Predictors of protein-energy wasting in haemodialysis patients: a cross-sectional study.

BACKGROUND: Protein-energy wasting (PEW) is a highly prevalent condition in haemodialysis patients (HD). The potential usefulness of nutritional-inflammatory markers in the diagnosis of PEW in chronic kidney disease has not been established completely. We hypothesised that a combination of serum albumin, percentage of mid-arm muscle circumference and standard body weight comprises a better discriminator than either single marker of nutritional status in HD patients. METHODS: A cross-sectional study was performed in 80 HD patients. Patients were categorised in two groups: well-nourished and PEW. Logistic regression analysis was applied to corroborate the reliability of the three markers of PEW with all the nutritional-inflammatory markers analysed. RESULTS: PEW was identified in 52.5% of HD patients. Compared with the well-nourished patients, PEW patients had lower body mass index, serum pre-albumin and body cell mass (all P < 0.001) and higher C-reactive protein (s-CRP) (P < 0.01). Logistic regression analyses showed that the combination of the three criteria were significantly related with s-CRP >1 mg dL(-1) , phase angle <4°, and serum pre-albumin <30 mg dL(-1) (all P < 0.05). Other indicators, such as lymphocytes <20% and Charlson comorbidity index, were significantly involved (both P < 0.01). A receiver operating characteristic curve (area under the curve) of 0.86 (P < 0.001) was found. CONCLUSIONS: The combined utilisation of serum albumin, percentage of mid-arm muscle circumference and standard body weight as PEW markers appears to be useful for nutritional-inflammatory status assessment and adds predictive value to the traditional indicators. Larger studies are needed to achieve the reliability of these predictor combinations and their cut-off values in HD patients and other populations.

Evaluation of oxidant-antioxidant balance in patients on maintenance haemodialysis: a comparative study of dialyzers membranes.

BACKGROUND: Haemodialysis (HD) exacerbates oxidative stress (OS). The polymethyl-methacrylate (PMMA)-BK-F membrane ameliorates OS and inflammation markers compared to polyacrylonitrile (PAN/AN69) and cellulose membranes. This may be due to the size of pore radius, high flux or other specific properties of PMMA membranes. AIM: To compare OS and inflammatory status in HD-treated end stage renal disease patients with membranes of different pore size radius and flux. METHODS: 47 patients of both sexes were studied. The HD membranes with which the patients were normally treated were changed to BK-P or B-3 membranes for 6 months. Intracellular and extracellular components of the oxidant-antioxidant balance (OAB), C-reactive protein (CRP), beta2-micro-globulin (beta2mu-globulin), albumin and transferrin were measured. RESULTS: A significant decrease in red cell membrane thiobarbituric acid reacting substances and an increase in cytosolic superoxide dismutase (SOD) and plasma total antioxidant substances were observed in all patients after 6 months of treatment with BK-P and B-3 membranes except SOD and CRP in patients previously dialysed with triacetate cellulose membranes. Albumin and transferrin remained unmodified. beta2mu-globulin significantly decreased after treatment with PMMA membranes. CONCLUSION: BK-P and B-3 HD membranes improved the OAB, beta2mu-globulin and CRP compared to PAN/AN69 and cellulose diacetate membranes.

Short daily versus conventional hemodialysis quality of life: a cross-sectional multicentric study in Spain.

BACKGROUND: End-stage renal disease is a major health problem worldwide nowadays. Although conventional hemodialysis is the most widely used modality, short daily hemodialysis has been proposed as a more physiologic treatment. The objective of this article is to compare the quality of life of patients on each hemodialysis modality. METHODS: A multicentric cross-sectional study was performed in 9 Spanish hospitals. Patients treated for at least 3 months with conventional or short daily hemodialysis were included and quality of life measured using the Euroqol-5D quality of life questionnaire. Bayesian models were used for analyzing quality of life results. RESULTS: Ninety-three patients were included, 27 were on daily hemodialysis and 66 on conventional hemodialysis. All models demonstrated a better quality of life for daily hemodialysis versus conventional hemodialysis. Only 14% of the patients on conventional hemodialysis were willing to change to a daily schedule. CONCLUSIONS: Short daily hemodialysis shows a better quality of life than conventional hemodialysis with all Bayesian approaches considered.

