Prevalence of obesity and obesity-associated muscle wasting in patients on peritoneal dialysis.

BACKGROUND AND AIMS: A progressive decrease in muscle mass until full-blown sarcopenia may occur in patients on peritoneal dialysis (PD) and worsen their life quality and expectancy. Here we investigate the prevalence of obesity and obesity-associated muscle wasting in PD patients. PATIENTS AND METHODS: The study design was observational, cross sectional. Body composition was assessed with BIA and BIVA in 88 PD patients (53.4 ± 13.1 years; 67% male). Patients with obesity and/or with reduced muscle mass were identified using FMI and SM/BW cutoff values, respectively. Inflammatory status was assessed by measuring CRP and fibrinogen blood levels. RESULTS: A total of 44.3% of the patients showed a reduced muscle mass (37.5% moderate and 6.8% severe). The prevalence of obesity was 6.1%, 81.8%, and 100% in patients with normal, moderately, and severely reduced muscle mass, respectively (p < 0.05). Of the total, 15.2% of the patients with normal muscle mass, 18.4% of those with moderately reduced muscle mass, and 66.7% of those with severely reduced muscle mass had diabetes. The prevalence of severe muscle mass loss was higher in those with diabetes than in those without diabetes (22.2% vs. 2.8%, p < 0.05). Patients with obesity-associated muscle wasting showed higher fibrinogen (613.9 ± 155.1 vs. 512.9 ± 159.5 mg/dL, p < 0.05) and CPR (1.4 ± 1.3 vs. 0.6 ± 0.8 mg/dL, p < 0.05) blood concentrations than those with normal body composition. CONCLUSION: Obesity and diabetes were strongly associated with muscle mass loss in our PD patients. It remains to be established whether prevention of obesity with nutritional interventions can halt the occurrence of muscle mass loss in patients on PD.

Effect of a Short-Course Treatment with Synbiotics on Plasma p-Cresol Concentration in Kidney Transplant Recipients.

OBJECTIVE: We evaluated whether a short-term course with synbiotics may lower plasma p-Cresol concentrations in kidney transplant patients (KTRs) who accumulate this uremic toxin both because of increased production by their dysbiotic gut microbiome and because of reduced elimination by the transplanted kidneys. METHODS: Thirty-six KTRs (29 males, mean age 49.6 ± 9.1 years) with transplant vintage > 12 months, stable graft function, and no episode of acute rejection or infection in the last 3 months were enrolled in this single-center, parallel-group, double-blinded, randomized (2:1 synbiotic to placebo) study. Synbiotic (Probinul Neutro, CadiGroup, Rome, Italy) or placebo was taken at home for 30 days, as 5 g powder packets dissolved in water three times a day far from meals. The main outcome measure was the decrease in total plasma p-Cresol measured by high-performance liquid chromatography at baseline and after 15 and 30 days of placebo or synbiotic treatment. RESULTS: After 15 and 30 days of treatment, plasma p-Cresol decreased by 40% and 33% from baseline (both p < 0.05), respectively, in the synbiotic group, whereas it remained stable in the placebo group. After 30 days of treatment, no significant change was observed in either group in renal function, glycemia, plasma lipids, or albumin concentration. Treatment was well tolerated and did not induce any change in stool characteristics. CONCLUSION: The results of this pilot study suggest that treatment with synbiotics may be effective to lower plasma p-Cresol concentrations in KTRs. Prospective larger scale, longer term studies are needed to establish whether cardiovascular prognosis could also be improved with this nutritional intervention.

Imaging of the peritoneum evaluated by 99mTc-icodextrin scintigraphy in peritoneal dialysis patients: preliminary data.

