Examine the optimal multidisciplinary care teams for patients with chronic kidney disease from a nationwide cohort study.

Background: Multidisciplinary team-based integrated care (MDC) has been recommended for patients with chronic kidney disease (CKD). However, team-based specific structured care systems are not yet established. Therefore, we investigated the efficacy of MDC system and the optimal number of professionals that make up the team for maintaining kidney function and improving prognosis. Methods: This nationwide, multicenter, observational study included 2,957 Japanese patients with CKD who received MDC from 2015 to 2019. The patients were divided into four groups according to the number of professionals in the MDC team. Groups A, B, C, and D included nephrologists and one, two, three, and four or more other professionals, respectively. Changes in the annual decline in estimated glomerular filtration rate before and after MDC were evaluated. Cox regression was utilized to estimate the correlation between each group and all-cause mortality and the start of renal replacement therapy (RRT) for 7 years. Results: The change in eGFR significantly improved between before and at 6, 12, and 24 months after MDC in all groups (all p < 0.0001). Comparing group D to group A (reference), the hazard ratio (HR) for all-cause mortality and the start of the RRT was 0.60 (95% confidence interval, 0.48-0.73; p < 0.0001) after adjustment for multiple confounders. Lower HR in group D was confirmed in both diabetes and nondiabetes subgroups. Conclusion: An MDC team comprised of five or more professionals might be associated with improvements in mortality and kidney prognosis. Furthermore, MDC might be effective for treating CKD other than diabetes.

Inpatient multidisciplinary care can prevent deterioration of renal function in patients with chronic kidney disease: a nationwide cohort study.

Background: Multidisciplinary care is necessary to prevent worsening renal function and all-cause mortality in patients with chronic kidney disease (CKD) but has mostly been investigated in the outpatient setting. In this study, we evaluated the outcome of multidisciplinary care for CKD according to whether it was provided in an outpatient or inpatient setting. Methods: This nationwide, multicenter, retrospective, observational study included 2954 Japanese patients with CKD stage 3-5 who received multidisciplinary care in 2015-2019. Patients were divided into two groups: an inpatient group and an outpatient group, according to the delivery of multidisciplinary care. The primary composite endpoint was the initiation of renal replacement therapy (RRT) and all-cause mortality, and the secondary endpoints were the annual decline in the estimated glomerular filtration rate (ΔeGFR) and the changes in proteinuria between the two groups. Results: Multidisciplinary care was provided on an inpatient basis in 59.7% and on an outpatient basis in 40.3%. The mean number of health care professionals involved in multidisciplinary care was 4.5 in the inpatient group and 2.6 in the outpatient group (P < 0.0001). After adjustment for confounders, the hazard ratio of the primary composite endpoint was significantly lower in the inpatient group than in the outpatient group (0.71, 95% confidence interval 0.60-0.85, P = 0.0001). In both groups, the mean annual ΔeGFR was significantly improved, and proteinuria significantly decreased 24 months after the initiation of multidisciplinary care. Conclusion: Multidisciplinary care may significantly slow deterioration of eGFR and reduce proteinuria in patients with CKD and be more effective in terms of reducing initiation of RRT and all-cause mortality when provided on an inpatient basis.

Effectiveness and current status of multidisciplinary care for patients with chronic kidney disease in Japan: a nationwide multicenter cohort study.

BACKGROUND: Multidisciplinary care is well established in clinical practice, but its effectiveness in patients with chronic kidney disease (CKD) remains unclear. The aim of this study was to determine whether multidisciplinary care could help to avoid worsening kidney function in patients with CKD. METHODS: This nationwide study had a multicenter retrospective observational design and included 3015 Japanese patients with CKD stage 3-5 who received multidisciplinary care. We assessed the annual decrease in estimated glomerular filtration rate (ΔeGFR) and urinary protein in the 12 months before and 24 months after the start of multidisciplinary care. All-cause mortality and initiation of renal replacement therapy were investigated according to baseline characteristics. RESULTS: Most of the patients had CKD stage 3b or higher and a median eGFR of 23.5 mL/min/1.73 m2. The multidisciplinary care teams consisted of health care professionals from an average of four disciplines. ΔeGFR was significantly smaller at 6, 12, and 24 months after initiation of multidisciplinary care (all P < 0.0001), regardless of the primary cause of CKD and its stage when multidisciplinary intervention was started. Urinary protein level also decreased after initiation of multidisciplinary care. After a median follow-up of 2.9 years, 149 patients had died and 727 had started renal replacement therapy. CONCLUSION: Multidisciplinary care may significantly slow the decline in eGFR in patients with CKD and might be effective regardless of the primary disease, including in its earlier stages. Multidisciplinary care is recommended for patients with CKD stage 3-5. TRIAL REGISTRATION: UMIN00004999.

