterial stiffness and vascular calcification in HD patients. METHODS: Coronary artery calcification score (CACs) determined by multislice computed tomography, arterial stiffness by pulse wave velocity (PWV) and carotid artery intima-media thickness (CA-IMT) by carotid Doppler ultrasonography were assessed in 131 long-term prevalent HD patients. sTWEAK levels were measured by ELISA (Bender MedSystems, Vienna, Austria). RESULTS: Mean serum sTWEAK level was 237.0 ± 147.5 pg/mL (range 78-937). sTWEAK level was inversely correlated with CA-IMT at a borderline significance (r=-0.168, p=0.05). Neither carotid-radial PWV nor carotid-femoral PWV values correlated with sTWEAK. sTWEAK level was higher in patients with severe vascular calcification (CACs ≥400) compared to patients with CACs <400 (264.5 ± 146.8 pg/mL vs. 205.04 ± 122.4 pg/mL, p=0.02).The association between sTWEAK and vascular calcification persisted after multivariate adjustment. CONCLUSIONS: There exists a weak inverse correlation between sTWEAK and carotid atherosclerosis and a positive correlation with coronary artery calcification in long-term HD patients. Our data give support for a role for sTWEAK in the pathogenesis of vascular injury in HD patients.

Epicardial adipose tissue volume and cardiovascular disease in hemodialysis patients.

OBJECTIVE: Epicardial adipose tissue (EAT) is proposed as a cardiovascular risk marker in non-uremic subjects. However, little is known about its role in patients with higher cardiovascular risk profile such as chronic kidney disease. The aim of this study was to investigate the relationship between EAT and several cardiovascular surrogate markers (coronary artery calcification (CAC), arterial stiffness and atherosclerosis) in patients on maintenance hemodialysis. METHODS: A total of 191 prevalent hemodialysis patients were enrolled in this cross-sectional study. EAT and CAC scores (CACs) were determined by multi-slice computerized tomography, arterial stiffness by carotid-femoral pulse wave velocity (PWV), and carotid artery intima-media thickness (CA-IMT) by B-mode doppler ultrasonography. RESULTS: Mean age was 59 ± 13 years and time on hemodialysis 75 ± 44 months. Twenty percent of the patients had diabetes. Mean EAT volume was 62.6 ± 26.8 cm(3)/m(2). Mean CA-IMT and PWV values increased across the EAT tertiles. EAT was correlated with age, female gender, body mass index, albumin and lipid parameters. Additionally, CA-IMT and PWV values were positively correlated with EAT. EAT volume was significantly higher in patients with CACs >10 compared to the patients with CACs ≤10. Despite the univariate associations between EAT and cardiovascular surrogate markers, only age, body mass index and total cholesterol levels were associated with EAT in adjusted models. CONCLUSIONS: In prevalent hemodialysis patients, EAT is correlated with atherosclerosis, arterial stiffness and the presence of CAC. However, this correlation is not independent of other risk factors.

Association of insulin resistance with arterial stiffness in nondiabetic peritoneal dialysis patients.

BACKGROUND: Insulin resistance is a risk factor for cardiovascular morbidity and mortality in the general and end-stage renal disease populations. In this study, we investigated the association between insulin resistance and arterial stiffness in nondiabetic peritoneal dialysis (PD) patients. METHODS: Fifty-three patients were enrolled. Patients were divided into 2 groups as homeostasis model assessment of insulin resistance (HOMA-IR) ≤ 2.97 (low) and >2.97 (high). Carotid-femoral pulse wave velocity (c-f PWV) analysis and intima-media thickness of the carotid artery were measured. RESULTS: Mean age was 46 ± 12 years and HOMA-IR was 2.97 ± 1.77 (0.77-8.88). Mean c-f PWV was 7.6 ± 1.7 m/s. HOMA-IR was positively correlated with age, body mass index, and c-f PWV and negatively with serum HDL cholesterol and parathormone. In linear regression analysis, age and mean arterial pressure were predictors for c-f PWV. When patients were divided into 2 groups according to median age as ≤ 49 and >50, mean arterial pressure, male gender, and age were predictors for c-f PWV in patients aged ≤ 49, whereas HOMA-IR was the only predictor for c-f PWV in patients aged >50 years. CONCLUSION: Insulin resistance is an independent risk factor for arterial stiffness in PD patients older than 50 years. IR is not associated with carotid intima-media thickness.

