How do disorders related to hospitalisation influence haemodialysis patients' nutrition?

INTRODUCTION: Hospitalizations are frequent in hemodialysis patients and is often accompanied by nutritional deterioration showed by a loss of weight and a reduction of albumin serum levels. This phenomenon is related with length of stay having its origin in a complex interplay of factors. Our aim in this study was to analyze if changes in body weight and other nutritional parameters are influenced by the illnesses presented during hospitalization. PATIENTS AND METHODS: Over a period of three years, we retrospectively chose chronic haemodialysis patients that were admitted for more than four days, excluding those cases that died in the hospital. We randomly chose one admission episode per patient so as to avoid excessive weighing of repeated admissions. We took data concerning weight changes, pre-admission and post-discharge analytical results, analytical results following first week of hospital stay, disorders causing hospital admission and those that developed during the hospital stay. We created a point score system to record the total of illnesses presented. RESULTS: The study included 77 patients, aged 67±12 years and having undergone haemodialysis for 31±34 months. Hospital stay was 17.8±12.6 days (median, 12 days). We observed that many patients admitted for digestive and osteoarticular disorders, heart failure or coronary syndrome lost more weight during their hospital stay, although no significant differences were reached. The total number of disorders suffered during the hospital stay was independent of the cause of hospitalisation. Anaemia,heart arrhythmias and signs of heart failure were associated with longer hospital stays, however it was only anaemia that was significantly related to greater weight loss. Weight loss was not related to surgery or infections. Albumin levels during the first week of hospital stay were different depending on the disorder upon admission. It was lower when the patients were admitted for digestive disorders (ANOVA, P=.05). Changes in albumin and creatinine levels before and after the hospital stay did not differ among disorders. We observed a relationship between having presented with more disorders during the stay and a longer stay, lower initial albumin and greater weight loss following discharge. In the multivariate analysis, we found the following weight loss predictors: stay, anaemia, and sepsis. We also found the following hospital stay predictors:Charlson's comorbidity index, heart arrhythmias, anaemia, sepsis and surgery. CONCLUSIONS: Malnutrition during the hospital stay depends on the duration and the number of disorders that develop during this time, the cause of admission having less impact on this. Albumin levels decrease earlier in patients that are going to develop more disorders during hospital stay.

[Loss of weight in hemodialysis patients after hospitalization is related with length of stay and degree of inflammation]. / La pérdida de peso en pacientes en hemodiálisis tras su hospitalización tiene relación con la duración de la estancia y con el grado de inflamación.

BACKGROUND: It is frequent to observe that hemodialysis patients suffer important loss of weight during hospital stay. This issue has not been investigated previously. Our aim in this study was to analyze factors associated with this loss of weight and what changes occur after admission in biochemical parameters with nutritional interest. PATIENTS AND METHODS: We retrospectively selected patients undergoing chronic hemodialysis who were admitted at hospital for acute or chronic pathologies, with a minimum length of stay of 4 days, taking only one episode of admission per patient. We chose loss of weight observed at hospital discharge, at 2 and 4 weeks later and we also collected routine laboratory data and adequacy parameters before and after the hospital admission and basic biochemical parameters in the first week of hospital stay. RESULTS: We included 77 patients, with 67±12 years and 30±34 months in dialysis. Forty (51.9%) were female (51.9%) and 22 diabetics (28.6%). Length of stay was 17.8±12.6 days (median 12). There were 70.4% patients who suffered a loss of weight at discharge and 81.4% at 4 weeks, without differences in sex or diabetes. Weight decreased significantly with a mean of -1.09 kg (95%CI -0.73 to -1.44). After 2 weeks the loss of weight was -1.64 kg (95%CI -1.21 a -2.07 kg) and after 4 weeks was -1.94 kg (95%CI -1.47 a -2.42 kg). Comparing parameters before and after admission, we observed a significantly decrease in serum urea levels (before 134±40 vs after 119±36 mg/dl; p= 0.001), creatinine (before 8.1±2.6 vs after 7.5±2.6 mg/dl; p < 0.001), phosphate (before 5.2±1.7 vs after 4.3±1.5 mg/dl; p < 0.001) and albumin (before 3.70±0.48 vs after 3.56±0.58 g/dl; p=0.05), without changes in adequacy parameters. Greater loss of weight at 4 weeks from discharge was correlated with larger length of stay (r= 0.41; p < 0.001), greater body mass index at admission (r= -0.23; p=0.05) and lower serum albumin at admission (r= 0.39; p= 0.012). It was also correlated with a lower serum albumin (r= 0.27; p=0.05), lower creatinine (r= 0.30; p= 0.02) and lower protein intake (nPNA) (r= 0.47; p= 0.002) after discharge. Lower serum albumin levels at admission were correlated with greater decreases of creatinine after discharge (r= 0.42; p= 0.009) and larger length of stay (r= -0.61; p < 0.001). Employing multivariate analysis we found that loss of weight was associated to length of stay and serum potassium levels before admission. CONCLUSIONS: Hospitalization of hemodialysis patients have a negative nutritional impact causing a significant loss of weight, probably reflecting a reduction of muscle mass. We found that length of stay in hospital is a basic factor associated with this nutritional impairment. The pathologies promoting hospitalization could influence this derangement through inflammation but this hypothesis should be investigated.