[Vaccination scheme in advanced chronic kidney disease]. / Calendario de vacunas en la enfermedad renal cronica avanzada.

1. VACCINATION AGAINST HEPATITIS B a) All patients with chronic advanced renal disease and negative serology for HBsAg and antiHBs are to be vaccinated against hepatitis B (Evidence level: B). b) For classic vaccines (Engerix B and HBVAxpro) the adult vaccine dose is 40 mcg (20 mcg in the paediatric population). There are two dose regimens based on the medicinal product used: 0, 1 and 6 months with HBVAxpro and 0, 1, 2 and 6 months with Engerix B. With the new vaccine Fendrix, the dose is 20 mcg and the schedule 0, 1, 2 and 6 months (Evidence level: C). c) The antiHBs titre is to be measured 1-2 months after administration of the last dose. In patients whose antibody titres are below 10 mIU/mL, a booster may be administered, checking the response or administering a second full vaccination (Evidence level: B). d) In responders, antibody levels are to be tested at least once a year. If the antiHBs titre is below 10 mIU/mL, a booster is to be administered (Evidence level: C). 2. VACCINATION AGAINST INFLUENZA a) All patients with chronic advanced renal disease are to be vaccinated every year against influenza (Evidence level: B). b) The vaccination dose and regimen are the same as recommended for the general population (Evidence level: C) 3. VACCINATION AGAINST PNEUMOCOCCUS a) Vaccination against pneumococcus is recommended in patients with chronic renal disease associated with nephrotic syndrome or who may be future candidates for renal transplant (Evidence level: B). b) There is no evidence of the clinical value of the pneumococcal vaccine in adult patients with chronic renal failure, not transplanted. However, some regions are recommending routine vaccination in the population aged >or= 60 years, the age of a high percentage of our patients. c) To maintain immunisation, revaccination is required every 3- 5 years. 4. OTHER VACCINES a) Vaccination against hepatitis A is recommended in patients with renal failure associated with chronic liver disease or who are candidates for renal transplant (Evidence level: C). b) The recommendations for vaccination against tetanus and diphtheria are the same as for the general population (Evidence level: C). c) Chickenpox vaccine is indicated in children with chronic renal disease, particularly if they are candidates for transplant (Evidence level: B). Although there is no evidence of the value of this vaccine in adults, it is advisable to perform it in those who may be candidates for renal transplant with no protecting antibodies. d) There is no evidence of the clinical value of the vaccine against Staphylococcus aureus.

[Unawareness of the K/DOQI guidelines for bone and mineral metabolism in predialysis chronic kidney disease: results of the OSERCE Spanish multicenter-study survey]. / Desconocimiento de las guías K/DOQI sobre la alteración del metabolismo óseo-mineral asociada a la enfermedad renal crónica no en diálisis: resultados de la encuesta en el estudio multicéntrico español OSERCE.

Since its publication in 2003, the K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease (CKD) have become a worldwide reference. The aim of this study was to analyze the observance to these guidelines in patients with a glomerular filtration rate < 60 ml/min/1,73m2 not yet included in dialysis in a Spanish multicenter cohort. A questionnaire by investigator/centre was completed by 32 different nephrologists participating in the OSERCE study and representing the overall Spanish public health net. We observed that biochemical parameters were measured less frequently than recommended, except in CKD stage 3. The therapeutic goals for intact PTH were not properly reported by 59 % of the consulted nephrologists for stages 3 and 4, whereas only 22% did not report them properly for stage 5. The goals for phosphorus were not adequately reported in 50 % of cases (stages 3 y 4) and 60 % (stage 5). For calcium, these values were 70 %, 73.3 % and 65.5 % for stages 3, 4 and 5, respectively. A corrected plasma calcium between 9.5 and 10.2 mg/dl is still considered adequate for 31%. As much as 87% nephrologists stated that they did not sistematically measure calcidiol plasma levels. In general, these results demonstrate that there is a great degree of unawareness of K/DOQITM predialysis guidelines. Thus, their poor implementation is probably not only due to the lower availability of approved therapeutic agents, the difficult achievement of goals or the disbelief on current recommendations. It would be desirable that forthcoming guidelines such as the KDIGO could also consider the need of educational efforts for CKD-Mineral and Bone Disorder.