AIM: In this study, we proposed a peritoneal scintigraphy with a different marker, the 99mTechnetium-Icodextrin, to evaluate the distribution of the dialysate within the peritoneal cavity in peritoneal dialysis (PD) patients. METHODS: 99mTc-Icodextrin scintigraphy was performed in 16 PD patients. 0.5 ml of 7.5% Icodextrin solution was labeled with 74 megabecquerel (MBq) of 99mTc and then added to 2,000 ml of dialysate solution (2.5% dextrose). The peritoneum scintigraphy was performed by a SPECT gamma camera with the peritoneal cavity filled and after the complete drainage of the radio compound-dialysate mixture. The images were reviewed for evidence of peritoneal leaks, hernias, loculated fluid collections, and peritoneal membrane adhesions. RESULTS: Abnormal findings were detected by 99mTc-Icodextrin scintigraphy in 4 (25%) out of 16 patients and included retroperitoneal (n = 1), diaphragmatic (n = 1) and inguinal (n = 1) leakages and peritoneal membrane adhesions (n = 1). CONCLUSIONS: Peritoneum scintigraphy with 99mTc-Icodextrin is a useful method to detect some complications occurring during peritoneal dialysis; it offers excellent imaging to assess these complications.

Identification of sarcopenia and dynapenia in CKD predialysis patients with EGWSOP2 criteria: An observational, cross-sectional study.

OBJECTIVES: Using the new European Working Group on Sarcopenia in Older People (EWGSOP2) criteria, we identified sarcopenic and dynapenic patients in a cohort of predialysis patients with chronic kidney disease (CKD), and evaluated their clinical and laboratory characteristics. METHODS: The study population consisted of 85 (55 men) clinically stable predialysis CKD patients (92.9% in stages 3-5), with a median age of 65.0 (52.5-72.0) y. We classified as sarcopenic the patients with handgrip strength (HGS) and muscle mass both lower than the respective EWGSOP2 cutoff values and as dynapenic those in whom only HGS was less than these reference values. HGS was measured with a hand dynamometer, whereas muscle mass was measured by bioimpedance analysis. Renal function was evaluated as Modification of Diet in Renal Disease estimated glomerular filtration rate. RESULTS: The prevalence of sarcopenia and dynapenia was, respectively, 7.1% and 17.6%. As reported in previous studies, serum albumin and hemoglobin were lower in sarcopenic patients than in patients with preserved muscle mass and strength. However, unlike in these studies, sarcopenia prevalence did not increase with CKD stage, and estimated glomerular filtration rate was similar between groups. Moreover, no difference was identified in any of the aforementioned parameters between dynapenic patients and patients with preserved muscle mass and strength. CONCLUSIONS: The EWGSOP2 criteria identified sarcopenia in CKD with a prevalence similar to previous diagnostic criteria. In addition, they found that dynapenia was highly prevalent. Nevertheless, the EWGSOP2 criteria could be better adapted to CKD patients to improve their ability to detect high-risk sarcopenic and dynapenic patients.

Utilization of antihypertensive drugs in obesity-related hypertension: a retrospective observational study in a cohort of patients from Southern Italy.

BACKGROUND: Although the pathophysiological mechanisms of arterial hypertension are different in obese and lean patients, hypertension guidelines do not include specific recommendations for obesity-related hypertension and, therefore, there is a considerable uncertainty on which antihypertensive drugs should be used in this condition. Moreover, studies performed in general population suggested that some antihypertensive drugs may increase body weight, glycemia and LDL-cholesterol but it is unclear how this impact on drug choice in clinical practice in the treatment of obese hypertensive patients. Therefore, in order to identify current preferences of practitioners for obesity-related hypertension, in the present work we evaluated antihypertensive drug therapy in a cohort of 129 pharmacologically treated obese hypertensive patients (46 males and 83 females, aged 51.95 ± 10.1 years) that came to our observation for a nutritional consultation. METHODS: Study design was retrospective observational. Differences in the prevalence of use of the different antihypertensive drug classes among groups were evaluated with χ(2) square analysis. Threshold for statistical significance was set at p < 0.05. RESULTS: 41.1 % of the study sample was treated with one, 36.4 % with two and the remaining 22.5 % with three or more antihypertensive drugs. In patients under single drug therapy, ß-blockers, ACEIs and ARBs accounted each for about 25 % of prescriptions. The prevalence of use of ß-blockers was about sixfold higher in females than males. Diuretics were virtually never used in monotherapy regimens but were used in more than 60 % of patients on dual antihypertensive therapy and in all patients assuming three or more drugs. There was no significant difference in the prevalence of use of any of the aforementioned drugs among patients with obesity of type I, II and III or between patients with or without metabolic syndrome. CONCLUSIONS: Our data show that no first choice protocol seems to be adopted in clinical practice for the treatment of obesity-related hypertension. Importantly, physicians do not seem to differentiate drug use according to the severity of obesity or to the presence of metabolic syndrome or to avoid drugs known to detrimentally affect body weight and metabolic profile in general population.

