Determinants of the Change in Arterial Stiffness in Peritoneal Dialysis Patients.

Arterial stiffness is an important risk factor for cardiovascular disease (CVD) in patients with end-stage renal failure. However, little is known about the factors that contribute to arterial rigidity in peritoneal dialysis (PD) patients. The aim of this study was to define the pattern and determinants of the longitudinal change in arterial stiffness after PD initiation.Arterial stiffening was estimated for 46 PD patients by using brachial-ankle pulse wave velocity (baPWV) and carotid intima-media thickness (cIMT). The cross-sectional relationship between the arterial markers and their clinical determinants was studied. The longitudinal effects of blood pressure (BP), body fluid status, and glucose were studied over the two years after initiating PD.Multivariate analysis showed that higher baPWV was associated positively with urinary protein excretion (P < 0.001), systolic BP (P = 0.001), and hemoglobin A1c (P = 0.003). In contrast, increased cIMT correlated with smoking (P = 0.004) and hypoalbuminemia (P = 0.04), suggesting that endothelial dysfunction is implicated in the atherogenic process. Neither cIMT nor baPWV correlated significantly with other PD-related covariates of volume overload, peritoneal solute transport, kidney function, and C-reactive protein. Longitudinal observation demonstrated that BP had a greater influence on baPWV changes than hyperglycemia or fluid status.Our study indicates that 1) baPWV represent an arterial marker that integrates multifactorial interaction between modifiable variables including BP and plasma glucose; and 2) intervention aimed at controlling BP as well as nutritional conditions (glucose and albumin) may reduce CVD risk in PD patients.

The relationships between visit-to-visit blood pressure variability and renal and endothelial function in chronic kidney disease.

Visit-to-visit blood pressure variability has been shown to be an independent risk factor for cardiovascular diseases. High visit-to-visit blood pressure variability and endothelial dysfunction are observed in patients with chronic kidney disease. It is therefore assumed that high variability in visit-to-visit blood pressure measurements may be associated with endothelial dysfunction in these patients. The present study investigated the associations between visit-to-visit blood pressure variability and renal and endothelial function in patients with chronic kidney disease. We analyzed 150 consecutive patients with predialysis chronic kidney disease who visited our outpatient clinic from January 2006 to December 2010. The study examined the relationships between variability in visit-to-visit systolic blood pressure levels or mean systolic blood pressure (M SBP) and estimated glomerular filtration rate (eGFR) and flow-mediated dilation, an index of endothelial function. Variability in visit-to-visit systolic blood pressure showed a significant negative association with eGFR, independent of age, hemoglobin A1c, low-density lipoprotein (LDL) cholesterol and uric acid, whereas M SBP did not. Similarly, variability in SBP showed a significant negative association with flow-mediated dilation, independent of age, eGFR, HbA1c, LDL cholesterol and M SBP. These data indicate that variability in visit-to-visit blood pressure measurements is associated with impaired renal and endothelial function in patients with chronic kidney disease. This finding suggests that reducing blood pressure fluctuations might have beneficial effects in patients with chronic kidney disease, although this point needs to be addressed by future studies.

Renal and vascular protective effects of ezetimibe in chronic kidney disease.

OBJECTIVE: Dyslipidemia is a risk factor for not only cardiovascular diseases (CVD), but also chronic kidney disease (CKD). Ezetimibe, a cholesterol absorption inhibitor, lowers cholesterol levels by inhibiting both extrinsic and intrinsic cholesterol absorption via the gastrointestinal duct. However, very few studies have examined its efficacy and safety for patients with dyslipidemia complicated with CKD. METHODS: Thirty-seven dyslipidemic patients (low density lipoprotein cholesterol (LDL-C) levels ≥120 mg/dL) complicated with CKD were given ezetimibe (10 mg/day) for twenty-four weeks. The efficacy and safety of the therapy, including the anti-atherosclerotic and renal protective effects, were then examined. RESULTS: Significant decreases were observed in the levels of LDL-C (158.9 ± 26.9 mg/dL→123.0 ± 31.8 mg/dL; p<0.0001), remnant-like lipoprotein cholesterol (9.3 ± 5.3 mg/dL→7.3 ± 3.8 mg/dL; p<0.05) and lipoprotein (a) (22.0 ± 16.1 mg/dL→16.4 ± 11.0 mg/dL; p<0.01). The estimated glomerular filtration rate did not change, but the urine protein to creatinine ratio decreased significantly (1,107.3 ± 1,454.2 mg/gCre→732.1 ± 1,237.8 mg/gCre; p<0.05). No changes were observed in the carotid intima media thickness, but the brachial-ankle pulse wave velocity decreased significantly (1,770.4 ± 590.3 cm/sec→1,702.5 ± 519.9 cm/sec; p<0.05). No adverse events were observed. CONCLUSION: Ezetimibe can be safely administered even to patients with CKD. The results of this study indicate that ezetimibe may provide some renal protection and suppress the complications of CVD in CKD patients.

Peritoneopericardial communication after aortic valve replacement in a peritoneal dialysis patient.

A 73-year-old male undergoing peritoneal dialysis (PD) for end-stage renal disease due to diabetic nephropathy was diagnosed with aortic stenosis and was admitted to our hospital in September, 2009. The patient underwent replacement of the ascending aorta with an artificial blood vessel plus aortic valve replacement without any notable complications. PD was restarted 3 days after the surgery and large amounts of light red fluid from the drain placed in the pericardium were observed just after resumption of PD solution. The patient was diagnosed with peritoneopericardial communication. PD was discontinued and hemodialysis was performed only with intermittent lavage of the peritoneal cavity. The amount of drainage was spontaneously decreased, and on the 17th day after surgery, PD was resumed. The patient is undergoing PD without recurrence of peritoneopericardial communication, 59 months after the onset of symptoms. Peritoneopericardial communication in a patient with PD developing after open-heart surgery is rare because such a case has been documented in only one case report. However, since massive pericardial effusion may cause severe cardiac problems, we consider that the communication between the peritoneal cavity and the pericardium needs to be checked for in patients with PD after cardiac surgery.

An autopsy case of pulmonary fissure induced by zygomycosis.

For immunodeficient patients, fungi are life-threatening pathogens. In this paper, we present an autopsy case of combined zygomycosis and aspergillosis. A female in her 70s on chronic hemodialysis was admitted to a hospital suffering bloody sputum, dyspnea, and fever, probably due to perinuclear anti-neutrophil cytoplasmic antibody-related vasculitis. Antibiotics were administered and immunosuppressive therapy was started, resulting in an improvement in her condition. Pneumonia later developed, followed by pulmonary bleeding and intractable pneumothorax from which she ultimately died. On autopsy, the upper lobe of the left lung was found to have hemorrhagic necrosis and showed a large longitudinal fissure. Microscopically, Zygomycota were observed in both the lungs and heart, while Aspergillus was found in the middle lobe of the right lung. Zygomycosis, which usually has a poor prognosis, is assumed to have induced hemorrhagic infarction of the lungs, inducing pulmonary bleeding and necrosis, despite the use of lipid formulations of amphotericin B, which are effective medicines against Zygomycota.