[Preliminary results of the Spanish Society of Nephrology multicenter study of quality performance measures: hemodialysis outcomes can be improved]. / Resultados del proyecto de mejora de la calidad de la asistencia en hemodiálisis: estudio multicéntrico de indicadores de calidad de la Sociedad Española de Nefrología (SEN).

INTRODUCTION: The Spanish Society of Nephrology "Quality in Nephrology Working Group" (QNWG) was created in 2002. The aims of this group are the identification, diffusion, implementation and consolidation of a systematic, objective and comprehensive set of quality performance measures (QPMs) to help along the improvement of patient care and outcomes on hemodialysis, by means of strategies of feedback and benchmarking, and the design of quality improvement projects. The objective of this study is to present the preliminary results of a set of quality performance measures obtained in a group of Spanish hemodialysis centers, as well as to evaluate the repercussion of the application of the aforementioned thecniques on the observed results. METHODS: During 2007 a total of 28 hemodialysis units participated in the study; 2516 patients were evaluated. A specific software was designed and used to facilitate the calculation of CPMs in each unit. The clinical indicators used refered to dialysis adequacy; anemia; mineral metabolisme; nutrition; viral infections; vascular access; mortality, morbidity (number and days of hospital admissions); and renal transplant. Every three months each center received its own data and its comparison with the rest of the group. RESULTS: Except for hemoglobin levels we observed a global improvement. The percentage of centers reaching the stablished standards defined by the QNWG passed from 65% to 90,9% for Kt/V Daugirdas II (> 1,3 in > that 80% of the patients); from 71,4 % to 77,2 % for PTH (> 30 % of patients with serum PTH between 150 and 300 pg/ml); and from 42,8 % to 63,5 % for phosphate (> 75 % of patients with a serum phsphate < 5,5 mg/dl). More than 50% of centers showed an improvement in their final results as compared with their own initial results in all analyzed CPMs. Those centers that did not obtained an improvement in their results started the study with better percentages of acomplishment than those that showed a significant improvement in QPMs. (80,6+/-15,4 versus 71,8+/-16,6 respectively; p<0,001) CONCLUSIONS: We are starting to make progresses in our knowledge of clinical results in our hemodialysis units, although there is still a long way to go over. To monitor and share CPMs results within hemodialysis centers might help to improve their results as well as to reduce intecenters variability.

Anemia associated with pegylated interferon-alpha2a and alpha2b therapy in hemodialysis patients.

AIMS: Anemia is a well-known side effect of interferon therapy since interferons are potent inhibitors of erythropoiesis. The aim of this study was to compare the anemia associated with pegylated interferon (PEG-IFN) (alpha2a versus alpha2b therapy in hemodialysis patients (HD) with chronic hepatitis C. METHODS: In order to study the anemia, doses of erythropoietic growth factors (EGF), hemoglobin (Hb) and erythropoietin resistance index (ERI) were compared at baseline and after PEG-IFN-alpha2a or alpha2b therapy in 16 HD patients with chronic C hepatitis. Pharmacokinetic studies were performed in 4 of those treated with PEG-IFN-alpha2b and 2 patients treated with PEG-IFN-alpha2a. Secondary end-points were viral response and serious adverse events. RESULTS: At 4-6 months after the beginning of therapy, both PEG-IFN-alpha induced a significant increment in the erythropoietin resistance index. This increment was significantly higher in patients treated with PEG-IFN-alpha2a when compared with alpha2b (45 vs 9.9, p = 0.012). The pharmacokinetics of PEG-IFN-alpha2a and alpha2b in HD patients were different, the C(max), C(min) and the area under the serum concentration time curve, were all higher in patients treated with PEG-IFN-alpha2a compared with PEG-INF-alpha2b. Discontinuation of therapy occurred in 2 (28.5%) of the 7 patients in the PEG-IFN-alpha2a group and in 4 (44%) of the 9 patients in the PEG-IFN-alpha2b group. Three (42%) subjects in the alpha2a group and 5 (55%) in the alpha2b group had a response at the end of the 48 weeks of therapy. In 4 (44.4%) of the 9 patients treated with alpha2b the viral response was sustained. CONCLUSIONS: In summary, patients treated with PEG-IFN-alpha2a have a major inhibitory effect on erythropoiesis. This could be explained by the different pharmacokinetic properties of PEG-IFN-alpha2a and alpha2b. Further studies are needed to clarify how these findings influence the efficacy, safety and cost-effectiveness of the PEG-IFN-alpha2.