Effects of Calcium Polystyrene Sulfonate Formulation Change from Dry Syrup to Oral Solution in Patients with Chronic Kidney Disease.

Calcium polystyrene sulfonate, a cation exchange resin preparation, is used to treat hyperkalaemia. The effects of switching from dry syrup to oral solution forms have been rarely evaluated. We investigated changes in serum potassium levels, incidence of adverse events, and patients' perception and satisfaction associated with the change in calcium polystyrene sulfonate dosage forms from dry syrup to oral solution in chronic kidney disease patients. The study population was comprised of 24 patients. The chronic kidney disease cause, glomerular filtration rate category, and albuminuria category was G4 in 10 cases (41.7%) and G5 in 8 cases (33.3%). No significant difference was observed between groups before and after the change in dosage form. Contrastingly, the ease of intake (P=0.0047), taste (P=0.0056), and satisfaction (P<0.001) indicated positive significant improvements. Changing the calcium polystyrene sulfonate dosage form from dry syrup to oral solution in patients with chronic kidney disease improved patient satisfaction while maintaining efficacy and safety. For patients in whom weight gain is not a problem, we recommend changing the dosage form from dry syrup to oral solution for calcium polystyrene sulfonate.

Relationship between compliance with management target values and renal prognosis in multidisciplinary care for outpatients with chronic kidney disease.

BACKGROUND: Although multidisciplinary care (MDC) is necessary for controlling chronic kidney disease (CKD), its impact on compliance with management target values in the CKD guidelines remains unclear. This study was designed to clarify the relationship between compliance with management target values and renal prognosis in CKD outpatients who received MDC. METHODS: There were 255 outpatients with pre-dialysis CKD who received MDC. Achievement rates of systolic, and diastolic blood pressure, hemoglobin, uric acid, low-density lipoprotein cholesterol, and hemoglobin A1c values determined according to CKD guidelines were compared before and 12 months after MDC. In addition, after dividing achievement rates of the target values at 12 months after MDC into four groups (A < 30% ≤ B < 60% ≤ C < 80% ≤ D), dialysis initiation and renal survival rates were compared. RESULTS: There was a significant increase in the overall achievement rate from 62.8 to 69.1% (p < 0.001). The higher the achievement rate after MDC, the lower the dialysis initiation rate (A 72.7%, B 35.3%, C 20.5%, D 8.2%, p < 0.001). There was also a significantly higher renal survival rate (p < 0.001). These findings suggest that MDC for CKD raised awareness of health literacy, and improved the achievement rate of target values. Furthermore, the higher the achievement rate, the later the initiation of dialysis, which led to improvement of renal survival. CONCLUSIONS: MDC can improve compliance with management target values for CKD, suggesting that it may improve renal prognosis.

Effect of multidisciplinary care of dialysis initiation for outpatients with chronic kidney disease.