[Technical- rganizational and Welfare Aspects Of The First Home Hemodialysis Program in Campania].

To activate a program of home hemodialysis (HHD) and to ensure its sustainability and success, it is essential to provide a structured path with the realization of a programmatic document detailing the technological requirements and the type of organization and assistance in line with the regulations currently in force. The path must consider the following: (a) eligibility clinical criteria of the patient and the caregiver, (b) analysis of the most recent HHD literature and the reasons of the choice of the latest technology, (c) accurate information of the patient and the caregiver with their approval, (d) care coverage and hospital admission modalities (e) suitability of the rooms where the patient will perform the HHD treatment, (f) training program of the patient and the caregiver, home treatment start and patient follow-up. The implementation of this structured process has allowed us to launch a successful HHD program: this modus operandi has preventively defined the pathway care and analyzed the priorities of risk. We have analyzed the HHD process to identify the possible problems and predictable critical situations in home health care. The experience with the HHD is promising: the patients did not show any clinical problems and reported a better quality of life; this dialysis method can be considered as further treatment option to selected patients, according to the eligibility criteria.

[Home Hemodialysis: Experience and Preliminary Results Of The First Center In Campania].

The Home Hemodialysis (HHD) is an uncommon dialytic option that can offer better clinical outcomes and a more satisfactory quality of life. The Health Plan of the Region Campania 2011-2013 states that" the system of home care for regional planning is particularly important". From August 2014 to March 2015 two patients, on standard dialysis (HD) as inpatients at Dialysis Centre of the University "Federico II" of Naples, started Short Daily Home Hemodialysis (SDHD) (4-6 dialysis treatments%week, 2.5 hours per session) using the portable cycler NxStage System One). The data collected showed that the clinical benefits described in the literature were confirmed in patients enrolled in this HHD program. Shorter and more frequent hemodialysis sessions allowed a significant reduction in interdialytic weight gain and greater intradialytic hemodynamic stability. A significant reduction in blood pressure and anti-hypertensive drugs were obtained. The control of phosphorus appeared better and hemoglobin was to target with a lower dose of weekly erythropoetin. The patients reported a greater well-being and a reduction in post-dialytic asthenia. No problem has been reported in using the vascular access (CVC and FAV) by the patient%caregiver. The dialysis adequacy and efficiency were comparable between SDHD and HD. The experience with the HHD is encouraging as the patients achieved an adequate dialysis dose without any complications reporting an improving sense of well-being and a better quality of life.

[The use of Cinacalcet in chronic kidney disease: a case report]. / Utilizzo del calcio-mimetico in terapia conservativa: un caso clinico.