Pegylated interferon-alpha2a kinetics during experimental haemodialysis: impact of permeability and pore size of dialysers.

BACKGROUND: Therapeutics in end-stage renal disease (ESRD) patients undergoing haemodialysis (HD) has to consider potential drug clearance during the dialysis procedure. Pegylated interferon-alpha (PEG-IFN-alpha), a middle-size protein drug active against viral hepatitis, allows convenient once-weekly dosing due to prolonged plasma half-life. AIM: To investigate the impact of permeability and dialyser pore size on PEG-IFN-alpha blood levels during experimental HD. METHODS: Polymethylmetacrylate (PMMA) membrane 1.6 m2 dialysers with three different permeabilities/pore sizes were selected. RESULTS: A 40 kDa PEG-IFN-alpha2a (PEGASYS) was not cleared (< 5%) through low-flux/small pore size (25 A;B3A) and high-flux/middle-large pore size (60 A;BKP) dialysers, and was partially (approximately 15%) through intermediate permeability/large pore size (100 A;BKF) dialysers. In contrast, unmodified 17 kDa IFN-alpha2a(Roferon-A) was removed (65%-95%) through BKP or BKF, but not B3A, PMMA dialysers. Moreover, 12 kDa PEG-IFN-alpha2b(PegIntron) was cleared (40%-80%) through PMMA dialysers with pore sizes > or = 60 angstroms. When B3A or BKP were replaced every hour PEG-IFN-alpha2a plasma levels remained constant throughout three experimental-HD-sessions, but PEG-IFN-alpha2b was cleared partially every BKP replacement. Porosity differ among high-flux dialysers. Neither PEG-IFN-alpha2a nor PEG-IFN-alpha2b were removed after three HD sessions through (27/31/33 A) pore size polysulphone dialysers. Although PEG-IFN-alpha2a was not cleared through middle pore-size (43 A/AN69ST) polyacrylonitrile dialyser, PEG-IFN-alpha2b was partially removed. CONCLUSIONS: The pharmacokinetics of Peg-IFN-alpha may vary in a patient on dialysis.

Prevalence of TT virus in serum and peripheral mononuclear cells from a CAPD population.

BACKGROUND: A novel virus named TT virus (TTV) has been isolated recently from patients with posttransfusional hepatitis of unknown etiology. The prevalence of TTV in several groups at risk has been reported, however, there is no information about the prevalence of TTV in patients on continuous ambulatory peritoneal dialysis (CAPD) without blood transfusions or hemodialysis antecedents. OBJECTIVE: To study the incidence of TTV in serum and peripheral blood mononuclear cells (PBMC) of CAPD patients. DESIGN: TTV DNA was detected by polymerase chain reaction, using primers from the open reading frames (ORF) 1 and 2, in serum and PBMC from 22 CAPD patients who had not received blood transfusions or hemodialysis therapy prior to CAPD. As controls, sera from 20 patients with chronic viral hepatitis (10 with HBV and 10 with HCV) and 20 healthy donors were included in the study. RESULTS: TTV DNA was detected in the serum of 5 of 22 (22.7%) CAPD patients with both sets of primers. Four of the 5 (80%) patients with TTV DNA in their serum were TTV positive in their PBMC with primers from ORF1 and ORF2. Five of 20 (25%) patients with chronic viral hepatitis (2 patients with HBV and 3 with HCV) and 4 of 20 (20%) healthy donors were TTV DNA positive in serum. No relation was found between TTV infection and the underlying kidney disease, previous surgery, and abnormal alanine aminotransferase levels. CONCLUSION: We have found a relatively high prevalence of TTV that is similar to that found in healthy donors and in patients with chronic viral hepatitis.