BACKGROUND: The aim of comprehensive multidisciplinary care (MDC) by the chronic kidney disease (CKD) team is not only to prevent worsening renal function, but also provide education on the selection of renal replacement therapy (RRT) by shared decision making (SDM). The purpose of this study was to examine the effects of MDC for predialysis outpatients on dialysis therapy, especially with regard to peritoneal dialysis (PD). METHODS: This study evaluated 112 CKD patients who underwent dialysis at our hospital starting from 2012, with 53 outpatients receiving MDC from the CKD team and 59 outpatients not receiving MDC. Annual decreases in the estimated glomerular filtration rates (ΔeGFR), the duration from the time of intervention to dialysis initiation, the urgent dialysis rate using a temporary catheter, and the PD selection rate were compared and examined between the two groups. The ΔeGFR, the duration from intervention to PD initiation, and the PD retention rate were compared between 18 PD patients in the MDC group and 10 PD patients in the non-MDC group. RESULTS: The MDC group had a significantly lower ΔeGFR, significantly longer duration, and a significantly lower urgent dialysis initiation rate versus the non-MDC group. Moreover, there was a significantly higher PD selection rate, significantly prolonged duration, and significantly higher PD retention rate. CONCLUSIONS: Multidisciplinary CKD team care for outpatients is effective in delaying the progression of CKD and avoiding the initiation of urgent dialysis; contributing to improved PD selectivity and continuity by SDM.

Resistance to Erythropoiesis-Stimulating Agents in Pre-Dialysis and Post-Dialysis Mortality in Japanese Incident Hemodialysis Patients.

BACKGROUND/AIMS: There is lack of definitive evidence about the association between erythropoiesis-stimulating agent (ESA) responsiveness in the pre-dialysis phase and mortality. Therefore, we conducted a hospital-based, retrospective, cohort study to assess the predictive value of ESA response for prognosis in incident hemodialysis patients. METHODS: A total of 108 patients without preexisting cardiovascular disease who had been started on maintenance hemodialysis were studied. ESA responsiveness just before starting dialysis was estimated using an erythropoietin resistance index (ERI). The endpoint was defined as all-cause death. RESULTS: During a mean follow-up period of 3.1 ± 1.6 years, 18 (17%) patients died. Overall, the multivariate Cox regression analysis revealed that the log-transformed ERI remained an independent predictor of all-cause death after adjustment using a propensity score (hazard ratio 2.25, 95% CI 1.25-4.06). CONCLUSIONS: Among incident hemodialysis patients, hyporesponsiveness to ESA may be associated with mortality.

Usefulness of multidisciplinary care to prevent worsening renal function in chronic kidney disease.

BACKGROUND: Comprehensive education about lifestyle, nutrition, medications and other types of treatment is important to prevent renal dysfunction in patients with chronic kidney disease (CKD). However, the effectiveness of multidisciplinary care on CKD progression has not been evaluated in detail. We aimed to determine whether multidisciplinary care at our hospital could help prevent worsening renal function associated with CKD. METHODS: A total of 150 pre-dialysis CKD outpatients accompanied (n = 68) or not (n = 82) with diabetes mellitus (DM) were enrolled into this study. We assessed annual decreases in estimated glomerular filtration rates (ΔeGFR), and measured systolic blood pressure (SBP), diastolic blood pressure (DBP), hemoglobin (Hb), uric acid (UA), low-density lipoprotein cholesterol (LDL), hemoglobin A1c (HbA1c) values and urinary protein to creatinine ratios (UPCR) 12 months before and after multidisciplinary care. In addition, changes in the number of medications and prescription ratio before and after multidisciplinary care were assessed in 90 patients with CKD who could confirm their prescribed medications. RESULTS: The ΔeGFR significantly improved between before and after multidisciplinary care from - 5.46 to - 0.56 mL/min/1.73 m2/year, respectively. The number of medications and prescription ratio showed no significant changes before and after multidisciplinary care. The ratios of improved ΔeGFR were found in 66.7% of all patients, comprising 63.1% of males and 76.9% of females, 64.8% without DM and 69.4% with DM. Values for UA, LDL, and HbA1c were significantly reduced among patients with improved ΔeGFR. CONCLUSION: Comprehensive multidisciplinary care of outpatients might help prevent worsening renal function among patients with CKD.

Thallium-201 washout rate of stress myocardial perfusion imaging as a predictor of mortality in diabetic kidney disease patients initiating hemodialysis: an observational, follow-up study.