[Analysis of the efficacy and factors influencing the response of secondary hyperparathyroidism patients on hemodialysis to cinacalcet]. / Análisis de la eficacia y de los factores que influyen en la respuesta del hiperparatiroidismo secundario de pacientes en hemodiálisis a cinacalcet.

BACKGROUND: Treatment of secondary hyperparathyroidism with cinacalcet improves control of PTH, phosphorus, calcium and Ca x P product, enabling to achieve targets recommended by K/DOQI guidelines for PTHi in only 30-50% of patients, in studies with a very selected population. The aim of this study was to analyze its effectiveness in real clinical practice, comparing results with targets recommended by K/DOQI and KDIGO guidelines and to investigate factors having influence on PTH responsiveness to cinacalcet. METHODS: We collected data of evolution of 74 patients on hemodialysis with secondary hyperparathyroidism who were treated with cinacalcet for at least 6 months. RESULTS: According K/DOQI targets we observed a reduction of proportion of patients with PTHi > 300 pg/ml to 50%, a decrease of hyperphosphoremia from 38.4% to 23.3% and proportion of patients with Ca x P product > 55 mg2/dl2 from 37.8% to 15.1%. By contrast, presence of hypocalcemia increases from 2.7% to 12.3%. Comparing with KDIGO targets, proportion of patients with PTHi > 600 pg/ml decreased from 41.1% to 16.4% and with hyperphosphoremia from 68.5% to 52.1%. However, when considering patients with baseline PTHi > 600 pg/ml prevalence of P > 4.5 mg/dl decreased from 83.3% to 55.2%. We observed significant changes of phosphate binders after cinacalcet treatment with an increase in calcium carbonate doses (pre 0.61 +/- 1.53 g of calcium/day vs post-cinacalcet 0.95 +/- 1.98 g of calcium/day; p = 0.03) that was prescribed to prevent hypocalcemia and not as phosphate binder. Responsiveness were lower in patients who were taking higher doses of sevelamer at baseline, showing at the end of the study higher PTHi (no-sevelamer: 312 +/- 245 pg/ml; sevelamer < 6.4 g/day: 510 +/- 490 pg/ml; sevelamer > 6.4 g/day: 526 +/- 393 pg/ml; p = 0.04) and phosphorus (no-sevelamer: 4.5 +/- 1.2 mg/dl; sevelamer < 6.4 g/day: 4.2 +/- 1.5 mg/dl; sevelamer > 6.4 g/day: 5.7 +/- 0.9 mg/dl; p=0.01) serum levels. Use of paricalcitol did not show any influence on PTH response. Patients achieving targets for PTH at the end of the study showed a good response early, with a significant decrease of PTHi levels at three months (159 +/- 84 vs 630 +/- 377 pg/ml; p < 0.001) with significantly lower doses of cinacalcet (33.8 +/- 22.5 vs 51.1 +/- 25.1 mg/day; p = 0.003). Using multivariate analysis we found that percent of PTHi reduction was related with baseline PTHi levels and taking sevelamer as phosphate binder at baseline. CONCLUSION: Use of cinacalcet improves grade of control of secondary hyperparathyroidism in non-selected patients in hemodialysis, showing poor response in population with higher PTHi levels and who takes higher doses of sevelamer at baseline. By contrast, a reduction of PTHi levels at 3 months of treatment with relatively lower doses is a pronostic marker of good response to cinacalcet treatment.