[Evaluation of osteodystrophy parameters in a pre-dialysis unit]. / Valoración de parámetros de osteodistrofia en una unidad de prediálisis.

A cross-sectional study was developed with 100 of the first-time pre-dialysis patients visiting the Princesa University Hospital's Advanced Chronic Kidney Disease (ACKD) unit, with the aim of analysing various parameters of osteodystrophy at this time. Parameters evaluated were: age, gender, renal function, osteodystrophy serum parameters, comorbidity index (ICED) and the patients' origin to establish correlations between these parameters. Mean iPTH levels were higher irrespective of the patients' origin, and were significantly higher in men than in women, the former also having poorer renal function and higher comorbidity score. The mean levels of calcium, phosphorous, alkaline phosphatase and CO2 did not justify this rise in iPTH. Nutritional parameters NPNA and albumin were adequate in spite of ageing. At early stages of ESRD, iPTH could be elevated and ACKD units play an important part its early detection and subsequent treatment.

[Prognostic significance of programmed dialysis in patients who initiate renal substitutive treatment. Multicenter study in Spain]. / Significado pronóstico de la diálisis programada en pacientes que inician tratamiento sustitutivo renal. Un estudio multicéntrico español.

BACKGROUND: The aim of our study was to analyse patient characteristics, mortality and costs, all of them in relation to whether starting dialysis was planned or unplanned. METHODS: A total of 362 patients (227 male and 135 female) from five hospitals of the National Health System, who were started on chronic renal replacement therapy (RRT) during 1996 and 1997 were included. Patients who were started on RRT after acute renal failure were excluded. We carried out a retrospective analysis of the demographic characteristics, patients' conditions at the time of initiating dialysis and outcome and costs at six and thirty-six months of treatment. Patients were classified as planned (PL-D) or unplanned dialysis (UNPL-D), depending on whether or not the patient had a vascular or peritoneal access ready to use for initiating RRT. RESULTS: One hundred and eighty-six patients (51.4%) started on dialysis in the PL-D group whereas 176 (48.6%) did it as UNPL-D. In this latter group, 135 (37.3% of the total) had previously been monitored by a nephrologist, and 41 (11.3%) initiated dialysis without previous nephrological follow-up. UNPL-D was associated with older age (p < 0.001), non-nephrological follow-up (p < 0.001), diabetes (34.7% vs 22.6%) (p = 0.011), haemodialysis as a first mode of RRT (94.9 vs 81.7%) (p < 0.001), higher comorbidity risk (p < 0.001), dialysis initiation with uraemic symptoms or fluid overload (p < 0.001), increased blood transfusion requirement (p < 0.001) and lower serum albumin (p < 0.001), creatinine clearance (p < 0.001), haemoglobin concentration (p < 0.001), and weight (p = 0.002). In the PL-D group the main primary renal diseases were glomerular and polycystic disease, whereas interstitial and diabetic nephropathy were higher in UNPL-D group (p = 0.005). Multivariate analysis showed that previous non nephrological follow-up, uraemic symptoms, interstitial nephritis as primary renal disease correlated with UNPL-D initiation, and it was followed by choosing haemodialysis as first RRT. UNPL-D was also associated with increased number of days of hospitalization at the initiation of dialysis, and during the first 6 months (p < 0.001), increase of hospitalization days (p = 0.009), and increased 6-month-mortality (10.2% vs 3.2%) (p = 0.015, log rank test), and three-year mortality (24.2 vs 36.9%) (p = 0.006, log rank test). The costs of UNPL-D were fivefold that of the PL-D group. CONCLUSION: UNPL-D has been associated with worse overall clinical conditions at the initiation of chronic replacement therapy, choosing haemodialysis as first RRT, increased morbi-mortality and subsequent increase of costs.

[Guidelines on hemodialysis-associated viral infections]. / Guías sobre enfermedades víricas en hemodiálisis (HD).