BACKGROUND: Thallium-201 washout rate of stress myocardial perfusion imaging (MPI) has been reported to correlate with coronary flow reserve which is a parameter of myocardial microcirculation. However, the evidence for its use in diabetic kidney disease (DKD) has been lacking, and the association between thallium-201 washout rate and adverse outcomes including death is unknown. Therefore, the present study was conducted to evaluate the predictive ability of thallium-201 washout rate for mortality in DKD patients initiating hemodialysis. METHODS: A total of 96 patients with type 2 diabetes who had been started on maintenance hemodialysis undergoing stress MPI with thallium-201 within 1 year, 72 men and 24 women, with a median age of 67 years, were studied. The endpoint was defined as all-cause death. The Cox proportional hazards model was used to calculate hazard ratios (HR) and 95% confidence intervals (CI). RESULTS: During the mean follow-up period of 3.4 ± 2.1 years, 18 (18.8%) deaths occurred. Cumulative survival rates during the follow-up period, with thallium-201 washout rate levels in the lowest tertile (3.1-36.2%), the middle tertile (36.5-46.3%), and the highest tertile (46.4-66.2%), were 51.0, 86.5, and 85.3%, respectively. Overall, the multivariate Cox regression analysis revealed that thallium-201 washout rate remained an independent predictor of death after adjusting by confounding variables (HR 0.91, 95% CI 0.85-0.97). CONCLUSIONS: Among DKD patients initiating hemodialysis, thallium-201 washout rate seems to be useful for predicting death.

Usefulness of an Upright T-Wave in Lead aVR for Predicting the Short-Term Prognosis of Incident Hemodialysis Patients: A Potential Tool for Screening High-Risk Hemodialysis Patients.

BACKGROUND/AIMS: An upright T-wave in lead aVR (aVRT) has recently been reported to be associated with cardiovascular death and mortality among the general population and patients with prior cardiovascular disease (CVD). However, evidence for the predictive ability of aVRT in patients with chronic kidney disease is lacking. Therefore, a hospital-based, prospective, cohort study was conducted to evaluate the predictive ability of an upright aVRT for the short-term prognosis in incident hemodialysis patients. METHODS: Among 208 patients who started maintenance hemodialysis, 79 with preexisting CVD (CVD cohort) and 129 with no history of CVD (non-CVD cohort), were studied. An upright and non-upright aVRT were defined as a wave with a positive deflection in amplitude of ≥0 mV and a negative deflection in amplitude of <0 mV, respectively. The endpoint was all-cause death. RESULTS: Overall, the prevalence of an upright aVRT was 22.6% at baseline. During the mean follow-up period of 2.1 ± 1.0 years, 33 deaths occurred. Cumulative survival rates at 3 years after starting dialysis in patients with an upright and non-upright aVRT were 50.0 and 80.7%, respectively, in the CVD cohort and 92.0 and 91.3%, respectively, in the non-CVD cohort. In the CVD cohort, multivariate Cox regression analysis showed that an upright aVRT was an independent predictor of death after adjusting for confounding variables. CONCLUSION: Among Japanese hemodialysis patients at high risk for CVD, an upright aVRT seems to be useful for predicting death.

The FRAX ® as a predictor of mortality in Japanese incident hemodialysis patients: an observational, follow-up study.

The World Health Organization Fracture Risk Assessment Tool (FRAX(®)) was recently developed to estimate the 10-year absolute risk of osteoporotic fracture among the general population. However, the evidence for its use in chronic kidney disease patients has been lacking, and the association between the FRAX(®) and mortality is unknown. Therefore, a hospital-based, prospective, cohort study was conducted to evaluate the predictive ability of the FRAX(®) for mortality in hemodialysis patients. A total of 252 patients who had been started on maintenance hemodialysis, 171 men and 81 women, with a mean age of 67 ± 14 years, was studied. The endpoint was defined as all-cause death. The Cox proportional hazards model was used to calculate hazard ratios and 95 % confidence intervals. During the mean follow-up period of 3.4 ± 2.7 years, 61 deaths occurred. The median (interquartile range) of the FRAX(®) for major osteoporotic fracture was 6.9 (4.6-12.0) % in men and 19.0 (7.6-33.0) % in women. Cumulative survival rates at 5 years after starting dialysis, with the FRAX(®) levels above and below the median, were 51.9 and 87.9 %, respectively, in men and 67.4 and 83.7 %, respectively, in women. Overall, in men, the multivariate Cox regression analyses revealed that the log-transformed FRAX(®) remained an independent predictor of death after adjusting by confounding variables. However, in women, the significant association between the FRAX(®) value and the outcome was eliminated if age was put into these models. Among Japanese hemodialysis patients, the FRAX(®) seems to be useful for predicting death, especially in men.