[Incidence and risk factors for non-traumatic lower extremity amputation in hemodialysis patients]. / Incidencia y factores de riesgo de amputación no traumática de miembros inferiores en los pacientes en hemodiálisis.

BACKGROUND AND AIMS: The purpose of this study was to assess the incidence and risk factors for non-traumatic lower extremity amputation (LEA) in patients on haemodialysis (HD). METHODS: We investigated our HD population attending our clinic between Jan 1988 and Dec 2002, who had had LEA. Uni- and multivariate analyses were used to determine association of LEA with demographic characteristics such as diabetes, hypertension, smoking, myocardial infarction, stroke, dyslipidaemia, haematocrit, urea, creatinine, calcium, phosphorous, parathyroid hormone (PTH) and albumin levels. RESULTS: Of 516 patients, 20 (3.9%) underwent 32 amputations; 21 major and 11 minor. The incidence was 1. I amputees/100 p-years. There were 11 (10.8%) diabetics and 9 (2.2%) non-diabetics; incidence of 4.2 and 0.6 amputees/100 p-years, respectively. Non-diabetic amputees were older than non-amputees: 68.9 vs 58.2 years (p = 0.013) and had been on HD longer: 71.4 +/- 44 vs 42 +/- 37 months (p = 0.019). There were 60% deaths within the first year of amputation and the causes were 60% cardiovascular. Univariate analysis indicated significant association of LEA with ageing, diabetes, smoking, myocardial infarction, stroke, high cholesterol, and low PTH levels. Multivariate Cox regression identified independent associations of amputation with diabetes, previous myocardial infarction and stroke and/or transient ischaemic attack. CONCLUSIONS: The incidence of LEA in HD patients is very high and is associated with diabetes and previous cardiovascular events. Advanced age and longer time on HD are factors related to LEA in non-diabetics. With increasing numbers of diabetics and older people on HD, new strategies are needed for peripheral arterial disease management so as to avoid its progression to critical ischaemia.

[Fistulae or catheter for elderly who start hemodialysis without permanent vascular access?]. / Acceso vascular permanente en pacientes de edad avanzada que inician hemodiálisis: fístula o catéter?

UNLABELLED: Autologous access is the best vascular access for dialysis also in older patients and it should be mature when patient needs hemodialysis. It is not always possible. Surgeon availability and demographic characteristics of patients (age, diabetes, vascular disease...) are factors that determine primary vascular access. AIM: To analyse outcome and vascular access complications in elderly who start hemodialysis without vascular access. PATIENTS AND METHODS: All patients older than 75 years who initiated hemodialysis without vascular access between January 2000 and June 2002 were included, They were divided en two groups depending on primary vascular access. GI: arterio-venous fistulae. GIIl: Tunnelled cuffed catheter. Epidemiological and analytical data, vascular access complications related, as well as patient and first permanent vascular access survival from their inclusion in dialysis up to December 2002 were analysed and compared in both groups. RESULTS: 32 patients were studied. GI: n = 17 (4 men) and GIIl: n =1 5 (8 men), age: 79.9 +/- 3.8 and 81.7 +/- 4 years respectively (ns). There were no differences in sex and comorbidity (diabetes, ischemic heart disease, peripheral vascular disease and hypertension). It took GI 3 months to get a permanent vascular access suitable for using, while it took GIIl 1.3 months (p < 0.005) The number of temporary untunnelled catheters was higher in GI (3.35 vs 1.87 p < 0.05). Vascular access complications: 70.6% of infections occur in GI (incidence (I) = 48 infections/100 patients-year) while only 29.4% were detected in GII (I = 25 infections/100 patients-year). 70% of central venous thrombosis happen in GI (I: 25 CVT/100 patients-year) vs 30% in GIIl (I = 14.4/100 patients-year) (ns). No significant differences neither in bleeding (66.7% vs 33.3%) nor ischemia (75% vs 25%) were found. Dialysis dose (Kt/V) as well as anaemia degree were similar in both groups. Permanent vascular access survival after 2 years was 45.8% in GI and 24% in GII (ns). Patient survival was similar in GI and GII (72% vs 51% ns). CONCLUSIONS: Elderly who start hemodialysis without vascular access took longer to get a suitable permanent vascular access when arterio-venous fistulae is placed than with a tunnelled cuffed hemodialysis catheter. As a consequence, vascular access complications are larger, infection ones are the most common. In these patients a tunnelled catheter should be inserted at the time a peripheral arterio-venous access is created, in order to avoid temporary untunnelled catheters.