The viric infections influence morbi-mortality in Chronic kidney Disease patients in hemodialysis therapy and can affect to the Staff of the Units. The guides considered the most relevant virus at the present moment: C Virus, B Virus and HIV. To prevent horizontal nosocomial transmission is necessary the observance always the universal precautions in the HD units, although sometimes can appeared seroconversions and epidemic bud when exist a break of these. Is analyzed different situations with special focus in units for acute patients. The following steps under the suspicious of the epidemic bud appeared in one of the annexes together with legislation according to this case. Respect to the staff in every one of the virus is shown prevention patterns, serologic markers to perform when an accident with infected blood occur, also is considered when treatment is indicated. The guides considered too the conditions necessary for include these patients on waiting list for kidney transplantation.

Hemodialysis vascular assessment by an ultrasound dilution method (transonic) in patients older than 65 years.

UNLABELLED: Malfunction of vascular access is one of the most frequent causes of morbidity and mortality in hemodialysis patients (HD). Early diagnosis makes possible the most frequent vascular access (VA) used in HD patients. The arteriovenous fistula (AVF), both autologous or heterologous, is the appropriate correction by an interventional radiologist or by surgery, before thrombosis appears. For this purpose, a follow-up of VA is mandatory. New technologies offer non-invasive methods for this purpose. In HD sessions ultrasound 'on line' and ultrasound-dilution techniques permit us to monitor vascular access in HD patients. Also transonic technology has been validated for this purpose, although the limitations of its use among elderly patients is unknown. Using the Transonic HD01 monitor, we studied vascular access in 45 patients in HD older than 65 years, and compared them with 47 patients who were younger than 65 years. The parameters analyzed were: effective flow Qt, recirculation, venous pressure and access flow. We found no significant differences between these parameters but in both groups found that the effective flow measure by Transonic was lower than that measured by a blood pump. Both groups contained patients who had no recirculation but had an access flow that was lower than expected. To rule out stenosis of VA in those patients, we performed an Eco Doppler confirming that all patients had stenosis. With this method, one can determines the access flow and thus predicts the possibility of future thrombosis. CONCLUSION: Our data confirm that one can evaluate VA in patients older than 65 years with Transonic HD01 monitor, and also in patients younger than 65 years. Due to the special characteristics of the vessels in elderly patients, Transonic HD01 monitor is a good method by which to monitor VA in them.

Comparisons of hemodialysis and CAPD in patients over 65 years of age: a meta-analysis.

This meta-analysis had the aim of studying the available studies on comparison between Hemodialysis and Peritoneal Dialysis in the elderly. The final objective was to reach, if possible, evidence for potential differences. In the case that no differences could be demonstrated, contribute to accept that HD and PD are similar techniques to be offered to elderly people requiring dialysis. The question formulated was this: Do we have adequately contrasted data on results for survival, hospitalization rate, quality of life and morbidity on hemodialysis and peritoneal dialysis in the elderly (more than 65 years old)? As data sources we selected eight papers that compared the general results of these two dialysis techniques. Different elements were considered in this selection because none reached the two first levels in the hierarchy of sources of evidence, and only two reached the third level--that of prospective studies; this is because an oral presentation of data has been included in a meta-analysis. Another four papers--uni- or multicenter retrospective studies compared the results obtained with PD and HD. The remaining two papers--reports from nationwide registries that compare of mortality rates, adjusted for co-morbid conditions and age, present specific results on groups of elderly patients. Three papers compare particular aspects of the two techniques, including nutritional status, psychiatric and psychosocial aspects and rehabilitation, in this case comparing PD with home hemodialysis patients. Finally, we have included the opinions of healthy elderly people on dialysis issues. This meta-analysis of these different studies suggests that the mortality and hospitalization rate of elderly people treated by PD is similar to that of similar people treated by HD. In consequence, we have no reasons to select either therapy on behalf of the patient. The nephrologist should consider and inform the patient and family about the relative advantages and disadvantages of both techniques and tailor dialysis technique choice to the specific individual to assure the best results. Local circumstances should also be considered.

Catheter malfunction due to spontaneous permcath displacement into medium suprahepatic vein.

One of the last options, when the other possibilities of vascular access present malfunction, is the insertion of a permanent catheter in a central vein, preferentially internal jugular vein. This option is considered when arteriovenous access is impossible. We report a case of malfunction due to a permanent catheter dis-placement solved by vascular interventional radiology.