Declining prevalence of coronary artery disease in incident dialysis patients over the past two decades.

AIM: The medical management of patients with chronic kidney disease(CKD) has changed within the past 20 years. We speculate that this change has resulted in a decrease in the prevalence of atherosclerotic cardiovascular disease in patients with CKD. The aim of the present study was to analyze changes in the prevalence of coronary artery disease(CAD) in patients newly started on hemodialysis, as well as trends in clinical factors and medications over the past two decades. METHODS: This single-center cross-sectional study examined data for 315 consecutive patients starting hemodialysis(age, 64±12 years; men, 73%; diabetic nephropathy, 57%) between January 1993 and December 2010. All patients were routinely screened for CAD within three months of starting hemodialysis, regardless of whether ischemic heart disease was suspected. The patients were categorized into six groups based on the date of the initial dialysis session in order to compare the historical prevalence of unidentified CAD(uCAD) in association with the clinical factors. In addition, we performed a subgroup analysis among 222 patients without known cardiac disease. RESULTS: The prevalence of uCAD gradually declined from 69% to 25% over 18 years(p＜0.001 for trend). The mean high-density lipoprotein cholesterol(HDL-C) concentration increased(p＜0.001 for trend), while the median C-reactive protein(CRP) level decreased over time. In parallel with these trends, the proportion of statin users significantly increased over time(p＜0.001 for trend). The use of erythropoiesis-stimulating agents(ESAs) and renin angiotensin aldosterone system inhibitors(RAS-Is) also increased during the same period(both p＜0.001 for trend). A univariate logistic regression analysis identified a significant association between the prevalence of uCAD and the use of ESAs(OR: 0.565, p=0.016) or RAS-Is(OR: 0.501, p=0.004). In addition, a lower BMI, lower HDL-Clevel and higher CRP level were found to be closely associated with uCAD, independent of confounding variables. The findings for the new dialysis patients without cardiac disease were similar. CONCLUSIONS: The prevalence of uCAD in patients with end-stage kidney disease has remarkably decreased over the past two decades. Major improvements in the medical management of CKD may modify the prevalence of coronary atherosclerosis.

Efficacy of N-terminal pro-brain natriuretic peptide digit number for screening of cardiac disease in new haemodialysis patients.

AIM: The usefulness of the absolute N-terminal pro-brain natriuretic peptide (NT-ProBNP) concentration and its digit number for screening for cardiac disease was explored in new haemodialysis patients. METHODS: A cross-sectional study involving 71 (68 ± 14 years, 83% male) new dialysis patients was conducted. Receiver operator characteristic curve analysis was performed to identify the cutoff level of NT-proBNP for identifying cardiac disease at the start of dialysis. RESULTS: The median NT-proBNP concentration was 6576 pg/mL just before the first dialysis session and its mean digit number was 4.3 ± 0.6. Overall, 67%, 52%, 9% and 35% of patients had left ventricular (LV) hypertrophy, LV dilatation, systolic dysfunction and significant coronary artery disease, respectively. NT-proBNP levels of about 6000, 10,000 and 14,000 pg/mL were the best cutoff levels for the diagnosis of coronary artery disease (AUC, 0.754; P < 0.001), LV systolic dysfunction (area under the curve (AUC), 0.765, P = 0.001) and LV dilatation (AUC, 0.685, P = 0.008), respectively. Interestingly, 4.5 was the best digit number cutoff for all cardiac abnormalities. These findings suggest that a digit number of 5 or more means a potentially high risk for cardiovascular disease and a digit number of 3 or less means a relatively low risk. CONCLUSIONS: The NT-proBNP concentration just before the first dialysis session is a useful tool for screening for cardiac abnormalities. Considering the wide variation of the NT-proBNP cutoff levels depending on each cardiac abnormality, the digit number could be potentially easier to use for initial risk stratification for cardiac disease in new dialysis patients.