Effects of thrice weekly nocturnal hemodialysis on arterial stiffness.

OBJECTIVE: In this study, we compared the changes in arterial stiffness in chronic hemodialysis patients treated with 8-h vs. 4-h thrice weekly in-center hemodialysis. METHODS: Sixty prevalent chronic hemodialysis patients assigned to 8-h nocturnal in-center thrice weekly HD (NHD) and 60 control cases assigned to 4-h thrice weekly conventional HD (CHD) were followed for one year. Radial-carotid pulse wave velocity, augmentation index and echocardiography were performed at baseline and 12th month. RESULTS: Mean age of the patients was 49±11 years, 30.8% were female, 27.5% had diabetes mellitus and mean dialysis vintage was 57±47 months. Baseline demographical, clinical and laboratory parameters were similar between groups. During a mean follow-up of 15.0±0.1 months, blood pressure remained similar in both groups while the number of mean daily anti-hypertensive substances decreased in the NHD group. In the NHD group, time-averaged serum phosphorus and calcium-phosphorus product were lower than the CHD group. Pulse wave velocity and augmentation index decreased in the NHD group (from 11.02±2.51 m/s to 9.61±2.39 m/s and from 28.8±10.3% to 26.2±12.1%; p=0.008 and p=0.04, respectively). While augmentation index increased in the CHD group (28.0±9.4 to 31.0±10.7%, p=0.02), pulse wave velocity did not change. Subendocardial viability ratio and ejection duration improved in the NHD group (from 135±28 to 143±25%, p=0.01 and from 294±34 ms to 281±34 ms, p=0.003, respectively), accompanied by regression of left ventricular mass index. In multiple stepwise linear regression analyses, NHD was associated with improvements in augmentation index, ejection duration and subendocardial viability ratio. CONCLUSIONS: These data indicate that arterial stiffness is ameliorated by implementation of longer hemodialysis sessions.

Serum paraoxonase 1 activity predicts arterial stiffness in renal transplant recipients.

AIM: Paraoxanase 1 (PON 1) has been shown to protect against atherosclerosis by modifying lipoproteins. Its activity decreases in dialysis patients but is restored after transplantation. Whether it affects arterial stiffness is unclear. In this study we aimed to investigate the effects of PON 1 on arterial stiffness in renal transplant patients. METHODS: Seventy renal transplant recipients were enrolled. Arterial stiffness was measured using a Syphmocor device. PON-1 activity was assessed from the rate of enzymatic hydrolysis of paraoxon to p-nitrophenol. RESULTS: Mean age was 39.0 ± 9.6 years and 5.7% of the patients were diabetic. Post-transplant follow-up time was 46.7 ± 37.9 months. Eighty-five percent received anti-hypertensive and 12.9% anti-hyperlipidemic medication. Mean PON1 activity was 75.9 ± 52.4 U/L. PON1 activity was negatively correlated with systolic and diastolic blood pressure, mean arterial pressure, LDL-cholesterol and carotid-femoral pulse wave velocity (cf-PWV). Mean c-f PWV was 8.10 ± 1.39 m/s. Cf-PWV was positively correlated with age, systolic and diastolic blood pressure, mean arterial pressure, proteinuria and negatively correlated with PON1, PON1/HDL ratio and creatinine clearance. In linear regression analysis, PON1 was a predictor of cf-PWV in a model that included age, gender, diabetes, mean arterial pressure, urine protein level, creatinine clearance and PON 1. CONCLUSIONS: Reduced PON1 activity is significantly associated with increased arterial stiffness. The results of this study show the possible role of PON1 for arterial stiffening in renal transplant recipients.