[Health-related quality of life in elderly patients in haemodialysis]. / Calidad de vida relacionada con la salud en pacientes ancianos en hemodiálisis.

INTRODUCTION: In view of the increasing interest in measuring health-related quality of life (HRQOL) and that is widely accepted Quality of life (QL) is a valid marker of results of treatment in chronic dialysis, we marked the aim to determine QL of the patients > or = 75 years in chronic haemodialysis and to determine the influence of different factors (comorbidity, analytical, cognitive deterioration, depression and self-sufficiency) over the results. METHODS: We used the Kidney Disease Quality of Life (KDQOL-SF), questionnaire of health that has been become an useful instrument for measuring CV into this population. Demographic and analytical data, comorbidity (Charlson Index), depression (Yesavage), self-sufficiency (Karnofsky) and impaired cognitive function (Cognitive Mini-Exam) were collected. We evaluated the influence of these factors on the different dimensions of the KDQOI-SF and compared our scores with general Spanish population scores standardised according to age and sex. RESULTS: We included 51 patients (24 men) with a mean age 79.5 +/- 3.7 years and 39 +/- 56 months in dialysis. Women had lower scores than men in all scales of KDQOL-SF. We found that months in dialysis, depression scale, Karnofsky scale and cognitive deterioration test were also influencing about these scores. Multivariate analysis showed that CV is especially associated with sex, depression, cognitive deterioration and self-sufficiency. After we calculated standardised scores according to age and gender, out population showed a level of CV lower than general population, especially in female gender. CONCLUSIONS: In our population the women had worse CV than men. The CV of the elders in HD is lower than general population of equal sex and age and it was not modified with factors related to the end-stage renal disease and its treatment. Suffering from cognitive deterioration or depression had an important impact on the well-being of our patients, which would justify a wider diagnostic and therapeutic boarding in these patients.

[Platelet antiaggregation and hemorrhagic risk in hemodialysis]. / Antiagregación plaquetaria y riesgo hemorrágico en hemodiálisis.