Increment of monthly mean predialysis heart rate reflects early cardiac overload in hemodialysis patients with normal cardiac function.

BACKGROUND: The aim of our study was to examine the association of heart rate (HR) with the onset of congestive heart failure (CHF), and to compare the predictive value of HR with that of the serum level of human atrial natriuretic peptide (hANP) and the cardiothoracic ratio (CTR). METHODS: Thirty-eight patients on chronic hemodialysis (HD) aged 68 ± 11 years (61% men, 41% with diabetes) who had normal cardiac function were enrolled in this study. Among them, 6 patients had suffered CHF. Baseline characteristics and HR, hANP and CTR were compared between the 2 groups. RESULTS: At baseline, the monthly mean pre-HR (before HD), CTR and hANP values were higher in CHF patients compared with non-CHF patients. In the CHF group, the monthly mean pre-HR increased progressively beginning 10 months before the onset of CHF, which was earlier than the increments of hANP and CTR. A significant difference between the CHF and non-CHF groups was observed earlier for monthly mean pre-HR (4 months before CHF) and ANP (4 months before CHF) than for CTR (2 months before CHF). CONCLUSIONS: The increment of monthly mean pre-HR may reflect the early phase of cardiac overload, and is of equal significance to hANP. Further large-scale prospective studies are required to confirm these results.

Magnetic resonance imaging in congenital facial palsy.

We report magnetic resonance (MR) findings in a patient with congenital unilateral facial palsy and a patient with atypical Moebius syndrome. MR imaging showed a complete deficiency of right facial nerve in the patient with congenital unilateral facial palsy and bilateral, thin proximal facial nerves in the Moebius syndrome patient. Three-dimensional constructive interference in steady state (3D-CISS) MR imaging, especially reconstructions perpendicular to the bilateral internal auditory channel, was very useful when diagnosing patients with facial palsy due to the associated facial nerve abnormalities.

[A case of Möbius syndrome presenting with symptoms of severe infantile form of congenital muscular disorder].

Möbius syndrome is a rare disorder characterized by congenital bilateral facial nerve palsy. Abducent palsy or other cranial nerve palsy, facial malformations, limb malformations, and skeletal malformations are common features associated with this syndrome. We report a 9-month-old infant in whom congenital muscular disorder was previously suspected because of facial muscle involvement (mask-like face), respiratory and swallowing disturbances, and hypotonia since birth. After an improvement in the respiratory infection, she showed slightly exaggerated deep tendon reflexes and an improvement in muscle tone. The occurrence of combined facial nerve palsy, glossopharyngeal nerve palsy, vagus nerve palsy, and hypoglossal nerve palsy strongly suggested that she had Möbius syndrome. Finally, the absence of the roots of bilateral facial nerves on an MRI confirmed that the disorder was Möbius syndrome. We propose that a thin slice MRI should be obtained to observe the cranial nerves around the brain stem if patients show symptoms of congenital myopathy or congenital myotonic dystrophy as well as facial nerve and other cranial nerve paralyses.

Independent risk factors for progression of coronary atherosclerosis in hemodialysis patients.