Secondary Hyperparathyroidism is an important concurrent cause of cardiovascular and osteo-articular events, as well as, high morbidity and mortality for patients suffering from chronic kidney disease in conservative therapy and dialysis. The usual therapies, such as the vitamin D active metabolites and the phosphate binders did not always demonstrate effective in SHP control. New drugs, such as the calcimimetics, are available, resulting beneficial in highly reducing PTH levels. The only calcimimetic drug clinically used is cinacalcet, whose use is planned only in patients undergoing dialysis (peritoneal and extracorporeal). We describe the clinical case of a caucasian woman of 82 yrs old, with chronic kidney disease and secondary hyperparathyroidism resistant to usual therapies, in conservative treatment, which is prescribed cinacalcet (off-label). At first we found a worsening of the indices of renal function secondary to the effects of the drug on the hydrosaline balance. Increasing the hydrosaline intake we have seen the reduction and the subsequent stability of exams. Cinacalcet was effective in controlling the levels of parathyroid hormone and has contributed significantly to the achievement of optimal calcium-phosphorus balance. In view of these data, there is no doubt in taking in consideration the use of this drug also in the earliest stages of IRC.

Complications of native arteriovenous fistula: the role of color Doppler ultrasonography.

Color Doppler ultrasonography (CDUS) is a readily available, inexpensive and noninvasive method, which has improved the survival of native arteriovenous fistula (AVF) by increasing the early diagnosis of complications. Although angiography has been currently considered as the gold standard for imaging of vascular access abnormalities, CDUS may be superior in some aspects, since it provides information both on the morphology and on the function of vascular access and it is the only tool directly available to the nephrologist. In addition, CDUS offers the advantage of a non-invasive bedside procedure with lower costs and with no need for radiocontrast.

Evidence that p-cresol and IL-6 are adsorbed by the HFR cartridge: towards a new strategy to decrease systemic inflammation in dialyzed patients?

INTRODUCTION: Hemodialysis (HD) and hemodiafiltration clear only with a low efficiency the plasma from interleukin-6 and p-cresol, two protein-bound uremic toxins associated with high cardiovascular risk in end stage renal disease. HFR Supra is a double-chamber hemodiafiltration system in which the ultrafiltrate returns to the patient after its regeneration through a resin cartridge that binds hydrophobic and protein-bound solutes. In the present study, we evaluated whether the HFR cartridge can also bind total p-cresol and IL-6 and remove them from the ultrafiltrate. METHODS: We compared the levels of IL-6 and p-cresol in ultrafiltrate samples collected at the inlet (UFin) and at the outlet (UFout) of the cartridge at the start or at the end of a 240 min HFR session in 12 inflamed chronic HD patients. The pro-inflammatory activity of the ultrafiltrate samples was also determined by evaluating the changes that they induced in IL-6 mRNA expression and protein release in peripheral blood mononuclear cells from 12 healthy volunteers. IL-6 and p-cresol circulating levels were also assessed in peripheral plasma blood samples collected before and after HFR and, for comparison, a control HD. RESULTS: p-Cresol and IL-6 were lower in UFout than in UFin both at the start and at the end of the HFR session, suggesting that they were retained by the cartridge. IL-6 mRNA expression and release were lower in PBMC incubated with UFout collected at the end than with UFin collected at the start of HFR, suggesting that passage through the cartridge reduced UF pro-inflammatory activity. Plasma total p-cresol decreased by about 53% after HFR, and 37% after HD. IL-6 circulating values were unmodified by either these dialysis procedures. CONCLUSIONS: This study shows that the HFR-Supra cartridge retains total p-cresol and IL-6 in the ultrafiltrate and lowers plasma total p cresol but not IL-6 levels. TRIAL REGISTRATION: ClinicalTrials.gov NCT01865773.