UNLABELLED: Although the efficacy of antiplatelet therapy in the prevention of cardiovascular disease in chronic renal failure is not clearly defined, the improvement in cardiovascular disease outcomes in the general population has resulted in its use in dialysis patients. The hemorrhagic risk of hemodialysis patients treated with anti-platelet agents has not been clarified. Our aim was to evaluate the risk of bleeding in hemodialysis patients treated with antiplatelet agents. We assessed haemorrhagic complications (HC) in 190 haemodialysis patients from May 1998 to August 2000. HC was defined an event that required hospitalization and/or blood product transfusion. We evaluated the bleeding events in the haemodialysis patients treated with antiplatelet agents and compare them to those not receiving this therapy to establish the relative risk of bleeding. Uni- and multivariate analyses were conducted to establish the relationships between the haemorrhagic event and the following variables: age, gender, time on dialysis, dialysis membrane (synthetic or cellulosic), systemic anticoagulation during haemodialysis, anaemia (haematocrit), PTH, urea, dialysis efficacy (Kt/V), hypertension, diabetes, use of erythropoietin and antisecretory gastric agents. RESULTS: 81 (42.6%) were treated with antiplatelet agents. Of the 190 patients, 28 (14.7%) had 36 haemorrhagic events (10.3 episodes/100 patient-years); 31 digestive-tract haemorrhages, 4 intracranial and 1 pulmonary. Twenty (24.7%) of patients treated with antiplatelet agents had 16.2 episodes/100 patient-years and 8 (7.3%) without this therapy had 6 episodes/100 patient-years (p < 0.01). In the multivariate analysis the antiplatelet therapy remained associated with higher probability of having a haemorrhagic complication (OR 3.8; CI 95%: 1.52-9.76, p = 0.004). Older age (OR 1.03; CI 95%: 1-1.06, p = 0.043), anaemia (OR 0.91; CI 95%; 0.84-0.9, p = 0.027) and hypertension (OR 2.99; CI 95%: 1.05-8.48, p = 0.039) remained associated with the risk of bleeding. 88.2% of patients that had a digestive-tract haemorrhage with antiplatelet therapy were receiving an antisecretory agent (histamine H2-receptor antagonist or a proton-pump inhibitor). CONCLUSIONS: 1) dialysis patients with antiplatelet therapy had a higher haemorrhagic risk. The relative risk of bleeding was more than three times that of the dialysis population without antiplatelet therapy, and 2) older age and hypertension were associated with the haemorrhagic risk. Optimal correction of anaemia was associated with less probability of bleeding.

[Beneficial effect of AN69 membranes on anemia in hemodialyzed patients]. / Efecto beneficioso de las membranas de AN69 sobre la anemia de los pacientes en hemodiálisis.

UNLABELLED: Biocompatible hemodialysis membranes induce a smaller inflammatory response in hemodialysis patients, and remove a larger amount of higher molecular weight retention products, then cellulose membranes. These phenomena could improve uremic anemia in hemodialysis patients. The objective was to evaluate the effects of biocompatible AN69 membranes on anemia in hemodialysis patients. Twenty-five stable patients undergoing hemodialysis with cuprophane membrane for more than 6 months were studied prospectively. These patients were stratified in 2 groups. Group I (GI): 14 patients switched over to a more biocompatible dialyzer (from cuprophan to AN69) and Group II (GII): 11 patients continued treatment with the same cuprophan membrane. The study lasted 5 months. Baseline hematocrit (%), ferritin (ng/mL), transferrin saturation (%), KTV, PCR (g/kg/day) and dose of erythropoietin (EPO) (UI/week) were measured and were revised monthly. Target hematocrit was 33%-35%. A significant increase of hematocrit became obvious after 2 months in GI without changes in dose of EPO and intensity of dialysis, meanwhile GII remains stable. CONCLUSION: Hemodialysis using AN69 membranes increases hematocrit without modifying intensity of dialysis.

[A comparison of phosphorus-chelating effect of calcium carbonate versus calcium acetate before dialysis]. / Comparación del efecto quelante del fósforo de carbonato vs acetato cálcico en prediálisis.

INTRODUCTION: The hyperphosphatemia, hypocalcemia and low calcitriol levels are pathogenic factors for secondary hyperparathyroidism in chronic renal failure. The phosphorus control is essential to prevent secondary hyperparathyroidism. There are not comparatives studies to test the efficacy of control of phosphorus binders in predialysis patients. AIM: To compare the efficacy of calcium carbonate vs calcium acetate as phosphate binder in predialysis patients. MATERIAL AND METHODS: The present study includes 28 patients with chronic renal failure (mean clearance of creatinine 21 ml/min). Patients were separated into two groups: Group 1: (n = 14) received calcium carbonate 2,500 mg/day (1,000 mg of calcium); Group 2: (n = 14) receives calcium acetate 1,000 mg (254 mg of calcium). Calcium and phosphorus were determined every 4 months; i-PTH, alkaline phosphatase and clearance of creatinine were determined every six months. RESULTS: Both groups were comparable regarding age, renal function, calcium, phosphorus, alkaline phosphatase and i-PTH on basal situation and the end of study were not different. The serum calcium increased, not significantly, in the calcium carbonate group (group 1) [from 9.2 to 9.8 mg/dl (p = 0.05)], however it was not modified in the calcium acetate group (group 2). The serum phosphorus decreased significantly (p < 0.05) in both groups, independently of the calcium levels. Alkaline phosphatase and i-PTH not was modified during the study period. CONCLUSIONS: 1) Both calcium carbonate and calcium acetate are similarly effective as phosphate binder. 2) The carbonate group required four fold greater doses of calcium that acetate group. 3) The calcium acetate has less hypercalcemic effect than calcium carbonate.