Not uncommonly, hemodialysis patients with normal results in myocardial perfusion tests can still have a cardiac event within 2 years of evaluation. We examined possible risk factors for progression of coronary atherosclerosis in hemodialysis patients. We prospectively evaluated ability of myocardial perfusion imaging carried out under pharmacologic stress to predict 2-year outcomes in 77 hemodialysis patients, specifically thallium-201 single-photon emission computed tomography (SPECT) using high-dose adenosine triphosphate as the stressor. The primary end-point was a cardiac event (cardiac death, non-fatal acute coronary syndrome, or hospitalization for acute ischemic heart failure). Factors independently influencing duration until a cardiac event in hemodialysis patients were identified using stepwise multiple regression analysis. Myocardial perfusion defects were shown in 36 patients. Patients with a perfusion defect were more likely to have cardiac events than those with normal perfusion (78% vs. 15%, P < 0.001). Time until occurrence of a cardiac event in hemodialysis patients showed a significant, independent association with known coronary artery disease [regression coefficient (RC) = -3.391, P = 0.046], elevated C-reactive protein (RC = -5.813, P = 0.005), and a reversible myocardial perfusion defect (RC = -7.386, P < 0.001). An analysis based on the 'best cut-off' of CRP as identified on the basis of the ROC curve augmented the positive and negative predict value of CRP for the prediction of coronary events to 65 and 74%, respectively. Myocardial perfusion SPECT and measuring the plasma concentration of CRP might be useful for the prediction of hemodialysis patients with progression of coronary atherosclerosis.

Relationship between serum albumin level before initiating haemodialysis and angiographic severity of coronary atherosclerosis in end-stage renal disease patients.

BACKGROUND: In patients with chronic kidney disease (CKD), although strong associations have been observed between malnutrition and atherosclerosis, the relationship between serum albumin concentration and angiographic changes of coronary artery disease (CAD) remains poorly explored. The goal of the present study was, in patients with CKD, to clarify the relationship between the angiographic severity of CAD and serum albumin concentration reflecting either inflammation or nutrition or both. METHODS: In this study, 100 end-stage renal disease (ESRD) patients were enrolled, who commenced long-term dialysis therapy at our hospital and underwent coronary angiography within 3 months of the first haemodialysis (HD) session. Mean age was 63+/-11 years, 20% of the subjects were female and 62% had diabetes. Severity of CAD was evaluated in terms of (i) number of vessels exhibiting CAD (>or=75% stenosis) and (ii) Gensini score (GS). Clinical characteristics and laboratory findings were recorded at initiation of long-term HD therapy. We then evaluated a possible association with the presence and degree of CAD. RESULTS: Sixty-four patients exhibited signs of CAD. Forty-one among them (64%) had multivessel disease. On univariate logistic regression analysis, age, diabetes and hypoalbuminaemia were significantly associated with multivessel CAD. Univariate linear regression analysis demonstrated a positive correlation of age and diabetes with GS, and an inverse correlation of BMI and serum albumin level with GS. Stepwise regression analysis showed age and serum albumin level to be independently associated with multivessel CAD and GS. The ROC curves demonstrated best cut-off levels of age and albumin for predicting multivessel CAD to be 70 years and 3.15 g/dl, respectively. CONCLUSION: Hypoalbuminaemia at the initiation of dialysis is an important predictor of advanced CAD, particularly in male and in diabetic patients. It may reflect mainly a state of inflammation. However, malnutrition as a confounding factor cannot be entirely excluded.

Aberrant peroxisome morphology in peroxisomal beta-oxidation enzyme deficiencies.

Peroxisomes are ubiquitous organelles in eukaryotic cells and surrounded by a single membrane, and undergo considerable changes in size, shape and number. Peroxisomal disorders are classified into two categories: peroxisome biogenesis disorders (PBDs) and single-enzyme deficiencies (SEDs). Morphologically aberrant peroxisomes called 'peroxisomal ghosts' in PBDs are well known, however, a morphological approach to the study of peroxisomes in SEDs has been rarely reported. Here, we investigated the morphology of peroxisomes in cultured fibroblasts from patients lacking peroxisomal beta-oxidation enzymes, including acyl-CoA oxidase (AOX) or D-3-hydroxyacyl-CoA dehydratase/D-3-hydroxyacyl-CoA dehydrogenase bifunctional protein (D-BP). Morphological analysis by immunofluorescence examination using an antibody against catalase revealed a smaller number of large peroxisomes in fibroblasts from these patients. Moreover, immunoelectron microscopy using an antibody against the 70-kDa peroxisomal membrane protein (PMP70) showed large peroxisomes with various horseshoe-shaped membrane structures. These results give an important clue to elucidating the division of peroxisomes and how peroxisomes change in size, shape, number and position within cells, which are subjects for future study.