Plasma p-cresol lowering effect of sevelamer in peritoneal dialysis patients: evidence from a Cross-Sectional Observational Study.

p-Cresol is a by-product of the metabolism of aromatic aminoacid operated by resident intestinal bacteria. In patients with chronic kidney disease, the accumulation of p-cresol and of its metabolite p-cresyl-sulphate causes endothelial dysfunction and ultimately increases the cardiovascular risk of these patients. Therapeutic strategies to reduce plasma p-cresol levels are highly demanded but not available yet. Because it has been reported that the phosphate binder sevelamer sequesters p-cresol in vitro we hypothesized that it could do so also in peritoneal dialysis patients. To explore this hypothesis we measured total cresol plasma concentrations in 57 patients with end-stage renal disease on peritoneal dialysis, 29 receiving sevelamer for the treatment of hyperphosphatemia and 28 patients not assuming this drug. Among the patients not assuming sevelamer, 16 were treated with lanthanum whereas the remaining 12 received no drug because they were not hyperphosphatemic. Patients receiving sevelamer had plasma p-cresol and serum high sensitivity C-reactive protein concentrations significantly lower than those receiving lanthanum or no drug. Conversely, no difference was observed among the different groups either in residual glomerular filtration rate, total weekly dialysis dose, total clearance, urine volume, protein catabolic rate, serum albumin or serum phosphate levels. Multiple linear regression analysis showed that none of these variables predicted plasma p-cresol concentrations that, instead, negatively correlated with the use of sevelamer. These results suggest that sevelamer could be an effective strategy to lower p-cresol circulating levels in peritoneal dialysis patients in which it could also favorably affect cardiovascular risk because of its anti-inflammatory effect.

Immunomodulatory effect of continuous venovenous hemofiltration during sepsis: preliminary data.

INTRODUCTION: Severe sepsis and septic shock are the primary causes of multiple organ dysfunction syndrome (MODS), which is the most frequent cause of death in intensive care unit patients. Many pro- and anti-inflammatory mediators, such as interleukin-6 (IL-6), play a strategic role in septic syndrome. Continuous renal replacement therapy (CRRT) removes in a nonselective way pro- and anti-inflammatory mediators. OBJECTIVE: To investigate the effects of continuous venovenous hemofiltration (CVVH) as an immunomodulatory treatment of sepsis in a prospective clinical study. METHODS: High flux hemofiltration (Qf = 60 ml/Kg/hr) was performed for 72 hr in thirteen critically ill patients suffering from severe sepsis or septic shock with acute renal failure (ARF). IL-6 gene expression was measured by real-time PCR analysis on RNA extracted from peripheral blood mononuclear cell before beginning of treatment (T0) and after 12, 24, 48, and 72 hours (T1-4). RESULTS: Real-time PCR analysis demonstrated in twelve patients IL-6 mRNA reduction after 12 hours of treatment and a progressive increase after 24, 48, and 72 hours. CONCLUSIONS: We suggest that an immunomodulatory effect might exist during CVVH performed in critically ill patients with severe sepsis and septic shock. Our data show that the transcriptional activity of IL-6 increases during CVVH.

Dietary intake as a link between obesity, systemic inflammation, and the assumption of multiple cardiovascular and antidiabetic drugs in renal transplant recipients.

We evaluated dietary intake and nutritional-inflammation status in ninety-six renal transplant recipients, 7.2 ± 5.0 years after transplantation. Patients were classified as normoweight (NW), overweight (OW), and obese (OB), if their body mass index was between 18.5 and 24.9, 25.0 and 29.9, and ≥ 30 kg/m(2), respectively. Food composition tables were used to estimate nutrient intakes. The values obtained were compared with those recommended in current nutritional guidelines. 52% of the patients were NW, 29% were OW, and 19% were OB. Total energy, fat, and dietary n-6 PUFAs intake was higher in OB than in NW. IL-6 and hs-CRP were higher in OB than in NW. The prevalence of multidrug regimen was higher in OB. In all patients, total energy, protein, saturated fatty acids, and sodium intake were higher than guideline recommendations. On the contrary, the intake of unsaturated and n-6 and n-3 polyunsaturated fatty acids and fiber was lower than recommended. In conclusion, the prevalence of obesity was high in our patients, and it was associated with inflammation and the assumption of multiple cardiovascular and antidiabetic drugs. Dietary intake did not meet nutritional recommendations in all patients, especially in obese ones, highlighting the need of a long-term nutritional support in renal transplant recipients.