[Hemodialysis with 2.5 mEq/L of calcium in relative hypoparathyroidism: long-term effects on bone mass]. / Hemodiálisis con 2,5 mEq/L de calcio en el hipoparatiroidismo relativo: efectos a largo plazo en la masa ósea.

Low PTH secretion is known to be associated with Adynamic Bone Disease (ABD). Positive balance calcium by CaCO3 or dialysate calcium (DCa) might play a role in the parathyroid gland suppression and a decrease in DCa to 2.5 mEq-l or lower has been proposed. The long-term effect of this procedure on bone mineral density (BMD) has not been established. The aim was to evaluate the effect of lowering dialysate calcium on bone mass in patients with relative hypoparathyroidism. We studied 20 patients with intact PTH below 120 pg/ml, using 3 mEq/l DCa and CaCO3 as sole phosphate binder. Sex: 10M/10F. Age: 57 +/- 13 yrs. Months on dialysis: 40 +/- 29. None of them had previous renal transplantation, parathyroidectomy nor aluminic toxicity. BMD of the lumbar spine was assessed by Quantitative Computed Tomography (QCT). They were randomized in two groups (GI and GII), with similar age, sex, and time on dialysis. There were no difference in BMD, levels of intact PTH, serum calcium, phosphate and AP (Alkaline Phosphatase) GI (n = 11; 5M/6F) was transferred to 2.5 mEq/l DCa and GII (n = 9; 5M/4F) continued using 3 mEq/l. BMD was measured one year later. Calcium, phosphate and AP were measured monthly and PTH every three months. After one year of hemodialysis with 2.5 mEq/l of calcium dialysate, BMD showed a significant reduction. BMD mg/cc Baseline (B): 146.09 +/- 54; Final (F): 125.42 +/- 54 (p < 0.01). Z-score B: 0.13 +/- 1.89; F: -0.68 +/- 1.89 (p < 0.05). GII did no show change. The mean change: GI: -15 +/- 13%, GII: 1.28 +/- 17% (p < 0.05); Z-Score GI: -0.81 +/- 0.92, GII: 0.27 +/- 0.67 (p < 0.01). A separate analysis of BMD in both sexes (GI) revealed a tendency for females to lose more bone mineral than males: F: = 17.12 +/- 7.1%. M: -12.23 +/- 18.6% (ns). GI: PTH and AP increased: PTH B: 38.75 +/- 41; F: 99 +/- 69 (p < 0.01); AP: B: 118.4 +/- 47; F: 152 +/- 38 (p < 0.01). GII: PTH B: 53.8 +/- 28; F: 79 +/- 5 (ns). AP: B: 125.1 +/- 36; F: 138 +/- 38 (ns). The rate of BMD loss inversely correlated with the increase of PTH (r = -0.61, p < 0.01). Serum calcium and phosphate did not change. In GI CaCO3 doses were: B: 332 +/- 261; F: 537 +/- 260 (as grams of element calcium, every three months, p < 0.01). By multiple lineal regression only delta PTH and DCa were predictors of greater BMD loss. In conclusion, the use of 2.5 mEq/l dialysate calcium resulted in: 1) Loss of trabecular vertebral bone mass. 2) Increase in PTH secretion and biochemical markers of bone formation. 3) A greater CaCO3 dose.